Chapter 24

Assessing Musculoskeletal
System
Structure and Function

 Composed of bones, muscles, and joints

 Controlled and innervated by nervous system
 Provide structure and movement of body

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Bones
 206 bones
 Axial: head, trunk
 Appendicular: extremities,
shoulders, hips
 Types: compact, spongy
 Osteoblasts, osteoclasts
 Red and yellow marrow
 Periosteum
 Shapes: short, long, flat,
irregular

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Skeletal Muscles #1

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Skeletal Muscles #2

 Types: voluntary (skeletal), smooth, cardiac

 Tendons: attach muscles to bones
 Assist with posture, produce body heat, allow body
to move

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Skeletal Muscles #3

 Abduction–Adduction Circumduction

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Skeletal Muscles #4

 Eversion–Inversion Pronation–Supination

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Skeletal Muscles #5

 Flexion–Extension
 Hyperextension: joint
bends greater than
180 degrees
 Dorsiflexion: toes draw
upward toward ankle
 Plantar flexion: toes
point away from ankle

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Skeletal Muscles #6

 Protraction–Retraction Rotation

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Question #1

Which skeletal muscle movement means “to move

forward”?

A. Abduction
B. Flexion
C. Protraction
D. Eversion

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Answer to Question #1

C. Protraction

Protraction means moving forward. Abduction is

moving away from the midline of the body. Bending
the extremity at the joint and decreasing the angle of
the joint is known as flexion. Moving outward is known
as eversion.

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Joints #1

 Where two or more bones meet

 Provide variety of range of motion (ROM)
 Classifications:
o Fibrous: joined by fibrous connective tissue,
immovable
o Cartilaginous: joined by cartilage
o Synovial: space between bones filled with
synovial fluid, provides lubrication for movement
 Joined by ligaments, encased by capsule
 Bursae, provides cushion

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Joints #2

 Tip to remember:
Bone to bone = ligament
Bone to muscle = tendon
B–B–L
B–M–T

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Joints #3

 Temporomandibular Elbow

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Joints #4

 Sternoclavicular Shoulder

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Joints #5

 Wrist, fingers, thumb Vertebrae (lateral view)

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Joints #6

 Hip Knee

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Joints #7

 Ankle and foot

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Biological (Genetic) and Cultural Behavior
Variations #1

 Many biologic variations of bones and muscles

 Frontal bone thicker in Blacks; parietal bones thicker in Whites
 Ethnic differences in lengths of radius and ulna
 Difference in number of vertebrae
 Difference in incidence of arthritis: non-Hispanic Whites (41.3
million), non-Hispanic Blacks (6.1 million), Hispanics (4.4
million), non-Hispanic Asians (1.5 million); 26% women, 19.1%
men (CDC, 2019)
 Osteoporosis-related fractures: 51% Europeans and Americans,
followed by Western Pacific and Southeast Asia (2000)

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Biological (Genetic) and Cultural Behavior
Variations #2

 Lactose intolerance: 80% to 95% of Asians and

Native Americans; 18% to 26% of northern
Europeans
 Some African Americans have large gluteal
prominence that tends to look like lumbar lordosis.
 Unequal lengths of ulna and radius have been found
in some ethnic groups (Swedes, Chinese).

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Older Adult Considerations #1

 Osteoporosis: affects 200 million women worldwide:

approximately 1/10 aged 60, 1/5 aged 70, 2/5 aged 80, 2/3
aged 90; one in three women and one in five men will have
fractured bone
 Bone lose density with age, risk for bone fracture, especially
wrists, hips, vertebrae.
 Joint-stiffening conditions may be misdiagnosed as arthritis,
especially in older adult.
 Osteoporosis is more common as person ages because bone
resorption increases, calcium absorption decreases, and
production of osteoblasts decreases.
 Some positions during physical examination will be
uncomfortable due to decreased flexibility.

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Older Adult Considerations #2

 Slower movements, reduced flexibility, decreased

muscle strength due to age-related muscle fiber and
joint degeneration, reduced elasticity of tendons,
joint capsule calcification
 May have impaired sense of position in space,
contributing to risk of falling
 Kyphosis is common.
 Do not insist client touches toes when bending
forward unless client comfortable with the
movement.
 May have bow-legged appearance due to decreased
muscle control
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Question #2

Is the following statement true or false?

Decreased estrogen levels after menopause increase

the risk of osteoporosis.

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Answer to Question #2

True

Decreased estrogen levels in postmenopausal women

decrease bone mass density, making them prone to
osteoporosis.

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Collecting Subjective Data: The Nursing
Health History

 History of present health concern

 Personal health history
 Family history
 Lifestyle and health practices

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General Routine Screening

 Observe posture and gait.

 Inspect the following for symmetry, color, mobility:
TMJ, sternoclavicular joint, cervical, thoracic and
lumbar spin, shoulders, arms, elbows, wrists, hands,
fingers, hips, knees, ankles, and feet.
 Palpate the following for tenderness, heat, swelling,
or nodules: TMJ, sternoclavicular joint, cervical,
thoracic, and lumbar spin, shoulders, arms, elbows,
wrists, hands, fingers, hips, knees, ankles, and feet.

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Focused Specialty Assessment #1

 Measure the ROM with goniometer of: TMJ, cervical

and lumbar spin, shoulders, elbows, wrists, fingers,
hips, knees, ankles, and toes.
 Palpate the anatomic snuffbox.
 Test for carpal tunnel syndrome (CTS).
 Test for thumb weakness.
 Observe for the “flick” signal.

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Focused Specialty Assessment #2

 Perform “squeeze test” of hand and foot.

 Measure leg length.
 Perform the budge test.
 Perform the ballottement test.
 Perform the straight leg raising (Lasegue test).

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Collecting Objective Data: Physical
Examination #1

 Provides data regarding client’s posture, gait, bone

structure, muscle strength, joint mobility, ability to
perform ADLs.
 Includes inspecting and palpating joint, muscles,
and bones; testing ROM, assessing muscle strength.
 Preparing the client
o Room at comfortable temperature
o Adequate draping
o Explain procedure
o Demonstrate as needed

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Collecting Objective Data: Physical
Examination #2

 Equipment
o Tape measure
o Goniometer
o Skin marking pen

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Collecting Objective Data: Physical
Examination #3

 Physical assessment
o Observe gait and posture.
o Inspect joints, muscles, extremities for size,
symmetry, and color.
o Palpate joints, muscles, extremities for tenderness,
edema, heat, nodules, and crepitus.
o Test muscle strength and ROM of joints.
o Compare bilateral findings of joints and muscles.
o Perform special tests for CTS.
o Perform the “bulge,” “ballottement,” and McMurray
knee tests.

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Collecting Objective Data: Physical
Examination #4

 Posture and gait

o Inspection
 Observe posture.
 Observe gait.
 Temporomandibular joint
o Inspection and palpation
 Inspect and palpate the TMJ.
 Test ROM.

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Collecting Objective Data: Physical
Examination #5

 Sternoclavicular joint
o Inspection and palpation
 With client sitting, inspect the sternoclavicular
joint.
 Cervical, thoracic, and lumbar spine
o Inspection and palpation
 Observe cervical, thoracic, and lumbar curves.
 Palpate spinous processes and paravertebral
muscles.
 Test ROM on cervical spine.

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Collecting Objective Data: Physical
Examination #6

 Cervical, thoracic, and lumbar spine—(cont.)

o Inspection and palpation—(cont.)
 Test lateral bending.
 Evaluate rotation.
 Test ROM of lumbar spine.
 Test for back and leg pain.
 Measure leg length.

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Collecting Objective Data: Physical
Examination #7

 Shoulders, arms, and elbows

o Inspection and palpation
 Inspect and palpate shoulders and arms.
 Test ROM.
 Elbows
o Inspection and palpation
 Inspect for size, shape, deformities, redness,
or swelling.
 Test ROM.

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Collecting Objective Data: Physical
Examination #8

 Wrists
o Inspection and palpation
 Inspect wrist size, shape, symmetry, color, and
swelling; palpate for tenderness and nodules.
 Perform squeeze test.
 Palpate anatomic snuffbox.
 Test ROM.
o Tests for CTS
 Perform Phalen test, test for Tinel sign, observe
flick signal, test for thumb weakness.

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Collecting Objective Data: Physical
Examination #9

 Hands and fingers

o Inspection and palpation
 Inspect size, shape, symmetry, color, and
swelling.
 Test ROM.
 Repeat maneuvers against résistance.

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Collecting Objective Data: Physical
Examination #10

 Hips
o Inspection and palpation
 Inspect symmetry and shape of hips with
client standing; convex thoracic curve,
concave lumbar curve.
 Palpate for stability, tenderness, and crepitus.
 Test ROM, with and without resistance.
 Lasegue test or straight leg raising.

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Collecting Objective Data: Physical
Examination #11

 Knees
o Inspection and palpation
 Inspect size, shape, symmetry, swelling,
deformities, and alignment with client supine then
sitting with knees dangling.
 Palpate for tenderness, warmth, consistency,
nodules.
 Perform bulge test if swelling is present.
 Perform ballottement test.
 Test ROM.
 Test for pain and injury.

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Collecting Objective Data: Physical
Examination #12

 Ankles and feet

o Inspection and palpation
 With client sitting, standing, and walking,
inspect position, alignment, shape, and skin.
 Palpate ankles and feet for tenderness, heat,
swelling, or nodules.
 Test ROM.

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Ottawa Ankle Rules for X-ray Referral

 Ankle x-ray indicators

o Malleolar area pain, bone tenderness at tips of 6-
cm edges of lateral malleolus or medial
malleolus
o Inability to bear weight immediately or during
examination
 Foot x-ray indicators
o Pain in midfoot area and bone tenderness at
bone of fifth metatarsal or navicular bone area
o Inability to bear weight immediately or during
examination

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Validating and Documenting Findings

 Validate all assessment data collected.

 Verify data are reliable and accurate.
 Document assessment data following health care
facility or agency policy:
o COLDSPA
o SBAR

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Analyzing Data to Make Informed Clinical
Judgments

 Selected client concerns

o Opportunity to improve health
o Risk for client concerns
o Actual client concerns
 Selected collaborative problems
o RC: Risk for Complications
 Medical problems

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Question #3

Which test is being conducted in this figure?

A. Tinel test
B. Phalen test
C. Flick signal test
D. Squeeze test

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Answer to Question #3

B. Phalen test

The Phalen test is conducted by asking the client to

place the backs of both hands against each other
while flexing the wrists 90 degrees with fingers
pointed downward and wrists dangling. The client
should hold this position for 60 seconds. This will test
the client for possible carpel tunnel syndrome. The
Tinel and flick tests are also used to determine carpal
tunnel syndrome. The squeeze test is conducted on
the wrist.

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Osteoporosis #1

 Bones demineralize and become porous and fragile,

susceptible to fractures; occurs silently and
progressively; often no symptoms until first fracture
 Most common fractures: spine, wrist, hip
 Affects 200 million women worldwide
 Screening: in women aged 65 years and older,
postmenopausal women younger than 65 whose
fracture risk is same or more than that of a 65-year-
old White woman who has no additional risk factors

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Osteoporosis #2

 Fixed risk factors

o Age, female gender, ethnicity, family history of
osteoporosis, previous fracture, menopause/
hysterectomy, long-term glucocorticoid therapy,
rheumatoid arthritis, primary/secondary
hypogonadism in men
 Modifiable risk factors
o Alcohol intake, smoking, low BMI, poor nutrition,
vitamin D deficiency, eating disorders, low
dietary calcium intake, insufficient exercise,
frequent falls

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Osteoporosis #3

 Risk factors for fracture

o Age 65 or older, vertebral compression fracture,
fracture with minimal trauma after age 40,
family history of osteoporotic fracture, long-term
use of glucocorticoid therapy, medical
conditions, primary hyperparathyroidism,
tendency to fall, spinal fracture apparent on x-
ray, hypogonadism, early menopause,
rheumatoid arthritis, hyperthyroidism, low body
weigh, if present weight is more than 10% below
weight at age 25, low calcium intake, excess
alcohol, smoking, low bone mineral density

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Osteoporosis #4

 Client education
o Teach parents to help their children.
 Ensure nutritious diet with adequate calcium
intake.
 Avoid protein malnutrition and undernutrition.
 Maintain an adequate supply of vitamin D.
 Participate in regular physical activity.
 Avoid effects of secondhand smoke.

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Osteoporosis #5

 Client education—(cont.)
o Teach clients to prevent bone loss.
 Ensure nutritious diet with adequate calcium
intake.
 Avoid undernutrition, particularly effects of
severe weight loss diets or eating disorders.
 Maintain adequate supply of vitamin D.
 Participate in regular weight-bearing activity.
 Avoid active and secondhand smoking and
heavy drinking.

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Abnormal Spinal Curvatures #1

 Thoracic kyphosis, lordosis, and scoliosis

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Abnormal Spinal Curvatures #2
 Flattening of the
lumbar curvature Lumbar hyperlordosis

Reprinted with permission from Miniaci, A. (2013). Disorders of the shoulder: Sports injuries. Wolters Kluwer.

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Abnormal Spinal Curvatures #3

 Kyphosis Ankylosing spondylitis

Courtesy of Martin Herman, M.D.

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Abnormal Spinal Curvatures #4

 Scoliosis

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Abnormalities Affecting Wrists, Hands,
and Fingers #1
 Acute rheumatoid arthritis Thenar atrophy

Reprinted with permission from Bickley, L. S., Szilagyi,

Reprinted with permission from Ballantyne, J. C., P. G., & Hoffman, R. M. (2016). Bates’ guide to
Fishman, S. M., & Rathmell, J. P. (2019). Bonica’s physical examination and history taking (12th ed.,
figure in Table 16-7). Lippincott Williams
management of pain (5th ed., Fig. 34-5). Wolters
Kluwer & Wilkins.

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Abnormalities Affecting Wrists, Hands,
and Fingers #2

 Chronic rheumatoid arthritis

Boutonniére deformity Swan-neck deformity

Reprinted with permission from Wiesel, S. W. (2016). Operative techniques in orthopaedic surgery (2nd
ed., Fig. 6-105-2B, C). Lippincott Williams & Wilkins

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Abnormalities Affecting Wrists, Hands,
and Fingers #3

 Ganglion Tenosynovitis

SPL/Science Source

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Abnormalities Affecting Wrists, Hands,
and Fingers #4

 Osteoarthritis

Heberden nodes Bouchard nodes

Reprinted with permission from Bickley, L. (2013).

Bates’ guide to physical examination and history-taking
(11th ed., Fig. 16-73). Lippincott Williams & Wilkins; Dr P. Marazzi/Science Source.

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Abnormalities Affecting the Feet and
Toes #1

 Acute gouty arthritis Callus

Dr P. Marazzi/Science Source.

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Abnormalities Affecting the Feet and
Toes #2

 Flat feet

Reprinted with permission from Bickley, L. S., & Examining flat feet, Reprinted with permission from
Szilagyi, P. (2003). Bates’ guide to physical Diab, M., & Staheli, L. T. (2015). Practice of paediatric
examination and history taking (8th ed.). Lippincott orthopaedics (3rd ed.). Wolters Kluwer.
Williams & Wilkins.

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Abnormalities Affecting the Feet and
Toes #3

 Hallux valgus Corn

Reprinted with permission from Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.).
Lippincott Williams & Wilkins.)

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Abnormalities Affecting the Feet and
Toes #4

 Hammer toe Plantar wart

Reprinted with permission from Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd
ed.). Lippincott Williams & Wilkins.)

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Question #4

Is the following statement true or false?

Calluses are painful thickenings of the skin that occur

over bony prominences and at pressure points.

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Answer to Question #4

False

Calluses are nonpainful areas of thickened skin that

occur at pressure points. Corns are painful thickenings
of the skin that occur over bony prominences and at
pressure points.

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