Musculoskeletal

assessment
Musculoskeletal assessment
 Introduction

The musculoskeletal system is the

supporting framework and collectively
the largest system in the body.

It is word of 2 syllables
Muscle + Skeletal
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)
 1-Types
1. Skeletal muscles (voluntary
and striated),
2. Cardiac muscles
(involuntary and striated)
3. Smooth/visceral muscles
(involuntary and non-striated)
Skeletal muscles
 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.
•
.
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
 The function of muscles is

• Movement of body parts: by isotonic &

isometric contractions
• Maintenance of posture
• Production of body heat
 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
Consists of:
1. The Skeleton (bones)
2. Articular system (Joints)
3. Supportive connective tissues
(Cartilage, ligaments, tendons)
 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.
 Typs of bones cells:
• 1-Osteoblasts :function in bone
formation by secreting bone matrix.
• 2-Osteocytes are mature bone cells
involved in bone-maintenance functions.
• 3-Osteoclasts: involved in destroying,
resorbing, and remolding bone.
 TYPES OF BONE
There are 206 bones in the human body, divided into four categories:

 Long bones (e.g, femur)

 Short bones (e.g., metacarpals)

 Flat bones (e.g., sternum)

 Irregular bones (e.g., vertebrae)

Types of
bones:

 Long bones
 Short bones
 Flat bones
Irregular
bones
Bones of the Cranium
Frontal View
 Frontal

Frontal View
Parietal

Frontal View
Temporal

Frontal View
 Nasal

Frontal View
Vomer

Frontal View
 Zygoma

Frontal View
Maxilla

Frontal View
 Mandible

Frontal View
 Frontal
Parietal

Temporal
Nasal

Vomer Zygoma
Maxilla

Mandible

Frontal View
Lateral View
Frontal

Lateral View
 Parietal

Lateral View
 Temporal

Lateral View
Nasal

Lateral View
Zygoma

Lateral View
Maxilla

Lateral View
Mandible

Lateral View
 Sphenoid

Lateral View
 Occipital

Lateral View
 Mastoid Process

Lateral View
External Auditory Meatus

Lateral View
 Frontal Parietal

Sphenoid
Nasal
Temporal
Zygoma Occipital
Maxilla
Mastoid Process

Mandible

External Auditory Meatus

Lateral View
Sutures
 Sagittal

Sutures
Frontal
(Coronal)

Sutures
 Squamous

Sutures
 Lambdoid

Sutures
 Sagittal

Frontal
(Coronal)

Squamous

Lambdoid

Sutures
Bones of the
Appendicular
Skeleton
Clavicle
Scapula
Costals (Ribs)
Sternum
Vertebra
Humerus
Ulna
Radius
Clavicle
Scapula
Sternum Costals (Ribs)
Humerus

Ulna Vertebra

Radius
Sacrum
Ilium
Ischium
Pubis
Femur
Patella
Tibia
Fibula
 Ilium Sacrum
Ischium Pubis

Femur
Patella

Fibula

Tibia
Bones of the Hand
 Carpels

Bones of the Hand

 Metacarpels

Carpels

Bones of the Hand

 Phalanges

Metacarpels

Carpels

Bones of the Hand

Bones of the Foot
 Tarsals

Bones of the Foot

 Metatarsals

Tarsals

Bones of the Foot

 Phalanges

Metatarsals

Tarsals

Bones of the Foot

 2- Joints
Joint: the point at which two or more
bones meet. The synotide 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)
 .
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
 Classification of Joints
• (1) Synarthroses or fibrous
• (2) amphiarthroses or cartilaginous
• (3) diarthroses or synovial = movable joints
Movable joints
 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).
(2)Ligaments
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.
Also support many internal
organs; including the uterus, the
bladder, the liver, and the
diaphragm and supporting the
breasts.
(3)Tendons:

connect muscles to bones, When muscles

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

PHYSICAL EXAMINATION
COLLECTING SUBJECTIVE DATA
Current symptoms

 Have you had any recent weight gain?

 Describe any difficulty chewing you have.

 Is it associated with tenderness or pain?

 Describe any joint, muscle, or bone pain you have.

 CON….
Past History
 Describe any past problems or injuries you have had to your joints, muscles, or
bones. What treatment was given? Do you have any after effects from the injury
or problem? When were your last tetanus and polio immunizations?

 Have you ever been diagnosed with diabetes mellitus, sickle cell anemia,
systemic lupus erythematous(SLE), or osteoporosis?

 For middle aged and female clients:

 Have you started menopause? Are you receiving estrogen replacement therapy?
 CON

Family History

 Do you have a family history of rheumatoid arthritis, gout, or osteoporosis?

 Life-style and health practices

 What activities do you engage in to promote the health of your
musculoskeletal system (e.g., exercise, diet, weight reduction)?

 Do you smoke tobacco? How much and how often?

 Do you drink alcohol or caffeinated beverages? How much and how often?

 Describe your typical 24- hours diet. Are you able to consume milk or milk-
containing products? Do you take any calcium supplements?
 Describe your activities during a typical day. How much time do you spend in
the sunlight?
 CON….
 Describe any routine exercise in which you engage.

 Describe your occupation.

 Describe your posture at work and at leisure. What type of shoes do you usually
wear?

 Do you have difficulty performing normal activities of daily living? Do you use
assistive devices (e.g., walker, cane, braces) to promote your mobility?
 How have your musculoskeletal problems interfered with your ability to interact
or socialize with others? Have they interfered with your usual sexual activity?

 How did you view yourself before you had this musculoskeletal problem, and
how do you view yourself now?

 Has your musculoskeletal problems added stress to your life? Describe.

 Assessment of musculoskeletal
system

 Subjective Data
• History collection
 Objective Data
• Physical examination
 General principles of joint
examination

 Ensure that the joints to be examined are fully exposed

and the patient is resting comfortably.
 Provide privacy
 Be sensitive to patients feeling and physical comfort
The routine for examination

 Inspection
 Palpation
 Movement of joint(s)
 INSPECTION
 Observe any lack of symmetry and
any evidence of trauma or disease.
 Look for muscle wasting;
 Inspect the joint contour (shape)and observe
any evidence of swelling, deformity or inflammation
 Ask client to point to any painful areas including sites or
radiation of pain
 Palpation

 Palpate for warmth swelling and tenderness in

the areas of swelling redness and the areas where the
patient reported pain
 Hand should be warm to prevent spasm
 Both superficial and deep palpation are performed
 Usually begins from neck shoulder elbow wrist hand
back hip knees ankles and feet
 MOVEMENTS

 Active ROM
 Passive ROM
 Muscle Strength scale
0 No detection of muscular contraction

1 A barely detectable flicker or trace of

contraction with observation or palpation
2 Active movement of body part with elimination of
gravity.
3 Active movement against gravity only
and not against resistance
4 Active movement against gravity & some
resistance
5 Active movement against full resistance
without evident fatigue (Normal muscle
strength)
The neutral position

 The range of most movements

are described with the neutral
position in mind
 In the neutral position
the limbs are extended with
the feet dorsiflexed at 90 degrees
and the forearms in mid-pronation
Main anatomical movements

 Adduction -movement of the part

distal to the joint towards the midline
 Abduction -movement away
from the midline
Main anatomical movements

 Flexion - bending of joint

away from neutral position
 Extension - movement to straighten
a joint towards the neutral position
 Hyperextension - occurs when
the joint can be extended beyond
the neutral position
 Main anatomical movements

 Pronation - rotation of the

forearm so that the palm
faces backwards
 Supination - rotation of the
forearm so that the palm
faces forwards
Main anatomical movements

CIRCUMDUCTION
Main anatomical
movements
 DORSIFLEXION

 PLANTAR FLEXION
 Main anatomical
movements
 Eversion

 Inversion
Main anatomical
movements
Assessment -Gait:
GAIT
From behind:
 GAIT
From side:
GAIT

Observe Gait
Observe the client’s gait as the client enters and walks around the room.
Note:
 Base of support
 Weight bearing stability
 Feet position
 Stride
 Stride length
 Cadence
 Arm swing
 Posture
Assessment of temporomandibular
joint

 Inspection
 Palpation
 Muscle strength
 Inspect and palpate the TMJ
 Test ROM
 Test CN V function
TMJ palpation
TMJ
STEPS
1. As the client’s mouth opens, your fingers
should glide into a shallow depression of
the joints. Confirm the smooth motion of
the mandible
2. The joint may audibly or palpably clicks as
the mouth opens. This is normal
3. Palpate the CONTRACTED TEMPORALIS
AND MASSETER MUSCLES. HOW?
Test CN V function
– contract temporal and masseter
muscle
TMJ and cranial nerve 5 testing
-Instruct to clench teeth as you palpate
-compare right and left sides for size,
firmness and strength.
- ask the person to open mouth against your
resistance and to move jaw forward and
laterally against your resistance.
TMJ ROM
STEPS
1. Ask the client to open the mouth as wide
as possible. Confirm that the mouth
opens with ease to a smuch as 3 to 6 cm
between the upper and lower incisors.
2. With the mouth slightly open, ask the
client to push out the lower jaw and
return to neutral position. The jaw should
protrude and retract with ease.
3. Ask the client to move the lower jaw
from side to side.
.Confirm that the jaw moves laterally from 1
to 2 cm without deviation or dislocation.
4. Last, ask the client to close the mouth. The
mouth should close completely without pain
or discomfort.
Test ROM
 o normal finding:
 jaws move laterally 1 to 2 cm
 (+) snapping and clicking – may be felt and heard
 mouth opens 1-2 inches (distance bet upper and lower teeth)
 jaw protrudes and retracts easily
o abnormal finding:
 decreased ROM, swelling, tenderness, crepitus – arthritis
 decreased muscle strength – muscle and joint dse
 decreased ROM, clicking, popping, grating sound – TMJ
dysfunction

Inspect and palpate the TMJ

o normal finding:
full ROM against contraction
contraction palpated with no pain or spasms
o abnormal finding:
lack of full contraction – CN V lesion
 Pain or spasms – myofacial pain syndrome

ROM & CN V function

Sternoclavicular joint
 Maria Carmela L. Domocmat, RN, MSN
http://www.orthoandsportspt.com/media/img/1076/shoulder_anato
my_bones03.jpg
 Inspection and palpation
onormal finding:
no visible bony growth, swelling, redness
joint – nontender
oabnormal finding:
swollen, red, enlarged joint or tender
painful joint – joint inflammation

Sternoclavicular joint
STERNOCLAVICULAR JOINT

Inspect and palpate

With client sitting, inspect the
sternoclavicular joint for location in
midline, color, swelling, and masses.
Then palpate for tenderness or pain.
Cervical, Thoracic and Lumbar Spine
ia
CERVICAL SPINE

 Inspection
 Palpation
 ROM
→cervical spine
→throracic and lumbar
Leg and back pain
Measur leg length
CERVICAL,THORASIC,AND LUMBAR SPINE

 Inspect and palpate

o normal finding:
cervical and lumbar spines – concave
thoracic spine – convex
spine –straight; 24 vertebrae
African Americans – large gluteal prominence
– spine appear lumbar lordosis
variation number of vertebrae
Afr Ame women – 23 vertebrae
o abnormal finding:
flattened lumbar curvature – herniated lumbar
disc, ankylosing spondylitis
scoliosis - lateral curvature of thoracic spine
with increase in convexity on curved side
lordosis – exaggerated lumbar curve;
pregnancy, obesity
kyphosis – rounded thoracic convexity
Unequal height of hips, unequal leg lengths
OBSERVE THE CERVICAL, THORACIC
AND LUMBAR FROM SIDE THEN
BEHIND
Maria Carmela L. Domocmat, RN, MSN
.

Maria Carmela L. Domocmat, RN, MSN

.
-.
 Palpate spinousprocesses and the
paravertebral muscles on both sides of the
spine for tenderness or pain
o normal finding:
nontender spinous processes
well-developed firm and smooth, nontender
paravertebral muscles
no muscle spasms
o abnormal finding:
pain and tenderness of spinal processes and
paravertebral muscles – compression
fractures, lumbosacral muscle strain
 TEST ROM OF THE CERVICAL SPINE

Test ROM by asking the client to:

 Touch chin to chest(flexion).
Look up at
ceiling(hyperextension).
Touch each ear to the shoulder on
that side (lateral bending).
Maria Carmela L. Domocmat, RN, MSN
 Cervical spine movements
 Rotation - ask the
patient to look back
over each shoulder
in turn - normal
approx. 70 degrees
o normal finding:
 flexion - 450; extension - 450
 rotation -700
 full ROM against resistance
  pain and tenderness of spinal processes and
paravertebral muscles compression fractures ad
lumbosacral muscle strain
 cervical strain
 impaired ROM and neck pain – form abnormalities soft tissue
(muscles, ligaments, nerves) – due straining or injuring neck
(i.e, sleeping in wrong position, carrying heavy suitcase,
automobile crash)
 impaired ROM, pain that radiates to back, shoulder,
arms - cervical disc degenerative dse, spinal cord tumors
 neck pain with loss of sensation in legs – cervical spinal
cord compression
 impaired ROM, neck pain assoc with fever, chills,
headache – serious infection (e.g., meningitis)

abnormal findings R
TEST ROM OF THE THORACIC ANDLUMBAR
SPINE
 o flexion – bendforward, touch toes
o lateral bending
o lumbar extension
o rotation

Test ROM of thoracic and lumbar

spine
LATERAL BENDING
-Sit or stand behind the standing
client.
- Stabilize the pelvis with your hands
and ask the client to bend sideways to
the right and to the left.
FLEXION

- Ask the client to bend forward and

touch the toes.
- Confirm that the lumbar concavity
disappears with this movement and
that the back assumes a single- c
shaped convexity
HYPEREXTENSION

- Ask the client to bend backward as

far as is comfortable.
ROTATION

-Ask the client to twist the shoulders

to the left and to the right.
o normal finding:
flexion – 900
smooth movement, lumbar concavity
flattens out, spine remains straight
lateral bending - 350
hyperextension - 300
rotation - 300
o abnormal finding:
 lateral curvature disappears- functional scoliosis
 unilateral exaggerated thoracic convexity – structural
scoliosis
 impaired ROM, pain lumbar and thoracic regions -
low back strain from injury to soft tissues
 impaired ROM lumbar and thoracic regions –
osteoarthritis, ankylosing spondylitis, congenital
abnormalities
TEST FOR LEG AND
BACK PAIN
Lasègue’s test
o Or straight leg raising
o if (+) low back pain that
radiates down the back
o to check for herniated
nucleus pulposus
STEPS

- Client lie flat and raise each relaxed

leg independently to point of paiN
- point of pain – dorsiflex foot
-Note degree of elevation when pain
occurs; distribution and character of
pain, results from dorsiflexion
Lasègue’s te st
o normal finding:
able to raise leg to 90 degree angle
mild pain of hamstring
o abnormal finding:
pain that shoots and radiates down one or both
legs (sciatica) below the knees – herniated
intervertebral disc
continuous, aching pain at night not relieved by
rest – metastases
lower back pain with tenderness and limited
ROM – osteoporosis
MEASURE LEG LENGTH
 o leg lengths - if suspect client has 1 leg
longer
distance from anterior superior iliac spine and
medial malleolus; cross tape on medial side of
knee
o if still look unequal – assess apparent
leg lengths
measure from nonfixed point (umbilicus) to a
fixed point (medial malleolus) each leg

Measure leg length

o normal finding:
equal or within 1 cm

o abnormal finding:
unequal leg lengths – scoliosis
equal true leg lengths but unequal apparent leg
lengths – abnormalities in structure or position
of hips and pelvis
Shoulders, Arms, and Elbows
INSPECTION
o normal finding:
shoulders –symmetrically round, no redness,
swelling, deformity or heat, no tenderness
muscles -fully developed
clavicle and scapulae – even and symmetric
o abnormal finding:
flat, hollow, less rounded shoulders –
dislocation
muscle atrophy – nerve or muscle damage or
lack of use
 Shoulder

Palpation:
 Clavicle
Tenderness of sternoclavicular
joint , acromioclavicular joint
greater tubercle of humerus
- tenderness, swelling, heat – shoulder stains,
sprains, arthritis, bursitis, degenerative joint
disease

- Shoulder pain without palpation or

movement ,may result from insufficient
circulation to myocardium. Known as- MI
 Shoulder Movement
*Flexion * Abduction
*Extension * Adduction
*Internal rotation * External rotation
o flexion – move arms forward elbows straight ;
hyperextension – move arms backward
o adduction – hands front of body past midline ;
abduction – hands together overhead
o external rotation – hands together behind head,
elbows flexed ;
internal rotation – behind back
o shrug shoulders
o repeat all against resistance

Test ROM
o normal finding:
flexion - 1800 ; hyperextension - 500
adduction - 500 ; abduction - 1800
external and internal rotation - 900
o abnormalfinding:
 painful and limited abduction, muscle weakness &
atrophy – rotator cuff tear
 sharp catches of pain when bringing hands overhead –
rotator cuff tendinitis
 chronic pain and severe limitation of all shoulder
motions – calcified tendinitis
 unable shrug shoulders against resistance - lesion of
CN
XI
 decreased muscle strength against resistance – muscle
and joint dse
ELBOWS

INSPECT AND PALPATE

 Inspect
for size, shape, deformities,
redness, or swelling.

 Withthe elbow relaxed and flexed

about 70o, use your thumb and
middle fingers to palpate the
olecranon process and epicondyles.
 Inspect for size, shape, deformities, redness, or
swelling
oelbows flex and extended
oelbows relaxed and flexed abt 700 – palpate
olecranon process and epicondyles use
thumb and middle fingers

Inspect for size, shape,

deformities, redness, or swelling
o normal finding:
symmetric, without deformity, redness,
swelling
nontender, without nodules
Elbow Palpation
o abnormal finding:
redness, heat, swelling- bursitis of olecranon
process- trauma or arthritis
firm, nontender, subq nodules – rheumatoid
arthritis or rheumatic fever
tenderness or pain over epicondyles –
epicondylitis (tennis elbow) – repetitive
movements of forearm or wrists
TEST ROM OF ELBOW
o flexion – flex elbow, bring hand to
forehead
o extension – straighten elbow
o pronation – arm out, turn palm down
o supination – turn palm up

Test ROM
SUPINATION AND PRONATION
o normal finding:
flexion – 1600
extension – 900
pronation – 900
supination – 900
some – lack 5 to 10 0 ; or have
hyperextension
o abnormal finding:
decreased muscle strength against resistance
– muscle and joint dse
WRISTS
 o palpate anatomic snuffbox
o hollow area on back of wrist at base of
fully extended thumb

o normal finding:
symmetric without redness, swelling
nontender, free of nodules
no tenderness anatomic snuffbox

Inspect and palpate

ganglion
To assess wrist strength
 1. Maintain wrist
flexion while you try
to extend the wrist.

2. Try to extend the

wrist as you try to
flex it
o abnormal finding:
rheumatoid arthritis – swelling, tenderness,
nodules
ganglion - nontender, round, enlarged,
swollen, fluid-filled cyst ; dorsum of wrist
snuffbox tenderness – scaphoid fracture –
result of falling on outstretched hand

#
o flexion – bend down ; extension – bend
back
o deviation – client hold wrist straight;
move hand outward and inward

Test ROM
Range Of Motion
Wrists, Hands, and Fingers.
onormal finding:
flexion - 90 0
hyperextension - 700
ulnar deviation - 55 0
radial deviation - 200
Swedes, Chinese – unequal lengths of ulna and
radius
o abnormal finding:
 ulnar deviation of wrist and fingers with limited
ROM – rheumatoid arthritis
 epicondylitis of lateral side of elbow– increased pain
with extension of wrist and fingers against resistance
 epicondylitis of medial side of elbow– increased
pain with flexion of wrist and fingers against
resistance
 decreased muscle strength against resistance –
muscle and joint dse
 ◦ Phalen’s test
◦ Tinel’s sign

Test for Carpal Tunnel Syndrome

 Progressive sensory changes including paresthesias
and numbness of the thumb, index finger, and ring
finger of the involved hand; leads to pain waking
the patient up at night.
 Motor changes beginning with clumsiness and
progressing to weakness; edema and thenar
atrophy may be noted.
 Positive Tinel’s sign: Increased paresthesias on
tapping of tendon sheath (ventral surface of central
wrist).
 Positive Phalen test: Increased symptoms with
acute palmar flexion for 1 minute.

Carpal Tunnel Syndrome

o normal finding:
no tingling, numbness, pain
o abnormal finding:
(+)tingling, numbness, pain – (+) carpal tunnel
syndrome
numbness, pain , impaired function of hand
and fingers - median nerve entrapped in carpal
tunnel
TEST FOR CARPAL TUNNEL
SYNDROME(PHALEN’S TEST)
  PHALEN’S TEST

Phalen's Test is also known a Wrist

Flexion Test and is an
orthopedic special test used to help
diagnose injury to the median nerve
in the wrist especially as it relates to
the carpal tunnel
 TINELS SIGN
A way to detect irritated nerves.
It is performed by lightly tapping
(percussing) over the nerve
to elicit a sensation of tingling
or "pins and needles" in the
distribution of the nerve
TINEL’S SIGN
HANDS AND FINGERS
INSPECT AND PALPATE
 Inspect for size, shape, symmetry,
swelling, and color.

 Palpate for tenderness and

nodules.
 o normal finding:
symmetric, nontender, without nodules
fingers – lie in straight line
no swelling, deformities
rounded protuberance – next to thumb over
thenar prominence
smaller protuberance adjacent small finger

Inspect and palpate

Palpate the joints
between the carpal, meta-
carpal, and phalangea l
bones.
Use your thumbs and index
fingers to palpate each of
these joints.

Interphalangeal joints
Metacarpophalangeal joints
Radiocarpal groove an d
wrist
Maria Carmela L. Domocmat, RN, MSN
 ask the client to
squeeze your first
two fingers as hard
as he or she can.
 If you cross your
fingers, you will not
feel as much
discomfort if the
client is exceptional
strong.
 Progressive sensory changes including paresthesias
and numbness of the thumb, index finger, and ring
finger of the involved hand; leads to pain waking
the patient up at night.
 Motor changes beginning with clumsiness and
progressing to weakness; edema and thenar
atrophy may be noted.
 Positive Tinel’s sign: Increased paresthesias on
tapping of tendon sheath (ventral surface of central
wrist).
 Positive Phalen test: Increased symptoms with
acute palmar flexion for 1 minute.

Carpal Tunnel Syndrome

  place backs of both hand against each
other while flexing wrists 900 downward
 hold for 60 sec

Phalen’s test
 In the first of these
tests, for 1 minute.
The experience of
numbness and
paresthesia over the
palmar surface of the
hand and the first
three fingers and part
of the fourth is called
Phalen’s sign. The
symptoms resolve
quickly after the hand
returns to the resting
position.
 tapping over the median nerve
(palmar aspect of wrist).
 The client’s sensation of tingling or
prickling is known as Tinel’s sign.

Tinel’s sign
o normal finding:
no tingling, numbness, pain
o abnormal finding:
(+)tingling, numbness, pain – (+) carpal tunnel
syndrome
numbness, pain , impaired function of hand
and fingers - median nerve entrapped in carpal
tunnel
o abnormal finding:
 swollen, stiff, tender finger joints – acute rheumatoid
arthritis
 boutonnière deformity – flexion of proximal
interphalangeal joint and hyperextension of distal
interphalangeal joint
 swan-neck deformity - hyperextension of proximal
interphalangeal joint with flexion of distal
interphalangeal joint
swan-neck deformity boutonnière deformity
o abnormal finding:
 thenar atrophy (atrophy thenar prominence) – carpal tunnel
syndrome
 osteoarthritis
 Heberden’s nodes - hard, painless nodules over distal
interphalangeal joints
 Bouchard’s nodes - hard, painless nodules over proximal
interphalangeal joints
thenar atrophy
TEST ROM

Ask the client to:

 Spread the fingers apart.
ROM OF FINGERS
o abduction – spread fingers apart ; adduction
– make a fist
o flexion – bend fingers down ; hyperextension
– bend up
o thumb abduction - move thumb away; thumb
adduction – touch thumb base of sml finger
o repeat all against resistance

Test ROM
http://www.ncbi.nlm.nih.gov/books/N
BK27290/bin/ch4f4-57.jpg
1. Extend the fingers while you push down on the dorsal
surface
2. Flex the fingers while you push up on the
ventral surface.
3. Spread the fingers as far apart as possible
while you try to push them together.
4. Push the fingers as close together as possible
while you try to pull th em apart.

To assess finger strength

o normal finding:
abduction - 20 0
adduction - 900
flexion - 900
hyperextension - 300
thumb flexion/adduction- 500
Dupuytren’s contra cttur e
e s-
 It is a very common problem and often arises in
the hands of middle aged persons; however, it can
be seen as early as the twenties. This entity does
run in families in some cases. It is seven times
more common in men than women. It has been
associated with diabetes and can be seen in
alcoholics with cirrhosis of the liver. It has also
been associated with epilepsy but may be a result
of the use of anticonvulsant drugs rather than the
presence of epilepsy itself. The underlying cause is
unknown.

Dupuytren’s contracture
o abnormal finding:
Dupuytren’s contracture – inability to
extend ring and little fingers
tenosynovitis (infection of flexor tendon
sheathes) - painful extension of finger
decreased muscle strength against resistance
– muscle and joint dse
o abnormal finding:
Tenosynovitis
infection of flexor tendon sheathes
painful extension of finger
decreased muscle strength against resistance
– muscle and joint dse
 When a tendon (a fibrous, non-elastic band of
tissue which attaches a muscle to a bone) and its
surrounding soft tissue (called the tenosynovium)
are injured—either by a direct injury or due to
micro-trauma like excessive repetitive
movements—they become inflamed, swollen, and
painful. This condition is called Tenosynovitis. (A
less accurate and rarely used term to describe this
condition is tendonitis.)
 While all of the tendons of the wrist and hand may
become inflamed and painful, the most common
form of tenosynovitis seen in the hand and wrist is
called deQuervain's Tenosynovitis. deQuervain's
Tenosynovitis affects the thumb and wrist.

Maria Carmela L. Domocmat, RN, MSN

 affects two thumb tendons: the abductor pollicis
longus (APL) and the extensor pollicis brevis (EPB).
These tendons connect their respective muscles,
which lie on the back of the forearm, to the thumb.
These tendons are responsible for extending the
thumb backwards, and for moving the thumb away
from the palm of the hand.
 On their way to the thumb, the APL and EPB travel
side-by-side along the inside of the wrist. They
pass through a tunnel in the wrist which is covered
by a non-elastic type of fibrous tissue called the
Extensor Retinaculum. The function of this tunnel is
to hold the tendons in place.

deQuervain's
Tenosynovitis
Hips
 Inspect and palpate
ostand
onormal finding:
buttocks – equally sized
iliac crests – symmetric height
hips – stable, nontender, without crepitus
o abnormal finding:
instability, inability to stand, and/or
deformed hip area – fractured hip
tenderness, edema, decreased ROM,
crepitus – hip inflammation, degenerative jt
dse
o
supine
o hip flexion
flexion with knees straight - raise extended
leg
flexion with knee flexed - flex knee to
chest; keep other leg extended
Note: if had total hip replacement – do not
test ROM unless physician gives
permission; reduce risk of dislocating
prosthesis

Test ROM
o abduction – move extended leg away from
midline of body as far as possible ; adduction –
toward midline of body as far as possible
o internal/ external hip rotation – bend knee and
turn leg inward then outward
o hyperextension – prone, lift extended leg off
table ; or client stand and swing extended leg
backward
o repeat all against resistance
onormal finding:
flexion with knees straight – 900
flexion with knee flexed -1200
abduction – 45-500 ; adduction – 20 to 300
internal hip rotation - 400 ; external hip rotation -
450
hyperextension - 150
oabnormal finding:
inability to abduct hip – hip dse
pain, decrease internal hip rotation –
osteoarthritis, femoral neck stress fracture
pain or palpation of greater trochanter; pain as
client moves from standing to lying down –
bursitis of hip
 evaluates flexion contractures of the
hip
 With the client in the supine position,
ask the client to pull one knee up
toward the chest as far as possible.
 Approximate the extent of the flexion
contracture by noting the degree of
flexion of the opposite leg (the angle
between the client’s leg and the
table).

Thomas test
 normal finding:
◦ when the hip is flexed, the opposite
leg remains flat on the examination
table
 abnormal finding
◦ for the individual with an immobile
hip, the opposite hip and leg flex in
response to flexion of the leg.

Thomas test
Knees
 Supine, sitting
 Inspect size, shape, symmetry, swelling, deformities,
alignment, qudricep muscle atropy
 Palpate tenderness, warmth, consistency, nodules
obegin 10 cm above patella
ouse fingers and thumb to move downward
the knee
Knee palpation
http://www.sciencephoto.com/image/265069/350wm/M3301436-Swollen_knee-
SPL.jpg
http://www.marvistavet.com/assets/i
mages/knee_meniscus_model.gif
 o indication: if (+) swelling to determine cause
of swelling (if due to accumulation of fluid or
soft tissue swelling)
o helps detect small amounts of fluid in knee
o client supine – use ball of your hand firmly
to stroke the medial side of knee upward, 3-
4x – to displace any accumulated fluid
o then press lateral side of knee
o look for bulge on medial side of knee

Bulge test
 A test for small effusions in the knee joint is
called the bulge sign.
 Take the ball of your hand and firmly milk the
medial aspect of the knee upward two to three
times to displace fluid
 Then press or tap behind the lateral margin of
the knee.
 A positive bulge sign will show a swelling or
bulge of fluid in the hollow area medial to the
patella.
 The bulge sign is useful for assessing small
effusions, but
 It may be absent in large effusions.

Bulge sign
http://www.hipandkneeadvice.com/index.php/knee-procedures/
 1. Quadriceps Tendon
2. Patella
3. Patellar Tendon
4. Tibia
5. Fibula
6. Posterior Cruciate Ligament
7. Anterior Cruciate Ligament
8. Lateral Collateral Ligament
9. Lateral Meniscus
10. Lateral Femoral Condyle
11. Femur
http://www.trialsightmedia.com/exhibit_store/images/kneeanatomy.jpg
http://static.howstuffworks.com/gif/adam/images/en/knee-arthroscopy-normal-
anatomy-picture.jpg
http://www.healthscout.com/common/images/8/8716_11265_5.jpg
 The ligaments which attach the upper leg bone
(femur) to the large lower leg bone (tibia)
create a hinge joint called the knee. The
anterior and posterior cruciate ligaments are 2
short, strong ligaments which criss-cross each
other in the middle of the joint.
 o normal finding:
no bulge of fluid appears on medial side
of knee
o abnormal finding:
bulge of fluid on medial side; with sml amt
of joint effusion

Bulge test
Maria Carmela L. Domocmat, RN, MSN
 When considerable fluid is present in the
suprapatellar pouch, ballottement of the
patella may be possible.
 Ballottement involves applying downward
pressure with one hand while pushing the
patella backward against the femur with a
finger of the opposite hand. Examine the
popliteal region with the client in the
prone position or while standing.
 Swelling of the joint in the region, which
is called Baker’s cyst, is generally an
extension of the articular cavity.

Ballottement of the
patella
o helps detect large amts of fluid in knee
o client supine
o firmly press nondominant thumb and index
finger on each side of patella
this displaces fluid in suprapatellar bursa located
between femur and patella
o with dominant fingers – push patella down on
femur
o feel fluid wave or a click
o normal finding:
no movement of patella
patella rests firmly over femur
o abnormal finding:
(+) ballottement test – meniscal tears
(+) fluid wave or click – large amts of joint
effusion
Maria Carmela L. Domocmat, RN, MSN
 o as compress the patella –
slide it distally against
the underlying femur
o normal finding:
 no pain
 crepitus may be present
o abnormal finding:
 (+) pain and crepitus -
patellofemoral disorder

Palpate tibiofemoral space

o flexion o extension
o hyperextension

o fullROM against
resistance

Test ROM
o normal finding:
flexion – 1200 to 1300
extension - 00
hyperextension - 150
full ROM against resistance
o abnormal finding:
decreased ROM with synovial thickening –
osteoarthritis
inability to extend knee fully - flexion
contractures
decreased muscle strength against resistance
– muscle and joint dse
. To test range of motion of the
knee, ask the client to do the
following:
 Straighten and stretch the leg.
 Bend the knee.

Range of Motion
 To test muscle strength in the
knee, ask the client to do the
following:
 Extend the leg as you try to bend
it (quadriceps muscle strength)
 Bend the knees as you try to
straighten them(hamstring
muscle strength)

Muscle Strength
Maria Carmela L. Domocmat, RN, MSN
 McMurray’s test

Test pain and injury

  if complains of a “giving in” or “locking” of knee

 supine; flex one knee and hip

 place your thumb and index finger on 1 hand on
either side of knee
 other hand – hold heel of foot up
 rotate lower leg and foot laterally
 slowly extend knee – note pain or clicking
 repeat – rotate leg medially

McMurray’s test
o normal finding:
no pain or clicking
o abnormal finding:
(+) pain, clicking – torn meniscus of knee

Ankles and Feet
 client
sit, stand, walk: inspect position,
alignment, shape skin
o normalfinding:
 toes
 usually point forward and lie flat
 may point in – pes varus
 may point out – pes valgus
 toes and feet – in alignment with lower leg
 smooth, rounded medial malleolar prominences with
prominent heels and metatarsophalangeal joints
 skin – smooth, free of corns and calluses
 longitudinal arh – most of weight bearing is on foot
midline
o abnormalfinding:
 hallux valgus – laterally deviated great toe; possible overlapping of
2nd toe; formation enlarged, painful, inflamed bursa (bunion) on
medial side
 pes planus or flat feet – feet with no arches
 pes cavus – feet with high arches
 corns – painful thickening of skin over bony prominences and at
pressure points
 calluses – nonpainful thickened skin that occurs at pressure points
 verruca vulgaris- painful warts
 plantar warts – warts under a callus; appear as tiny dark spots
 hammer toe – hyperextension at metatarsophalangeal joint with
flexion at proximal interphalangeal joint; common 2nd toe
hallux valgus
1.jpg
pes pplaannuussoorrffllaattffeeeett
pes cavus
  Corns are areas of thick, hardened, dead skin. They form to protect the skin and structures
under the skin from pressure, friction, and injury. They may look grayish or yellowish, be less
sensitive to the touch than surrounding skin, and feel bumpy.

Corns
 Corns are usually found where toes rub together. A soft corn is found between toes (usually
between the fourth and fifth toes), while a hard corn is often found over a bony part of a toe
(usually on the fifth toe).
calluses
 Corns and calluses form on the skin because of repeated pressure
or friction. A corn is a small, tender area of thickened skin that
occurs on the top or side of a toe. A callus is a rough, thickened
area of skin that appears because of repeated irritation or
pressure to an area of skin. Calluses usually develop on the palms
of the hand and soles of the feet.
  Warts, also called verrucae, are small benign growths usually
caused by a viral infection of the skin or mucous membrane. The
virus infects the surface layer of skin. The viruses that cause
warts are members of the human papilloma virus (HPV) family, of
which there are many different strains. Warts are not cancerous
but some strains of HPV, usually not associated with warts, have
been linked with cancer formation. Warts are contagious from
person to person and from one area of the body to another on
the same person.
verruca vulgaris
plantar warts
  hammertoes are a contracture of the toes as a result of a muscle
imbalance between the tendons on the top and the tendons on
the bottom of the toe.
 Hammer toe is a condition where a toe bends downward like a
claw. You can be born with hammer toe or develop it from
wearing short, narrow shoes. Symptoms of hammer toe include
foot pain, calluses on the sole of the foot, or corns on the top of
the toe. Treatment of mild cases and cases in children can include
foot manipulation and splinting of the toe. More severe cases may
need surgery to straighten the toe joint.

http://0.tqn.com/f/p/440/graphics/images/en/9360.jpg
 http://images.rxlist.com/images/SlideShow/diabetes_foot_problems_s8_corns.jpg

A hammertoe is a toe that is bent because of a weakened muscle. The weakened muscle makes the tendons (tissues that
connect muscles to bone) shorter, causing the toes to curl under the feet. Hammertoes can run in families. They can also

hammer toe
be caused by shoes that are too short. Hammertoes can cause problems with walking and can lead to other foot problems,
such as blisters, calluses, and sores. Splinting and corrective footwear can help in treating hammertoes. In severe cases,
surgery to straighten the toe may be necessary.
http://feetdoc.com/hammer_toes.ht
m
 o normal finding:
 no tenderness, heat, swelling, nodules
o abnormal finding:
 gouty arthritis- tender, painful, reddened, hot, swollen
metatarsophalangeal joint of great toe
 rheumatoid arthritis – nodules of posterior ankle
 pain and tenderness metatarsophalangeal joints –
inflammation of joints, rheumatoid arthritis,
degenerative joint dse
 plantar fasciitis – tenderness of calcaneus of bottom
of foot

palpate tenderness, heat, swelling,

nodules
o dorsiflexion – point toes upward ;
plantar flexion –downward
o eversion – turn soles outward;
inversion – inward
o abduction – rotate foot outward ;
adduction – inward
o flexion – turn toes under foot ;
extension – upward
o repeat all with resistance

Test ROM
o abduction– rotate foot outward ;
adduction – inward
.
o normal finding:
200 dorsiflexion ankle and foot; 45 0 plantar
flexion
200 eversion; 300 inversion
100 abduction; 200 adduction
400 flexion; 400 extension
o abnormal finding:
decreased ROM without or against
resistance – muscle and joint dse
hammer toe – hyperextension of
metatarsophalangeal joint and flexion
of proximal interphalangeal joint
ABNORMAL WRISTS,
HANDS, AND FINGERS
 Boutonniere and swan-neck deformities
 Ganglion.
 Osteoarthritis.
 Tenosynovitis.
 Acute rheumatoid arthritis.
 Chronic rheumatoid arthritis
 Thenar atrophy
ABNORMAL ANKLES,
FEET, AND TOES
 Acute gouty arthritis.
 Callus.
 Corn.
 Flat feet.
 Hallux valgus
 Hammer toe.
 RELATED NURSING CARE
• Maintain privacy of patient
• patient is asked to remove some or all of his
clothes and to wear a gown during the exam.
• may also be asked to remove jewelry, removable
dental appliances, eye glasses and any metal
objects or clothing that might interfere with the
x-ray images.
• If contrast medium is used, assess for allergy to
shellfish, iodine, or contrast medium used in
previous tests. If allergy is present, test will not
be performed.