MUSCULOSKELETAL

ASSESSMENT
N2102
OBJECTIVES
Utilizing a body systems approach, the student will:
a. Apply anatomy, physiology, biology, chemistry,
psychology, developmental psychology, and sociology
concepts to the assessment the musculoskeletal system of
the adult
b. Apply health history and physical examination principles
for holistic assessment the musculoskeletal system of the
adult
c. Conduct and document (EMR) a health history and physical
examination of the adult while applying the principles of caring,
therapeutic communication, interprofessional communication, and
professionalism
d. Utilize concepts of genetics and genomics when assessing the
musculoskeletal system
OBJECTIVES
e. Interpret common laboratory and diagnostic findings for the
musculoskeletal system of the adult
f. Based on national guidelines (Healthy People 2020, AHRQ Clinical
Prevention Guidelines, and other appropriate national standards),
recommend the appropriate health promotion and clinical prevention
strategies for the adult
g. Assess self and patient scenarios utilizing the clinical reasoning model for
the musculoskeletal system of the adult
h. Identify and interpret common laboratory and diagnostic tests
i. Demonstrate professionalism in the clinical simulation laboratory by:
honoring confidentiality of scenarios and other’s health histories;
respecting other’s self-determination and human dignity; and exhibiting
integrity by abiding by laboratory guidelines, equipment use, and dress
code
j. Describe expected and unexpected findings in the musculoskeletal system
to include ethnic, cultural, and age variations
Subjective Data Health Promotion Objective Data

Musculoskeletal
System

Labs & Diagnostics

Risk Factors
STRUCTURE & FUNCTION

 Bones- ligaments
 Muscles- tendons

 Cartilage

 Joints

 Bursae
 HEALTH HISTORY
Present Health Status
PMH

Family History
Problem Based History
 Pain- “point to the pain”
 Clarify and record the mechanism of injury (especially if there is
a hx of trauma)
 Determine if pain is localized or diffuse, acute or chronic,
inflammatory or non-inflammatory
 Problems with movement

Problems with daily activities

FOUR KEY AREAS TO ADDRESS
 Onset of symptoms
 Deformity

 Paralysis

 Pain
ONSET OF SYMPTOMS
 What specific things do
we want to know about
their symptoms?
DEFORMITY
 May occur as a result of
dislocations, fractures, spurs, or
enlargement of bones.
 When a deformity is present,
another body part may shift to
compensate for the imbalance.
 What kinds of things do we want
to know about the deformity?
PARALYSIS
 Important to note the following:
 time of onset
 extent of involvement
 progression or regression
 presence or absence of sensory
disturbances
PAIN
 Most common symptom in orthopedics!
 Critical features of pain:

-type
-location
-severity
-duration
-precipitating factors
-alleviating factors
PRINCIPLE TECHNIQUES USED TO
ASSESS THE MS SYSTEM
 Inspection

 Palpation
 REMEMBER TO…INSPECT AND PALPATE EACH
BODY PART AND TEST ITS ROM AND MUSCLE
STRENGTH

Compare side…. ……to side

Examine each muscle and  Examine each muscle and

joint bilaterally, comparing
two sides of the patient’s
body.
Remember both sides of
the body must be in the
same position for a
comparison to be made.
joint bilaterally,
comparing two sides of
the patient’s body.
 Remember both sides of
the body must be in the
same position for a
comparison to be made
INSPECTION INCLUDES:
 Visual Screening—What things are we looking for and
documenting?
PALPATION

 Utilized to detect pain, tenderness, swelling, localized

temperature changes, and marked changes in shape and
muscle tone.
 Palpate all bones, joints, and surrounding muscles.

 What are we looking for and documenting?

TEST ACTIVE AND PASSIVE ROM
 Goniometer
 Six Basic Types of Joint Motion:

1. Flexion & Extension

2. Adduction & Abduction
3. Inversion & Eversion
4. Pronation & Supination
5. Internal & External
rotation
6. Dorsiflexion & Plantar
Flexion
SKELETAL MUSCLE MOVEMENTS
OTHER MEASUREMENTS TO CONSIDER
 Length of extremities can be assessed for comparison.
 The circumference of arms and legs can be measured to
tell if there is swelling in a muscle.
MUSCLE STRENGTH GRADING SCALE
 Scale is from 0-5
0/5= no evidence of contractility seen.
1/5= only slight contractility, no joint motion
2/5= Complete range of motion with gravity eliminated (passive ROM)
3/5= Complete range of motion against gravity
4/5= Complete range of motion against gravity and some resistance
5/5= Complete range of motion against gravity and full resistance
CARPAL TUNNEL ASSESSMENT
Tinel’s test Phalen’s test
DIAGNOSTIC PROCEDURES
 Aspirations (Arthrocentesis)
 Biopsy
 Arthroscopies
 X-rays
 Arthrogram
 Myelogram
 Bone Scan
 CT Scan
 MRI
 Bone Mineral Density (BMD)
 EMG
TERMS
Kyphosis BOTH Lordosis
SCOLIOSIS
SCOLIOSIS
 May develop in a localized area or involve the entire
spinal column.
 Degree of curvature may be mild, moderate, or severe.
 Vertebral growth is completed at approx. age 15 for
women and 17 for men—existing scoliosis at this age
persists into adult life.
ASSESS
 Gait
 Height

 Shoulders for symmetry

RHEUMATOID ARTHRITIS
DEFINITION
 Chronic, systemic inflammatory disease characterized by
recurrent inflammations involving the synovia or linings
of joints--- leading to destructive changes in the joints.
PATHO
 Involves peripheral joints however, is a systemic disease
that attacks connective tissues throughout the body.
 Usually develops insidiously but onset is associated with
disturbances that deplete the patient’s physical and
emotional reserves.
PATHO CONT.
 Initially produces non-specific signs and symptoms.
 Later more localized signs and symptoms develop.

 Stiffness in the morning is the most common symptom.

OSTEOARTHRITIS
OSTEOARTHRITIS
 Idiopathic, slowly progressive, non-inflammatory
disease of the synovial lined joints.
 Characterized by deterioration & erosion of articular
cartilage and the formation of new bone or spurs at the
articular margins.
OSTEOARTHRITIS
 Most common of all arthritis
 Twice as prevalent in those who are obese

 Mainly affects weight bearing joints

 May involve one or more joints

 Hips and knees particularly susceptible

 Spine is common

 Hand—Heberden’s nodes and Bouchard’s nodes

OSTEOARTHRITIS
OSTEOPOROSIS
FACTS
Today affects
more than 28
million Americans
80% are women.
CAUSE??—UNKNOWN BUT RISK FACTORS
ARE:
 postmenopausal women
 tall or thin, small-boned
frame (<127 pounds)
 family history of broken
bones or stooped posture—
especially on mother’s side
 late menarche or early
menopause are at greater risk
due to decreased estrogen
levels
 RISK FACTORS CONT.
 advanced age-> 65 years and
older and greatest risk
 diet low in calcium and Vitamin
D
 inactive lifestyle

 Caucasian/Asian

 cigarette smoking

 excessive use of alcohol

 prolonged use of certain meds

SIGNS AND SYMPTOMS
 Tooth loss
 Back pain

 Loss of height

 Protrusion of upper back

(Dowager’s hump)
NIH- RECOMMENDED DIETARY
ALLOWANCES (RDAS) FOR CALCIUM
Age Male Female Pregnant Lactating
0–6 months* 200 mg 200 mg    
7–12 months* 260 mg 260 mg    

1–3 years 700 mg 700 mg    

4–8 years 1,000 mg 1,000 mg    
9–13 years 1,300 mg 1,300 mg    
14–18 years 1,300 mg 1,300 mg 1,300 mg 1,300 mg
19–50 years 1,000 mg 1,000 mg 1,000 mg 1,000 mg
51–70 years 1,000 mg 1,200 mg    
71+ years 1,200 mg 1,200 mg  

https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
FOODS HIGH IN CALCIUM
 Milk  Almonds
 Yogurt  Canned Salmon

 Cheese  sardines

 Ice cream

 tofu

 Broccoli
FOODS THAT CAN DECREASE CALCIUM
 Carbonated colas  Foods high in fat
 Fiber and wheat bran (lg  Large amounts of
amts) chocolate
 Excessive caffeine
VITAMIN D
NIH- RECOMMENDED DIETARY
ALLOWANCES (RDAS) FOR VITAMIN
D 
Age Male Female Pregnancy Lactation
0–12 months* 400 IU 400 IU    
(10 mcg) (10 mcg)
1–13 years 600 IU 600 IU    
(15 mcg) (15 mcg)
14–18 years 600 IU 600 IU 600 IU 600 IU
(15 mcg) (15 mcg) (15 mcg) (15 mcg)
19–50 years 600 IU 600 IU 600 IU 600 IU
(15 mcg) (15 mcg) (15 mcg) (15 mcg)
51–70 years 600 IU 600 IU    
(15 mcg) (15 mcg)
>70 years 800 IU 800 IU
(20 mcg) (20 mcg)

https://ods.od.nih.gov/factsheets/VitaminD-
HealthProfessional/
CULTURAL CONSIDERATIONS
 Asians and Caucasians have higher incidence of
osteoporosis
 AA have greater bone density when compared to
Caucasians
 OA occurs more frequently in AA males than in
Caucasian males and develops twice as frequently in AA
females as Caucasian females.
 HEALTH PROMOTION FOR MS SYSTEM
 Nutrition, exercise, and weight
 Low back: lifting and biomechanics

 Preventing falls

 Osteoporosis: prevention and screening

CONSIDERATION FOR THE
HOSPITALIZED PATIENT
 Patient with a cast:
 Assess for circulation
(including cap. refill),
sensation, movement, skin
temperature

 Patient with external fixator:

 Assess for circulation
(including cap. refill),
sensation, movement, skin
temperature and edema
Subjective Data Health Promotion Objective Data

Musculoskeletal
System

Labs & Diagnostics

Risk Factors
 Subjective Data Health Promotion Objective Data
Present Health Status • Education about benefits of physical
PMH activity Inspection
Family Hx • Education about health care for • Skeleton & extremities for alignment,
Problem Based History chronic joint disease contour, symmetry, size, color & gross
-pain • Encouragement and education about deformities
arthritis self help groups exercise • Muscles for size and symmetry
-problems with movement
-problems with ADLs
programs, and weight reduction Palpation
programs. • Bones for tenderness
• Dispel myths about arthritis as “a part • joints for tenderness, nodules, heat, &
Joints of getting old” edema
Pain (WILDA , PQRSTU, OLDCARTS) • Promote exercise, better nutrition • Muscles for tenderness, heat, edema, &
Stiffness tone
(calcium and Vit. D), smoking • Test muscle strength and compare sides
Swelling, heat and redness cessation, decreased ETOH (grading)
Muscles consumption • AROM or PROM
Pain (cramps) • Safety in home, work and when EXAMINATION OF SPECIFIC
Weakness participating in sports to reduce MS REGIONS
injuries Head, Neck, & Jaw
Atrophy?
• Routine screen for osteoporosis in • Flexion and hyperextension
Bones
women 65+ • Rotation
Pain
Deformity • TMJ
Trauma (fx, sprain, dislocation) Shoulders, Elbow, Arm, Wrist, & Hand
Functional assessment (ADLS)
Self- care behaviors
Musculoskeletal • Circumduction
• extension and flexion
Exercise program
Wt gain/loss System • Supination and pronation
• Adduction and abduction
Meds?
• internal and external rotation
Chronic disability
Labs & Diagnostics Back/Spine
Risk Factors • Arthrocentesis
•
•
Flexion
Hyperextension
• TMJ- females b/w puberty ad • Biopsy • Lateral bending
menopause are 90% of cases; • Rotation
malocclusion, bruxism, abnormal • Arthroscopy Hip/leg
bite
• Gout- male, 20% +family hx, • X-Ray • Rotation
• Circumduction
obesity, HTN (diuretics), DM,
hyperlipidemia, arteriosclerosis;
• Arthrogram • Abduction and adduction
•
medications (thiazides and ASA) • Myelogram • Flexion of hip
OA- women > 45 more than men
but in men under 45 yo more than • Bone Scan Knee & Foot
women; overweight, overuse of • Hyperextension
joints, injury to hip or knoee, lack • CT Scan • Extension
•
of exercise
Osteoporosis- whites and Asian
• MRI • Dorsiflexion and plantar flexion
• Eversion and inversion
women, small bones and thin • BMD • Abduction and adduction
women (under 127 pounds)
• EMG
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