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MUSCOLOSKELETAL ASSESSMENT

LESSON #12

Web Sites of Interest:

Images of most body systems: tutorials, lab exercises & examinations, “case of the
week,” & links to other sites
http://telpatah2.med.utah.edu/WebPath/webpath.html

Alphabetical lists of diseases & disorders


http://www.mic.ki.se/Diseases/alphalist.html

Variety of topics
http://www.mayohealth.org

Primary Functions: Key Points


Structure for soft tissues
Protect vital organs
Storage for minerals
Produce RBCs (bone marrow)
Stability & mobility for physical activity

Assess for:
Symmetry
Muscle strength
Range of motion
Balance
Coordination
Gait
Reflexes

Development of Musculoskeletal System

Fetal: Cartilage calcifies & becomes bone

Childhood: Bone increases in length via epiphyses


Increase in diameter
New bone tissue around bone shaft
Ligaments stronger than gone until puberty
Bone growth completed about age 20
Peak bone mass around age 35
Example: average healing time for fractures
Infant 2-3 weeks
Young child 4 weeks
Older child 6-8 weeks
Adolescent 8-12 weeks

Aging :
Fibrosis of connective tissue
Increased collagen

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Decreased water
Tendons less elastic
Decreased reaction time
Increased bone reabsorption (increased risk for fractures)
Decreased bone density (increased risk for fractures)
Deterioration of cartilage around joints (decreased ROM, stiffness, pain)

Common Musculoskeletal Problems

Systemic: Examples:
RA (rheumatoid arthritis)
Systemic Lupus Erythematosis
Polymyositis
Symptoms:
Inflammation
Fever
Changes in lab values
Chronic weakness
Joint stiffness

Localalized: Examples:
Lumbar strain
Tennis elbow
Symptoms:
History of trauma
Inflammatory response
Erythema
Edema
Restriction of motion
Pain

Facts: 1 of 7 suffers from M-S disorder


Cost 60 billion annually
Ranks second for reasons for visits to medical office

Structure
Bone: Collagen fibers: gel of calcium & phosphate

Bursae: Fibrous sac between tendons & bones beneath


Synovial membrane secretes fluid, which acts as a cushion,
allowing tendon to contract & relax over bone
Bursitis: inflammation of bursa. Connective tissue surrounding joint

Muscles: Organs of contraction to cause movement

Ligaments: Attach bone to bone

Tendons: Attach muscle to bone

Cartilage: Type of connective tissue:


Involved with joint function & bone length
Joints: Connection between bones, made up on fibrous, cartilaginous tissue
Three basic types of joint movement:
• Immovable: fixed
• Slightly movable: “symphysis” (fibrous cartilage joins
articulating bones)

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• Movable: most common
• Hinge (flexion – extension)
• Pivot (rotation on one axis)
• Condyloid (2 axis movement)
• Saddle (2 axis, similar to condyloid)
• Ball & socket (multiple axis & rotation)
• Plane joint (multiple axis, more limited)

Selected Anatomical References (for skeletal system)

Medial: ulnar & tibial aspects of extremities


Lateral: radial & fibular aspects of extremities
Median plane: anterior – posterior
Coronal plane: vertical – lateral
Ventral: anterior
Dorsal: posterior
Hands: Palmer = anterior surface: Dorsal = top of hand
Feet: Planter – sole: Dorsal = top
Displacements: Valgus = lateral: Varus = medial

Range of Motion for Joints: may be measured with goniometer

Muscle Strength: May be measured with range of motion, and either passive or active

MUSCLE FUNCTION LEVEL GRADE %NORMAL LOVETT SCALE


No contraction 0 0 0 (zero)
Slight contraction 1 10 T (trace)
Full ROM, passive 2 25 P (poor)
Full ROM, active 3 50 F (fair)
Full ROM, some resistance 4 75 G (good)
Full ROM, full resistance 5 100 N (normal)

History:

PMH
Viral illness or chronic illness
Limitation of movement
Spasm
Precipitating factors: injury, activity
Stress
Numbness/tingling
Crepitus
Injury (sensation, mechanism of injury, direct trauma, twist,
pain, swelling, trauma to nerves or soft tissues, fractures
Employment
Exercise
Weight
Nutrition

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Cigarette use
Medications
Breast implants (autoimmune responses, especially in joints)

FH: Congenital deformities, scoliosis, back problems, arthritis

Common Symptoms: Pain (check dull vs sharp: temporal effects)


Weakness (check weakness vs fatigue)
Proximal weakness: more consistent with myopathy
Distal weakness: more consistent with neuropathy
Deformity
Limitation of movement
Stiffness
Joint clicking

Assessment: Consider:
full exposure, symmetry & diameter measurements

Inspection: Note symmetry, bones, joints, muscles, symmetry,


Swelling, nodules, atrophy, wasting, masses, deformities

Palpation: bones, joints, muscles


Note: tenderness, creptius, heat, muscle strength

Passive & active ROM: slowly


Note: limitations, stiffness, tenderness, crepitus, function,
Strength, wasting, inflammation, redness, warmth
Goniometer: may be used to measure degrees of flexion
& extension

Muscle strength: use rating scale (as outlined above)

Gait

Spine

Joint Pain:

Inflammation Present:
Yes - RA, SLE
No – Osteoarthritis

Number of joints involved:


Monoarticular - gout, trauma, septic arthritis, lyme disease
Polyarticular - RA, SLE

Joint pain & site of involvement


Distal interphalangeal (DIP):
more common with osteoarthritis

Metacarpal interphalangeal (PIP) wrists:

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more common with RA, SLE

First metatarsal phalangeal:


Consider gout, osteoarthritis

Osteoarthritis:

Affects 1/4 population


Degeneration of articular cartilage
Weight bearing & distal finger joints
Pain worsens with exercise
Morning stiffness or immobility
Heberdon’s nodes

Rheumatoid Arthritis:

Chronic inflammatory condition


Insidious onset of weeks to months
Fatigue, malaise, morning stiffness
Swelling of joints, polyarticular, PIP, MCP joints commonly affected
ROM may be limited, tenderness of joints

Laboratory Assessment:
• CBC & differential (H & H may be low)
• Erythrocyte sedimentation rate (inflammatory process)
• Urinalysis
• RF: Rheumatoid Factor titer
(a macroglobulin type antibody, elevated in rheumatoid arthritis)
• ANA: Antinuclear Antibodies
(an immunofluorescent test for differential diagnosis of
rheumatic disease, for detection of antinucleoprotein factors
& patterns associated with several autoimmune diseases,
particularly systemic lupus erythematosis (SLE)

Low Back Pain:

Disables 5.4 million


Lifetime prevalence 60-90%

Risk Factors:
Repetitive lifting
Exposure to vibration
Cigarette smoking
Osteoporosis - Spinal stenosis
Obesity
Lack of exercise

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Increased age

Differential Diagnosis:
Acute lumbar-sacral sprain
Postural backache
Lumbar sick syndrome
Osteoarthritis
Irritable bowel syndrome
Urinary disorders (including bladder, kidney, prostate)
GYN disorders
Ankylosing spondylitis (chronic inflammatory, AM stiffness,
limitation of spinal movement)
Tumors

Exam:

Inspection: curvatures, iliac crests, leg length, scoliosis,


flexion deformity of hips, lordosis

Palpation: each spinal process

Passive & active ROM

Heal - toe talking toe & heel walking may help; differentiate some neuropathies
(tandem) Example: difficulty walking on heel (L5)
difficulty walking on toes (S1)

DTRs Rating (0 – 4+ scale) & symmetry


1 no response
1+ diminished
2+ normal
3+ increased
4+ hyperactive

Motor strength

Sensation

Straight Leg Raising (SLR) helpful in evaluating back pain


Supine SLR Examples:
Distracted or sitting SLR Sciatica: pain descends down
posterior thigh & below the knees &
coughing or sneezing increases pain
Nerve Root (disc): usually elicited on same,
ipsilateral side
Muscle strain: more associated with pain
Elicited on opposite, contralateral side

Hip Flexion Deformity (supine position) When hip is flexed on abdomen,


Contralateral leg thigh flexes

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Hip ROM Restricted abduction is a common in osteoarthritis
Restricted hip rotation is an early sign of
degenerative hip disease
External hip rotation limitation, followed by reduced
abduction & adduction, then flexion
Trendelenburg test: positive test indicates disorders of femur, hip or
related muscle groups

Lumbar Disc Syndrome:

With repetitive trauma: progressive degeneration of nuclei pulposus leading to protrusion or complete
extrusion of disc into n neural canal
• 95% at 4 & 5 L spaces
• Most common between 3rd & 4th decades

Clinical Features: Low back pain


Restriction of back motion
Radicular pain (pain radiates down leg & below knee (nerve root)
Paresthesias
Local tenderness

Acute Lumbar-Sacral Strain:

Related to muscular, ligaments, or facial strain secondary to specific trauma


or continuous mechanical stress
• Most common in age 20-40
• Obesity & lack of exercise

Clinical Features: Low back pain


Muscle spasm
Local tenderness or swelling
Neurologic exam negative (no radicular pain)

Treatment: Bedrest Ice - 24 hours


Heat - dry or moist NSAIDS
Low back exercises May need muscle relaxant

Cauda Equina: Massive midline protrusion


Medical emergency
Presentation: weakness to legs, urinary changes, impotence, loss of
sphincter tone & saddle anesthesia

Knee:
• Largest joint in body
• No intrinsic stability, depends on ligaments, muscles, menisci & capsule for support
• Medial collateral ligament: limits abduction
• Lateral collateral ligament: limits adduction
• Anterior cruciate ligament: prevents anterior knee displacement
• Posterior cruciate ligament: prevents posterior knee displacement
• Quadriceps: control extension & prevent hip dislocation
• Hamstrings: support tendon for ankle & lower leg

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• Meniscus: cartilage above tibia & fibula, facilitate knee movement

Knee Injuries:
Strains & sprains of the knee are often caused by forces that create abduction of the leg
at the knee, with hyperextension of the knee or by direct blows to the knee
• Strain: injury mostly to muscles
• Sprain injury to supporting ligaments, tendons & muscles

Knee Pain History:

Position of leg at time of injury (rotation, flexion, extension)


Popping? (often associated with anterior crutiate injury)
Stepping out of joint? (often associated with patellar injury)
Swelling? Immediate (ligament)
Gradual (meniscus: 24 – 42 hours post injury)
Stiffness?
Loss of function?

Exam:

Inspection: skin, color


Palpation: pulses, effusion
ROM: normal flexion 130 degrees & extension 15 degrees

Knee Stability Testing:

• Anterior – Posterior Stability


• Anterior drawer test (anterior cruciate ligament)
• Posterior drawer test (posterior cruciate ligament)
• Lachman test

• Lateral Stability
• Valgus & varus stress tests: (lateral & medial collateral ligaments)

• Rotation Tests: for assessment of meniscus


• McMurry
• Apley compression

• Injury to Meniscus: Normal rotation of tibia is forcibly prevented as knee is flexed or extended
Simple twisting injury to knee can tear meniscus
Medial meniscus injuries 10 X more common than lateral meniscus injuries

Clinical features:
Inability to flex knee
Knee pan - well localized
Swelling – gradual (24 – 48 hours: longer than tendon injury)
Locking of knee (or clicking)
Popping or tearing
Walking up & down stairs difficult
Joint effusion
Limited ROM & weight bearing
Positive McMurray
Normal X-ray

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Treatment: Rest
Immobilization of knee
Ice
Elevation
ROM - quadriceps strengthening exercises
Possible surgery

Lesions of Ligaments: medial collateral ligament injury

Forceful stress against knee - abduction


Ability to bear weight is lost
Immediate swelling: (pain, stiffness, ecchymosis, tenderness)
Popping or tearing
Positive Lachman or Positive Drawer

Sprains to Ligaments & Tendons:

• Grade I: stretching of fibers without damage: joint is stable


• Grade II: partial disruption of fibers with some laxity
More swelling & ecchymosis
• Grade III: tears, unstable joint, marked swelling, pain & ecchymosis

Treatment: Grade I or II Protection


Rest
Ice
Compression
Elevation
Support
NSAIDS
Grade III Orthopedic Consultation

R – rest I - ice
I – ice C - compression
C – compression E - elevation
E – elevation S – stability

Anterior Knee Pain: Seen in adolescents & young adults


Athletes
Irregular pattern of movement of patella
Over-use type of syndrome

Clinical features: Pain beneath or near patella


Aggravated by walking up & down stairs, squatting or prolonged sitting
No pain during activity - pain follows activity
Credits
Swelling
Positive compression, shrug and/or apprehension tests

Treatment: R
I
C
E
NSAIDS

Osgood-Schlater Disease:
Involved the growing tibial tuberosity

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Adolescents, 8 - 15 years
Bilateral
Males > Females
Self-limited

Clinical features:
Local pain & swelling over tibial tuberosity
Pain with stair walking, exercise, squatting on knee
Lateral x-ray may release variable degrees of separations & fragmentation
of tibial epiphysis

Treatment: Remove stress on tendon


Abstinence from physical activity

Carpal Tunnel Syndrome:


Compression of medial nerve of wrist
Associated with: hypothyroidism, gouty arthritis, decreased B6

Clinical features:
Numbness/Tingling of long & index fingers
+ Tinel & Phalan signs

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