Health Assessments and Joint Function Quiz

Musculoskeletal System

• The musculoskeletal system comprises bones, joints, and muscles.
• It provides support, allowing an upright stance.
• It's essential for movement.
• It encases and protects vital internal organs.
• It produces red blood cells (RBCs) within bone marrow.
• It stores essential minerals.

Musculoskeletal Components

• Bones and cartilage are specialized connective tissues.
• Fibrous, cartilaginous, and synovial joints are articulation points of two or more bones.
  • Joints are places where bones connect.
• Ligaments are fibrous bands connecting bones, strengthening and preventing unwanted movement.
• Bursae are fluid-filled sacs cushioning and reducing friction between tissues.
• Muscles are skeletal, voluntary muscles controlled by conscious thought/action; they are connected to bones by tendons.

Types of Joints

• Fibrous joints are connected by fibrous tissue or cartilage, offering no movement. Sutures in the skull are an example.
• Cartilaginous joints are separated by fibrocartilaginous discs, permitting limited movement. Vertebrae are an example.
• Synovial joints are freely movable, separated by a cavity lined with a synovial membrane that releases synovial fluid. This fluid lubricates the joint and helps to nourish the cartilage; ligaments surround and stabilize the joint.

Terminology

• Articular disease: affecting the joints
• Extra-articular disease: affecting tissues outside the joints
• Crepitation: A crackling or grating sound that may occur during movement, particularly in joints.

Synovial Joint (Diagram)

• Includes cartilage, synovial membrane, synovial cavity, and capsular ligaments
• Facilitates smooth movement
• Exhibits a cushioning function through bursae.

Muscles

• Muscles account for 40-50% of body weight.
• Muscle contractions facilitate movements.
• Muscles are classified as skeletal, smooth, and cardiac.
• This study focuses on voluntary (skeletal) muscles.
• Skeletal muscles contain fasciculi (bundles of muscle fibers).

Skeletal Muscle Movements

• Flexion: bending a limb at a joint
• Extension: straightening a limb at a joint
• Abduction: moving a limb away from the body's midline
• Adduction: moving a limb toward the body's midline
• Pronation: turning the forearm so the palm faces downwards
• Supination: turning the forearm so the palm faces upwards
• Circumduction: moving an arm in a circular motion around the shoulder
• Inversion: moving the sole of the foot inwards towards the midline
• Eversion: moving the sole of the foot outwards away from the midline
• Rotation: movement around a central axis
• Protraction: moving a body part forward, parallel to the ground
• Retraction: moving a body part backward, parallel to the ground
• Elevation: raising a body part
• Depression: lowering a body part

Temporomandibular Joint (TMJ)

• Articulation of mandible and temporal bone.
• Located anterior to the tragus of the ear.
• Three motions:
  • Hinge action for opening and closing jaws
  • Gliding for protrusion/retraction
  • Gliding for side-to-side movement of the lower jaw

Spine and Vertebrae

• Vertebrae are 33 connecting bones vertically stacked
• Intervertebral discs act as shock absorbers.
• Each disc has a soft, semiliquid nucleus pulposus.
• Spinal movement causes compression on one side, with expansion on the other.
• Excessive compression can lead to disc rupture and herniation of the nucleus pulposus into the spinal column.
• It potentially compresses the spinal nerves and causes pain.

Spinal Curvatures

• Spine has a double-S shape with four curves.
• Cervical and lumbar curves are concave (inward)
• Thoracic and sacrococcygeal curves are convex (outward).

Surface Landmarks of Spine

• Vertebrae number in the human body:
  • 7 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 3-4 coccygeal

Shoulder Girdle

• Includes humerus, scapula, and clavicle and their associated muscles and tendons
• Provides high mobility to the upper limb (more than in other joint combinations)
• The rotator cuff comprises four important muscles that support the shoulder joint.

Shoulder Joint (Diagram)

• Shows various parts of the shoulder joint including muscles, bursae, and the glenohumeral joint

Rotator Cuff Tear (Diagram)

• Anatomical visual of normal and torn rotator cuff tendons

Elbow and Carpals

• The elbow joint connects the humerus, radius, and ulna.
  • Includes the medial and lateral epicondyles, for example.
• The elbow's movement occurs through flexion and extension, with radioulnar joints also present.
• The wrist joint (radiocarpal joint) connects the radius to the carpal bones (in 2 planes).
  • Its motions include flexion, extension, rotation, radial, and ulnar deviation.
• The midcarpal joint allows further motion.

Trivia

• Over half the bones in the human body are located in the hands and feet.

Hip

• The hip joint combines the acetabulum and the head of the femur.
• Provides ball-and-socket action.
• Offers stability for weight bearing and enhances movement.
• Important bony landmarks for examination include the iliac crest and the greater trochanter of the femur.

Knee

• The knee joint is an articulation of the femur, tibia, and patella
• Hinge joint: motion occurs in a single plane, with flexion and extension of lower leg on a single plane.
• Contains wedge-shaped cartilages (medial and lateral menisci) to act as cushions.
• Stabilizers of the knee include collateral ligaments (medial and lateral) and cruciate ligaments (anterior and posterior).

Ankle and Foot

• The ankle (tibiotalar) joint comprises the tibia, fibula, and talus.
• A hinge joint that permits flexion (dorsiflexion) and extension (plantar flexion)
• Important landmarks include the medial malleolus and the lateral malleolus.
• Joints below the ankle allow inversion and eversion.

Subjective Data

• Collect information on pain, stiffness, swelling, heat, redness, and limited movement in body joints, muscles, and bones.
• Evaluate knee injuries if present.

Health History Questions

• Joints:
  • Pain (location, quality, and severity, onset, duration, frequency).
  • Aggravating or precipitating factors
  • Associated clinical presentations (limitations of motion, swelling, or erythema)
  • Impact on ADLs
• Muscles:
  • Location of pain or cramping
  • Pain during walking versus rest (consider claudication) if related to peripheral arterial disease (PAD)
  • Associated clinical presentations
  • Muscle characteristics (weakness, etc)
  • Symptom patterns (onset and duration)
• Bones:
  • Pain (at rest and/or with movement, associated with posture).
  • Deformities or trauma history with impacts on ROM
  • History of accidents or trauma & impact on bones
  • Medical/surgical treatment (residual deficits)
  • Neurological or physical deficits (numbness, tingling, limping, etc.)

Functional Assessment (ADLs)

• Determine the impact of joint, muscle, or bone problems on everyday activities (bathing, dressing, eating, toileting etc).

Patient-Centered Care

• Gather data on occupational hazards, exercise patterns, diet, medications, supplements, smoking history, and impact on activities of daily living (ADLs), psychosocial stressors, pain, depression.
• Explore the impact of acute/chronic disability or self-esteem disturbances.
• Investigate relevant questions about functional abilities and safety risks.

Aging Adult

• Assess for new onset weakness, falls, use of mobility devices.
• Recommend DXA screening as appropriate based on age and risk factors

Physical Examination Preparation

• The aim of musculoskeletal examinations is to gauge function and identify abnormalities related to daily activities.
• Record observations, and note any age-specific abnormalities.
• Begin examination with an orderly approach (head to toe, proximal to distal, & midline outwards).
• Comparative observations between body sides (left and right) helps identify asymmetries and potential problems.

Order of Examination

• Inspection is the initial step. Note joint size, contour, skin color, swelling, and any masses for identification of abnormalities.
• Palpation involves feeling the joint, skin tissues for temperature, tenderness, swelling, bony areas, muscles and the joint capsule for identification of abnormalities.
• Range of motion (ROM) assessment is next. Involves observing active & passive motion, including any limitations.
• Muscle Testing involves probing areas related to prime mover muscle groups and their strengths.

Muscle Grading Scale

• A standardized system grading muscle strength from 0-5.

Temporomandibular Joint (TMJ) - palpation

• Assess for palpation of contracted muscles, especially in relation to teeth clenching.
• Look for clicks/snaps.
• Compare strength and size between both sides of the jaw.
• Utilize resistance to test movement functions, including side-to-side and forward movements
• Note swelling, movement limits, and associated pain or other relevant issues

Cervical Spine

• Observe and document posture & spinal alignment.
• Palpate spinous processes, sternomastoid and trapezius muscle to search for tenderness - especially in relation to muscle spasms
• Check ROM (range of motion), and observe for symmetry in movement.
  • Use resistance method for full range of motion testing.
• Note any related neurological or other problems.

Shoulder

• Observe and document shoulder alignment in a posterior and anterior view.
• Test for underlying neck trauma.
• Identify areas of reported discomfort to ensure no related problems to the area.
• Palpate for atrophy, swelling, tenderness, and any muscle spasms.
• Use methodical methods evaluating strength and ROM.
• Ensure appropriate assessment methods for cranial nerve XI, specifically, in relation to the shoulder shrug.

Elbow

• Assess size and contour of elbow joint in both flexed and extended positions.
• Examine for deformity, redness, and swelling; also, palpate the olecranon bursa
• Assess the normally present hollows to check for abnormal swelling
• Palpate with elbow flexed at 70° in relaxed position, using stabilizing techniques to assess ROM and muscle strength accurately.

Wrist and Hand

• Inspect both dorsal and palmar surfaces and look for position, contour, swelling, nodules, redness, deformity.
• Palpate each joint in wrist and hands for assessment of strength and ROM, and examine muscle function
• Use stabilizing techniques for muscle testing, to precisely assess their strength and range of motion.

Testing for Carpal Tunnel Syndrome:

• Phalen Test: Assess median nerve palmaris function.
• Tinel Sign: Assesses median nerve function (used in conjunction with the Phalen test).

Hip

• Simultaneously examine the hip and spine; observe posture alignment of iliac crests, gluteal folds, and buttocks during stance.
• Observe gait for evenness and symmetric movements, as well as range of motion (ROM).
• Examine and palpate hip joints for tenderness or crepitation in a supine posture.
• Assess range of abduction (ability to take the hip away from the body midline) and evaluate any common motion dysfunctions.

Knee

• Ensure the patient is in either a supine or sitting position.
• Observe lower leg alignment, assessing knee shape and contour.
• Screen the quadriceps muscle in the anterior thigh.
• Assess the ROM for limitations and any present pain.
• Perform relevant exams such as ballottement of the patella, bulge sign, and McMurray tests.

Ankle and Foot

• Examine ankles and feet while the patient is standing and during walking, noting joint positions, contour, and any relevant issues.
• Observe the long and longitudinal arches (flat feet status).
• Take note for any calluses or unusual friction patterns present.
• Review any relevant shoes for signs of abnormal wear or accommodation.
• Assess the plantar (pointing downwards) and dorsiflexion (pointing upwards) motions against resistance.
• Palpate metatarsophalangeal joints (between thumbs and fingers).

Spine

• Assess if the patient is standing, draped, and upright.
• Assess and document spinal alignment, posture and relevant abnormalities (kyphosis or lordosis), especially associated with aging
• Evaluate for tenderness and any associated pain as required.
• Assess range of motion (including flexibility, spinal curves, and any problems) to discover any limitations.

Straight Leg Raise (Lasègue's) Test

• Assess back and leg pain, potentially linked to herniated nucleus pulposus.
• Elevate the affected leg (with the knee extended) to just before pain emerges (or to where pain occurs).
• Dorsiflex the foot (flex the foot upward).
  • Positive findings would demonstrate sciatic pain.
• The unaffected leg remains flat. Observe the affected leg and inquire into any involved side issues.

Genetics and Environment

• Bone mineral density (BMD): Higher BMD signifies denser bone, while lower BMD predicts hip and vertebral fractures/osteoporosis.
• Racial/ethnic differences: Non-Hispanic Black adults exhibit higher BMD. However, they also face higher mortality after hip fracture.
• Gender differences: Women generally have earlier peak BMD and undergo a more rapid decline compared to men. This is associated with higher fracture risk in post-menopausal white women.

Developmental Competence (Infants, Adolescents, Pregnancy, Aging Adults)

• Infants & Adolescents: Methods of musculoskeletal examination for infants/adolescents are similar to adults. Adolescents commonly experience kyphosis due to prolonged poor posture, but scoliosis is also important to detect.
• Pregnancy: Hormonal changes commonly increase mobility in pregnancy, impacting joints and posture. Progressive lordosis (an exaggerated curve) in the lumbar spine is a common finding.
• Aging adult: Bone remodeling (resorption/deposition) is involved in bone health in aging patients and potentially impacted by factors like low bone mass. Age-related posture changes (e.g., kyphosis) and loss of muscle mass (atrophy) contribute to musculoskeletal issues among the elderly.

Common Musculoskeletal Abnormalities

• Rheumatoid arthritis: Systemic, chronic inflammatory joint disease manifesting with heat, redness, swelling, and especially morning stiffness improving with movement.
• Osteoarthritis: Degenerative, non-inflammatory joint affliction that gradually involves cartilage destruction, frequently accompanied by pain and stiffness.
• Osteoporosis: Bone disease due to reduced bone density/mineral content, rising the risk of fractures. Factors like lack of physical activity contribute to its development in women and older individuals.
• Common abnormalities include joint effusion(fluid build up), torn rotator cuff, gouty arthritis, carpal tunnel syndrome, and scoliosis (abnormal spinal curvature).

Health Promotion and Patient Teaching

• Diet: Maintain a diet rich in calcium & vitamin D to support bone health.
• Smoking Cessation: Important for overall and musculoskeletal health.
• Alcohol Intake: Recommend moderation of alcohol intake for musculoskeletal health.
• Exercise Promotion: Encourage suitable exercise levels (weight-bearing, etc).
• Osteoporosis Screening: Promote screening appropriate for the population based on factors like age.
• Fall prevention: Important for elderly persons (to reduce the risk of fractures).

Additional History Questions related to Aging Adult

• Assess for any losses of function, self-care deficits, or potential safety risks.
• Investigate whether they have had new onset weakness, falls or any stumbling issues.
• Note whether the patient uses a mobility device, which suggests potential concerns with mobility.
• Consider recommendations for DXA screening (for females age 65 or older and/or postmenopausal, younger women).