Weber Ch Musculoskeletal

• •Provides support & mobility for the body;
• •Is a protection for internal organs;
• •Produces blood cells (hematopoiesis);
• •Stores minerals such as calcium & phosphorus.

• –Compact bone
• – hard & dense (shaft & outer bone layer)
• –Spongy bone
• – with spaces (center & ends of bones)
• –Osteoblasts build/form bone
• –Osteoclasts break down bone/ continually remodel to accommodate stress

• Hematopoiesis = production of blood cells
• Most bones = combination of compact & spongy bone

Function of bone dictates shape and surface features:

–Long bones—levers; flat surface for attachment of muscles with grooves at end—passage of tendon or nerve (humerus, femur, fibula, and phalanges)

–Short bones—carpals and tarsals (cube shaped)

–Flat bones—cranium, ribs, and scapula

–Irregular bones—vertebrae

• 206 bones in body
• Humerus = upper arm
• Phalanges = fingers & toes
• Carpal = wrist
• Tarsals = ankle

• •Axial Skeleton – head, neck, & trunk
• •Appendicular Skeleton–
• extremities, shoulders & hips

•Articulations where two or more bones come together; help hold bones while allowing movement

• •Classified in two ways -
• 1.Material between bones
• •Fibrous
• •Cartilaginous
• •Synovial

• 2.Degree of movement
• •Immovable joints/synarthrodial (ex. skull)
• •Slightly movable joints/amphiarthrodial (ex. symphysis pubis)
• •Freely movable joints/diarthrodial
• (ex. knee, fingers) with Range of Motion

•Cartilage: semi-smooth, gel-like supporting tissue; strong and able to support weight

•Bursae: small sacs in connective tissues adjacent to selected joints (shoulders and knees); reduce friction when muscles & tendons rub against each other

•Difference more functional than structural

–Ligaments—strong, dense, flexible bands of connective tissue; hold bones to bones

–Tendons—strong, nonelastic cords of collagen at end of muscles to attach to bones

• Abduct = move away from midline (out)
• Adduct = move toward midline (in)
• Circumduction = circular
• Inversion = inward
• Eversion = outward
• Extension = straighten extremity so increase joint angle
• Flexion = bend extremity so decrease joint angle
• Rotate = turn midline & back (head & shoulders)

• •Present Health History/Chief Complaint - why patient came to see MD - how is this effecting your lifestyle?
• •Past Health History
• •Family History
• •Lifestyle & Health Practices

• •Pain or Stiffness
• •Problems with Movement / Mobility
• •Problems with Activities of Daily Living (ADL’s)
• •“OLDCARTS” to work up
• Onset of pain
• Location of pain
• Duration of pain
• Characteristics of pain (describe)
• Aggravating and alleviating factors
• Related symptoms
• Treatments (self)
• Severity on scale 0 to 10

Bone pain = deep, dull, boring or intense & not related to movement unless bone fractured then sharp pain

• Muscle pain = crampy with weakness;
• occurs with walking but relieved by rest due to peripheral vascular ischemia

Joint pain = with edema, redness/erythema & inflammation

Viral illness – myalgia/muscle aches & pain

• Low back pain = most common W.C. injury behind repetitive injuries; 1:5 or 60 –80 mil. with low back
• pain

• •Did pain occur suddenly? During day when do you feel pain?
• •Where was pain felt? First noticed? Related to movement or shoot to another part of body?
• •Describe how it feels.
• •Does pain move one joint to another? Any injury, overuse, or strain of muscles/joints?
• •What makes pain worse? Change with weather? What was done to relieve the pain? How effective was that?
• •Severity on scale of 0 to 10

• •How long have you had problem? Joints swollen, red, or hot to touch? Movement limited?
• •Have you had a recent sore throat?
• •Muscle weakness? Which ones? How long? Does it get worse throughout day?
• •Do knees or ankles give way with pressure on them? When does that occur? What do you think makes this
• happen?
• •Joints felt as if locked and won’t move? When? How often? What relieves? What makes it worse?

• Recent sore throat & mobility problems/joint pain 10 – 14 days after think rheumatic fever
• Proximal muscle weakness = myopathy
• Distal muscle weakness = neuropathy
• Joint instability if knees/ankles give way or joints lock

• •What activities are limited by musculoskeletal disorder? To what extent are activities limited? How
• do you compensate?

• Any impaired mobility or function may cause a self-care deficit
• •For clients who have chronic disability or crippling disease
• –How has illness affected interactions with family? Has it affected relationships with friends?

ADL= activities of daily living (bathing, toileting, dressing/grooming, eating, walking, communicating)

• Chronic disability may affect self-esteem, body image, role performance or social relationships
• Preventative care – recommend bone density testing q 2 yrs. After age 65 (National Osteoporosis Foundation)

•Accidents/trauma affecting bones or joints—fractures, strains of joints, sprains, dislocations? When? Continuing problems or difficulties?

• •Congenital
• bone or joint problems?
• Describe. Altered your activities? How have you adapted?

• •Surgery
• on bones, joints, or muscles? Procedure? When occurred? Outcome?

• •Chronic
• diseases? Loss of bone density/ osteoporosis?

•Menopause?

• •Curvature of spine?
• •Osteoporosis?
• •Back problems?
• •Arthritis—rheumatoid, osteoarthritis, or gout?

•Diet high in calcium & low in purines

• •Medications?
• What/how often? Take as prescribed? Prevent loss of bone density?

• •Exercise? How often?
• •Smoke?
• •Alcohol? How much and often?
• •Occupational hazards - Do you lift, push, pull, bend, or stoop frequently part of daily routine at home/work?
• •Psychosocial problems

• 80-90% nonCaucasians with lactose intolerance as adults
• Need vit D (sunlight) to absorb calcium

Purines = meat organs, sardines, gravies, herring fish

• Medications – diuretics can cause muscle weakness (electrolyte deficiencies)
• steroids can cause osteoporosis
• statin cholesterol lowering drugs can cause muscle aches/weakness
• Calcium supplements (l000 – l500 mg per day)

• Exercise
• 3 x/wk. X 20 – 45 min.; sports safety (stretch, helmets, elbow pads)

Smoking & ETOH associated with osteoporosis

• Low back injuries cost $1 bil. Per year or $45 –
• 54 bil. in lost wages & productivity

• Psychosocial problems – pt with mobility problems or ADL with body image disturbance or
• depression due to isolation (no socialize)

Overview: cephalocaudal organization with side-to-side comparisons for examining bones, muscles, and joints

• Sequence -
• •Inspect skeletal bones, joints & muscles
• •Palpate bones, joints, & muscles
• •Observe range of motion
• •Test for muscle strength

• •Observe gait & posture
• •Inspect, bones, joints, muscles & extremities for size,
• symmetry & color
• •Palpate bones, joints, muscles & extremities for
• tenderness, edema, heat, modules or crepitus
• •Test muscle strength and range of motion against resistance
• •Test for carpal tunnel (Phalen & Tinel)
• •Special knee tests (bulge, ballottement & McMurray)

• •inspect axial skeleton/extremities—alignment, contour, symmetry, size, and gross deformities
• –Body symmetric, straight spine (normal curves), knees straight line (hips – ankles), feet flat, forward

• •Inspect muscles—size and symmetry
• –Bilateral symmetry, muscle circumference
• –Dominant side > larger than nondominant
• –Fasciculations vs. spasms

• Spine normal curves –
• cervical = concave (neck)
• thoracic = convex (shoulders)
• lumbar = concave (waist)
• Careful measurement of muscle circumference noting where measurements taken (if < 1 cm off then not significant)
• Fasciculations = localized muscle twitching of single muscle group (due to drugs or low Na+)
• Spasm = generalized involuntary muscle contractions

• •Palpate bones, joints, and muscles for tenderness, heat, edema, & tone
• –Bones nontender, joints/muscles same temp as tissue, no tenderness/edema on palpation; firm muscles

• •Observe each major joint/adjacent muscle— range of motion, tenderness on movement, joint stability, and deformity
• –Full ROM, joint stability, without tenderness, heat, edema, crepitus, deformity, contracture

• Bones,
• joints & muscles should be nontender, same temp, no
• edema, and firm muscles (not hard or soft)

• Decreased ROM with:
• Inflammation
• Arthritis
• Fluid in joint
• Contracture of muscle/ligament

• Increased ROM with:
• Tears in connective tissue
• Fractures
• Crepitus = crackling sound heard after knee surgery

• ROM:
• Flexion (bend or shorten joint angle)
• Extension (straighten or increase joint angle)
• Hyperextension
• lateral (side)
• Rotation/circumdection( circle)
• Abduction (away from body)
• Adduction (toward/across body)
• Internal rotation
• External rotation
• Supination (palm up)
• Pronation (palm down)
• Opposition (other fingers)
• dorsiflexion (toes up)
• Plantar flexion (toes down)
• Inversion (sole of foot turns medially/inward)
• Eversion = sole of foot turns laterally/outward

• •Test muscle strength and compare contralateral sides
• –Part of MS/neuro exam overlap
• –Flex muscle, then resist when force applied
• –Bilaterally symmetric with full resistance to opposition (5 out of scale of 5)

• •Observe gait—conformity, symmetry, and rhythm
• –Conformity, regular smooth rhythm, leg swing length symmetry swaying/symmetric arm swing
• •“Nudge test”—push on sternum from behind to see if falls backwards - not recommended for use on elderly

• Specific Regions - JAW
• •Palpate temporomandibular joint—movement, sounds, tenderness
• –Smooth jaw movement, without pain (audible/palpable snap ok)
• •Observe jaw—pain, limited ROM, crepitus with locking or popping indicates TMJ.
• –Protrude/retract chin without difficulty/pain
• –Open mouth (3 – 6 cm between teeth)
• –Move jaw side to side without pain (1-2 cm)

• •Palpate neck—soft & firm without pain, masses, or spasm
• •Observe neck for range of motion
• –Flex 45o Extend 55o Lateral 40o Rotate 70o
• •Test neck muscles for strength-resistance
• –Chin to chest flex forward, extend back, & head to side against resistance

• •Inspect cervical, thoracic, & lumbar spine for alignment & symmetry (concave/ convex, kyphosis, scoliosis, lordosis)
• •Observe ROM of thoracic & lumbar spine
• (75o flexion to touch toes, 30o hyper-extend, 35o lateral to sides)
• •Palpate posterior neck, spinal processes, paravertebral muscles—alignment and tenderness
• •Percuss the spinal processes—tenderness

• Inspect the shoulders/shoulder girdle—equality of height/contour
• –Structures smooth, regular, bilaterally symmetric; shoulders level rounded, firm, smooth contour, no bony prominences; equal distance from vertebrae
• •Palpate the shoulders—firmness, fullness, tenderness, and masses
• •Test the trapezius muscles for strength (shrug against resistance; also CN XI)
• •Observe the shoulders for ROM
• –180o straight extension;
• –50o back hyperextension;
• –180o shoulder abduction;
• –50o adduction;
• –90o external/internal rotation

• •Test the arms for muscle strength against resistance
• –Unable to break extension of triceps/ flexion of biceps muscles
• –Extend 180 / Flex 160 degrees

• •Palpate the elbows for tenderness, edema, and nodules
• •Observe the elbows for range of motion
• –Supination
• –Pronation

• Palpate the elbows for tenderness, edema, and nodules
• Smooth olecranon processes, without nodules, edema, discomfort; lateral epicondoyle non-tender without edema
• Observe the elbows for range of motion
• 160o flexion;
• 180o extension;
• 90o supination(palm up)
• 90 pronation (palm down)

• •Inspect joints of wrists and hands for position, contour, and number of digits (swan-neck, boutonniere, bouchard & heberden’s nodes)
• •Palpate each joint of hand and wrist for surface characteristics and tenderness
• •Observe for ROM wrists & fingers
• •Test for muscle strength
• (spread fingers & bilateral grasps against resistance)

• •Inspect hips for symmetry & equal height
• •Palpate hips (iliac crests) for stability and tenderness
• –Bilaterally symmetry with stability, no pain
• •Observe hips range-of-motion
• –90o hip flexion from straight leg raise
• –120o hip flexion with knee flexed
• –45o abduction outward, 30o adduction inward
• –30o hyperextension in prone position
• 45o external rotation (heel bent on knee – Patrick’s test
• •Test hips—muscle strength
• –Raise leg from supine position—able to overcome resistance
• –Extend leg from sitting position—able to maintain extension (quadriceps)
• –Bend knee from sitting—able to maintain flexion (hamstrings)

•Inspect knees—symmetry/ alignment (tibia & ankle)

•Palpate knees—contour, tenderness, edema (popliteal)

• •Observe knee ROM
• –130o knee flexion to buttock
• –15o knee hyperextension
• •Test leg muscles strength by flexing & extending against resistance

• Knee Effusion –
• –Bulge test – supine, extend knee & milk medial aspect upward 2-3 x then tap on lateral side of patella for fluid wave/bulging (small )
• –Ballottement test – supine, extend knee & put downward pressure on suprapatellar with thumb & fingers then with other hand push patella firmly against femur and feel for fluid wave (large)

• McMurray’s test (torn meniscus)– supine with one foot flat on table near buttocks, flex knee 90o while
• supporting with hand then with other hand on heel, rotate & extend lower leg inward/outward; + if pain, click, or locking of knee

• •Inspect/palpate ankles/feet/toes (claw or hammer toes)
• •Observe ankles/feet: range-of-motion
• •Test ankle/feet muscles strength (walk toes, heels, sides)

• –Decrease in bone mass
• –Intervertebral disks lose water shrink with decreased height
• –Lordotic or convex curve of back flattens
• –Flexion/extension of back decrease changing posture to more flexed (kyphosis & scoliosis)
• –Cartilage & ligaments calcify / less elastic so harder to exercise
• -Decrease muscle mass & strength
• -Slower range of motion & unstable gait lead to falls

• Partial or complete break in continuity of a bone (open vs. closed fractures)
• Signs & Symptoms:
• •Sharp pain due to muscle spasm
• •Deformity (cardinal sign)
• •Loss of function with shortening of tissue around bone
• •Edema / swelling
• Risk Factors for Hip Fractures

• Loss of bone density (osteopenia) and decreased bone strength
• Signs & Symptoms:
• •Silent / asymptomatic
• •Decrease in height
• •Spontaneous fractures (vertebre most common place)
• •Kyphosis / dowager’s hump

Risk Factors for Osteoporosis

• •Readiness for enhanced activity & exercise
• •Risk for trauma RT repetitive movements
• •Risk for injury RT osteoporosis & fractures
• •Impaired physical mobility RT decreased muscle strength
• •Activity intolerance RT joint pain
• •Acute/chronic pain RT joint, muscle or bone problems
• •Impaired skin integrity RT immobility
• •Disturbed body image RT skeletal deformities
• •Impaired social interaction RT immobility & depression