NURSING MOSCULOSKELETAS SYSTEM

PHYSICAL ASSESSMENT ON MUSCULOSCELETAL SYSTEM

LECTURER:

Ns. Dally Rahman, S.Kep, M.kep

MEMBERS OF GROUP I
Muhammad Ilham Zul (1511314001)
Suci Raesman (1511314021)
Siti Sarah Nurfalah (1511314011)
Hafsari Wulandari (1511314024)
Elfadhela Miranda (1511314010)

NURSING FACULTY
ANDALAS UNIVERSITY
PADANG
2017/2018
 CHAPTER I

INTRODUCTION

A. BACKGROUND

In examining the musculoskeletal system it is important to keep the concept of function in mind.
Note any gross abnormalities of mechanical function beginning with the initial introduction to
the patient. Continue to observe for such problems throughout the interview and the examination.

On a screening examination of a patient who has no musculoskeletal complaints and in whom no

gross abnormalities have been noted in the interview and general physical examination, it is
adequate to inspect the extremities and trunk for observable abnormalities and to ask the patient
to perform a complete active range of motion with each joint or set of joints.

If the patient presents complaints in the musculoskeletal system or if any abnormality has been
observed, it is important to do a thorough musculoskeletal examination, not only to delineate the
extent of gross abnormalities but also to look closely for subtle anomalies.

To perform an examination of the muscles, bones, and joints, use the classic techniques of
inspection, palpation, and manipulation. Start by dividing the musculoskeletal system into
functional parts. With practice the examiner will establish an order of approach, but for the
beginner it is perhaps better to begin distally with the upper extremity, working proximally
through the shoulder. Then, beginning with the temporomandibular joint, pass on to the cervical
spine, the thoracic spine, the lumbar and sacral spine, and the sacroiliac joints. Finally, in the
lower extremity, again begin distally with the foot and proceed proximally through the hip.

B. FORMULA

1.1 What is Physical Assessment on Musculoskletal System ?

1.2 What the step ?

 CHAPTER II

“Physical Assessment on Musculosceletal System”

2.1. Perform a Functional Assessment for Safety.

Musculoskeletal assessment varies a great deal according to the setting where it is

performed and the ability of the patient to participate. For example, a nurse who is assessing
an older patient who lives in her own home may be most interested in finding out if the
patient has the strength, balance, and joint range of motion she needs to carry out her daily
activities safely. In this setting, the nurse might conduct a functional assessment by
observing as the patient rises from a chair or from bed, navigates stairs, and picks up an
object from the floor. The nurse assesses the patient’s musculoskeletal function with an eye
on safety. For a hospitalized patient, however, the exam will differ and will vary from
patient to patient. For example, the nurse caring for a patient who has had a stroke may
focus the assessment on muscle strength, while an orthopedic patient requires careful
assessment of joint range of motion. The skills presented in this module will prepare you to
do a general musculoskeletal assessment that you can then tailor to meet the specific needs
of each of your patients.

2.2. Inspect Posture, Movement, and General Body Symmetry.

Like most assessments, begin the musculoskeletal exam with inspection. If the patient is
ambulatory, you will gather important information by just watching him move about the
room. Does he use any aids to ambulate, such as a cane or walker? If he does use a cane,
note which hand he holds it in, because you will want to assess his muscle strength in that
hand and arm. Notice the patient’s gait and balance, which you will assess formally later in
the exam. If the patient is seated or in bed, your assessment may be more limited, but you
can still learn a lot by simply observing. Does the patient propel his own wheelchair? Does
he do this with his arms, his feet, or both? Is he positioned correctly in the wheelchair,
sitting upright with his lower back against the seat back, or is he slumped down with his
buttocks sliding forward across the seat? Can he reposition himself in the wheelchair?
Similarly, if the patient is lying in bed, is he positioned correctly and does he appear
comfortable? Can he reposition himself in bed, that is, turn from side to side, sit up to dangle
his legs over the side of the bed, and maintain balance?
2.3. Inspect and Palpate the Spine for Contour and Tenderness

Part of musculoskeletal assessment is checking the configuration and range of motion of

the patient’s spine. This is easiest to do if your patient can stand, but it is possible to do a
limited spine assessment of a patient who is in a chair or bed. Inspect the spine from a lateral
view, looking for the normal curvatures. The cervical area should be concave, the thoracic
area slightly convex, the lumbar area concave, and the sacral area assuming a convex
contour. This configuration is commonly called a double S curve and is normal, as long as
none of the curves is excessive. Pronounced convexity of the thoracic spine is common in
older patients, especially those who have osteoporosis and have had vertebral fractures. This
condition, called kyphosis, can restrict lung expansion. Less common is an excessive
concavity of the lumbar spine, which is called lordosis. Examine the spine from a posterior
view, looking for signs of scoliosis, or lateral curvature of the spine. You may have to
palpate the vertebral column to delineate its borders clearly, especially if the patient has a
fleshy back. Mild scoliosis is usually of little consequence, but more severe curvature can
restrict lung function. A useful clue for detecting scoliosis is finding asymmetric folds in the
soft tissue of the back. Also, if the patient is able to bend forward, abnormal lateral-spine
curvature is easier to see, as the hips and shoulders may not be level. Spine screening is
important for children and adolescents to expedite intervention before growth is completed,
but it is also important for older patients who are at risk for osteoporosis and vertebral-
compression fractures. Be sure to palpate along the spine for any areas of tenderness.

2.4. Inspect the Limbs for Skin Changes and Symmetry

Next, turn your attention to the patient’s extremities, which you can assess using
simultaneous inspection and palpation. Begin with his arms, which should be bared to the
shoulders. Throughout the assessment, inspect your patient’s skin, noting color, hydration,
scars, lesions, rashes, bruises, and intravenous-access sites in his arms. Beginning with his
shoulders and with one hand on each of his shoulders, palpate as you inspect his extremities
bilaterally, comparing side to side. From his shoulders, move your hands down to palpate his
upper arms, then elbows, forearms, and finally his hands and fingers. Palpate the joints
carefully for symmetry, and palpate all muscle groups for size, symmetry, and tone. The
joints and muscle groups of the extremities should be symmetric bilaterally. Muscle mass
should be firm and smooth. Hypotonic or lax muscle tone is called flaccidity, while
increased or hypertonic muscle tone is spasticity. You may encounter muscle atrophy as
well, usually related to aging or disuse or both.

2.5. Palpate the Limbs for Muscle Stength, Joint Range of Motion, and Crepitus.
 Assess muscle strength systematically. A five-point scale is traditionally used, in which
5+ muscle strength is normal. On this scale, the ability to move a limb against gravity but
not against resistance is considered 3+ muscle strength, while the ability to generate a visible
muscle contraction but no limb movement is 1+. Paralysis, then, would be a muscle strength
of zero. Test your patient’s muscle strength by asking him to flex and then to extend first his
shoulder, then his elbow, and finally his wrist while you provide resistance. Assess muscle
strength in the hand by testing grip strength; just ask the patient to squeeze your fingers. To
avoid discomfort, you might ask the patient to give your fingers a “little squeeze” and then
have him increase pressure gradually until he demonstrates normal grip strength. You can
carry out all these tests of muscle strength easily while your patient is sitting or lying in bed.

Now, assess your patient’s joint range of motion by asking him to move each joint –
shoulder, elbow, wrist, thumb, and fingers – through range of motion. You may choose to
palpate each joint with both of your hands as the patient moves, feeling for crepitus, which is
clicking or crunching within the joint. Be aware, though, that many people have joint
crepitus, especially in the knees, without pain or limitation in function. Nurses rarely
perform formal range-of-motion testing during which joint motion is measured in degrees,
but you should assess general range of motion. Check shoulder motion by asking the patient
to reach over his head, to touch his opposite shoulder, and to reach behind his back, both
over his shoulder and under. Elbow motion is limited to flexion and extension and is easy to
assess. Check wrists, likewise, for flexion and extension, but also check for full supination
and pronation of the forearms. Finally, ask the patient to clench and unclench his hands to
check range of motion of his fingers and thumb. Be sure to ask about any pain or discomfort
with joint movement and document any limitations in range of motion.

Next, carry out the same sequence of inspection and palpation of the lower extremities.
Inspect and palpate the skin, joints, and muscle groups from the hips, thighs, and knees to
the calves, ankles, and feet. Check joints for symmetry and muscle groups for symmetry,
mass, and tone. You can test lower-extremity muscle strength easily in a patient who is
either seated or lying in bed. Ask him to flex and then extend each hip against resistance you
provide with your hand against his thigh; repeat with knee flexion and extension and finally
ankle dorsiflexion and plantar flexion. Your ability to test hip range of motion is limited in a
bed-bound or chair-bound patient, but you can check knee and ankle range of motion.
Again, ask about discomfort with movement.

2.6. Perform a Peripheral Vascular Assesssment

Although testing peripheral vascular status isn’t really part of the musculoskeletal exam,
it is convenient to include this assessment as you examine the extremities. For the upper
 extremities, check the radial pulses bilaterally and simultaneously, noting rate, rhythm, and
amplitude. Remember, pulses are graded from 0 to 4+, with 2+ reflecting normal pulse
amplitude. If the radial pulses are normal, there is usually no need to check the brachial
pulse.

In the lower extremities, the most common pulse tested is the dorsalis pedis pulse, found
on the dorsum of the foot between the extensor tendons to the great toe and the toe next to it.
You might need a Doppler to find this pulse. If you can’t palpate the dorsalis pedis pulse,
move proximally and check the posterior tibial pulse, which lies posterior to the medial
malleolus of the ankle, that is, on the tibial side of the ankle. Besides checking these pulses,
evaluate peripheral blood flow by evaluating the skin. Warm hands and feet are signs of
adequate blood flow, as is the ability of the skin to bear hair. Thin, shiny, hairless skin,
especially of the lower legs, is a common sign of peripheral vascular disease. Finally, edema
of the feet and ankles is often seen in patients who have peripheral venous insufficiency.

2.7. Assess Gait.

If your patient can ambulate, assess his gait and balance. A normal gait is actually a
complex action, but you can easily assess all the components of gait. Clear a space in the
room that allows the patient to take five or six steps, and then ask him to walk that distance,
using his normal gait. Watch for smoothness of the gait and for specific gait components.
First, the heel should strike the floor, then the foot should come down flat against the floor,
then the patient should push off with the ball of his foot, and finally the foot should swing
through an arc before the next heel strike. The toes should point forward, and the foot should
swing straight forward between steps. The base of the gait, which is the distance between the
right and left feet, should not exceed 2 to 4 inches. Watch also for arm swing; the arms
should swing in opposition to the legs. Gait abnormalities to watch for include small, halting
steps, an uneven gait due to favoring of one side, a wide-based gait, and foot drop, which
causes the patient to lift that foot abnormally high during swing-through. If you think a gait
looks abnormal, try to break down the components to pinpoint the abnormality. Gait
assessment does take a bit of practice, but a trip to a mall or airport provides a wealth of
gait-assessment opportunities.

Gait assessment usually includes asking the patient to demonstrate four different gaits.
After assessing his normal gait, ask the patient to walk the same distance, using tandem
walking, which is also called heel-to-toe walking. Used also as a field sobriety test, tandem
walking adds a balance requirement to gait testing. Next, ask the patient to walk several
steps on tiptoe, which assesses foot strength and coordination, and then to walk on his heels,
which is another test of coordination.
 Balance testing is part of both the musculoskeletal and the neurologic exams. The most
common test of balance is the Romberg test. Ask the patient to stand about 2 feet in front of
you, with his feet together, toes pointed forward, and his hands at his sides. While you
extend your hands so that one is on either side of the patient, ask him to close his eyes.
Watch to see how well he can maintain balance in that position. A minimum of swaying is
normal, but if the patient sways more than a couple of inches, stop the test and document
that the patient demonstrated difficulty maintaining balance on Romberg testing.

Actually conduct few musculoskeletal exams that are as detailed as the one described in
this module. But, if you master the assessment skills included here, you will be well
prepared to complete this important assessment for patients in a variety of practice settings.

2.8. Musculoskeletal Examination

Examination of the musculoskeletal (MS) system can be one of the most complex
aspects of the general physical exam. The extent of the examination must vary according to
the problem(s) being assessed and the time available to perform the exam. Levels of
complexity of the exam can be expressed as follows:

1. Screening exam of MS system: performed on nearly all patients; detects abnormalities of

function not always apparent on history and may provide diagnostic clues to clinical
questions.
2. Detailed examination of symptomatic region of the musculoskeletal system (e.g., the
patient complaining of knee pain).
3. Examination of the patient with established systematic disorder affecting the
musculoskeletal system (e.g., rheumatoid arthritis) under treatment.
4. Examination of the new patient with diffuse musculoskeletal complaints.

The “screening” exam can concentrate on inspection and observation of function.

Pathology involving the joints very rarely produces symptoms without effect on function.
Thus, except in a detailed exam, palpation can be dispensed with if function is normal.

Prior to specific examination of the musculoskeletal regions, the patient’s general

appearance, bodily proportions and ease of movement should be noted.

 Required Equipment:
No additional equipment is required

 Optional Equipment
1. Gonimeter (to measure angles)
2. Stethoscope (to auscultate temporomandibular joint (TMJ))
 3. Non-elastic tape measure

 Examination Techniques:
1. Inspection – Visual examination, range of motion of joints (active and passive)
2. Palpation – Joint muscle examination, use finger tips and thumbs
3. Percussion – Use ulnar surface of fist for spine examination
4. Motor Examination – Neuromuscular testing for strength, sensation and
reflexes. (will be covered in neurology section of course)
5. Auscultation – Use stethoscope on TMJ and audible tendinous rubs
Special maneuvers – Techniques used to elicit otherwise occult finding

The following outline is one detailed approach for a fairly extensive

musculoskeletal examination: Patient in gown seated on examination table.
Examiner stands facing patient.

A. Hands
1. Inspect hands
Note: Swelling, Redness, Nodules, Ability to make fist, Deformity, Muscular atrophy,
Joint symmetry.
2. Assess range of motion (active range of motion, done by the patient)
a. Instruct patient to flex and extend fingers of both hands; patient should attempt
to touch tips of fingers to palmar crease at level of metacarpophalangeal joints.
b. Have patient make fist with thumbs across the knuckles
3. Palpate the following interphalangeal joints
-Distal
-Proximal
-Metacarpophalangeal
Note: Swelling, bogginess (soft, water logged or swollen deeper tissues that hinder
function), tenderness, bony enlargement

B. Wrists
1. Inspect wrists
Note: Swelling, Redness, Nodules, Ability to make fist, Deformity, Muscular atrophy,
Joint symmetry.
2. Assess active range of motion (done by patient)
With arms extended palms turned down, instruct patient to:

a. Flex wrist to 90o downward

b. Extend wrist to 90o upward
 With arms in neutral position (handshake position), instruct patient to:

1. Supinate wrist to 90o

2. Pronate wrist to 90o
Note: Supination and pronation are motions that originate from the elbow but
are demonstrated at the wrists.

3. Place thumb on dorsum of patient’s wrist with fingers beneath it. Palpate the
following joints:
-Metacarpocarpal
-Carporadial
-Carpoulnar
Note: Swelling,Synovial Bogginess,Tenderness
.

C. Elbows.
1. Assess active range of motion
a. Instruct patient to extend and flex elbow
b. With arms extended, have patient supinate and pronate each hand
2. With patient’s forearm supported and elbow flexed to about 70o palpate the
following: - Extensor surface of ulna
- Olecranon process
- Groove on either side of olecranon process. Remember, the ulnar nerve runs
through the medial groove.
Note: Swelling,Synovial Bogginess,Tenderness.

D. Shoulders and Environs

1. Inspect shoulders and shoulder girdle anteriorly

Note: Swelling,Joint symmetry,Deformity,Muscular atrophy

2. Inspect scapula and related muscles posteriorly

3. Assess active range of motion

- Screen for shoulder abnormalities by having patient clasp hands behind head and
extend arms so that elbows are “up against the wall” parallel to coronal plane.
- With arms at sides, abduct arm to 90o (abduction)
- With scapular motion elevate arm to 180o (move arms to a vertical position
near head)
Note: Symmetry and rhythm of movement
 E. Head and Neck

1. Inspect Neck

Note: Deformities, Abnormal posture

2. Assess active range of motion for cervical spine (head and neck) Instruct patient
to:

a. Touch chin to chest (flex neck) – Normal is 45o of flexion.

b. Touch chin to each shoulder (rotate neck) – Normal is 70o of rotation,
each side.
c. Touch ear to corresponding shoulder (lateral bending) – Normal is 40o
of lateral bending, each side.
d. Put head back (extend neck) – Normal is 45o of hyperextension of neck.

F. Feet
1. Inspect feet
Note: Swelling, Deformity, Nodules, Calluses,Corns,Flat feet
2. Have patient curl and extend toes, then “cup” the arch of the foot to screen for
abnormalities. This also assesses active range of motion. Note any deformity like claw
toe or hammer toe (see lecture slides).

H. Knees
1. Inspect knees
Note: Alignment – valgus (lateral malalignment of lower leg) or varus
(medial malalignment deformity)

G. Ankles
1. Inspect ankles

Note: Bogginess,Swelling,Nodules

2. To screen for abnormalities, have patient flex, extend, invert and evert the foot (active
range of motion).
3. Palpate anterior surface of ankle joint
Note: Bogginess, Swelling
I. Hips
1. Assess passive range of motion

a. Rotate each extended leg externally and internally and then return to original position.
Repeat maneuver with each knee and hip partially flexed at knee. Should have about
45o of internal and external range of motion.

b. Check for full extension of hip (0o) and active flexion (~110o) as well as
passive flexion (~130o).
c. Thomas test (to detect occult hip flexion contracture): Have patient flex right
knee and pull firmly against abdomen. This flattens the normal lumbar lordosis.
Note: Degree of flexion of left hip

J. Spine.

1. Inspect spinal profile

Note: Cervical lordosis, Dorsal kyphosis, Lumbar lordosis, Skin creases below
buttocks

2. Inspect patient’s gait

Note:Smoothness, Uninterrupted motion, Antalgic gait related to pain

3. Inspect dorsolumbar spine

Note: Symmetry of movement as patient flexes and extends Smooth curve of spine
Range of motion (how far can patient bend); Normal is about 90 o Compare
convexity of lumbar curve

K. Special Maneuvers
1. Perform the following maneuvers on patients suspected of having sacroiliac
disease, herniated nucleus pulposus (disc), hip abnormality, or neurologic disease which
may involve the legs.
a. Trendelenburg sign (to detect gluteal weakness)

- Assess both hips

- Having patient stand on one leg and note if opposite hip remains parallel or
slightly elevated (normal or negative). A positive Trendelenberg sign occurs when
the opposite hip falls below the parallel plane. This indicates weak intrinsic
muscles of the hip opposite to the fallen one.
b. Straight leg raising test (to detect hip or sciatic disease)
- With patient supine, raise patient’s leg up to 70o from examination table, then
sharply dorsiflex the forefoot; this indicates a positive test if there is pain
radiating down the posterior leg to at least the popliteal fossa. Raising the leg
beyond 70o is not necessary.

- Increased pain down the affected leg when the opposite (contralateral) leg
is raised is a positive crossed straight leg raising sign.
 CHAPTER III

Examination of the musculoskeletal (MS) system can be one of the most complex
aspects of the general physical exam. The extent of the examination must vary according to the
problem(s) being assessed and the time available to perform the exam. Levels of complexity of
the exam can be expressed as follows:

1. Screening exam of MS system: performed on nearly all patients; detects abnormalities of

function not always apparent on history and may provide diagnostic clues to clinical
questions.

2. Detailed examination of symptomatic region of the musculoskeletal system (e.g., the

patient complaining of knee pain).

3. Examination of the patient with established systematic disorder affecting the

musculoskeletal system (e.g., rheumatoid arthritis) under treatment.

4. Examination of the new patient with diffuse musculoskeletal complaints.

 REFERENCESS

EDUCATION, N. (n.d.). Physical Examination of Musculoskeletal system. 2011, 1–12.

Goldberg, C. (2010). Musculoskeletal Examination: General Principles and Detailed Evaluation
Of the Knee & Shoulder. Musculoskeletal Examination: General Principles and Detailed
Evaluation Of the Knee & Shoulder.
http://fhs.mcmaster.ca/surgery/documents/clinical_test.pdf