Examination of musculoskeletal system with relevant diseases and recent diagnostic techniques

1. PRESENTED BY
DR. NEHA FATHIMA
PG SCHOLAR, DEPT. OF MOALIJAT.

2. INTRODUCTION
MUSCULOSKELETAL SYSTEM COMPRISES OF:
1. BONES - SKELETON – AXIAL AND APPENDICULAR
2. MUSCLES
3. JOINTS
4. LIGAMENTS – BONE TO BONE ATTACHMENT
5. TENDONS – MUSCLES TO BONE ATTACHMENT
6. CARTILAGES
LIGAMENT
CARTILAGE

3.  FUNCTIONS OF
MUSCLES:
 WORKS WITH SKELETAL
SYSTEM TO PRODUCE
VOLUNTARY MOVEMENT
 HELPS TO CIRCULATE
BLOOD
 MOVE FOOD THROUGH
DIGESTIVE SYSTEM
 FUNCTIONS OF
SKELETAL SYSTEM:
 SUPPORT
 PROTECTION
 MOVEMENTS
 STORAGE OF MINERALS
 PRODUCTION OF BLOOD
CELLS
FUNCTIONS OF
MUSCULOSKELETAL SYSTEM

4. MUSCLE TISSUE

5. TYPES OF MUSCLES
CARDIAC
MUSCLE
SKELETAL
MUSCLE
SMOOTH
MUSCLE

6. BONE ANATOMY - GROSS

7. BONE TISSUE

8.  BONES ARE ONE OF THE TYPE OF CONNECTIVE TISSUE.
 THERE ARE SIX TYPE OF BONES:
SKELETAL SYSTEM
LONG
BONES
SHORT
BONES
FLAT BONES
SESAMOID
BONES
IRREGULAR
BONES
PNEUMATIC
BONES

9. JOINTS:

10.  STRUCTURAL CLASSIFICATION
 FIBROUS JOINTS: SUTURES, SYNDESMOSIS.
GOMPHOSIS
 CARTILAGINOUS: PRIMARY/SYNCHONDROSIS,
SECONDARY/SYMPHYSIS/AMPHIARTHROSIS
 SYNOVIAL JOINTS: BALL AND SOCKET JT, SADDLE JT,
CONDYLAR JT,ELLIPSOID JT, HINGE JT, PIVOT JOINT,
PLANE JT.
TYPES OF JOINTS:

11. BALL AND SOCKET JT.
HINGE JOINT
SADDLE JOINT
ELLIPSOID JOINT
PIVOT JOINT

12. 1. PAIN
2. STIFFNESS
3. REDNESS
4. SWELLING
5. WEAKNESS
6. LOCKING AND TRIGERRING
7. DEFORMITY
8. EXTRA-ARTICULAR MANIFESTATIONS
COMMON SIGN AND SYMPTOMS

13.  ORIGINATES FROM JOINTS (ARTHALGIA),
MUSCLES (MYALGIA) OR OTHER SOFT
TISSUES
 LOCALISED – EX. GOUT
 DIFFUSE PAIN – OSTEOMALACIA, PAGET’S
DISEASE
 AGGRAVATES AT MOVEMENT - FRACTURES
 PAIN PRESENT AT REST – INFLAMMATION,
INFECTION, TUMOR
 PAIN AFTER INJURY
 EPISODIC PAIN
 FLITTING JOINT PAIN
PAIN

14. EXAMINATION CAN BE DONE IN TWO PARTS
1. GENERAL OBSERVATION
2. EXAMINATION OF INDIVIDUAL JOINTS
EXAMINATION
1. GAIT AND POSTURE
2. MOBILITY
3. INDEPENDENCE
4. MUSCLE WASTING – Primarily due to muscle disease
as in Polymyositis and Secondarily due to disuse,
either due to joint pain or nerve root compression or
peripheral neuropathy.
5. LONG BONES
6. FRACTURES
7. JOINTS
8. TENDONS
GENERAL OBSERVATION

15.  BONES:
1. ALTERATION IN SHAPE OR OUTLINE, SHORTENING.
2. DEFORMITY OF CHEST
3. LOCALISED SWELLING OF LONG BONES
EXAMINATION – GENERAL PRINCIPLES

16. EXAMINATION – GENERAL PRINCIPLES
PALPATION
TENDERNESS OF BONES IS FOUND IN LOCAL LESIONS
WHEN THERE IS A DESTRUCTIION, ELEVATION OR
IRRITATION TO PERIOSTEUM AS IN OSTEITIS FIBROSA
CYSTICA, MYELOMATOSIS, INFECTION OF BONES AND
RARELY IN LEUKAEMIA

17. 1. COMMON, PAINFUL AND DISTRESSING.
2. CAN INVOLVE ANY BONE.
3. FRACTURES IN HEALTHY BONES ARE DUE TO
TRAUMA.
4. FRACTURES OF RIBS, VERTEBRAE, SKULL ARE
MOST FREQUENTLY DUE TO COMPLICATIONS OF
BONE DISEASE.
5. MULTIPLE RIB FRACTURES ARE DUE TO FALLS.
6. FRACTURES WITHOUT TRAUMA WHEN A BONE IS
WEAKENED BY DISAESE ARE PATHOLOGICAL
FRACTURES.
7. PRESENTS WITH PAIN, SWELLING AND LOSS OF
MOVEMENT.
FRACTURES

18. LOOK IF IT IS OPEN/CLOSE?
DEFORMITY ( dinner fork deformity in colles’
fracture)
LOCALISED TENDERNESS AND SWELLING
(swelling may be not found if the overlying muscle
mass is large)
CREPITUS (due to abnormal motion of bone
ends)
EVALUATE NERVE SUPPLY TO LIMB DISTAL TO THE
SITE OF FRACTURE (ask to voluntarily move ankle
joint in fracture of femur, if absent, nerve injury
must be suspected)
WHAT TO EXAMINE?

19. INSPECTION:
IMPORTANT TO DECIDE WHETHER IT IS INFLAMMATORY OR
NON-INFLAMATORY.
LOOK FOR SWELLING OR DEFORMITY OF JOINT.
INFLAMMATION ASSOCIATED WITH REDNESS, TENDERNESS
AND WARMTH.
WHETHER THE INVOLVEMENT IS SYMMETRICAL
(RHEUMATOID ARTHRITIS) OR ASYMMETRICAL (PSORIATIC
ARTHROPATHY)
EXAMINATION OF JOINTS:

20. •PALPATION:
•TENDERNESS
•DETERMINE WHETHER THE SWELLING IS DUE TO BONY
ENLARGEMENT, OSTEOPHYTES OR EFFUSION
EXAMINATION OF JOINTS
ASSESSMENT OF TENDERNESS
GRADE - 1 PATIENT SAYS THE JOINT IS TENDER
GRADE - 2 PATIENT WINCES
GRADE - 3 PATIENT WINCES & WITHDRAWS THE
AFFECTED PART
GRADE - 4 PATIENT WILL NOT ALLOW TO TOUCH
THE JOINT

21.  CREPITUS:
 THIS CAN BE FEEL BY
PLACING ONE HAND
OVER THE JOINT WHILE
IT IS MOVED PASSIVELY
WITH OTHER.
(OSTEOARTHRITIS,
CARTILAGINOUS
FRAGMENTS IN THE
JOINT SPACES
 RANGE OF MOVEMENT:
 ESTIMATE THE DEGREE
OF LIMITATION BASED
ON THE COMPARISON
WITH NORMAL SIDE.
 BOTH ACTIVE AND
PASSIVE MOVEMENT
SHOULD BE ASSESED.
 LIMITATION OF
MOVEMENT MAY BE DUE
TO PAIN,
INFLAMMATION,
CONTRACTURES,
MUSCLE
SPASM,EFFUSION, BOMY
OVERGROWTH ETC.
CREPITUS AND RANGE OF MOVEMENT

22. EXAMINATION OF INDIVIDUAL JOINTS
 SPINE:
 INSPECTION
LOOK FOR DEFORMITY
(SCOLIOSIS,KYPHOSIS,LORDOISIS,GIBBUS)

23. CERVICAL SPINE:
• THE FOLLOWING MOVEMENTS SHOULD BE TESTED
1. FLEXION ( TOUCH CHIN TO CHEST)
2. FLEXION ( LOOK UPTO THE CEILING)
3. ROTATION ( LOOK OVER THE SHOULDERS ONE AFTER
OTHER)
4. LATERAL BENDING (TOUCH THE SHOULDER WITH
EAR)
• ANY PAIN OR PARAESTHESIA IN ARM, SUGGESTS
NERVE ROOT INVOLVEMENT.
• IN CERVICAL NERVE INJURY, NEVER ELICIT ROM.
EXAMINATION OF INDIVIDUAL JOINTS

24. THORACIC SPINE AND LUMBAR SPINE:
•THE FOLLOWING MOVEMENTS ARE TO BE TESTED:
1. FLEXION (TOUCH THE TOES WITHOUT BENDING
KNEES)
2. EXTENSION (BEND BACKWARDS)
3. LATERAL BENDING (RUN THE HANDDOWN THE SIDE
OF THIGH AS FAR AS POSSIBLE)
4. THORACIC ROTATION (SIT WITH ARMS CROSSED,
TWIST ROUND TO THE LEFT AND RIGHT AS FAR AS
POSSIBLE)
Examination of individual joints

25. • PAINFUL RESTRICTED SPINAL MOVEMENTS
IMPORTANT SIGN OF CERVICAL AND LUMBAR
LORDOISIS, ALSO BE FOUND IN VERTEBRAL DISC
DISEASE.
• SPINAL MOVEMENTS VIRTUALLY ABSENT IN
ANKYLOSING SPONDYLITIS.
• PAIN AND LIMITATION OF SLR (Straight Leg Raising)
IN PROLAPSED INTERVERTEBRAL DISC WHERE
IRRITATION OR COMPRESSION OF ONE OF THE
ROOTS OF SCIATIC NERVE.
• SAME CONDITION IN TIGHTNESS OF HAMSTRINGS.
• LASEGUE’S SIGN
Examination of individual joints

26. •NEUTRAL POSITION – ARM TO SIDE, ELBOW FLEXED
AT 90 DEGREE AND FOREARMS POINTING FORWARD.
•SCAPULA IS MOBILE, SO THE EXAMINATION CAN BE
DONE AFTER HOLDING THE SCAPULA BETWEEN
FINGER AND THUMB ON THE POSTERIOR CHEST
WALL.
•MOVEMENTS TO BE EXAMINE:
1. FLEXION
2. EXTENSION
3. ABDUCTION
4. ROTATION IN ABDUCTION
5. ROTATION IN NEUTRAL POSITION
• SUPRASPINATOUS TENDINITIS: FULL ROM + , BUT
PAINFUL ARC ON ABDUCTION
• SUBACROMIAL IMPINGEMENT: (due to bursitis or
rotator cuff abnormality) PRODUCES SEVERE PAIN
AT THE END OF ABDUCTION.
EXAMINATION OF SHOULDER:

27. THE ELBOW
• NEUTRAL POSITION IS
FOREARM EXTENDED.
• MOVEMENTS TO BE
EXAMINED
1. FLEXION
2. HYPEREXTENSION
• GOLFER’S ELBOW –
PAIN ON WRIST FLEXION
• TENNIS ELBOW – PAIN
ON WRIST EXTENSION
FOREARM:
• NEUTRAL POSITION IS
ARM BY THE SIDE,
ELBOW FLEXED TO 90
DEGREE WITH THUMB
UPPERMOST.
• MOVEMENTS TO
EXAMINE:
1. SUPINATION
2. PRONATION
EXAMINATION OF ELBOW, FOREARM

28.  THE WRIST:
 NEUTRAL
POSITION IS
HAND IN THE
LINE OF
FOREARM AND
PALM DOWN
 MOVEMENTS TO
BE TESTED
1. DORSIFLEXION
2. PALMAR
FLEXION
3. ULNAR
DEVIATION
4. RADIAL
DEVIATION
 THE FINGERS:
 NEUTRAL
POSITION IS
WITH FINGERS
EXTENSION
 TEST FLEXION
AT:
1. METACARPOPH
ALANGEAL
JOINT
2. PROXIMAL
INTERPHALAN
GEAL JOINT
3. DISTAL
INTERPHALAN
GEAL JOINT
 THE THUMB:
 NEUTRAL
POSITION IS
THUMB
ALONGSIDE
FOREFINGER
AND
EXTENDED.
 MOVEMENTS
TO BE TESTED:
1. EXTENSION
2. FLEXION
3. OPPOSITION
4. ABDUCTION
EXAMINATION OF WRIST, FINGERS AND
THUMB

29.  HEBERDEN’S NODES AND BOUCHARD’S NODES
 SWAN NECK DEFORMITY
 PSORIATIC PIITING DEFORMITY
EXAMINATION OF HAND:

30.  ULNAR NERVE LESION – CLAW HAND
 MEDIAN NERVE LESION - HAND OF BENEDICT
DEFORMITY
EXAMINATION OF HAND:

31. THE HIP:
•NEUTRAL POSITION IS HIP
IN EXTENSION WITH
PATELLA POINTING
FORWARDS.
•MOVEMENTS TO BE TESTED:
1. FLEXION
2. ABDUCTION
3. ADDUCTION
4. ROTATION IN FLEXION
5. ROTATION IN EXTENSION
6. EXTENSION
• ADDITIONAL
EXAMINATION
1. TRENDELENBURG TEST
2. MEASUREMENT OF TRUE
AND APPARENT
SHORTENING.
THE KNEE
• NEUTRAL PSITION IS
COMPLETE EXTENSION
1. OBSERVE ANY VALGUS
(LATERAL ANGULATION
OF TIBIA) OR VARUS
(MEDIAL ANGULATION)
ON STANDING.
2. LOOK FOR MUSCLE
WASTING
3. SWELLING
4. TENDERNESS
EXAMINATION OF HIP AND KNEE

32. THE ANKLE:
•NEUTRAL POSITION IS
OUTER BORDER OF FOOT AT
AN ANGLE OF 90 DEGREES
WITH LEG AND MIDWAY
BETWEEN INVERSION AND
EVERSION.
•LOOK FOR VALGUS AND
VARUS DEFORMITY
•CALF MUSCLE WASTING IN
LONG STANDING ANKLE
DISEASES
•MOVEMENTS TO BE TESTED
•DORSIFLEXION
•PLANTAR FLEXION
•THE FOOT:
•THERE MAY BEABNORMAL
SPREAD OF 2 ADJACENT
WOSIF THERE IS
INTERPHALANGEAL BURSA
IN BETWEEN. (Daylight sign)
•CHECK FOR HALLUX
VALGUS (Lat. Deviation of
big toe), CLAW TOES
(Abnormal curvatures)
•MOVEMENTS TO BE
TESTED:
1. SUBTALAR INVERSION
AND EVERSION
2. METATARSOPHALANGEAL
AND INTERPHALANGEAL
FLEXION/EXTENSION
EXAMINATION OF ANKLE AND FOOT:

33. CONGENITAL DISEASES:
1. SPINA BIFIDA - Neural tube defect, spine and spinal
cord doesn’t form properly.
2. OSTEOGENESIS IMPERFECTA (BRITTLE BONE DISEASE)
– Inherited connective tissue disorder. Triad – blue
sclera, osseous fragility, conductive hearing loss.
3. ARTHROGRYPOSIS MULTIPLEX – Involves variety of
conditions involving multiple joint contractures.
4. MARFAN SYNDROME – Inherited disorder that affects
connective tissues. Mutation in gene FBN1.
5. FIBROUS DYSPLASIA – It is a benign, non-cancerous
condition in which scar tissue in grows in place of
normal bone.
6. DUCCHENE MUSCULAR DYSTROPHY – It is a genetic
disorder- progressive muscle degeneration and
weakness due to alteration of protein called
‘Dystrophin’.
PATHOLOGIC CONDITIONS OF
MUSCULOSKELETAL SYSTEM

34. 1. OSTEOARTHRITIS: (Degenerative joint disease, wear
and tear disease)
2. RHEUMATOID ARTHRITIS
3. CRYSTAL ARTHRITIS: Deposition of Calcium
pyrophosphate.
4. GOUT
ACQUIRED SKELETAL DISEASES

35. 5. CERVICAL SPONDYLOSIS: Age related, wear and tear
affecting the spinal disks of neck.
6. ANKYLOSING SPONDYLITIS: Inflammatory disease that
causes some of bones to fuse and makes them less
flexible and hunched posture.
7. OSTEOMYELITIS:
ACQUIRED SKELETAL DISEASES

36. 8. KOCH’S SPINE: Tuberculosis of spine
9. OSTEOMALACIA: Nutritional disease, caused due
to long standing deficiency of vitamin D that
results in less resorption of calcium and weakens
the bones.
10.RICKETS: same as osteomalacia but occurs in
children
11.OSTEOPOROSIS

37. 12.REITER’S SYNDROME
13.SJOGREN’S SYNDROME
14.FELTY SYNDROME

38. 15.FROZEN SHOULDER
16.SPRAIN
17.MUSCLE TEAR OR STRAIN

39. 18.TENOSYNOVITIS
19.BURSITIS:
20.AVASCULAR NECROSIS:

40. 21.BRACHIAL PLEXUS INJURY:
21.LUMBOSACRAL PLEXUS INJURY:
21.CENTRAL GIANT CELL GRANULOMA:

41. 1. CBP
2. ESR
3. CRP
4. RA FACTOR
5. ANTINUCLEAR ANTIBODY TESTS
6. ARTHROCENTESIS
7. ARTHROGRAPHY
8. BIOPSIES
9. X RAY
INVESTIGATIONS:

42. X-RAYS:
CLAVICLE FRACTURE
COLLES’ FRACTURE
GREENSTICK FRACTURE

43. X-RAYS:
OA
RA
GOUT

44. X-RAYS:
CERVICAL SPONDYLOSIS ANKYLOSING SPONDYLOSIS

45. X-RAYS:
(MRI)
FROZEN SHOULDER

46. X-RAYS:
AVASCULAR NECROSIS
MRI

47. X-RAYS:
ACUTE LYMPHOBLASTIC LEUKEMIA
CENTRAL GIANT CELL GANULOMA