Musculoskeletal System


image Skin-marking pencil

image Reflex hammer

image Tape measure


Begin examination as patient enters rooms, observing gait and posture. During examination, note ease of movement when patient walks, sits, rises, takes off garments, and responds to directions.

Inspect skeleton and extremities, comparing sides
Inspect anterior, posterior, lateral aspects of posture; ability to stand erect; body parts; extremities.  

image Size, alignment, contour, symmetry

Measure extremities when lack of symmetry is noted in length or circumference.

EXPECTED:Bilateral symmetry of length, circumference, alignment, position and number of skinfolds; symmetric body parts; and aligned extremities.
UNEXPECTED:Gross deformity, lordosis, kyphosis, scoliosis, bony enlargement.
Inspect skin and subcutaneous tissues over muscles, cartilage, bones, joints
  UNEXPECTED:Discoloration, swelling, or masses.
Inspect muscles, and compare sides
imageSize and symmetry EXPECTED:Approximately symmetric bilateral muscle size.
UNEXPECTED:Gross hypertrophy or atrophy, fasciculations, or spasms.
Palpate all bones, joints, surrounding muscles (palpate inflamed joints last)
imageMuscle tone EXPECTED:Firm.
UNEXPECTED:Hard or doughy, spasticity.
imageCharacteristics UNEXPECTED:Heat, tenderness, swelling, fluctuation of a joint, synovial thickening, crepitus, resistance to pressure, or discomfort to pressure on bones and joints.
Test each major joint and related muscle groups for active and passive range of motion, and compare sides
Ask patient to move each joint through range of motion (see instructions for specific joints and muscles in individual sections that follow), then ask patient to relax as you passively move same joints until end of range is felt. EXPECTED:Passive range of motion often exceeds active range of motion by 5 degrees. Range of motion with passive and active maneuvers should be equal between contralateral joints.
UNEXPECTED:Pain, limitation of motion, spastic movement, joint instability, deformity, contracture, discrepancies greater than 5 degrees between active and passive range of motion. When increase or limitation in range of motion is found, measure angles of greatest flexion and extension with goniometer, as shown in figure below, and compare with values as described for specific joints in individual extremities.



Test major muscle groups for strength, and compare contralateral sides
For each muscle group, ask patient to contract a muscle by flexing or extending a joint and to resist as you apply opposing force. Compare bilaterally. EXPECTED:Bilaterally symmetric strength with full resistance to opposition.
UNEXPECTED:Inability to produce full resistance. Grade muscular strength according to table below.

Muscle Strength Assessment

Muscle Function Level Grade
No evidence of contractility 0
Slight contractility, no movement 1
Full range of motion, gravity eliminated* 2
Full range of motion against gravity 3
Full range of motion against gravity, some resistance 4
Full range of motion against gravity, full resistance 5

* Passive movement.

From Jacobson, 1998.

Inspect dorsum and palm of each hand
imageCharacteristics and contour EXPECTED:Palmar and phalangeal creases, palmar surfaces with central depression with prominent, rounded mound on thumb side (thenar eminence) and less prominent hypothenar eminence on little-finger side.
imagePosition EXPECTED:Fingers able to fully extend and aligned with forearm when in close approximation to each other.
UNEXPECTED:Deviation of fingers to ulnar side or inability to fully extend fingers; swan neck or boutonnière deformities.
imageShape EXPECTED:Lateral finger surfaces gradually tapered from proximal to distal aspects.
UNEXPECTED:Spindle-shaped fingers, bony overgrowths at phalangeal joints.
Palpate each joint in hand and wrist
Palpate interphalangeal joints with thumb and index finger, as shown in the figure on p. 220, A; metacarpophalangeal joints with both thumbs, as shown in the figure on p. 220, B; and wrist and radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist, as shown in the figure on p. 220, C. EXPECTED:Joint surfaces smooth.
UNEXPECTED:Nodules, swelling, bogginess, tenderness, or ganglion.


A, Palpating the interphalangeal joints with thumb and index finger. B, Palpating metacarpophalangeal joints with both thumbs. C, Palpating radiocarpal groove with thumbs on dorsal surface and fingers on palmar aspect of wrist.

Assess integrity of median nerve

image Tinel sign

Strike median nerve where it passes through carpal tunnel with index or middle finger.

UNEXPECTED:Tingling sensation radiating from wrist to hand along pathway of median nerve.

image Thumb abduction test

Apply downward pressure on thumb as patient holds thumb perpendicular to hand, palm side up.

EXPECTED:Full resistance to pressure.
UNEXPECTED:Inability to produce full resistance.

image Phalen test

Have patient hold both wrists in fully palmar-flexed position with dorsal surfaces pressed together for 1 minute.

UNEXPECTED:Numbness, paresthesia in distribution of median nerve.

image Katz hand diagram

Have patient mark specific locations of pain, numbness, tingling in hands and arms on diagram.

UNEXPECTED:Pain, numbness, tingling in pattern shown in figure on below.

Redrawn from D’Arcy and McGee, 2000.

Test range of motion
Ask patient to perform the following movements:  

image Metacarpophalangeal flexion and hyperextension

Bend fingers forward at metacarpophalangeal joint, then stretch fingers up and back at knuckle.

EXPECTED:90-degree metacarpophalangeal flexion and as much as 30-degree hyperextension.

image Thumb opposition

Touch thumb to each fingertip and to base of little finger, then make a fist.

EXPECTED:Able to perform all movements.

image Finger abduction and adduction

Spread fingers apart, and then touch them together.

EXPECTED:Both movements possible.

image Wrist extension and hyperextension

Bend hand at wrist up and down.

EXPECTED:90-degree flexion and 70-degree hyperextension.

image Radial and ulnar motion

With palm side down, turn each hand to right and left.

EXPECTED:20-degree radial motion and 55-degree ulnar motion.
Test muscle strength
Ask patient to perform the following movements:  

image Wrist extension and hyperextension

Maintain wrist flexion while you apply opposing force.

EXPECTED:Bilaterally symmetric with full resistance to opposition.
UNEXPECTED:Inability to produce full resistance.

image Hand strength

Grip two of your fingers tightly.

EXPECTED:Firm, sustained grip.
UNEXPECTED:Weakness or pain.
Inspect elbows in flexed and extended positions
imageContour UNEXPECTED:Subcutaneous nodules along pressure points of extensor surface of ulna.

image Carrying angle

Inspect with arms at sides passively extended, palms facing forward.

EXPECTED:Usually 5 to 15 degrees laterally.
UNEXPECTED:Lateral angle exceeding 15 degrees (cubitus valgus) or a medial carrying angle (cubitus varus).
Palpate extensor surface of ulna, olecranon process, medial and lateral epicondyles of humerus, groove on each side of olecranon process
Palpate with patient’s elbow flexed at 70 degrees. UNEXPECTED:Boggy, soft, tenderness at lateral epicondyle or along grooves of olecranon process and epicondyles.
Test range of motion
Ask patient to perform the following movements:  

image Flexion and extension

Bend and straighten elbow.

EXPECTED:160-degree flexion from full extension at 0 degrees.

image Pronation and supination

With elbow flexed at right angle, rotate hand from palm side down to palm side up.

EXPECTED:90-degree pronation and 90-degree supination.
UNEXPECTED:Increased pain with pronation and supination of elbow.
Test muscle strength
Ask patient to maintain flexion and extension, as well as pronation and supination, while you apply opposing force. EXPECTED:Bilaterally symmetric with full resistance to opposition.
UNEXPECTED:Inability to produce full resistance.
Inspect shoulders, shoulder girdle, clavicles and scapulae, area muscles
image Size and contour EXPECTED:All shoulder structures symmetric in size and contour.
UNEXPECTED:Asymmetry, hollows in rounding contour, or winged scapula.
Palpate sternoclavicular and acromioclavicular joints, clavicle, scapulae, coracoid process, greater trochanter of humerus, biceps groove, area muscles

Palpate the biceps groove by rotating the arm and forearm externally. Follow the biceps muscle and tendon along the anterior aspect of the humerus into the biceps groove.

Palpate the muscle insertion for the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder.

EXPECTED:No tenderness or masses, bilateral symmetry.

UNEXPECTED:Pain, tenderness, mass.
Test range of motion
Ask patient to perform the following movements:  
imageShoulder shrug EXPECTED:Symmetric rising.

image Forward flexion

Raise both arms forward and straight up over head.

EXPECTED:180-degree forward flexion.

image Hyperextension

Extend and stretch both arms behind back.

EXPECTED:50-degree hyperextension.

image Abduction

Lift both arms laterally and straight up over head.

EXPECTED:180-degree abduction.

image Adduction

Swing each arm across front of body.

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on Musculoskeletal System

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