Musculoskeletal holistic

Grading muscle strength (% normal)

5/5: Active motion against full resistance (100%) Normal 4/5: Active motion against some resistance (75%) Slight Weakness (Good) 3/5: Active motion against gravity (50%) Average Weakness (Fair) 2/5: Passive ROM (25%) Poor ROM (Poor) 1/5: Slight flicker of contraction (10%) Severe Weakness (Trace) 0/5: No muscular contraction (0%) Paralysis (Zero)

Knee and lower leg

Hinge joint is point of articulation between femur, tibia, patella Movements include flexion, extension, and sometimes hyperextension

ball and socket joint

allow complete rotation to move in all directions; hips and shoulders

condyloid joint

allows movement in two directions: flexion and extension, abduction and adduction

gliding joint

allows one bone to slide over another; found in wrist and ankles

Shoulder range of motion

ball-and-socket flexion: raise arm from side to side position forward to position above head extension: return arm to position at side of the body hyperextension: move arm behind body, keeping elbow straight abduction: raise arm side to side to position above head with palm away from head adduction: lower arm sideways and across body as far as possible internal rotation: with elbow flexed, rotate shoulder by moving arm until thumb is inward and toward back external rotation: with elbow flexed, move arm until thumb is up and lateral to the head circumduction: move arm in a full circle

Hip range of motion

ball-and-socket joint flexion: move leg forward and up extension: move leg back beside other leg hyperextension: move leg behind body abduction: move leg laterally away from body adduction: move leg back toward medial position and beyond if possible internal rotation: turn knee toward the inside external rotation: turn knee toward the outside circumduction: move leg in a circle

Flexion

bending a limb at a joint

plantar flexion

bending of the sole of the foot by curling the toes toward the ground

Acromioclavicular joint:

between acromion process and clavicle

Sternoclavicular joint:

between sternal manubrium and clavicle

Wrist range of motion

condyloid flexion: move palm toward inner aspect of forearm extension: move fingers so fingers, hands, and forearms are in the same place hyperextension: bring dorsal surface to hand as far back as possible radial extension: bend wrist medially toward thumb ulnar extension: bend wrist laterally toward fifth finger; referred to as radial/ulnar deviation

toe range of motion

condyloid joint flexion: bend toes extension: straighten toes adduction: bring toes together abduction: spread toes apart

fingers range of motion

condyloid joint flexion: make fist extension: straighten fingers hyperextension: bend wrist as far back as possible abduction: spread fingers apart adduction: bring fingers together

Depression

lowering a body part.

Extension

straightening a limb at a joint

Collecting Subjective Data: Past Medical History

- Accidents or trauma affecting bones or joints including fractures, strains of joints, sprains, dislocations? When? Continuing problems or difficulties? - Congenital bone or joint problems? Describe. Altered your activities? How have you adapted? - Have you had surgery on bones, joints, or muscles? Procedure? When did it occur? What was the outcome?

Collecting Subjective Data: Present health status

- Any chronic diseases? Loss of bone density/osteoporosis? - Take medications? What/how often? Take as prescribed? Prevent loss of bone density? - Changes in ability to move/participate in usual activities? Changes in muscle strength? How do you adapt to changes? - Exercise? How often? Smoke? Alcohol? How much and often? - Sports? Which and how often? Protect yourself from injury while exercising or playing sports? - Do you lift, push, pull, bend, or stoop frequently as part of daily routine at home or work? How do you protect yourself from muscle strain/injury?

Problems with daily activities

- Are activities (ADLs) limited by musculoskeletal disorder? To what extent are activities limited? How do you compensate? - Note that 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?

Names of joints in hand describe location

- Distal interphalangeal (DIP) joint is distal joint of fingers - Proximal interphalangeal (PIP) joint is middle joint of each finger - Metacarpophalangeal (MCP) joint attaches metacarpal to carpal joint

Problems with Movement

- How long have you had movement problem? Are 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? When? What do you think makes it happen? - Joints felt as it locked and won't move? When? How often? What relieves the pain? What makes it worse?

collecting subjective data: family history

- In your family, is there history of curvature of spine or back problems? Describe. - In your family, is there history of arthritis- rheumatoid arthritis, osteoarthritis, or gout?

Anatomy and Physiology

- Musculoskeletal system provides support and mobility for body and is protection for internal organs - Consists of bones, muscles, and joints Produces blood cells and stores minerals such as calcium and phosphorus

Problem-based history: Pain

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

Age-Related Variations: Older Adults

-Assessing musculoskeletal system of older adults usually follows same procedures as that for younger adults -Older adults may be slower at performing range-of-motion, and muscle strength may be less than a younger adult

Aging adult

-Bone remodeling is cyclic process of resorption and deposition; after age 40 resorption occurs more rapidly than deposition -- Net effect is loss of bone density, or osteoporosis -Postural changes are evident with aging, and decreased height is most noticeable -- Shortening of vertebral column caused by loss of water content and thinning of intervertebral disks -- Decreases in height of individual vertebrae, which occurs in later years from osteoporosis -Other postural changes are kyphosis, backwards head tilt to compensate for kyphosis, and slight flexion of hips and knees -Distribution of subcutaneous fat changes through life: contour different, even if weight is same as when younger -- Begin to lose fat and deposit it in abdomen and hips -In 80s and 90s, fat further decreases in periphery, especially noticeable in forearms and apparent over abdomen and hips -Loss of subcutaneous fat leaves bony prominences more marked -Absolute loss in muscle mass occurs; some decrease in size, and some atrophy, producing weakness -Contour of muscles becomes more prominent, and muscles and tendons feel more distinct -Lifestyle affects musculoskeletal changes -- Sedentary lifestyle hastens musculoskeletal changes of aging -- Physical exercise increases skeletal mass and helps prevent or delay osteoporosis -- Physical activity delays or prevents bone loss in postmenopausal and older women

Anatomy and Physiology: Elbow and Wrist

-Elbow joint consists of humerus, radius, and ulna forming a hinge joint -- Permits extension, flexion, and sometimes hyperextension, pronation, and supination of forearm provided also -Wrist joins radius and carpal bones with discs of wrist ligaments, and fibrous capsule forming a condyloid joint -- Permits flexion, extension, hyperextension, and radial and ulnar flexion/deviation

Age Related Variations: Infants, Children, and Adolescents

-Infants' movement is assessed during voluntary movement, and hip joints and feet are assessed for abnormalities -Children's motor development compared with standardized tables for age and sequences -Musculoskeletal assessment of older child and adolescent follows same procedures as adults and reveals similar expected findings

Ankle & Foot Assessment

-Inspect ankles and feet for contour, alignment, number of toes -Palpate ankles and feet for contour, edema, and tenderness -- Ankles should be smooth without deformity -- Feet should be straight, aligned with long axis of lower leg -- Five toes -- Structures should be smooth, non-edematous, non-tender -Observe ankles and feet for range of motion -- 20 degrees dorsiflexion, 45 degrees plantar flexion from midline -- 20 degrees eversion, 30 degrees inversion from midline -- Equal bilateral flexion and extension of toes

General Inspection of Musculoskeletal System

-Inspect axial skeleton and extremities for alignment, contour, symmetry, size, and gross deformities - Body symmetric, even contour of shoulders, level scapulae and iliac crests, straight spine with normal curves (cervical=concave, thoracic=convex, lumbar=concave), knees straight line (hips and ankles), feet flat, forward -Inspect muscles for size and symmetry - Muscle size should appear symmetric bilaterally; dominant side may be slightly larger - Muscle size may be measured

Hip Assessment

-Inspect hips for symmetry and palpate hips for stability and tenderness -Observe hips for range of motion -- 120 degrees flexion from straight extended position (knee bent) -- 90 degrees hip flexion from straight extended position -- 45 degrees external hip rotation from straight midline position -- 40 degrees internal hip rotation from straight midline position -- 45 degrees abduction, 30 degrees adduction -- 30 degrees hyperextension (assess client in prone position or standing) -- And circumduction (all moves included)

Hand and Wrist Assessment

-Inspect joints of wrists and hands for position, contour, and number of digits. -- Should be smooth, firm, and symmetric with 5 digits on each -Palpate each joint of hand and wrist for surface characteristics and tenderness. -- Should be smooth, without nodules, edema, or tenderness -Test for muscle strength of wrists and fingers. -- Ask client to extend and spread fingers while you attempt to push together; have client grip your first two fingers of each hand -- Normal finding: Able to overcome resistance; bilaterally equal grip strength -Observe for range of motion of wrists and fingers. -- Symmetrical flexion/extension -- 70 degrees hyperextension (wrist) 90 degrees palmar flexion (wrist), 90 degrees metacarpophalangeal joint flexion, 30 degrees hyperextension, 50-60 degrees ulnar deviation, 20 degrees radial deviation, finger abduction, adduction, finger flexion/extension, thumb flexion/extension & opposition

Knee Assessment

-Inspect knees for symmetry and alignment -- Knees lined with tibia; ankle without medial or lateral deviation -Palpate knees for contour, tenderness, and edema -- Suprapatellar pouch should be smooth, non-tender, non-edematous -- Medial and lateral aspects of the tibiofemoral joint space should be non-edematous, non-tender -- Popliteal space should be smooth, non-tender -Observe knees for range of motion -- 130 degrees flexion from straight extended position -- 15 degrees if able to hyperextend from midline

spine assessment

-Inspect shoulders -- Vertebrae aligned in straight line, shoulders level -- Cervical concave, thoracic convex, lumbar concave -Observe range of motion for thoracic and lumbar spine -- Ask client to touch toes, lean back, bend laterally right and left, rotate trunk right and left (you may need to stabilize hips) -- 75 degrees of flexion while touching toes, 30 degrees back from neutral with hyperextension, 35 degrees lateral flexion, 30 degrees rotation in both directions

Shoulder assessment

-Inspect shoulders and shoulder girdle for equality of height and contour -- Structures smooth, regular, bilaterally symmetric; shoulders level, rounded, firm, smooth contour, no bony prominences -- Each shoulder equidistant from vertebral columns -Palpate the shoulders for firmness, fullness, tenderness, and masses -- Non-tender, smooth, firm, full without masses, bilaterally symmetric; larger on dominant side -Observe shoulders for range of motion -- 180 degrees straight extension/flexion. 50 degrees back hyperextension. 180 degrees shoulder abduction. 50 degrees adduction. 90 degrees external/internal rotation and (cicumduction-all movements combined)

Gait & Face/Neck Assessment

-Observe gait for conformity, symmetry, and rhythm -- Conformity (arms and legs in opposite alignment), regular smooth rhythm, leg swing, length symmetry, smooth swaying/symmetric arm swing -Inspect face and neck musculature for symmetry -Palpate the temporomandibular joint for movement, sounds, and tenderness -Observe jaw for range of motion -Observe neck for range of motion (ROM) -- Ask the client to flex chin, hyperextend head, laterally bend right and left, rotate from midline in each direction (flexion, hyperextension, lateral flexion, rotation)

Elbow Assessment

-Palpate elbows for tenderness, edema, and nodules. -Observe the elbows for range of motion. -- Ask the client to flex and extend the elbow (flexion & extension) -- Assess pronation and supination by having the client rotate palms up and down (pronate and supinate) -- Should achieve 90 degrees in each direction -- Movements should be bilaterally equal without discomfort

Skeletal muscles produce the following movements:

1. *Flexion*- bending a limb at a joint. 2. *Extension*- straightening a limb at a joint. 3. *Abduction*- moving a limb away from midline. 4. *Adduction*- moving a limb toward midline. 5. *Pronation*- turning the forearm so the palm is down. 6. *Supination*- turning the forearm so the palm is up. 7. *Circumduction*- moving the arm in a circle around the shoulder. 8. *Inversion*- moving the sole of the foot inward at the ankle. 9. *Eversion*- moving the sole of the foot outward at the ankle. 10. *Rotation*- moving the head around a central axis. 11. *Protraction*- moving a body part forward and parallel to the ground. 12. *Retraction*- moving a body part backward and parallel to the ground. 13. *Elevation*- raising a body part. 14. *Depression*- lowering a body part.

Hip and thigh

Acetabulum and femur form hip joint Ball-and-socket joint: flexion, extension, hyperextension, abduction/adduction, internal/external rotation, and circumduction

5/5 strength

Active motion against full resistance (100%) Normal

3/5 strength

Active motion against gravity (50%) Average Weakness (Fair)

4/5 strength

Active motion against some resistance (75%) Slight Weakness (Good)

Functional assessment

An evaluation of the person's ability to carry out basic self-care activities of daily living (ADLs) - bathing - dressing - feeding - toiliting - transfer ability - continence

Ankle

Hinge joint: flexion (dorsiflexion) and extension in one plane (plantar flexion) Smaller joints within permit pivot or rotation movement, producing inversion and eversion

Foot

Interphalangeal joint is between distal phalanx and proximal phalanx Metatarsophalangeal joint is between proximal phalanx and first metatarsal Tarsometatarsal joint attaches first metatarsal to tarsal Has gliding joint allowing inversion and eversion of foot Toes are condyloid joints allowing flexion and extension, as well as abduction and adduction

hinge joint

Joint between bones (as at the elbow or knee) that permits motion in only one plane

Sample Charting: Objective

Joints and muscles symmetric; no swelling, masses, deformity; normal spinal curvature. No tenderness to palpation of joints; no heat, swelling, or masses. Full ROM; movement smooth, no crepitance, no tenderness. Muscle strength- able to maintain flexion against resistance and without tenderness

Musculoskeletal components

Muscles Temporomandibular joint Spine Shoulder Elbow Wrist and carpals Hip Knee Ankle and foot

Sample Charting: Assessment

Muscles and joints appear healthy and functional

0/5 strength

No muscular contraction (0%) Paralysis (Zero)

Collecting objective data step 2`

Observe range of motion and palpate major joints and adjacent muscles for tenderness on movement, joint stability, and deformity - Ask client to perform active ROM for each joint then move the client's joint through the full ROM passively, if indicated by history

Bouchard's nodes

Osteoarthritis (PIP swelling secondary to osteophytes)

Collecting objective data step 1

Palpate bones for tenderness; joints and muscles for tenderness, heat, edema, tone. - Bones should be non-tender, joints/muscles same temperature as tissue, no tenderness/edema on palpation; firm muscles

2/5 strength

Passive ROM (25%) Poor ROM (Poor)

Upper extremities: Shoulder

Shoulder joint is point where humerus and glenoid fossa of scapula articulate - Ball-and-socket joint permits flexion, extension, hyperextension, abduction, adduction, and internal and external rotation Two other joints contribute to shoulder movement - Acromioclavicular joint: between acromion process and clavicle - Sternoclavicular joint: between sternal manubrium and clavicle

Anatomy and Physiology: Skull and Neck

Skull - Six cranial bones and 14 facial bones Neck (Cervical Spine) - Neck supported by cervical vertebrae, ligaments, and sternocleidomastoid and trapezius muscles. - Movements permitted include flexion, extension, hyperflexion, lateral flexion, and rotation

1/5 strength

Slight flicker of contraction (10%) Severe Weakness (Trace)

Hand

Small, subtle movements or articulations within hand between carpals and metacarpals, between metacarpals and proximal phalanges, and between middle and distal phalanges - Hand (metacarpophalangeal) flexion, extension, and hyperextension - Fingers are able to flex and extend, abduct and adduct - Thumb: extension, flexion, opposition

Anatomy and Physiology: Spine

Spine composed of 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae - Cervical, thoracic, and lumbar are separated from each other by fibrocartilaginous discs, sacral vertebrae are fused - Vertebrae with discs move slightly over one another permitting flexion, hyperextension, lateral bending, and rotation, cervical joints are most active

Sample charting: Subjective

States no joint pain, stiffness, swelling, or limitation. No muscle pain or weakness. No history of bone trauma or deformity. Able to manage all usual daily activities with no physical limitations. Occupation involves no musculoskeletal risk factors. Exercise pattern is brisk walk 1 mile 5x/week.

Heberden's nodes

Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis

Assessing Upper Extremity Strength

Test arms for muscle strength - Ask client to hold arms up while you try to push them down - Ask client to extend arm while you resist by pushing arm to flexing position (triceps strength). Compare sides. - Ask client to flex arm while you try to extend his or her forearm. Compare sides.

Assessing Lower Extremity Strength

Test leg muscles for strength - Test quadriceps with client sitting, place hand in front of knee and prevent straightening. Compare sides - Test hamstrings with client sitting, have client flex knee while you attempt to straighten it. Compare sides - Should maintain flexion and extension against resistance

Collecting objective data step 3

Test muscle strength, compare sides and grade (0-5) - Expect muscle strength to be 5, bilaterally symmetric, with full resistance to opposition. Documented as 5/5 with client's value in the numerator, and expected value in the denominator.

lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition)

scoliosis

abnormal lateral curvature of the spine (S-shaped curve)

Thumb range of motion

condyloid joint flexion: move thumb across palmar surface extension: move thumb straight away from hand abduction: extend thumb laterally (usually done when placing fingers in adduction and abduction) adduction: move thumb back toward hand opposition: touch thumb to each finger of same hand

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

Spine range of motion

flexion: bend forward extension: stand straight hyperextension: bend backward lateral flexion (or abduction): bend to the side adduction: side bent to straight rotation: move away from hips

Foot Range of Motion

gliding joint inversion: turn sole of foot medially (toward body) eversion: turn sole of foot laterally (away from body)

types of joints

gliding, hinge, pivot, condyloid, saddle, ball and socket hinge

Elbow range of motion

hinge joint flexion: bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder extension: straighten elbow by lowering hand hyperextension: bend lower arm back as far as possible, not found in everyone

Knee range of motion

hinge joint flexion: bring heel toward back of thigh extension: return heel to floor

Ankle range of motion

hinge joint dorsiflexion: point your toes down plantar flexion: toes point up at 90 degree angle

dorsiflexion

movement that bends the foot upward at the ankle

Retraction

moving a body part backward and parallel to the ground

Protraction

moving a body part forward and parallel to the ground.

Abduction

moving a limb away from midline

Adduction

moving a limb toward midline

Circumduction

moving the arm in a circle around the shoulder

Rotation

moving the head around a central axis

Inversion

moving the sole of the foot inward at the ankle.

Eversion

moving the sole of the foot outward at the ankle.

cervical spine range of motion

pivot joint flexion: bring chin to rest on chest extension: return head to erect position hyperextension: bend head back as far as possible lateral flexion: tilt head as far as possible toward each shoulder rotation: tilt head as far as possible to right and left

Forearm range of motion

pivot joint supination: turn lower hand and arm so palm is up pronation: turn lower arm so palm is down

Elevation

raising a body part

pivot joint

rotating bone turns around an axis; i.e. connection between radius/ulna and humerus

Hyperextension

the extreme or overextension of a limb or body part beyond its normal limit

Pronation

turning the forearm so the palm is down

Supination

turning the forearm so the palm is up

saddle joint

type of joint found at the base of each thumb; allows grasping and rotation