HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
STRUCTURE AND FUNCTION
• The body’s bones, muscles, and joints
o Compose the musculoskeletal system.
• Musculoskeletal system
o Controlled and innervated by the nervous system, the
musculoskeletal system’s overall purpose is to provide
structure and movement for body parts.
BONES
• Bones
o Provide structure, give protection, serve as levers, store
calcium, and produce blood cells.
o A total of 206 bones make up the axial skeleton (head and
trunk) and the appendicular skeleton (extremities,
shoulders, and hips).
• Composed of osseous tissue.
• Bones can be divided into two types:
1. Compact bone
- Is hard and dense and makes up the shaft and outer
layers.
2. Spongy bone
- Contains numerous spaces and makes up the ends
and centers of the bones.
• Osteoblasts and osteoclasts
o Bone tissue is formed by active cells called osteoblasts and
broken down by cells referred to as osteoclasts.
• Bones contain red marrow that produces blood cells and
yellow marrow composed mostly of fat.
• Periosteum
o Covers the bones.
o It contains osteoblasts and blood vessels that promote
nourishment and formation of new bone tissues.
• Bone shapes vary and include short bones (e.g., carpals), long
bones (e.g., humerus, femur), flat bones (e.g., sternum, ribs),
and bones with an irregular shape (e.g., hips, vertebrae).
SKELETAL MUSCLES
• The body consists of three types of muscles: skeletal, smooth,
and cardiac.
• The musculoskeletal system is made up of 650 skeletal
(voluntary) muscles, which are under conscious control.
• Skeletal muscles
o Made up of long muscle fibers (fasciculi) that are arranged
together in bundles.
o Joined by connective tissue.
o They attach to bones by way of strong, fibrous cords called
tendons.
o They assist with posture, produce body heat, and allow the
body to move. Skeletal muscle movements include:
1. Abduction: Moving away from midline of the body.
2. Adduction: Moving toward midline of the body.
3. Circumduction: Circular motion.
4. Inversion: Moving inward.
5. Eversion: Moving outward.
6. Extension: Straightening the extremity at the joint
and increasing the angle of the joint.
7. Hyperextension: Joint bends greater than 180
degrees.
8. Flexion: Bending the extremity at the joint and
decreasing the angle of the joint.
9. Dorsiflexion: Toes draw upward to ankle.
10. Plantar flexion: Toes point away from ankle.
11. Pronation: Turning or facing downward.
12. Supination: Turning or facing upward.
13. Protraction: Moving forward.
14. Retraction: Moving backward.
15. Rotation: Turning of a bone on its own long axis.
16. Internal rotation: Turning of a bone toward the center
of the body.
17. External rotation: Turning of a bone away from the
center of the body.
JOINTS
• Joint (or articulation)
o It is the place where two or more bones meet.
o They provide a variety of ranges of motion (ROM) for the
body parts and may be classified as fibrous, cartilaginous,
or synovial.
1. FIBROUS JOINTS
• E.g., sutures between skull bones.
• Are joined by fibrous connective tissue.
• Are immovable.
2. CARTILAGINOUS JOINTS
• E.g., joints between vertebrae.
• Are joined by cartilage.
3. SYNOVIAL JOINTS
• E.g., shoulders, wrists, hips, knees, ankles.
• They contain a space between the bones that is filled with
synovial fluid, a lubricant that promotes a sliding movement of
the ends of the bones.
• Bones in synovial joints are joined by ligaments, which are
strong, dense bands of fibrous connective tissue.
• Synovial joints are enclosed by a fibrous capsule made of
connective tissue and connected to the periosteum of the bone.
• Articular cartilage smooths and protects the bones that
articulate with each other.
• Some synovial joints contain bursae, which are small sacs filled
with synovial fluid that serve to cushion the joint.
COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
• Assessment of the musculoskeletal system helps to evaluate
the client’s level of functioning with activities of daily living
(ADLs).
• This system affects the entire body, from head to toe, and
greatly influences what physical activities a client can and
cannot do.
• Only the client can give you data regarding pain, stiffness, and
levels of movement and how ADLs are affected.
• In addition, information regarding the client’s nutrition,
activities, and exercise is a significant part of the
musculoskeletal assessment.
• Pain or stiffness is often a chief concern with musculoskeletal
problems; therefore, a pain assessment may also be needed.
o It is very important to remember to investigate signs and
symptoms reported by the client.
• Remember, too, that the neurologic system is responsible for
coordinating the functions of the skeleton and muscles.
o Therefore, it is important to understand how these
systems relate to each other and to ask questions
accordingly.
• Assessment of the musculoskeletal system will provide the
nurse with information about the client’s daily activity and
exercise patterns that promote either healthy or unhealthy
functioning of the musculoskeletal system.
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CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
• Client teaching regarding exercise, diet, positioning, posture,
and safety habits to promote health thus becomes an essential
part of this examination.
COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION
• Physical assessment of the musculoskeletal system provides
data regarding the client’s posture, gait, bone structure, muscle
strength, and joint mobility, as well as the client’s ability to
perform ADLs.
• The physical assessment includes inspecting and palpating the
joints, muscles, and bones, testing ROM, and assessing muscle
strength.
PREPARING THE CLIENT
• Because this examination is lengthy, be sure that the room is at
a comfortable temperature and provide rest periods as
necessary.
• Provide adequate draping to avoid unnecessary exposure of
the client yet adequate visualization of the part being
examined.
• Explain that you will ask the client frequently to change
positions and to move various body parts against resistance
and gravity.
• Clear, simple directions need to be given throughout the
examination to help the client understand how to move body
parts to allow you to assess the musculoskeletal system.
• Demonstrating to the client how to move the various body
parts and providing verbal directions facilitate examination.
EQUIPMENT
1. Tape measure
2. Goniometer(optional)
3. Skin marking pen (optional)
PHYSICAL ASSESSMENT
• Observe gait and posture.
• Inspect joints, muscles, and extremities for size, symmetry, 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.
FINDINGS
ABNORMAL FINDINGS
GAIT
INSPECTION
• Uneven weight bearing is evident.
• Client cannot stand on heels or toes.
• Toes point in or out.
• Client limps, shuffles, propels forward, or has wide-based gait.
• Falling backward easily
o Seen with cervical spondylosis and Parkinson’s disease.
TEMPOROMANDIBULAR JOINT (TMJ)
INSPECTION AND PALPATION
INSPECT AND PALPATE THE TMJ
• Decreased ROM, swelling, tenderness, or crepitus
o May be seen in arthritis.
• Decreased muscle strength with muscle and joint disease.
• Decreased ROM, and a clicking, popping, or grating sound
o May be noted with TMJ dysfunction.
TEST ROM
• Lack of full contraction with cranial nerve V lesion.
• Pain or spasms
o Occur with myofascial pain syndrome.
STERNOCLAVICULAR JOINT
INSPECTION AND PALPATION
• Swollen, red, or enlarged joint or tender, painful joint
o Seen with inflammation of the joint.
CERVICAL, THORACIC, AND LUMBAR SPINE
INSPECTION AND PALPATION
• A flattened lumbar curvature
o May be seen with a herniated lumbar disc or ankylosing
spondylitis.
• Lateral curvature of the thoracic spine with an increase in the
convexity on the curved side
o Seen in scoliosis.
• An exaggerated lumbar curve (lordosis)
o Is often seen in pregnancy or obesity.
• Unequal heights of the hips
o Suggests unequal leg lengths.
• Compression fractures and lumbosacral muscle strain
o Can cause pain and tenderness of the spinal processes and
paravertebral muscles.
TEST ROM OF THE CERVICAL SPINE
• Cervical strain
o Is the most common cause of neck pain.
o It is characterized by impaired ROM and neck pain from
abnormalities of the soft tissue (muscles, ligaments, and
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
o 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
o May occur with cervical spinal cord compression.
TEST LATERAL BENDING
• Limited ROM
o Seen with neck injuries, osteoarthritis, spondylosis, or with
disc degeneration.
EVALUATE ROTATION
• Decreased ROM against resistance
o Seen with joint or muscle disease.
• Lateral curvature
o Disappears in functional scoliosis.
• Unilateral exaggerated thoracic convexity
o Increases in structural scoliosis.
• Spinal processes are out of alignment.
• Low back strain from injury to soft tissues
o Is a common cause of impaired ROM and pain in the
lumbar and thoracic regions.
• Other causes of impaired ROM in the lumbar and thoracic
areas include osteoarthritis, anky-losing spondylitis, and
congenital abnormalities that may affect the spinal vertebral
spacing and mobility.
MEASURE LEG LENGTH
• Unequal leg lengths
o Are associated with scoliosis.
• Equal true leg lengths but unequal apparent leg lengths
o Are seen with abnormalities in the structure or position of
the hips and pelvis.
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CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
SHOULDERS, ARMS, AND ELBOWS
INSPECTION AND PALPATION
INSPECT AND PALPATE SHOULDERS AND ARMS
• Flat, hollow, or less-rounded shoulders
o Seen with dislocation.
• Muscle atrophy
o Seen with nerve or muscle damage or lack of use.
• Tenderness, swelling, and heat
o May be noted with shoulder strains, sprains, arthritis,
bursitis, and degenerative joint disease (DJD).
TEST ROM
• Painful and limited abduction accompanied by muscle
weakness and atrophy
o Are seen with a rotator cuff tear.
• Client has sharp catches of pain when bringing hands overhead
with rotator cuff tendinitis.
• Chronic pain and severe limitation of all shoulder motions
o Are seen with calcified tendinitis.
• Inability to shrug shoulders against resistance
o Seen with a lesion of cranial nerve XI (spinal accessory).
• Decreased muscle strength
o Seen with muscle or joint disease.
ELBOWS
INSPECTION AND PALPATION
INSPECT FOR SIZE, SHAPE, DEFORMITIES, REDNESS, OR SWELLING
• Redness, heat, and swelling
o May be seen with bursitis of the olecranon process due to
trauma or arthritis.
• Firm, nontender, subcutaneous nodules
o May be palpated in rheumatoid arthritis or rheumatic
fever.
• Tenderness or pain over the epicondyles
o May be palpated in epicondylitis (tennis elbow) due to
repetitive movements of the forearm or wrists.
TEST ROM
• Decreased ROM against resistance
o Seen with joint or muscle disease or injury.
WRISTS
INSPECTION AND PALPATION
• Swelling
o Seen with rheumatoid arthritis.
• Tenderness and nodules
o May be seen with rheumatoid arthritis.
• A nontender, round, enlarged, swollen, fluid-filled cyst
(ganglion)
o May be noted on the wrists.
• 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
o Occurs when pressure is applied on the side of the hand
between the two tendons leading to the thumb.
• Snuffbox tenderness
o May indicate a scaphoid fracture, which is often the result
of falling on an outstretched hand.
TEST ROM
• Ulnar deviation of the wrist and fingers with limited ROM
o Is often seen in rheumatoid arthritis.
• Increased pain with extension of the wrist against resistance
o Is seen in epicondylitis of the lateral side of the elbow.
• Increased pain with flexion of the wrist against resistance
o Is seen in epicondylitis of the medial side of the elbow.
• Decreased muscle strength
o Is noted with muscle and joint disease.
TESTS FOR CARPAL TUNNEL SYNDROME
PERFORM PHALEN’S TEST
• If symptoms develop within a minute with Phalen’s test, carpel
tunnel syndrome is suspected.
• Client may report tingling, numbness, and pain with carpal
tunnel syndrome.
• However, if the test lasts longer than a minute, pain and
tingling may occur even in clients without carpel tunnel
syndrome.
PERFORM TEST FOR TINEL’S SIGN
• Tingling or shocking sensation experienced with test for Tinel’s
sign.
• Median nerve entrapped in the carpal tunnel
o Results in pain, numbness, and impaired function of the
hand and fingers.
OBSERVE FOR THE FLICK SIGNAL
• If the patient responds with a motion that resembles shaking a
thermometer (flick signal), carpal tunnel may be suspected.
TEST FOR THUMB WEAKNESS
• Client cannot raise the thumb up from the plane and stretch the
thumb pad to the little finger pad
o This indicates thumb weakness in carpal tunnel syndrome.
HANDS AND FINGERS
INSPECTION AND PALPATION
• Pain, tenderness, swelling, shortened finger, depressed
knuckle and/or inability to move the finger
o Seen with finger fractures.
• Swollen, stiff, tender finger joints
o Are seen in acute rheumatoid arthritis.
• Boutonnière deformity and swan-neck deformity
o Are seen in long-term rheumatoid arthritis.
• Atrophy of the thenar prominence
o May be evident in carpal tunnel syndrome.
• In osteoarthritis, hard, painless nodules
o May be seen over the distal interphalangeal joints
(Heberden’s nodes) and over the proximal interphalangeal
joints (Bouchard’s nodes).
TEST ROM
• Inability to extend the ring and little fingers
o Seen in Dupuytren’s contracture.
• Painful extension of a finger
o May be seen in tenosynovitis (infection of the flexor
tendon sheathes).
• Decreased muscle strength against resistance
o Is associated with muscle and joint disease.
HIPS
INSPECTION AND PALPATION
• Instability, inability to stand, and/or a deformed hip area
o Are indicative of a fractured hip.
• Tenderness, edema, decreased ROM, and crepitus
o Are seen in hip inflammation and DJD.
• The most common injuries of the hip and groin region in
athletes are groin pulls and hamstring strains.
• Strains
o A stretch or tear of muscle or tendons.
o Often occur in the lower back and the hamstring muscle.
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CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
TEST ROM
• Inability to abduct the hip
o Is a common sign of hip disease.
• Pain and a decrease in internal hip rotation
o May be a sign of osteoarthritis or femoral neck stress
fracture.
• Pain on palpation of the greater trochanter and pain as the
client moves from standing to lying down
o May indicate bursitis of the hip.
• Decreased muscle strength against resistance
o Seen in muscle and joint disease.
KNEES
INSPECTION AND PALPATION
• Knees turn in with knock knees (genu valgum) and turn out
with bowed legs (genu varum)
• Swelling above or next to the patella
o May indicate fluid in the knee joint or thickening of the
synovial membrane.
• Tenderness and warmth with a boggy consistency
o May be symptoms of synovitis.
• Asymmetric muscular development in the quadriceps
o May indicate atrophy.
TESTS FOR SWELLING
• Bulge of fluid
o Appears on medial side of knee, with a small amount of
joint effusion.
PERFORM THE BALLOTTEMENT TEST
• Fluid wave or click palpated, with large amounts of joint
effusion.
• A positive ballottement test
o May be present with meniscal tears.
• A patellofemoral disorder
o May be suspected if both crepitus and pain are present on
examination.
TEST ROM
• Osteoarthritis
o Is characterized by a decreased ROM with synovial
thickening and crepitation.
• Flexion contractures of the knee
o Are characterized by an inability to extend knee fully.
• Decreased muscle strength against resistance
o Seen in muscle and joint disease.
TEST FOR PAIN AND INJURY
• Pain or clicking
o Is indicative of a torn meniscus of the knee.
ANKLES AND FEET
INSPECTION AND PALPATION
WITH THE CLIENT SITTING, STANDING, AND WALKING, INSPECT
POSITION, ALIGNMENT, SHAPE, AND SKIN
• A laterally deviated great toe with possible overlapping of the
second toe and possible formation of an enlarged, painful,
inflamed bursa (bunion) on the medial side
o Is seen with hallux valgus.
• Common abnormalities include feet with no arches (pes planus
or “flat feet”), feet with high arches (pes cavus); painful
thickening of the skin over 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).
PALPATE ANKLES AND FEET FOR TENDERNESS, HEAT, SWELLING, OR
NODULES
• Ankles are the most common site of sprains, which occur with
stretched or torn ligaments (tough bands of fibrous tissue
connecting bones in a joint; Mayo Clinic Staff, 2011).
• Tender, painful, reddened, hot, and swollen
metatarsophalangeal joint of the great toe
o Seen in gouty arthritis.
• Nodules of the posterior ankle
o May be palpated with rheumatoid arthritis.
• Pain and tenderness of the metatarsophalangeal joints
o Seen in inflammation of the joints, rheumatoid arthritis,
and DJD.
• Tenderness of the calcaneus of the bottom of the foot
o May indicate plantar fasciitis.
• Plantar fasciitis is the most common cause of heel pain, which
occurs when the strong supportive band of tissue in the arch of
the foot becomes irritated and inflamed.
• Use the Ottawa ankle and foot rules (Box 24-3) to determine
need for X-ray referral.
TEST ROM
• Decreased strength against resistance
o Seen in muscle and joint disease.
• Hyperextension of the metatarsophalangeal joint and flexion
of the proximal interphalangeal joint
o Is apparent in hammer toe.
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM
HEALTH ASSESSMENT | NCM 101
CHAPTER 3: ASSESSING MUSCULOSKELETAL SYSTEM