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1
Musculoskeletal System
Chapter 15
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Anatomy and physiology Review
MS consists of :
– Muscles
– Tendons
– Ligaments
– Bones
– Cartilage
– Joints
– Bursa
Bones
– 206 bones in human
skeleton
Joints
– Articulation of two or
more bones
– Classified by shape
and motion
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Temporomandibular Joint (TMJ)
Articulation of mandible and
temporal joint
Permits speaking and chewing
Hinge and gliding action
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Spine
33 connecting vertebrae
7 cervical
12 thoracic
5 lumbar
5 sacral
3 - 4 coccygeal
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Spine
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Shoulder
Articulation of humerus with glenoid fossa of the
scapula
Ball and socket
4 muscles and tendons make up the rotator cuff
Subacromial bursa
Acromion process
Greater tubercle
Coraciod process
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Shoulder
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Elbow
Articulations of humerus, radius, and
ulna
Hinge joint and rotation
Landmarks: medial and lateral
epicondyles, and olecranon process
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Elbow
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Wrist and Carpals of the Hand
Articulation of radius and carpal bones
Flexion and extension
Side-to-side deviation
Rotation
Midcarpal
Metacarpophalangeal and interphalangeal
permit finger motion
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Wrist and Carpals of the Hand
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Hip
Articulation between the acetabulum and
head of femur
Ball and socket
Weight-bearing function
Landmarks: anterior superior iliac spine,
ischial tuberosity, and greater trochanter
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Hip
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Knee
Articulation of femur, tibia, and patella
Hinge joint
Flexion and extension
Ligaments: cruciate and collateral
Landmarks: quadriceps and tibial
tuberosity
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Knee
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Ankle and Foot
Articulation of tibia, fibula, and talus
Hinge joint
Flexion (dorsiflexion)
Extension (plantar flexion
Inversion and eversion
Landmarks: medial and lateral malleous
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Ankle and Foot
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Health History
Ask pt about backache
Ask about pain in the neck and assess if associated with weakness, loss of sensation, loss of bladder or bowel function
Do you have any pains in your joints?,
Ask pt to point to the pain
Assess for limitation of motion
Assess for systemic feature as fever, rash, anorexia,
weakness, wt loss
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Assess mechanism of injury
Determine if it is inflammatory or noninflammatory e.g. fever, chills, warmth, redness in septic arthritis
Assess for symptoms elsewhere in the body as skin condition ( e.g. butterfly rash on a cheeks in SLE), preceding sore throat in acute RF.
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Additional Questions for Aging Adults
Do you have any loss of function?
Have you had weaknesses in the past month?
Have you had an increase in falls or have you
had trouble with balance?
Do you use any mobility aids? (cane, crutches,
walker)
Are you on any medications?
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Musculoskeletal Examination
Inspection: size and contour of joint, color,
swelling, masses, or deformity
Palpation: heat, tenderness, landmarks, and
any thickened synovial membranes
Range of Motion (ROM): active and
passive, flexibility of joint
Muscle Testing: test strength of muscle
groups for a particular joint22Ra'eda Almashaqba
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Muscular Movements
Flexion
Extension
Abduction
Adduction
Pronation
Supination
Circumduction
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Rotation
Protraction
Retraction
Elevation
Depression
Inversion
Eversion.
ROM’s
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Measuring Range of Motion
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Examination of TMJ
Inspection and palpation:
- Inspect for swelling or redness. Rounded bulge around 1/2cm anterior to the external auditory meatus suggest swelling
- To palpate the joint place the tips of the index finger in front of the tragus, then ask pt to open his mouth
Abnormalities: tenderness, swelling, lost of movement (lateral motion may be lost earlier and more significant than upper
vertical)
-
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check for smooth motion, note any swelling, tenderness
- Palpate the muscle of mastication( maseter, temporal, and pterygoid)
R.O.M and maneuvers:
- Ask pt to open and close the mouth
- Protrusion and retraction ( move mouth
backward, and forward)
- Side to side
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Examination of the Shoulder
Inspection :
- Posteriorlly & anteriorly
- Note any swelling, deformity, muscle atrophy, or fasciculation, or abnormal positioning
- Look for swelling of the joint capsule, or bulge in subacromial bursa
- Look for color changes, skin alteration, unusual bony contour
e.g. scoliosis may cause elevation of one shoulder
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Palpation:
- Locate the bony landmarks of the shoulder an then palpate the painful area.
R.O.M:
- flexion, extension, abduction, adduction, internal and external rotation
- Ask pt to raise both arms to shoulder level (90o ) with palm facing down ( test Glenohumeral motion)
- Raise the arms above the head palms facing each other.
- Place both hands behind the neck, elbows outside ( external rotation and abduction)
- Place both hands behind the back ( internal rotation and adduction)
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The Elbow
Inspection & palpation:
- Inspect the contour of the elbow, note any nodule or swelling
- Palpate the olecranon process& epicondyle for tenderness
- Note any displacement of the olecranon
- Palpate the groove between the epicondyles and the olecranon, note any tenderness, swelling, or thickening
e.g. swelling over the olecranon process indicate olecranon bursitis
Nodules over olecranon bursa in RA.30Ra'eda Almashaqba
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R.O.M:
- Flexion & extension at the elbow ( ask the pt
to bend and straighten the elbow)
- Pronation & supination of the forearm (
place pt arms at sides with elbow flexed, ask
pt to turn the palms up, and to turns the
palms down)
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The Wrist & Hands
Inspection:
- Observe the position of hands in motion to see if it smooth and natural
- Inspect the palmar and dorsal surface of the wrist and hand for swelling over the joint
- Note any deformities of the wrist, hands, fingers, radial or ulnar deviation
- Observe the palm contour( thenar& hypothenar eminences)
- Note any thickening of flexor tendon or flexion contractures in the fingers 33Ra'eda Almashaqba
Palpation:
- At the wrist palpate the distal radius and ulna on the lateral and medial surface
- Palpate the groove of each wrist by the thumb on dorsum and fingers beneath it. Note any swelling, bogginess, or tenderness
- Palpate the 8 carpal bones then each of the 5 metacarpals, proximal, medial, distal phalanges
- Note any swelling, bogginess, or tenderness
- Examine the finger and thumb by using index and thumb start at PIP joint then DIP joint
- Check for swelling, bogginess, tenderness, bony enlargement.
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R.O.M:
For the wrist:
- Flexion( stabilize pt forearm, extend the wrist,
ask the pt to flex the wrist)
- Extension (stabilize pt forearm, flex the wrist,
your hand on dorsal metacarpal of the pt hand,
ask pt to extend the wrist against gravity
- Ulnar & radial deviation( with the palms down,
ask pt to move the wrist medially and laterally)
- Test grip strength.
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For Fingers:
- Flexion, extension
- Adduction, abduction
For Thumb:
- flexion( ask pt to move the thumb across the palm an touch the base of the 5th finger
- Extension( move the thumb back across the palm and away from the fingers
- Abduction (move the thumb anteriorly away from the palm)
- Adduction (move thumb backdown)
- Opposition ( ask the pt to touch the thumb to each of the fingertips)
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Test sensation:
- Pulp of the index finger for median nerve
- Pulp of the 5th finger for ulnar nerve
- Dorsal web space of the thumb and index
finger for radial nerve
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The Spine
Inspection:
- Observe pt posture
- Assess erect position of the head, smooth, coordinate neck movement
- Inspect the pt from the side for spinal curvature
Palpation:
- Spinous process with your thumb
- Palpate the sacroiliac joint
- Percuss the spine for tenderness by using ulnar surface of your fist
- Palpate Paravertebral muscle for tenderness and spasm
- Flex pt hip and ask pt to lye in opposite side palpate the sciatic nerve( lies midway between the greater trochanter and the Ischial tuberosity 38Ra'eda Almashaqba
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R.O.M:
For the neck
- Flexion: chin touch the chest
- Extension: look up at the ceiling
- Rotation: turn the head to each side, look directly over the shoulder
- Lateral binding: each ear touching the shoulder
For the spinal column:
- Flexion: bend forward touch the toes
- Extension: place your hand on the posterior superior iliac spine, fingers pointed towered the midline, ask pt to bend backward as far as possible
- Rotation: one hand on the pt hip the other on the opposite shoulder, then rotate the trunk , repeat for the other side
- Lateral bending: place your hand on the pt hip, ask pt to lean to both side as far as possible
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The Hip
Inspection:
- Observe the pt gait( 2 phase)
1. Stance: foot on ground, bear wt
2. Swing: foot moves, no bear wt
- Observe the gait for width
- Assess the lumbar spine for lordosis, assess the
length of the legs for symmetry.
- Anterior and posterior surface of the hip for
atrophy and bruising 40Ra'eda Almashaqba
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Palpation:
- Palpate the inguinal ligament
- NAVEL
- If hip painful palpate the psoas bursa (below
the IL)
- Pt resting on one side, hip internally rotated,
palpate the Trochanteric bursa, the
ischiogluteal bursa
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R.O.M:
- Flexion: pt supine, place your hand under lumbar spine,
ask the pt to bend each knee in turn up to the chest, and
firmly against the abdomen, observe the degree of
flexion at the hip and knee
- Extension:pt lying face down, extend the thigh
posteriorlly, then place the pt near the edge of the
examination table and extend the leg posteriorlly
- Abduction: press the opposite anterior superior iliac
spine with one hand, the other hand, grasp the ankle
and abduct the extended leg until you feel the iliac
spine move, then stand at the foot of the table, grasp
both ankles and spread them maximally 42Ra'eda Almashaqba
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Adduction: pt supine, hold one ankle, move the
leg medially across the body over the opposite
extremity
External & Internal rotation: flex the leg to 90o at
hip an knee, stabilize the thigh with one hand, the
other hand grasp the ankle and swing the lower
leg medially ( external rotation), and then swing
the leg laterally
( internal rotation)
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The Knee
Inspection
- Observe pt gait
- Check knee alignment, contour, any atrophy of quadriceps muscle
e.g. bowleg and knock knee common flexion contractures in limb paralysis
- Look for loss of the normal hollows around the patella , any other swelling in or around the knee
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Palpation:
- Palpate ligaments, menisci border, knee bursae
- Palpate the patellar tendon and ask pt to extend the leg to ensure intactness of the tendon
- Patellofemoral grinding test: pt in supine position knee extended, compress the patella against the underlying femur, ask pt to tighten the quadriceps muscle, check for smooth sliding motion
- Palpate while pt flex knee the MCL, LCL
- Palpate the lateral and medial menisci
- Note any irregular bony ridge along the joint margins 45Ra'eda Almashaqba
- Feel any thickening or swelling in the suprapatellar
pouch, and the side of the patella, 10 cm above the
superior border of the patella, feel with your thumb and
finger, note any tenderness, or warmth
- Palpate the bursae of the knee
Tests to detect fluid in the knee:
- Bulge sign (for minor effusion): knee extend, lt hand
above the knee, apply pressure on the suprapatellar
pouch, milking fluid downward, apply pressure on the
medial aspect of the knee, tap the knee with the Rt hand
behind the lateral margin of the patella, watch for
Fluid wave46Ra'eda Almashaqba
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Balloon sign (for major effusion): place the
index finger and thumb of your Rt hand on each
side of the patella, the Lt hand compress the
suprapatellar pouch against the femur, feel for
fluid entering the spaces next to the patella
under Rt thumb and index finger
Balloting the patella: to assess large effusion,
compress the suprapatellar pouch, watch for
fluid retuning to the suprapatellar pouch
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R.O.M:
- Flexion
- Extension
- Internal rotation ( ask pt to rotate foot
medially)
- External rotation ( ask pt to rotate foot
laterally)
- Review table p 550- 551
- To test Achilles tendon integrity ask pt to
kneel on chair, squeeze the calf muscle, watch
for planter flexion at the ankle 48Ra'eda Almashaqba
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The Ankle & foot
Inspection:
-observe all surface of the ankle and feet
- Note any deformity, nodules, swelling, calluses or corns
Palpation:
- With your thumb palpate the anterior aspect of each ankle joint, note any bogginess, swelling, or tenderness
- Feel along the Achilles tendon for nodules and tenderness
- Palpate the heel and the planter fascia for tenderness
- Palpate the MCP joint for tenderness by the thumb and the fingers
- Palpate the head of the 5 metatarsals and the grooves between them by the thumb (on dorsum) and index finger (on the planter surface)
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R.O.M:
- Flexion and extension at the ankle (tibiotalar)
joint
- Inversion and Eversion at the foot( the subtalar
and transverse tarsal joints)
- The Ankle (Tibiotalar) joint: dorsiflex and
planterflex the foot at the ankle
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Special technique
- Thumb abduction:
ask the pt to raise the thumb perpendicular to the palm
as you apply pressure on the distal phalanx ( test the
strength of the abductor pollicis brevis)
- Tinel’s sign:
Percuss by your finger in the volar aspect of the wrist
over the course of median nerve
- Phalen’s test:
flex the pt wrist and hold it for 60 sec
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For LBP with radiation to the leg:
- Check the straight leg raising (LaSegue’s Test ) on each side in turn : while pt on supine position, raise the straighten leg until pain occurs, then dorsiflex the foot, record the degree of elevation at which the pain occurs
- Examine the pt sensory, motor, reflexes at the lumbosacral levels
Measuring the length of the leg:
- Place pt on supine position
- Leg extended
- Measure the distance between the anterior superior iliac spine and the medial malleous, the tape should cross the knee on its medial side
– For the apparent leg length
• Measure from a nonfixed point (umbilicus) to a fixed point (medial malleous).
– Apparent leg length is unequal if patient have pelvic obliquity or adduction or flexion deformity in the hip.
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Describing limited motion of a joint:
- It is described in degrees
- By using goniometers
e.g. the normal angle for elbow flexion is from
0o to 160o, when there limitation documented
as follows elbow flex from 45o to 90o
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Rheumatoid arthritis
Chronic, systemic,
inflammatory disease
that attacks the joints,
and surrounding
tissues, hand, knees,
hips, and feet
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Deformities
of RA
Swan neck deformity
Boutinniere Deformity
Ulnar Shift
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Osteoarthritis
A chronic degeneration of joint cartilage caused by aging or trauma
Pain, stiffness, swelling
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Osteoarthritis: Cont.
Heberdens Nodes
Bouchards Nodes
Hard, nontender nodes
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Osteoporosis
A decrease
in bone
mass,
porous,
brittle, and
prone to
fracture
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Contractures
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Lordosis
Lordosis is the
abnormal
increase in
normal lordotic
(anterior)
curvature of the
lumbar spine
60
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Spinal Abnormalities
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