Download MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE

MENNONITE COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
Diagnostic Reasoning for Advanced Practice Nursing 431
MODULE: MUSCULOSKELETAL SYSTEM
OBJECTIVES:
Upon completion of this module, the student will be able to:
1. Perform an appropriate musculoskeletal assessment on a client.
2. Incorporate appropriate aspects of the complete musculoskeletal assessment into the routine
examination of clients.
3. Describe the overall musculoskeletal assessment process.
4. Perform branching exams and describe the significance of these exams.
REQUIRED READINGS:
Read applicable sections of the course textbook.
STUDY QUESTIONS:
1. Define, describe, or demonstrate:
a. flexion
b. extension
c. abduction
d. adduction
e. internal rotation
f. external rotation
g. ulnar
h. radial
i. volar
j. lateral
k. dorsal
l. medial
m. palmar
n. synovial membrane
o. disc
p. ligament
q. tendon
r. sprain
s. strain
t. bursa
u. avulsion
2. List the cardinal symptoms of the MSK system.
3. How do you screen for scoliosis?
4. How do you assess leg strength?
5. What is the significance of:
a. Positive drawer test?
b. Positive McMurray maneuver?
6. Chart the results of a complete MSK exam.
7. Test the strength of your muscle knowledge! Match the correct scientific muscle name to the
general movement that it causes:
_____
_____
_____
_____
_____
_____
_____
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
gastrocnemius
sternocleidomastoid
rectus femoris
triceps brachii
pectoralis major
rhomboid
gluteus maximus
_____
_____
_____
_____
_____
_____
Pulls shoulder blades together in back
Raises the arm up to should level
Pulls the arm down from overhead and to the side
Brings the arm across the chest
Bends the elbow
Straightens the arm
Straightens the leg
Pulls the entire leg back behind the body
Bends the knee
Allows you to stand up on your tip toes
Helps you to bend at the waist or sit up
Allows you to stand up tall with good posture
Pulls the head down towards the chest
rectus abdominis
biceps brachii
semimembranosis
erector spinae
latissimus dorsi
deltoid
ASSESSMENT OF THE MUSCULOSKELETAL SYSTEM
Musculoskeletal (MSK) disorders may arise from many different structures of the MSK system—the
bones, muscles, joints, bursa, tendons, ligaments, cartilage, or the soft tissues surrounding joints.
Numerous diseases, including neurological diseases, can affect muscles, joints, and soft tissue.
The joints in the MSK system are held together by ligaments and tendons, fibrous bands of connective
tissue which attach muscles to bones. Cartilage, dense connective tissue, cushions parts of the skeletal
system. A synovial membrane lines joint cavities and secretes synovial fluid, a lubricant. Bursa, sacs
containing synovial fluid, are located between tendons, ligaments, and bones; they are designed to
reduce friction.
MSK History
MSK history is usually challenging, because of the many different types of presenting complaints, related
to many different anatomical structures.
General history items to be assessed:
1. Employment: past, current, potential for accidents, injuries and joint stress injuries
2. Exercise: type frequency, overall conditioning pre and post exercise
3. Activities of daily living: ability to perform self-care, including housework, walking, and climbing
stairs
4. Weight: recent gain or loss, underweight or overweight
5. Nutrition: intake of calcium, vitamin D, calories and protein
6. Medications: NSAIDs, muscle relaxants
History of Present Illness
Joint symptoms
1. Character: stiffness, limited movement, change in size, contour, deformity, swelling, warmth,
redness, pain or ache. Always find out if the symptoms are unilateral or bilateral and how they
limit or interfere with daily activities.
2. Associated events: time of day, activity, specific movements, injury, weather, strenuous activity
3. Time factors: change in frequency or character of episodes (better or worse as day progresses);
nature of onset: slow vs. abrupt
4. Treatment: exercise, rest, weight reduction, PT, heat, ice, splints, medications, joint injections,
RICE (rest, ice, compression, elevation)
Muscle symptoms
1. Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic, spasms,
clumsiness, wasting, aching, or pain
2. Precipitating factors: injury, strenuous activity, sudden movement, stress on muscles
3. Treatments: heat, ice, splints, rest, medications
Skeletal symptoms
1. Character: difficulty with gait or limping
2. Associated events: injury, recent fractures, strenuous activity, sudden movement, stress
3. Treatments: rest, splint, meds, herbs, or poultices
Acute Trauma
1. What exactly was the patient doing when the injury occurred?
2. In what direction did the extremity or joint twist or turn?
3. Did the patient hear any pop or tearing founds?
4. Did pain and swelling occur immediately or a few hours later?
a. Immediate swelling/deformity usually indicates a potential fracture
5. Can the patient use the extremity—walking/range of motion
6. Is the injured body part swollen, numb, misaligned?
Past Medical History
1. Trauma: nerves, soft tissue, bones, joints, residual problems: bone infection (osteomyelitis)
2. Surgery on joint
3. Chronic illness: cancer, arthritis, osteoporosis, renal or neurologic disorder
4. Skeletal deformities or congenital anomalies
Family History
1. Congenital abnormalities of hip, foot, etc.
2. Scoliosis or back problems
3. Arthritis: rheumatoid, osteoarthritis, gout, ankylosis, spondylitis
4. Genetic disorders: osteogenesis imperfect, dwarfing syndrome
Physical Examination of the MSK System
INSPECTION
Inspection is one of the most important parts of MSK assessment. Begin inspection by observing the
gait and posture of the patient as he enters the room. Observe how the patient walks, sits, rises from a
chair, or takes off a coat or jacket. The entire body surface must be exposed and examined with good
lighting. Provide support to injured or deformed body joints. Examine each body region systematically
and symmetrically (comparing both sides of the body).
Observe the patient’s posture, from the front, the back, and sides. Observe ability to stand erect
without support, the symmetry of body parts, and the alignment of extremities. Observe the spine for
lordosis, kyphosis, or scoliosis.
Inspect the skin, muscles and soft tissues for discoloration, swelling, masses. Inspect joints and
extremities (compare both sides) for overall size, deformity, bony enlargement, alignment, contour and
symmetry of size, length, and position, and number of skin folds. Muscle size should be similar
bilaterally, without atrophy or hypertrophy.
PALPATION
Palpate all bones, joints, and surrounding muscles. Note any heat, tenderness, swelling, crepitus, or
resistance to pressure. No pain or discomfort when pressure is applied to bones and joints. Muscles
should feel firm but not hard or soft.
RANGE OF MOTION
Examine active and passive range of motion for all major joints. First, the patient should be asked to
perform active ROM as this will allow the examiner to carefully observe for signs of pain, deformity, and
limited ROM.
MUSCLE STRENGTH
Muscle strength evaluation is usually integrated with the neurological exam. Ask the patient to flex
muscle, then resist as you apply force against the flexed muscle. Muscle strength should be equal
bilaterally. Full muscle strength resistance is graded as 5. No muscle contraction is graded as 0.
ASSESSMENT OF THE ELDERLY CLIENT: MSK
In addition to postural changes, the MSK system undergoes other changes as a result of the aging
process. There is a decrease in the number of fibers in muscle and their bulk, and a decrease in collagen
content. Muscle contours at the point of attachment become prominent despite the replacement of
muscle mass by fat. There is an overall increase in the fat to muscle proportions in the body. Muscle
atrophy occurs throughout the body and is especially noticeable in the small muscles of the hands.
Despite the existing atrophy, muscle strength is not significantly diminished. Fasciculations of the
eyelids, hands, and feet may occur and are spontaneous, of short duration, and do not occur regularly.
Leg cramps, especially at night, seem to increase in incidence in the aged population. Paresthesias of
the legs may also occur. This symptom is precipitated by inactivity and usually relieved by motion.
Degenerative joint disease or osteoarthritis is considered to be a part of the aging process and
predominantly affects the knees, hips, spine, cervical spine, shoulders, and distal interphalangeal joints.
Cartilage loses its elasticity, and bony proliferation of joints occurs. The joint capsule and synovium
become thickened and synovial fluid decrease. Bony spurs form at the joint margins.
Although osteoporosis is frequently concomitant with the aging process, it is not considered, in general,
a “normal” change. Bone density does decrease with aging, however, as a result of decreased calcium
absorption, and inactivity, and, in women, postmenopausal estrogen decline.
MSK HISTORIES: OLDER ADULTS
Weakness:
1. Onset: sudden or gradual, localized or generalized, occurred with activity or after sustained
activity
2. Associated symptoms: stiffness of joints, muscle spasms, muscle tension, any particular activity,
dyspnea
Increase in minor injuries
Stumbling, falls, limited agility, associated with poor vision?
Change in ease of movement
Loss of ability to perform sudden movements, change in exercise endurance, pain, stiffness,
localized to particular joints or generalized?
Nighttime muscle spasms
Frequency, associated back pain, numbness or coldness of extremities
Claudication
Known joint injuries, abnormalities or deformities
Subjective Complaints
1. Numbness and tingling of legs
2. Muscle weakness
3. Enlargement of terminal joints of fingers
4. Muscle tremors, “charley horses”
5. Joint paint with activity, relieved with rest
6. Stiffness on rising lasting only a few minutes
7. Joint “creaking and cracking”
8. Hip, knee, or spinal pain
Objective Findings
1. Muscle atrophy—thin body, hands with deep
interosseous spaces, thin, flabby arms and
legs
2. Fasciculations of muscles
3. Increased resistance of extremities and head
to passive moves
4. Slowed movements
5. Joint enlargement
6. Bony overgrowth or cysts at joint margins;
Heberden’s nodes
7. Crepitation on joint movement
8. X-ray: joint narrowing, bony sclerosis or
cysts, sharping of articular margins,
decreased density of bones (cortical
thinning)
MUSCULOSKELETAL EXAMINATION: STUDENT VALIDATION
** Branching Exam Procedure
COMPONENT ACTIVITIES
NECK
1.
ROM- extension, flexion, rotation, lateral rotation
2.
Strength- resistance to extension, flexion, rotation, lateral
flexion
SHOULDER
1. Inspect and palpate major muscles
2. Palpate, assess and name:
a. Sternoclavicular joint
b. Acromioclavicular joint
c. Coracoid process
d. Biceps groove
e. Greater tubercle of humerus
f. Acromion
3. Range of motion
a. Touch opposite shoulder in front (flexion, horizontal abduction)
b. Touch opposite shoulder in back (abduction, external rotation)
c. Place thumb up spine as far as possible (extension, internal
rotation)
4. Shoulder girdle strength - Resist examiner pushing arms down as
follows:
a. Anterior leaf (flexors) - arms out, palms up
b. Middle leaf (abductors) - arms out, palms down
c. Posterior leaf (extensors) - arms out, thumbs down
5. Anterior shoulder subluxation - abduct and externally rotate
shoulder with client relaxed; examiner rotates arm further backward
to assess for subluxation
6. Internal and external rotation (rotator cuff) strength tests with
elbows at side, arm bent 90º -resist examiner pushing hands
together and resist pushing hands apart
UPPER EXTREMITIES
1. Biceps/triceps muscle strength:
a. Resist extension (biceps)
b. Extend arm against resistance (triceps)
2. Elbow:
a. Inspect and palpate - over medial and lateral epicondyles for
tenderness
b. ROM - flexion, extension, pronation, supination
DONE
NOT
DONE
COMMENTS
3. Wrist:
a. Palpation for tenderness, swelling, warmth, crepitus, nodules and
over “anatomic snuff box” at base of thumb for navicular pain
b. ROM - flexion, extension, medial and lateral deviation
c. Strength-make a fist and resist flexion and extension
d. Ligament stability- wrist in neutral position, stress medially and
laterally
e. **Examine for carpal tunnel syndrome
i. Tinel's sign
ii. Phalen's test
4. Hands and Fingers
a. Inspection - spread fingers - thickened joints, deformities
b. ROM - curl fingers - look for full flexion of PIP at DIP joints
c. ROM - touch thumb to each finger
d. Grip strength
e. Ulnar collateral ligament stability stress test: make loop between
thumb & index finger-resist examiner pulling
LOWER EXTREMITIES
1.
Flexibility
a.
Hamstrings-Straight Leg Raise
b. Low back - passively bring knee to chest (flex hip and knee)
c. Abductors (groin) - while returning hip to normal position with
knee bent, passively abduct leg into frog position
2. Quadriceps strength - tighten both quads compare size and
consistency of vastus medialis muscle
3. Knee
a. Inspection - tighten quads - observe hollow spaces for swelling
b. Palpation - above patella, medial and lateral joint lines, patella
tendon and tibial tubercle, popliteal fossae
c. Patella examination - palpate underside of patella at medial and
lateral facets for retropatellar pain:
i. With muscles relaxed, push patella laterally (attempting to dislocate
patella) - observe apprehension of client
ii. Push patella from above distally to check for crepitus
d. ** Ligament testing:
i. ** Medial collateral @ 0 & 30 - stress from outside to inside
ii. **Lateral collateral @ 0 & 30 - stress from inside to outside (best
done by sitting on exam table and having client bring his leg across
your lap)
iii. **Anterior cruciate - drawer test or Lachman test for laxity
iv. **Posterior cruciate - observe knees bent at 90º from side to side
detect absence of contour of tibial tubercle
e. **Examine for meniscus injury: **McMurray’s
f. **Bulge Sign
g. ** Ballottement for floating patella
5. Tibia - palpate while running hand down tibia (for shin splints)
6. Ankle
a. Palpate malleoli and ligaments around malleoli
b. ROM - plantarflex, dorsiflex, invert, evert
c. **Ligament stress tests: anterior drawer, talar tilt, inversion stress
CLIENT SITTING
a.
Straighten knee against resistance
b.
Lift knee from table to resistance
CLIENT STANDING
1. BACK - General posture
a. Inspection - deformities
2. Scoliosis check- bend forward and touch toes; straighten slowly.
Look for lateral curvature, unequal thoracic bumps and unequal
elbow- trunk angles
3. Palpate spine and paravertebral muscles
4. ROM:
a.
Tilt torso by running hand down leg to knee
b.
Rotate torso by looking backward over shoulder
c.
Hands on hips-extend torso backward
5. Muscle Symmetry:
a.
Clasp hands behind head, push against occiput
b.
Clasp hand behind back, push against lumbar spine
c.
Place hands on hips, try to touch elbows together
6. Palpate anterior iliac spines, iliac crests, greater trochanter
7. Flexibility:
a.
b.
Gastrocnemius- lean against wall, knees straight, heels on
floor
Soleus- lean against wall, bend one knee, heels on floor
c.
Quadriceps- bend knee to buttock
d.
Hip Flexor- extend bent knee back as far as possible with
knee pointing straight down (not to side)