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A. The Musculoskeletal System BONES: DIVISIONS

Nasa baba anaphy 1. Axial Skeleton – bones that form the
longitudinal axis of the body. Axial means
B. Data Collection relating to or situated in the central part of the
body.
1. Collecting subjective data
- Nurse patient interaction (interview) Skull
● Cranium – 8
● History of present health concern
● Face – 14
● Past health history
Hyoid – 1
● Family history
Vertebral Column
● Lifestyle and health practices ● Cervical – 7
2. Collecting objective data ● Thoracic – 12
- Nurse patient interaction (physical exam) ● Lumbar – 5
● Preparing the client ● Sacrum – 1
● Coccyx – 2
● Preparing the pieces of equipment
● Physical assessment 2. Appendicular Skeleton – articulated bones of
✔ The data collected will be shared to the the upper and lower limbs and girdles
members of the health team.
✔ To support data collected: Classification of Bones According to Shape
C. Diagnostic and Laboratory Exams a) Long Bone – femur or thigh bone
b) Flat Bone – parietal bone from roof of skull
Will be done = outcome/findings → medical
c) Irregular Bone – sphenoid bone from skull
diagnosis → nursing diagnosis (NCP)
d) Short Bone – carpal or wrist bone
STRUCTURE OF THE MUSCULOSKELETAL
Types Of Bones
SYSTEM
● Bones ● Spongy bone
● Muscles - Hematopoiesis
● Ligaments - Bone formation
● Tendons ● Compact Bone – provides support
● Cartilage
● Joints Structure Of a Long Bone
● Synovium ● Proximal epiphysis
● Bursae ● Diaphysis
● Distal epiphysis
1. Bones
Functions of the Bones BONE MARROW
● Provides Shape – body 1. Red bone marrow – Production of
RBC,WBC and platelets
● Provides Framework – to support internal
organs 2. Yellow bone marrow – Functions in times of
stress - transformed to red marrow to assist
● Protection – internal organs
in hematopoiesis.
● Movement – attachment for tendons
ligaments MICROSCOPIC STRUCTURE OF COMPACT
● Bone Maintenance – bone remodeling BONES
● Transport Of Nutrients – to bone cells by Canaliculi – small fluid filled channels that are
blood and lymph vessels and remove used for exchange of Ca, PO4, nutrients and
wastes wastes products through gap junctions
● Storage And Release – minerals
● Blood Cell Formation BONE HISTOLOGY
Bone Matrix – is the extracellular element of bone
tissue

Haversian System – concentric layers of ossified
bone matrix arrange around a central Haversian
canal. The matrix forms a circular pattern
BONE MATRIX
It is made up of:
✔ Organic components (35%)
● Composed of cells, fibers, and organic
substances (OSTEOID)
● Collagen is most abundant organic
substance
● Collagen fibers (Bone Resilience)
✔ Inorganic mineral salts (65%)
● Primarily calcium phosphate
(hydroxyapatites)
● Gives bone its hardness; strength to
resists compression
● Minerals – calcium & phosphorous (bone
strength)
o If mineral removed, bone is too
bendable
o If collagen removed, bone is too
brittle
CELLS OF BONE TISSUE
● Osteogenic Cell – develop into an osteoblast
● Osteoblast – forms bone tissue
– Cells that build bones and secrete bone
matrix in which inorganic minerals, such as
calcium salts are deposited.
● Osteocyte – maintains bone tissue
– Former osteoblasts that have been trapped
in the matrix they formed.
– Are mature bone cells involved in
maintaining bone tissue.
– Controls the extracellular concentration of
calcium and phosphate
● Osteoclast – ruffled border
– Functions in resorption, the destruction of
bone matrix
– The process of ossification and
calcification transforms the blast cells into
mature bone cells
– Cells that are involve in the destruction,
resorption, and remodeling of bone.
Normal Bone Remodeling
Resorption → Reversal → Formation → Resting
BONE FORMATION – bone formation and growth
are stimulated by the growth hormone from the
anterior pituitary gland in the brain
1. Intramembranous Ossification
– Takes place in connective tissue
membrane
– Produces flat bones of skull and clavicle
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2. Endochondral Ossification – takes place in
cartilage
APPOSITIONAL BONE GROWTH – growth of a
bone by addition of bone tissue to its surface
– Growing bones widen as they lengthen
– Bone is resorbed at endosteal and added
at periosteal surface
● Osteoblasts – add bone tissue to the
external surface of the diaphysis
● Osteoclasts – remove bone from the internal
surface of the diaphysis
– Bone growth & ossification continue
longitudinally:
o Female – 15y/o; Male – 16
o Bone maturation & shaping continue →
21y/o both sexes
No Elongation – Dwarfism
Achondroplasty – long bones stop growing in
childhood
– normal torso, short limbs
– failure of cartilage growth
Pituitary
– lack of growth hormone
– normal proportions with short stature
BONE MAINTENANCE
1. Physical Activity (weight bearing activity)
stimulates bone formation and remodeling.
● Thick and strong bones
● Weak bones (calcium loss)
2. Good Dietary Intake → bone health
● Calcium 1500 mg/day – to maintain adult
bone mass
● Eat calcium rich foods
● Dairy products – cheese, yogurt, milk
(drink 16-24 ounces of milk/day)
● Nondairy sources – canned sardines,
salmon, tofu, green leafy vegetables
3. Calcitriol (Active Vitamin D)
● Functions to increase the amount of calcium
in the blood by promoting absorption of
calcium from the GIT.
● Facilitates mineralization of osteoid tissue.
4. Major Hormonal Regulators of Calcium
Homeostasis
a) Parathormone (↓ Calcium levels in the
blood)
● Bone Resorption – Circulation =
normal calcium levels
b) Thyroid Hormones
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● Thyroid hormones are important in 3. Bony callus formation
skeletal growth during infancy and 4. Bone remodeling
childhood (direct effects on
osteoblasts). Tendon – tissue that attaches a muscle to other
● Hypothyroidism leads to decreased body parts, usually bones. Tendons - connective
bone growth tissues that transmit the mechanical force of
● Hyperthyroidism can lead to muscle contraction to the bones
increased bone loss, suppression of Ligament – fibrous connective tissue which
PTH, decreased vitamin D metabolism, attaches bone to bone, and usually serves to hold
decreased calcium absorption. Leads structures together and keep them stable.
to osteoporosis.
Cartilage
c) Glucocorticoids
– Is a resilient and smooth elastic tissue,
● Glucocorticoids (cortisol) are rubber-like padding that covers and protects
necessary for skeletal growth. the ends of long bones at the joints
Excess glucocorticoids – Is a structural component of the rib cage, the
● Decrease renal calcium reabsorption ear, the nose, the bronchial tubes, the
● Interfere with intestinal calcium intervertebral discs, and many more other
absorption body components
● Stimulate PTH secretion Skeletal Muscle
● Interfere with growth hormone – one of three major muscle types, the others
production gonadal steroid production being cardiac muscle and smooth muscle. It
Net result: Rapid Osteoporosis (bone is a form of striated muscle tissue which is
loss) under the voluntary control of the somatic
o Patient (rheumatoid problems) nervous system.
receiving long term synthetic cortisol – contract voluntarily (via nerve stimulation),
or corticosteroids (prednisone
[Deltasone, Prednicot]) = Higher risk Frontal Lobe – Initiates muscle contraction,
for fracture speech, concentration, planning, problem solving
and motor control
5. Growth Hormone
Parietal Lobe – Touch and pressure, taste, body
● stimulates the liver to produce insulin like awareness
growth factor 1
● (IGF-1) → accelerates bone modeling in Temporal Lobe – Hearing and Facial recognition
children and adolescents. Occipital Lobe – Vision
● Growth hormone fuels childhood growth
and helps maintain tissues and organs Cerebellum – Coordination
throughout life. It's produced by the
pea-sized pituitary gland — located at the 2. Muscles
base of the brain – biological machines made up of proteins
– To convert chemical energy into mechanical
6. Sex Hormones – Estrogen and testosterone work and force
a) Estrogen – stimulates osteoblast and – Obtained from atp and cp
inhibits osteoclast
b) Testosterone - ↑ skeletal growth → MUSCLE CONTRACTION
↑muscle mass → ↑ weight bearing stress ● Action potential causes the release of Ca++ at
on bones → ↑ bone formation. the NMJ
● A neurotransmitter releases a chemical
7. Blood Supply to the Bone: substance from the motor end fiber, causing
● ↓ blood supply→ ↓ osteogenesis and stimulation of the muscle fiber.
bone density→ bone necrosis (deprived of ● That substance called Acetylcholine (Ach)
blood) o Acetylcholine is found between the nerve
synapses, or gaps, between nerve cells.
BONE HEALING When activated, it causes the contraction of
BONE INJURY – Bone fracture → blood vessels & skeletal muscles
soft tissue tear ● Ach causes the muscle fibers to become
stimulated and contract (shorten).
Fracture Repair
1. Hematoma Formation Functional Characteristics of Muscles
2. Fibrocartilaginous callus formation

Excitability – ability to receive and respond to
stimuli.
Conductivity – the ability to receive a stimulus
and transmit a wave of excitation (electrochemical
activity)
Contractility – the ability to shorten forcibly when
stimulated.
Extensibility – the ability to be stretched or
extended.
Elasticity – the ability to bounce back to original
length.
SKELETAL MUSCLE
● Muscle contraction – excess energy ( from
ATP) is dissipated in the form of HEAT.
● Isometric contraction – Length of the
muscle remains constant, but the force
generated by the muscles is increased
● Isotonic contraction – Shortening of the
muscle with no increase in tension within the
muscle.
MUSCLE – Exercise, Disuse and Repair
Hypertrophy – enlargement of muscles due to an
increase muscle tension over a long time.
ex. Regular exercise with weights
Atrophy – decrease of muscle due to disuse of
muscle over a long period of time.
ex. Bed rest and immobility
3. Joints
● The area where two bones are attached for the
purpose of permitting body parts to move.
● Formed of fibrous connective tissue and
cartilage
Shoulder Joints
1. Sternoclavicular
2. Acromioclavicular
3. Glenohumeral
4. Scapulothoracic
Knee Joint
Synovial joint – joins bones with a fibrous joint
capsule that is continuous with the periosteum of
the joined bones, constitutes the outer boundary of
a synovial cavity, and surrounds the bones'
articulating surfaces.
INTERVERTEBRAL DISCS
● Intervertebral fibrocartilage
● Lie between adjacent vertebrae in the spine.
● Each disc forms a cartilaginous joint to allow
slight movement of vertebrae.
● Act as a ligament to hold in the vertebrae
together.
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COLLECTING SUBJECTIVE
DATA: HISTORY OF PRESENT
HEALTH CONCERN
Nursing Assessment:
HISTORY OF PRESENT HEALTH CONCERN
● Character: Describe the s/s. How does it feel,
look, sound, smell & so forth?
● Onset: When did it begin?
● Location: Where is it? Does it radiate?
● Duration: How long does it last? Does it
reoccur?
● Severity: How bad is it?
● Pattern: What makes it better? What makes it
worse?
● Associated Factors: What other symptoms
occur with it?
Q – RECENT WEIGHT GAIN? Osteoarthritis of
the knee
Q – CHEWING DIFFICULTY? PAIN?
● TMJ dysfunction – jaw as “getting locked or
stuck”, clicking sound present with ROM
● TMJ pain
- Injury
- Wear and tear, or the overuse, of the joint
due to stress, anxiety, and tension.
- Clenching jaws or grinding of teeth
Q – JOINT, MUSCLE, BONE PAIN?
● Contusion – soft tissue injury produced by
blunt force - blow, kick or fall causing small
blood vessels to rupture and bleed into soft
tissues (ecchymosis).
● Bone Pain – dull, deep throbbing
● Joint/Muscle Pain – aching
● Fractures – sharp, knifelike pain
● Strain – is injury to muscles or tendons
caused by twist, pull, & or tear
● Sprain – injury to ligaments and supporting
muscle fiber around a joint from wrenching or
twisting motion
● Dislocation – when extreme force is put on
a ligament, allowing the ends of two
connected bones to separate.
● Fracture – break in the bone
CHECK – the status of tetanus immunization
OPEN FRACTURE OF THE FOREARM
SHOULDER DISLOCATION
- If the wound is clean and have not had a
tetanus booster in the last 10 years, it is
recommended to receive one.
- If the wound is dirty or tetanus-prone -
recommend a tetanus booster if have not

had a tetanus booster shot within the last 5
years.
External Fixators
● Roger Anderson – fracture long bones
Personal health history
Q – past problems or injuries? treatment?
aftereffects from injury or problem?
● Information provided – baseline data
● Past injuries – may affect current ROM
OSTEOMALACIA – inadequate bone
mineralization
NOTE: A history of recurrent fractures should
raise the question of possible physical abuse.
Q: tetanus immunization?
POLIOMTELITIS is also called infantile
paralysis. A disease that destroys the motor
neurons and causes paralysis.
Q: polio immunization?
● Central nervous system
● Risk factors for polio include lack of
immunization.
Q – Diabetes mellitus? Osteomyelitis?
Q – Sickle cell Anemia?
Hand foot syndrome – Dactylitis
Sickle Dactylitis – is one of the first
complications in sickle cell syndrome with the
highest incidence between ages six months and
two years. The sickle red cells cause painful
swelling of the hands and feet. This is treated
with fluids and pain medication. It usually will go
away in a few days without any problems
Q – Systemic Lupus Erythematosus (SLE)?
● LUPUS is an autoimmune disease, a
disorder in which the body attacks its own
healthy cells and tissues.
● BUTTERFLY RASH – rash spares the
Nasolabial Folds of the face, which
contributes to its characteristic appearance.
Individuals with lupus are at increased risk for
osteoporosis:
1. glucocorticoid medications often
prescribed to treat SLE can trigger
significant bone loss.
2. Pain and fatigue caused by the disease
can result in inactivity, further increasing
osteoporosis risk.
Q – ACTIVITIES?
● Exercise, diet, weight reduction
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Nursing Assessment:
LIFESTYLE & HEATH PRACTICES
Q – MEDICATIONS?
● Diuretics – alters electrolyte levels leading to
muscle weakness
● Steroids – can deplete bone mass
Excessive alcohol
1. Interferes with the balance of calcium,
2. It also increases parathyroid hormone (PTH)
levels
3. Interfere with the production of the vitamin
essential for calcium absorption.
4. Can cause hormone deficiencies in men and
women
5. Cortisol levels tend to be elevated in people
with alcoholism.
Q – CAFFEINE?
● High caffeine intake (greater than 300
milligrams per day) does increase the
amount of calcium excreted in the urine, and
the risk for osteoporosis-related fractures
was significant among women consuming 4
or more cups of coffee per day, this increase
in risk was seen only in those with calcium
intakes less than 700 milligrams per day.
Foods to avoid: GOUT
● Organ meat (liver, kidney, brains)
● Shellfish (tahong)
● Legumes (beans)
● Sardines
● Salted anchovies (dilis)
● Beer/wine
Q – ACTIVITIES ON A TYPICAL DAY
Sedentary lifestyle
● Risk of osteoporosis
● Exposure to 20 minutes of sunlight/ day
promotes the production of Vit D in the body.
Q – DESCRIBE ANY ROUTINE EXERCISE THAT
YOU DO?
● Improper body positioning in contact sports
results in injury to the bones, joints, or
muscles
Q – DESCRIBE YOUR OCCUPATION
Job related activities
● Incorrect body mechanics, 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.
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Q – ASSISTIVE DEVICES – Promote safety and

independence
CANE
● For clients with hemiparesis, to ease the
strain on weight bearing joints.
● When one cane is used for balance, it should
be held in the hand opposite the involved leg
● Prior to teaching the client how to
appropriately use the cane assess the risk of
fall
Central Dual Energy X-ray Absorptiometry
Tip: The tip should be covered with a rubber (DXA or DEXA) – imaging device
cap to prevent slipping on the floor.
● Xray detector
● Elbow – flex 30 degrees ● Focuses on hip and spine
● 6 inches lateral – big toe
● Cane should be use on the good side Hip assessment – foot is placed in a brace that
rotates the hip inward
● Advance the cane at the same time the
affected leg is move forward Peripheral DXA
WALKER ● Measures BMD of the forearm, finger, or
heel.
● Used primarily to provide balance for clients
who can bear weights ● Small device
● Poor balance and cannot use crutches ● Bone density reading within a few minutes.

CRUTCH WALKERS Collecting Objective Data:

● artificial supports that assist patients who PHYSICAL EXAMINATION
need aid in walking because of disease,
Gather data of the patient:
injury, or a birth defect.
● Posture
● Goals: Develop power in the shoulder girdle ● Gait
and upper extremities that bear the patient’s ● Bone structure
weight in crutch walking. ● Muscle strength
WHEELCHAIRS – These are used by clients ● Joint mobility
who are unable to use other measure of ● Ability to perform ADL
locomotion. Preparing the client
● Room at comfortable temperature
Q – Musculoskeletal problems ● Provide adequate draping
1. Socialization ● Need to change position
2. Sexual activity ● Rest periods provided
Sling – during ambulation
OBJECTIVE DATA: Always compare with
Q – View self before and after the contralateral side (one side of the body to the
musculoskeletal problem other)
Body image disturbance and chronic low Skeletal Component
self-esteem may occur with a disabling or crippling ● Note deviation from normal structure – bony
problem. deformities, length discrepancies, alignment,
amputations.
Q – Describe how his/her musculoskeletal ● Identify abnormal motion and CREPITUS
problem added stress to his/her life. (grating sensation), as found with fractures.
Often greatly affect activities of daily living and role
performance, resulting in changed relationships Joint Component
● Identify swelling
and increased stress.
● Note deformity
Q – Bone density screening? When was your ● Evaluate stability, which may be altered.
one? ● Estimate range of motion (ROM), both
actively and passively.
Muscle Component
● Inspect for size and contour of muscles.
● Assess coordination of movement

● Palpate for muscle tone
● Measure girth to note increases due to
swelling or bleeding into muscle or decrease
due to atrophy
MUSCLE COMPONENT
● Test muscle strength by asking the client to
move each extremity through its full ROM
against resistance.
- Apply some resistance against the part
being moved.
- Document muscle strength by using a
standard scale.
● Rate muscle strength in accord with the
strength table.
GRADING MUSCLE
TEST MUSCLE STRENGTH
● Sternocleidomastoid – Client turns the head
to one side against the resistance of your
hand. Repeat with the other side.
● Trapezius – Client shrugs the shoulder against
the resistance of your hands.
● Deltoid – Client holds arm up and resists while
you try to push it down. Compare strength –
both arms
● Pronator Drift – the affected arm will pronate
and fall.
● Biceps – Client fully extends each arm and
tries to flex it while you attempt to hold arm in
extension.
● Triceps – Client flexes each arm and then tries
to extend it against your attempt to keep it in
flexion.
● Wrist and finger muscles – Client spreads
the fingers and resist you attempt to push the
fingers together.
● Grip strength – Client grasps your index and
middle fingers while you try to pull it out.
● Hip muscles – Client is supine, both legs
extended; client raises one leg at a time while
you attempt to hold it down.
● Hip Abduction – Client is supine, both legs
extended. Place your hands on the lateral
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surface of each knee; client spreads the legs
apart against your resistance.
● Hip Adduction – Client is in same position as
for hip abduction. Place your hands between
the knee; client brings the legs together
against your resistance.
● Hamstrings – Client is supine, both knees
bent. Client resists while you attempt to
straighten the legs.
● Quadriceps – Client is supine, knee partially
extended; client resists while you attempt to
flex the knee. – KICK OUT
● Muscle of the ankles and feet – Client resists
while you try to dorsiflex the foot
● Ankle plantar flexion – press down on the
gas pedal
o Patient to move the large toe against the
examiner's resistance "up towards the
patient's face"
Physical Assessment
Skin Component
● Inspect traumatic injuries (e.g., cuts, bruises)
● Assess for warmth or coolness of skin.
Posture
● Assess posture – includes inspecting spinal
curvature and knee positioning. 
● Normal – a midline spine without lateral
curvatures and a concave lumbar curvature
that changes to convex curvature in the
flexed position.
● Kyphosis – exaggerated convex curvature
of the thoracic spine (humpback) elderly,
osteoporosis
● Lordosis – excessive concave curvature of
the lumbar spine (swayback) seen in
pregnant women
● Scoliosis – lateral curving deviation of the
spine congenital
Pieces of equipment
● Tape measure
● Goniometer (optional) – measures angles in
degrees.
● Skin marking pencil (optional)
Proximal Arm of the Goniometer
● The proximal arm extends from the central
disc (called the stationary or fixed arm).
● does not move during joint measurement.
Distal Arm
● The distal arm, also called moveable arm,
is the moveable part of the goniometer that
rotates on the circular disc.
● Describe the limited motion of the joint in
degrees

Gait
● can be assessed by having the patient walk
away
● a manner of walking or moving on foot
● Dorsiflexion and plantarflexion of the foot
● allows the foot to have some side-to-side
motion and thereby accommodate to uneven
terrain.
ABNORMALITIES
Spastic gait – Paretic/weak gait – stiff foot
dragging walk
Scissors gait – bilateral spastic paresis, legs flex
slightly at the hips (e.g., CEREBRAL PALSY)
Propulsive gait – Stooped rigid posture, head and
neck are bent forward (Parkinson’s disease)
Steppage gait – Results from foot drop caused by
weakness/paralysis. Foot hangs with the knees
pointing down.
Waddling gait – Duck like walk (muscular
dystrophy)
Limping
– Caused by painful weight bearing ask
patient to pinpoint area of discomfort
– One extremity is shorter than the other
NUDGE TEST
● Intended to examine the patient's ability to
react to an unknown disruption of their
balance.
● Therefore, it is important that you do not tell
the patient immediately before the nudge and
that you nudge them only once.
● Ability to maintain their sitting balance.
Nudge Locations
● Anterior Nudge – At sternum
● Posterior Nudge – Between scapular lines
● Lateral nudge – At acromion on dominant
or stronger side
In summary, nudges should be
– RANDOMLY inserted throughout test
– Given WITHOUT immediate warning
– Use LIGHT pressure, enough to require a
balance reaction
– ONE push only, for each direction
TEMPOROMANDIBULAR JOINT (TMJ)
Inspect and palpate the TMJ
● Open the mouth as widely as possible
(Normal – opens 1-2 inches)
● Move the jaw from side to side (Normal –
moves 1-2 cm, snapping and clicking may
be felt)
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● Protrude (push out) and retract (pull in) jaw –
(Easily)
TMJ: ABNORMAL FINDINGS
● Decreased ROM, swelling, tenderness, or
crepitus – arthritis.
● Decreased muscle strength with muscle joint
and disease.
TESTS FOR RANGE OF MOTION
● Open the mouth and move the jaw laterally
● Clench teeth – feel the contraction of the
temporal and masseter muscles to test the
integrity of CN V (trigeminal nerve) – No pain
AB FINDINGS:
● Lack of full contraction with cranial nerve
lesion.
● Pain or spasm present.
STERNOCLAVICULAR JOINT
Deviation From Normal
● Swollen, red, or enlarged joint or tender,
painful joint is seen with inflammation of the
joint
CERVICAL, THORACIC AND LUMBAR SPINE
● Observe – curves from the side then from
behind
● Observe for symmetry, note differences in
height of shoulders
● Palpate the spinous processes and
paravertebral muscles on both side for
tenderness or pain.
Deviation From Normal:
● Scoliosis
● Kyphosis – hunchback
● Lordosis – sway back
TEST ROM – CERVICAL SPINE
● Flexion. Touch the chin to the chest
● Extension. Move the head from the flexed
position to the upright position
● Hyperextension. Move the head from the
upright position back as far as possible –
look at the ceiling.
LATERAL BENDING
● Touch each ear to the shoulder on that side
● 40 DEGREES TO THE LEFT 40 DEGREES
TO THE RIGHT
Evaluate Rotation
● TURN HEAD TO RIGHT AND LEFT- 70
DEGREES
Repeat cervical procedures with resistance
CERVICAL SPINE – Abnormal findings
● Cervical strain is the most common cause of
neck pain
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– sleeping in the wrong position NORMAL – no pain and able to raise leg to 90
– carrying a heavy suitcase degrees
– automobile crash ● sciatic pain – (+) Lasegue’s sign
● Neck pain with loss of sensation – spinal
cord compression Shoulders, Arms, and Elbows
● Impaired ROM and neck pain with fever – Symmetrically round, no redness, swelling or
could be indicative of a serious infection deformity. Muscles are fully developed
(Meningitis) Shoulder – Inspection and palpation (sitting or
standing)
ROM – THORACIC & LUMBAR SPINE Deviation From Normal
Adams Forward bending test ● dislocation
– Ask to bend forward & touch the toes
Shoulder Joint
– Observe for symmetry of the shoulders,
scapula and hips. Deviation From Normal
– Sit down behind the client, stabilize his hips ● Impingement Syndrome – repetitive
– Bend sideways, bend backward toward you overhead movement of the arm or from the
& twist the shoulders one way then the other acute trauma
Normal Findings – SHOULDER ABDUCTION
● Flexion of 75 – 90 degrees ● Appley’s Scratch Test
● Lateral bending – 35 degrees – patient attempts to touch the opposite
scapula thus testing abduction and ER
Abnormal
and adduction and IR
● Impaired ROM & PAIN
– Good screening test for rom assessment
● low back strain, Osteoarthritis
Elbow
SCOLIOSIS
● Inspects for size, shape, deformities,
● Head (tilted) – does not line up over the hips redness or swelling both in flexed (70
● Neckline – uneven degrees) and extended position
● Shoulder blade protruding ● Extensor surface of the elbows should be
● Rib hump checked for any psoriatic plaques and
● Breast unequal in size rheumatoid nodules.
● Waistline asymmetrical ● Use thumb & index finger to palpate -
● Sideways lean olecranon process & epicondyles
a. Mild Scoliosis (less than 25 degrees) Deviation From Normal – elbow dislocation
● not serious and requires no treatment
other than monitoring Wrists
● examination is done every 3 months Inspection/Palpation
● exercise program may strengthen torso ● Inspect the wrist size, shape, symmetry, color
muscles and prevent curve progression and swelling.
● Palpate:
b. Moderate Scoliosis (between 25 and 40
- For tenderness and nodules
degrees) – BRACE
- The anatomic snuffbox
c. Dangerous curve (a curve of 40 degrees or
Deviation From Normal
more) – SURGERY
1. Rheumatoid arthritis
d. Severe Scoliosis (over 70 degrees) – Ribs 2. Ganglion Cyst
pressed LUNGS 3. Scaphoid fracture
e. Very Severe Scoliosis (Over 100 degrees) –
INJURY TO HEART AND LUNGS Tests for ROM
● Hyperextension – 90
Back and leg pain – HERNIATED NUCLEUS
● Wrist extension
PULPOSUS
● Wrist flexion
TEST FOR BACK AND LEG PAIN
Deviation From Normal: CTS
● Lasegue’s Test – straight leg raising
independently to the point of pain then Carpal Tunnel Syndrome (CTS)
DORSIFLEX client’s foot.
● Common among women
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● 30-60 y/o Adduction – Move each thumb back to the hand.
Cause: Performing repetitive hand & wrist Flexion – Move each thumb across the palmar
movements, repeatedly exposed to cold surface of the hand toward the 5TH finger
temperature, vibrations, or extreme direct
pressure. Extension – Move each thumb away from the
hand.
Common Among
● SECRETARY Abnormal Findings
● MEDICAL TRANSCRIPTIONIST ● Inability to extend the ring and little finger –
● PIANIST Dupuyten’s contracture
S/S – pain, numbness, paresthesia, and ● Painful extension of the finger –
weakness of the median nerve. tenosynovitis
Assessment
a. Phalen’s Test DE QUERVAIN'S TENDINITIS
- hold the wrist in acute flexion for 60 ● tendons around the base of the thumb are
seconds irritated or constricted.
- Numbness and burning in the fingers (+) ● Pain and tenderness along the thumb side
b. Tinel’s Test of the wrist.
- Pain, numbness and tingling when ● Noticeable when forming a fist, grasping,
percussing lightly over the median nerve is or gripping things, or when turning the
positive for CTS wrist.
● Tendinitis may be caused by overuse.
Hands and Fingers ● The Finkelstein test is conducted by
making a fist with the fingers closed over
Inspection
the thumb and the wrist is bent toward the
- size, shape, swelling, symmetry, and little finger.
color.
- Carpal’s palpation
Hips
- Feel the muscle bulk in the thenar
Client standing:
eminence
● Inspect the symmetry and shape of hips.
Abnormal Findings ● Palpate for stability, tenderness, crepitus
- Swollen, stiff, tender finger joints - ACUTE ● Buttocks equally sized; iliac crests are
Rheumatoid arthritis. asymmetric in height.
Osteoarthritis ● Hips – stable, non-tender, and without
● Heberden’s nodes (raised bony growths crepitus.
over the distal interphalangeal joints) are HIPS TEST R.O.M.
present.
● Bouchard’s nodes (raised bony growths Deviation From Normal
over the proximal interphalangeal joint of ● Fracture of the femoral neck
hand) are noted. ● Pain in front of the groin with stress
● HARD PAINLESS NODULES fracture of hip
THOMAS TEST - Hip Flexion/ Quad length
TEST ROM
Objective
Abduction – Spread the fingers of each hand
apart (Normal 20 degrees. ● To assess the length of the muscles
involved in hip flexion
Adduction – Bring the fingers of each hand ● Should not be conducted on clients
together (touching) suffering from low back pain unless
Hyperextension – Bend the fingers of each hand cleared by their physician
back as far as possible – 30 degrees. ● Detects hip flexion contracture by
extending affected hip while contralateral
Flexion – Bring the fingers of each hand toward
hip is held flexed
the inner aspect of the forearm – 90 degrees,
Thumb - 50 degrees ● (+) bad (-) good
● THE PATIENT’S STRAIGHT LEG RISES
Extension – Straighten each hand to the same OFF THE TABLE AND A MUSCLE
plane as the arm. STRETCH END WILL BE FELT
Abduction – Extend each thumb laterally

TRENDELENBURG TEST – assess whether the
hip abductors (particularly gluteus medius) are
functioning normally
- Observe patient from behind, ask him or
her to stand on one foot and then the other
(-) test- pelvis tilts up on contralateral side
(+) test: pelvis sags on the contralateral
side
PHYSICAL EXAMINATION
- Positive for this test when hip abductor
weakness when the pelvis sags more than
2 cm during the single leg stance on the
limb tested
Knees
Inspect – size, shape, symmetry, swelling,
deformities, and alignment.
● Palpates for tenderness, warmth,
consistency, and nodules.
● Knee symmetric, hollows present on both
sides of the patella, no swelling, or
deformities.
● Lower leg in alignment with upper leg
● Non tender, cool, muscle firm, no nodules,
no bulge.
TESTS FOR ROM
Flexion – Bend each leg, bringing the heel toward
the back of the thigh.
Extension – Straighten each leg, returning the
foot to its position beside the other foot.
Deviation From Normal
● Genu Valgum – knock knees
● Genu Varum – bow legged
● Swelling patella indicate fluid in the knee
joint
● Tenderness and warmth with a boggy
consistency is synovitis.
TEST FOR SWELLING
Bulge Test - Massage Test
- using your thumb and index finger- milk
down any fluid from above the knee
- Keep this hand in this position
- Now with the other hand, stroke the medial
side of the knee to empty the medial
compartment of fluid then stroke the lateral
side
- Observe the medial side of the knee for
any bulging. This may indicate an effusion
- Used in checking for small amounts of
fluids in the knee
Ballottement Knee Test
Musculoskeletal Assessment | Page 11 of 13
- Used in checking for larger amounts of
fluids in the knee
- If patella elevates due to large amount of
fluid – Ballottement knee test positive
KNEE INJURIES
- May hear/feel a click in the knee when
walking, especially when extending the leg.
- Not be able to straighten your knee
- Test is positive – If a clicking sound is
heard or felt.
ANTERIOR CRUCIATE LIGAMENT TEAR
TEAR – when the foot is firmly planted and leg
sustains direct force, forward or backward →
feeling /hearing a “pop” in the knee
Anterior Drawer Test – to test the integrity of the
anterior cruciate ligament (ACL)
Anterior and Posterior Drawer Tests
- AD Test – lower leg pulled up to check
knee joint laxity
- PD Test – lower leg pushed down to check
knee joint laxity
Lachman Test
- knee in 20 to 30 of flexion, then attempting
manual anterior tibial displacement while
stabilizing the femur.
- The test is considered positive if the
examiner fails to detect a reliable endpoint
Ankles and Feet
- With the client sitting, standing, and
walking, inspects position, alignment,
shape and skin.
- Palpates ankles and feet for tenderness,
heat and swelling
- Toes usually point forward and lie flat.
- Toes and feet are in alignment with lower
leg.
- Skin is smooth and free of corn and
calluses
Deviation From Normal:
- Tender, painful reddened, hot, and swollen
metatarsophalangeal joint of the great toe
(gouty arthritis)
- Tenderness of the calcaneous of the
bottom of the feet – plantar fasciitis
Test for ROM
Plantar flexion – Point the toes of each foot
downward (Normal – 20 degrees)
Dorsiflexion – Point the toes of each foot upward
(Normal – 45 degrees)
Adduction (Normal – 20 degrees)
Abduction (Normal – 10 degrees)

Inversion – Turn the sole of each foot medially
(Normal – 30 degrees)
Eversion – Turn the sole of each laterally (Normal
– 20 degrees)
NURSING DIAGNOSIS
● Altered Physical Mobility – due to
immobilization, loss of limb, stiffness, pain,
weakness, or inability to bear weight.
● Limited Activity – intolerance due to stiffness,
pain, limited mobility, fatigue.
● Pain due to injury, surgery, or joint disorder.
● Potential For Infection – due to trauma or
surgical incision
● Altered Tissue Perfusion – due to swelling
and pressure.
● Altered Self Care Ability – due to
immobilization
● Altered Body Image – due to change in
appearance and/or loss of mobility or function.
● Decreased Ability for Home Maintenance –
due to immobility or limited self-care ability.
● Potential For Disuse Syndrome – due to
immobility or trauma
IMPLEMENTATION
POSITIONING
– patients with musculoskeletal problems
MUST change their body position
frequently and get up in chair.
– to prevent pressure ulcers, circulatory
stasis, and respiratory and urinary
complications.
EXERCISE – ROM exercises both passive and
active are planned and carried out as soon as
feasible after decreased mobility occurs (disease,
injury, surgery).
● To maintain connective tissue within the joint
and ensure that every joint retains its
function and mobility
● ROM exercises – should be done 3 or 4
times/day
● Patient receives the first dose of pain
medication in the AM 30-60 min BEFORE
beginning exercise.
● Isometric exercise – may be
contraindicated with hypertension, increased
intracranial pressure or congestive heart
failure – significant increase in BP and heart
rate.
● Gradual Mobilization – progressive
mobilization involves assessing the patient’s
ability to move her limbs, turn herself in bed,
transfer herself from bed to chair and back
Musculoskeletal Assessment | Page 12 of 13
again, stand, walk – to measure signs of
independent movement
TIBIA AND FIBULA FRACTURES: AFTER
ORTHOPEDIC SURGERY
● Follow physical therapy and rehabilitation
programs
- Rehabilitation is the whole process of
restoring a person to a normal life after
illness or injury
● Set realistic goals
● Perform self-care care within limits of the
therapeutic regimen
ABNORMALITIES AFFECTING THE WRISTS,
HANDS AND FINGERS
1. RHEUMATOID ARTHRITIS
– usually affects joints symmetrically (on
both sides equally) may initially begin in a
couple of joints only, and most frequently
attacks the wrists, hands, elbows,
shoulders, knees, and ankles
2. RHEUMATOID ( LATE STAGE)
– boutonniere deformity of thumb
– Ulnar deviation of metacarpophalangeal
joints
– Swan neck deformity of fingers
3. OSTEOARTHRITIS OF THE KNEE
4. TENOSYNOVITIS – painful extension of the
finger
5. DUPUYTREN’S CONTRACTURE
– A flexion deformity-progressive contracture
of the palmar fascia which severely impairs
the function of the 4th, 5th, and middle finger
6. GANGLION
– A collection of gelatinous material near the
tendon sheaths and joints, appears as
round, firm, cystic swelling usually on the
dorsum of the wrist.
– Common in women younger than 50 y/o
– Locally tender and may cause an aching
pain
7. PLANTAR FASCITIS – Inflammation of the
foot-supporting fascia, presents as an acute
onset of heel pain experienced with first steps
in the morning.
8. CORN – Overgrowth of horny layer of
epidermis between the toes and is produced
by:
- Internal pressure – underlying bone is
prominent due to congenital/acquired
abnormality-commonly arthritis
- External pressure – ill-fitting shoes
9. INGROWN TOENAIL
 Musculoskeletal Assessment | Page 13 of 13
Onychocryptosis – free edge of a nail plate
penetrates the surrounding skin, either laterally or
anteriorly.
Cause: improper self-treatment
● external pressure (tight shoes or
stocking)
● internal pressure (deformed toes,
growth under the nail)
● trauma
● infection
10. HAMMER TOE – Flexion deformity of the
interphalangeal joint which may involve several
toes.
Acquired deformity – Tight socks/shoes may
push an overlying toe back into the line of
other toes.
- The toes are usually pulled upward, forcing
the metatarsal joints(ball of the foot)
downward
11. HALLUX VALGUS
Bunion – deformity in which the great toe
deviates laterally
S/S – Osseous enlargement (exostosis) of
the medial side of the first metatarsal head,over
which a bursa may form
12. CLAWFOOT – foot with abnormally high arch
and fixed equinus deformity of the forefoot.
a. Pes Planus
b. Pes Cavus
13. FLAT FOOT
14. MORTON’S NEUROMA
Plantar digital neuroma – swelling of the
3rd(lateral) branch of the median plantar nerve.
S/S – throbbing burning pain in the foot that is
usually relieved by rest.