At the end of this presentation, the student will
be able to:
Part 1
Musculoskeletal System
Lecture Outline
• STRUCTURE AND FUNCTION
• SUBJECTIVE DATA – HEALTH HISTORY
QUESTIONS
• OBJECTIVE DATA – THE PHYSICAL EXAM
• ABNORMAL FINDINGS
• Describe normal structure and function of
major joints of the MS system
• Perform health assessment of the major joints
of the MS system
• Distinguish physical assessment findings
associated with rheumatoid arthritis and
osteoarthritis and osteoporosis.
STRUCTURE AND FUNCTION
• Skeleton
– Bony framework of body
– 206 bones
– Support body like posts/beams of building
• Joints
– Articulation of 2 or more bones
– Functional units of MS system
• Muscles
– produce movement by contraction
B
1
Chapter 22
STRUCTURE & FUNCTION cont
STRUCTURE & FUNCTION cont
Synovial joints:
• Joints
• Cartilage layer covers surface of opposing bones
– Nonsynovial joints
• Stable connective tissue (slow cell turnover)
• Bones are joined by fibrous tissue
• Tough, firm consistency, yet flexible
• Immovable (or only slightly)
• Cushions the bones
• Gives smooth surface to facilitate movement
• Sutures of skull, (the vertebrae)
– The joint is covered by a fibrous capsule & supported by ligaments
– Ligament – fibrous bands bone to bone
– Synovial Joints
• Strengthens the joint
• Freely movable
• Bones are separated from each other & enclosed in a jint cavity
• Prevents undesirable movement directions
– Bursa – enclosed sac filled with synovial fluid
• The joint cavity is filled with a lubricant – synovial fluid
• Located in areas of potential friction
• Allows sliding which facilitates movement
• Help muscles and tendons glide smoothly over bone
Slide 20-2
Synovial Joint
STRUCTURE & FUNCTION cont
• Muscles – produce movement by contraction
– Fasciculi – bundles of muscle fibers
– Tendon – a strong fibrous cord that
attaches skeletal muscle to bone
Slide 22-7
2
Skeletal muscle movements
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Skeletal Muscle Movements
Flexion – bend limb
Extension – straighten limb
Abduction – move limb away from midline
Adduction – move limb toward midline
Pronation – turn forearm – palm down
Supination – turn forearm – palm up
Circumduction – move arm in a circle around the shoulder
Inversion – move sole of foot inward at ankle
Eversion – move sole of foot outward at ankle
Rotation – move head at central axis
Protraction – move body part forward, parallel to ground
Retraction – move body part backward, parallel to ground
Elevation – raise body part
Depression –lower body part
Slide 22-10
STRUCTURE & FUNCTION, cont.
• Temporomandibular Joint (TMJ)
– Articulation of mandible with temporal bone
– Permits jaw function for chewing & speaking
• Hinge motion to open and close jaw
• Gliding action for protraction (protrusion) & retraction
• Gliding action for side to side movement of lower jaw
Slide 20-3
3
STRUCTURE & FUNCTION, cont.
Landmarks of the Spine
• Spine
– Vertebrae
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33 connecting bones stacked in vertical column
7 cervical
12 thoracic
5 lumbar
5 sacral
3-4 coccygeal (coccyx)
– Landmarks of spine
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C7/T1 - prominent at neck base
T7/T8 - inferior angle of scapula
L4 - iliac crest
S2 - Posterior superior iliac spine (butt dimples)
Slide 22-14
Spine cont.
• Intervertebral discs
– Elastic, fibrocartilaginous plates between vertebrae
– Resilient tissue is shock absorber for movement
– Nucleus pulposa
• In center of disc
• Soft, semi-fluid mucoid material (toothpaste-like)
– Compression/rupture/herniation of disc
• Compress spinal nerves
• Cause pain
4
STRUCTURE & FUNCTION, cont
Shoulder
• Shoulder
– Glenohumeral joint – articulation of humerous to the
glenoid fossa of scapula
– Rotator cuff – enclosure of 4 muscles and tendons that
support & stabilize the shoulder
– Subacromial bursa – helps arm abduction
– Acromion process – bump of scapula, top of shoulder
Slide 22-18
Chapter 22
STRUCTURE & FUNCTION, cont.
Musculoskeletal System
• Elbow
– Medial and lateral epicondyles
– Olecranon process of ulna
• Wrist and Carpals
– Radiocarpal joint - wrist
– Metacarpophalangeal joints – fingers to hand
– Interphalangeal joints – finger joints
• Proximal = PIP joints
• Distal = DIP joints
Slide 20-4
5
Chapter 22
STRUCTURE & FUNCTION cont.
Musculoskeletal System
Bones of the Hand
• HIP
• Articulation between acetabulum & head of
femur
• 3 burase facilitate movement
• Palpate bony landmarks to guide exam
Slide 22-21
Slide 20-5
Hip Joint
Slide 22-23
Landmarks of the Knee
Slide 22-24
6
Ankle and Foot
STRUCTURE & FUNCTION, cont.
• Ankle and Foot
– Tibiotalar joint
– Medial and lateral
malleolus
– Metatarsals
Slide 22-26
Developmental Considerations
• Pregnant Woman
– Increased mobility of joints
– Changes in maternal posture
– Progressive lordosis
– Compensation for lordosis
Developmental Considerations
• The Aging Adult
– Postural changes
• Decrease in height
• Kyphosis
– Contour changes
• Decreased peripheral body fat
• Increased fat over abdomen & hips
– Range of Motion & muscle strength
• Same as younger adult unless disease is present
– Functional Assessment for ADLs
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Walk
Climb up & down stairs
Pick up objects from floor
Rise from sitting in chair
Rise from lying in bed
7
Chapter 22
Chapter 22
SUBJECTIVE DATA
1. Joints
SUBJECTIVE DATA
4. Functional assessment
(activities of daily living)
– Pain
– Stiffness
– Swelling, heat, redness
2. Muscles
 Bathing
 Toileting
 Dressing
 Grooming
 Eating
 Mobility
 Communicating
– Pain (cramps)
– Weakness
3. Bones
– Pain
– Deformity
– Trauma (fractures, sprains, dislocations)
4. Functional assessment
(activities of daily living)
5. Self-care behavior
Slide 20-6
Chapter 22
SUBJECTIVE DATA
Slide 20-6
OBJECTIVE DATA –
THE PHYSICAL EXAM
Preparation
Screening musculoskeletal examination
• Inspection & Palpation of each joint
• Observe ROM
4. Self-care behaviors
Occupation
Exercise
Weight
Medications
Social/ interpersonal
• Ask for active ROM
• If limitation is observed – gently guide through passive ROM
Complete musculoskeletal examination
• For persons with joint/MS symptoms/disease
Equipment Needed
Tape Measure
Goniometer, to measure joint angles
Skin marking pen
Slide 20-6
8
OBJECTIVE DATA –THE PHYSICAL EXAM
• Order of the Examination
–Inspection
»Size and contour of joint
»Skin and tissues over joint
–Palpation
»Skin temperature
»Muscles, bony articulations,
area of joint capsule
Inspection and Palpation
• Always compare contralateral sides!!
• Typically done together
OBJECTIVE DATA –THE PHYSICAL EXAM
• Order of the Examination
–Range of Motion
•Ask for active ROM
•If limitation is observed – gently guide through
passive ROM
–Muscle Testing
• Apply opposing force
• Grading muscle strength
Inspection and Palpation: Muscles
• Overall appearance of muscle mass
– Hypertrophy
• Increase in muscle size and shape
– Atrophy
• Reduction in muscle size and shape
• Thin, flabby muscles
• If a limb looks smaller/larger than its
counterpart
– During muscle relaxation, measure both limbs
at exactly the same distance from a nearby
joint at the site of maximum limb diameter
• A discrepancy of > 3cm is abnormal
9
Inspection and Palpation: Muscles
• Have person
– Contract muscle isometrically
• Isometric muscle contraction: without inducing
movement
– Then relax muscle
– Then contract again
– Watch for any involuntary movements
Inspection and Palpation: Joints
• Observe the shape of the joint while the joint
is in its neutral anatomic position
– Contour
• Dislocation: dislodgment of one bone out of the joint
cavity
• Subluxation: partial dislodgment of the bone from its
place in the joint cavity
– Symmetry
Inspection and Palpation: Muscles
• Apply light pressure with finger pads
• Palpate while person’s muscles are relaxing
and while they are isometrically contracting
– Hypotonicity
• Flaccidity
• Decreased muscle tine
– Spasticity
• Increased muscle tone
• Often noted with extreme flexion or extension
Inspection and Palpation: Joints
• Visually inspect the 2-3 inches of skin and
subcutaneous tissue surrounding the joint
– Erythema
– Edema
– Ecchymosis
– Nodules
– Deformities
– Masses
– Skin atrophy
– Skin breakdown
10
Inspection and Palpation: Joints
• Palpate the joint from the periphery inward
toward the center of the joint
– Swelling
– Tenderness
– Warmth
– Nodules
Range of Motion (ROM)
Range of Motion (ROM)
• Active
– person does the moving
– Have person move joint through each of its
various ROM movements
– Note the angle of each joint movement
– Note any pain, tenderness, or crepitus
Goniometer
• Passive
– person relaxes and allows you to move the joints
– Done if person is unable to do active ROM
• ALWAYS stop if the person complains of pain
• NEVER push a joint beyond its anatomic angle
• Use a Goniometer to determine exact ROM in
joints with limited ROM
11
Grading Muscle Strength
Muscle Strength
• As you are testing ROM
• Test muscle strength
– Ability to perform the ROM against resistance
• Symmetry
• Involuntary movements
• 5
Normal
• 4
Good
75%
• 3
Fair
50%
• 2
Poor
25%
• 1
Trace
10%
• 0
None
0%
100%
Complete ROM against full
resistance
Complete ROM against
moderate resistance
Complete ROM without
resistance
Complete ROM only if joint
fully supported
Muscle contraction visible
but insufficient to move joint
No visible or palpable muscle
contraction
Chapter 22
Musculoskeletal System
OBJECTIVE DATA –
Temporomandibular Joint
• Inspect joint area
• Palpate as person opens mouth
• Motion and expected range
– Open mouth maximally
– Protrude lower jaw and move side to side
– Stick out lower jaw
• Palpate muscles of mastication
Slide 20-8
12
TMJ
–Muscle Testing
»Apply opposing force
»Grading muscle strength
OBJECTIVE DATA –
THE PHYSICAL EXAM, cont.
Cervical Spine
Inspect alignment of head and neck
Palpate spinous processes (C7)and muscles
Motion and Expected Range
Chin to chest
Lift chin
Each ear to shoulder
Turn chin to each shoulder
Cervical Spine
–Muscle Testing
»Apply opposing force
»Grading muscle strength
13
Shoulder
–Muscle Testing
»Apply opposing force
»Grading muscle strength
14
15
Wrist and hand
.
16
Hands and Wrists
• Phalen’s Test
– Ask the person to hold
both hands back to
back while flexing the
wrists 90 degrees
– Normal –no symptoms
after 60 seconds
– Carpel tunnel
syndrome =
numbness/burning
• Tinel’s Sign
– Direct percussion of
the location of the
median nerve at the
wrist
– Normal – no symptoms
– Carpel tunnel
syndrome =
burning/tingling along
the nerve
• + Tinel’s sign
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