Assessment
of the Musculoskeletal System
The musculoskeletal system provides shape and support to the body,
allows movement, protects the internal organs, produces
red blood cells in the bone marrow (hematopoiesis), and stores calcium and
phosphorus in the bones. Although examining this system is usually only a small
part of the overall physical assessment, everything we do depends on an intact
musculoskeletal system. How extensive an assessment you perform depends largely
on each patient’s problems and needs.
Perform a comprehensive musculoskeletal assessment if you detect a
musculoskeletal abnormality or uncover a symptom that suggests musculoskeletal
involvement. Musculoskeletal problems are common in all age groups. Primary
problems may result from congenital, developmental, infectious, neoplastic,
traumatic, or degenerative disorders of the system itself. Secondary problems
can result from disorders of other body systems.
The goal of a complete musculoskeletal assessment is to detect risk
factors, potential problems, or musculoskeletal dysfunction early and then to
plan appropriate interventions, including teaching health promotion and disease
prevention and implementing treatment measures. By doing so, you can play a
significant role in preventing pain and dysfunction in your patients.
Anatomy and
Physiology Review
Before beginning your assessment,you
need to understand how the musculoskeletal system works. It consists of three
major components:bones,muscles,
and joints.Tendons, ligaments, cartilage, and bursae serve as connecting structures and complete the
system. Figure 20.1 illustrates the musculoskeletal system, anterior and
posterior views.
Bones. Composed of osseous
tissue, bones are divided into two types: compact bone, which is hard and dense
and makes up the shaft and outer layers, and spongy bone, which contains
numerous spaces and makes up the ends and centers of the bones. Osteoblasts and
osteoclasts are the cells responsible for the continuous process of creating
and destroying bone. Osteoblasts form new bone tissue, and osteoclasts break
down bone tissue. Bones also contain red marrow,which produces blood cells, and yellow marrow,which is composed mostly of fat.The
outer covering of bone, called the periosteum,
contains osteoblasts and blood vessels that promote nourishment and formation
of new bone tissue.
Bones vary in shape and include long bones (Fig. 20.2), such as the humerus and femur; short, flat bones, such as the
sternum and ribs; and bones with irregular shapes, such as the hips and
vertebrae.
Muscles. The body is
composed of skeletal, smooth, and cardiac muscle.Made
up of fasciculi (long muscle fibers) that are arranged in bundles and
joined by connective tissue, skeletal muscles attach to bones by way of strong,fibrous cords
called tendons. Ligaments are dense, flexible,
strong bands of fibrous connective tissue that tie bones to other bones.
Cartilage is dense connective tissue consisting of fibers embedded
in a strong, gel-like substance.Cartilage lacks nerve
innervation,blood vessels,and lymph vessels, so it is insensitive to pain and
regenerates slowly and minimally after injury. Regeneration occurs primarily at
sites where the articular cartilage meets the synovial membrane. Cartilage may
be fibrous, hyaline, or elastic.
Fibrous cartilage forms the symphysis pubis
and the intervertebral discs.Hyaline cartilage covers
the articular bone surfaces (where bones meet at a joint),connects
the ribs to the sternum, and is found in the trachea, bronchi, and nasal septum.Elastic cartilage is located in the auditory canal,
the external ear, and the epiglottis.
Joints. The joint or
articulation is the place where two or more bones meet. Joints provide range of
motion (ROM) for the body parts and are classified three ways: by the
degree of movement they permit, by the connecting tissues that hold them
together, and by the type of motion the structure permits. Figure 20.3
illustrates the fibrous and cartilaginous joints and Figure 20.4 the
synovial joints.
Bursae. Bursae are small,
disc-shaped synovial fluid sacs located at points of friction around joints.They act as cushions, thereby reducing the stress to
adjacent structures, and facilitate movement. Two examples of bursae are the prepatellar bursa
(in the knee) and the subacromial bursa (in the
shoulder).
Interaction with Other Body Systems. The neurological
and respiratory systems contribute to maintaining musculoskeletal functioning.
A problem in any of these systems may affect the functioning of the
musculoskeletal system.
Neurological System. The neurological
system is responsible for coordinating the functions of the skeleton and
muscles. If your patient has neurological complaints, combine the musculoskeletal
and neurological assessments because the spinal cord and nerves originate from
the spine and innervate the musculoskeletal structures of the back and the
extremities. A dysfunction in the neurological system is often reflected
as pain, abnormal movement, or paresthesias in the
extremities and/or back.The patient’s gait may
provide information on muscular weakness or neurological disease.
Back pain is a major source of disability in the United States. A large
proportion of the population complains of back pain at one time or another,with the most common
complaint being low back pain radiating into the hip and down the leg.This pain is usually of neurological origin and
emanates from the sciatic nerve. Pain may also be caused by arthritic disease
of the spine or hip or muscle spasm of the lower back. Understanding the
anatomy of the back and spinal nerve tracks will help you determine the pain’s
origin.
Respiratory System. The respiratory
system depends on the thorax, bony structures, and muscles of the chest to
protect the lungs and assist with breathing.The
accessory muscles,which
include the sternocleidomastoid,anterior serrati, scalene, trapezius, intercostal, and rhomboid
muscles, come into play when a person is involved in aerobic activities or when
the body has intrapulmonary resistance to air movement (e.g., chronic pulmonary
lung disease). These accessory muscles enhance ventilation by increasing chest
expansion and lung size during inspiration. Intercostal muscles also coordinate
rib movement; external intercostal muscles pull the ribs up and out,and internal intercostals pull the ribs down and inward. Contraction of
these muscles facilitates air movement into the lungs by decreasing intrathoracic pressure. As these muscles relax, exhalation
occurs as the lung recoils. Abdominal muscles can also assist with deep
breathing, tachypnea (rapid breathing), exercise,
coughing, and sneezing. An intact thoracic cage and normal accessory and
abdominal muscles are necessary for respiratory function.A
musculoskeletal injury or problem in these areas can result in altered
respiratory functioning.
Developmental, Cultural, and Ethnic Considerations
Infants and Children. Before birth, a
skeleton forms in the fetus; it is first composed of cartilage and then
later ossifies into true growing bone. After birth,bone growth continues rapidly during infancy and
then steadily during the childhood years. Another growth spurt occurs for both
boys and girls during adolescence. Long bones increase in diameter by depositing
new bone tissue around the shafts. Lengthening occurs at the epiphyses,which are specialized growth centers (growth
plates) located at the ends of long bones.Any injury
or infection at these growth plates puts the growing child at risk for bone deformity.Longitudinal growth of the bones continues until
closure of the epiphyses,which occurs at age 20.
Skeletal contour changes are also apparent in infants and children. At
birth, the spine has a single C-shaped curve. At 3 to 4 months of age, an
infant is able to raise his or her head from the prone position, allowing the
development of the anterior curve in the cervical neck region. As development
progresses and the infant is able to stand and walk,
the anterior curve develops in the lumbar region. This occurs between 12 and 18
months of age. A toddler stands with feet wide apart to provide balance as he
or she learns to walk.
The school-age child usually stands with the normal adult curvature,which should continue
until old age. Throughout childhood, the skeleton continues to grow linearly;
muscles and fat are responsible for significant weight increases.
Individual muscle fibers continue to grow as the child grows, with a
marked growth period noted during adolescence. At this time, muscles are
responding to increased growth hormone,adrenal
androgens, and testosterone in boys. Muscles vary in growth rate, size, and
strength, depending on genetic factors, nutritional status, and amount of
exercise.
Common knee deviations in children include genu varum
(bowlegs) and genu valgum (knock knees). In a child
with genu varum, the knees are approximately 5 cm
apart and the medial malleoli touch when the child stands. This variation is
common during the first years when the child is beginning to walk,but usually does not persist
beyond 2 to 3 years. When genu valgum is present in a
child, the knees touch and the medial malleoli are 7.5 cm or more apart when
the child is standing. These deviations are considered normal for a child aged
2 to 31⁄2 years and may persist until age 7.
Toddlers often have “potbellies” and lordosis
(accentuated lumbar curve). This posture is normal and helps the child adjust
to the change in the center of gravity. It should disappear as the child grows.
Spinal deformities in children may be structural,but more commonly are caused by poor posture.
Scoliosis (lateral curvature) may become apparent during adolescence,with girls at a higher risk than boys.The
spine does not grow straight, and the shoulders and iliac crests are not the
same height.Assessing for scoliosis is an important
component when working with adolescents.
Additional history questions for parents of infants and children
include:
■ Was
there a normal labor and delivery without trauma to the infant? (Trauma
increases the risk for fractures of the humerus and
clavicle.)
■ Did
the infant need to be resuscitated? (Anoxia may result in hypotonia
of muscles.)
■ Did
the infant develop as expected?
■ Has
the child ever had a broken bone or dislocation? If so, how were these injuries
treated?
■ Have you noticed any
bone deformity, spinal curvature, or unusual shape of the legs, toes, or feet?
Additional history questions for adolescents include:
■ Are you involved in
any sports? How often do you play or practice?
■ Do you use protective
or special equipment?
■ Do you warm up before
participating in an athletic activity?
These questions help assess the safety of the sport for the height and
weight of the adolescent and gauge the risk of injuries.
Pregnant Women. Progressive lordosis is the most characteristic change in posture in
pregnant women. It compensates for the enlarging fetus by shifting the center
of gravity and moving the weight of the enlarging fetus back on the lower
extremities.
This shift in balance may create strain on the low back muscles, which
may be felt as low back pain during late pregnancy. Anterior cervical flexion
during the third trimester, kyphosis (humpback), and slumped shoulders are
other postural changes that compensate for lordosis.Upper
back changes may put pressure on the ulnar and median nerves, creating aching,
numbness, and weakness in the upper extremities of some pregnant women.
Increased mobility in the sacroiliac, sacrococcygeal,and symphysis pubis joints
in the pelvis occurs in preparation for delivery,which
also contributes to the characteristic waddling gait.
Older Adults. With aging, bone density decreases because loss
of bone tissue occurs more rapidly than formation of new bone tissue. This results in osteoporosis, with women at a higher risk
than men and whites affected more often than African Americans.
Kyphosis with a backward head tilt to compensate and slight flexion
of the hips and knees are postural changes that occur with aging. Decreased
height is the most noticeable postural change. It occurs as a result of
shortening of the vertebral column secondary to the loss of water content and
thinning of the intervertebral discs.Both men and
women can expect a decrease in height beginning in their 40s and continuing
until age 60. After this age, height decreases occur
secondary to osteoporotic changes in the height of individual vertebrae. This
collapse of vertebrae results in a shortening of the trunk and comparatively
long extremities. This change in the spine, kyphosis and loss of height due to
collapse and wedging of the vertebral column, is often referred to as dowager’s
hump.
Contour changes also occur as a result of the distribution of
subcutaneous fat. Most men and women gain weight in their fourth and fifth
decades, losing fat in the face and depositing it in the abdomen and hips. This
distribution pattern continues into later years, but fat continues to decrease
in the periphery, especially the forearms.
The loss of subcutaneous fat in certain parts of the body contributes to
marked bony prominences. The tips of the vertebrae, ribs, and iliac crests may
become very noticeable and the body hollows (e.g., cheeks and axillae) become
deeper. There is loss of muscle mass,a
decrease in muscle size, and some muscle atrophy,which
contributes to generalized weakness.These muscle
changes can cause decreased agility, an abnormal gait with uneven rhythm and
short steps, and a wide base of support.Other
complicating factors include fear of falling, osteoporosis, painful arthritic joints,poor vision, and peripheral neuropathy.
Lifestyle can affect the musculoskeletal changes that occur with aging.
A sedentary lifestyle leads to decreased muscle mass and strength and increased
muscle atrophy. Decreased speed and strength, resistance to fatigue, reaction
time, and coordination are changes that can be prevented by physical exercise.
Physical activity also prevents or delays bone loss in aging adults.
Additional history questions for the aging adult should elicit
information about loss of function, self-care deficits,or
safety risks that may occur as a result of aging, injury, or illness.Ask the following questions:
■ Have you broken any
bones recently? If so, how?
■ Have you noticed any
weakness over the past months?
■ Have you had any
increase in stumbling or falls?
■ Do you use mobility
aids like a cane or walker to help you get around?
People of Different Cultures/Ethnic Groups. When assessing the
musculoskeletal system, you need to consider your patient’s ethnicity because
it can affect musculoskeletal anthropomorphic and physical characteristics.
Performing the
Musculoskeletal Assessment
Health History. Obtaining a
thorough and accurate health history is crucial to your assessment of the
musculoskeletal system. As the health history interview progresses, clarify
exactly what the patient means by certain subjective complaints, including the
location, character, and onset of any symptoms. Only the patient can give you
data regarding pain, stiffness, ability to move,and how daily activities have been affected.
The history provides the subjective data that will direct the physical
examination. If time is an issue and you are unable to perform a complete
health history, perform a focused history on the motor-musculoskeletal system.
Biographical Data. A review of the
biographical data may identify patients who are at risk for musculoskeletal
problems. Consider the patient’s age, sex, marital status, race, ethnic origin,
and occupation as possible risk factors. For example, women are at a higher risk
than men for osteoporosis and rheumatoid arthritis (RA); an occupation that
requires heavy lifting increases the risk for injury to muscles, joints, and
supporting structures; and the risk for degenerative joint disease (DJD;
osteoarthritis) increases with age. Even a patient’s address may have significance.
For example, Lyme disease,which
has musculoskeletal repercussions, is endemic on the northeast coast from
Massachusetts to Maryland, in the midwest states of
Wisconsin and Minnesota, and on the west coast from northern California to
Oregon.
Current Health Status. Begin your
assessment with questions about the patient’s current health status, because
she or he is most interested
in this.The major symptoms to watch
for, in order of importance, are pain,weakness, and
stiffness.
Symptom Analysis.
Pain. Pain can result from bone, muscle, or joint problems.
Bone pain is not usually associated with movement unless there is a fracture,
but muscle pain is. Current or recent illness can cause muscle aches.Bone pain is deep, dull, and throbbing;muscle pain takes the form of cramping or soreness.
In RA, joint pain and stiffness are worse in the morning. In osteoarthritis,
the joints are stiff after rest and pain is worse at the end of the day.
Weakness. Muscle weakness associated with certain diseases
migrates from muscle to muscle or to groups of muscles. Knowing the symptom
patterns and when they occur can help identify the disease process responsible
for weakness. Identifying the weakness related to proximal or distal muscle
groups is also helpful.Proximal weakness is usually a
myopathy;distal weakness is
usually a neuropathy.
Be sure to ask the patient if the weakness interferes with his or her
ability to perform everyday activities. For example, proximal weakness of the
upper extremities often presents itself as difficulty lifting objects or
combing hair. Proximal weakness of the lower extremities presents as difficulty
with walking and crossing the knees. Patients with polymyalgia rheumatica have proximal muscle weakness. A distal weakness
of the upper extremities is manifested by difficulty in dressing or
turning a doorknob. Patients with myasthenia gravis have difficulty with
diplopia, swallowing, and chewing, along with generalized muscle weakness.
Stiffness. Stiffness is a common musculoskeletal complaint. It is
important to ascertain if the stiffness is worse at any particular time of the
day. For example, patients with RA are stiff on arising because of the period
of joint rest that occurs during sleep.
Balance and
Coordination Problems. Problems with
balance and coordination often indicate a neurological problem. These problems
often manifest as gait problems or difficulty in performing activities of
daily living (ADLs). The patient may complain of falling or losing balance or
may have ataxia—irregular and uncoordinated voluntary movements.Gait
problems are associated with cerebellar disorders, Parkinson’s disease,
multiple sclerosis (MS),herniated disc, stroke,Huntington’s chorea, brain tumor, inner ear problems,
medications, and exposure to chemical toxins.
Other Related Symptoms. Certain
musculoskeletal diseases may produce multiple symptoms. For example, acute
rheumatic fever, gout, and autoimmune inflammatory diseases may cause
fever and joint pain. A woman with back pain and vaginal discharge may have a
gynecological disease. Lower back pain and weight loss suggest tuberculosis
(TB) of the spine.Bowel and bladder dysfunction
suggest a herniated disc.Therefore, also ask the
patient:“Do you have a sore throat, fever, joint pain, rash,weight
loss, diarrhea, numbness, tingling, or swelling?”
Past Health History. After taking the
past health history, compare it with the patient’s present musculoskeletal
status or uncover risk factors that might predispose the patient to
musculoskeletal disorders.
Family History. The purpose of the family history is to
identify predisposing or causative factors for musculoskeletal problems.After assessing the current and past musculoskeletal
health status, investigate possible familial tendencies toward problems.
Review of Systems. The review of
systems (ROS) allows you to assess the interrelationship of the musculoskeletal
system to every other system. Often, you may uncover important facts that your
patient failed to mention earlier.
Psychosocial Profile. The psychosocial
profile can reveal patterns in the patient’s life that may affect the
musculoskeletal system and put her or him at risk for musculoskeletal
disorders.
Physical Assessment. Now that you have
collected the subjective data, begin collecting the objective data by means of
the physical examination. Keep all pertinent history findings in mind as
you proceed. These findings, along with those from the physical
examination, will complete the assessment picture.Then
you can analyze the data, formulate nursing diagnoses, and develop a plan of a
care. Because a musculoskeletal problem might be present, you will need to know
normal musculoskeletal function before you can determine abnormal findings.
The anatomy will direct your assessment.
Approach. Physical assessment of the musculoskeletal
system provides data on the patient’s posture, gait, cerebellar function and
bone structure,muscle
strength, joint mobility, and ability to perform ADLs. You will use inspection,
palpation, and percussion to assess the musculoskeletal system. Be systematic
in your approach, working from head to toe and comparing one side with the
other. Inspect and palpate each joint and muscle; then assess range of motion
(ROM) and test muscle strength. Perform inspection and palpation simultaneously
during this assessment.
Performing a General Survey. Before examining
specific areas, scan the patient from head to toe, looking for general
appearance and signs of musculoskeletal problems. For example:
■ Obtain the patient’s
vital signs. Elevations in temperature are associated with Lyme disease, RA,
and infections such as osteomyelitis.
■ Be
alert for signs of pain or discomfort as your patient performs ROM. If signs or
symptoms of pain are present with movement, never force a joint.
Performing a Head-to-Toe Physical Assessment. Now look for
changes in every system that might signal a musculoskeletal problem.
Performing a Musculoskeletal Physical Assessment. Now that you have
completed a head-to-toe scan, focus on the specifics of the examination.
Proceed in this order:
■ Assess
posture, gait, and cerebellar function.
■ Measure
limbs.
■ Assess joints and test
joint movement.
■ Assess muscle
strength and ROM.
■ Perform additional
tests to assess for wrist, spine, hip, and knee problems, if necessary.
Assessing Posture, Gait, and Cerebellar Function.
Posture. Begin by assessing your patient’s posture, or his or
her position in relation to the external environment. Posture should be erect,with the head midline.The spine is best assessed with the patient
standing. Inspect from the front, back, and side, looking for alignment and
noting symmetry of shoulders, scapula, and iliac crests. Adults have four
normal curvatures. The cervical and lumbar curves are concave, and the thoracic
and sacral curves are convex.When assessing for
spinal curvature deformities, it is important to determine if the deformity is
structural or functional (postural) in nature. To assess for kyphosis and
scoliosis, have the patient bend forward from the waist with her or his arms
relaxed and dangling.Then stand behind the patient to
check for curvatures.The curvatures disappear in
functional kyphosis and scoliosis but remain in the structural form. To assess
for lordosis,have the
patient stand against a wall and flatten her or his back against it. If
you can freely slide your hand through the lumbar curve, the patient has
structural lordosis. An alternative method is to have
the patient lie supine with the knees slightly flexed and attempt to flatten
her or his lumbar curve. If she or he can, the lordosis
is functional. Next, have your patient stand erect with the feet together and
note the position of the knees. Are the knees midline? Draw an imaginary line
from the anterior superior iliac crest to the feet. Normally, this line should
transect the patella. Note if the patella deviates away from the midline.Normally, the knees should be less than 2.5 cm
(1") apart and the medial malleoli (ankle bones) less than 3 cm (11⁄8")
apart.
Gait. Next,assess your patient’s gait.Pay particular attention to the base of support
(distance between the feet) and stride length (distance between each step). Is
there a wide base of support? The average base of support for an adult is about
2 to 4 inches.The average stride length for an adult
is about 12 to 14 inches. Stride length depends in part on leg length, so the
longer the legs, the greater the stride length.
Also pay attention to the phases of the gait—stance and swing. The
stance phase has four components: heel strike, foot flat,midstance, and push-off. During midstance,
the weight shifts to bearing the full body weight. The swing phase has three
components: accelerate, swing-through, and decelerate. Figure 20.6 illustrates
the two phases and their components. If you do not detect a gait problem, chart
“phases conform.” If you do detect a problem, try to identify the specific
portion of the gait that is abnormal.For example,
someone with left-sided weakness from a stroke may have problems with the
acceleration portion of the swing phase and the midstance
portion of the stance phase. Continue to observe your patient’s gait, taking
note of posture and cadence as he or she walks.Ask yourself: Do the
arms swing in opposition? Is there toeing in or out? Are movements smooth and
coordinated?
Cerebellar
Function. Now, assess
cerebellar function, including balance, coordination, and accuracy of
movements.
Balance. To assess balance, look at
your patient’s gait. If he or she has a gait problem,you will be unable to proceed further. If there are
no gait problems, have the patient tandem (heel-to-toe) walk, heel-and-toe
walk, hop in place, do a deep knee bend, and perform the Romberg test.To perform the Romberg test, have the patient stand
with feet together and eyes open; then have him or her close the eyes. If
cerebellar function is intact,he
or she will be able to maintain balance with minimal swaying with eyes closed
(negative Romberg test). Keep in mind that balance problems may also occur with
inner ear disorders.
Coordination. Next, assess coordination.
Note the patient’s dominant side.Usually this side is
more coordinated.To test upper extremity
coordination, have the patient perform rapid alternating movements (RAMs) by
patting her or his thigh with one hand, alternating between the supinate and
the pronate hand position.Have her or him perform finger-thumb
opposition to further test hand coordination. To test lower extremity
coordination, have the patient perform rhythmic toe tapping and then run the
heel of one foot down the shin of the opposite leg. Remember to test each side
separately and compare findings.
Accuracy of Movements. Point-to-point localization
is used to assess accuracy of movements. Have the patient touch his or her finger
to the nose with the eyes open, then closed.Or have
him or her touch your finger at various positions.
Taking Limb Measurements. Limb measurements include both length and circumference.Measure arm lengths from the acromion process
to the tip of the middle finger.Measure leg
lengths from the anterior superior iliac crest crossing over the knee to the
medial malleolus.This is referred to as true leg
length. An apparent leg length measurement is measured from a nonfixed
point, the umbilicus, to the medial malleolus.
A true leg length discrepancy results from bone length inequality,
whereas an apparent leg length discrepancy may result from a pelvic tilt or flexion
deformity of the hip. Discrepancies between right and left should not exceed
more than 1 cm. Obviously, a leg length discrepancy
usually results in clinical problems such as gait disorders or hip or back
pain.
Limb circumference reflects actual muscle size or muscle mass.
Measure circumference on forearms, upper arms, thighs,and calves.Take note of
the patient’s dominant side,which may normally be up
to 1 cm larger than her or his nondominant side. To
ensure accurate circumference measurement, determine the midpoint of the
extremity being assessed. For example, if you are measuring upper arm
circumference, measure the distance from the acromion process to the olecranon
process, and use the midpoint to determine circumference; then do the same for
the opposite arm.
Assessing Joints and Muscles. Inspect the size, shape,color,and symmetry of each
joint, noting masses,deformities, and muscle atrophy.Compare muscle and joint findings bilaterally
and palpate for edema, heat, tenderness, pain, nodules, crepitus, and stability.
Test active ROM (in which the patient performs the movement)
and passive ROM (in which you put the joint through the ROM) of the joint (Fig.
20.7). Changes in articular cartilage, scarring of the joint capsule,
and muscle contractures all limit motion. It is important to determine the
types of motion the patient can no longer perform, especially the ADLs.
Joint clicking or crepitus may occur normally sometimes or may be
associated with dislocations of the humerus, temporomandibular joint (TMJ) problems, displacement of the
biceps tendon from its groove, damaged knees, or DJD.
Joint deformity may result from a congenital malformation or a chronic
condition. In any patient with a deformity, ask the following questions:
■ When did you first
notice the deformity?
■ Did
the deformity occur suddenly?
■ Did
it occur as the result of trauma?
■ Has
the deformity changed over time?
■ Has
it affected your range of motion?
Test muscle strength by asking the patient to put each joint through ROM
while you apply resistance to the part being moved.If
the patient is unable to move the part against resistance, then ask him or her
to perform the ROM against gravity. If this cannot be performed, attempt to
passively put the muscle through ROM. If this is not possible (because of a
contracture),palpate the muscle while the patient attempts to move it.Document muscle strength as shown in the box entitled
Rating Scale for Muscle Strength.
Begin your assessment by inspecting and palpating the muscles of the
upper and lower extremities.Assess muscle tone and
mass in both relaxed and contracted state, and then assess each joint and test
muscle strength as the patient performs ROM.
Additional Tests. You can perform the
following additional tests to assess for wrist, spinal, hip, and knee problems.
Tests for Wrist
Problems.
Phalen’s
Test. Have the patient flex the hands back to back at a 90-degree angle
and hold this position for about 1 minute (Fig.20.8). If the patient complains
of numbness or tingling anywhere from the thumb to the ring finger, the
test is positive for carpal tunnel syndrome.
Tinel’s
Test. Percuss lightly over the median nerve, located on the inner aspect of the
wrist (Fig. 20.9). If numbness and tingling occur on the palmar aspect
of the wrist and extend from the thumb to the second finger, the test is
positive for carpal tunnel syndrome.
Test for Arm Problems.
Pronator Drift. Perform this test if you
detect muscle weakness of the arms. Have the patient stand with arms extended,
hands supinated, and eyes open and then closed for at least 20 to 30 seconds
(Fig.20.10).Check for downward drift and pronation of the arms and hands.
Pronation and drift of one arm is called pronator
drift and may indicate a mild hemiparesis. Flexion of the fingers and
elbow may accompany pronator drift.A lateral and
upward drift may also occur in patients with loss of position sense. If your
patient is able to hold her or his arms extended without drift, gently tap
downward on the arms. If she or he has normal muscle strength, coordination,
and position sense, the arms will return to the horizontal position. A weak arm
is easily displaced and does not return to the horizontal position.
You can also assess drifting and weakness by having the patient hold his
or her arms over the head for 20 to 30 seconds.Then,
try to force the arms down to the sides as the patient resists.Drifting
or weakness may indicate a hemiparesis.
Test for Spinal Problems.
Straight Leg Raising (Lasègue’s Test).
Perform this test when the patient complains of low back pain that radiates
down the leg (sciatica). This test checks for a herniated nucleus pulposus.Ask the patient to lie flat
and raise the affected leg to the point of pain (Fig.20.11).Pain and sciatica
that intensify with dorsiflexion of the foot are a positive sign for a
herniated disc.
Tests for Hip
Problems.
Thomas Test. This test assesses for hip flexure contractures
hidden by excessive lumbar lordosis. Have the patient
lie supine with both legs extended and then flex one leg to her or his
chest (Fig.20.12).The test is positive if the opposite leg raises
off the table. Repeat the same maneuver on the opposite side.
Trendelenburg Test. This test is used to
assess for a dislocated hip and gluteus medius muscle
strength. Have patient stand erect and check the iliac crest—it should be
level. Then, have the patient stand on one foot and check again. If the iliac
crest remains level or drops on the side opposite the weight-bearing leg, the
gluteus medius muscle is weak or the joint is not
stable and there may be a hip dislocation on the weightbearing
side.
Tests for Knee
Problems. Perform one of the
following two tests if you noted swelling secondary to fluid accumulation
or soft tissue damage.
Bulge Test. Perform this test if you suspect small amounts of fluid.With the patient supine, stroke the medial side
of the knees upward several times to displace the fluid.Then,
press the lateral side of the knee, and inspect for the appearance of a bulge on
the medial side (Fig.20.13).
Patellar Ballottement. Perform this test if you suspect large amounts of
fluid. With the patient supine, press firmly with your left thumb
and index finger on each side of the patella (Fig. 20.14). This displaces
fluid into the suprapatellar bursa between the
femur and the patella. Then, gently tap on the kneecap. If fluid is
present, the patella will bounce back to your finger (floating
kneecap).
Lachman Test. If your patient
complains that his or her knee gives way or buckles, test anterior,posterior,medial, and lateral stability. To test
medial and lateral stability, have the patient extend the knee and attempt to
abduct and adduct it.Normally,no
movement should occur if the knee is stable. To assess the
anterior and posterior plane, have the patient flex the knee at least 30
degrees. Stabilize and grasp the leg below the patella, and attempt to
move it forward and back. If the joint is stable, no movement should occur
(Fig. 20.15).Another similar test for stability of the anterior cruciate
ligament (ACL) and posterior cruciate ligament (PCL) is the drawer test.With the patient’s knee flexed at a 90-degree
angle, apply anterior and posterior pressure against the tibia, and feel for movement.Movement of the tibia is a positive draw sign,
indicating an ACL or PCL tear.
To test stability of the collateral ligament, have the patient lie
supine with the knee slightly flexed.Place your
hand at the head of the fibula and apply pressure medially; then reverse
and apply pressure laterally. If the joint is unstable, movement will occur and
create a palpable medial or lateral gap at the joint.
Perform one of the following tests if your patient complains of clicks
or knee-locking and you suspect a torn meniscus.
McMurray’s Test. To perform McMurray’s test,
position the patient supine with her or his knee fully flexed (Fig. 20.16).
Place one hand on the heel and the other on the knee and gently internally and
externally rotate the foot as you bring the leg to full extension.The
test is positive if audible or palpable clicks occur or the knee locks.
Apley’s Test. Position the patient
supine with his or her knee flexed at 90 degrees (Fig. 20.17).Place one
hand on the heel and the other hand on the knee.Apply
pressure with both hands and gently rotate the foot. The test is positive if
audible or palpable clicks occur.
SUMMARY
■ This chapter taught you how to do a
thorough musculoskeletal assessment, including a health history and physical
examination.
■ Before you begin the assessment, you
need an understanding of the anatomy of the musculoskeletal system including
ROMs of the joints.
■ Since the musculoskeletal system has a
major impact on a person’s well-being and ability to function, begin by taking
a detailed health history.
■ The physical exam of the
musculoskeletal system uses inspection, palpation, and percussion. The exam
includes assessment of gait, posture, cerebellar function, limb measurement,
joints, and muscles.
■ Once you have completed your
assessment, analyze your findings, identify actual and potential health
problems, and write nursing diagnoses and a plan of care.