MSS

1
School of Nursing & Midwifery
Department of Adult Health Nursing
P.by: Habtemariam Mulugeta
College of Medicine & Health
Sciences
Wollo University - Habtemariam M.10/27/2020

Assessment of the Musculoskeletal System
2
10/27/2020 Wollo University - Habtemariam M.

Presentation Outline
• Objectives
• Introduction
• Subjective data
• Objective data
• Assessment of the muscle
• Assessment of the bones
• Assessment of the joints
• Assessment of specific Joints
• Assessment of selected area
• Reference
• Acknowledgment
10/27/2020 Wollo University - Habtemariam M. 3

Objectives
Wollo University - Habtemariam M. 4
At the end of the session, you will be able to:
–Discuss the Anatomy & Physiology of MSS
–Explain about assessment of joints, bone
& muscle of MSS
–Differentiate assessment of selected area
10/27/2020

Introduction
Review of anatomy and physiology of the
musculoskeletal system
• The musculoskeletal system consists of the
muscles, tendons, bones and cartilage
together with the joints
• The primary function of which is to produce
skeletal movements
Wollo University - Habtemariam M. 510/27/2020

Bones
• The skeleton is the name given to the
collection of bones that holds our body up.
• The skeleton = 206 bones
• Functions
1) Locomotion
2) Protection
3) Support and lever
4) Blood production
5) Mineral deposition

Muscles
• Muscles simply move us.
• Muscles= more than 600 voluntary or striated
muscles
• Three types of muscle
• 1. Skeletal Muscles
– Voluntary and striated
• 2. Cardiac muscles
– Involuntary and striated
• 3. Smooth/Visceral muscles
– Involuntary and NON-striated

The skeletal muscle terminology
Flexion - bending a limb at a joint
Extension - straightening a limb at a joint
Abduction - moving a limb away from the midline of the
body
Adduction - moving a limb toward the mid line of the body
Pronation - turning the forearm so that the palm is down
Supination - turning the forearm so that the palm is up
10Wollo University - Habtemariam M.10/27/2020

Terminology…
Circumduction - moving the arm in a circle around the
shoulder
Inversion - moving the sole of foot inward at the ankle
Eversion - moving the sole of foot outward at ankle
Rotation - moving the head around a central axis
Elevation - raising a body part
Depression - lowering a body part

Skeletal Muscle Movements

Tendons
• Bands of fibrous connective tissue that tie
bones to muscles

Ligaments
• Strong, dense and flexible bands of fibrous
tissue connecting bones to another bone

Joints
• The part of the Skeleton where two or more
bones are connected

Types of joints
1) Hinge (elbow)
2) Pivot (proximal radioulnar joint)
3) condyloid (wrist)
4) Saddle (thumb joints)
5) ball and socket (hip & shoulder)
6) plane (kneecap)

MOVEMENTS ALLOWED BY SYNOVIAL
JOINTS
• Three basic types of movement
– Gliding – One bone across the surface of another
– Angular movement – Movements change the angle
between bones
– Rotation – Movement around a bone's long axis
17

GLIDING
• Flat surfaces of two bones glide
across each other
• Gliding occurs between
– Carpals
– Articular processes of vertebrae
– Tarsals
SK DEPT OF ANATOMY AFMC 18

ANGULAR MOVEMENT
• Flexion
• Extension
• Dorsiflexion & Plantar-flexion
• Abduction
• Adduction
• Circumduction
SK DEPT OF ANATOMY AFMC 19

ROTATION
• Turning of a bone around its own
long axis
• Examples:
– Between C-1 & C-2 vertebrae
– Hip & shoulder joints
21

Six basic types of joint movement
1) flexion & extension
2) dorsiflexion & plantar flexion
3) adduction & abduction
4) Inversion & eversion
5) Internal & external rotation
6) Pronation & supination

Cartilages
• A dense connective tissue that consists of
fibers embedded in a strong gel-like substance

Bursae
• Sac containing fluid that are located around
the joints to prevent friction

Assessment of the musculoskeletal system

Subjective data
• Joint – pain, stiffness, swelling, heat, limitation of
movement
• Muscle - pain (cramps),weakness
• Bones - pain, trauma, fractures, dislocations
• Functional assessment(ADL) - any limits on usual
daily activities
• Self-care behaviors (exercise program)

Subjective data….
• Demographic Data: Some musculoskeletal
diseases are age-related or more prevalent by
gender or ethnic group.

Subjective data….
• Family History: Musculoskeletal problems with a
familial tendency include osteoporosis, bone cancer,
and rheumatoid arthritis.
• Past health history - these includes TB, polio, DM,
parathyroid problems, soft tissue infection,
neuromuscular disabilities, hip replacement,
• A person who has had a stroke is at increased risk for
shoulder subluxation (partial dislocation).

Subjective data….
• Surgery or other treatments- past hospitalizations
from musculoskeletal problems.
• Nutrition/Medications - use of hormone therapy,
Calcium, vitamin D supplements
• Oral contraceptive use in young women
may contribute to osteoporosis
• Steroids can affect calcium absorption.

Objective data
• In the assessment of the musculoskeletal system, direct
your attention to both structure and function, keeping the
activities of daily living in mind
• Detailed musculoskeletal assessment should include the
assessment of joint, muscle, and bone.
Inspection,
palpation,
 range of motion (movement),
Muscle testing (Apply opposing force and Grading
muscle strength)

1.Inspection
• Observe general body build, muscle configuration
• Note the size and contour of the joint ,
• Inspect the skin and tissues over the joints for color,
swelling, any deformity, muscle wasting, scars
• Presence of swelling is significant and signals for
joint irritation
• Swelling may be due to excess joint fluid(effusion),
or inflammation of surrounding soft tissue
(tendon).

Cont.
• use of an assistive devices such as walker.
Deformity include,
 Dislocation
 Subluxation
 Contracture (shortening of muscle) or
 Ankylosis (stiffness of a joint)

Contracture

2. Palpation
• Palpate each joint, including its skin for temperature,
its muscles, bony articulations, and area of joint
capsules
• Notice any heat, tenderness, swelling, or masses
• Joints normally are not tender to palpation.

Cont.
• A small amount of fluid is present in the joint but
it is not palpable
• Palpable fluid is abnormal. because fluid is
contained in an enclosed sac, the fluid will shift
and cause a visible bulging on another side

3. Range of motion (ROM)
• Ask for active ROM and if you see a limitation,
gently attempt passive motion.
• Joint motion normally causes no tenderness, pain or
crepitation.

 Inspection
 Evidence of wasting - compare sides
 muscle disuse
 lower motor neurone lesions / joint disease
 Abnormal bulk
 body builders / muscular dystrophies
 Spontaneous contractions
 muscle spasms / abnormal movements / fasciculation
 Palpate
 Tenderness (acute injury / some myopathies)
 The assessment of muscles generally should focus and
include the bulk, tone, and strength of muscles
Examination of muscles
10/27/2020
Wollo University - Habtemariam M.
37

Cont.
Muscle bulk
• When you assess the muscle bulk your patient pay
attention to the muscle of the hand, shoulder and thigh.
• Compare the contour and size of muscles and note the
sign of atrophy and flatness .
• If there is atrophy identify whether it is unilateral,
bilateral, proximal or distal.

Muscle bulk….
• Atrophy of muscle is may caused by
– Motor neuron disease
– Rheumatoid arthritis
– Protein-energy malnutrition
• Fasciculation in atrophic muscle suggest
peripheral nerve damage

Atrophy

Arthritis and atrophic muscle

Muscle tone
• Muscle tone is defined as a slight residual tension
maintained by a normal muscles with an intact nerve
supply when it relaxed voluntary.
Technique
• Ask the patient to relax.
• Take one hand with your hand, while supporting the
elbow, flex and extend the patients finger, wrist, and
elbow
• Then combine this action in to a single smooth
movement and note the degree of resistance.
• If you suspect the degree of resistance hold the forearm
and shake the hand loosely forward and back ward.

Muscle tone…
• Normally, the hand moves back and forth freely but is
not completely floppy.
• Marked floppiness indicates hypotonic muscle (flaccid
paralysis)
• If resistance is increase determine whether it varies as
you move the limb or whether it persists through out
the range of movement and in both direction (during
both flexion and extension).

Muscle strength
Technique
• Ask the patient to move actively against your
resistance or to resist your movement
• Grade the strength of the individual muscles
on a 0-5 scale according to the following
criteria

Muscle strength….
Grade 0 = no muscular contraction is detected
Grade 1 = trace of contraction
Grade 2 = active movement of the body part with
gravity eliminated.
Grade 3 = active movement against gravity
Grade 4 = active movement against gravity and
some resistance
Grade 5 = active movement against full résistance.
G - V ***This is the normal muscle strength

Muscle strength…
Weakness (paresis) or plegia (paralysis) may be caused
by;
• Peripheral or central nerve damage
• Problems of neuron transmission
• Musculoskeletal problems
• Symmetrical weakness of the proximal muscles suggests
a myopathy (disorder of the muscles).
• Symmetrical weakness of the distal muscles suggests a
polyneuropathy (disorder of peripheral nerves)

Assessment of the bone
• Inspect any deformities, mal-alignment,
fracture.
• Palpate for tenderness

Assessment of the joints
• Majorly Use the techniques of;
–inspection and
–palpation,
• Joint Movement (ROM)

Inspection of joint
 Swellings
 Skin changes
 colour - redness - inflammation or infection
 scars, previous surgery
 rashes
 Adjacent structures
 muscles - wasting of muscles above and below a joint often
accompanies joint disease
 compare to opposite side
 Deformity
 misalignment of bones making up the joint
 valgus - distal part displaced laterally
 varus - distal part displaced medially

Palpation of joint
 Feel for any swelling and its nature
 hard suggests bone
 spongy or boggy suggests synovial thickening
 fluctuance suggests an effusion (fluid)
 position - joint or periarticular (e.g. bursa)
 Tenderness
 assess joint margin, related ligaments, tendons
and adjacent bony structures

Palpation of joint
 Temperature
 compare with opposite side
 if bilateral joint involvement compare tissues
above and below the joint for comparison
 Joint crepitus
 a palpable grating sensation appreciated by a
hand placed on the joint during movement
 Tendon crepitus
 a dry, friction rub palpable when tendons move

Joint movement
 Range of joint movement
 Active movement
 movement undertaken by the patient alone
 Passive movement
 movement undertaken by the examiner
 The spine should not be moved passively
If a full ROM is demonstrated actively then passive
is not required.
If movement is impeded or painful passive
movement can help identify if the cause.

Specific Joints to be examined
• Fingers - flexion/extension; abduction/adduction
• Thumb - flexion/extension; abduction/adduction;
• Wrist - flexion/extension; radial/ulnar deviation
• Forearm - pronation/supination (function of both
elbow and wrist)
• Elbow - flexion/extension .

Specific Joints….
• Hip - flexion/extension; abduction/adduction;
internal/external rotation …
• Knee - flexion/extension
• Ankle - flexion (plantar flexion)/extension
(dorsiflexion)
• Foot - inversion/eversion
• Toes - flexion/extension
• Spine - flexion/extension; right/left bending; right/left
rotation

Comprehensive Musculoskeletal
System Assessment

Method of examination of selected area
Temporo-mandibular joint
• Stand in front of the patient
• With sitting position,
• inspect the area just anterior to the ear
• Place the tips of your first fingers in front of each ear
and ask the person to open and close the mouth.
• Protrude lower jaw and move it side to side
Abnormal – swelling, crepitus and pain

Palpation of temporo-mandibular joint

Cervical spine
• Inspection: The spine should be straight and the
head erect
• Palpate the spinous processes, sternomastoid and
trapezius muscles
• They should feel firm, with no muscle spasm or
tenderness
• Ask for flexion, extension, lateral bending and
rotation
• Limited ROM; pain with movement and failure of
flexion are abnormal findings

Upper extremity
Shoulders
• Inspect and compare both shoulders posteriorly and
anteriorly
• Compare shoulders for equality of bony landmark
• Normally there is no redness, muscular atrophy,
deformity or swelling
• Palpate both shoulders noting, muscular spasm or
atrophy, swelling, heat or tenderness

Shoulders…
• Test ROM by performing
(1) Raise (abduct) the arms to shoulder level (90°) with
palms facing down
(2) Raise the arms to a vertical position above the
head with the palms facing each other
(3) Place both hands behind the neck, with elbows out
to the side (tests external rotation); and
(4) Place both hands behind the back
(tests internal rotation ).
• Abnormal – limited ROM, asymmetry, pain

Elbow
• Inspect the size and contour of the elbow in both flexed
and extended positions
• Look for any deformity, redness or swelling
• Palpate with the elbow flexed.
• palpate the olecranon process the medial and lateral
epicondyles of humerus.
• With your right thumb and fingers, palpate the area of the
olecranon bursa for heat, swelling, tenderness,
consistency or nodules

Elbow…
Abnormal
– Subluxation (a partial dislocation) of the elbow
– Swelling and redness of the olecranon bursa
– Effusion and subcutaneous nodules (raised, firm,
non-tender)
Test ROM by asking the person to make flexion of
elbow, extension, pronation and supination.
• To test muscle strength have the person flex the elbow
against your resistance on the wrist and ask the person
to extend the elbow against your resistance

Wrist and hand
• Inspect the hand and wrists on the dorsal and palmar sides.
• Normally there is no swelling, or redness, deformity, or
nodules.
• Palpate each joint in the wrist and hand.
• Facing the person, support the hand with fingers under it
and palpate the wrist firmly with both your thumbs on its
dorsum.
• Move your palpating thumbs side to side to identify the
normal depresses areas.

Wrist and hand…
• Normally the joint surface feel smooth, with no
swelling, nodules, or tenderness.
• Palpate the metacarpophalangeal joints with your
thumbs and
• use thumb and index fingers in a pinching motion to
palpate the side of the interphalangeal joints
• Normally there is no tenderness, thickening, warmth,
or nodules.

Wrist and hand…
Test for ROM
• By asking the person to do flexion and extension of the hand
and wrist
• By asking the person to make a fist extend and spread the
fingers and
• do flexion of wrist and extend them and move hand laterally
and medially
• For muscle strength test, position the person forearm
supinated (palm up) and ask the person to flex the wrist
against your resistance at the palm

Phalen's Test (Median Nerve)
• Ask the patient to press the backs of the hands
together with the wrists fully flexed (backward
praying).
• Have the patient hold this position for 60 seconds
and then comment on how the hands feel.
• Pain, tingling, or other abnormal sensations in the
thumb, index, or middle fingers strongly suggest
carpal tunnel syndrome.
• (the median nerve in the wrist becomes
compressed, causing pain and numbness)

Tinel's Sign (Median Nerve)
• Direct tapping of the location of median nerve at the
wrist produces no symptoms in the normal hand
• Pain, tingling, or electric sensations strongly suggest
carpal tunnel syndrome.

Lower extremity
>>> HIP
• Inspection of the hip begins with careful observation of the
patient’s gait on entering the room.
• Observe the two phases of gait
1.Stance— when the foot is on the ground and bears weight
2.Swing— when the foot moves forward and does not bear
weight
• Assess ROM by asking the person to do hip flexion with
straight, hip flexion with knee flexed.
• Internal and external rotation knee flexed; abduction and
adduction with extended legs and hyper extension in prone
position

Rotation
Flexion Abduction
Adduction

knee
• With supine position and extended legs,
• inspect the knee’s shape and contour
• Normally it is concave or hollows on either side of the patella.
• Check them for any sign of swelling.
>> palpation
• Palpate the thigh with your thumbs and fingers and note any
warmth, tenderness, thickening or nodularity.
• When swelling occurs, check whether it is due to soft tissue
swelling or increased fluid in the joint

Bulge sign (for minor effusions)
• If swelling in the suprapatellar pouch,
– the bulge sign confirms the presence of fluid
Techniques
• Firmly stroke up on the medial aspect of the knee two to
three times to displace any fluid
• Tap/press the lateral aspect
• Watch the medial side in the hollow for a distinct bulge
from a fluid wave
• Normally there is none 75Wollo University - Habtemariam M.10/27/2020

Checking for the bulge sign.

Ballotable of the Patella (for major effusions).
• This test is reliable when larger amount of fluid are present
• Use your left hand to compress the suprapatellar pouch
• With your right hands, push/tap the patella sharply against the
femur
• If no fluid is present, the patella already is sung against the
femur
• If fluid has collected, your tap on the patella displaces the fluid
and you will hear a tap as the patella bumps up on the femur
• Check ROM by asking the person to do knee flexion and
extension

Checking for ballottement.

Ankle and foot
• The person in supine position
• inspect noting any deformities, nodules, or swellings.
• Palpation
• Support the ankle by grasping the heel with your
fingers while palpating with your thumbs.
• With your thumbs, palpate the anterior aspect of
each ankle joint, noting any swelling, or tenderness.

Ankle and foot…
• Palpate the heads of the five metatarsals and the grooves
between them with your thumb and index finger.
• Place your thumb on the dorsum of the foot and your
index finger on the plantar surface
• They should feel smooth with no swelling or tenderness.
• Test for ROM by asking the person to do dorsiflexion,
plantar flexion, inversion and eversion of foot.

Spine
• With standing,
• inspect the entire back and note if the spine is straight
from up to down.
• From the side note the normal convex thoracic curve and
the concave lumbar curve.

Cont.
• Ask the patient if he is aware of
sore spots.
• Palpate the spinous process and
be gentle with the sore spots.
• Normally non-tender.

Posture
Normal -
Comfortably erect

Lordosis - Increased Curvature of the
Spine in concave
manner

>> Kyphosis is a curving of the spine that causes
a bowing of the back, which leads to a
hunchback or slouching posture
>> View the spine from the side to determine
kyphosis.

Scoliosis – curvature of the spine away from
middle or sideways
• The examiner should stand behind the patient and
observe the alignment of the spine in the flexed
position to determine scoliosis.

• Assess ROM 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.

Reference
1) CURRENT Diagnosis & Treatment Rheumatology-3rd ed.
John B. Imboden, MD: The McGraw-Hill Education, LLC
2) Jarvis, Carolyn. Physical Examination and Health
Assessment. 2nd ed. Philadelphia: W.B. Saunders, 1996.
3) Nursing assessment—Handbooks, manuals, etc. I. Jensen,
Sharon, 1955– Nursing health assessment.
4) Bates’ guide to physical examination and history-taking.—
11th ed./Lynn S. Bickley, Peter G. Szilagyi. p.; cm.
10/27/2020

Acknowledgment
• First I would like to express my heartfelt gratitude to
WU CMHS for giving me this chance to enhance my
knowledge and skill.
• Secondly I would like to thank my instructor Dr. Prem
Kumar for sharing me his deep knowledge,
experience and expertise.
• Last but not least I would like to thank my family and
friends in helping me in ideas and material during my
entire work.
10/27/2020

Thank You

MSS

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