Musculoskeletal

Assessment

Bernard S. Barranco, RN, MAN,EdD

 Relationship of Musculoskeletal System to Other Systems
Musculoskeletal systemENDOCRINE
 Musculoskeletal system provides
protection to endocrine structures.
 Growth and sex hormone affect
growth of MS system.
 Thyroid/parathyroid control calcium
and calcitonin.

CARDIOVASCULAR
 Delivers nutrients to MS system and RESPIRATORY
removes wastes.  Chest muscles and bones protect lungs.
 Provides calcium if needed for  Muscles are essential for breathing.
cardiac contraction.  Respiratory system provides oxygen and
removes carbon dioxide.

GASTROINTESTINAL
 Provides nutrients to MS system (calcium
LYMPHATIC/ and phosphorus).
HEMATOLOGIC  Abdominal muscles protect
 Bone marrow produces blood cells  abdominal structures and organs.
and lymphocytes.
 Lymphatic system respond as a GENITOURINARY
defense for MS system.  MS system protects renal
structures
 Kidneys reabsorb calcium and
phosphorus as needed.
INTEGUMENTARY
REPRODUCTIVE  Skin provides protective covering for
 MS system protects muscles and joints.
reproductive organs.  Skin provides vitamin D synthesis
 Sex hormones affect growth. needed for calcium and phosphorus
bone growth.
Developmental Considerations
Fetus - skeleton formed

After birth -bone growth

continues rapidly during
infancy and then steadily
during the childhood years

SKELETAL CONTOUR
At birth - the spine has a
single C-shaped curve
(Skeletal Contour)

3- 4 months of age- infant is

able to raise his or her head
from the prone position
Infant and Children
Anterior curve develops in the
lumbar region (stand and
walk)
School-age - stands with the
normal adult curvature

GROWTH SPURT
Adolescence - occurs for both
boys and girls
Developmental Considerations
MUSCLE
Muscle fibers continue to
grow as the child grows.

Adolescence – muscle
responding to increased
growth hormone,adrenal
androgens, and testosterone
(boys)

Toddlers -“Potbellies” and

lordosis
(accentuated lumbar curve).
This posture is normal and
Children helps the child adjust to the
change in the center of
gravity.
Developmental Considerations
“”Lordosis” – progressive
change in posture in pregnant
women

Low back pain - during late

pregnancy

Increased mobility:
sacroiliac,sacrococcygeal,and
symphysis pubis joints
(preparation for delivery)

Pregnant women
Developmental Considerations
Bone density decreases (loss
of bone tissue)

Osteoporosis -with women at

a higher risk

POSTURAL CHANGE
“Kyphosis” with a backward
head tilt to compensate
and slight flexion of the hips

Shortening of height
(shortening of the vertebral
Older People column secondary to the loss
of water content and thinning
of the intervertebral discs)

FAT DISTRIBUTION
Most men and women gain
weight in their fourth and fifth
decades, losing fat in the
face and depositing it in the
abdomen and hips.
Developmental Considerations
GENERALIZED WEAKNESS
(loss of muscle mass and
size, and some muscle
atrophy)

GAIT
Decreased agility / uneven
rhythm and short steps / wide
base of support.

Decreased speed and

strength - resistance to
fatigue, reaction time, and
coordination.
Older People
 Cultures/Ethnic Groups

AFRICAN AMERICAN CHINESE AMERICAN FILIPINO AMERICAN

Greater bone density Generally shorter than Westerners Short in stature.
Hip measurements smaller Average adult height ranges from 5’
(females 4.14 cm smaller; males
7.6 cm smaller).
Bone length shorter.
Bone density less.
 HISTORY OF PRESENT ILLNESS
Joint symptoms
 Character: stiffness or limitation of movement, change in size
or contour, swelling or redness, constant pain or pain with
particular motion, unilateral or bilateral involvement,
interference with daily activities, joint locking or giving way.

 Associated events: time of day, activity, specific movements,

injury, strenuous activity, weather

 Efforts to treat: exercise, rest, weight reduction, physical

therapy, heat, ice, braces or splints

 Medications: nonsteroidal antiinflammatory drugs (NSAIDs),

acetaminophen, corticosteroids, topical analgesics
 HISTORY OF PRESENT ILLNESS
Muscular symptoms
 Character: limitation of movement, weakness or fatigue,
paralysis, tremor, tic, spasms, clumsiness, wasting, aching or
pain

 Precipitating factors: injury, strenuous activity, sudden

movement, stress

 Efforts to treat: heat, ice, splints, rest, massage

 Medications: muscle relaxants, statins, NSAIDs

 HISTORY OF PRESENT ILLNESS
Skeletal symptoms
 Character: difficulty with gait or limping; numbness, tingling, or
pressure sensation; pain with movement, crepitus; deformity or
change in skeletal contour

 Associated event: injury, recent fractures, strenuous activity,

sudden movement, stress; post menopause

 Efforts to treat: rest, splints, chiropractic, acupuncture

 Medications: hormone therapy, calcium; calcitonin

 HISTORY OF PRESENT ILLNESS
Injury
 Sensation at time of injury: click, pop, tearing, numbness,
tingling, catching, locking, grating, snapping, warmth or
coldness, ability to bear weight

 Mechanism of injury: direct trauma, overuse, sudden change of

direction, forceful contraction, overstretch

 Pain: location, type, onset (sudden or gradual), aggravating or

alleviating factors, position of comfort

 Swelling: location, timing (with activity or injury)

 Efforts to treat: rest, ice, heat, splints

 Medications: analgesics, NSAIDS

 HISTORY OF PRESENT ILLNESS
Back pain
 Abrupt or gradual onset, better or worse with activity

 Character of pain and sensation: tearing, burning, or steady

ache; tingling or numbness; location and distribution (unilateral
or bilateral), radiation to buttocks, groin, or legs; triggered by
coughing or sneezing and sudden movements

 Associated event: trauma, lifting of heavy weights, long distance

driving, sports activities, change in posture or deformity

 Efforts to treat: rest, avoid standing or sudden movements,

chiropractic, acupuncture

 Medications: muscle relaxants, analgesics, NSAIDs

 FAMILY HISTORY

 Congenital abnormalities of hip or foot

 Scoliosis or back problems
 Arthritis: rheumatoid, osteoarthritis, gout

Genetic disorders: skeletal dysplasia, rickets

Note: Types of Arthritis

Osteoarthritis (degenerative joint disease) is deterioration of the bone cartilage in the joint,
leading to pain and limited
Rheumatoid arthritis is an autoimmune disease causing inflammation of the joint. (Common to
women)
Gout is a hereditary metabolic disorder with a build up of uric acid (hyperuricemia) in the
joints, resulting in inflammation and pain.
(Common to men)
Equipment:
1. Tape measure- measure
limb lengths and
circumferences.
2. Goniometer - measure joint
Range of Motion
3. Skin marking pencil

To obtain a goniometer reading:

Match the angle of the joint being measured to the
arms of the goniometer
General survey:
 Observing the gait and posture when
the patient enters the examination
room.
 Note how the patient walks, sits, rises
from sitting position, takes off a coat,
and responds to other directions
given during the examination

Consideration:
 Good lighting- expose the body surface
 Position the patient to provide the greatest
stability to the joints.
 Position the extremities uniformly as you
examine and look for asymmetry.
Performing a Musculoskeletal Physical Assessment
Inspection

Inspection of overall body posture.

Note:
 Even contour of the shoulders
 Level scapulae and iliac crests
 Alignment of the head over the gluteal folds
 Symmetry and alignment of extremities
 The occiput, shoulders, buttocks, and heels should be able to
touch the wall the patient stands against.
Performing a Musculoskeletal Physical Assessment
Inspection
 Inspect the skin and subcutaneous tissues
overlying the articular structures for discoloration,
swelling, and masses.
 Observe the extremities for overall size, gross
deformity, bony enlargement, alignment, contour,
and symmetry of length and position.

 Inspect the muscles for gross hypertrophy or

atrophy , fasciculation and spasms.

Note:
 Muscle size should approximate symmetry
bilaterally.
 Fasciculation (muscle twitching) occurs after injury
to a muscle’s motor neuron.
 Muscle wasting occurs after injury as a result of
pain, disease of the muscle, or damage to the
motor neuron.
 Performing a Musculoskeletal Physical Assessment
Palpation
 Palpate any bones, joints, tendons, and surrounding muscles .
 If symptomatic - Palpate inflamed joints last.
 Note any heat, tenderness, swelling, crepitus, pain, and resistance to
movement.
 No discomfort should occur when you apply pressure to bones or
joints.

Note:
 Muscle tone should be firm
 Crepitus (a grating sound or sensation) can be felt when two irregular
bony surfaces rub together as a joint moves
Performing a Musculoskeletal Physical Assessment
Range of Motion
 Examine both the active and passive range
of motion for each major joint and its related
muscle groups.
 Muscle tone is often evaluated
simultaneously.

Active ROM:
 Allow adequate space for the patient to
move each muscle group and joint through
its full range.
 Instruct the patient to move each joint
through its range of motion as detailed in
specific joint and muscle sections.

Passive ROM
 Muscles should have slight tension.
 Passive range of motion often exceeds
active range of motion by 5 degrees.
Performing a Musculoskeletal Physical Assessment
Range of Motion
Note for:
Pain
Weakness
Limitation of motion
Spastic movement
Joint instability
Deformity
Crepitation
Tenderness
 Performing a Musculoskeletal Physical Assessment
Range of Motion

 When a joint appears to have an increase or

limitation in its range of motion, a
goniometer is used to precisely measure
the angle.

1. Begin with the joint in the fully extended or

neutral position
2. Flex the joint as far as possible.
3. Measure the angles of greatest flexion and
extension, comparing these with the
Use of goniometer to measure joint range of motion. expected joint flexion and extension values
 Performing a Musculoskeletal Physical Assessment
Muscle Strength
 Evaluating the strength of each muscle group
is considered part of the neurologic
examination.
 Usually integrated with examination of the
associated joint for range of motion.

1. Ask the patient first to contract the muscle

you indicate by extending or flexing the joint
2. Resist as you apply force against that muscle
contraction
Evaluation of muscle strength: flexion of
3. Alternatively, tell the patient to push against
the elbow against opposing force.
your hand to feel the resistance.

Note
 Compare the muscle strength bilaterally
 Expect muscle strength to be bilaterally
symmetric with full resistance to opposition.
Performing a Musculoskeletal Physical Assessment

Muscle Strength

Note:
 Muscle strength is grade 3 or less, disability is present
 Weakness may result from an underlying muscle disorder,
pain, fatigue, or overstretching.
 Performing a Musculoskeletal Physical Assessment

Muscle Strength
Grading Muscle Strength
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of muscle is palpable or visible
2: 25% of normal strength; full muscle movement against gravity, with support
3: 50 % of normal strength; normal movement against gravity
4: 75% of normal strength; normal full movement against gravity and against minimal
resistance
5: 100% of normal strength; normal full movement against gravity and against full
resistance
Specific Joints and Muscles
Palpate: Temporomandibular joint
Test ROM of joints, and note condition of skin, erythema,
edema, heat, deformity, crepitus, tenderness, and
stability of all joints.

 Locate the temporomandibular joints by placing your

fingertips just anterior to the tragus of each ear.
 Allow your fingertips to slip into the joint space as the
patient’s mouth opens, and gently palpate the joint
space

 Normal: audible or palpable snapping or clicking

 Abnormal: pain, crepitus, locking, or popping
Specific Joints and Muscles
Palpate: Temporomandibular joint
 Ask patient to laterally move the jaw left and
right and then open the mouth against
resistance.
(Expect a space of 3 to 6 cm between the upper
and lower teeth when the jaw is open)

 Feel for contraction of temporal and masseter

muscles to test integrity of cranial nerve V
(trigeminal).
 (The mandible should move 1 to 2 cm in each
direction)

 Protrude and retract the chin. Both movements

should be possible

 Strength of the temporalis and masseter muscles may be

evaluated by asking the patient to clench the teeth while you
palpate the contracted muscles and apply opposing force.
 This maneuver simultaneously tests cranial nerve V (the
trigeminal nerve).
Specific Joints and Muscles
Inspection: Shoulders

 Inspect the contour of the shoulders, the

shoulder girdle, the clavicles and
scapulae, and the surrounding
musculature.
 Expect symmetry of size and contour of
all shoulder structures.

ABNORMAL FINDINGS
Asymmetric and one shoulder has hollows
in the rounding contour, suspect a shoulder
dislocation
 Specific Joints and Muscles
Range of Motion: Shoulders

Shrugged shoulders.
Expect the shoulders to rise symmetrically.
CN XI (Accessoy)

Abduction and adduction Forward flexion and hyperextension.

Swing each arm across the front of the

body.
 Expect adduction of 50 degrees
Specific Joints and Muscles
Range of Motion: Shoulders

Internal rotation External rotation

Place both arms behind the hips, Place both arms behind the head,
elbows out. elbows out.
 Expect internal rotation of 90 degrees  Expect external rotation of 90
degrees
Specific Joints and Muscles
Inspection: Elbow
Note any deviations in the carrying
angle between the humerus and
radius while the arm is passively
extended, palm forward

The carrying angle is usually 5 to 15

degrees laterally.
Specific Joints and Muscles
Inspection: Elbow
 Inspect for symmetry, swelling, color, and
masses.
 Flex the patient’s elbow 70 degrees and
palpate the extensor surface of the ulna,
the olecranon process, and the medial
and lateral epicondyles of the humerus.
 Then palpate the groove on each side of
the olecranon process for tenderness,
swelling, and thickening of the synovial
membrane

Abnormal Findings

Epicondylitis or tendonitis
 Soft, or fluctuant swelling; point tenderness at
the lateral epicondyle or along the grooves of
the olecranon process and epicondyles
 Increased pain with pronation and supination of
the elbow
Specific Joints and Muscles
Range of Motion: Elbow
With the elbow fully extended
at 0 degrees, bend and
straighten the elbow.
 Expect flexion of 160
degrees and extension
returning to 0 degrees or
180 degrees of full extension
With the elbow flexed at a right
angle, rotate the hand from palm
side down to palm side up.
 Expect pronation of 90
degrees and supination of 90
degree
 To evaluate the strength of the elbow
muscles maintain flexion and extension
while you apply opposing force.
Specific Joints and Muscles
Inspection: Hand and Wrist
 Inspect the dorsal and palmar aspects of the
hands
Note for
 Contour
 Position
 Shape
 Number and completeness of digits.

 Note the presence of palmar and phalangeal

creases.
 The palmar surface of each hand should have a
central depression with a prominent, rounded
mound (thenar eminence) on the thumb side of
the hand and a less prominent (hypothenar
eminence) on the little finger side of the hand.
 Expect the fingers to fully extend when in close
approximation to each other and to be aligned
with the forearm.
 Specific Joints and Muscles
Hand and Wrist
ABNORMAL FINDINGS

Ulnar deviation and subluxation of Swan neck deformities.

metacarpophalangeal joints
 Specific Joints and Muscles
Palpation : Joints(Hand and Wrist)

Proximal interphalangeal joints Metacarpophalangeal joints Radiocarpal groove and wrist.

Palpate each joint in the hand and wrist:

 Palpate the interphalangeal joints with your thumb and index finger.
 The metacarpophalangeal joints are palpated with both thumbs.
 Palpate the wrist and radiocarpal groove with your thumbs on the dorsal
surface and your fingers on the palmar aspect of the wrist .

Note:
 Joint surfaces should be smooth and without nodules, swelling,
bogginess, or tenderness.
 Specific Joints and Muscles
Hand and Wrist
ABNORMAL FINDINGS

Swelling or spindle-shaped enlargement Telescoping digits with hypermobile

Degenerative joint disease
of the proximal interphalangeal joints joints.

Gouty arthritis
Specific Joints and Muscles
Range of Motion: (Hand and Wrist)
 Bend the fingers forward at the
metacarpophalangeal joint; then stretch the
fingers up and back at the knuckle.
 Expect metacarpophalangeal flexion of 90
degrees and hyperextension up to 30
degrees
 Specific Joints and Muscles
Range of Motion: (Hand and Wrist)

Finger flexion: thumb to each Finger abduction

Finger flexion: fist formation Spread the fingers apart and then
fingertip and to the base of the touch them together. Both
little finger. movements should be possible

Wrist flexion and hyperextension Wrist radial and ulnar movement.

With the palm side down, turn each hand to
the right and left. Expect radial motion of 20
degrees and ulnar motion of 55 degrees
Specific Joints and Muscles
Range of Motion: (Hand and Wrist)

Goniometer is used to measure joint angle.

Specific Joints and Muscles
Hand Strength
Test muscle strength by repeating
movements against resistance and
hand grip.

To avoid painful compression -

Two fingers of one hand side by
side in the handshake position.

Finger extension, abduction, adduction,

and thumb opposition may also be used
to evaluate hand strength.
Inspection/Palpation: Cervical spine
 Inspect the patient’s neck from both the anterior and
posterior position, observing for alignment of the
head with the shoulders and symmetry of the
skinfolds and muscles.

 Expect the cervical spine curve to be concave with

the head erect and in appropriate alignment.

 Palpate the posterior neck, cervical spine, and

paravertebral, trapezius, and sternocleidomastoid
muscles.

 The muscles should have good tone and be

symmetric in size, with no palpable tenderness or
muscle spasm.
 Range of Motion: Cervical spine

Flexion and hyperextension Lateral bending Rotation.

Bend the head forward, chin to the Bend the head to each side, ear to each Turn the head to each side, chin to
chest. shoulder. shoulder.
 Expect flexion of 45 degrees.  Expect lateral bending of 40 degrees.  Expect rotation of 70 degrees.

Bend the head backward, chin

toward the ceiling.
 Expect extension of 45 degrees.
 Range of Motion: Cervical spine
Flexion with palpation of the Extension against resistance Rotation against resistance.
sternocleidomastoid muscle

The strength of the sternocleidomastoid and trapezius muscles is evaluated with

the patient maintaining each of the above positions while you apply opposing
force.
 With rotation, cranial nerve XI is simultaneously tested
Palpation: Thoracic and Lumbar

With the patient standing erect, palpate along the spinal

processes and paravertebral muscles.
 No muscle spasms or spinal tenderness should be
noted.

Percuss for spinal tenderness

1. First by tapping each spinal process with one finger
and then by percussing each side of the spine along
the paravertebral muscles with the ulnar aspect of
your fist.
 No muscle spasm or spinal tenderness with
palpation or percussion should be elicited.
Inspection: Thoracic and Lumbar
Inspection of the spine for lateral curvature
and lumbar convexity.

• Ask the patient to bend forward slowly and touch the

toes while you observe from behind.

• Inspect the spine for unexpected curvature( back

should remain symmetrically flat as the concave curve
of the lumbar spine becomes convex with forward
flexion)

Scoliosis- lateral curvature or rib hump

• Then have the patient rise but remain bent at the

waist to fully extend the back (Reversal of the lumbar
curve should be apparent)
Range of Motion: Thoracic and Lumbar
Flexion

Bend forward at the waist and,
without bending the knees, try to
touch the toes.
 Expect flexion of 75 to 90
degrees
Bend back at the waist as far as
possible.
 Expect hyperextension of 30
degrees
Range of Motion: Thoracic and Lumbar

Lateral bending Rotation of the upper trunk.

Bend to each side as far as Swing the upper trunk from
possible. the waist in a circular motion
 Expect lateral bending of front to side to back to side
35 degrees bilaterally while you stabilize the pelvis.

 Expect rotation of the

upper trunk 30 degrees
forward and backward
 ABNORMAL FINDINGS

ABNORMALFINDINGS/

Kyphosis: Accentuated thoracic curve Scoliosis: Lateral “S” spinal deviation. Lordosis: Accentuated lumbar curve.
Inspection: Hips

Inspect the hips anteriorly and posteriorly

while the patient stands.

Major landmarks - iliac crest and the

greater trochanter of the femur

Note any asymmetry:

 Iliac crest height
 Size of the buttocks
 Number and level of gluteal folds.
 Hips
 Inspect for symmetry and shape with patient standing.
 Palpate for stability, tenderness, tenderness, and crepitus.
■ Test ROM:

1. Extend (patient supine or standing, leg straight)

2. Flex (raise extended leg and flex knee to chest while keeping other leg extended)
3. Abduct (move extended leg away from midline of body as far as possible)
4. Adduct (move extended leg toward midline of body as far as possible)
5. Internal rotation (bend knee and turn leg inward)
6. External rotation (bend knee and turn leg outward)
7. Hyperextend (lie prone and lift extended leg off table), and stand and swing
extended leg backward.

NOTE: Test muscle strength by repeating ROM against resistance.

NURSING A L E R T!!!
Do not adduct, internally rotate, or flex more than 90 degrees on
patients with hip replacements. ( Hip displacement)
 Range of Motion: Hips
Hip Flexion, knee extended Hip extension, knee extended Hip flexion, knee flexed

Supine, raise the leg with the
knee extended above the body.
 Expect up to 90 degrees of
hip flexion
While either standing or prone, swing
the straightened leg behind the body
without arching the back.
 Expect hip hyperextension of 30
degrees or less
While supine, raise one knee to the
chest while keeping the other leg
straight.
 Expect hip flexion of 120 degrees
 Range of Motion: Hips
Abduction Internal rotation External rotation

While supine, swing the leg laterally and

medially with knee straight. With the
adduction movement, passively lift the
opposite leg to permit the examined leg full
movement.
 Expect up to 45 degrees of abduction
and up to 30 degrees of adduction
While supine, flex the knee keeping
the foot on the table and then rotate
the leg with the flexed knee toward
the other leg.
 Expect internal rotation of 40
degrees
While supine, place the lateral aspect
of the foot on the knee of the other leg;
move the flexed knee toward the table
(FABER test —
F lex, AB duct, and E xternally R otate)

 Expect 45 degrees of external

rotation

Note:
 To test hip flexion strength, apply resistance while the patient maintains flexion
of the hip when the knee is flexed and then extended.
 Muscle strength can also be evaluated during abduction and adduction, as well
as by resistance to uncrossing the legs while seated.
Inspection: Legs and Knees
• Inspect the knees and their popliteal spaces in both flexed
and extended positions,

Major landmarks: tibial tuberosity, medial and lateral tibial

condyles, medial and lateral epicondyles of the femur,
adductor tubercle of the femur.
• Inspect the extended knee for its natural concavities on
the anterior aspect, on each side, and above the patella.

• Observe the lower leg alignment.

 The angle between the femur and tibia is expected to be
less than 15 degrees.

• Variations in lower leg alignment are genu valgum (knock-

knees) and genu varum (bowlegs).
• Excessive hyperextension of the knee with weight bearing
(genu recurvatum) may indicate weakness of the
quadriceps muscles.
 Inspection: Legs and Knees

Genu valgum: Knees touch and medial malleoli Genu varum: Knees are greater than 5 cm (2 inches) apart
are 7.5 cm (3 inches) or more apart and medial malleoli touch.
Palpation: Legs and Knees

 Palpate the popliteal space, noting

any swelling or tenderness.

 Then palpate the tibiofemoral joint

space, identifying the patella, the
suprapatellar pouch, and the
infrapatellar fat pad.

 The joint should feel smooth and

firm, without tenderness, swelling,
nodules, or crepitus
Range of Motion: Knees
•Bend each knee.
 Expect 130 degrees of flexion.

Straighten the leg and stretch it.

 Expect full extension and up to 15
degrees of hyperextension.

 The strength of the knee muscles is evaluated with the

patient maintaining flexion and extension while you
apply opposing force. The patient may be sitting or
standing for this assessment.
Inspection: Feet and Ankles
 Inspect the feet and ankles while the patient is
bearing weight (i.e., standing and walking) and
while sitting.

 Landmarks of the ankle include the medial

malleolus, the lateral malleolus, and the Achilles
tendon.
 Expect smooth and rounded malleolar
prominences, prominent heels, and prominent
metatarsophalangeal joints.
 Calluses and corns indicate chronic pressure or
irritation.
 Observe the contour of the feet and the position,
size, and number of toes.

 The feet should be in alignment with the tibias.

 Pes varus (in-toeing) and pes valgus (out-toeing)
are common alignment variations.
 Weight bearing should be on the midline of the foot
Inspection: Foot
Pes planus (flatfoot) Pes cavus (high instep)

Foot that remains flat even

when not bearing weight
 Range of Motion: Foot
Abduction and adduction.

Point the foot toward the ceiling.
 Expect dorsiflexion of 20
degrees
Point the foot toward the floor.
 Expect plantar flexion of 45
degrees.
Bending the foot at the ankle,
turn the sole of the foot toward
and then away from the other
foot.
 Expect inversion of 30
degrees and eversion of 20
degrees
Rotating the ankle, turn
the foot away from and
then toward the other foot
while the examiner
stabilizes the leg.
 Expect abduction of 10
degrees and adduction
of 20 degrees

 Have the patient maintain dorsiflexion and plantar flexion while you apply
opposing force to evaluate the strength of the ankle muscles.
 Abduction and adduction of the ankle and flexion and extension of the great
toe may also be used to evaluate muscle strength.
Inspection: Toes
 The toes should be straight forward, flat,
and in alignment with each other.

 Hyperextension of the
metatarsophalangeal joint with flexion of
the toe’s proximal joint is called
hammertoe
 A flexion deformity at the distal
interphalangeal joint is called a mallet
toe.
 Claw toe is hyperextension of the
metatarsophalangeal joint with flexion of
the toe’s proximal and distal joints.

 Hallux valgus is lateral deviation of the

great toe, which may cause overlapping
with the second toe.
 Inspection: Toes

Hallux valgus with bunion Protruding metatarsal heads Hammertoes.

with callosities

Claw toes.
Mallet toe
Palpate: Achilles tendon

 Palpate the Achilles tendon, the anterior

surface of the ankle, and the medial and
lateral malleoli.

 A persistently thickened Achilles tendon

may indicate the tendonitis that can
develop with spondyloarthritis
 Use the thumb and fingers of both
hands to compress the forefoot and to
palpate each metatarsophalangeal joint,
looking for discomfort or swelling.