College of Medicine and Health Science

Department of Adult Health Nursing

Musculoskeletal assessment

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Introduction
• The musculoskeletal system is the supporting
framework and collectively the largest system in
the body.

• It is word of 2 syllables
• Muscle + Skeletal

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So it Consists of:
• A. Muscles (accounts for approximately 50%
of the body weight):
• B. Bony structures and connective tissue
(accounts for approximately 25% of the body
weight):
• 1-The Skeleton
• 2-Supportive connective tissues
• 3-Articular system(Joints)

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Bones of the human skeleton

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Anterior and posterior view of
human muscle

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Types muscles
1.Skeletal muscles (voluntary
and striated),
2.Cardiac muscles
(involuntary and striated)
3.Smooth/visceral muscles
(involuntary and non-
striated)

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7
Skeletal muscles

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Types of Muscle Contractions:
• 1-isometric contraction, the length of the muscles
remains constant but the force generated by the
muscles is increased; an example of this is when
one pushes against an immovable wall.
• 2- Isotonic contraction, is characterized by
shortening of the muscle with no increase in
tension within the muscle; an example of this is
flexion of the forearm.

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• NB: Many muscle. movements are a combination of
isometric and isotonic contraction.
• For example, during walking, isotonic contraction
results in shortening of the leg, and isometric
contraction causes the stiff leg to push against the
floor

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The function of muscle
• Movement of body parts: by isotonic & isometric
contractions
• Maintenance of posture
• Production of body heat

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SKELETAL FUNCTION
Movement
Support: protects the internal body organs
 factory which produces red blood cells from
the bone marrow of certain bones and white cells
from the marrow of other bones
 a storehouse for minerals - calcium, for
example - which can be supplied to other parts of
the body

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 Consists of:
1. The Skeleton (bones)
2. Articular system (Joints)
3. Supportive connective tissues
• (Cartilage, ligaments, tendons)

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1-The Skeleton(Bones):
Mobility and weight-bearing capacity are directly
related to the bone’s size and shape.
Bones: composed of : cells, protein matrix, and
mineral deposits.

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2- Joints
Joint: the point at which two or more bones
meet. The synovial membrane lines the joints. It
secretes synovial fluid that acts as a lubricant so
the joint can move smoothly
Components: (Synovial fluid-Cartilage-
Tendons-Ligaments-Bursa)

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• Bursa: disc shaped, fluid-filled synovial sacs that
develop at points of friction around joints, between
tendons, cartilage & bone decrease friction & promote
ease of motion

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Movable joints

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Joint motion produced by muscle
contraction - terms
• Flexion • Inversion
• Extension • Eversion
• Dorsiflexion • Internal rotation
• Plantar flexion • External rotation
• Adduction • Pronation
• Abduction • Supination

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Muscular Movements
• Flexion: decrease angle of a joint/bending limb at a joint
• Extension: increase angle of a joint/straitening limb at a
joint
• Abduction: away from the midline
• Adduction: adding to the midline
• Pronation: palms down
• Supination: palms up
• Circumduction: circular motion
• Inversion: soles of feet inward
• Eversion: soles of feet outward

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Muscular Movements
• Rotation: movement about a central axis (head)
• Protraction: head movement forward and parallel
to the ground
• Retraction: head movement backward
• Elevation: raising a body part (shoulders)
• Depression: lowering a body part (shoulders)

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3- Supportive connective tissue
• (A)Cartilage : cushioning tissue within a joint
so that the bone ends do not rub together
-Hyaline cartilages (trachea, nose and articular
surface of bones)
Elastic cartilage ( ear, epiglottis, and larynx)
Fibrous cartilage (between the vertebral disks,
between bones of the pelvic girdle, knee, and
shoulder).

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(B)Ligaments
I. Is a small band of dense, white, fibrous
elastic tissue , connect bones to each other at
the joint level to limit dislocation and
provide stability while permitting controlled
movement at the joint.
II. Also support many internal organs;
including the uterus, the bladder, the liver,
and the diaphragm and supporting the
breasts.

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(C)Tendons:

• connect muscles to bones, When muscles contract

(shorten), tendons at each end of the muscle cause
the bone to move

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ASSESSMENT OF
MUSCULOSKELETAL SYSTEM
Component of the physical examination
• Inspection
• Palpation
• ROM
• Muscle testing

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Aims of musculoskeletal
assessment:
• For the patient presenting with a musculoskeletal
problem his primary complaint is likely to be that of
 pain
a decrease in functional ability.
-Thus, the aim of the musculoskeletal assessment is
• To determine the degree to which the
patient’s activities of daily living are
affected, through a systematic
assessment.
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General aspects a of
musculoskeletal assessment:
• two objective stages together ; inspection and
palpation. rather than inspecting all joints and then
returning to palpate.
• To discover you must uncover but ensure
• privacy and dignity.
• Always ask whether the patient has any pain and if
so, assess the pain-free side first.

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General aspects of
musculoskeletal assessment:
• position for patient comfort
• Always compare each side.
• Organize your examination of the bones, muscles
and joints in a head-to toe method. This will help
avoid omissions.
• Always start each part of the examination from
the neutral position

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Patient Preparation
 Explain procedure
to patient
 Use firm support,
gentle movement
 Patient comfortable
 Adequate Lighting

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A-Subjective Data;
•1.emographic data: Age, sex, and Work………etc.
•2. Present history musculoskeletal complaint:
what’s functional limitation?
-Symptoms in single vs. multiple joints?
-Acute vs. slowly progressive?
-If injurymechanism?
-Prior problems w/area?
-Systemic symptoms?

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• (3)PQRST: useful in gathering data about any
complaint/problem/symptom.
• Provocative or Palliative
What causes the symptom?
What makes is better or worse?
What have you done to get relief?

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• Quality or Quantity
What is the character of the symptom i.e. pain: is it
crushing, piercing, dull, sharp?
How much of it are you experiencing now?
• Region or Radiation
Where is the symptom?
Does it spread?

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• Severity
• How does the symptom rate on a severity scale of 1
to 10 with 10 being the most intense?
• Timing &Time
• Timing:
 When did the symptom begin?
 How long does it last (Identify 24 hour pattern of
presenting complaint?
• Time: How often does it occur? Is it sudden or
gradual?

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4. Effects of presenting
musculoskeletal complaint on:
• activities of daily living: able to care for
himself (independently-with assistance -
complete dependence)
• Activity-Exercise Pattern ,Nutritional-
Metabolic Pattern, Elimination Pattern,
Sleep Pattern, Role-Relationship Pattern

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(5) Past Health History and
Concurrent health conditions:
• (A)Certain illnesses can affect the musculoskeletal
system either directly or indirectly :-
• Tuberculosis, poliomyelitis, diabetes mellitus
parathyroid problems, hemophilia, rickets, soft
tissue infection, and neuromuscular disabilities.
• Arthritic and connective tissue diseases (e.g., gout,
psoriatic arthritis, systemic lupus erythematous)

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• B-History of trauma, surgery, period of prolonged
immobilization , Alcohol use
,Smoking, Family history of osteoporosis
C- Diet: Adequate amounts of vitamins C and D,
calcium, and protein are essential for a healthy, intact
musculoskeletal system.

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D- Medications:
• For any possible side effects include
 anti-seizure drugs(osteomalacia),
 corticosteroids( vascular necrosis, decrease bone
and muscle mass) and
 potassium depleting diuretics( muscle cramps and
weakness)
• A history of medication use and response to pain
medication aids in designing medication
management regimens

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Musculoskeletal Side Effects of
Medications/Substances
• -Amphetamines : Muscle hyperactivity
• -Anticoagulants: Bleeding into the joints
• -Antipsychotics: Dystonic movements, altered
gait
• -Caffeine: Muscle hyperactivity
• -Corticosteroids: Necrosis of femur head
• -Diuretics: Muscle weakness and cramping
• -Phenothiazines: Gait disturbances

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(B)Objective Data:
(1) Inspection:
Inspection:
• For a comprehensive assessment, inspection should be
carried out observing from anterior, posterior and
lateral views. Inspection should assess for:
• 1-Shape: size , contour ,symmetry (Alike on both
sides)
• 2- structure: Normal or deviated from normal
(Deformities
,fracture…)
• muscle configuration: hypertrophy/atrophy (steroid
use, malnutrition)
• body build , posture and body alignment : (Standing,
Sitting and recumbent)
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(B)Objective Data:
(1) Inspection:
3-structural relationships:(Gait-in voluntary
movements -Full Rom of all joints)
• - Shoulders level, Scapulae level, Iliac crests level
4- skin condition
• swelling/edema (effusions, hematoma)
• discoloration (vascular insufficiency, bruising,
hematoma)
• pressure sores, necrosis, scarring scars indicating
any previous surgery or trauma

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wing scapula Varus (bow legs)

Valgus (knock-knees)
ganglion cyst

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(2) Palpation
• Palpate joints, bursal sites, bones and surrounding
muscles.
• During Palpation: Assess the patient for both
verbal and non-verbal cues of pain, Ask the patient,
‘Does the pain radiate elsewhere from the initial
region?’

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Palpation should assess for the
following:( TEC)2
• T: increased temperature (use the back of the
hand above, below and on the joint and
compare with the other side)
• T:tenderness
• E: edema/ swelling
• E: enlargement (bone tumor)
• C: crepitus (osteoarthritis, listen for crepitus
as well as feeling)
• C:Consistency and tone of muscle

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During assessment
• The part may has :
1. Muscles
2. Bones
3. Joints, those must be assessed

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1-MUSCLE ASSESSMENT

•A-Muscle mass
• General view of muscle:
- Atrophy
- Hypertrophy
- Of normal

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 B-Muscle Testing
• Test strength of contractile tissue
• Muscle strength should be equal bilateral and resist your
opposing force.

• Grading Muscle Strength:

• 5: Full ROM against gravity, full resistance.
• 4: Full ROM against gravity, some resistance.
• 3: Full ROM against gravity.
• 2: Full ROM with gravity eliminated (Passive motion).
• 1: Slight contraction.
• 0: No contraction.
• - It is considered a disability if muscle strength is less than
grade 3.
• Strength Deficits
• Muscular injury, Nerve involvement, Pain which
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inhibits movement
Muscle strength
• Muscle strength should be equal bilaterally and should fully resist your
opposing force

•
• 5- full ROM against gravity , full resistance , 100,
normal
• 4- full ROM against gravity , some resistance 75,
good
• 3- full ROM with gravity , 50,
fair
• 2- full ROM with gravity eliminated(passive 25,
poor
• motion)
• 1 –slight contraction 10,
trance
• 0-no contraction 0,
zero 48
2-Bones
• Examine for:
• 1- Deformity
• 2- Tumors
• 3- Pain: is the pain focal (fracture/trauma,
infection, malignancy, Paget’s disease, osteoid
osteoma), or diffuse (malignancy, Paget’s disease,
osteomalacia, osteoporosis, metabolic bone
disease)?

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3-Joint
1 Signs of inflammation, injury (swelling, redness,
warmth)?
• Deformity? Compare with opposite side
2 activity and Range of motion–what can’t they do?
• Specific limitations? Discrete event (e.g. trauma)?
Mechanism of injury?
3 Palpate joint  warmth? Point tenderness? Over
what structure(s)?
4 Strength, neuro-vascular assessment.
5 If acute injury& pain  difficult to assess as
patient

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Swelling

• Localized
• General
• Joint fluid: effusion
• General inflammation: surrounding soft tissue
• Trauma within the joint (ligament tear, articular
cartilage tear, menisci tear)
• Bursa sac involvement
• Fracture

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Pre-Patella Bursitis
Localized vs General Swelling

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4-Limb measurement

• Limbs are in the neutral

position. The patient is lying
straight
• Full length upper limb –
measure from the acromion
process to the end of the
middle finger.
• Full length lower limb –
lower edge of the ileum to
tibial malleolus.
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Range of movement (ROM)
• Assess (Type: Active, Passive, Full, Limited,
Stiffness, contractures)
• If ROM is limited – determine the cause (excess
fluid or any loose bodies in the joint e.g. cartilage,
joint surface irregularity e.g. osteoarthritis,
contracture of muscle, ligaments or capsule)
• Range of motion assessed by:
1 goniometer, most accurate which measures the
angle of the joint.
2 Symmetry
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Range of Motion (ROM)

• Active: AROM
• Passive: PROM
• Resistive: RROM or manual

• Note pain and decrease in motion

• Note any crepitation.
• Bilateral comparison

• Goniometer: objective measure of ROM

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Range of Motion Deficits?
• Muscular weakness
• Muscle spasms
• Joint problems: arthritis, cartilage, ligament
• Mechanical blockage
• General pain
• Nerve involvement

Biceps Rupture

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Range of Motion
• Head and Neck
• Temporomandibular joint (TMJ)
• TMJ: for speaking and chewing
-inspection and palpation
-ROM :vertical/lateral/protrude.
 Temporomandibular joint (TMJ)
• Inspect: Mouth movements (deformity,
swelling, or dislocation)
• Palpate TMJ for audible and palpable snap or
clicking (normal)
– Abnormalities: tenderness, Crepitus, swelling, lost
of movement (lateral motion may be lost earlier and
more significant than upper vertical)
– Arthritis, dislocation
• Compare Rt. & Lt. side for strength & firmness.
• Indicates the integrity of the Cranial nerve V
(trigeminal).

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 Cervical Spine
• Inspect and palpate the associated muscles
(spinous processes, trapezius, sternomastoid, &
paravertebral)

• Assess muscle strength applying opposite force

• Integrity of cranial nerve XI (spinal). ROM:
• Flexion
• Extension
• Lateral flexion/bending
• Rotation
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Shoulders
• Posterior and lateral views
• Inspect size, contour, muscle atrophy, deformity,
swelling (best seen anteriorly), or dislocation.
• Palpate for any tenderness (as a result of local or referred
pain), spasm, atrophy, swelling, or heat.

• ROM:
• Flexion/extension/hyperextension
• Abduction/adduction
• Internal/external rotation

• Muscle Strength
• Shrug the shoulders
• Integrity of cranial nerve XI (Spinal)
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Elbow
• Inspection
(size/contour (in both flexed and extended
position)/deformity/redness/swelling )
• Palpation
olecranon process (of the ulna)/ medial and lateral
epicondyle of humerus )
-ROM
Elbow
• Normal: fairly solid joint
• Abnormalities:
• Soft, boggy, or fluctuating swelling (in synovial
thickening or effusion)
• Effusion or synovial thickening: bulge or fullness in
grove of the olecranon process
• Common in gouty arthritis
• Nodules over olecranon bursa in RA.
• Subluxation of the elbow: forearm dislocated
posteriorly
• Swelling and redness of the olecranon bursa Olecranon Bursitis
• Inflammation and local tenderness of the (goose egg) Inflammation
epicondyles, head of radius, and tendons are of Olecranon Bursa
common (Tennis Elbow).
• Muscle strength
• ROM:
• Flexion/extension
• Pronation/supination
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Range of Motion
• Hands and Wrists
Inspection & Palpation:
ROM
• flexion/extension
• radial/ ulnar deviation
 Fingers &Thumb :
Inspection and palpation
ROM
• flexion/extension
• abduction/adduction
Wrist and Hand
• Inspection:
• The skin smooth with knuckle wrinkles
• Hand muscles are full with a rounded mound
proximal to the thumb (thenar eminence) and
little finger (when ass. contours of the palm).
• Note atrophy or contracture
• Note deformities: ulnar deviation, ankylosis
(extreme flexion), swan-neck,

• Palpation: (Radiocarpal, Midcarpal,

metacarpophalangeal, & interphalangeal joints)
• Normally: smooth with no bogginess, nodules,
tenderness.
• Loss of ROM is the most common and
significant functional loss of the wrist
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Wrist and Hand
• Muscle strength
• ROM:
• Flexion/extension
• Radial (adduct.) & ulnar
(abduct)deviation
• Abduction/Adduction
• Hand grip, & Thumb movement
• Fingers: Make a fist, touch finger
with the thumb (Flexion); extend
and spread fingers (extension)
• Thumb ROMs (Flexion/extension;
abduction/Adduction; opposition)
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Special Test
• Phalen’s test
• Hold both hands back-to-back while flexing
the wrist in 90 degrees for 60 seconds
• Normal finding: no pain
• If numbness & burning produced, is a
positive sign for tunnel syndrome.
• Tinel sign:
• Directly percuss over the median nerve at
the wrist
• Normally, no pain
• If pain, burning & tingling produced
along the nerve, the patient have
Positive Tinel’s sign and indicate
Carpal Tunnel Syndrome

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“Muscle testing and phalen test” “Tinel`s sign”
 Osteoarthritis (radial deviation Ulnar Deviation
Heberden’s & buouchard’s nodes) with Chronic RA

Contracture

Atrophy of thenar
eminence
Ankylosis

Swan neck &

Boutonniere deformity

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Common Abnormalities

Carpal Tunnel Syndrome with

Acute RA (tender, swellen, “spindle-
Atrophy of Thenar Eminence
shaped” swelling of proximal
interphalangeal joints.

Ganglion Cyst
Dupuytern’s
Contracture 74
Mallet Finger

Finger Dislocation

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Carpal tunnel syndrome

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THORCIC AND LUMBAR
SPINE
Inspect:
Alignment, space between
scapula's, shoulders, iliac
crest, and gluteal folds.
Curvature (convex thorax,
concave lumbar)
Any Kyphosis (in elderly),
Lordosis (in obese), or
scoliosis
Palpate paravertebral muscles:
firm, no tenderness or spasm
ROM:
Lateral bending
Flexion/extension
Rotation

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78
 THORCIC AND LUMBAR SPINE
Lower back Pain: (supine, raise
straightened leg, then dorsiflex
foot)
Leg length discrepancy
From the anterior iliac spine to
the medial malleolus crossing the
medial side of the knee
Normally, no true bone Low Back
discrepancy
Equal leg length
For the apparent leg length
Measure from a nonfixed point
(umbilicus) to a fixed point
(medial malleolus).
Apparent leg length is unequal if
patient have pelvic obliquity or
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adduction or flexion deformity in
Lower extremity (Hip)
• Inspect: (standing & walking)
• Stance (when foot on), swing (when foot moves
forward)
• Gait: Smooth, continuous rhythm &even (equal leg
lengths & hip motion, 2-4 inches width of the base)
• Lumbar portion for slight lordosis: (excessive lordosis)
• Anterior-posterior surfaces: Levels of iliac crests,
gluteal folders, buttocks (atrophy)

• palpation for hip joints

• ROM:
• Hip flexion
• Flexion/extension
• Abduction/adduction
• Internal/external rotation
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 Knee
• Inspect: with the pt. in supine position
• Alignment & contour of leg with thigh (bow legs, knock knees)
• Normal concavities or hollows on sides of patella are present
• Swelling, fullness in prepatellar bursa & suprapatellar pouch.
• Quadriceps muscle atrophy
• Gait: smooth rhythmic flow; flexion & extension (during swing &
stance
.Palpation: the pt. in supine position (A: suprapatteler pouch)
( tenderness/nodules/swelling/warmth )
 starting 10 cm above patella with Lt thumb and fingers in a grasping
fashion
• Note consistency of tissue; normally tissue feels
solid, smooth joint
• Feels fluctuant or boggy with synovitis of
suprapatellar pouch.
• B: Tibiofemoral joint: smooth, absent of pain, not
crepitus.
• Muscle strength
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Knee
• The ballon Sign (for major effusion)
-place the thumb & index finger of your Rt hand on each side of
the patella.
-with the Lt hand compress the suprapatellr pouch against the
femur. Feel for fluid entering (balooning into) the spaces
(positive ballon sign).
• Normally, no fluid is present and patella already is snug
against the femur
• If fluid is collected, then tap on the patella displaces
the fluid, and you will hear a tap as the patella bumps
up on the femur.

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• Ballotting the Patella:
Reliable when large effusion are present
Compress the suprapatellar pouch and pallotte or push
the petella sharply against the femur.
Watch for fluid returning to the suprapatllar pouch.
Ankles and foot

• Inspection and palpation

• Ankles( ROM )
• flexion (plantar flexion) / extension
(dorsiflexion)
• Foot( ROM )
• inversion/ eversion
 Foot & Ankle
• Inspect: in setting, standing and walking position
• Position and alignment of ankle, feet, and toes
• Skin condition
• Arch
• Calluses or bursa due to abnormal friction
• Swelling, inflammation, hammer toe, lesions, ulcers,
nodules, etc.
• Palpation: ankle, achilles tendon, MTP joints, 5 MT.
• ROM:
• Dorsiflexion (extension) /plantarflexion (flexion)
• Foot ( ROM ) Inversion/Eversion
• Muscle strength against resistance

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Osteoporosis

90
 Common Abnormalities

Osteoporosis (OP): Osteoarthritis (OA):

Rheumatoid Arthritis (RA):
Decrease in bone mass
Affects joints and
bones are more brittle
surrounding connective
and more prone to
tissues; Inflammation of
break or fracture easily synovial membrane leads to
thickening, fibrosis, and
ankylosis.
Symmetric and bilateral; heat;
redness; swelling; painful
motion;
Deterioration of articular
cartilage and formation of
new bone
Noneinflammatory,
Localized, and progressive
Asymmetric; stiffness;
swelling; painful motion;
limitation in motion.
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 Common Abnormalities

Prepatellar Subcutaneous
Bursitis Nodules raised, firm,
nontender, occur with
RA; common at
olecranon bursa

Gouty Arthritis: cause joint

Olecranon Bursitis effusion or synovial
(goose egg) Inflammation thickening; soft, boggy, or
of Olecranon Bursa
fluctuating fullness ; redness
and heat on palpation 92
 Common Abnormalities Callus: hypertrophy of
epithelium (thickened skin of
Hallux Valgus (abn. Medial abduction.
Of great toe & enlarged 1st metatarsal)
with Bunion and hammer Toes
(hyperextended metatarsophalangeal
joint and flexed proximal
interphalangeal joint
the sole, painless)
Corns: thickening of the
normally thin skin, painful, at
boney area.
Wart: (verruca Vulgaris):
noncancerous skin growths on
the soles of your feet (often
develop beneath pressure
points )
Ingrown Toenail: sharp edge
of the toenail dig into & injure
lateral nail fold (soft tissue
grows over the nail), tender,&
reddened)
Neuropathic ulcer: develop at
pressure points of feet due to
neuropathy as in DM
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Diagnostic procedures
Bone Marrow Aspiration
• Is frequently done for evaluation of possible hematological
disorders
• Bone marrow is usually aspirated from sternum or iliac
crest in adults
• Preparation for procedure require explanation of the
procedure and giving some tranquilizers for anxious
patients.
• The skin area is cleansed and then a small area is
anesthetized with local anesthesia.
• Bone marrow needle is introduced with a twisting motion
and marrow is aspirated.
• After finishing procedure, pressure is applied to site for
several minutes.
• The site of aspiration is observed closely for 24 hours for
signs of bleeding and infection.
Diagnostic procedure
Electromyography (EMG)
• EMG: to evaluate and record electrical activity of
skeletal muscles.
• EMG is performed using an electromyograph, to produce a
record called an electromyogram. An electromyograph
detects (bya very thin needle attached with electrode) the
electrical potential generated by muscle cells when these
cells are electrically or neurologically activated.
• EMG is most often used when people have symptoms of
weakness, and examination shows impaired muscle
strength.( e.g. CTS)
• It can help to tell the difference between muscle weakness
caused by injury of a nerve attached to a muscle and
weakness due to neurological disorders.
95
Diagnostic Procedures
Bone Densitometry:
• Is used to estimate bone density, through the use of x-
ray or ultrasound
• Bone densitometry is used to measure the bone
mineral content and density. This measurement can
indicate decreased bone mass. Bone densitometry is
used primarily to diagnose osteoporosis and to
determine fracture risk.
• The testing procedure measures the bone density of
the bones of the spine, pelvis, lower arm, and thigh.

96
.
Bone densitometry testing may also be used:
• to confirm a diagnosis of osteoporosis if you have
already fractured
• to predict your chances of fracturing in the future
• to determine your rate of bone loss and/or monitor
the effects of treatment

• Before the imaging study, the nurse should consider:

• If patient pregnant, claustrophobia, inability to tolerate
position, deformity, metal implants, hair clips, hearing
aid.

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