Chapter 23

Musculoskeletal System

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 Structure and Function
 Musculoskeletal system consists of bones, joints, and muscles.
 Needed for support and to stand erect
 Needed for movement
 To encase and protect inner vital organs
 To produce RBCs in the bone marrow
 Serve as a reservoir for storage of essential minerals
 Musculoskeletal components:
 Bones and cartilage—specialized forms of connective tissue
 Fibrous, cartilaginous and synovial joints—joints or articulations are
places of union of two or more bones
 Ligaments—fibrous bands from one bone to another that strengthen
the joint and prevent unwanted movement
 Bursa—enclosed fluid filled sac that serves as a cushion
 Muscle—skeletal, voluntary control connected by tendon to bone

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 Fibrous, Cartilaginous and Synovial
Joints
 Fibrous joints
 Bones united by interjacent fibrous tissue or cartilage and do not move
(sutures in skull)
 Cartilaginous joints
 Separated by fibrous by fibrous cartilage and are slightly moveable
(vertebrae)
 Synovial joints
 Freely moveable joints separated by one another and enclosed in a
cavity lined with synovial membrane that secretes fluid
 Contains a layer of avascular cartilage
 Surrounded by ligaments
 Bursae located in areas of potential friction to facilitate movement of
muscles and tendons

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Synovial Joint

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 Skeletal Muscles (1 of 2)
 Skeletal muscles produce following movements:
 Flexion: bending limb at joint
 Extension: straightening limb at joint
 Abduction: moving limb away from midline of body
 Adduction: moving limb toward midline of body
 Pronation: turning forearm so that palm is down
 Supination: turning forearm so that palm is up
 Circumduction: moving arm in circle around shoulder

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 Skeletal Muscles (2 of 2)
 Skeletal muscles produce following movements:
 Inversion: moving sole of foot inward at ankle
 Eversion: moving sole of foot outward at ankle
 Rotation: moving head around central axis
 Protraction: moving body part forward, parallel to
ground
 Retraction: moving body part backward, parallel to
ground
 Elevation: raising a body part
 Depression: lowering a body part

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Skeletal Muscle Movements

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 Temporomandibular Joint (TMJ)
 Articulation of mandible and temporal bone
 Can feel it in depression anterior to tragus of
ear
 TMJ permits jaw function of speaking and
chewing.
 Allows three motions:
 Hinge action to open and close jaws
 Gliding action for protrusion and retraction
 Gliding for side-to-side movement of lower jaw

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 Spine and Vertebrae
 Vertebrae: 33 connecting bones stacked in vertical
column
 Can feel spinous processes in furrow down midline of
back
 Vertebrae in humans:
 7 cervical
 12 thoracic
 5 lumbar
 5 sacral
 3 to 4 coccygeal

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 Spine Landmarks
 Surface landmarks orient you to their levels.
 Spinous processes of C7 and T1 prominent at base
of neck
 Inferior angle of scapula normally at level of
interspace between T7 and T8
 Imaginary line connecting highest point on each iliac
crest crosses L4
 Imaginary line joining two symmetric dimples that
overlie posterior superior iliac spines crosses
sacrum

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Surface Landmarks of Spine

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 Spine
 Lateral view shows vertebral column having four curves, a double-
S shape.
 Cervical and lumbar curves are concave (inward or anterior).
 Thoracic and sacrococcygeal curves are convex.
 Balanced or compensatory nature of curves, together with
intervertebral disks, allows spine to absorb shock.
 Intervertebral disks are elastic fibrocartilaginous plates that constitute
one fourth the length of column.
 Nucleus pulposus—disk center composed of soft, semifluid, mucoid
material
 Allow for compensatory expansion on each side
 Motions of vertebral column:
 Flexion, extension, abduction, and rotation

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 Shoulder
 Shoulder girdle:
 Humerus, scapula, clavicle, joints and muscle
 Glenohumeral joint: articulation of humerus with glenoid fossa of
scapula
 Ball-and-socket action allows mobility of arm on many axes.
 Rotator cuff:
 Group of four (SITS) muscles and tendons support and stabilize
shoulder.
 Subacromial bursa:
 Assists with abduction of the arm
 Palpable landmarks to guide your examination:
 Scapula and clavicle form shoulder girdle
 Can feel the bump of the scapula’s acromion process at very top of
shoulder

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Shoulder Joint

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 Elbow and Wrists and Carpals
 Elbow
 Elbow joint contains three bony articulations: humerus, radius, and
ulna of forearm.
 Palpable landmarks are medial and lateral epicondyles of humerus
and large olecranon process of ulna between them.
 Radius and ulna articulate with each other at two radioulnar joints, one
at elbow and one at wrist.
 Wrist, or radiocarpal joint
 Articulation of radius on thumb side and row of carpal bones
 Condyloid action permits movement in two planes at right angles:
flexion and extension, and side-to-side deviation
 Midcarpal joint: articulation allows flexion, extension, and some
rotation

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 Bones of Hand
 Incorrect image. Need f0055. See screenshot

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 Hip
 Hip: articulation between acetabulum and head of the
femur
 Ball-and-socket action permits wide range of motion on many
axes.
 More stability for weight-bearing function
 Muscles enhance stability and bursae facilitate
movement.
 Palpation of bony landmarks will guide examination.
 Iliac crest—anterior superior spine to posterior
 Ischial tuberosity
 Greater trochanter of the femur

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 Knee (1 of 2)
 Knee joint: articulation of three bones—femur, tibia, and
patella—in common articular cavity
 Largest joint in body; hinge joint, permitting flexion and
extension of lower leg on single plane
 Synovial membrane is largest in body.
 Two wedge-shaped cartilages, called medial and lateral
menisci, cushion tibia and femur.

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 Knee (2 of 2)
 Knee stabilized by two sets of ligaments:
 Cruciate give anterior and posterior stability and help control
rotation.
 Collateral ligaments give medial and lateral stability and
prevent dislocation.
 Landmarks of knee joint:
 Quadriceps muscle, felt on anterior and lateral thigh
 Tibial tuberosity—felt as bony prominence in the midline
 Note lateral and medial condyles of tibia.
 Medial and lateral epicondyles of femur are on either side of
patella.

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Landmarks of Knee

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 Ankle and Foot (1 of 2)
 Ankle or tibiotalar joint: articulation of tibia, fibula, and talus
 Hinge joint: limited to flexion (dorsiflexion) and extension (plantar
flexion) in one plane
 Landmarks are two bony prominences on either side
 Medial malleolus and the lateral malleolus
 Help stability of ankle
 May be torn in eversion or inversion sprains of ankle
 Joints distal to ankle give additional mobility to foot.
 Subtalar joint permits inversion and eversion of foot.
 Foot has longitudinal arch, with weight-bearing distributed between
parts that touch ground, the heads of metatarsals and calcaneus
(heel).

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Ankle and Foot (2 of 2)

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 Developmental Competence:
Infants and Children
 By 3 months, fetus has formed “scale model” of the skeleton of
cartilage.
 Ossification to true bone continues in utero.
 Bone growth continues rapidly during infancy and steadily in
childhood, until adolescent growth spurt.
 Bone growth occurs in two dimensions.
 Epiphyses: specialized growth plates at end of long bones
 Longitudinal growth continues until closure of epiphyses; last closure
occurs about age 20.
 Although skeleton contributes to linear growth, muscles and fat are
significant for weight increase.
 Muscles vary in size and strength in different people due to genetics,
nutrition, and exercise.

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 Developmental Competence:
Pregnant Woman
 Increased levels of circulating hormones cause increased mobility
in joints.
 Estrogen, relaxin, and corticosteroids
 Increased mobility in sacroiliac, sacrococcygeal, and symphysis
pubis joints in pelvis contributes to noticeable changes in maternal
posture.
 Most characteristic change is progressive lordosis leading to
increased back strain.
 Compensatory postural change anterior flexion of neck and slumping
of shoulder girdle
 Pressure on ulnar and median nerves seen in last trimester

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 Developmental Competence:
Aging Adult
 Bone remodeling is cyclic process of resorption and deposition.
 After age 40, resorption occurs more rapidly than deposition.
 Risk for osteoporosis
 Postural changes and decreased height are most noticeable.
 Kyphosis with slight flexion of hips and knees to compensate
 Distribution of subcutaneous fat changes leading to different
contour
 Loss of subcutaneous fat leaves bony prominences more marked.
 Absolute loss in muscle mass
 Decrease in size and atrophy producing weakness
 Impact of sedentary lifestyle

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 Culture and Genetics
 Bone mineral density (BMD)
 Higher BMD = denser bone
 Low BMD consistent predictor of hip and vertebral fractures
 Racial/ethnic differences in BMD seen nationally and
globally
 Gender differences in BMD
 Identifying attainment of peak BMD
 Earlier peak and rapid decline of BMD associated with increased
fracture risk in Caucasian women

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 Subjective Data
 Joints: pain, stiffness, swelling, heat, redness,
limitation of movement
 Knee joint (if injured)
 Muscles: pain (cramps) or weakness
 Bones: pain, deformity, trauma (fractures,
sprains, or dislocation)
 Functional assessment (ADLs)
 Patient-centered care

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 Health History Questions: Joints
 Ask about
 Pain: Do you have any pain in or problems with your joints?
 Location: Unilateral or bilateral
 Characteristics: Quality: and severity
 Onset, duration and frequency
 Aggravating or precipitating factors
 Associated clinical presentations
 Limitation of motion, stiffness, swelling or erythema
 Impact on ADLs

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Health History Questions: Muscles
 Ask about
 location of pain or cramping.
 pain while walking versus pain relief at rest.
 associated clinical presentations.
 muscle characteristics: weakness and size. Ask whether the
person has any weakness in his or her muscles?
 onset and duration of symptoms.

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 Health History Questions: Bones
 Ask about
 pain: at rest and/or affected by movement.
 presence of deformity due to injury or trauma and effect on
ROM.
 history of accidents or trauma with impact on bones.
 medical and/or surgical treatment—any residual deficits.
 presence of back pain—provide pain characteristic description.
 presence of neurological or physical deficits.

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 Functional Assessment of ADLs
 Ask about
 Do joint (muscle, bone) problems create any limits on your usual ADLs? Which
ones?
 Screens safety of independent living , need for home services and quality of life
 Ask specific questions about all of these topic areas:
• Bathing
• Toileting
• Dressing
• Grooming
• Eating
• Mobility
• Communicating

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 Patient-Centered Care
 Ask about
 occupational hazards.
 exercise program pattern.
 dietary review: recent weight gain or weight loss.
 medications: Rx and OTC r/t muscle/bone health.
 supplemental vitamins and minerals: vitamin D and calcium.
 smoking history.
 impact on ADLs: acute versus chronic disability.

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 Additional History Questions (1 of 2)
 Infants and children
 Labor and delivery information
 Achievement of developmental milestones
 History of broken bones/trauma with treatment and/or residual
deficits
 Presence of bone/spinal deformity
 Adolescent
 History or sports activities
 Pattern of warm up and exercise
 Interventions if injury occurs

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 Additional History Questions (2 of 2)

 Aging adult
 Use functional assessment history questions to elicit
any loss of function, self-care deficit, or safety risk.
 New onset weakness
 Increase in falls or stumbling
 Use of mobility device
 Recommendation for DEXA screening for females
ages 65 and older

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 Physical Examination Preparation
 Purpose of musculoskeletal examination is to assess function for
ADLs and to screen for abnormalities.
 Note additional ADL data as person goes through motions necessary
for examination.
 Age-specific screening measures, such as Ortolani’s sign for infants or
scoliosis screening for adolescents
 Take an orderly approach: head to toe, proximal to distal, and from
midline outward
 Perform bilateral comparison.
 Be aware of normal and abnormal findings.
 Provide instructions to patient r/t assessment activities.

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 Order of Examination
 Inspection
 Note size and contour of joint; inspect skin and tissues over joints for
color, swelling, and any masses or deformity.
 Palpation
 Palpate each joint, including skin for temperature, muscles, bony
articulations, and area of joint capsule; notice any heat, tenderness,
swelling, or masses which signal inflammation.
 Joints normally not tender to palpation
 If tenderness occurs, localize to specific anatomic structures.
 Range of motion (ROM)
 Ask for active voluntary ROM while stabilizing the body area proximal to
that being moved.
 If you see a limitation gently use passive ROM.

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 Muscle Testing
 Test strength of prime mover muscle groups for
each joint; repeat motions for active ROM.
 Ask person to flex and hold as you apply
opposing force.
 Muscle strength should be equal bilaterally and
should fully resist opposing force.
 Use standardized grading scale to report results
(0 to 5 range).

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 Temporomandibular Joint (TMJ)
 Inspection and palpation
 Audible and palpable snap or click occurs in many healthy people as
mouth opens.
 Palpate contracted temporalis and masseter muscles as person
clenches teeth.
 Compare right and left sides for size, firmness, and strength.
 Ask person to move jaw forward and laterally against your resistance,
and to open mouth against your resistance.
• This tests integrity of cranial nerve V (trigeminal nerve).
 Observe for swelling, limitation of motion and/or reported pain.

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 Cervical Spine
 Inspect alignment of head and neck.
 Spine should be straight and head erect.
 Palpate spinous processes and sternomastoid,
trapezius, and paravertebral muscles.
 They should feel firm, with no muscle spasm or tenderness.
 Repeat motions while applying opposing force.
 Person normally can maintain flexion against full
resistance.
 This tests integrity of cranial nerve XI (spinal nerve).
 Observe for limitation of motion and/or reported pain.

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 Shoulder
 Inspect and compare both shoulders posteriorly and anteriorly.
 Do not attempt if you suspect neck trauma.
 If person reports shoulder pain, ask him or her to point to spot with
hand of unaffected side.
 Shoulder pain may be from local causes or may be referred pain which
could be potentially serious.
 Pain from a local cause is reproducible during the examination by
palpation or motion.
 While standing in front of person, palpate both shoulders, noting any
muscular spasm or atrophy, swelling, heat, or tenderness.
 Use a methodical method to assess muscle strength and ROM.
 Shoulder shrug also tests integrity of cranial nerve XI, spinal accessory
nerve.

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 Elbow
 Inspect size and contour of elbow in both flexed and
extended positions.
 Look for deformity, redness, or swelling.
 Check olecranon bursa and the normally present hollows on
either side of the olecranon process for abnormal swelling.
 Palpate elbow flexed about 70 degrees and relaxed.
 Use stabilizing technique to support extremity during
assessment.
 Test ROM and assess muscle strength.

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 Wrist and Hand
 Inspect hands and wrists on dorsal and palmar sides.
 Note position, contour, and shape; normally no swelling or redness,
deformity, or nodules are present.
 Palpate each joint in wrist and hands.
 Perform ROM and assess muscle strength.
 Use stabilizing technique to support extremity during muscle testing.
 Perform testing to determine presence of Carpal Tunnel Syndrome.
 Phalen test—acute flexion of wrist produces numbness and burning if
+
 Tinel sign test—percussion of median nerve produces burning and
tingling if +

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 Hip
 Inspect hip joint together with spine later in examination
as person stands; note symmetric levels of iliac crests,
gluteal folds, and equally sized buttocks.
 Smooth, even gait reflects equal leg lengths and functional hip
motion.
 Help person into supine position and palpate hip joints;
joints should feel stable and symmetric, with no
tenderness or crepitation.
 Assess ROM.
 Limitation of abduction of hip while supine is most common
motion dysfunction found in hip disease.

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 Knee
 Person should remain supine with legs extended.
 Inspect lower leg alignment, knee shape, and contour.
 Check quadriceps muscle in anterior thigh for any atrophy.
 Perform ROM to assess for any limitation or presence of pain.
 Enhance palpation with knee in supine position; start high on
anterior thigh above patella.
 If swelling observed, test for bulge sign and ballottement of patella
to distinguish soft-tissue swelling or increased fluid in joint.
 Perform McMurray’s test if meniscal tear is suspected.
 Audible click on examination is + for presence of tear.

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 Ankle and Foot (1 of 2)
 Inspect while person is sitting and when standing and
walking.
 Compare both feet, noting contour of joints; foot should align
with long axis of lower leg.
 Weight-bearing should fall on middle of foot; most feet have a
longitudinal arch, but this can vary normally from “flat feet” to
high instep.
 Toes point straight forward and lie flat; note locations of
calluses or bursal reactions as they reveal areas of abnormal
friction.
 Examining well-worn shoes helps assess areas of wear and
accommodation.

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 Ankle and Foot (2 of 2)
 Palpation
 Palpate metatarsophalangeal joints between your
thumb on dorsum and fingers on plantar surface.
 Perform ROM to assess for any limitation or
presence of pain.
 Assess muscle strength by asking person to
maintain dorsiflexion and plantar flexion against your
resistance.

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 Spine (1 of 3)
 Person should be standing, draped in gown open at back.
 Place yourself far enough back so that you can see entire back.
 Inspect and note if spine is straight.
 From side, note normal convex thoracic curve and concave lumbar
curve.
 Kyphosis: Enhanced thoracic curve typically seen in aging people
 Lordosis: Pronounced lumbar curve seen in obese people
 Palpate spinous processes; normally straight and not tender.
 Palpate paravertebral muscles; should feel firm with no tenderness or
spasm.

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 Spine (2 of 3)
 Check ROM of spine by asking person to touch toes;
look for flexion of 75 to 90 degrees, and smoothness and
symmetry of movement.
 Concave lumbar curve should disappear with this
motion; back should have single convex C-shaped
curve.
 If you suspect spinal curvature during inspection, this
may be more clearly seen when person touches toes.
 While person is bending over, mark a dot on each
spinous process; when person resumes standing,
dots should form a straight vertical line.

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 Spine (3 of 3)
 Stabilize pelvis with your hands; check ROM.
 Bend sideways: lateral bending of 35 degrees
 Bend backward: hyperextension of 30 degrees
 Twist shoulders to one side, then the other: rotation
of 30 degrees, bilaterally.
• These maneuvers reveal gross restrictions only; movement
is still possible even if some spinal fusion has occurred.
 Finally, ask person to walk on his or her toes for a
few steps, then return walking on heels.

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 Straight Leg Raising or
Lasègue’s Test
 These maneuvers reproduce back and leg pain and
may confirm presence of herniated nucleus pulposus.
 Straight leg raising while keeping the knee extended
normally produces no pain.
 Raise affected leg just short of point where it produces
pain; then dorsiflex foot.
 Test positive if it reproduces sciatic pain; if lifting
affected leg reproduces sciatic pain, it confirms
presence of herniated nucleus pulposus.
 Raise unaffected leg leaving other leg flat; inquire about
involved side.

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Straight Leg Raising Test

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 Measure Leg Length Discrepancy
 Perform this measurement if you need to determine
whether one leg is shorter than other.
 For true leg length, measure between fixed points, from
anterior iliac spine to medial malleolus, crossing medial
side of knee.
 Normally these measurements are equal or within 1 cm,
indicating no true bone discrepancy.

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Leg Length Discrepancy

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 Developmental Competence:
Infants (1 of 2)
 Examine infant fully undressed and lying on back; maintain
temperature.
 Feet and legs
 Note any positional deformities, a residual of fetal positioning.
 Note relationship of forefoot to hindfoot.
 Check for tibial torsion, a twisting of the tibia.
 Hips
 Check hips for congenital dislocation; most reliable is Ortolani’s
maneuver, which should be done at every visit until infant is 1 year old.
 Allis test is also used to check for hip dislocation.

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 Developmental Competence:
Infants (2 of 2)
 Hands and arms
 Inspect hands, noting shape, number, and position of fingers and palmar
creases.
 Palpate length of clavicles; the bone most frequently is fractured during birth.
 Back
 Lift infant and examine back; note normal single C-curve of newborn’s spine.
 Inspect length of spine for any tuft of hair, dimple in midline, cyst, or mass;
normally none is present.
 Observe ROM through spontaneous movement.
 Test muscle strength by lifting up the infant with your hands under the axillae;
baby with normal muscle strength wedges securely between your hands.

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 Developmental Competence:
Preschool and School-Age Children
 Back: note posture; you should note a “plumb line” from back of
head, along spine, to middle of sacrum
 Shoulders: level within 1 cm; scapulae symmetric; lordosis common
throughout childhood
 Observe legs and feet for various deformities, such as
 bowleg, knock knees, flatfoot, pigeon toes.
 Check Trendelenburg sign progressively for subluxation of hip
 Particularly, check arm for full ROM and presence of pain.
 Look for subluxation of elbow (head of radius).
 Palpate bones, joints, and muscles of extremities as in adult
examination.

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 Developmental Competence:
Adolescents
 Proceed with same musculoskeletal examination as for adult; pay
special note to spinal posture.
 Kyphosis is common during adolescence because of chronic poor
posture.
 Screen for scoliosis with forward bend test.
• From behind standing child, ask child to stand with feet shoulder width
apart and bend forward slowly to touch the toes.
 Expect straight vertical spine while standing and also while bending
forward; posterior ribs should be symmetric, with equal elevation of
shoulders, scapulae, and iliac crests.

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 Developmental Competence:
Pregnancy
 Proceed through same examination as for adult.
 Expected postural changes in pregnancy include:
 Progressive lordosis
 Toward third trimester, anterior cervical flexion
 Kyphosis and slumped shoulders
 When pregnancy at term, protuberant abdomen and
relaxed mobility in joints create characteristic “waddling”
gait.

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 Developmental Competence:
Aging Adult
 Postural changes include decrease in height, more
apparent in eighth and ninth decades.
 Kyphosis common, with backward head tilt to
compensate
 Contour changes include a decrease of fat in body
periphery; fat deposition over abdomen and hips.
 Bony prominences become more marked.
 ROM testing
 Get Up and Go test
 Perform functional assessment for ADLs.

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Health Promotion and Patient Teaching

 Focus on the following areas:

 Diet to protect and maintain healthy bones
 Smoking cessation
 Alcohol intake pattern
 Exercise promotion
 Osteoporosis Screening
 Fall prevention risk

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 Abnormalities
Affecting Multiple Joints
 Inflammatory conditions
 Rheumatoid arthritis
 Ankylosing spondylitis: type of arthritis that causes
inflammation in the joints and ligaments of the spine
 Degenerative conditions
 Osteoarthritis (degenerative joint disease)
 Osteoporosis

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 Abnormalities: Shoulder, Elbow and Spine
 Shoulder
 Atrophy
 Dislocated shoulder
 Joint effusion
 Tear of rotator cuff
 Frozen shoulder—adhesive capsulitis
 Elbow
 Olecranon bursitis
 Arthritis
 Rheumatoid nodules
 Epicondylitis—tennis elbow
 Spine
 Scoliosis
 Herniated intervertebral disc

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 Wrist and Hand Abnormalities
 Wrist and hand
 Ganglion cyst
 Colles’ fracture
 Carpal tunnel syndrome with atrophy of thenar eminence
 Ankylosis
 Dupuytren’s contracture
 Conditions caused by chronic rheumatoid arthritis:
 Swan-neck and boutonniere deformities
 Ulnar deviation or drift
 Degenerative joint disease or osteoarthritis
 Acute rheumatoid arthritis
 Syndactyly
 Polydactyly

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Abnormalities: Knee and Ankle and Foot
 Knee
 Osgood-Schlatter disease
 Post-polio muscle atrophy
 Mild synovitis
 Prepatellar bursitis
 Swelling of menisci
 Ankle and foot
 Achilles tenosynovitis
 Tophi with chronic gout/acute gout
 Hallux vagus with bunion and hammer toes
 Plantar fasciitis
 Ingrown toenail
 Plantar wart

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 Congenital or Pediatric Abnormalities

 Developmental dysplasia of the hip

 Talipes equinovarus (clubfoot)
 Spina bifida
 Coxa plana (Legg-Calvé-Perthes syndrome) –
flattened femoral head

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 Summary Checklist: Musculoskeletal
Examination
 Inspection
 Size and contour of joint
 Skin color and characteristics
 Palpation of joint area
 Skin, muscles, bony articulations, and joint capsules
 ROM
 Active
 Passive (if limitation noted in active ROM is present)
 Measure with goniometer (if abnormality in ROM is present)
 Muscle testing

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