Assessing Musculoskeletal System2 PDF

CHAPTER 24
Assessing Musculoskeletal
System
Case Study skeletal (voluntary) muscles, which are under conscious control
(Fig. 24-2, p. 509). Made up of long muscle fibers (fasciculi)
Frances Funstead, a 55-year-old Cauca- that are arranged together in bundles and joined by connec-
sian woman, presents to the occupational tive tissue, skeletal muscles attach to bones by way of strong,
health nurse asking for help with her back fibrous cords called tendons. Skeletal muscles assist with pos-
pain. She works on an assembly line and ture, produce body heat, and allow the body to move. Skeletal
believes her back pain may be related to muscle movements (illustrated in Box 24-1) include:
her job. • Abduction: Moving away from midline of the body
• Adduction: Moving toward midline of the body
• Circumduction: Circular motion
• Inversion: Moving inward
• Eversion: Moving outward
Structure and Function • Extension: Straightening the extremity at the joint and
increasing the angle of the joint
The body’s bones, muscles, and joints compose the musculo- • Hyperextension: Joint bends greater than 180 degrees
skeletal system. Controlled and innervated by the nervous sys- • Flexion: Bending the extremity at the joint and decreasing
tem, the musculoskeletal system’s overall purpose is to provide the angle of the joint
structure and movement for body parts. • Dorsiflexion: Toes draw upward to ankle
• Plantar flexion: Toes point away from ankle
BONES • Pronation: Turning or facing downward
Bones provide structure, give protection, serve as levers, store • Supination: Turning or facing upward
calcium, and produce blood cells. A total of 206 bones make • Protraction: Moving forward
up the axial skeleton (head and trunk) and the appendicular • Retraction: Moving backward
skeleton (extremities, shoulders, and hips; Fig. 24-1). • Rotation: Turning of a bone on its own long axis
Composed of osseous tissue, bones can be divided into • Internal rotation: Turning of a bone toward the center of
two types: compact bone, which is hard and dense and makes the body
up the shaft and outer layers; and spongy bone, which contains • External rotation: Turning of a bone away from the center
numerous spaces and makes up the ends and centers of the of the body
bones. Bone tissue is formed by active cells called osteoblasts
and broken down by cells referred to as osteoclasts. Bones con- JOINTS
tain red marrow that produces blood cells and yellow marrow
composed mostly of fat. The joint (or articulation) is the place where two or more bones
The periosteum covers the bones; it contains osteoblasts and meet. Joints provide a variety of ranges of motion (ROM) for
blood vessels that promote nourishment and formation of the body parts and may be classified as fibrous, cartilaginous,
new bone tissues. Bone shapes vary and include short bones or synovial.
(e.g., carpals), long bones (e.g., humerus, femur), flat bones Fibrous joints (e.g., sutures between skull bones) are joined
(e.g., sternum, ribs), and bones with an irregular shape (e.g., by fibrous connective tissue and are immovable. Cartilagi-
hips, vertebrae). nous joints (e.g., joints between vertebrae) are joined by carti-
lage. Synovial joints (e.g., shoulders, wrists, hips, knees, ankles;
Fig. 24-3, p. 510) contain a space between the bones that is filled
SKELETAL MUSCLES
with synovial fluid, a lubricant that promotes a sliding move-
The body consists of three types of muscles: skeletal, smooth, ment of the ends of the bones. Bones in synovial joints are joined
and cardiac. The musculoskeletal system is made up of 650 by ligaments, which are strong, dense bands of fibrous connective
507
508 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Cranium
Facial bones Clavicle
Mandible
Scapula
Humerus
Sternum
Costal
Ribs
cartilage
Radius
Vertebral
column Carpals
Ilium
(of pelvis) Ulna
Pelvis
Meta-
Sacrum carpals
Phalanges
Femur
Patella
Calcaneus
Fibula
Tibia
Tarsals
FIGURE 24-1 Major bones of the skeleton. The axial skeleton is shown in
Metatarsals Phalanges yellow; the appendicular skeleton is shown in blue.
BOX 24-1 ILLUSTRATED GLOSSARY OF SKELETAL MOVEMENT TERMS
Eversion Inversion
Circumduction
Abduction Flexion
Extension
Adduction
Rotation
Pronation
Supination
Protraction Retraction
24 • • • ASSESSING MUSCULOSKELETAL SYSTEM 509
Orbicularis Temporalis
oculi
Masseter Orbicularis
oris
Sternocleidomastoid
Trapezius
Deltoid
Pectoralis major
External
Serratus anterior oblique
Biceps brachii
Brachioradialis
Flexor carpi
Intercostals
Extensor carpi
Abdominal
aponeurosis Internal oblique
(tendon)
Rectus abdominis
Sartorius
Adductors
of thigh Quadriceps
femoris
Peroneus Gastrocnemius
longus
Tibialis
anterior Soleus
A
FIGURE 24-2 Muscles of the body: (A) anterior; (B)
posterior. (continued on following page) Anterior view
tissue. Synovial joints are enclosed by a fibrous capsule made of Only the client can give you data regarding pain, stiffness,
connective tissue and connected to the periosteum of the bone. and levels of movement and how ADLs are affected. In addi-
Articular cartilage smooths and protects the bones that articulate tion, information regarding the client’s nutrition, activities, and
with each other. exercise is a significant part of the musculoskeletal assessment.
Some synovial joints contain bursae, which are small sacs Pain or stiffness is often a chief concern with musculoskeletal
filled with synovial fluid that serve to cushion the joint. Box 24-2 problems; therefore, a pain assessment may also be needed. It is
(p. 511) reviews the appearance, characteristics, and motion of very important to remember to investigate signs and symptoms
major joints. reported by the client.
Remember, too, that the neurologic system is responsible
for coordinating the functions of the skeleton and muscles.
Nursing Assessment Therefore, it is important to understand how these sys-
tems relate to each other and to ask questions accordingly.
COLLECTING SUBJECTIVE DATA: Assessment of the musculoskeletal system will provide the
nurse with information about the client’s daily activity and
THE NURSING HEALTH HISTORY
exercise patterns that promote either healthy or unhealthy
Assessment of the musculoskeletal system helps to evaluate the functioning of the musculoskeletal system. Client teaching
client’s level of functioning with activities of daily living (ADLs). regarding exercise, diet, positioning, posture, and safety hab-
This system affects the entire body, from head to toe, and greatly its to promote health thus becomes an essential part of this
influences what physical activities a client can and cannot do. examination.
(Epicranial
aponeurosis)
Sternocleidomastoid
Teres minor Trapezius
Deltoid
Teres major
Latissimus
dorsi Triceps brachii
(Olecranon
(Lumbodorsal of ulna)
fascia)
Gluteus
Gluteus maximus medius
(Iliotibial tract)
Hamstring group:
Biceps femoris
Semitendinosus
Semimembranosus
Gastrocnemius
Peroneus longus
(Achilles tendon)
B Posterior view FIGURE 24-2 (Continued)
Articular cartilage
Synovial fluid
Femur
Ligament of the
Greater head of the femur
trochanter
of femur
Synovial membrane
Ligaments and
joint capsule
FIGURE 24-3 Components of synovial joints

(right hip joint).
BOX 24-2 UNDERSTANDING MAJOR JOINTS
TEMPOROMANDIBULAR STERNOCLAVICULAR
Articulation between the temporal bone and mandible. Junction between the manubrium of the sternum and the
Motion: clavicle; has no obvious movements.
• Opens and closes mouth.
• Projects and retracts jaw. Sternoclavicular
joint
• Moves jaw from side to side. Acromioclavicular
joint
Zygomatic arch
of temporal bone
Temporomandibular
joint Subacromial
area
Condyle
of mandible
Glenohumeral
Bicipital joint
groove
External auditory
meatus
Mastoid SHOULDER
process
Articulation of the head of the humerus in the glenoid cavity
Styloid
process of the scapula. The acromioclavicular joint includes the clavicle
and acromion process of the scapula. It contains the subacro-
ELBOW mial and subscapular bursae. Motion:
• Flexion and extension
Articulation between the ulna and radius of the lower arm
• Abduction and adduction
and the humerus of the upper arm; contains a synovial mem-
• Circumduction
brane and several bursae. Motion:
• Rotation (internal and external)
• Flexion and extension of the forearm
• Supination and pronation of the forearm Coracoclavicular
Coracoacromial ligaments Sternoclavicular
ligament joint
Humerus Coracoid
Acromion
Subacromial
bursa Clavicle
Humerus Manubrium
Synovial Supraspinatus
membrane
Lateral (distended)
epicondyle
Medial
epicondyle
Deltoid Coracobrachialis
Annular (middle Scapula
ligament portion)
Olecranon
process
Biceps
Ulna Radius
Left posterior view. Right anterior view.
Continued on following page

BOX 24-2 UNDERSTANDING MAJOR JOINTS (Continued)
WRIST, FINGERS, THUMB Distal interphalangeal

joint (DIP) Distal phalanx
Articulation between the distal radius, ulnar
bone, carpals, and metacarpals. Contains liga- Proximal interphalangeal Middle phalanx Phalanges
ments and is lined with a synovial membrane. joint (PIP)
Motion: Proximal phalanx
• Wrists: Flexion, extension, hyperextension,
adduction, radial and ulnar deviation
• Fingers: Flexion, extension, hyperextension,
abduction, and circumduction Metacarpophalangeal
Metacarpal joint (MCP)
• Thumb: Flexion, extension, and opposition
bones
Hamate Trapezoid
Pisiform Trapezium
Carpal Carpal
bones Triquetral Capitate bones
Lunate Scaphoid
Ulna Radius
VERTEBRAE (LATERAL VIEW) Right anterior view.
Thirty-three bones: 7 concave-shaped cervical (C); 12 convex-
shaped thoracic (T); 5 concave-shaped lumbar (L); 5 sacral (S);
and 3–4 coccygeal, connected in a vertical column. Bones are HIP
cushioned by elastic fibrocartilaginous plates (intervertebral Articulation between the head of the femur and the acetabulum.
discs) that provide flexibility and posture to the spine. Para- Contains a fibrous capsule. Motion:
vertebral muscles are positioned on both sides of vertebrae. • Flexion with knee flexed and with knee extended
Motion: • Extension and hyperextension
• Flexion • Circumduction
• Hyperextension • Rotation (internal and external)
• Lateral bending • Abduction
• Rotation • Adduction
Atlas Anterior superior

(1st cervical) iliac spine
Axis
Cervical
(2nd cervical)
vertebrae Hip joint
Transverse
process Articular
capsule Iliopectineal
Intervertebral Greater bursa
Thoracic disk trochanter
vertebrae of femur
Body (centrum)
of vertebra
Spinous
process
Intervertebral Trochanteric
Lumbar bursa Ischial
foramen Ischial
vertebrae tuberosity bursa
(for spinal nerve)
Sacrum
Sacral
vertebrae Right anterior view.
Coccyx
Coccygeal
vertebrae
Left lateral view.

KNEE ANKLE AND FOOT

Articulation of the femur, tibia, and patella; contains fibrocar- Articulation between the talus (large posterior foot tarsal),
tilaginous discs (medial and lateral menisci) and many bursae. tibia, and fibula. The talus also articulates with the navicular
Motion: bones. The heel (calcaneus bone) is connected to the tibia and
• Flexion fibula by ligaments. Motion:
• Extension • Ankle: Plantar flexion and dorsiflexion
• Foot: Inversion and eversion
• Toes: Flexion, extension, abduction, adduction
Femur
Adducter tubercle
Tibia
Lateral epicondyle Tibiotalar

Medial epicondyle Transverse joint
Achilles
tarsal joint tendon
Lateral
Medial Patella meniscus
meniscus Metatarsophalangeal Talus
Lateral joint
Subtalar joint
Medial collateral collateral
ligament ligament
Calcaneus
Medial condyle Lateral condyle
of tibia Distal Longitudinal
of tibia phalanx First
Proximal arch
Head of fibula phalanx metatarsal
Patellar
tendon Right lateral view.
Tibial
tuberosity
Tibia
Fibula
Left anterior view.
History of Present Health Concern

QUESTION RATIONALE
Have you had any recent weight gain? Weight gain can increase physical stress and strain on the musculo-
skeletal system.
Describe any difficulty that you have chewing. Is it associated with Clients with temporomandibular joint (TMJ) dysfunction may have
tenderness or pain? difficulty chewing and may describe their jaws as “getting locked or
stuck.” Jaw tenderness, pain, or a clicking sound may also be present
with TMJ.
Describe any joint, muscle, or bone pain you have. Where is the pain? Bone pain is often dull, deep, and throbbing. Joint or muscle
What does the pain feel like (stab, ache)? When did the pain start? pain is described as aching, but has been differentiated between
When does it occur? How long does it last? Any stiffness, swelling, mechanical- and inflammatory-type pains (Chan & Chan, 2011).
limitation of movement? Sharp, knife-like pain occurs with most fractures and increases
with motion of the affected body part. Motion increases pain as-
sociated with many joint problems but decreases pain associated
with rheumatoid arthritis (Rheumatoid arthritis vs osteoarthritis,
2012).
Fibromyalgia, manifested by chronic pain and fatigue, affects
about 5 million Americans. Diagnosis is made based on a person’s
symptoms as no there are no objective findings on X-rays or lab
tests. Persistent pain and fatigue interferes with the client’s ADLs
(Davis, 2007).
Personal Health History

QUESTION RATIONALE
Describe any past problems or injuries you have had to your joints, This information provides baseline data for the physical examination.
muscles, or bones. What treatment was given? Do you have any Past injuries may affect the client’s current ROM and level of function
aftereffects from the injury or problem? in affected joints and extremities. A history of recurrent fractures
should raise the question of possible physical abuse.
OLDER ADULT CONSIDERATIONS
Bones lose their density with age, putting the older
client at risk for bone fractures, especially of the wrists, hips,
and vertebrae. Older clients who have osteomalacia or osteo-
porosis are at an even greater risk for fractures.
When were your last tetanus and polio immunizations? Joint stiffening and other musculoskeletal symptoms may be a
transient effect of the tetanus, whooping cough, diphtheria, or polio
vaccines (Department of Health, Victoria, Australia, 2011).
Joint-stiffening conditions may be misdiagnosed as
arthritis, especially in the older adult.
Have you ever been diagnosed with diabetes mellitus, sickle cell Having diabetes mellitus, sickle cell anemia, or SLE places the
anemia, systemic lupus erythematosus (SLE), or osteoporosis? client at risk for development of musculoskeletal problems such as
osteoporosis and osteomyelitis. Clients who are immobile or have
a reduced intake of calcium and vitamin D are especially prone to
development of osteoporosis.
Osteoporosis is more common as a person ages because
that is when bone resorption increases, calcium absorption
decreases, and production of osteoblasts decreases as well.
For middle-aged women: Have you started menopause? Are you Women who begin menarche late or begin menopause early are at
receiving estrogen replacement therapy? greater risk for development of osteoporosis because of decreased
estrogen levels, which tend to decrease the density of bone mass
(Li & Zhu, 2005).
Family History
QUESTION RATIONALE
Do you have a family history of rheumatoid arthritis, gout, or osteo- These conditions tend to be familial and can increase the client’s risk
porosis? for development of these diseases.
Lifestyle and Health Practices

QUESTION RATIONALE
What activities do you engage in to promote the health of your This question provides the examiner with knowledge of how much the
muscles and bones (e.g., exercise, diet, weight reduction)? client understands and actively participates in trying to promote the
health of the musculoskeletal system.
What medications are you taking? Some medications can affect musculoskeletal function. Diuretics, for
example, can alter electrolyte levels, leading to muscle weakness.
Steroids can deplete bone mass, thereby contributing to osteopo-
rosis. Adverse reactions to HMG-CoA reductase inhibitors (statins)
can include myopathy, which can cause muscle aches or weakness
(DiVita, 2010).
Do you smoke tobacco? How much and how often? Smoking increases the risk of osteoporosis (see Evidence-Based
Practice 24-1, p. 517).
Do you drink alcohol or caffeinated beverages? How much and how Excessive consumption of alcohol or caffeine can increase the risk of
often? osteoporosis.
QUESTION RATIONALE
Describe your typical 24-hour diet. Are you able to consume milk or Adequate protein in the diet promotes muscle tone and bone growth;
milk-containing products? Do you take any calcium supplements? vitamin C promotes healing of tissues and bones. A calcium defi-
ciency increases the risk of osteoporosis. A diet high in purine (e.g.,
liver, sardines) can trigger gouty arthritis.
CULTURAL CONSIDERATIONS
Lactose intolerance (a deficiency of the lactase enzyme)
affects up to 15% of northern Europeans, up to 80% of African
Americans and Latinos, and up to 100% of Native Americans
and Asians (Swagerty, Walling, & Klein, 2002).
Describe your activities during a typical day. How much time do you A sedentary lifestyle increases the risk of osteoporosis. Prolonged
spend in the sunlight? immobility leads to muscle atrophy. Exposure to 20 minutes of
sunlight per day promotes the production of vitamin D in the body.
Vitamin D deficiency can cause osteomalacia.
Describe any routine exercise that you do. Regular exercise promotes flexibility, bone density, and muscle tone
and strength. It can also help to slow the usual musculoskeletal
changes (progressive loss of total bone mass and degeneration
of skeletal muscle fibers) that occur with aging. Improper body
positioning in contact sports results in injury to the bones, joints,
or muscles.
Describe your occupation. Certain job-related activities increase the risk for development of
musculoskeletal problems. For example, incorrect body mechan-
ics, heavy lifting, or poor posture can contribute to back problems;
consistent, repetitive wrist and hand movements can lead to the
development of carpal tunnel syndrome.
Describe your posture at work and at leisure. What type of shoes do Poor posture, prolonged forward bending (as in sitting) or backward
you usually wear? Do you use any special footwear (i.e., orthotics)? leaning (as in working overhead), or long-term carrying of heavy
objects on the shoulders can result in back problems. Contracture
of the Achilles tendon can occur with prolonged use of high-heeled
shoes.
Do you have difficulty performing normal activities of daily living Impairment of the musculoskeletal system may impair the client’s
(bathing, dressing, grooming, eating)? Do you use assistive devices ability to perform normal ADLs. Correct use of assistive devices can
(e.g., walker, cane, braces) to promote your mobility? promote safety and independence. Some clients may feel embar-
rassed and not use their prescribed or needed assistive device.
How have your musculoskeletal problems interfered with your ability Musculoskeletal problems, especially chronic ones, can disable
to interact or socialize with others? Have they interfered with your and cripple the client, which may impair socialization and prevent
usual sexual activity? the client from performing the same roles as in the past. Back
problems, joint pain, or muscle stiffness may interfere with sexual
activities.
How did you view yourself before you had this musculoskeletal Body image disturbances and chronic low self-esteem may occur
problem, and how do you view yourself now? with a disabling or crippling problem.
Has your musculoskeletal problem added stress to your life? Describe. Musculoskeletal problems often greatly affect ADLs and role perfor-
mance, resulting in changed relationships and increased stress.
Have you ever had a bone density screening? When was your last The U.S. Preventive Services Task Force (USPSTF, 2011) recommends
one? that women younger than 60 get bone density scans if they have risk
factors for osteoporosis including a history of fractured bones, being
Caucasian, smoking, alcohol abuse, or a slender frame.
Ask clients to complete the online interactive International Osteo- Answering “yes” to any of these questions does not mean one has
porosis Foundation (IOF) One-Minute Osteoporosis Risk Test (http:// osteoporosis. However, positive answers indicate that the client has
www.iofbonehealth.org/iof-one-minute-osteoporosis-risk-test) and to risk factors that may lead to osteoporosis and fractures.
discuss the results with their health care provider.
Case Study
The case study introduced at the beginning of the chapter is now used to demonstrate how a nurse would use
the COLDSPA mnemonic to explore Ms. Funstead’s presenting concerns of back pain.
Mnemonic Question Data Provided

Character Describe the sign or symptom “I have a dull, achy pain in my lower back. My back feels stiff
(feeling, appearance, sound, and painful when I try to move certain ways.”
smell, or taste if applicable).
Onset When did it begin? “I first noticed the pain about 2 weeks ago. It has gotten worse
over the past 2 or 3 days.”
Location Where is it? Does it radiate? “It’s in my lower back, just below my waist.” Client denies
Does it occur anywhere else? radiation of pain, numbness or paresthesias in the lower
extremities.
Duration How long does it last? Does it “I usually notice it in the morning when I first get up. It gets
recur? worse on days I have to work, getting in and out of the car,
bending over, and sometimes just when I change positions. I
have noticed that standing for long periods of time makes it
really bad.”
Severity How bad is it? or How much “It’s bad enough that I have had to ask my supervisor for breaks
does it bother you? after standing for a couple hours. After work, I go home and lie
down. I haven’t been cooking or cleaning for the past week.”
Client rates pain as 7 on scale of 0–10 prior to taking ibuprofen.
An hour after taking ibuprofen, rates pain as 3–4 on a scale of
0–10.
Pattern What makes it better or worse? “Ibuprofen has helped some, but it seems to wear off before
the next dose is due. I’ve tried resting and stretching too. Rest-
ing and stretching help some, but the pain never goes away
completely.”
Associated factors/ What other symptoms occur Client denies bowel or bladder incontinence. “I haven’t been
How it Affects the with it? How does it affect you? able to walk with my friends after work for the past 2 weeks.
client Also, I haven’t been able to have sexual relations with my
husband. I am tired of hurting.”
After investigating Frances Funstead’s concerns regarding cola throughout the day. Her 24-hour diet recall includes:
back pain, the nurse continues with the health history. Breakfast—cereal bar and coffee; lunch—low-calorie frozen
Ms. Funstead denies any recent weight gain. She denies meal, yogurt, apple, diet cola; dinner—chicken noodle soup,
any past problems with joints, muscles, or bones. She salad, fruit smoothie, 8-oz glass of 2% milk. Activities in a typ-
reports that her immunizations are up to date. Denies dia- ical day include: Awakens at 5:30 AM and gets ready for work.
betes, sickle cell anemia, SLE, or osteoporosis. Ms. Funstead Works from 7 AM to 3 PM. Walks after work with friends. Goes
reports that she is postmenopausal and not taking any homes, prepares dinner, does household chores, watches TV;
estrogen replacement therapy. in bed by 10:30 PM.
Ms. Funstead denies family history of rheumatoid Ms. Funstead works at a local factory on an assembly
arthritis, gout, or osteoporosis. line. She picks up small parts and places them in a motor.
Ms. Funstead reports that she tries to walk 30 minutes She twists from side to side throughout the work day. She
three times weekly and is usually successful. Client denies has one 15-minute break in the morning, 30 minutes for
issues with weight gain or loss, but does feel as if she needs lunch, and one 15-minute break in the afternoon. She
to lose weight. Ms. Funstead’s medications include: Calcium stands while at work and is required to wear steel-toed
with vitamin D supplement two times daily, ibuprofen shoes. She denies difficulty performing ADLs until this
400 mg every 8 hours as needed. back problem developed. She does not require the use of
Client denies use of tobacco or alcohol. She admits to assistive devices for mobility. Client denies any change in
drinking 3–4 cups of coffee each morning and 32 oz of diet body image or self-esteem.
24-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: OSTEOPOROSIS
INTRODUCTION • Race/ethnicity
Osteoporosis is a disease in which bones demineralize and • Menopause/hysterectomy
become porous and fragile, making them susceptible to frac- • Long-term glucocorticoid therapy
tures. The International Osteoporosis Foundation (IOF, 2011a) • Rheumatoid arthritis
notes, “The loss of bone occurs ‘silently’ and progressively.” • Primary/secondary hypogonadism in men
Because progress is silent, no symptoms are noted until the Modifiable:
first fracture occurs unless careful screening takes place in • Alcohol (greater than 2 drinks a day)
people over 50 with risk factors for osteoporosis. • Smoking (past or current history)
According to the IOF (2011b), osteoporosis affects “200 mil- • Low body mass index (<20 kg/m2)
lion women worldwide—approximately one-tenth of women • Poor nutrition (low calcium intake and low protein intake)
aged 60, one-fifth of women aged 70, two-fifths of women aged • Vitamin D deficiency
80 and two-thirds of women aged 90.” One in 3 women and • Eating disorders (lead to nutrition deficiencies)
1 in 5 men will have a fractured bone, with hip, forearm, and • Insufficient exercise (especially sedentary lifestyle)
vertebral fractures predominating. Europeans and Americans Assess for the following risk factors for fracture (Osteoporosis
accounted for 51% of osteoporosis-related fractures in the year Canada, 2011):
2000, followed by people from the Western Pacific and South- • Age 65 or older
east Asia. The IOF states, “The great majority of people at high • Vertebral compression fracture
risk (possibly 80%), who have already had at least one osteopo- • Fracture with minimal trauma after age 40
rotic fracture, are neither identified nor treated.” Furthermore, • Family history of osteoporotic fracture (especially parental
“Between 1990 and 2000, there was nearly a 25% increase in hip hip fracture)
fractures worldwide. The peak number of hip fractures occurred • Long-term (more than 3 months continuously) use of glu-
at 75–79 years of age for both sexes.” cocorticoid therapy such as prednisone
• Medical conditions (such as celiac disease, Crohn’s disease)
HEALTHY PEOPLE 2020 GOAL that inhibit absorption of nutrients
Healthy People 2020 (2012) describes osteoporosis as a dis- • Primary hyperparathyroidism
ease that is “marked by reduced bone strength leading to • Tendency to fall
an increased risk of fractures (broken bones).” Included with • Spinal fracture apparent on x-ray
osteoporosis in the topics and objectives are arthritis and • Hypogonadism (low testosterone in men, loss of menstrual
chronic back conditions. periods in younger women)
• Early menopause (before age 45)
GOAL (for all 3 conditions)
• Rheumatoid arthritis
Prevent illness and disability related to arthritis and other rheu- • Hyperthyroidism
matic conditions, osteoporosis, and chronic back conditions. • Low body weight (<60kg)
OBJECTIVES (OSTEOPOROSIS) • If your present weight is more than 10% below your
weight at age 25
• Reduce the proportion of adults with osteoporosis by 10%,
• Low calcium intake
from 5.9% of adults aged 50 years and older in 2005–2008,
• Excess alcohol (consistently more than 2 drinks a day)
to 5.3%.
• Smoking
• Reduce the number of hip fractures in adults aged 65 years
• Low bone mineral density (BMD)
and older by 10% (both females and males).
Risk factors are additive, meaning that the more risk factors
SCREENING you have, the greater your risk of developing osteoporosis.
The U.S. Preventive Services Task Force (USPSTF, 2011) recom- CLIENT EDUCATION (IOF, 2011A)
mends screening for osteoporosis in women aged 65 years
Teach Parents of Children and Adolescents to
or older and in younger women whose fracture risk is equal
Help Their Children
to or greater than that of a 65-year-old Caucasian woman
• Ensure an adequate calcium intake that meets the relevant
who has no additional risk factors. The USPSTF concludes that
dietary recommendations in the country or region where
the current evidence is insufficient to assess the balance of
they live
benefits and harms of screening for osteoporosis in men. The
• Avoid undernutrition and protein malnutrition
inclusion of women under 65 years of age (and as young as
• Maintain an adequate supply of vitamin D through suffi-
50) is a new recommendation. The risk factors they must have
cient exposure to the sun and through diet
to indicate screening include, “having parents who fractured
• Participate in regular physical activity
bones, being white, a history of smoking, alcohol abuse, or a
• Avoid smoking
slender frame” (Goodman, 2011). The recommended screen-
• Be educated about the risk of high alcohol consumption
ing is for bone density scan.
Teach Clients to Prevent Bone Loss
RISK ASSESSMENT • Adequate calcium and vitamin D intake (recommendations
Assess for the following risk factors for osteoporosis (IOF, range from country to country, varying between 800 to
2011a): 1300 mg per day, depending on age)
• History of fractures • Regular, weight-bearing exercise
• Dowager’s hump • Not to smoke or quit if smoking
• Height reduction • Avoid heavy drinking
Unmodifiable: • Middle-aged and older adults should follow these funda-
• Age mental principles: Assess their risk of developing osteopo-
• Female gender rosis and, with medical advice, consider medications to help
• Family history maintain an optimal bone mass and to decrease the risk of
• Previous fracture fracture.
COLLECTING OBJECTIVE DATA: Provide adequate draping to avoid unnecessary exposure of the
PHYSICAL EXAMINATION client yet adequate visualization of the part being examined.
Explain that you will ask the client frequently to change posi-
Physical assessment of the musculoskeletal system provides tions and to move various body parts against resistance and
data regarding the client’s posture, gait, bone structure, muscle gravity. Clear, simple directions need to be given throughout
strength, and joint mobility, as well as the client’s ability to the examination to help the client understand how to move
perform ADLs. body parts to allow you to assess the musculoskeletal system.
The physical assessment includes inspecting and palpating Demonstrating to the client how to move the various body
the joints, muscles, and bones, testing ROM, and assessing parts and providing verbal directions facilitate examination.
muscle strength. See Assessment Guide 24-1 for guidelines to
use when performing the musculoskeletal assessment. OLDER ADULT CONSIDERATIONS
Some positions required for this examination may
Preparing the Client be very uncomfortable for the older client who may have
Because this examination is lengthy, be sure that the room is at a decreased flexibility. Be sensitive to the client’s needs and
comfortable temperature and provide rest periods as necessary. adapt your technique as necessary.
ASSESSMENT GUIDE 24-1 Assessing Joints and Muscles

The following are guidelines for assessing joints and muscle strength:
Joints
1. Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle
atrophy. Compare bilateral joint findings.
2. Palpate for edema, heat, tenderness, pain, nodules, or crepitus. Compare bilateral
joint findings.
3. Test each joint’s range of motion (ROM). Demonstrate how to move each joint
through its normal ROM, then ask the client to actively move the joint through
the same motions. Compare bilateral joint findings.
Older clients usually have slower movements, reduced flexibility,
and decreased muscle strength because of age-related muscle fiber and
joint degeneration, reduced elasticity of the tendons, and joint capsule
calcification.
If you identify a limitation in ROM, measure ROM with a goniometer (a device that
measures movement in degrees). To do so, move the arms of the goniometer to
match the angle of the joint being assessed. Then describe the limited motion of
the joint in degrees: for example, “elbow flexes from 45 degrees to 90 degrees.”
Goniometer
Muscles
1. Test muscle strength by asking the client to move each extremity through its full ROM against resistance. Do this by applying some
resistance against the part being moved. Document muscle strength by using a standard scale (see the following Rating Scale for Muscle
Strength). If the client cannot move the part against your resistance, ask the client to move the part against gravity. If this is not possible,
then attempt to move the part passively through its full ROM. If this is not possible, then inspect and feel for a palpable contraction of the
muscle while the client attempts to move it. Compare bilateral joint findings.
CLINICAL TIP
Do not force the part beyond its normal range. Stop passive motion if the client expresses discomfort or pain. Be espe-
cially cautious with the older client when testing ROM. When comparing bilateral strength, keep in mind that the client’s
dominant side will tend to be the stronger side.
2. Rate muscle strength in accord with the following strength table.
Rating Explanation Strength Classification

5 Active motion against full resistance Normal
4 Active motion against some resistance Slight weakness
3 Active motion against gravity Average weakness
2 Passive ROM (gravity removed and assisted by examiner) Poor ROM
1 Slight flicker of contraction Severe weakness
0 No muscular contraction Paralysis
Equipment Physical Assessment

• Tape measure • Observe gait and posture.
• Goniometer (optional) • Inspect joints, muscles, and extremities for size, symmetry,
• Skin marking pen (optional) and color.
• Palpate joints, muscles, and extremities for tenderness,
edema, heat, nodules, or crepitus.
• Test muscle strength and ROM of joints.
• Compare bilateral findings of joints and muscles.
• Perform special tests for carpal tunnel syndrome.
• Perform the “bulge,” “ballottement,” and McMurray’s knee
tests.
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Gait
INSPECTION
Observe gait. Observe the client’s gait as the Evenly distributed weight. Client able to Uneven weight bearing is evident. Client
client enters and walks around the room. stand on heels and toes. Toes point straight cannot stand on heels or toes. Toes point in
Note: ahead. Equal on both sides. Posture erect, or out. Client limps, shuffles, propels forward,
• Base of support movements coordinated and rhythmic, arms or has wide-based gait. (See Chapter 25,
• Weight-bearing stability swing in opposition, stride length appropri- Assessing Neurologic System, for specific
• Foot position ate. abnormal gait findings.)
• Stride and length and cadence of stride
• Arm swing
• Posture
Assess for the risk of falling backward in the Client does not fall backward. Falling backward easily is seen with cervical
older or handicapped client by performing spondylosis and Parkinson’s disease.
the “nudge test.” Stand behind the client
and put your arms around the client while
you gently nudge the sternum.
OLDER ADULT
CONSIDERATIONS
Some older clients have an impaired
sense of position in space, which may
contribute to the risk of falling.
Temporomandibular Joint (TMJ)

INSPECTION AND PALPATION
Inspect and palpate the TMJ. Have the Snapping and clicking may be felt and heard Decreased ROM, swelling, tenderness, or
client sit; put your index and middle fingers in the normal client. crepitus may be seen in arthritis.
just anterior to the external ear opening
(Fig. 24-4A, p. 520). Ask the client to open Mouth opens 1–2 inches (distance between Decreased muscle strength with muscle and
the mouth as widely as possible. (The tips of upper and lower teeth). The client’s mouth joint disease. Decreased ROM, and a click-
your fingers should drop into the joint spaces opens and closes smoothly. Jaw moves ing, popping, or grating sound may be noted
as the mouth opens.) laterally 1–2 cm. Jaw protrudes and retracts with TMJ dysfunction.
• Move the jaw from side to side (Fig. 24-4B, easily.
p. 520).
• Protrude (push out) and retract (pull in)
jaw (Fig. 24-4C, p. 520).

Temporomandibular Joint (TMJ) (Continued)
A B
FIGURE 24-4 Inspecting and palpating the temporomandibular

joint. (A) Put your index and middle fingers just anterior to
the external ear opening and have the client open the mouth.
C (B) Move the jaw from side to side. (C) Protrude (push out) and
retract (pull in) jaw.
Test ROM. Ask the client to open the mouth Jaw has full ROM against resistance. Con- Lack of full contraction with cranial nerve V
and move the jaw laterally against resis- traction palpated with no pain or spasms. lesion. Pain or spasms occur with myofascial
tance. Next, as the client clenches the teeth, pain syndrome.
feel for the contraction of the temporal and
masseter muscles to test the integrity of
cranial nerve V (trigeminal nerve).
Sternoclavicular Joint
With client sitting, inspect the sternoclavicular There is no visible bony overgrowth, swell- Swollen, red, or enlarged joint or tender,
joint for location in midline, color, swelling, and ing, or redness; joint is nontender. painful joint is seen with inflammation of
masses. Then palpate for tenderness or pain. the joint.
Cervical, Thoracic, and Lumbar Spine

Observe the cervical, thoracic, and lumbar Cervical and lumbar spines are concave; tho- A flattened lumbar curvature may be seen
curves from the side, then from behind. Have racic spine is convex. Spine is straight (when with a herniated lumbar disc or ankylosing
the client standing erect with the gown observed from behind). spondylitis. Lateral curvature of the thoracic
positioned to allow an adequate view of spine with an increase in the convexity on
OLDER ADULT
the spine (Fig. 24-5). Observe for symmetry, the curved side is seen in scoliosis. An exag-
CONSIDERATIONS
noting differences in height of the shoulders, gerated lumbar curve (lordosis) is often seen
An exaggerated thoracic curve (kyphosis)
iliac crests, and buttock creases. in pregnancy or obesity (Abnormal Findings
is common with aging.
24-1, p. 539). Unequal heights of the hips
suggests unequal leg lengths.
CULTURAL CONSIDERATIONS
Some findings that appear to be
abnormalities are, in fact, variations
related to culture or sex. For example,
some African Americans have a large
gluteal prominence, making the spine
appear to have lumbar lordosis. In addi-
tion, the number of vertebrae may differ.
Racial and sex variations from the usual
24 include 11% of African American
women with 23, and 12% of Eskimo and
Native American men with 25 (Andrews
& Boyle, 2008).
Palpate the spinous processes and the para- Nontender spinous processes; well-developed, Compression fractures and lumbosacral
vertebral muscles on both sides of the spine firm and smooth, nontender paravertebral muscle strain can cause pain and tenderness
for tenderness or pain. muscles. No muscle spasm. of the spinal processes and paravertebral
muscles.
Test ROM of the cervical spine. Test ROM Flexion of the cervical spine is 45 degrees. Cervical strain is the most common cause
of the cervical spine by asking the client to Extension of the cervical spine is 45 degrees. of neck pain. It is characterized by impaired
touch the chin to the chest (flexion) and ROM and neck pain from abnormalities
to look up at the ceiling (hyperextension) of the soft tissue (muscles, ligaments, and
(Fig. 24-6). nerves) due to straining or injuring the neck.
Causes of strains can include sleeping in the
wrong position, carrying a heavy suitcase, or
being in an automobile crash.
Cervical disc degenerative disease and

spinal cord tumors are associated with
impaired ROM and pain that radiates to the
back, shoulder, or arms. Neck pain with a
loss of sensation in the legs may occur with
cervical spinal cord compression.
CLINICAL TIP
Impaired ROM and neck pain
associated with fever, chills, and head-
ache could be indicative of a serious
infection such as meningitis.
0°
Extension Flexion
45°
55°
FIGURE 24-5 Normal curve of the spine. FIGURE 24-6 Normal range of motion of the cervical spine:
hyperextension-flexion.
Cervical, Thoracic, and Lumbar Spine (Continued)
Test lateral bending. Ask the client to Normally the client can bend 40 degrees to Limited ROM is seen with neck injuries,
touch each ear to the shoulder on that side the left side and 40 degrees to the right side. osteoarthritis, spondylosis, or with disc
(Fig. 24-7). degeneration.
Evaluate rotation. Ask the client to turn About 70 degrees of rotation is normal. Limited ROM is seen with neck injuries,
the head to the right and left (Fig. 24-8). osteoarthritis, spondylosis, or with disc
degeneration.
0°
Right Left
Right Left
40° 40°
70° 70°
Rotation Rotation
Lateral Lateral
bending bending
0°
FIGURE 24-7 Normal range of motion of the cervi- FIGURE 24-8 Normal range of motion of the cervi-
cal spine: lateral bending. cal spine: rotation.
Ask the client to repeat the cervical ROM Client has full ROM against resistance. Decreased ROM against resistance is seen
movements against resistance. with joint or muscle disease.
Test ROM of the thoracic and lumbar spine. Flexion of 75–90 degrees, smooth move- Lateral curvature disappears in functional
Ask the client to bend forward and touch the ment, lumbar concavity flattens out, and the scoliosis; unilateral exaggerated thoracic
toes (flexion; Fig. 24-9). Observe for symme- spinal processes are in alignment. convexity increases in structural scoliosis.
try of the shoulders, scapula, and hips. 0°
Spinal processes are out of alignment.
Extension
OLDER ADULT to 30°
CONSIDERATIONS
Similarly, ask an older client to bend
forward but do not insist that he or she
touch toes unless the client is comfort-
able with the movement. Flexion
to 90°
FIGURE 24-9 Thoracic and lumbar

spines: flexion.
Sit down behind the client, stabilize the Lateral bending capacity of the thoracic and Low back strain from injury to soft tissues is
client’s pelvis with your hands, and ask the lumbar spines should be about 35 degrees a common cause of impaired ROM and pain
client to bend sideways (lateral bending), (Fig. 24-10A); hyperextension about 30 in the lumbar and thoracic regions. Other
bend backward toward you (hyperextension), degrees; and rotation about 30 degrees causes of impaired ROM in the lumbar and
and twist the shoulders one way then the (Fig. 24-10B). thoracic areas include osteoarthritis, anky-
other (rotation). losing spondylitis, and congenital abnor-
malities that may affect the spinal vertebral
spacing and mobility.
Right lateral 0° Left lateral 0°

flexion to 35° flexion to 35° Rotation to 30°
A B
FIGURE 24-10 Thoracic and lumbar spines: (A) lateral bending; (B) rotation
Test for back and leg pain. If the client

has low back pain that radiates down the
back, perform the straight leg test to check
for a herniated nucleus pulposus. Ask the
client to lie flat and raise each relaxed leg
independently to the point of pain. At the
point of pain, dorsiflex the client’s foot (Fig.
24-11, p. 524). Note the degree of eleva-
tion when pain occurs, the distribution and
character of the pain, and the results from
dorsiflexion of the foot.
Measure leg length. If you suspect that the Measurements are equal or within 1 cm. If Unequal leg lengths are associated with
client has one leg longer than the other, mea- the legs still look unequal, assess the appar- scoliosis. Equal true leg lengths but unequal
sure them. Ask the client to lie down with legs ent leg length by measuring from a nonfixed apparent leg lengths are seen with abnor-
extended. With a measuring tape, measure point (the umbilicus) to a fixed point (medial malities in the structure or position of the
the distance between the anterior superior malleolus) on each leg. hips and pelvis.
iliac spine and the medial malleolus, crossing
the tape on the medial side of the knee (true
leg length; Fig. 24-12, p. 524).

Cervical, Thoracic, and Lumbar Spine (Continued)
FIGURE 24-11 Performing the straight leg test.

FIGURE 24-12 Measuring leg length (true leg length).
Shoulders, Arms, and Elbows

Inspect and palpate shoulders and Shoulders are symmetrically round; no red- Flat, hollow, or less-rounded shoulders are
arms. With the client standing or sitting, ness, swelling, or deformity or heat. Muscles seen with dislocation. Muscle atrophy is
inspect anteriorly and posteriorly for sym- are fully developed. Clavicles and scapulae seen with nerve or muscle damage or lack of
metry, color, swelling, and masses. Palpate are even and symmetric. The client reports use. Tenderness, swelling, and heat may be
for tenderness, swelling, or heat. Anteriorly no tenderness. noted with shoulder strains, sprains, arthritis,
palpate the clavicle, acromioclavicular bursitis, and degenerative joint disease
joint, subacromial area, and the biceps. (DJD).
Posteriorly palpate the glenohumeral joint,
coracoid area, trapezius muscle, and the
scapular area.
Test ROM. Explain to the client that you Extent of forward flexion should be 180 Painful and limited abduction accompanied
will be assessing ROM (consisting of flexion, degrees; hyperextension, 50 degrees; adduc- by muscle weakness and atrophy are seen
extension, adduction, abduction, and motion tion, 50 degrees; and abduction 180 degrees. with a rotator cuff tear. Client has sharp
against resistance). Ask client to stand with catches of pain when bringing hands over-
both arms straight down at the sides. Next, head with rotator cuff tendinitis. Chronic
ask the client to move the arms forward pain and severe limitation of all shoulder
(flexion), then backward with elbows motions are seen with calcified tendinitis.
straight (Fig. 24-13).
Then have the client bring both hands

together overhead, elbows straight, fol-
lowed by moving both hands in front of
the body past the midline with elbows
straight (this tests adduction and abduc-
tion) (Fig. 24-14).
In a continuous motion, have the client bring Extent of external and internal rotation Inability to shrug shoulders against
the hands together behind the head with should be about 90 degrees, respectively. resistance is seen with a lesion of cranial
elbows flexed (this tests external rotation; nerve XI (spinal accessory). Decreased
Fig. 24-15A) and behind the back (internal The client can flex, extend, adduct, abduct, muscle strength is seen with muscle or
rotation; Fig. 24-15B). Repeat these maneu- rotate, and shrug shoulders against resis- joint disease.
vers against resistance. tance.
180°
180°
Abduction
Hyperextension
up to 50° Forward
flexion
50°
Adduction
FIGURE 24-13 Normal range of motion of the shoulder: flexion/ FIGURE 24-14 Normal range of motion of the shoulder: adduction/
extension. abduction.
90°
External
rotation Internal
rotation
90°
A B
FIGURE 24-15 Normal range of motion of the shoulder: (A) external rotation;
(B) internal rotation.
Elbows
Inspect for size, shape, deformities, red- Elbows are symmetric, without deformities, Redness, heat, and swelling may be seen
ness, or swelling. Inspect elbows in both redness, or swelling. with bursitis of the olecranon process due to
flexed and extended positions. trauma or arthritis.
With the elbow relaxed and flexed about Nontender; without nodules. Firm, nontender, subcutaneous nodules
70 degrees, use your thumb and middle may be palpated in rheumatoid arthritis or
fingers to palpate the olecranon process and rheumatic fever. Tenderness or pain over the
epicondyles. epicondyles may be palpated in epicondylitis
(tennis elbow) due to repetitive movements
of the forearm or wrists.
Test ROM. Ask the client to perform the Normal ranges of motion are 160 degrees of Decreased ROM against resistance is seen
following movements to test ROM, flexion, flexion, 180 degrees of extension, 90 degrees with joint or muscle disease or injury.
extension, pronation, and supination. of pronation, and 90 degrees of supination.
Some clients may lack 5–10 degrees or have
hyperextension.
Flex the elbow and bring the hand to the The client should have full ROM against
forehead (Fig. 24-16A). resistance.
Straighten the elbow.
Then the hold arm out, turn the palm down,

then turn the palm up (Fig. 24-16B).
Last, have the client repeat the movements

against your resistance.
160°
Flexion
Supination Pronation
90° 90°
A B
Extension
0°
FIGURE 24-16 Normal range of motion of the elbow: (A) flexion/extension; (B) prona-
tion/supination.
Wrists
Inspect wrist size, shape, symmetry, color, Wrists are symmetric, without redness, or Swelling is seen with rheumatoid arthritis.
and swelling. Then palpate for tenderness swelling. They are nontender and free of Tenderness and nodules may be seen with
and nodules (Fig. 24-17). nodules. rheumatoid arthritis. A nontender, round,
enlarged, swollen, fluid-filled cyst (ganglion)
may be noted on the wrists (Abnormal Find-
ings 24-2, p. 541).
Signs of a wrist fracture include pain,

tenderness, swelling, and inability to hold
a grip; as well as pain that goes away and
then returns as a deep, dull ache. Extreme
tenderness occurs when pressure is applied
on the side of the hand between the two
tendons leading to the thumb (UCSF Medical
Center, 2012).
FIGURE 24-17 Palpating the wrists.
Palpate the anatomic snuffbox (the hollow No tenderness palpated in anatomic snuff- Snuffbox tenderness may indicate a scaph-
area on the back of the wrist at the base of box. oid fracture, which is often the result of
the fully extended thumb; Fig. 24-18). falling on an outstretched hand.
Anatomic
snuff box
A B
FIGURE 24-18 (A) Anatomic snuffbox. (B) Palpating the anatomic snuffbox.
Test ROM. Ask the client to bend the wrist Normal ranges of motion are 90 degrees of Ulnar deviation of the wrist and fingers with
down and back (flexion and extension; flexion, 70 degrees of hyperextension, 55 limited ROM is often seen in rheumatoid
Fig. 24-19A, p. 528). degrees of ulnar deviation, and 20 degrees arthritis.
of radial deviation. Client should have full
Next. have the client hold the wrist straight ROM against resistance. Increased pain with extension of the wrist
and move the hand outward and inward against resistance is seen in epicondylitis of
(deviation; Fig. 24-19B, p. 528). Repeat these CULTURAL CONSIDERATIONS the lateral side of the elbow. Increased pain
maneuvers against resistance. Unequal lengths of the ulna and with flexion of the wrist against resistance
radius have been found in some ethnic is seen in epicondylitis of the medial side
groups (e.g., Swedes and Chinese) (Over- of the elbow. Decreased muscle strength is
field, 1995). noted with muscle and joint disease.

Wrists (Continued)
0°
Radial
deviation
to 20°
Ulnar
Extension deviation
to 70° to 55°
0°
Flexion
A to 90°
FIGURE 24-19 Range of motion of the wrists: (A) flexion/hyperextension; (B) radial–ulnar deviation.
Tests for carpal tunnel syndrome. No tingling, numbness, or pain result from If symptoms develop within a minute with
Phalen’s test or from Tinel’s test (WebMD, Phalen’s test, carpel tunnel syndrome is
Perform Phalen’s test. Ask the client to rest 2010). suspected. Client may report tingling, numb-
elbows on a table and place the backs of ness, and pain with carpal tunnel syndrome.
both hands against each other while flexing
the wrists 90 degrees with fingers pointed However, if the test lasts longer than a
downward and wrists dangling (Fig. 24-20A). minute, pain and tingling may occur even in
Have the client hold this position for clients without carpel tunnel syndrome.
60 seconds.
Perform test for Tinel’s sign: Use your finger No tingling or shocking sensation experi- Tingling or shocking sensation experienced
to percuss lightly over the median nerve enced with test for Tinel’s sign. with test for Tinel’s sign. Median nerve
(located on the inner aspect of the wrist; entrapped in the carpal tunnel results in pain,
Fig. 24-20B). numbness, and impaired function of the hand
and fingers (Fig. 24-21).
A B
FIGURE 24-20 Tests for carpal tunnel syndrome: (A) Phalen’s test; (B) Tinel’s test.
Flexor retinaculum
Carpal canal
(sulcus carpi)
Median nerve
FIGURE 24-21 Median nerves entrapped in the carpal

tunnel results in pain, numbness, and impaired function
of the hand and fingers.
Observe for the flick signal. Ask the client, Client will not shake or flick wrist when If the patient responds with a motion that
“What do you do when your symptoms are asked this question. resembles shaking a thermometer (flick
worse?” signal), carpal tunnel may be suspected.
Test for thumb weakness: Client can raise thumb up from the plane Client cannot raise the thumb up from the
• Ask the client to raise thumb up from the and stretch the thumb finger pad to the little plane and stretch the thumb pad to the little
plane of the palm. finder pad. finger pad. This indicates thumb weakness in
• Ask the client to stretch the thumb so that carpal tunnel syndrome.
its pad rests on the pad of the little finger
pad.
Hands and Fingers

Inspect size, shape, symmetry, swelling, and Hands and fingers are symmetric, nontender, Pain, tenderness, swelling, shortened finger,
color. Palpate the fingers from the distal end and without nodules. Fingers lie in straight depressed knuckle and/or inability to move
proximally, noting tenderness, swelling, bony line. No swelling or deformities. Rounded the finger is seen with finger fractures (UCSF
prominences, nodules, or crepitus of each protuberance noted next to the thumb over Medical Center, 2012).
interphalangeal joint. Assess the metacar- the thenar prominence. Smaller protuberance
pophalangeal joints by squeezing the hand seen adjacent to the small finger. Swollen, stiff, tender finger joints are seen
from each side between your thumb and in acute rheumatoid arthritis. Boutonnière
fingers. Palpate each metacarpal of the hand, deformity and swan-neck deformity are
noting tenderness and swelling. seen in long-term rheumatoid arthritis (see
Abnormal Findings 24-2, p. 540). Atrophy of
the thenar prominence may be evident in
carpal tunnel syndrome.
In osteoarthritis, hard, painless nodules

may be seen over the distal interpha-
langeal joints (Heberden’s nodes) and
over the proximal interphalangeal joints
(Bouchard’s nodes) (see Abnormal Findings
24-2, p. 540).

Hands and Fingers (Continued)
Test ROM (Fig. 24-22). Ask the client to (A) Normal ranges are 20 degrees of abduc- Inability to extend the ring and little fingers is
spread the fingers apart (abduction), (B) tion, full adduction of fingers (touching), 90 seen in Dupuytren’s contracture. Painful exten-
make a fist (adduction), (C) bend the fingers degrees of flexion, and 30 degrees of hyper- sion of a finger may be seen in tenosynovitis
down (flexion) and then up (hyperextension), extension. The thumb should easily move (infection of the flexor tendon sheathes; see
(D) move the thumb away from other fingers, away from other fingers and 50 degrees of Abnormal Findings 24-2, p. 540).
and then (E) touch the thumb to the base of thumb flexion is normal.
the small finger. Decreased muscle strength against resis-
The client normally has full ROM against tance is associated with muscle and joint
Repeat these maneuvers against resistance. resistance. disease.
30° Hyperextension
to 30°
0°
Flexion
A B C to 90°
90°
FIGURE 24-22 Normal range of motion of the fingers:

(A) abduction; (B) adduction; (C) flexion–hyperextension;
D E (D) thumb away from fingers; (E) thumb touching base of
small finger.
Hips
With the client standing, inspect symmetry Buttocks are equally sized; iliac crests are Instability, inability to stand, and/or a
and shape of the hips (Fig. 24-23). Observe symmetric in height. Hips are stable, non- deformed hip area are indicative of a
for convex thoracic curve and concave lum- tender, and without crepitus. fractured hip. Tenderness, edema, decreased
bar curve. Palpate for stability, tenderness, ROM, and crepitus are seen in hip inflam-
and crepitus. mation and DJD.
The most common injuries of the hip and

groin region in athletes are groin pulls and
hamstring strains (Cluett, 2009).
Strains, a stretch or tear of muscle or

tendons, often occur in the lower back
and the hamstring muscle (Mayo Clinic
Staff, 2011).
FIGURE 24-23 Inspecting the hips and buttocks.
Test ROM (Fig. 24-24, p. 532). Normal ROM: 90 degrees of hip flexion with Inability to abduct the hip is a common sign
the knee straight and 120 degrees of hip of hip disease.
If the client has had a total
hip replacement, do not test
flexion with the knee bent and the other leg
remaining straight. Pain and a decrease in internal hip rotation
ROM unless the physician gives permis-
may be a sign of osteoarthritis or femoral
sion to do so, due to the risk of dislocat-
ing the hip prosthesis.
Normal ROM: neck stress fracture. Pain on palpation of
• 45–50 degrees of abduction the greater trochanter and pain as the client
With the client supine, ask the client to: • 20–30 degrees of adduction moves from standing to lying down may
• Raise extended leg (Fig. 24-24A, p. 532). • 40 degrees internal hip rotation indicate bursitis of the hip.
• Flex knee up to chest while keeping other • 45 degrees external hip rotation.
leg extended (Fig. 24-24B, p. 532). • 15 degrees hip hyperextension.
• Move extended leg (Fig. 24-24C, p. 532)
away from midline of body as far as pos-
sible and then toward midline of body as
far as possible (abduction and adduction).
• Bend knee and turn leg (Fig. 24-24D, p. 532)
inward (rotation) and then outward
(rotation).
• Ask the client to lie prone (Fig. 24–24E,
p. 532) and lift extended leg off table.
Alternatively, ask the client to stand and
swing extended leg backward.
Repeat these maneuvers against resistance. Full ROM against resistance. Decreased muscle strength against
resistance is seen in muscle and joint
disease.

Hips (Continued)
90°
120°
Hip flexion
Hip flexion with knee
with knee flexed
straight
0°
A B Extension
to 0°
40°
45° Internal
rotation
External
rotation
45°
30°
C Abduction 0° Adduction
15°
D
0°
FIGURE 24-24 Normal range of motion of the hips: (A) hip flexion with extended knee straight; (B) hip flexion with knee bent;
(C) abduction/adduction; (D) internal and external rotation; (E) hyperextension.
Knees
With the client supine then sitting with Knees symmetric, hollows present on both Knees turn in with knock knees (genu
knees dangling, inspect for size, shape, sym- sides of the patella, no swelling or deformi- valgum) and turn out with bowed legs
metry, swelling, deformities, and alignment. ties. Lower leg in alignment with the upper (genu varum). Swelling above or next to the
Observe for quadriceps muscle atrophy. leg. patella may indicate fluid in the knee joint or
thickening of the synovial membrane.
Palpate for tenderness, warmth, consis- Nontender and cool. Muscles firm. No Tenderness and warmth with a boggy
tency, and nodules. Begin palpation 10 cm nodules. consistency may be symptoms of synovitis.
above the patella, using your fingers and Asymmetric muscular development in the
OLDER ADULT
thumb to move downward toward the knee quadriceps may indicate atrophy.
CONSIDERATIONS
(Fig. 24-25).
Some older clients may have a
bow-legged appearance because of
decreased muscle control.
Tests for swelling. If you notice swelling, No bulge of fluid appears on medial side of Bulge of fluid appears on medial side of
perform the bulge test to determine if the knee. knee, with a small amount of joint effusion.
swelling is due to accumulation of fluid or
soft-tissue swelling. The bulge test helps to
detect small amounts of fluid in the knee.
With the client in a supine position, use the
ball of your hand firmly to stroke the medial
side of the knee upward, three to four times,
to displace any accumulated fluid (Fig.
24-26A).
Then press on the lateral side of the knee

and look for a bulge on the medial side of
the knee (Fig. 24-26B).
B
FIGURE 24-25 Palpating the knee area. FIGURE 24-26 Performing the “bulge” knee test: (A) stroking the
knee; (B) observing the medial side for bulging.
Knees (Continued)
Perform the ballottement test. This test No movement of the patella is noted. Patella Fluid wave or click palpated, with large
helps to detect large amounts of fluid in the rests firmly over the femur. amounts of joint effusion. A positive bal-
knee. With the client in a supine position, lottement test may be present with meniscal
firmly press your nondominant thumb and tears.
index finger on each side of the patella. This
displaces fluid in the suprapatellar bursa,
located between the femur and patella. Then
with your dominant fingers, push the patella
down on the femur (Fig. 24-27). Feel for a
fluid wave or a click.
Press here to milk

fluid behind patella
Tap patella, if it rebounds against
your fingers, fluid is present
FIGURE 24-27 Performing the “ballottement” knee test.
Palpate the tibiofemoral space. As you com- There is no pain on examination. Crepitus A patellofemoral disorder may be suspected
press the patella, slide it distally against the may be present. if both crepitus and pain are present on
underlying femur. Note crepitus or pain. examination.
Test ROM (Fig. 24-28). Ask the client to: Normal ranges: 120–130 degrees of flexion; Osteoarthritis is characterized by a
• Bend each knee up (flexion) toward but- 0 degrees of extension to 15 degrees of decreased ROM with synovial thickening and
tocks or back. hyperextension. crepitation. Flexion contractures of the knee
• Straighten the knee (extension/hyperex- are characterized by an inability to extend
tension). knee fully.
• Walk normally.
Repeat these maneuvers against resistance. Client should have full ROM against resis- Decreased muscle strength against resis-
tance. tance is seen in muscle and joint disease.
Test for pain and injury. If the client com- No pain or clicking noted. Pain or clicking is indicative of a torn menis-
plains of a “giving in” or “locking” of the cus of the knee.
knee, perform McMurray’s test (Fig. 24-29).
With the client in the supine position, ask the
client to flex one knee and hip. Then place
your thumb and index finger of one hand on
either side of the knee. Use your other hand
to hold the heel of the foot up. Rotate the
lower leg and foot laterally. Slowly extend
the knee, noting pain or clicking. Repeat,
rotating lower leg and foot medially. Again,
note pain or clicking.
180°
130°
Flexion
15°
0° Hyperextension
Extension
FIGURE 24-28 Normal range of motion of the knee. FIGURE 24-29 Performing McMurray’s test.
Ankles and Feet

With the client sitting, standing, and Toes usually point forward and lie flat; A laterally deviated great toe with possible
walking, inspect position, alignment, however, they may point in (pes varus) or overlapping of the second toe and possible
shape, and skin. point out (pes valgus). Toes and feet are formation of an enlarged, painful, inflamed
in alignment with the lower leg. Smooth, bursa (bunion) on the medial side is seen
rounded medial malleolar prominences with with hallux valgus. Common abnormalities
prominent heels and metatarsophalangeal include feet with no arches (pes planus
joints. Skin is smooth and free of corns and or “flat feet”), feet with high arches (pes
calluses. Longitudinal arch; most of the cavus); painful thickening of the skin over
weight bearing is on the foot midline. bony prominences and at pressure points
(corns); nonpainful thickened skin that
occurs at pressure points (calluses); and
painful warts (verruca vulgaris) that often
occur under a callus (plantar warts; Abnor-
mal Findings 24-3, p. 542).
Palpate ankles and feet for tenderness, No pain, heat, swelling, or nodules are Ankles are the most common site of sprains,
heat, swelling, or nodules (Fig. 24-30, p. noted. which occur with stretched or torn ligaments
536). Palpate the toes from the distal end (tough bands of fibrous tissue connecting
proximally, noting tenderness, swelling, bony bones in a joint; Mayo Clinic Staff, 2011).
prominences, nodules, or crepitus of each
interphalangeal joint. Tender, painful, reddened, hot, and swollen
metatarsophalangeal joint of the great toe is
seen in gouty arthritis. Nodules of the poste-
rior ankle may be palpated with rheumatoid
arthritis.

Ankles and Feet (Continued)
FIGURE 24-30 Palpating the ankles and feet.
Assess the metatarsophalangeal joints by Pain and tenderness of the metatarsopha-

squeezing the foot from each side with your langeal joints are seen in inflammation of
thumb and fingers. Palpate each metatarsal, the joints, rheumatoid arthritis, and DJD.
noting swelling or tenderness. Palpate the Tenderness of the calcaneus of the bottom of
plantar area (bottom) of the foot, noting the foot may indicate plantar fasciitis. Plantar
pain or swelling. fasciitis is the most common cause of heel
pain, which occurs when the strong sup-
portive band of tissue in the arch of the foot
becomes irritated and inflamed (American
Academy of Orthopaedic Surgeons, 2010).
Use the Ottawa ankle and foot rules (Box

24-3) to determine need for X-ray referral.
Test ROM (Fig. 24-31). Ask the client to: Normal ranges: Decreased strength against resistance is
• Point toes upward (dorsiflexion) and then • 20 degrees dorsiflexion of ankle and foot seen in muscle and joint disease.
downward (plantarflexion, Fig. 24-31A). and 45 degrees plantarflexion of ankle
• Turn soles outward (eversion) and then and foot. Hyperextension of the metatarsophalangeal
inward (inversion, Fig. 24-31B). • 20 degrees of eversion and 30 degrees of joint and flexion of the proximal interpha-
• Rotate foot outward (abduction) and then inversion. langeal joint is apparent in hammer toe (see
inward (adduction, Fig. 24-31C). • 10 degrees of abduction and 20 degrees Abnormal Findings 24-3, p. 542).
• Turn toes under foot (flexion) and then of adduction.
upward (extension). • 40 degrees of flexion and 40 degrees of
extension.
FIGURE 24-31 Normal range of motion of the feet and ankles:

A
(A) dorsiflexion–plantarflexion; (continued)
B C
FIGURE 24-31 (Continued) (B) eversion–inversion; (C) abduction–adduction.
Repeat these maneuvers against resistance. Client has full ROM against resistance. Decreased strength against resistance is
common in muscle and joint disease.
Case Study
The chapter case study is now used to dem- Palpation: Cervical, thoracic, and lumbar spinous processes
onstrate the physical examination of Fran- nontender. Lumbar paravertebral muscles are firm,
ces Funstead’s back. taut, and tender bilaterally. Lumbar spine: Flexion is
Inspection: Posture erect. Movement is decreased at 60 degrees; lateral bending is decreased at
coordinated and rhythmic. Arms swing 25 degrees and guarded bilaterally; hyperextension is
in opposition. Able to stand on heels normal at 30 degrees; rotation decreased at 20 degrees
and toes. Cervical and lumbar spines are bilaterally and elicits discomfort. The straight leg test is
concave. Thoracic spine is convex. negative. Leg length is equal.
BOX 24-3 VALIDATING AND

DOCUMENTING FINDINGS
ANKLE X-RAY INDICATORS
Validate the musculoskeletal assessment data you have collected.
Malleolar-area pain and bone tenderness at the tips of This is necessary to verify that the data are reliable and accurate.
6-cm edges of the lateral malleolus or medial malleolus, or
the inability to bear weight immediately or during exami-
nation indicate the need for an ankle x-ray. Case Study
FOOT X-RAY INDICATORS Think back to the case study. The occu-
pational health nurse documented the
Pain in the midfoot area and bone tenderness at the base
of the fifth metatarsal or the navicular bone area, or the
following subjective and objective assess-
inability to bear weight immediately or during examina- ment findings of Frances Funstead’s back
tion, indicate the need for a foot x-ray. examination.
Biographic Data: F.F., 55-year-old Caucasian woman. Alert on heels and toes. Cervical and lumbar spines are
and oriented. Asks and answers questions appropriately. concave. Thoracic spine is convex.
Palpation: Cervical, thoracic, and lumbar spinous pro-
Reason for Seeking Health Care: “I have pain and stiff-
cesses nontender. Lumbar paravertebral muscles are
ness in my lower back.”
firm, taut, and tender bilaterally.
History of Present Health Concern: The client reports that Lumbar spine: Flexion is decreased at 60 degrees; lateral
2 weeks ago she developed low back pain and stiffness bending is decreased at 25 degrees and guarded
that has increased over the past 2–3 days. She describes bilaterally; hyperextension is normal at 30 degrees;
the pain as dull and achy. F.F. states that the pain is rotation decreased at 20 degrees bilaterally and
worse in the morning and with certain movements such elicits discomfort. Lasègue’s test (straight leg test) is
as getting in and out of the car, bending over, and chang- negative. Leg length is equal.
ing positions suddenly. She has also noted that the pain
increases after standing for long periods of time. Despite
taking ibuprofen and resting, the pain continues. Client
rates pain as 7 on scale of 0–10 prior to taking ibupro-
fen. An hour after taking ibuprofen, rates pain as 3–4 Analysis of Data: Diagnostic
on scale of 0–10. Ibuprofen, resting, and stretching alle-
viate the pain somewhat; however, the pain never goes
Reasoning
away. Client denies paresthesias and bowel/bladder
After collecting subjective and objective data pertaining to the
incontinence.
musculoskeletal assessment, identify abnormal findings and
Personal History: Ms. Funstead denies any recent weight client strengths. Then cluster the data to reveal any significant
gain. She denies any past problems with joints, muscles, patterns or abnormalities. These data may then be used to
or bones. She reports that her immunizations are up to make clinical judgments about the status of the client’s mus-
date. Denies diabetes, sickle cell anemia, SLE, or osteo- culoskeletal system.
porosis. Ms. Funstead reports that she is postmeno-
pausal and not taking any estrogen replacement therapy.
SELECTED NURSING DIAGNOSES
Family History: Ms. Funstead denies family history of
rheumatoid arthritis, gout, or osteoporosis. Following is a list of selected nursing diagnoses (health
promotion, risk, or actual) that you may identify when ana-
Lifestyle and Health Practices: Ms. Funstead reports that lyzing the cue clusters.
she tries to walk 30 minutes three times weekly and
is usually successful. Client denies issues with weight Health Promotion Diagnoses
gain or loss, but does feel as if she needs to lose weight. • Readiness for Enhanced Self-health Management: activity
Ms. Funstead’s medications include: Calcium with vita- and exercise patterns related to expressed desire to improve
min D supplement two times daily, ibuprofen 400 mg status
every 8 hours as needed.
Client denies use of tobacco or alcohol. She admits Risk Diagnoses
to drinking 3–4 cups of coffee each morning and 32 oz • Risk for Trauma related to repetitive movements of wrists or
of diet cola throughout the day. Her 24-hour diet recall elbows with recreation or occupation
includes: Breakfast–cereal bar and coffee; lunch—low- • Risk for Injury: Pathologic fractures related to osteoporosis
calorie frozen meal, yogurt, apple, diet cola; dinner— • Risk for Injury to joints, muscles, or bones related to envi-
chicken noodle soup, salad, fruit smoothie, 8-oz glass ronmental hazards
of 2% milk. Activities in a typical day include: Awakens • Risk for Disuse Syndrome
at 5:30 AM and gets ready for work. Works from 7 AM to • Risk for Urinary Tract Infection related to urine stasis sec-
3 PM. Walks after work with friends. Goes homes, pre- ondary to immobility
pares dinner, does household chores, watches TV; in bed
by 10:30 PM. Actual Diagnoses
Ms. Funstead works at a local factory on an assem- • Impaired Physical Mobility related to impaired joint move-
bly line. She picks up small parts and places them in ment, decreased muscle strength, or fractured bone
a motor. She twists from side to side throughout the • Activity Intolerance related to muscle weakness or joint
work day. She has one 15-minute break in the morning, pain
30 minutes for lunch, and one 15-minute break in the • Constipation related to decreased gastric motility and mus-
afternoon. She stands while at work and is required to cle tone secondary to immobility
wear steel-toed shoes. She denies difficulty performing • Ineffective Sexuality Pattern related to lower back pain
ADLs. She does not require the use of assistive devices • Acute (or Chronic) Pain related to joint, muscle, or bone
for mobility. Client denies any change in body image problems
or self-esteem. • Impaired Skin Integrity related to prolonged pressure on
Physical Exam Findings the skin secondary to immobility
Inspection: Posture erect. Movement is coordinated and • Impaired Social Interaction related to depression or immo-
rhythmic. Arms swing in opposition. Able to stand bility
• Disturbed Body Image related to skeletal deformities
ABNORMAL FINDINGS
SELECTED COLLABORATIVE PROBLEMS
Case Study
After grouping the data, certain collaborative problems may
become apparent. Remember that collaborative problems After collecting and analyzing the data
differ from nursing diagnoses in that they cannot be pre- for Frances Funstead, the nurse deter-
vented by nursing interventions alone. However, these physi- mines that the following conclusions are
ologic complications of medical conditions can be detected appropriate:
and monitored by the nurse. In addition, the nurse can use
physician- and nurse-prescribed interventions to minimize the
complications of these problems. The nurse may also have to Nursing Diagnoses
refer the client in such situations for further treatment of the • Acute pain: lower back r/t possible work pattern strain
problem. on back muscles
Following is a list of collaborative problems that may be • Readiness for Enhanced Self-health Management r/t
identified when obtaining a general impression. These prob- seeking help from occupational health nurse
lems are worded as Risk for Complications (RC), followed by • Impaired Home Maintenance r/t limitations on abil-
the problem: ity to care for home
• RC: Osteoporosis • Risk for Interrupted Family Processes r/t inability to
• RC: Joint dislocation participate in sexual relations with husband, and to
• RC: Compartmental syndrome fulfill usual home maintenance role
• RC: Pathologic fractures Potential Collaborative Problems
• RC: Nerve damage, vertebral or sciatic
MEDICAL PROBLEMS • RC: Slipped or herniated disc
• RC: Emotional depression
After grouping the data, it may become apparent that the • RC: Leg muscle paralysis
client’s signs and symptoms clearly require medical diag- To view an algorithm depicting the process of diag-
nosis and treatment. Referral to a primary care provider is nostic reasoning for this case, go to .
necessary.
ABNORMAL FINDINGS 24-1 Abnormal Spinal Curvatures

FLATTENING OF THE LUMBAR CURVE KYPHOSIS
Flattening of the lumbar curvature may be seen with a her- A rounded thoracic convexity (kyphosis) is commonly seen
niated lumbar disc or ankylosing spondylitis. in older adults.
(Used with permission from Frymoyer, J.W., Wiesel, S.W. et al.

(Courtesy of Martin Herman, M.D.)
[2004]. The adult and pediatric spine. Philadelphia: Lippincott
Williams & Wilkins.)

ABNORMAL FINDINGS
ABNORMAL FINDINGS 24-1 Abnormal Spinal Curvatures (Continued)

LUMBAR LORDOSIS SCOLIOSIS
An exaggerated lumbar curve (lum- A lateral curvature of the spine with an increase in convexity on the side that is
bar lordosis) is often seen in preg- curved is seen in scoliosis.
nancy or obesity.
(Used with permission from Berg, D. &

Worzala, K. [2006]. Atlas of adult physical
diagnosis. Philadelphia: Lippincott Williams &
Wilkins.)
(Used with permission from SIU/Biomedical

Communications/Custom Medical Stock
Photography.)
(Used with permission from Oatis, C.A.

[2004]. Kinesiology: The mechanics
and pathomechanics of human move-
ment. Baltimore: Lippincott Williams &
Wilkins.)
ABNORMAL FINDINGS 24-2 Abnormalities Affecting the Wrists, Hands, and Fingers
The following abnormalities are commonly associated with the upper extremities. Early detection is important because
early intervention may help to preserve dexterity and daily function.
ACUTE RHEUMATOID ARTHRITIS CHRONIC RHEUMATOID ARTHRITIS

Tender, painful, swollen, stiff joints are seen in acute rheu- Chronic swelling and thickening of the metacarpophalan-
matoid arthritis. geal and proximal interphalangeal joints, limited range of
motion, and finger deviation toward the ulnar side are seen
in chronic rheumatoid arthritis.
(© 1991 National Medical Slide Bank/CMSP.)
(© 1995 Science Photo Library.)

ABNORMAL FINDINGS
ABNORMAL FINDINGS 24-2 Abnormalities Affecting the Wrists, Hands,
and Fingers (Continued)
BOUTONNIÈRE AND SWAN-NECK associated with arthritic changes in other joints. Flexion and
DEFORMITIES deviation deformities may develop.
Flexion of the proximal interphalangeal joint and hyper-
extension of the distal interphalangeal joint (boutonnière
deformity) and hyperextension of the proximal interpha-
langeal joint with flexion of the distal interphalangeal joint
(swan-neck deformity) are also common in chronic rheu-
matoid arthritis.
Heberden’s nodes (© 1991 National Medical Slide Bank/CMSP).
Similar nodules on the proximal interphalangeal joints

(Bouchard’s nodes) are less common. The metacarpopha-
langeal joints are spared.
Boutonnière deformity (© 1990 CMSP).
Bouchard’s nodes (© 1991 National Medical Slide Bank/CMSP).
TENOSYNOVITIS
Painful extension of a finger may be seen in acute tenosy-
novitis (infection of the flexor tendon sheaths).
Swan neck deformity (© 1991 National Medical Slide Bank/CMSP).
GANGLION
Nontender, round, enlarged, swollen, fluid-filled cyst (gan-
glion) is commonly seen at the dorsum of the wrist.
(© 1995 Michael English, M.D./CMSP.)
THENAR ATROPHY
Atrophy of the thenar prominence due to pressure on the
median nerve is seen in carpal tunnel syndrome.
OSTEOARTHRITIS
Osteoarthritis (degenerative joint disease) nodules on the
dorsolateral aspects of the distal interphalangeal joints
(Heberden’s nodes) are due to the bony overgrowth of osteo- Normal
hypothenar
arthritis. Usually hard and painless, they may affect middle- eminence
aged or older adults and often, although not always, are
Flattened
thenar
eminence
(Used with permission from Bickley, L. S., & Szilagyi, P. [2003].
Bates’ guide to physical examination and history taking [8th ed.].
Philadelphia: Lippincott Williams & Wilkins.)
ABNORMAL FINDINGS
ABNORMAL FINDINGS 24-3 Abnormalities of the Feet and Toes

The following abnormalities affect the feet and toes, typically causing discomfort and impeding mobility. Early detection
and treatment can help to restore or maximize function.
ACUTE GOUTY ARTHRITIS CORN

In gouty arthritis, the metatarsophalangeal joint of the Corns are painful thickenings of the skin that occur over
great toe is tender, painful, reddened, hot, and swollen. bony prominences and at pressure points. The circular, cen-
tral, translucent core resembles a kernel of corn.
(© 1995 Science Photo Library/CMSP.)
FLAT FEET
A flat foot (pes planus) has no arch and may cause pain and
swelling of the foot surface. (Used with permission from Goodheart, H. P. [2003]. Goodheart’s
Medial border becomes convex photoguide of common skin disorders [2nd ed.]. Philadelphia:
Lippincott Williams & Wilkins.)
HAMMER TOE
Hyperextension at the metatarsophalangeal joint with flex-
ion at the proximal interphalangeal joint (hammer toe)
commonly occurs with the second toe.
Sole touches floor

(Used with permission from Bickley, L. S. & Szilagyi, P. [2003].
Bates’ guide to physical examination and history taking [8th ed.].
Philadelphia: Lippincott Williams & Wilkins.)
CALLUS
Calluses are nonpainful, thickened skin that occur at pres-
sure points.
PLANTAR WART
Plantar warts are painful warts (verruca vulgaris) that often
occur under a callus, appearing as tiny dark spots.
HALLUX VALGUS
Hallux valgus is an abnormality in which the great toe
is deviated laterally and may overlap the second toe. An
enlarged, painful, inflamed bursa (bunion) may form on
the medial side.
(Used with permission from Goodheart, H. P. [2003]. Goodheart’s
photoguide of common skin disorders [2nd ed.]. Philadelphia:
Lippincott Williams & Wilkins.)
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Concepts in Action Animations Documentation tools
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CHAPTER 24

Facial bones Clavicle

BOX 24-1 ILLUSTRATED GLOSSARY OF SKELETAL MOVEMENT TERMS

Teres minor Trapezius

B Posterior view FIGURE 24-2 (Continued)

FIGURE 24-3 Components of synovial joints

BOX 24-2 UNDERSTANDING MAJOR JOINTS

Left posterior view. Right anterior view.

Continued on following page

BOX 24-2 UNDERSTANDING MAJOR JOINTS (Continued)

WRIST, FINGERS, THUMB Distal interphalangeal

Atlas Anterior superior

Left lateral view.

KNEE ANKLE AND FOOT

Lateral epicondyle Tibiotalar

History of Present Health Concern

Personal Health History

Lifestyle and Health Practices

Mnemonic Question Data Provided

24-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: OSTEOPOROSIS

ASSESSMENT GUIDE 24-1 Assessing Joints and Muscles

Rating Explanation Strength Classiﬁcation

Equipment Physical Assessment

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Temporomandibular Joint (TMJ)

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Temporomandibular Joint (TMJ) (Continued)

FIGURE 24-4 Inspecting and palpating the temporomandibular

Cervical, Thoracic, and Lumbar Spine

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Cervical disc degenerative disease and

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Cervical, Thoracic, and Lumbar Spine (Continued)

FIGURE 24-9 Thoracic and lumbar

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Right lateral 0° Left lateral 0°

Test for back and leg pain. If the client

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Cervical, Thoracic, and Lumbar Spine (Continued)

FIGURE 24-11 Performing the straight leg test.

Shoulders, Arms, and Elbows

Then have the client bring both hands

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Straighten the elbow.

Then the hold arm out, turn the palm down,

Last, have the client repeat the movements

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Signs of a wrist fracture include pain,

FIGURE 24-17 Palpating the wrists.

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

FIGURE 24-21 Median nerves entrapped in the carpal

Hands and Fingers

In osteoarthritis, hard, painless nodules

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Hands and Fingers (Continued)

FIGURE 24-22 Normal range of motion of the fingers:

The most common injuries of the hip and