MUSCULOSKELTAL SYSTEM

Structure & Function

- The musculoskeletal system consists of the body’s bones, joints, and muscles.
o Support
o Movement
o Protect inner organs
o Produce RBC, hematopoiesis
o Reservoir for storage of essential minerals
- Bones
o Bone and cartilage are specialized forms of connective tissue.
- Joints
o Place of union between 2 or more joints.
o Functional units of the musculoskeletal system b/c they permit the mobility needed for ADLs
o Nonsynovial Joints
 Bones are united by fibrous tissue or cartilage and are (slightly) immovable.
o Synovial Joints
 Freely movable b/c bones are separated from each other and are enclosed in a joint cavity
 Cavity is filled with a lubricant or synovial fluid.
 Cartilage covers the surface of opposing bones.
 Avascular, receives nourishment from synovial fluid
 Very stable connective tissue with low cell turnover
 Tough, firm consistency, yet is flexible
o Joint is surrounded by fibrous capsule and is supported by ligaments.
 Fibrous bands running directly from one bone to another that strengthen the joint and help
movement in undesirable directions.
o Bursa – enclosed sac filled with viscous synovial fluid much like a joint; located in areas of friction
- Muscles
o 40-50% of body’s weight
o Contraction produce movement
o 3 types: skeletal, smooth, cardiac
o Each skeletal muscle is composed of muscle fibers (fasciculi) and is attached to bone by a tendon.
o Movements:
 Flexion  Pronation  Rotation
 Extension  Supination  Protraction
 Abduction  Circumduction  Retraction
 Adduction  Inversion  Elevation
 Eversion  Depression
- Temporomandibular Joint
o Articulation of the mandible and temporal bone.
o Motions:
 Hinge to open/close jaw
 Gliding for protusion/retraction
 Gliding for side to side movement of lower jaw
- Spine
o 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 3-4 coccygeal vertebrae
o The spinous processes of C7 and T1 are prominent at the base of the neck.
o The inferior angle of the scapula normally is at the level of the interspace between T7 and T8.
o An imaginary line connecting the highest point on each iliac crest crosses L4.
o An imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines
crosses the sacrum.
o The vertebral column has 4 curves (double S shape).
 o The intervertebral disks are elastic fibrocartilaginous plates that constitute 1/4 of the column.
o Each disk center has a nucleus pulposus, made of soft, semifluid, mucoid material that has the
consistency of toothpaste in the young adult.
o Motions: flexion, extension, abduction, rotation.
- Shoulder
o The glenohumeral joint is the articulation of the humerus with the glenoid fossa of the scapula.
o Motion: ball and socket joint allows many axes
o Four powerful muscles and tendons support and stabilize it as the rotator cuff of the shoulder.
o The large subacromial bursa helps during abduction of the arm.
o The scapula and the clavicle connect to form the shoulder girdle.
o You can feel the bump of the scapula’s acromion process at the very top of the shoulder.
- Elbow
o The elbow joint contains the 3 bony articulations of the humerus, radius, and ulna of the forearm.
o The olecranon bursa lies between the olecranon process and the skin.
o Motions: flexion, extension
o Palpable landmarks: medial & lateral epicondyles of humerus, large olecranon process of ulna
- Wrist and Carpals
o Over half of the body’s 206 bones are in the hands and feet.
o The wrist (radiocarpal joint) is the articulation of the radius and a row of carpal bones.
 Motions: flexion, extension, side to side deviation
o The midcarpal joint is the articulation between the two parallel rows of carpal bones.
 Motions: flexion, extension, some rotation
o Metacarpophalangeal and interphalangeal joints
 Motions: flexion, extension
- Hip
o The hip joint is the articulation between the acetabulum and the head of the femur.
o Motion: ball and socket joint allows many axes
o More stability for its weight-bearing function due to muscles that spread over the joint, strong fibrous
articular capsule, and the very deep insertion of the head of the femur.
o Three bursae facilitate movement.
o Palpation: anterior superior iliac spine, ischial tuberosity, greater trochanter
- Knee
o The knee joint is the articulation of 3 joints – femur, tibia, patella.
o Largest joint in the body
o Hinge joint
 Motion: flexion, extension of the lower leg on a single plane
o Knee’s synovial membrane is the largest in the body.
o The knee’s synovial membrane forms a sac at the superior border of patella, called suprapatellar pouch.
o Medial & lateral menisci cartilages cushion the tibia and femur.
o The joint is stabilized by cruciate & collateral ligaments.
o Numerous bursae prevent friction (prepatellar bursa, infrapatellar fat pad).
o Landmarks:
 quadriceps muscle  tendon 
 tibial tuberosity – bony prominence in midline
 lateral, medial condyles of tibia
 medial, lateral epicondyles of femur
- Ankle and Foot
o The ankle (tibiotalar joint) is the articulation of the tibia, fibula, and talus.
o Hinge joint
 Motion: flexion (dorsiflexion), extension (plantar flexion)
 Subtalar joint – inversion, eversion
o Landmarks: medial malleolus, lateral malleolus
 o Strong, tight medial & lateral ligaments extend from each malleolus onto the foot for lateral stability of
the ankle joint.

Aging Adult
- Loss of bone matrix (resorption) occurs more rapidly than new bone growth (deposition).
- Osteoporosis – Loss of bone density; affects females more than males, whites more than blacks
- Postural changes evident with decreased height
o Long bones don’t shorten with age
o Decreased height is due to shortening of the vertebral column and height of individual vertebrae
- Kyphosis, backward head tilt, slight flexion of hips and knees
- Men & women gain weight in their 40s and 50s
- Begin to lose fat in the face and deposit it in abdomen  bony prominences more marked
- Absolute loss in muscle mass
- Changes are all hastened by a sedentary lifestyle

Cross Cultural Care

- Long bones of blacks are significantly longer, narrower, and denser than those of whites.

Subjective Data
- Joints
o Joint pain and loss of function are the most common musculoskeletal concerns.
o Rheumatoid arthritis:
 Involves symmetric joints.
 Worse in the morning when arising
 Movement decreases pain
o Osteoarthritis is worse later in the day; movement increases pain.
o Tendinitis is worse in the morning, improves during the day.
o Joint pain 10-14 days after an untreated strep throat suggests rheumatic fever.
o Decreased ROM may be due to joint injury to cartilage or capsule, or to muscle contracture.
- Muscles
o Myalgia is usually felt as cramping or aching. Often included in viral illness.
o Pain with walking and going away with rest suggests intermittent claudication.
o Weakness may involve musculoskeletal or neurologic systems.
- Bones
o Fracture causes sharp pain that increases with movement.
o Other bone pain usually feels dull and deep and is unrelated to movement.
- Functional Assessment
o Screens for safety of independent living, the need for home health services, and quality of life.
- Self-care behaviors
o Assess for self-esteem disturbance, loss of independence, body image disturbance, role performance
disturbance, social isolation.

Objective Data
Preparation:
- The purpose of the musculoskeletal examination is to assess function for ADL and to screen for any
abnormalities.
- A screening musculoskeletal examination suffices for most people:
o Inspection and palpation of joints integrated with each body region.
o Observation of ROM as person proceeds through motions.
o Age-specific screening measures.
- A complete musculoskeletal examination is appropriate for persons with articular disease, a history of
musculoskeletal symptoms, or any problems with ADLs.
- Take an orderly approach.
- Support each joint at rest.
- Compare corresponding paired joints.

Order of the Examination:

- Inspection
o Size and contour
o Swelling may be excess joint fluid (effusion), thickening of the synovial lining, inflammation of
surrounding soft tissue (bursae, tendons) or bony enlargement.
o Deformities include dislocation, subluxation (partial dislocation of a joint), contracture (shortening of a
muscle leading to limited ROM of joint), or ankylosis (stiffness or fixation of a joint).
- Palpation
o Palpate each joint, skin for temperature, muscles, bony articulations, and area of joint capsule.
o Note any heat, tenderness, swelling, or masses.
o Joints normally are not tender to palpation.
o Palpable fluid is abnormal.
- Range of Motion
o Active ROM while stabilizing the body area proximal to that being moved.
o If you see a limitation, gently attempt passive motion.
o Use a goniometer to measure angles precisely.
o Joint motion normally causes no tenderness, pain, or crepitation.
o Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over
bone during motion.
 Crepitation is an audible and palpable crunching or grating that accompanies movement. It
occurs when the articular surfaces in the joints are roughened.
- Muscle Testing
o Test the strength of the prime mover muscle groups for each joint.
o Ask the person to flex and hold as you apply opposing force.
o Muscle strength should be equal bilaterally and should fully resist your opposing force.
o Grading
 5 – 100% Full ROM against gravity,  3 – 50% Full ROM w/ gravity
full resistance  2 – 25% Full ROM w/o gravity (passive)
 4 – 75% Full ROM against gravity,  1 – 10% Slight contraction
some resistance  0 – 0% No contraction

1. Temporomandibular Joint
a. Inspect joint area
b. Palpate
i. in front of each ear as patient opens mouth
 An audible and palpable click occurs in many healthy people as the mouth opens.
 Abnormal: crepitus & pain occur with temporomandibular joint dysfunction
ii. The contracted temporalis and masseter muscles as the patient clenches teeth
c. Motion and Expected Range
i. Open mouth maximally – vertical motion, 3-6cm
ii. Protude lower jaw and move side to side – lateral motion, 1-2cm
iii. Stick out lower jaw
d. Opposition tests the cranial nerve V (trigeminal).
2. Cervical Spine
a. Inspect the alignment of head and neck.
i. Spine should be straight and head erect.
b. Palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles.
i. They should feel firm, with no muscle spasm or tenderness.
 c. Motion and Expected Range
i. Touch chin to chest – flexion of 45 degrees
ii. Lift the chin toward ceiling – hyperextension of 55 degrees
iii. Touch each ear toward the shoulder – lateral bending of 40 degrees
iv. Turn chin toward each shoulder – 70 degrees
d. Opposition tests the cranial nerve XI (spinal).
3. Shoulders
a. Inspect and compare both shoulders posteriorly and anteriorly.
i. No redness, muscular atrophy, deformity, or swelling is present.
ii. Abnormal:
 Dislocated shoulder loses the normal rounded shape and looks flattened laterally.
 Swelling from excess fluid is best seen anteriorly.
b. Palpate both shoulders and the pyramid-shaped axilla standing in front of the patient.
i. No muscular spasm or atrophy, swelling, heat, tenderness, adenopathy, or masses.
c. Motion and Expected Range
i. With arms at sides and elbows extended, move both arms forward and up in wide vertical arcs,
then move them back – forward flexion of 180 degrees, hyperextension up to 50 degrees
ii. Rotate arms internally behind back, place back of hands as high as possible toward the scapulae
– internal rotation of 90 degrees
iii. With arms at sides and elbows extended, raise both arms in wide arcs in the coronal plane.
Touch palms together above head – abduction 180 degrees, adduction 50 degrees
iv. Touch both hands behind the head with elbows flexed and rotated posteriorly – external
rotation of 90 degrees
d. Opposition tests the cranial nerve XI (spinal).
4. Elbow
a. Inspect the size and contour of the elbow in both flexed and extended positions.
i. Subluxation of the elbow shows the forearm dislocated posteriorly.
b. Palpate with the elbow flexed at 70 degrees and as relaxed as possible.
i. Extensor surface of the elbow.
 Abnormal: Epicondyles, head of radius, and tendons are common sites of inflammation
and local tenderness. It is commonly called “tennis elbow”.
ii. Either side of the olecranon process using varying pressure.
 Tissues and fat pads feel fairly solid.
 Abnormal:
a. Effusion or synovial thickening shows first as a bulge or fullness in groove on
either side of the olecranon process, and it occurs with gouty arthritis.
b. Subcutaneous nodules are raised, firm, and nontender, and overlying skin
moves freely.
iii. Olecranon bursa for heat, swelling, tenderness, consistency, or nodules.
c. Motion and Expected Range
i. Bend and straighten the elbow – flexion of 150-160 degrees, extension at 0 degrees
ii. Movement of 90 degrees in pronation & supination – touch front & back sides of hand to table
d. Opposition tests the muscle strength.
5. Wrist and Hand
a. Inspect the hands and wrists on the dorsal and palmar sides, noting position, contour, and shape.
i. Normal functional position of the hand shows the wrist in slight extension.
ii. Thenar eminence – rounded mount of muscle on hand
iii. Abnormal:
1. Subluxation of wrist
2. Ulnar deviation
3. Ankylosis – wrist in extreme flexion
4. Dupuytren’s contracture – flexion contracture of fingers
5. Swan-neck or boutonniere deformity in fingers.
 6. Atrophy of thenar eminence.
b. Palpate each joint in the wrist and hands.
i. The joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness.
ii. Abnormal: Heberden’s and Bouchard’s nodules – hard & nontender, occurs with osteoarthritis
c. Motion and Expected Range
i. Bend hand at the wrist – hyperextension of 70 degrees
ii. Bend hand down at the wrist – palmar flexion of 90 degrees
iii. Bend the fingers up and down at the metacarpophalangeal joints – flexion of 90 degrees,
hyperextension of 30 degrees
iv. With palms flat on table, turn them outward and in – ulnar deviation of 50-60 degrees, radial
deviation of 20 degrees
v. Spread fingers apart, make a fist – abduction of 20 degrees, fist tight
vi. Touch the thumb to each finger and to the base of little finger – equal bilateral response
d. Opposition tests the muscle strength.
e. Phalen’s Test – Ask the person to hold both hands back to back while flexing the wrists 90 degrees.
Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.
i. (+) Numbness and burning in a person with carpal tunnel syndrome.
f. Tinel’s Sign – direct percussion of the location of the median nerve at the wrist produces no symptoms
i. (+) Burning and tingling along distribution with carpal tunnel syndrome.
6. Hip
a. Inspect the hip joint together with the spine later. Note symmetric levels of iliac crests, gluteal folds, and
equally sized buttocks.
i. A smooth, even gait reflects equal leg lengths and functional hip motion.
b. Palpate the hip joints.
i. The joints should feel stable and symmetric, with no tenderness or crepitance.
c. Motion and Expected Range
i. Raise each leg with knee extended – hip flexion of 90 degrees
ii. Bend each knee up to the chest while keeping the other leg straight – hip flexion of 120 degrees
 (+) Thomas Test – if flexion reveals a flexion deformity in the opposite hip
iii. Flex knee and hip to 90 degrees. Swing the foot outward/inward – internal rotation of 40
degrees, external rotation of 45 degrees
 Abnormal: Limited internal rotation of hip is an early and reliable sign of hip disease.
iv. Swing leg laterally/medially with knee straight – abduction of 40-45 deg, adduction of 20-30 deg
 Abnormal: Limitation of abduction is most common motion dysfunction in hip disease.
v. When standing, swing straight leg back behind body – hyperextension of 15 degrees
7. Knee
a. Inspect lower leg alignment, knee’s shape and contour, quadriceps muscle for atrophy.
i. The lower leg should extend in the same axis as the thigh.
ii. Distinct concavities, or hollows, are present on either side of the patella.
iii. Abnormal:
 Angulation deformity:
a. Genu varum (bowledgs)
b. Genu valgum (knock knees)
c. Flexion contracture
 Atrophy of the quadriceps muscle occurs with disuse or chronic disorders.
b. Palpate by starting high on the anterior thigh above the patella. Note consistency of the tissues.
i. Muscles and soft tissues should feel solid. The joint should feel smooth, with no warmth,
tenderness, thickening, or nodularity.
ii. To distinguish whether swelling is due to soft tissue swelling or increased fluid in joint:
 Bulge Sign – Occurs with very small amounts of effusion. Firmly stroke up on the medial
aspect of the knee to displace any fluid. Tap on the lateral aspect. Watch the medial side
in the hollow for a distinct bulge from a fluid wave.
  Ballottement of the Patella - Reliable when larger amounts of fluid are present.
Compress the suprapatellar pouch to move any fluid into the knee joint. Push the
patella sharply against the femur.
a. (+) The tap on the patella moves it through the fluid, and you will hear a tap as
the patella bumps up on the femoral condyles.
iii. Abnormal:
 Irregular bony margins occur with osteoarthritis.
 Pronounced crepitus is significant and occurs with degenerative diseases of knee.
c. Motion and Expected Range
i. Bend each knee – flexion of 130-150 degrees
ii. Extend each knee – can be 0- 15 degrees hyperextension
iii. Check knee ROM during ambulation
 Sudden locking, or sudden bluckling occurs with ligament injury.
d. Opposition tests muscle strength.
e. McMurray’s Test – test for meniscal tears
i. Perform this test when the patient has reported a history of trauma followed by locking, giving
way, or local pain in the knee.
ii. With the patient supine, hold the heel and flex the affected knee & hip. Externally rotate the leg
and push an inward stress on the knee. Slowly extend the knee.
iii. Normally the leg extends smoothly with no pain.
iv. (+) A “click” is positive for torn meniscus.
8. Ankle and Foot
a. Inspect both feet, nothing position of feet & toes, contour of joints, and skin characteristics.
i. The feet should align with the long axis of the lower leg.
ii. The toes point straight forward and lie flat.
iii. The ankles are smooth bony prominences.
iv. Skin is smooth with even coloring and no lesions.
v. Abnormal:
 Hallux valgus.
 Hammertoes. Claw toes.
 Calluses reveal areas of abnormal friction.
b. Palpate the joints.
i. No fullness, swelling, tenderness.
c. Motion and Expected Range
i. Point toes toward the floor – plantar flexion of 45 degrees
ii. Point toes toward the nose – dorsiflexion of 20 degrees
iii. Turn soles of feet in and out – eversion of 20 degrees, inversion of 30 degrees
iv. Flex and straighten toes
d. Opposition tests muscle strength.
9. Spine
a. Inspect
i. Note whether the spine is straight by following an imaginary vertical line from the head through
the spinous processes and down through the gluteal cleft, and by noting equal horizontal
positions for the shoulders, scapulae, iliac crests, and gluteal folds, and equal spaces between
arm and lateral thorax on the two sides.
 The knees and feet should be aligned with the trunk and should be pointing forward.
 Note the normal convex thoracic curve and concave lumbar curve.
 Abnormal:
a. A difference in shoulder elevation and in level of scapulae and iliac crests occur
with scoliosis.
b. Kyphosis – enhanced thoracic curev in aging people
c. Lordosis – pronounced lumbar curve in obese people
d. Lateral tilting and forward bending occur with a herniated nucleus pulposus.
 b. Palpate the spinous processes, paravertebral muscles.
c. Motion and Expected Range
i. Bend forward and touch the toes – flexion of 75-90 degrees, single convex C-shaped curve
ii. Bend sideways – lateral bending of 35 degrees
iii. Bend backwards – hyperextension of 30 degrees
iv. Twist shoulder to sides – rotation of 30 degrees, bilaterally
d. Straight Leg Raising / LaSegue’s Test
i. Reproduce back and leg pain and help confirm the presence of a herniated nucleus pulposus.
ii. Raise the affected leg just short of the point where it produces pain, then dorsiflex the foot.
iii. (+) if it produces sciatic pain; confirms presence of herniated nucleus pulposus.
e. Leg Length Discrepancy
i. For true leg length, measure between fixed points, from the anterior iliac spine to the medial
malleolus, crossing the medial side of the knee.
ii. Should be equal or within 1cm.
iii. For apparent leg length, measure from a nonfixed point (umbilicus) to a fixed point (medial
malleolus) on each leg.
iv. Abnormal: If true leg lengths are equal but apparent leg lengths are unequal, it occurs with
pelvic obliquity or adduction/flexion deformity in the hip.

Aging Adult:
- For those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform a functional
assessment for ADLs.
- Walk – shuffling pattern; swaying; arms out to help balance; broader base of support; person may watch feet
- Climb up stairs – holds handrail; haul body up; may lead with favored leg
- Walk down stairs – holds handrail with both hands; descending sideways; lowering the weaker leg first
- Pick up object from floor – bends at waist instead of bending knees; holds furniture to support
- Rise up from sitting in chair – uses arms to push off chair arms; upper trunk leans forward before body
straightens; feet planted wide in broad base of support
- Rise up from lying in bed – may roll to one side; push with arms to lift torso; grab bedside table

Abnormal Findings
- Multiple Joints o Prepatellar bursitis
o Inflammatory Conditions o Swelling of menisci
 Rheumatoid Arthritis o Osgood-Schlatter disease
 Ankylosing spondylitis o Chondromalacia patellae
o Degenerative Conditions
 Osteoarthritis - Wrist and Hand
 Osteoporosis o Ganglion cyst
- Shoulder o Colles’ fracture
o Atrophy o Carpal tunnel syndrome
o Dislocated shoulder o Ankylosis
o Joint effusion o Dupuytren’s contracture
o Tear of the rotator cuff o Swan-neck & boutonniere deformities
o Frozen shoulder / adhesive capsulitis o Ulnar deviation or drift
o Subacromial bursitis o Osteoarthritis
- Elbow o Acute RA
o Olecranon bursitis o Syndactyly
o Gouty arthritis o Polydactyly
o Subcutaneous nodules - Ankle and Foot
o Epicondylitis / tennis elbow o Achilles tenosynovitis
- Knee o Chronic/acute gout
o Mild synovitis o Hallux vagus w/ bunion & hammer toes
o Callus - Spine
o Plantar wart o Scoliosis
o Ingrown toenail o Herniated nucleus pulposus