2. Review of Anatomy and Physiology
• The musculo-skeletal system consists of the
muscles, tendons, bones and cartilage
together with the joints
• The primary function of which is to produce
skeletal movements
3. Muscles
Three types of muscles exist in the body
• 1. Skeletal Muscles
– Voluntary and striated
• 2. Cardiac muscles
– Involuntary and striated
• 3. Smooth/Visceral muscles
– Involuntary and NON-striated
6. BONES
• Variously classified according to shape, location and
size
• Functions
1. Locomotion
2. Protection
3. Support and lever
4. Blood production
5. Mineral deposition
10. • CHECK YOUR EQUIPMENT PRIOR
TO ENTERING THE PATIENT’S
ROOM. MAKE SURE YOU HAVE
EVERYTHING YOU NEED TO
COMPLETE YOUR ASSESSMENT
PRIOR TO ENTERING THE
PATIENT’S ROOM
11. Make the Patient Comfortable
• Showing concern for privacy and patient
modesty must become ingrained in your
professional behavior
• Be sure to close nearby doors or
examination room PRIOR to beginning
physical examination
• Your goal is to visualize one area of the
body at a time
12. Make the Patient
Comfortable
• Be sensitive to the patient’s feelings and
physical comfort
• When you have completed the examination,
show your attentiveness, by rearranging the
patients pillows, or adding blankets for
warmth; make sure their immediate
environment is to their satisfaction
• Be sure to lower the bed completely, and
make sure side rails are up and call bell is in
the patient’s reach
• As you leave be sure to WASH YOUR HANDS
16. Outlines
2. Review of Anatomy and physiology
of musculoskeletal system
3. Physical Exam
4. Inspection
5. Palpation
6. ROM (Rang of motion)
17. Objectives
• Apply knowledge of Anatomy and
physiology of musculoskeletal
system
• Differentiate between normal and
abnormal
• Implement physical assessment
18. Musculoskeletal
• Muscle or joint pain
• Stiffness
• Arthritis
• Gout
• Backache
• If present, describe location or affected joints or
muscles, any swelling, redness, pain, tenderness,
stiffness, weakness, or limitation of motion or
activity; include timing of symptoms duration, and
any history of trauma
• Neck or low back pain
• Joint pain with systemic features such as fever,
chills, rash, anorexia, weight loss, or weakness
19. Skin
• Rashes
• Lumps
• Sores
• Itching
• Dryness
• Changes in color
• Changes in hair or nails
20.
21. What do muscles do ?
• Muscles simply move you!
• Without muscles you couldn't open your
mouth, speak, shake hands, walk, talk, or
move your food through your digestive
system.
• There would be no exploring, running,
climbing, smiling, blinking, breathing. You
couldn't move anything inside or outside
you. The fact is, without muscles, you
wouldn't be alive for very long
22.
23. The skeleton is the name given to the
collection of bones that holds our body
up.
Our skeleton is very important to us. It
does three major jobs.
1. It protects our vital organs such as
the brain, the heart, and the lungs.
2. It gives us the shape that we have.
Without our skeleton we would just be
a blob of blood and tissue on the floor.
3. It allows us to move. Because our
muscles are attached to our bones,
when our muscles move, they move
the bones, and we move
24. Physical Exam
1. 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.
25. • Ask the client to point to, or
otherwise identify, any painful areas,
including sites of radiation of
pain.
Screening questions for
musculoskeletal disorders
1. Do you have any pain or
stiffness in your arms, legs or
back?
2. Can you walk up and down
stairs without difficulty?
3. Can you dress yourself in
everyday clothes without any
difficulty?
26. • Assessment of Gait
• Ask the patient to walk back and forth
across the room.
• Observe for equality of arm swing ,
balance and rapidity and ease of heels
turning.
• Next, ask the patient to walk on his
tiptoes, then on heels.
• Ask the patient to tandem walk.
• Test patient's ability to stand with feet tiptoes
together with eyes open and then
closed. (Romberg's test). Reassure
patient that you will support him, in
case he becomes unsteady.
• Normal: Person can walk in balance
with the arms swinging at sides and can
turn smoothly. Person should be able to
stand with feet together without falling
with eyes open or closed.
tandem
27. Upper Extremity Muscles
• Inspect the muscles of
the shoulder, arm,
forearm and hand.
• Note muscle size (bulk).
• Look for asymmetry,
atrophy and
fasciculation.
• Look for tremor and
other abnormal
movement at rest and
with arms outstretched.
28. Determine muscle power
by
• Gently trying to
Abduction
overpower
contraction of each
group of muscles.
– Shoulder:
Abduction
(Deltoid) Adduction
–, Adduction
–, (Trapezius) (Trapezius
30. – Hand: Grip
Grip
– opposition of
thumb and index finger
– opposition of
thumb and little finger
and
– finger abduction and
31. • Determine limb tone
(resistance to
passive stretch).
• With the patient
relaxed
• Gently move the
limb at the shoulder,
elbow and wrist
joints and note
whether tone is
normal, increased or
decreased
32. Normal findings
• Muscles are symmetrical in size with
no involuntary movements.
• In some, muscles may be slightly
larger on the dominant side.
• Muscle power obviously varies. You
should not be able to overpower with
reasonable resistance.
• You have to learn to appreciate the
normal tone from practice.
33. Neck: Range of Motion of
• Fix the head with one hand while you
examine neck
• Inspection
– Note the normal concavity of cervical
spine
– Identify Transverse process of C7
– Observe Trapezius and Sternomastoid
muscles
• Palpation
– Feel each spinous process looking for focal
areas of tenderness
– Joint
• Feel for crepitus during passive motion Touch chin
– Para spinal muscles
• Range of motion
– Active
• Touch chin for flexion
• Throw head back for extension
Throw head back
34. • Touch each shoulder with ears for
lateral flexion
• Touch each shoulder with chin for
lateral rotation
– Passive
• Feel for crepitus during passive
motion
• Normal:
– 30 degree rotation, able to
touch chest with chin, 55
degree extension and 40
degree lateral bend.
– No resistance during the range
of motion.
35. Muscles of Lower Extremity
Inspect the muscles of the hip,
knee and ankle.
• Note muscle size (bulk).
• Look for asymmetry, atrophy
and fasciculation.
Hip flexion
• Look for abnormal movement.
• Determine muscle power by
gently trying to overpower
contraction of each group of
muscles.
– Hip: Flexion (Iliopsoas), Extension
(Gluteus maximus), Abduction,
Adduction.
36. Assessment of the
Musculoskelet al System
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)
37. The Knee Exam
• Inspection
• Make sure that both knees are
fully exposed. The patient should
be in either a gown or shorts.
Rolled up pant legs do not
provide good exposure!
• Watch the patient walk.
• Do they limp or appear to be in varus Knee
pain? deormity ,more
• When standing, is there evidence marked on the left
of bowing (varus) or knock- leg
kneed (valgus) deformity? There
is a predilection for degenerative
joint disease to affect the
medical aspect of the knee, a
common cause of bowing.
38. • Is there evidence of
atrophy of the
quadriceps, hamstring,
or calf muscle groups?
Knee problems/pain can
limit the use of the
affected leg, leading to While both legs have
well developed
wasting of the muscles. musculature,
the left calf and
hamstring are bulkier
than the right
39. – Knee : Flexion (Hamstrings),
Extension (Quadriceps)
– Ankle : Dorsiflexion (Tibialis Knee extension
anterior), Plantar flexion
(Gastronemius).
• Determine limb tone
resistance to passive stretch.
With the patient relaxed,
gently move the limb at the
hip, knee and ankle and note
Knee flexion
whether tone is normal,
increased or dicreased.
Flex the hip and knee.
• Support the knee, dorsiflex the Dorsiflexion
ankle sharply and hold the foot
in this position checking for
clonus.
40. (Spine (Bone
• The examiner should stand behind the
patient and observe the alignment of the
spine in the flexed position to determine
scoliosis.
• View the spine from the side to determine
kyphosis.
• Ask the patient if he is aware of sore spots.
Palpate the spinous process and be gentle
with the sore spots. Percuss one vertebra
at a time, starting from head.
• .
41. • Assess range of motion
of spine by having patient
bend down to pick up an
object without bending his
legs while you hold his
hips.
• Normal:
• Gentle concavities in
cervical and lumbar
regions and a convexity in
the thorax.
• Vertebral line and gluteal
cleft align
42. Posture
Normal - •
Comfortably erect
Look for straight lines
across body parts
Treatment Return to top Treatment depends on the cause of the disorder: Congenital kyphosis requires corrective surgery at an early age. Scheuermann's disease is initially treated with a brace and physical therapy. Occasionally surgery is needed for large (greater than 60 degrees), painful curves. Multiple compression fractures from osteoporosis can be left alone if there is no neurologic problems or pain, but the osteoporosis needs to be treated to help prevent future fractures. For debilitating deformity or pain, surgery is an option. Kyphosis caused by infection or tumor needs to be treated more aggressively, often with surgery and medications. Treatment for other types of kyphosis depends on the cause. Surgery may be necessary if neurological symptoms develop. Expectations (prognosis) Return to top Adolescents with Scheuermann's disease tend do well even if they need surgery, and the disease stops once they stop growing. If the kyphosis is due to degenerative joint disease or multiple compression fractures, correction of the defect is not possible without surgery, and improvement of pain is less reliable. Complications Return to top Disabling back pain Neurological symptoms including leg weakness or paralysis Decreased lung capacity Round back deformity
There are three general causes of scoliosis: Congenital scoliosis is due to a problem with the formation of vertebrae or fused ribs during prenatal development. Neuromuscular scoliosis is caused by problems such as poor muscle control or muscular weakness or paralysis due to diseases such as cerebral palsy , muscular dystrophy , spina bifida, and polio. Idiopathic scoliosis is of unknown cause, and appears in a previously straight spine. Idiopathic scoliosis in adolescents is the most common type. Some people may be prone to the curving of the spine. Most cases occur in girls. Curves generally worsen during growth spurts. Scoliosis in infants and juveniles are less common. They commonly affect a similar number of boys and girls. Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. Untrained observers usually can't notice the curving. Routine scoliosis screening is now done in middle and junior high schools. Many cases, which previously would have gone undetected until they were more advanced, are now being caught at an early stage. There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation results. The greater the initial curve of the spine, the greater the chance the scoliosis will get worse after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing problems. Symptoms Return to top The spine curves abnormally to the side (laterally) Shoulders or hips appearing uneven Backache or low-back pain Fatigue Treatment depends on the cause of the scoliosis, the size and location of the curve, and how much more growing the patient is expected to do. Most cases of adolescent idiopathic scoliosis (less than 20 degrees) require no treatment, but should be checked often, about every 6 months. As curves get worse (above 25 to 30 degrees in a child who is still growing), bracing is usually recommended to help slow the progression of the curve. There are many different kinds of braces used. The Boston Brace, Wilmington Brace, Milwaukee Brace, and Charleston Brace are named for the centers where they were developed. Each brace looks different. There are different ways of using each type properly. The selection of a brace and the manner in which it is used depends on many factors, including the specific characteristics of your curve. The exact brace will be decided on by the patient and health care practioner. A back brace does not reverse the curve. Instead, it uses pressure to help straighten the spine. The brace can be adjusted with growth. Bracing does not work in congenital or neuromuscular scoliosis, and is less effective in infantile and juvenile idiopathic scoliosis. Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of getting worse even after bone growth stops. Surgery involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is done through a cut in the back, on the abdomen, or beneath the ribs. A brace may be required to stabilize the spine after surgery.
