This document provides information on examining the musculoskeletal system. It begins by outlining the objectives of reviewing anatomy and physiology, differentiating normal and abnormal findings, and focused history and physical exam. Various techniques for examining muscles, bones, and joints are described, including inspection, palpation, range of motion tests, and assessing for tenderness, swelling, and deformities. Common musculoskeletal disorders that may be identified during the history and physical exam are also listed. The document aims to equip practitioners to properly examine the musculoskeletal system and identify any potential disorders.

1. BESTY VARGHESE
Krishna Institute of Medical
Sciences Deemed to be University,
Karad Sciences (Accredited with
NAAC A+ grade with CGPA 3.39)
PHOTO

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Objectives
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.
1. Review knowledge of Anatomy & Physiology of Musculoskeletal System
2. Differentiate Normal & Abnormal MSS
3. Focused History Collection & Physical Exam- MUST
 To assess the severity and consequences of the condition
 To make an accurate diagnosis
 To Prevent complications due to late detection
 To construct a clear management plan

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 In the very old…
 In the very young…
INTRODUCTION

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Anatomy & Physiology: Muscles & Bones
Movement, support, protection, heat generation, and blood circulation

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From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.
The Musculoskeletal Examination
Steps..
1. To perform examination of muscles, bones and joints, use techniques of
inspection, palpation & manipulation.
2. https://www.youtube.com/watch?v=aUMTPa_9qlY
3. On screening examination, no musculoskeletal complaints, ask client to
perform complete active range of motion with each joints or set of joints.

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Screening….Musculoskeletal History
Can you locate the pain?
Is the problem symmetrical?
Do you have any pain or stiffness in your muscles, joint or back?
Any H/o gout or arthritis?
Can you dress yourself completely without difficulty?
Can you “walk up and down stairs” without difficulty?
Any clinical abnormal symptoms?(e .g ., rash, fever)?
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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Assessment of Musculoskeletal System
Category What to ask Rationale
Physical
Examination
Inspect, Palpate and observe range of motion
(ROM) of affected areas
Altered gate, tone, size, shape, posture, contractures,
deformities, ROM, pain and effects on ADLs can be
determined
Assess warm, color, circulation and movements
of affected areas
Nerve function, sensation, movements, weakness, and
potential development of compartment syndrome can be
determined
Palpate all pulses below involved area Alternations may indicate altered vascular integrity of
affected area or demonstrate developing compartment
syndrome
Palpate muscles, joints allows for evaluation of
skin temp, local tenderness, swelling &
crepitation
To find out any infection- inflammatory non inflammatory
disorders
Gait, motion of spine- smoothness, height of
shoulders, hip symmetry
Lumbar lordosis- contractility of spine, Kyphosis-excessive
curvature of thor spine, scoliosis

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GENERAL ASSESSMENT
Rapid and sensitive screening method
G- Gait
A- Arms
L- Legs
S- Spine

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General observation
G- Gait
A-
L-
S-

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G-
A- Arms
L-
S-

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History Taking
1. CHIEF COMPLAINTS
Mode of onset and duration of
symptoms
Pain and swelling
Pattern of joint involvement
Stiffness
Deformity
Impairment of movement
Constitutional and extra – articular
symptoms

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History of present illness
Acute onset (duration less
than 6 weeks)
Causes
Gouty arthritis
Septic arthritis
Gradual onset (duration
more than 6 weeks)
Rheumatoid arthritis
Osteoarthritis
Seronegative arthritis
Intermittent attacks of arthritis
Gouty arthritis
Migratory attacks of arthritis
Rheumatic fever
Gonococcal arthritis
Viral arthritis

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• Bony pain:
• Continuous aching pain disturbing
sleep
• Joint pain:
• Sharp pain related to posture or
movement associated with stiffness
Assessment of joint pain
• Mode of onset
• Acute/ gradual/intermittent/
migratory / pain disturbing sleep
Pain

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Hand examination
Check the hand (power) grip and
pinch grip (between index finger and
thumb)

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Sites of Somatic Reference of Different Joint Pains
• Joint pain
• Site of referred pain
Joint pain Site of referred pain
Cervical spine Head/ over the shoulder
Lumbar spine Buttocks/ posterior thigh
Shoulder Lateral aspect of upper arm
Elbow Forearm
Hip Outer aspect of thigh or knee or
both

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Range of motion (Play Video)
https://www.youtube.com/wa
tch?v=D8sjGPYrtwI&ab_chann
el=TheUpperHand
Measured with a
protracter/goniometer
Assess for active and passive
movement
Physical Examination

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Stiffness of joints
Inflammatory arthritis
•Early morning stiffness
persisting for more than 30
minutes
•More than 1 hr- rheumatoid
arthritis
•Stiffness is precipitated by
prolonged rest and lasts
several hrs
•Improves with activity and
anti inflammatory drugs
Non inflammatory arthritis
•Intermittent stiffness
•Stiffness may increase by activity
•Lasts less than one hour
•Stiffness is accompanied only by
pain without other inflammatory
symptoms
•Stiffness may be due to pain and
deformity

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Palpation
Check for tenderness
Determine whether swelling
is due to bony enlargement
/ thickening of the synovial
tissues/ effusion into the
joint space
Grading of the joint tenderness
1. The patient says joint is tender
2. The patient winces
3. The patient winces and
withdraws the affected part
4. The patient will not allow the
joint to be touched

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Body Movements Produced by Muscle Contraction
 Flexion—bending at a joint (eg, elbow)
 Extension—straightening at a joint
 Abduction—moving away from midline
 Adduction—moving toward midline
 Rotation—turning around a specific axis (eg, shoulder joint)
 Circumduction—cone-like movement
 Supination—turning upward
 Pronation—turning downward
 Inversion—turning inward
 Eversion—turning outward
 Protraction—pushing forward
 Retraction—pulling backward

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G-
A-
L-Legs
S-
• Examine the lower limbs for
swelling, deformities or limb
shortening
• Range of motion

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Hip Joint: Normal vs Abnormal

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Knee joint: Normal vs Abnormal

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Other abnormalities of the knee joint
Medial and lateral angulations of the knee – varus and
valgus deformities
Quadriceps wasting occurs in long standing knee joint
disease
Tenderness at knee joint margins

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Normal vs Abnormal Toe Joints

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Ankle joint
• Neutral position – with the outer
border of the foot at an angle of 90
degree with leg and midway
between inversion and eversion
• Movements:
• Dorsiflexion- 20
• Plantar flexion – 50
• Eversion (20) and inversion (30)
• Wasting of calf muscles occur in
long standing ankle disease

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• Inspection:
• Scoliosis
• Symmetrical paraspinals
• Normal shoulder and gluteal muscle bulk and
symmetry
• Level iliac crests
• Normal cervical and lumbar lordosis
• Movement
G-
A-
L-
S-Spine

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The Joints
• “look, feel and move”
• Inspection / palpation /
range of movement
• Compare the corresponding
joints on the two sides of the
body
• Avoid causing undue
discomfort
Inspection :
• Inflammation – redness
with tenderness and
warmth
• Look for swelling and
deformity
• Symmetrical distribution

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The bones
• The examination of the bones should
always be directed by information
obtained from the history….

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• Look for any
alteration in shape
or outline
• Measure any
shortening
In Paget’s disease…
Bowing of the long bones, particularly tibia and femur, is associated
with bony enlargement, and usually, increased local temperature
Rickets …
Alteration in shape of the bone due to epiphyseal enlargement
Localized swelling of long bone due to infections, cysts or tumors
Spontaneous fracture – secondary carcinoma, multiple myeloma,
generalized osteitis fibrosa cystica or osteogenesis imperfecta
The bones
Inspection

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The bones
Palpation
Bone tenderness
Occur in local lesions and injury
Fractures
Long bones- due to trauma
Wrists, hips, and vertebrae- bone
disease
Multiple rib fractures- falls
Without trauma- pathologic

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Other Skeletal Trauma
• Dislocation
• Subluxation
• Injuries to Support Structures
• Tendon tear-tendon separates in whole or in part from tissue to which it is attached
• Ligament tear-caused by an extreme motion
• Strain- An excessive stretching of a muscle or tendon
• Sprain- An excessive stretching of a ligament usually caused by a twisting motion
• Avulsion- the action of pulling or tearing away.
• Tendonitis- inflammation of a tendon, most commonly from overuse but also from infection or
rheumatic disease.
• Bursitis- inflammation of a bursa, typically one in a shoulder joint.
• RICE acronym
• Rest
• Ice
• Compression
• Elevation

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In Old-OSTEOPOROSIS
DOWAGER’S HUMP OSTEOPOROTIC CHANGES
SEVERE OSTEOPOROSIS

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RHEUMATOID ARTHRITIS
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.
MUSCLE ATROPHY SWAN NECK DEFORMITY
From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B.
Saunders.
BOUTONNIERE DEFORMITY

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Vit D Deficiency related to Ortho
• Vitamin D deficiency can lead to a loss of bone density, which
can contribute to osteoporosis and fractures (broken bones).
Severe vitamin D deficiency can also lead to other diseases. In
children, it can cause rickets.
• Osteomalacia refers to a marked softening of bones- bone
fracture
• Other Vit D absorption problems- Autoimmune disorders,
malabsorption, metabolic disorders/ inborn errors of
metabolism
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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Sports-Related Injuries- self-inflicted injuries
• Rotator Cuff Tears- A rotator cuff tear often occurs in people who repeatedly
perform the same shoulder motions.
• Epicondylitis (Tennis Elbow)-
• Lateral & Medial Collateral Ligament Injury
• Anterior & Posterior Cruciate Ligament Injury
• Meniscal Injuries- occurring cartilage injuries of the knee.
• Rupture of Achilles Tendon- The Achilles Tendon is the strong fibrous band
that attaches the calf muscles to the calcaneus bone.
• Special Signs of

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Infectious Bone Disease: Osteomyelitis
Inflammation of bone caused by infection, generally in the legs, arm or spine.
• Infections can reach bones by travelling through the bloodstream or spreading from nearby tissue.
• Common symptoms include pain, fever and chills.
• Treatment is usually surgery to remove portions of bone that have died. This is followed by strong antibiotics, often by an IV, for at
least six weeks.
• Difficult to treat
• Physical disability
• Bacteria
• Exogenous
• Endogenous
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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Bone Tumors
A mass of unusual cells growing in a bone. Most bone tumours aren't cancerous.
• Causes of bone tumours include abnormal healing of an injury, inherited conditions and
radiation therapy. They can also be caused by bone cancer or another cancer that has
spread to the bone from other parts of the body.
• A bone tumour may cause a painless mass. Some people have dull, aching pain. In
some cases, minor injury causes a fracture near the tumour.
• Treatments include surgery and radiation. Some non-cancerous tumours go away
without treatment.
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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COMPLICATIONS If not treated/Identified
Fat embolism
Compartment syndrome
Infection and osteomyelitis
Avascular necrosis
Pulmonary emboli
Venous thrombosis
Delayed union & nonunion

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From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.
PATIENT MUSCULOSKELETAL HEALTH EDUCATION
based on ICU Experience
1. Early activity - Both passive and active to maintain integrity of
musculoskeletal system- Prevent Pressure Sore- Braden score
2. Range of motion exercises- extremities – early walking in neuro
3. DVT Prevention & Stockings
4. prolonged bedrest -impaired skin integrity
5. Prolonged bedrest - self-perception –change body image
6. Suction & Clear Airway-Early weaning a patient off ventilation.

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Common Disorders of Musculoskeletal System- find from H/P Exam
1. 1. Musculoskeletal Injuries- bones, muscles, ligaments, nerves, or
tendons
2. 2. Fractures- Complete, Incomplete, Open/compound, pathological
3. 3. Infection & Osteomylitis
4. 4. Sports Injuries- Sprains, strains, soft tissue injuries, Rotator Cuff Tears-,
Tennis Elbow, Ligament Injury
5. 5. Bone Infection- Osteomylitis
6. 6. Bone tumors
7. 7. Joint disorders- Rhumatoid arthritis, Psoriatric Artritis
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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In Short
 History & Physical Examination as per age group will lead
exam further to diagnosis & further management
 Eg:- Diagnosis studies as per H/ P
Imaging Procedures- X-ray, CT, MRI
Nuclear Studies-Bone Scan
Endoscopic Studies-Arthroscopy
Other Studies-Arthrocentesis, Electromyography, Biopsy
 Prevent complications due to late detection
 construct a clear management plan
From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W.B.
Saunders.

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50. Q/A Session