Physical assessment of Musculoskeletal system

1. MUSCULOSKELETAL
SYSTEM
PHYSICAL EXAMINATION

2. General principles of joint
examination
 Ensure that the joints to be examined are fully exposed
and the patient is resting comfortably.
 Provide privacy
 Be sensitive to patients feeling and physical comfort

3. Objectives
 Apply knowledge of anatomy and physiology of
musculoskeletal system
 Differentiate between normal and abnormal
 Implement physical assessment

4. When to conduct Assessment
 Bone or muscle injury
 Medications to treat bone or muscle problem
 Past surgeries for muscle or bones
 Family history of bones or muscle disorders
 Pain
 Symptoms limiting your daily activities
 Frequent falling

5. Common musculoskeletal disorders
 Tendinitis
 Carpal tunnel syndrome
 Osteoarthritis
 Rhematoid arthritis
 Fibromalagia
 Bone fractures

6. Assessment of musculoskeletal
system
 Subjective Data
• History collection
 Objective Data
• Physical examination

7. Neurovascular Assessment

Assess for Note and report
• Color Pallor ,cyanosis, redness, or discoloration
• Temperature Unusual coolness or warmth
• Pain Pain that is worse on passive motion pain that no longer
responds to analgesics
• Movement Alteration in movement
• Sensation Alteration in feeling ,tingling or paresthesias
• Pulses Diminished or absent pulses
• Capillary
refill
Nailbed that does not blanch in 3 -5 seconds

8. The routine for joint examination is:
Inspection
Palpation
Movement of joint(s)

9. 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
 Ask client to point to any painful areas including sites or
radiation of pain

10. INSPECTION
 BEHAVIOUR
─ Mental Status
 GENERALAPPEARANCE
− Age,Sex
− Posture
− Nutritional Status
 SKIN
− Turgor
− Texture
− Intregrity

11. − Temperature
− Erythema over joints
− Swelling
− Subcutaneous nodule
− Synovial cyst
− Tenderness
− General Hygiene
 NAILAND HAIR
 SYMMETRY

12. Palpation
 Palpate for warmth swelling and tenderness in
the areas of swelling redness and the areas where the
patient reported pain
 Hand should be warm to prevent spasm
 Both superficial and deep palpation are performed
 Usually begins from neck shoulder elbow wrist hand
back hip knees ankles and feet

13. MOVEMENTS
 Active ROM
 Passive ROM

14. The neutral position
 The range of most movements
are described with the neutral
position in mind
 In the neutral position
the limbs are extended with
the feet dorsiflexed at 90 degrees
and the forearms in mid-pronation

15. Main anatomical movements
 Adduction -movement of the part
distal to the joint towards the midline
 Abduction -movement away
from the midline

16. Main anatomical movements
 Flexion - bending of joint
away from neutral position
 Extension - movement to straighten
a joint towards the neutral position
 Hyperextension - occurs when
the joint can be extended beyond
the neutral position

17. Main anatomical movements
 Pronation - rotation of the
forearm so that the palm
faces backwards
 Supination - rotation of the
forearm so that the palm
faces forwards

18. Main anatomical movements
CIRCUMDUCTION

19. Main anatomical movements
 DORSIFLEXION
 PLANTAR FLEXION

20. Main anatomical movements
 Eversion
 Inversion

21. Main anatomical movements

22. Assessment -Gait:

23. GAIT
From behind:

24. GAIT
From side:

25. Examination of the spine
 Ask patient to undressndown to their underwear
 Inspect from the front,sides and behind ideally with patient sitting
and standing for:
• Pigmentations, abnormal hair growth or unusual skin creases
• Alignment of the neck and shoulder symmetry
• Kyphosis (thoracic spine curves giving a round shouldered or
hunched appearance)
• Lordosis (lumber spine curves pushing abdomen out, seen in
late stages of pregnancy)
• Scoliosis (thoracic and or lumbar spine curve laterally forming
a S or C shaped)

26. Inspection of spine
 Adams forward bend test :

27. Assessment of temporomandibular joint
 Inspection
 Palpation
 Muscle strength

28. Neck
 Palpation
 ROM
→Flexion
→Extension
→Lateral bending
 Muscle strength

29. Shoulder
 Inspect anteriorly: shoulder and
shoulder girdle
Posteriorly : scapula and muscles
 Inspect the shoulder contour
 Feel for tenderness and swelling,
redness and crepitus during motion
 Flexion -180 degrees
 Extension -approx. 65 degrees

30. Shoulder
Palpation:
 Clavicle
Tenderness of sternoclavicular joint , acromioclavicular joint greater tubercle
of humerus
 Glenohumeral joint (ball and socket joint)
 Scapula
 Acromioclavicular joint
 Glenohumeral joint
 sternoclavicular joint
 Scapulothoracic joint

31. Shoulder Movement
*Flexion * Abduction
*Extension * Adduction
*Internal rotation * External rotation

32. Shoulder movements
 Adduction -movement of the
distal part of the joint towards
the midline
 Abduction –movement
away from the midline

33. Shoulder movements
 Internal rotation -involves
moving the flexed forearm
across the front of the body.
The movement is limited by the
chest wall
 External rotation - the flexed
forearm is moved outwards

34. Elbow
 Inspection :
 Olecranon process for any tenderness or swelling
 Displacemnt of olecranon process
 ROM:
 Flexion
 Extension
 Pronation
 Supination
 Muscle strenghth

35. Wrist and hands
Inspection
 No redness or swelling
 No wrinkles
Palpation
 Palpate metacarpophalangeal joints
 Palpate interphallangeal joints

36. Interphalangeal joints
 Palpate the interphalangeal
joints individually between
finger and thumb
 DIP = distal interphalangeal
joint
 PIP = proximal
interphalangeal joint

37. Metacarpo-phalangeal joints
 Use a similar technique
to palpate metacarpo-phalangeal
joints
 With patient palms facing
down, support palms with fingers
 place thumbs on dorsal
metacarpo-phalangeal surface
and gently palpate

38. Finger movements
 Ask the patient to make a fist
(flexion of distal and proximal
interphalangeal and metocarpophalangeal joints)
 Then ask the patient to open their hand
(extension of interphalangeal and
metocarpophalangeal joints)
 Abduction, ask the patient to spread
their fingers apart.
 Adduction: ask them to put them back together.

39. Thumb flexion and extension
 Movement of flexion occurs
across the palm
 Extension takes the thumb
away from the lateral aspect
of the palm
 Occurs at the MCP joint
(Metacarpo-phalangeal joint)

40. Thumb abduction and adduction
 Abduction occurs at 90° to the palm
 Adduction returns the thumb
to the palm
 Occurs at CMC jointcarpo-metacarpal
joint

41. Thumb opposition
 The thumb is used to
touch the base of the little
finger
 This movement is important
for fine manipulative skills

42.  PHALEN’S TEST
Phalen's Test is also known a Wrist
Flexion Test and is an
orthopedic special test used to help
diagnose injury to the median nerve
in the wrist especially as it relates to
the carpal tunnel
 TINELS SIGN
A way to detect irritated nerves.
It is performed by lightly tapping
(percussing) over the nerve
to elicit a sensation of tingling
or "pins and needles" in the
distribution of the nerve

43. Movements of the spine
 Flexion
 Extension
 Lateral Flexion right and left
 Lateral Rotation right and left

44. Cervical spine movements

45. Cervical spine movements
 Lateral flexion - ask the patient
to touch their ears to their shoulders,
without raising the shoulders.
Normal approx. 45 degrees

46. Cervical spine movements
 Flexion -ask the patient to touch
their chin to their chest –normal
about 45 degrees
 Extension -ask the patient
to look upwards and back -normal
about 45 degrees

47. Cervical spine movements
 Rotation - ask the patient
to look back over each shoulder
in turn - normal approx. 70 degrees

48. Hip
 Inspection:
 Scars
 Asymmetry
 Pelvic tilt
 Leg length discrepancy
 Foot deformity
 Palpation

49. Movement of the Hip Joint
*Flexion * Abduction
*Extension *Adduction
*Internal and external rotation

50. Hip movements -flexion and extension
 Flexion-with the patient
lying supine and the knee flexed
passively flex the hip joint -normal
approx. 115 degrees
 Extension-with the patient
lying prone, support the knee and
with a hand on the buttock passively
extend the joint (normal approx. 30 degrees)

51. Hip movements -abduction and
adduction
 Abduction -normal approx. 45 degrees
 Adduction -judged by carrying
limb immediately in front of
other -normal approx. 30 degrees

52.  The person flexes the knee and hip
 The knee is held in one hand
and the foot in the other
 External rotation is achieved
by passively moving the foot
medially (normal approx. 45 degrees)
 Internal rotation is tested
by moving the foot laterally
(normal approx. 45 degrees
Hip movements -rotation

53. Thomas test
 Used to rule out hip
flexion contracture.

54. Inspection and palpation of the knee
 Inspect, comparing knees with patient supine
 Swellings may be detected by a loss of the medial and or lateral
dimples suggestive of an effusion
 Palpate for:
 presence / absence of patella and its mobility
 collateral ligaments
 the joint line for tenderness

55. Movements of knee
 Flexion
 Extension
 Hyperextension
 Lateral and medial collateral ligaments
 Anterior and posterior cruciate ligaments

56. Knee movements
 Flexion:The knee is flexed
with one hand resting on
the patella -normal
approx. 135 degrees
 Extension:The leg is
straightened to its fullest
extent -normal 5 degrees of
hyperextension

57. Movement of the ankle and foot
 Ankle
• Dorsiflexion
• flexion
• Inversion
• Eversion
 Toes
• Extension
• Flexion
• Abduction and adduction

58. Dorsiflexion and plantar flexion
 Ask the person to bend
their foot down into plantar
flexion -normal approx. 50 degrees
 Ask the person to bend
the foot upwards into
dorsiflexion –normal
approx. 20 degrees

59. Eversion and Inversion
 Isolate the heel by holding
it firmly
 Attempt inversion and
eversion by twisting the
mid-foot medially and laterally.

60. 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)

61. Common assessment abnormality
FINDINGS DESCRIPTION
• Ankylosis Abnormal stiffening and immobility of a joint
due to fusion of the bones
• Atrophy Gradually decline in effectiveness or vigour
due to underuse or neglect
• Contracture A condition of shortening and hardening of
muscles, tendons, or other tissue, often
leading to deformity and rigidity of joints.
• Pen planus Technical term for flatfoot.
• Crepitation A crackling sound or grating sensation as a
result of friction between bones

62. Common assessment abnormality
FINDINGS DESCRIPTION
• Effusion Escape of fluid into body part possibly with
swelling and pain
• Hypertrophy The enlargement of an organ or tissue from
the increase in size of its cells
• Kyphosis Excessive outward curvature of the spine,
causing hunching of the back.
• Lordosis Excessive inward curvature of the spine
• Scoliosis Abnormal lateral curvature of the spine.

63. Common assessment abnormality
FINDINGS DESCRIPTION
• Archiles
tendon
Achilles tendinitis is a common condition that causes
pain along the back of the leg near the heel.
• Dislocation Bone is displaced from its normal joint
• Ganglion
cyst
Fluid filled bump or mass over over a tendon sheath or
joint usually on dorsal surface of foot or wrist
• Lateral
epidondylytis
(tennis elbow)
Dull ache along outer aspect of elbow .Worsens with
twisting and grasping motions
• Myalgia General muscle tenderness and pain

64. Common assessment abnormality
FINDINGS DESCRIPTION
• Paresthesia Numbness or tingling sensation
• Plantar
fascitis
Burning sharp pain on the sole of foot
• Subluxation Partial dislocation of joint
• torticollis Neck is twisted in unusual position to one
side
• Valgum
deformity
(knock- knees)
When knees are together and there is more
than 1 inch (2.5cm)b/w medial malleoli
• Varum
deformity
(Bowlegs)
When knees are apart and the medial
malleoli are together space of more than
one inch (2.5cm)exists

65. Diagnostic Test
 Radiography(X-Ray)

66. ARTHROSCOPY

67. Athrocentesis

68. Arthrogram

69. MRI
 MRI scans are excellent for showing
up soft tissue such as ligaments and
tendons in joints. This is an MRI scan of
a knee

70. Electromyography(EMG)

71. Bone Sonometer

72. Bone scan

73. CT
 CT scan of sternoclavicular joints shows a needle in the right
sternoclavicularjoint while taking sample

74. Thank You