NUR 224 ‫ﻛﻠﯾﺔ اﻟﺗﻣرﯾض‬

Physical Assessment
and Health Promotion
Lecture 12 (Week 12)

Assessment of
Musculoskeletal System

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Mission: Contribute to society building that promotes sustainable

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research and community partnership in a stimulating environment for learning )) ‫وﺑﺣﺛﯾﺔ ﻣﺣﻔزة ﺗﺳﮭم ﻓﻲ ﺗطوﯾر وﺧدﻣﺔ اﻟﻣﺟﺗﻣﻊ‬
and creativity.
By the end of this lecture the students will be able to:
• Identify the structures and functions of the musculoskeletal
system
• Discuss the questions that should be asked to collect
subjective data about the musculoskeletal system of the
patients.
• Identify different assessment skills of musculoskeletal system
including inspection, palpation, range of movement and
muscles strength.
• Demonstrate an understanding of determining normal range
of movement (ROM) for different areas, joint strength and
muscle strength for all region of the musculoskeletal system.

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 Musculoskeletal Components

⬤ Nonsynovial or ⬤ Shoulder
synovial joints ⬤ Elbow
⬤ Muscles ⬤ Wrist and carpals
⬤ Temporomandibular ⬤ Hip
joint ⬤ Knee
⬤ Spine ⬤ Ankle and foot

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The musculoskeletal system consists of the body's bones, joints, and muscles.
(1) for support to stand erect, and (2) for movement (3) to encase and protect the
inner vital organs (e.g., brain, spinal cord, heart); (4) to produce the red blood cells,
white blood cells, and platelets in the bone marrow (hematopoiesis); and (5) as a
reservoir for storage of essential minerals such as calcium and phosphorus in the
bones.

Joint-place of union of 2 or more bones, are the functional units of the musculoskeletal
system → permit mobility
Synovial Joints:
Freely movable, have cartilage, ligament, and synovial fluid. ( knee, hip, wrist..)
Synovial fluid reduces friction during movement
Non-synovial Joints:
Immovable, united by fibrous tissue or cartilage (Sutures in the skull)
Slightly movable like the vertebra

Muscles- when they contact, they produce movement.

3 types: skeletal, smooth, & cardiac.

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 Skeletal Muscles
⬤ Skeletal muscles produce following
movements:
Flexion: bending limb at a joint
Extension: straightening limb at a joint
Abduction: moving limb away from midline of the
body
Adduction: moving limb toward midline of the
body
Pronation: turning the forearm so that palm is
down
Supination: turning the forearm so that palm is up
Circumduction: moving arm in circle around the
shoulder
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Skeletal muscles: voluntary muscles, attached to bone
by a tendon (strong fibrous cord). They produce
different movements

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 Skeletal Muscles
⬤ Skeletal muscles produce following
movements:
Inversion: moving sole of foot inward at the ankle
Eversion: moving sole of foot outward at the ankle
Rotation: moving head around central axis
Protraction: moving body part forward, parallel to
ground
Retraction: moving body part backward, parallel to
ground
Elevation: raising a body part
Depression: lowering a body part

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Skeletal Muscle Movements

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 Subjective Data Assessment
Joints:
1. Any problems with your joints? Any pain?
Location, Quality, Onset, Timing
2. Any stiffness in your joints?
3. Any swelling, heat, redness in your joints?
Suggests inflammation
4. Any limitation of movement in any joint?
Decreased ROM is due to injury to capsule or cartilage, or muscle
contracture
Muscles:
1. Any problems with your muscles? Cramping? Aching? Which
muscle?
2. Calf pain? During walking? Does it go away with rest?
3. Are you muscle aches associated with chills, fever (flu)?
4. Any weakness in your muscles? Do the muscles look smaller?

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 Subjective Data Assessment
Bones:
⬤ Any bone pain? Affected by movement?

⬤ Any deformity of any bone or joint? Is it due to injury?

Does it affect the ROM?

⬤ Any accidents or trauma?

⬤ Any fracture, sprain, strain, dislocation?

⬤ Back pain? Exact location and radiation?

⬤ Any numbness / tingling? Limping?

Strain: weakening or
Sprain: injury to soft
stretching of a muscle at the
tissues surrounding a joint
tendon area

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 Subjective Data Assessment
Functional Assessment (ADLs):
⬤ Do your joints problems (muscle, bone) affect your usual
activities of daily living (ADLs)?Which one?

Patient Centered Care:

⬤ Occupational hazards: Heavy lifting, chronic stress on joints?

Any alleviating measures?

⬤ Exercise program: Type, warm-up, pain during exercise.

⬤ Recent weight gain.

⬤ Usual daily diet: calories, food groups, proteins, calcium.

⬤ Medications: NSAID, Aspirin

⬤ Effect of disability on interaction with the family, friends,

self image.
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 Order of the Examination
⬤ Inspection
Note the size and contour of joint; inspect skin and tissues
over the joints for color, swelling, and any masses or
deformity
Presence of swelling signals joint irritation
Use the contralateral side for comparison
⬤ Palpation
Palpate each joint, including skin for temperature, muscles,
bony articulations, and area of joint capsule; notice any
heat, tenderness, swelling, or masses which signal
inflammation
Joints normally not tender to palpation
If tenderness occurs, localize to specific anatomic
structures, for example, skin, muscles, bursae, ligaments,
tendons, fat pads, or joint capsule
Synovial membrane normally is not palpable

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Bursae-fluid filled sac (synovial bursae)

Fat pad-(haversian gland)-mass of closely packed fat cell surrounded by fibrous

tissue (intraarticular fat pad-

Joint capsule- envelope surrounding synovial joint

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 Range of Motion (ROM)
⬤ Ask for active voluntary ROM while stabilizing the
body area proximal to that being moved
⬤ Familiarize yourself with the type of each joint and
its normal ROM so that you can recognize
limitations
⬤ For limitations, gently attempt passive motion;
anchor joint with one hand while other hand
slowly moves it to its limit; normal ranges of
active and passive motion should be the same
⬤ Joint motion normally causes no tenderness,
pain, or crepitation
⬤ Do not confuse crepitation with normal discrete
“crack” heard as tendon or ligament slips over
bone during motion, like knee bend
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 Muscle Testing

⬤ Test strength of prime mover muscle

groups for each joint; repeat motions for
active ROM
⬤ Ask person to flex and hold as you apply

opposing force
⬤ Muscle strength should be equal bilaterally

and should fully resist opposing force

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Grading System from No Voluntary
Movement to Full Strength:

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 Temporomandibular Joint
⬤ With person seated, inspect area just anterior to ear
⬤ Place tips of first two fingers in front of each ear and ask
person to open and close mouth
⬤ Drop fingers into depressed area over joint, and note smooth
motion of mandible
⬤ Audible and palpable snap or click occurs in many healthy
people as mouth opens
⬤ Open mouth maximally
⬤ Partially open mouth, protrude lower jaw, and move it side to
side.
⬤ Stick out lower jaw.
⬤ Palpate contracted temporalis and masseter muscles as
person clenches teeth
⬤ Compare right and left sides for size, firmness, and strength
⬤ Ask person to move jaw forward and laterally against your
resistance, and to open mouth against your resistance
This tests integrity of cranial nerve V (trigeminal nerve)
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Week 12: Physical Assessment and Health Promotion
 Cervical Spine
⬤ Inspect alignment of head and
neck
Spine should be straight, and
head erect
Ask the person to follow
these motions: Extension,
Flexion Lateral bending
⬤ Palpate spinous processes and
sternomastoid, trapezius
They should feel firm, with no
muscle spasm or tenderness
⬤ Repeat motions while applying
opposing force
⬤ Person normally can maintain
flexion against full resistance
This tests integrity of cranial
nerve XI (spinal nerve)

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 Shoulder
⬤ Inspect and compare both shoulders posteriorly and
anteriorly
Check size and contour of joint and compare
shoulders for equality of bony landmarks
Normally no redness, muscular atrophy,
deformity, or swelling is present
• While standing in front of person, palpate both
shoulders. Start at the clavicle, acromioclavicular
joint, scapula, greater tubercle of the humerus.
• Note any muscular spasm or atrophy, swelling, heat,
or tenderness
• Palpate the pyramid-shaped axilla. No adenopathy or
masses should be present

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 Shoulder
⬤ Test ROM by asking person
to perform four motions:
forward flexion, internal
rotation, abduction, external
rotation.
⬤ Cup one hand over the
shoulder to note any
crepitation; normally none is
present.
⬤ Test strength of shoulder
muscles by asking person to
shrug shoulders, flex
forward and up, and abduct
against your resistance
⬤ Shoulder shrug also tests
integrity of cranial nerve XI,
spinal accessory nerve

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 Elbow
Inspect size and contour of elbow in both
flexed and extended positions
Look for deformity, redness, or swelling
Check olecranon bursa and the
normally present hollows on either side
of the olecranon process for abnormal
swelling
Palpate with the elbow flexed about 70
degrees.
Use your left hand to support the
person's left forearm and palpate the
extensor surface of the elbow—the
olecranon process and the medial and
lateral epicondyles of the humerus—
with your right thumb and fingers.
Palpate for heat, swelling, tenderness,
consistency, or nodules.
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⬤ Olecranon bursa-is a pointy bone at the tip of
the elbow

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 Elbow
⬤ Test ROM
Bend and straighten the elbow
❑ Flexion of 150 to 160 degrees;

Extension at 0. Some healthy people

lack 5 to 10 degrees of full extension,
and others have5 to 10 degrees
of hyperextension.

Movement of 90 degrees in
pronation and supination
❑ Hold the hand midway; then
touch front and back sides of hand
to table.
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 Elbow
⬤ While testing muscle
strength, stabilize person’s
arm with one hand
Have person flex elbow
against your resistance
applied just proximal
to wrist
Then ask person to
extend elbow against
your resistance

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 Wrist and Hand
⬤ Inspect hands and wrists on dorsal and
palmar sides
Note position, contour, and shape;
normally no swelling or redness,
deformity, or nodules are present
⬤ Palpate each joint in wrist and hands
Normally joint surfaces feel smooth,
with no swelling, bogginess,
nodules, or tenderness
Palpate the metacarpophalangeal
joints with your thumbs, just distal
to and on either side of the knuckle
Use your thumb and index finger in
a pinching motion to palpate the
sides of the interphalangeal joints.
Normally no synovial thickening,
tenderness, warmth, or nodules are
present
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 Wrist and Hand
• Test ROM:
Instruct the Person to:
Bend hand up at wrist; Bend hand down
at wrist; Bend fingers up and down at
metacarpophalangeal joints; With palms
flat on table, turn them outward and in;
Spread fingers apart; make a fist; Touch
thumb to each finger and to base of
little finger
• For muscle testing, position
person’s forearm palm up and
resting on a table; stabilize by
holding your hand at person’s
mid-forearm; ask person to flex
wrist against your resistance
at palm

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Week 12: Physical Assessment and Health Promotion
 Carpal Tunnel Testing
⬤ Phalen test
Ask person to hold both hands back
–to- back while flexing wrists 90
degrees
Acute flexion of wrist for 60 seconds
produces no symptoms in the
normal hand
Test reproduces numbness and
burning in person with carpal tunnel
syndrome
⬤ Tinel Sign
Direct percussion of location of
median nerve at wrist produces no
symptoms in normal hand
Percussion of median nerve
produces burning and tingling along
its distribution, which is a positive
Tinel sign for carpal tunnel
syndrome 27
Week 12: Physical Assessment and Health Promotion
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 Hip
⬤ Inspect hip joint together with spine later in
examination as person stands; note
symmetric levels of iliac crests, gluteal folds,
and equally sized buttocks
Smooth, even gait reflects equal leg lengths and
functional hip motion
⬤ Help person into supine position and palpate
hip joints; joints should feel stable and
symmetric, with no tenderness or crepitation

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 ⬤ Hip
Assess ROM:
Limitation of abduction of hip while supine is most
common motion dysfunction found in hip disease

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 Knee
⬤ Inspect knee’s shape and contour; normally
distinct hollows present on either side of
patella; check for any sign of fullness or
swelling; note other locations for any
abnormal swelling
⬤ Check quadriceps muscle in anterior thigh
for any atrophy; because it is a prime mover
of the knee, it is important for joint stability
during weight-bearing

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 Knee
• Palpate the knee in the supine position
with complete relaxation of the
quadriceps muscle. Start high on the
anterior thigh, about 10 cm above the
patella using left thumb and fingers in a
grasping. Proceed down toward the knee
and suprapatellar pouch. The muscles
and soft tissues should feel solid, and the
joint should feel smooth, with no
warmth, tenderness, thickening, or
nodularity.

• Palpate the tibiofemoral joint. Note

smooth joint margins and absence of
pain.
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Week 12: Physical Assessment and Health Promotion
 Knee
Test ROM:
• Bend each knee. Flexion of
130 to 150 degrees.
• Extend each knee. A straight
line of 0 degrees in some
people; a hyperextension of 15
degrees in others.
• Check knee ROM during
ambulation

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 Ankle and Foot
⬤ Inspect while person is sitting and
when standing and walking
Compare both feet, noting
contour of joints; foot should
align with long axis of lower leg.

⬤ Support ankle by grasping heel with

your fingers while palpating with your
thumbs; joint spaces should feel
smooth, with no swelling or tenderness

⬤ Palpate metatarsophalangeal joints

between your thumb on dorsum and
fingers on plantar surface. Using a
pinching motion of your thumb and
forefinger, palpate the interphalangeal
joints on the medial and lateral sides of
the toes
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 Ankle and Foot
⬤ Test ROM
Assess muscle strength
asking person to maintain
dorsiflexion and plantar
flexion against your
resistance

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 Spine
⬤ Person should be standing, draped in
gown open at back
Place yourself far enough back so
that you can see entire back
⬤ Inspect and palpate spine and spinous

processes. Note if spine is straight by

following imaginary vertical line from
head through spinous processes to
gluteal cleft, and noting equal
horizontal positions for shoulders,
scapulae, iliac crests, and gluteal folds
⬤ From side, note normal convex thoracic

curve and concave lumbar curve

⬤ Check ROM of spine by asking person to

touch toes; look for flexion of 75 to 90

degrees, and smoothness and symmetry
of movement
Week 12: Physical Assessment and Health Promotion 36
 Spine
⬤ Stabilize pelvis with your hands;
Check ROM
Bend sideways: lateral bending
of 35 degrees
Bend backward: hyperextension
of 30 degrees
Twist shoulders to one side,
then the other: rotation of 30
degrees, bilaterally
• These maneuvers reveal gross
restrictions only; movement is
still possible even if some
spinal fusion has occurred
Finally, ask person to walk on
his or her toes for a few steps,
then return walking on heels
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 Kyphosis
⬤ An exaggerated posterior curvature of
the thoracic spine.

⬤ Causes severe back pain and

cardiopulmonary function.

⬤ Associated with aging.

⬤ Postural change with decrease in

height, shortening of trunk

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 Scoliosis
⬤ Lateral curvature of the
thoracic and lumbar segments
of the spine.

⬤ Most apparent during the

preadolescent growth spurt.

⬤ Asymmetry shape, ribs hump

up on one side as child bends
forward.

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 Summary Checklist:
Musculoskeletal Examination
Inspection
• Size and contour of joint
• Skin color and characteristics
Palpation of joint area
• Skin, muscles, bony articulations, and joint capsules
ROM
• Active
• Passive (If limitation in active ROM is present)
• Measure with goniometer (if abnormality in ROM is
present)
Muscle testing

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Goniometer-an instrument for the precise
measurement of angles. Especially one used to
measure the angles between the faces of crystals

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 Documentation

Week 12: Physical Assessment and Health Promotion 42

 Question
The nurse is assessing a patient’s risk of
developing osteoporosis. Which patient is
considered at high risk for osteoporosis?
1. A 65-year-old man being treated for
hypertension
2. A 55-year-old woman who has had right knee
replacement surgery
3. A 30-year-old woman who smokes and is taking
oral contraceptives
4. A 25-year-old man who plays numerous college
sports

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The correct answer is 2. A postmenopausal woman who
has had joint replacement surgery is at a higher risk for
osteoporosis than all those in options 1, 3, and 4.
Answer 1 is incorrect because hypertension and being
male does not increase the risk of osteoporosis.
Answer 3 is incorrect because smoking and taking oral
contraception places this patient at risk for
cerebrovascular accident and does not increase risk of
osteoporosis.
Answer 4 is incorrect because this patient is decreasing
his risk of getting osteoporosis by playing sports.

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 Question
A patient tells the nurse that she has
rheumatoid arthritis (RA). The symptoms this
patient is likely to exhibit are pain and stiffness
in the:
1. joints that increases with activity.
2. joints that is relieved with rest.
3. right elbow and left knee relieved with
medication.
4. joints that is worse in the morning and improves
with activity.

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The correct answer is 4. RA is worse
in the morning and improves with
activity.
Answer 1 is incorrect because
activity helps symptoms of RA.
Answer 2 is incorrect because rest
will increase stiffness associated with
RA.
Answer 3 is incorrect because
unilateral joint involvement is a
symptom of osteoarthritis (OA).

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 Next week’s lecture:

Assessment of
Male and Female Genitourinary System
Breast and Regional Lymphatics

Read Chapter pp. 509-526, 529-538, 853-867, 872-883, 912-932, 937-950

in the course
e-book

References

• Jarvis, C (2020). Physical Examination and Health Assessment (8th ed.).

Philadelphia: W.B. Saunders, USA.

Week 12: Physical Assessment and Health Promotion 47