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Nursing Assessment
Series Number 126
The Musculoskeletal System (126.5)
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T
he musculoskeletal system is actually comprised of two distinct body systems that function primarily
as a unit, the skeletal system and the muscular system.
The skeletal system is made up of 206 different bones, which come in four basic shapes: long bones, such
as the femur; short bones like the wrist and anklebones; flat bones, such as those in the skull or the
scapula; and irregular bones, like the vertebrae.
There are two types of bone tissue: compact bone, which is dense, smooth and very strong; and cancellous
bone, which is spongy and lightweight. Both types of bone tissue contain living cells, which help make
repairs if a bone is injured or broken.
A typical long bone has a main shaft called the diaphysis composed of compact bone, and two ends called
epiphyses composed of cancellous bone. The main shaft is covered with a membrane of living cells called
periosteum to which muscles and tendons attach themselves. Inside the main shaft is a cavity called the
medullary cavity, which contains bone marrow. Bone marrow stores fat, produces blood cells, and plays an
important part in the body’s immune system.
Without bone’s ability to grow larger or repair itself, our body would remain the same size from the time
we were infants, and every broken bone would remain a permanent injury. From birth to the time we are
around 18 to 25 years old, our bones go through a process called ossification. This involves cartilage or
connective tissues in the bone being replaced with bone tissue so that the bone increases in size and
strength. In adults bone formation is usually limited to repair and replacement. Approximately ten percent
of all adult bone tissue in our body is replaced each year.
Every stress that is put on a bone has an effect, and the bone reflects those stresses. For example, a person
who constantly hunches over has bones that will gradually become curved as they are remodeled by the
stress.
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After about age 50, skeletal bone is subject to a gradual weakening and decrease of density. Women after
menopause and men over the age of 50 are at risk of developing a condition called osteoporosis. This is a
disease that results in dramatic weakening and decrease of bone mass. Bones become so weak and brittle
that they are susceptible to fractures, especially the hip, spine and wrist.
The skeletal system is divided into two divisions: the axial skeleton, which consists of the bones that form
the longitudinal axis of the body, and the appendicular skeleton, which consists of the bones that are
appended to the axial skeleton. The axial skeleton includes 80 bones comprising the skull, vertebral
column, and thorax.
The upper part of the skull, called the cranium, is the main source of protection for the brain and consists
of 8 bones called the cranial bones.
The face is formed by 14 bones, called the facial bones, and includes the mandible whose movement
allows for eating and speech. 6 small bones reside in the inner ears, 3 in each one, and aid in the
transmission of sound.
The vertebral column supports the head, and encloses and protects the spinal cord and nerve roots. In
adults, it consists of 26 bones stacked one on top of the other called vertebrae. It is divided into five
sections: cervical, thoracic, lumbar, sacral and coccygeal. Children possess 33 vertebrae: as their bodies
mature the sacral and coccygeal vertebrae fuse.
Seen from the side, the spine is not a straight vertical line but rather has four distinct curves. These curves
increase the carrying strength of the vertebral column and make balance possible when standing in an
upright position. The joints between the vertebrae are cushioned by discs of cartilage, allowing for a great
deal of bending and twisting.
Because of the downward pressure exerted on the vertebrae by gravity, we go to bed every night a few
millimeters shorter than when we woke up in the morning. The disks recover as we sleep but as we get
older they lose some of their elasticity. As a result, an eighty-year-old man is often several centimeters
shorter than he was as a young adult.
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The thorax, or rib cage, surrounds and protects the heart, lungs and thoracic blood vessels. It consists of
the sternum and twelve pairs of ribs. The first 7 pairs of ribs are called “true ribs” because they are
connected to the sternum by costal cartilage. The next 3 pairs are called “false ribs” because they connect
only indirectly to the sternum by cartilage extensions. The last two pairs are called "floating ribs" because
they have no connection to the sternum at all. When we are born, our sternum is in 3 parts and is the last
bone in our body to fuse together, usually after the age of 30.
The appendicular skeleton consists of the bones of the shoulders, upper extremities, hips and lower
extremities.
The point where two bones meet is called an articulation, or joint. Joints are usually constructed of
cartilage and fibrous connective tissue, and are classified according to the amount of movement they allow.
Immovable or synarthroses joints include the sutures that connect different parts of the cranium. Partially
movable or amphiarthroses joints include the symphysis, which connects together the bones of the pelvis.
The most common joint is the freely movable or diarthrosis joint.
The majority of our muscle tissue, and the kind we are generally most familiar with, is skeletal muscle
tissue. There are over 600 skeletal muscles in our body and they range from the tiniest muscles in our inner
ear, which are only 1 millimeter long and almost invisible to the naked eye, to the giant gluteus maximus,
which forms most of each buttock. Skeletal muscles are also called voluntary muscles because we
generally have voluntary or conscious control over them.
Many skeletal muscles work in pairs. Because muscle tissue can only contract—that is, become shorter
and thicker—a muscle can pull but it cannot push. It will return to its original shape when it relaxes but it
has no power to push itself back to its relaxed shape. This is why most skeletal muscles are attached in
ways that let them pull against each other. Most of these muscle pairs are attached on opposite sides of a
joint. The strong tendons at the ends of the muscles are attached to the bone a little past the joint. A
tendon or sinew is a tough band of fibrous connective tissue that connects muscle to bone. They are similar
to ligaments except ligaments join one bone to another.
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For example, the biceps muscle on the upper surface of our upper arm is paired with the triceps muscle on
the lower surface. When the biceps muscle contracts it pulls on the bone and flexes the joint or makes its
angle smaller. When the triceps contracts it pulls in the opposite direction and extends the joint or makes
the angle larger. By working together with one muscle contracting and the other relaxing, these two
muscles can move the lower arm to any position within its range of movement.
Many skeletal muscles—like the biceps muscle—are spindle shaped, which means they are fatter in the
middle and taper toward the tendons at each end where they attach to bones. The fatter part of the muscle
is called the belly and is made up of bundles called fascicles. Each fascicle is itself a bundle of muscle
fibers. Each fiber is a single cell running the full length of the muscle, and can be up to 30 centimeters
long.
A single skeletal muscle fiber is an unusual cell. Unlike most of our body’s cells which each possess a
single nuclei, it possesses multiple nuclei on its outer surface, and is made up of bundles of myofibrils.
Myofibrils themselves are made up of actin or myosin filaments, which are arranged end-to-end in separate
units called sarcomeres. This gives muscle fiber its distinctively striated, or banded, appearance. The entire
skeletal muscle structure is rather like a car antenna or telescope—multiple bundles, tightly packed one
inside another.
Tissue surrounding the bundles contains blood vessels, which provide oxygen and fuel to the muscle, and
nerve cells, which transmit signals to the muscle causing it to contract. When a nerve signal is received,
calcium is released inside the muscle fibers, which causes them to contract.
Actual contraction occurs when thin actin filaments are pulled towards thicker myosin filaments thus
shortening the sarcomere. As this reaction takes place along each muscle fiber, the whole muscle
contracts—up to as much as 1/3 of its normal length. Subsequently, as the muscle relaxes, the actin
filaments slide back into their original positions and the whole muscle expands back to its original length.
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Subjective Data
The musculoskeletal assessment focuses on body structure and movement. Pain, injury, and mobility
issues often cause an individual to seek medical assistance.
The subjective assessment should cover all of the problems that affect physical activity. These include
muscular or skeletal pain, stiffness, swelling, redness, heat, impaired movement, muscle cramps,
weakness, deformity of bone or joints, trauma, and limitations in the ability to perform the activities of
daily living.
Musculoskeletal problems are a common cause of chronic pain, and assessing for pain must be a priority.
Ask about both frequency and intensity; actions that precipitate or exacerbate the pain; what relief
measures have been utilized, and the effectiveness of these measures.
Ask about current difficulties related to bones, muscles, and joints, and what form they take. Enquire
about a previous history of musculoskeletal injury or difficulties and family history of disorders such as
rheumatoid and osteoarthritis, fibromyalgia, and orthopedic surgeries including joint replacements.
Document the existence of congenital malformations and current or previous interventions.
Objective Data
The objective assessment is done using inspection, palpation, and range of motion. As you begin your
interaction, observe for freedom of movement, posture, and any obvious deformities. This information
will aid in the focus of your assessment.
Jaw, Neck and Shoulders
Begin standing directly in front of the patient.
Palpate the temporomandibular joint for tenderness or swelling.
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Instruct her to move her jaw forward and back, then side to side. As you perform your assessment, enquire
if any movements or palpation causes pain.
Visually inspect the neck, observing for swelling. Note if the head deviates right or left from midline.
Assess the cervical spine by having the patient tilt her head to each side as though touching her ear to her
shoulder.
Then have her tilt her head forward and touch her chin to her chest, then tip her head backward.
Now ask her to repeat the movements while you apply resistance with your hand, feeling for equal strength
side to side and up and down.
Inspect the shoulders from both the anterior and posterior aspects. Are they uniform in size and contour,
free from redness, lumps, or swelling? The muscles themselves are assessed by placing your hands over
them and feeling the movement.
If the individual reports pain in the shoulder area, stand in front of her and palpate the shoulders with both
hands, beginning at the clavicle and moving outward to the acromioclavicular joints, scapulae, greater
tubercle of the humerus, subacromial bursa, biceps groove, the anterior aspect of the glenohumeral joint,
and along the axilla. Note the points of tenderness.
Pain that occurs or increases in response to movement or palpation of an area of the body is known as
direct pain.
Pain that arises from a condition elsewhere in the body is called referred pain and occurs independently of
pathology at the pain site. Referred pain in the shoulder area may be related to potentially serious
conditions involving the heart, lungs, or GI tract.
Compare right to left at each examination point. Note tenderness, atrophy, and the presence of spasm,
swelling, or pain.
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Upper Extremities
Test the range of motion by having the patient lift both arms in an outward circular motion until they are
directly above the head, then bring them down in a forward arc passing midline and extending the hands
beyond the buttocks.
Have the patient relax her arms, and then cross them at the wrist behind her back, then place both hands on
the back of her head with her elbows out to the side. Note any limitations in her range of motion.
Further assess flexion of the elbow by having the patient hold her right hand at her side and raise it from
the elbow until her hand is tight against her shoulder. Repeat with the left.
With her hands held in front with the elbows bent to 90 degrees, ask the patient to pronate and supinate her
hands, then tighten and relax her fists. Note any hesitations, facial grimacing, unequal movement of one
side, or inability to perform.
Now palpate the joints of the wrist and the digits. Be alert to excessive size and tenderness.
Test arm strength by asking the patient to resist first your attempt to pull her bent arm out straight, then
pushing your hand away..
Lower Extremities
Have the patient lie down for the next portion of the assessment.
Inspect the feet for overall shape and toe configuration. Note corns, calluses, swelling, nodules, and
deformities such as bunions and hammer toes.
Support the foot in your hands and palpate the anterior ankle with your thumbs, then the Achilles tendon
with your fingertips. Joint spaces should be smooth with no swelling or tenderness. The tendon should be
firm and pain free.
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Check ankle flexion by supporting the foot with one hand beneath the ankle and with the other press the
foot upward, then gently rocking the ankle inward and outward.
Palpate the metatarsophalangeal joints with your thumb on the dorsum and your fingers on the plantar
surface of the foot for any swelling, tenderness, or nodules.
Palpate along the base of the toes at the ball of the foot. Finally, using your thumb and forefinger, palpate
the joints of each toe. Repeat the exam for the other foot.
Now palpate the hip joints, paying particular attention to swelling or tenderness in the area of the greater
trochanter, the ischial tuberosity, and the anterior superior iliac spine. This portion of the exam may not be
possible if the patient is significantly overweight.
The patient can demonstrate active range of motion while lying down. The movements are done first on
one side then the other. Those to be requested are as follows:

Foot dorsiflexion.

Foot plantar flexion.

Foot eversion.

Foot inversion. Hip flexion with the knee straight.

Hip flexion with the knee flexed.

External rotation at the hip.

Internal rotation at the hip.

Hip abduction and adduction. These are best done with the legs well apart at the beginning
of the exercise to allow room for adduction without crossing the legs.
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Spinal Column
The final aspect of the assessment is the spine. The spine must be visualized, so if the patient has not
already changed into a gown, have her do so now.
Begin with a visual assessment. Stand behind the patient with the back of the gown open or removed so
you can visualize the spine and scapulae.
Note any sideward curve or angle, called scoliosis, and document the level, approximate angle, and
whether the curve is to the right or left. You can determine the level by counting down the vertebrae.
Begin by locating the prominent spinous processes of C7 and T1, which are located at the base of the neck.
Ask the patient to bend forward as though to touch her toes to make abnormal lateral curves easier to
visualize.
There may be a right and left curve as the musculature attempts to achieve balance. Document both.
If the thoracic curve exceeds 50 degrees the patient is said to have kyphosis, commonly called hunchback.
This may be congenital or due to injury or osteoporosis.
Depending on the degree of angle and instability, lordosis and kyphosis can be severe disorders requiring
intervention.
Continue your exam by palpating the length of the spine, feeling for each spinous process and the spaces in
between. Note any swelling between the processes, as well as any tenderness or swelling.
The vertebral column is capable of four motions: flexion, extension, abduction, and rotation. Have the
patient demonstrate range of motion in the following manner:

Touch her toes. This should cause flattening of the lumbar curve, and increased flexion at the
cervical curve.
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
With her feet at shoulder width, have her lean first to the right, then the left.

Standing in the same position, now ask her to rotate her shoulders to the right and then the left.

Now stabilize her hips and ask her to arch her head and upper back backward with her hands at her
side.
Loss of range in these maneuvers can indicate a degree of spinal fusion. However, fusion may exist even
in patients who have relatively good spinal range of motion.
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