1. Assessing the Motor-
Musculoskeletal System

2. After you have successfully completed this chapter,
you should be able to:
Identify pertinent motor-musculoskeletal history
questions
obtain a motor-musculoskeletal history
perform a physical assessment of the motor-
musculoskeletal system
document motor-musculoskeletal findings
identify actual/potential health problems stated as
nursing diagnoses
differentiate between normal and abnormal
findings

3. Introduction:
the musculoskeletal system provides shape and support to the body, allows
movement, protectsthe internal organs, produces red blood cells in the bone marrow
(hematopoiesis), and stores calcium and phosphorus in the bones. Although examining
this system is usually only a small part of the overall physical assessment, everything
we do depends on an intact musculoskeletal system. How extensive an assessment
you perform depends largely on each patient’s problems and needs. Perform a
comprehensive musculoskeletal assessment if you detect a musculoskeletal
abnormality or uncover a symptom that suggests musculoskeletal involvement.
Musculoskeletal problems are common in all age groups. Primary problems may result
from congenital, developmental, infectious, neoplastic, traumatic, or degenerative
disorders of the system itself. Secondary problems can result from disorders of other
body systems. The goal of a complete musculoskeletal assessment is to detect risk
factors, potential problems, or musculoskeletal dysfunction early and then to plan
appropriate interventions, including teaching health promotion and disease
prevention and implementing treatment measures. By doing so, you can play a
significant role in preventing pain and dysfunction in your patients.

11. RELATIONSHIP OF MUSCULOSKELETAL
SYSTEM TO OTHER SYSTEMS
ENDOCRINE
MS system provides protection to endocrine structures. Growth and sex hormones affect growth
of MS system. Thyroid/parathyroid control calcium and calcitonin.
LYMPHATIC/ HEMATOLOGIC
Bone marrow produces blood cells and lymphocytes. Lymphatic system responds as a defense
for MS system.
RESPIRATORY
Chest muscles and bones protect lungs. Muscles are essential for breathing. Respiratory system
provides oxygen and removes carbon dioxide.
INTEGUMENTARY
Skin provides protective covering for muscles and joints. Skin provides vitamin D synthesis
needed for calcium and phosphorus bone growth.

12. CARDIOVASCULAR
Delivers nutrients to MS system and removes wastes. MS system provides calcium if
needed for cardiac contraction. Contraction of muscles assists with venous return.
GASTROINTESTINAL
Provides nutrients to MS system, especially calcium and phosphorus. Abdominal
muscles protect abdominal structures and organs.
GENITOURINARY
MS system protects renal structures. Kidneys reabsorb calcium and phosphorus as
needed.
REPRODUCTIVE
MS system protects reproductive organs. Sex hormones affect growth.

40. guillain barre syndrome

47. JOINT MOVEMENTS MOVEMENT DESCRIPTION
Extension Straightening or increasing the angle of a joint Flexion
Bending or decreasing the angle of a joint Hyperextension Straightening
beyond the normal angle of a joint Abduction Moving away from the
midline Adduction Moving toward the midline Circumduction Moving in
a circular fashion Internal rotation Turning inward toward the midline
External rotation Turning outward away from the Midline Pronation
Turning down Supination Turning up Inversion Turning inward (medially)
Eversion Turning outward (laterally) Retraction Moving backward
Protraction Moving forward Opposition Movement of thumb toward
fingerpad Reposition Movement of thumb back to anatomic position
Depression Movement by lowering body part Elevation Movement by
raising body part Ulnar deviation Movement of hand toward ulnar side
Radial deviation Movement of hand toward radial Side

49. TESTS FOR WRIST PROBLEMS
PHALEN’S TEST. HAVE THE PATIENT FLEX THE HANDS BACK TO
BACK AT A 90-DEGREE ANGLE AND HOLD THIS POSITION FOR
ABOUT 1 MINUTE . IF THE PATIENT COMPLAINS OF NUMBNESS
OR TINGLING ANYWHERE FROM THE THUMB TO THE RING FINGER,
THE TEST IS POSITIVE FOR CARPAL TUNNEL SYNDROME.
TINEL’S TEST. PERCUSS LIGHTLY OVER THE MEDIAN NERVE,
LOCATED ON THE INNER ASPECT OF THE WRIST . IF
NUMBNESS AND TINGLING OCCUR ON THE PALMAR ASPECT OF THE
WRIST AND EXTEND FROM THE THUMB TO THE SECOND FINGER,
THE TEST IS POSITIVE FOR CARPAL TUNNEL SYNDROME.

92. TEST FOR ARM PROBLEMS
Pronator Drift. Perform this test if you detect muscle weakness of the arms. Have
the patient stand with armsextended, hands supinated, and eyes open and then
closed for at least 20 to 30 seconds (Fig.20.10).Check for downward drift and
pronation of the arms and hands. Pronation and drift of one arm is called pronator
drift and may indicate a mild hemiparesis. Flexion of the fingers and elbow may
accompany pronator drift. A lateral and upward drift may also occur in patients
with loss of position sense. If your patient is able to hold her or his arms extended
without drift, gently tap downward on the arms. If she or he has normal muscle
strength, coordination, and position sense, the arms will return to the horizontal
position. A weak arm is easily displaced and does not return to the horizontal
position. You can also assess drifting and weakness by having the patient hold his
or her arms over the head for 20 to 30 seconds. Then, try to force the arms down
to the sides as the patient resists. Drifting or weakness may indicate a
hemiparesis.

93. Test for Spinal Problems
Straight Leg Raising (Lasègue’s Test). Perform
this test when the patient complains of low
back pain that radiates down the leg (sciatica).
This test checks for a herniated nucleus
pulposus. Ask the patient to lie flat and raise
the affected leg to the point of pain
(Fig.20.11).Pain and sciatica that intensify with
dorsiflexion of the foot.

94. Tests for Hip Problems
• Thomas Test. This test assesses for hip flexure contractures
hidden by excessive lumbar lordosis. Have the patient lie
supine with both legs extended and then flex one leg to her or
his chest (Fig. 20.12).The test is positive if the opposite leg
raises off the table. Repeat the same maneuver on the
opposite side. Trendelenburg Test. This test is used to assess
for a dislocated hip and gluteus medius muscle strength. Have
patient stand erect and check the iliac crest—it should be
level. Then, have the patient stand on one foot and check
again. If the iliac crest remains level or drops on the side
opposite the weight-bearing leg, the gluteus medius muscle is
weak or the joint is not stable and there may be a hip
dislocation on the weightbearing side.

95. Tests for Knee Problems
• Perform one of the following two tests if you noted swelling
secondary to fluid accumulation or soft tissue damage. Bulge
Test. Perform this test if you suspect small amounts of
fluid.With the patient supine, stroke the medial side of the
knees upward several times to displace the fluid.Then, press
the lateral side of the knee, and inspect for the appearance of
a bulge on the medial side (Fig. 20.13). Patellar Ballottement.
Perform this test if you suspect large amounts of fluid. With
the patient supine, press firmly with your left thumb and
index finger on each side of the patella (Fig. 20.14). This
displaces fluid into the suprapatellar bursa between the femur
and the patella. Then, gently tap on the kneecap. If fluid is
present, the patella will bounce back to your finger (floating
kneecap).

96. HELPFULHINT
• Check for hollows on either side of the patella. If hollows are
absent, fluid may be present. Lachman Test. If your patient
complains that his or her knee gives way or buckles, test
anterior,posterior,medial, and lateral stability. To test medial and
lateral stability, have the patient extend the knee and attempt to
abduct and adduct it. Normally, no movement should occur if the
knee is stable. To assess the anterior and posterior plane, have the
patient flex the knee at least 30 degrees. Stabilize and grasp the leg
below the patella, and attempt to move it forward and back. If the
joint is stable, no movement should occur (Fig. 20.15).Another
similar test for stability of the anterior cruciate ligament (ACL) and
posterior cruciate ligament (PCL) is the drawer test. With the
patient’s knee flexed at a 90-degree angle, apply anterior and
posterior pressure against the tibia, and feel for movement.
Movement of the tibia is a positive draw sign, indicating an ACL or
PCL tear.

97. To test stability of the collateral ligament, have the patient lie supine with the
knee slightly flexed. Place your hand at the head of the fibula and apply
pressure medially; then reverse and apply pressure laterally. If the joint is
unstable, movement will occur and create a palpable medial or lateral gap at
the joint. Perform one of the following tests if your patient complains of clicks
or knee-locking and you suspect a torn meniscus.
McMurray’s Test. To perform McMurray’s test, position the patient supine
with her or his knee fully flexed (Fig. 20.16). Place one hand on the heel and
the other on the knee and gently internally and externally rotate the foot as
you bring the leg to full extension. The test is positive if audible or palpable
clicks occur or the knee locks.
Apley’s Test. Position the patient supine with his or her knee flexed at 90
degrees (Fig. 20.17).Place one hand on the heel and the other hand on the
knee. Apply pressure with both hands and gently rotate the foot. The test is
positive if audible or palpable clicks occur.