o Contains fat and connective tissue

NCM 120: Health Assessment

MUSCLES
THE MUSCULOSKELETAL SYSTEM
The body consists of three types of muscles:
skeletal, smooth and cardiac.
STRUCTURE AND FUNCTION
The musculoskeletal system is made up of 650
The body’s bones, muscles and joints skeletal (voluntary) muscles, which are under
compose the musculoskeletal system conscious control.
Controlled and innervated by the nervous
system, the musculoskeletal system’s overall SKELETAL MUSCLE MOVEMENTS
purpose is to provide structure and Abduction – Moving away from midline of the
movement for body parts. body
Adduction – Moving toward midline of the
FUNCTIONS OF THE SKELETAL SYSTEM body
Circumduction – Circular motion
SUPPORT- Hard framework that supports and Inversion – Moving inward
anchors the soft organs of the body. Eversion – Moving outward
PROTECTION - Surrounds organs such as the Extension – Straightening the extremity at the
brain and spinal cord. joint and increasing the angle of the joint.
MOVEMENT - Allows for muscle attachment Flexion - Bending the extremity at the joint
therefore the bones are used as levers. and decreasing the angle of the joint
STORAGE - Minerals and lipids are stored Pronation – Turning or facing downward
within bone material. Supination – Turning or facing upward
BLOOD CELL FORMATION - The bone Protraction – Moving forward
marrow is responsible for blood cell Retraction – Moving backward
production. Rotation – Turning of a bone on its own long
axis
BONES Internal Rotation – Turning of a bone towards
Total of 206 bones (in adult) the center of the body.
Made up of axial skeleton (head and trunk) External Rotation – Turning of a bone away
and the appendicular skeleton (extremities, from the center of the body.
shoulder and hips).
Serves as storage site for minerals and JOINTS
contains bone marrow. The joint (or articulation) is the place where
two or more bones meet
CLASSIFICATION OF BONES Normally, bones fit together
Joints provide a variety of ranges of motion
(ROM) for the body parts and may be classifies
as fibrous, cartilaginous, or synovial
Fibrous joints- generally don’t move
Cartilaginous joints – Allow some movement
Synovial joints – Freely moveable
The 206 bones are connected by 360 joints
which compose of the fibrous, cartilaginous, or
synovial.

SYNOVIAL JOINTS
Found at all limb articulations
Surface covered with cartilage
Joint cavity covered with fibrous capsule
Cavity lined with synovial membrane and filled
with synovial fluid.

CLASSIFICATION OF JOINTS
Synarthrosis – Immovable (e.g. skull)
Amphiarthrosis – Slightly movable 9 e.g.
vertebral joints)
BONE MARROW Diarthrosis or Synovial – Freely movable
(e.g. shoulders, hips)
Red Bone Marrow
o Found in flat bones of sternum, ribs and
ileum
o Produces blood cells and hemoglobin
Yellow Bone Marrow
o Found in shaft of long bones
JOINTS OF THE BODY CONNECTORS OF THE BODY
Ball and Socket Joint - Round end of bone
fitting snuggly within another bone, Rotate in CARTILAGE
their sockets (shoulder and hip). It acts as a cushion between bones at a joint
and protects the bones.
A smooth, fibrous tissue-cushions the end of
each bone and synovial fluid fills the joint
space.
This fluid lubricates the joint and eases
movement, much as the brake fluid functions
in a car.

LIGAMENTS
Bands of connective tissue that connect bone
to bone
Either limit or enhance movement
Provide joint stability
Pivot Joint - Bone resting on top another Enhance joint strength
bone permitting free movement (neck, wrist
and ankles).
TENDONS
Attaches muscles to bones
Fibrous connective tissue bands that connect
bone to muscles
Enable bones to move when muscles contract

PROBLEMS OF THE SKELETAL SYSTEM

Fracture – Break

Dislocation – Out of joint

Hinge Joint - Movement at joint in one

direction like a door. Move in flexion and
extension (knee and elbow).
Sprain – Swelling in the joint ASSESSMENT OF THE MUSCULOSKELETAL
SYSTEM

HEALTH HISTORY-TAKING
General health history
o Present health status
o Past health status
o Family history
o Personal and psychological history

PROBLEM-BASED HISTORY
Common Related Problem
o Pain
o Problems with movement
o Problems with daily activities

INSPECT AND PALPATE JOINT

Arthritis – Inflamed and stiff

ASSESS RANGE OF MOTION

ASSESS MUSCLE STRENGTH

GENERAL CONSIDERATIONS
1. The patient should be undressed and gowned
as needed for this examination.
2. Some portions of the examination may not be
appropriate depending on the clinical situation
Scoliosis – Curvature of the spine 3. When taking a history for an acute problem,
always inquire about the mechanism of injury,
loss of function, onset of swelling (<24 hours)
and initial treatment.
4. When taking a history for a chronic problem,
always inquire about past injuries, past
treatments, effects on function and current
symptoms.
5. Always begin with inspections, palpation and
range of motion, regardless of the region you
are examining.
6. A complete evaluation will include a focused
neurological exam of the affected area.

REGIONAL CONSIDERATIONS
1. Remember that the clavicle is part of the
shoulder. Be sure to include in you
Osteoporosis – Brittle bones examination
2. The patella is much easier to examine if the
leg is extended and relaxed
3. Be sure to palpate over the spinous process of
each vertebrae
4. It is always helpful to observe the patient
standing and walking
5. Always consider referred pain
6. Pain with, or limitation of, rotation is often the
first sign of hip disease
5P’S OF MUSCULOSKELETAL INJUIRY 4/4 Good - Patient completes ROM against
gravity with moderate resistance.
Pain 3/5 Fair - Patient completes ROM against
Paresthesia – Sensation of pricking, tingling or gravity only.
creeping on the skin that has no objective 2/5 Poor - Patient completes full ROM with
cause. gravity eliminated (passive motion).
Paralysis – Body movement 1/5 Trace - Patient’s attempt at muscle
Pallor – Paleness or discoloration which can contraction is palpable but without joint
indicate neurovascular problems movement.
Pulse 0/5 Zero - No evidence of muscle contraction

ASSESSMENT TECHNIQUES EQUIPMENT

Inspect skeleton and extremities Tape measure
Inspect muscles Goniometer(optional)
Palpate bones and joints Skin marking pen(optional)
Observe range of motion of each joint and
adjacent muscles MEASURING RANGE OF MOTION
Test muscle strength and compare sides If any limitation or increase in ROM is noted,
use a goniometer to measure the angles
ASSESSING THE MUSCLES precisely.
Inspect all major muscle groups
ASSESSMENT TECHNIQUES
Check for symmetry. If a muscle appears
atrophied or hypertrophied, measure it by Taking limb measurement
wrapping a tape measure around the large
circumference of the muscle on each side of 1. Length (measuring the distance from the bony
points).
the body and compare the two gathered sizes.
2. Circumference
Note contracture and abnormal movements
such as spasm, tics, tremors and fasciculation. INSPECTION
Look for scars, rashes or other lesions
MUSCLE TONE Look for asymmetry, deformity or atrophy
Describe muscular resistance to passive Always compare with the other side
stretching
To test the patient’s arm muscle tone, move PALPATION
his shoulder through passive ROM exercises. Examine each major joint and muscle group
You should feel a slight resistance. Then let in turn
his arm drop, it should fall easily to his slide Identify any areas of tenderness
Test leg muscle tone by putting the patient’s Identify any areas of deformity
hip through passive ROM exercise and then Always compare with the other side
letting the leg fall to the examination table or
bed. Abnormal findings include muscle rigidity RANGE OF MOTION
and flaccidity. • Start by asking the patient to move through an
active range of motion.
MUSCLE STRENGTH • Proceed to passive range of motion if active
range of motion is abnormal.
Compare the right side with the left side
Sternocleidomastoid – Client turns the head
to one side against the resistance of your
hand. Repeat with the other side.
Trapezius – Client shrugs the shoulders
against the resistance of your hands.
Observe the patient’s gait and movement to
form an idea of his general muscle strength.
Grade muscle strength on a scale of 0 to 5
Document the results as a fraction, with the
score as the numerator and maximum strength
as the denominator.

GRADING MUSCLE STRENGTH

5/5 Normal - Patient moves joint through full
range of motion (ROM) and against gravity
with full resistance.
ASSESSMENT TECHNIQUE GAIT ABNORMALITIES
1. POSTURE
2. GAIT
ABNORMAL
3. CEREBELLAR FUNCTION
1. Spastic Gait - A stiff, foot-dragging walk caused by
ABNORMAL FINDINGS a long muscle contraction on one side.
2. Scissors Gait - Legs flexed slightly at the hips and
knees like crouching, with the knees and thighs
ABNORMAL hitting or crossing in a scissors-like movement.
3. Propulsive Gait - A stooped, stiff posture with the
Parkinsonian gait - Tremor of the Hands, head and neck bent forward.
Even at Rest Persistent Tremors. Shuffling gait 4. Steppage Gait - Foot drop where the foot hangs
Unbalanced & in Small Steps Curved in a with the toes pointing down, causing the toes to
Characteristic Way. scrape the ground while walking, requiring
someone to lift the leg higher than normal when
walking.
5. Waddling Gait - Duck-like walk that may appear in
childhood or later.

ARM AND LEG ON ONE SIDE

Arm bent; hand spastic or floppy, often of little
Cerebellar Ataxia - Ataxic gait and position: use
Left cerebellar tumor. She walks on tiptoe or outside of foot on
affected side.
This side completely or almost normal
SPASTIC HEMIPARESIS GAIT
Then palpate the spinous processes of the
cervical vertebrae and the areas above each
clavicle (supraclavicular fossae) for
tenderness, swelling, or nodules.

SPINE
Assess spinal position and curvature and the
range of spinal movement
Then palpate the spinal processes and the
areas lateral to the spine.
Have the patient bend at the waist level
Palpate the spine with your fingertips. Then
repeat the palpation using the side of your
hand, lightly striking the lateral areas to the
spine. Note tenderness, swelling, spasm.
a. Sways to the right in standing position ASSESSING THE RANGE OF SPINAL
b. Steady on the right leg MOVEMENT
c. Unsteady on the left leg
d. Ataxic gait Ask the patient to straighten up
Use a measuring tape to measure the
distance from the nape waist of his neck to
his.
Ask the patient to bend forward at the waist
Ask the patient to bend forward at the waist.
Continue to hold the tape at the patient's neck,
letting it slip through your fingers slightly to
accommodate the increased distance as the
spine flexes.
The length of the spine from neck to waist SHOULDER EXTERNAL AND INTERNAL
usually increases by at least 2" (5 cm) when ROTATION
the patient bends forward.
Have the patient abduct his arm with his elbow
UNEQUAL LEG DISCREPANCY / bent
INEQUALITY Ask him to place his hand first behind his head
and then behind the small of his back.

ASSESSING SHOULDER AND ELBOW

RANGE OF MOTION

ELBOW PRONATION AND SUPINATION

Have the patient place the side of his hand on
a flat surface with the thumb on top.
Ask him to rotate his palm down for pronation
and upward for supination.

ABNORMAL FINDINGS

ABNORMAL
Redness, heat and swelling may be seen with
bursitis of the olecranon process due to
trauma or arthritis
SCOLIOSIS Firm, nontender, subcutaneous nodules may
Early onset scoliosis is flexible. It is apparent be palpated in rheumatoid arthritis or
with standing and disappears with forward rheumatic fever.
standing. Tenderness or pain over the epicondyles may
Adult onset scoliosis is fixed. The curvature be palpated in epicondylitis due to repetitive
shows both on standing and on bending movements of the forearm or wrists.
forward
KYPHOTIC CURVE HANDS AND FINGERS
LORDOTIC CURVE
Hands and fingers are symmetric, non-tender
and without nodules
TYPES OF SCOLIOSIS Fingers lie in straight line
Healthy No swelling or deformity
Thoracic Scoliosis Kinematics
Lumbar Scoliosis
Thoraco-Lumbar Scoliosis ASSESSING FINGER RANGE OF MOTION
Combined Scoliosis
EXTENSION AND FLEXION
KYPHOSIS Ask the patient to keep his wrist still and move
only his fingers-first up toward the ceiling and
Excessive backward curve
then down toward the floor
The healthy spine has natural curves When
Have the patient make a fist with his thumb
curves become excessive there can be
remaining straight
problems.
Normal hyperextension is 30 degrees, normal
flexion, 90 degrees
Ask the patient to touch his thumb to the little
finger of the same hand. He should be able to
Lumbar Lordosis - Exaggerated lumbar curve fold or flex his thumb across the palm of his
hand so that it touches or points toward the
base of his little finger.

ABDUCTION AND ADDUCTION

To test abduction, have the patient spread his
fingers.
To test adduction, have the patient draw the
fingers back together.
PHALEN’S MANEUVER SWAN NECK DEFORMITY
Have the patient put the backs of his hands
together and flex his wrists downward at a 90-
degree angle
Pain or numbness in his hand or fingers during
this maneuver indicates a positive Phalen’s
sign.
The more severe the carpal tunnel syndrome,
the more rapidly the symptoms develop.

BOUTONNIERE DEFORMITY (TENDON TEAR)

ABNORMAL
Swollen, stiff, tender finger joints are seen in
acute rheumatoid arthritis.
Atrophy of the thenar prominence may be
evident in carpal tunnel syndrome.

TESTING FOR CARPAL TUNNER SYNDROME GANGLION

TINEL’S SIGN
Lightly percuss the transverse carpal ligament
over the median nerve where the patient's
palm and wrist meet.
If this action produces numbness and tingling
shooting into the palm or the index finger,
middle finger and lateral half of the ring finger
the patient has Tinel's sign and may have
carpal tunnel syndrome.

LOW EXTREMITY RANGE OF MOTION

Hip flexion with knee straight

Hip flexion with knee flexed
Internal & External rotation
Abduction
Adduction

RANGE OF MOTION OF THE KNEE

OSTEOARTHRITIS Flexion-Extension - 135 degrees

Hyperextension - 10 degrees
KNEE If there is an effusion present a palpated tap
will be present and the transmitted impulse
ABNORMAL FINDINGS will be felt by the fingers on either side of the
patella.

ABNORMAL ANKLE RANGE OF MOTION

Genu Valgum - Knees turn in with knock Dorsiflexion -20°
knees . Plantar Flexion - 500
Genu Varum - Turn out with bowed legs Inversion of Hind Foot - 50
Eversion of Hind Foot - 50

CALLUS

Common locations for callus

Small toes
Big toe
Big toe joint

Tenderness and warmth with a boggy

consistence may be symptoms of synovitis.
Asymmetrical muscular development in the
quadriceps may indicate atrophy
Bowleggedness HALLUX VALGUS
Knock Knees

ASSESSING FOR BULGE SIGN

To assess the patient for this sign, ask him to

lie down so that you can palpate his knee.
Then give the medial side of his knee two to
four firm strokes to displace excess fluid.

LATERAL CHECK

Tap the lateral aspect of the knee while checking for a

fluid wave on the medial aspect.
Brush stroke Bulge

BULGE SIGN
An assessment maneuver used to identify a ACUTE GOUTY ARTHRITIS
joint effusion, esp. at the knee.
The examiner tugs or "milks" the soft tissues
medial to the joint laterally and superiorly and
then presses on the lateral surface of the
joint in the opposite direction.

BALLOTTEMENT
Ballottement is a medical sign which
indicates increased fluid in the suprapatellar
pouch over the patella at the knee joint.
To test ballottement the examiner would
apply downward pressure towards the foot
with one hand, while pushing the patella
backwards against the femur with one finger
of the opposite hand.
Used to test for joint effusion
FLAT FEET ALTERATIONS OF MUSCULOSKELETAL
FUNCTION

MUSCULOSKELETAL INJURIES
Fractures
Dislocations & Subluxations
Sprains & strains of tendons and ligaments
Tendonitis & Bursitis
Disorders of bone
Metabolic
o Osteoporosis
o Osteomalacia
DEFORMATION OF THE FOOT o Paget Disease
Infectious - Osteomyelitis
Bone Tumors - Sarcoma

DISORDERS OF JOINTS
Noninflammatory - Osteoarthritis
Inflammatory - RA, Gout

DISRODERS OF SKELETAL MUSCLE

Secondary Muscular Dysfunction -
Contractures, Fibromyalgia
Myositis - Inflammatory Muscle Disease -
Muscle Tumors

PRIMARY SYMPTOMS OF
HAMMER TOE MUSCULOSKELETAL DISEASE

PAIN
May be bone, muscle, or joint
Bone pain may be with or without trauma
Time of day of occurrence helps define the
problem

WEAKNESS
Need to distinguish muscle weakness from
fatigue
Which muscle group involved - proximal or
distal
Proximal - Myopathy
Distal - Neuropathy

SHOULDER, ARM, WRIST, AND HAND DEFORMITY

STRENGTH Congenital or acquired

TESTING MUSCLE STRENGTH LIMITATION OF MOVEMENT

Biceps strength Ask questions to better define the problem
Triceps strength
BARLOW MANEUVER FOR CONGENITAL
TESTING HANDGRIP STRENGTH DISLOCATED HIP
Face the patient
Extend the first and second fingers of each
hand and ask him to grasp your fingers and
squeeze.
Don't extend fingers with rings on them

TESTING LEG STRENGTH

Ankle Strength - Plantar Flexion
Ankle Strength – Dorsiflexion
LOW EXTREMITY FINDINGS ON CHILDREN This is due to weakness of the proximal lower
extremity muscles such as the gluteus
"Bowlegged" stance is normal through the first muscles and the quadriceps.
two years of life. Resolves with growth and
ambulation.
Knock- kneed stance occurs normally between
2 and 3½ years of age.

HIP DISLOCATION
Dislocation of the hip functionally shortens and
weakens hip and pelvis muscles.
When a child stands on the dislocated hip, the
opposite side of the pelvis drops. THE MUSCULOSKELETAL SYSTEM OF THE
ELDERLY
MUSCULAR DYSTROPHY Muscle Atrophy
Is a group of congenital disorders Osteoarthritis
characterized by progressive symmetrical Osteoporosis
wasting of skeletal muscles without neural or Kyphosis
sensory defects. Decreased Intervertebral Disc Space
Duchenne's muscular dystrophy Joint Stiffness
Positive Gower's sign
OSTEOPOROSIS
Risk Factors
Classification
Diagnosis
Prevention
Treatment

REMEMBER…...

"Diseases of the musculoskeletal system rank first

among disease conditions that alter the quality of life...
the cost of which exceeds 60 billion dollars
annually..."

The musculoskeletal system encompasses the

muscles, bones, and joints.
The completeness of an assessment of this
system depends largely on the needs and
problems of the individual client.
The nurse usually assesses the
musculoskeletal system for muscle strength,
tone, size, and symmetry of muscle
development, and for tremors.
A tremor is an involuntary trembling of a limb
or body part.
Tremors may involve large groups of muscle
GOWER’S SIGN fibers or small bundles of muscle fibers.
Waddling wide-based gait An intention tremor becomes more apparent
Uses Gower's maneuver to rise from floor when an individual attempts a voluntary
Unable to walk independently by age 9-12. movement such as holding a cup of coffee.
A resting tremor is more apparent when the HIP ADDUCTION
client is relaxed and diminishes with activity.
A fasciculation is an abnormal contraction of Client is in same position as for hip abduction.
a bundle of muscle fibers that appears as a Place your hands between the knees; client
twitch. brings the legs together against your
Bones are assessed for normal form. resistance.
Joints are assessed for tenderness, swelling,
thickening, crepitation (a crackling, grating HAMSTRINGS
sound), and range of motion. Client is supine, both knees bent. Client resists
Body posture is assessed for normal standing while you attempt to straighten the legs.
and sitting positions.
QUADRICEPS
IMPLEMENTATION Client is supine, knee partially extended; client
resists while you attempt to flex the knee.
Introduce self and verify the client's identity.
Perform hand hygiene
MUSCLES OF THE ANKLES A ND FEET
Provide for client privacy
Inquire if the client has any history of the Client resists while you attempt to dorsiflex the
following: foot and again resists while you attempt to flex
o Muscle pain: onset, location, the foot.
character, associated phenomena
(e.g., redness and swelling of joints), BONES
and aggravating and alleviating Inspect the skeleton for structure
factors. No deformities
o Limitations to movement or inability to AbN - Bones misaligned
perform activities of daily living; Palpate the bones to locate any areas of
previous sports injuries; loss of edema or tenderness
function without pain. No tenderness or swelling
AbN - Presence of tenderness or swelling
TEST MUSCLE STRENGTH
(may indicate fracture, neoplasms, or
osteoporosis.
DELTOID
Client holds arm up and resists while you try to JOINTS
push it down.
Inspect the joint for swelling.
BICEPS Palpate each joint for tenderness, smoothness
of movement, swelling, crepitation, and
Client fully extends each arm and tries to flex it
presence of nodules.
while you attempt to hold arm in extension.
Assess joint range of motion
Joints move smoothly
TRICEPS
Varies to some degree in accordance with
Client flexes each arm and then tries to extend person's genetic makeup and degree of
it against your attempt to keep arm in flexion. physical activity
Ab Normal - Limited range of motion in one or
WRIST AND FINGER MUSCLES more joints
Client spreads the fingers and resists as you Document findings in the client record using
attempt to push the fingers together. printed or electronic forms or checklists
supplemented by narrative notes when
GRIP STRENGTH appropriate.
Client grasps your index and middle fingers EVALUATION
while you try to pull the fingers out.
Perform a detailed follow-up examination of
HIP MUSCLES other systems
Client is supine, both legs extended; client Based on findings that deviated from expected
raises one leg at a time while you attempt to or normal for the client.
hold it down. Relate findings to previous assessment data if
available.
HIP ABDUCTION
Client is supine, both legs extended.
Place your hands on the lateral surface of
each knee; client spreads the legs apart
against your resistance.