Musculoskeletal System Chapter 22

CHAPTER Musculoskeletal System T he musculoskeletal system provides the stability and mobility necessary for physical activity. Physical performance requires bones, tendons, ligaments, muscles, and joints that function smoothly and effortlessly. Because the musculoskeletal system serves as the body’s 22 main defense against external forces, injuries are common. Moreover, numerous disease processes affect the musculoskeletal system and can ultimately cause disability. The purpose of this chapter is to review a systematic approach to the evaluation of the musculoskeletal system. Physical Examination Components 1. Inspect the skeleton and extremities and compare sides for: Alignment Contour and symmetry Size Deformity 2. Inspect the skin and subcutaneous tissues over muscles and joints for: Color Number of skinfolds Swelling Masses 3. Inspect muscles and compare sides for: Size Symmetry Fasciculations or spasms 4. Palpate all bones, joints, and surrounding muscles for: Muscle tone Warmth Tenderness Swelling Crepitus 5. Test each major joint for active and passive range of motion and compare sides. 6. Test major muscle groups for strength and compare sides. Joints that deserve particular attention include the following: Hands and Wrists 1. Inspect the dorsum and palm of hands for: Contour Position Shape Number and completeness of digits 2. Palpate each joint in the hand and wrist. 3. Test range of motion by the following maneuvers: Metacarpophalangeal flexion (90 degrees) and hyperextension (30 degrees) Thumb opposition Forming a fist Finger adduction and abduction Wrist extension, hyperextension, and flexion Radial and ulnar motion 4. Test muscle strength by the following maneuvers: Wrist extension and hyperextension Hand grip strength Elbows 1. Inspect the elbows in flexed and extended positions for: Contour Carrying angle (5–15 degrees) 2. Palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus. 3. Test range of motion by the following maneuvers: Flexion (160 degrees) Extension (180 degrees) Pronation and supination (90 degrees) Shoulders 1. Inspect shoulders and shoulder girdle for contour. 2. Palpate the joint spaces and bones of the shoulders. 3. Test range of motion by the following maneuvers: Shrugging the shoulders Forward flexion (180 degrees) and hyperextension (up to 50 degrees) Abduction (180 degrees) and adduction (50 degrees) Internal and external rotation (90 degrees) 4. Test muscle strength by the following maneuvers: Shrugged shoulders Abduction with forward flexion Medial rotation Lateral rotation Temporomandibular Joint 1. Palpate the joint space for clicking, popping, and pain. 2. Test range of motion by having the patient perform the following: Opening and closing mouth Moving jaw laterally to each side Protruding and retracting jaw Continued 537 538 CHAPTER 22 Musculoskeletal System Anatomy And Physiology Physical Examination Components—cont’d 3. T est strength of temporalis muscles with the patient’s teeth clenched. Cervical Spine 1. Inspect the neck for alignment and symmetry of skinfolds and muscles. 2. Test range of motion by the following maneuvers: Forward flexion (45 degrees) Hyperextension (55 degrees) Lateral bending (40 degrees) Rotation (70 degrees) 3. Test strength of sternocleidomastoid and trapezius muscles (cranial nerve XI, spinal accessory). Thoracic and Lumbar Spine 1. Inspect the spine for alignment. 2. Palpate the spinal processes and paravertebral muscles. 3. Percuss for spinal tenderness. 4. Test range of motion. Hips 1. Inspect the hips for symmetry and level of gluteal folds. 2. Palpate hips and pelvis for: Instability Tenderness Crepitus 3. Test range of motion by the following maneuvers: Flexion (120 degrees), extension (90 degrees), and hyperextension (30 degrees) ANATOMY AND PHYSIOLOGY The musculoskeletal system is a bony structure that provides stability to the soft tissues of the body. Its joints are held together by ligaments, attached to muscles by tendons, and cushioned by cartilage, which facilitates movement (Figs. 22.1 and 22.2). The musculoskeletal system protects vital organs, provides storage space for minerals (phosphorus, calcium, and carbonate), and produces blood cells within the bone marrow (hematopoiesis). Most joints are synovial—freely moving articulations containing ligaments and cartilage covering the ends of the opposing bones, which are enclosed by a fibrous capsule. A synovial membrane lines the joint and secretes the serous lubricating synovial fluid. Bursae develop in the spaces of connective tissue between tendons, ligaments, and bones to promote ease of motion at points where friction would occur. Upper Extremities The radiocarpal joint (wrist) consists of the articulation of the radius and the carpal bones. Additional articulations occur between the proximal and distal rows of carpal bones. An articular disk separates the ulna and carpal bones, and the joint is protected by ligaments and a fibrous capsule. The wrist moves in two planes. There Adduction (30 degrees) and abduction (45 degrees) Internal rotation (40 degrees) External rotation (45 degrees) 4. Test muscle strength of hips with the following maneuvers: Knee in flexion and extension Abduction and adduction Legs and Knees 1. Inspect the knees for natural concavities. 2. Palpate the popliteal space and joint space. 3. Test range of motion by flexion (130 degrees) and extension (0–15 degrees). 4. Test the strength of muscles in flexion and extension. Feet and Ankles 1. Inspect the feet and ankles during weight bearing and non– weight bearing for: Contour Alignment with tibias Size Number of toes 2. Palpate the Achilles tendon and each metatarsal joint. 3. Test range of motion by the following maneuvers: Dorsiflexion (20 degrees) and plantar flexion (45 degrees) Inversion (30 degrees) and eversion (20 degrees) Flexion and extension of the toes 4. Test strength of muscles in plantar flexion and dorsiflexion. is flexion and extension movement as well as radial and ulnar (rotational) movement. The hand has articulations between the carpals and metacarpals, metacarpals and proximal phalanges, and middle and distal phalanges (Fig. 22.3). The forearm joints consist of the articulations between the radius and ulna at both the proximal and distal locations. These are important for pronation and supination. The elbow consists of the articulation of the humerus, radius, and ulna. Its three contiguous surfaces are enclosed in a single synovial cavity, with the collateral ligaments of the radius and ulna securing the joint. A bursa lies between the olecranon and the skin (Fig. 22.4). The elbow is a hinge joint, permitting movement of the humerus and ulna in one plane (flexion and extension). The glenohumeral joint (shoulder) consists of the articulation between the humerus and the glenoid fossa of the scapula. The acromion and coracoid processes and the ligament between them form the arch surrounding and protecting the joint (Fig. 22.5A). Four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and their tendons comprise the rotator cuff, reinforcing the glenohumeral joint to stabilize the shoulder and the position of the humeral head within the joint (Fig. 22.5B). The shoulder is a ball-and-socket joint that permits movement of the humerus in several axes. CHAPTER 22 Right anterior Head of humerus Femur Right posterior Humerus Right anterior Right posterior Patella Olecranon Fibula Radius Tibia Ulna Carpals Metacarpals Tarsals Metatarsals Phalanges A Phalanges Anterior Deltoid Biceps brachii long head Brachioradialis Posterior Pectoralis major Infraspinatus Teres minor Teres major Triceps long head Biceps brachii short head Triceps, lateral head Triceps, medial head Brachialis Pronator teres Anconeus Bicipital aponeurosis Palmaris longus Flexor carpi radialis Flexor digitorum superficialis Flexor retinaculum B Extensor retinaculum Deltoid Triceps, long head Triceps, medial head Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum communis Extensor carpi ulnaris Extensor digiti minimi Abductor pollicis brevis Abductor pollicis longus Anatomy And Physiology Lesser trochanter 539 FIG. 22.1 (A) Bones of the upper and lower extremities. (B) Muscles of the upper extremities. (C) Muscles of the lower extremities. Head of femur Greater trochanter Musculoskeletal System 540 CHAPTER 22 Musculoskeletal System Anterior FIG. 22.1, cont’d Anatomy And Physiology Iliopsoas Pectineus Adductor Tensor of longus fascia lata Sartorius Posterior Fascia over gluteus medius Adductor magnus Gluteus maximus Semitendinosus Biceps femoris long head Semimembranosus Iliotibial tract Biceps femoris short head Semimembranosus Rectus femoris Gracilis Vastus lateralis Vastus medialis Tendon of rectus femoris Patella Plantaris Patellar ligament Gastrocnemius Peroneus longus Tibialis anterior Extensor digitorum longus Peroneus longus Soleus Peroneus brevis Flexor hallucis longus Calcaneal tendon (Achilles tendon) C FIG. 22.2 (A) Bones of the trunk, anterior view. (B) Bones of the trunk, posterior view. (C) Superficial muscles of the trunk, anterior view. (D) Superficial muscles of the trunk, posterior view. Anterior Clavicle Posterior Manubrium of sternum Coracoid process Acromion process Glenoid cavity Body of sternum Scapula Thoracic vertebrae Xyphoid of sternum Lumbar vertebrae Ilium Sacrum Pubis A Symphysis pubis Anterior External oblique Transversus abdominis Internal oblique Pyramidalis C Sternocleidomastoid Trapezius Clavicle Deltoid Pectoralis major Serratus anterior Latissimus dorsi Rectus sheath (cut edges) Rectus abdominis Coccyx Ischium Acetabulum B Posterior Splenius capitis Levator scapulae Trapezius Rhomboideus minor Deltoid Supraspinatus Infraspinatus Infraspinatus Rhomboideus major fascia Teres minor Teres minor Teres major Teres major Serratus anterior Latissimus dorsi External oblique Lumbodorsal fascia Serratus External oblique posterior inferior Gluteus maximus D Gluteus medius CHAPTER 22 Metacarpophalangeal joint 541 FIG. 22.3 Structures of the wrist and hand joints. Distal interphalangeal joint Anatomy And Physiology Proximal interphalangeal joint Musculoskeletal System Ulna Carpals Articular disk Radioulnar joint Radius Ulna Carpometacarpal joint of thumb Radius Radiocarpal joint Humerus Olecranon bursa Lateral epicondyle Medial epicondyle Olecranon Annular ligament Coronoid process Ulna Radius FIG. 22.4 Structures of the left elbow joint, posterior view. Two additional joints adjacent to the glenohumeral joint complete the articulation of the shoulder girdle. These are the acromioclavicular joint which consists of the articulation between the acromion process and the clavicle, and the sternoclavicular joint which consists of the articulation between the manubrium of the sternum and the clavicle. Head and Spine The temporomandibular joint consists of the articulation between the mandible and the temporal bone in the cranium. Each is located in the depression just anterior to the tragus of the ear. The hinge action of the joint opens and closes the mouth. The gliding action permits lateral movement, protrusion, and retraction of the mandible (Figs. 22.6 and 22.7). See Chapter 11 for a description of the fused bones of the cranium. The spine is composed of cervical, thoracic, lumbar, and sacral vertebrae. All but the sacral vertebrae are separated from each other by fibrocartilaginous disks. Each disk has a central area of fibro-gelatinous material, known as the nucleus pulposus, that cushions the vertebral bodies (Fig. 22.8). The vertebrae form a series of joints that glide slightly over each other’s surfaces, permitting movement in several axes. The cervical vertebrae are the most mobile. Flexion and extension occur between the skull and C1, whereas rotation occurs between C1 and C2. The sacral vertebrae are fused, and with the coccyx, form the posterior portion of the pelvis. Lower Extremities The hip joint consists of the articulation between the acetabulum and the femur. The depth of the acetabulum in the pelvic bone—as well as the joint, which is supported by three strong ligaments—helps stabilize and protect the head of the femur in the joint capsule. Multiple bursae reduce friction in the hip. The hip is a ball-and-socket joint, permitting movement of the femur on many axes (Fig. 22.9). The knee consists of four bones (femur, tibia, fibula, and patella), with three separate articulating compartments: the lateral tibiofemoral, the medial tibiofemoral, and the patellofemoral. Fibrocartilaginous disks (medial and lateral menisci), which cushion the tibia and femur, are attached to the tibia and the joint capsule. Collateral ligaments give medial and lateral stability to the knee. Two cruciate ligaments cross obliquely within the knee, adding anterior and posterior stability. The anterior cruciate ligament protects the knee from hyperextension. There are four separate bursae in the anterior knee that help to reduce the friction of knee movement. 542 CHAPTER 22 Musculoskeletal System Anatomy And Physiology Supraspinatus Greater tubercle of humerus Articular capsule Acromioclavicular joint Clavicle Subacromial bursa Infraspinatus Supraspinatus muscle Biceps brachii tendon Teres minor Subscapularis muscle Glenoid fossa Subdeltoid bursa Synovial sheath Glenoid labrum Deltoid muscle Biceps, long head Humerus A B FIG. 22.5 Structures of the shoulder. (A) Structures of glenohumeral and acromioclavicular joints, anterior view. (B) Rotator cuff muscles of shoulder, posterior view. Auricularis anterior Fascia over temporalis Auricularis superior Frontalis Orbicularis oculi Procerus Nasalis Levator labii superioris Zygomaticus minor Zygomaticus major Orbicularis oris Depressor labii inferioris Depressor angulioris Rissorius Occipitalis Posterior auricular Sternocleidomastoid Trapezius Platysma FIG. 22.6 Muscles of the face and head, left lateral view. Articular tubercle Condyle of mandible Articular disk Spinous process Intervertebral disk Joint capsule Lamina Styloid process Stylomandibular ligament Nucleus pulposus Sacrum Ramus of mandible FIG. 22.7 Structures of the temporomandibular joint. Coccyx FIG. 22.8 Structures of vertebral joints. CHAPTER 22 Musculoskeletal System 543 FIG. 22.9 Structures of the hip. (From Rothrock, 2007.) Acetabular labrum Joint capsule (retracted) Anatomy And Physiology Pelvic bone Joint cavity Head of femur Greater trochanter Ligamentum teres Neck of femur Femur Transverse acetabular ligament Joint capsule Lesser trochanter Rectus femoris tendon Lateral patellar ligament Anterior cruciate ligament Fibular collateral ligament Head of fibula Fibula A Rectus femoris Femur Medial patellar ligament Patella (cut) Tibial collateral ligament Patellar ligament (cut) Tibia Rectus femoris Iliotibial tract Rectus femoris tendon Lateral patellar retinaculum Patella Biceps femoris tendon Head of fibula Patellar ligament Peroneus longus B Tibialis anterior Sartorius Gracilis Vastus medialis Joint capsule and tibial collateral ligament Medial patellar retinaculum Insertion of sartorius Insertion of gracilis Gastrocnemius Tibia Soleus FIG. 22.10 Structures of the knee, anterior view. (A) Bones and ligaments of the joint. (B) Muscles attaching at the knee. The knee is a hinge joint, permitting movement (flexion and extension) between the femur and tibia in one plane (Fig. 22.10). The tibiotalar joint (ankle) consists of the articulation of the tibia, fibula, and talus. It is protected by ligaments on the medial and lateral surfaces. The tibiotalar joint is a hinge joint that permits flexion and extension (dorsiflexion and plantar flexion) in one plane. Additional joints in the ankle—the talocalcaneal joint (subtalar) and transverse tarsal joint—permit it to pivot or rotate (pronation and supination). Articulations of the foot between the tarsals and metatarsals, the metatarsals and proximal phalanges, and the middle and distal phalanges allow flexion and extension (Fig. 22.11) to occur. Infants and Children During fetal development, the skeletal system emerges from embryologic connective tissues to form cartilage that calcifies to become bone. Throughout infancy and childhood, long bones increase in diameter through the growth of new bone tissue around the bone shaft. Increased length of long bones results from the proliferation of cartilage at the growth plates (epiphyses). In the smaller bones, such as the carpals, ossification centers form in calcified cartilage. Ligaments are stronger than bone until adolescence; as such, injuries to long bones and joints are more likely to result in fractures than in sprains. Review of Related History 544 CHAPTER 22 Musculoskeletal System Fibula Tibia Talonavicular joint (transverse tarsal joint) REVIEW OF RELATED HISTORY Tarsometatarsal joint For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations), as well as complementary and alternative therapies, are relevant for each. First metatarsal Metatarsophalangeal joint Proximal phalanx Distal phalanx Interphalangeal joint Sesamoid bone strength. A progressive decrease in reaction time, speed of movement, agility, and endurance also occurs. Subtalar joint Calcaneus FIG. 22.11 Bones and joints of the ankle and foot. Adolescents Rapid growth during Tanner stage 3 (see Chapter 8) results in decreased strength in the epiphyses, as well as overall decreased strength and flexibility, leading to greater potential for injury. Bone growth is completed at about age 20 when the last epiphysis closes and becomes firmly fused to the shaft. Once bone growth stops, bone density and strength continue to increase. Peak bone mass is not achieved until about 35 years of age. Pregnant Patients Increased hormone levels contribute to the elasticity of ligaments and softening of the cartilage in the pelvis at about 12 to 20 weeks of gestation. As a result, there is increased mobility of the sacroiliac, sacrococcygeal, and symphysis pubis joints. As the fetus grows, lordosis (inward curvature of the lower spine) occurs in an effort to shift the center of gravity back over the lower extremities. The ligaments and muscles of the lower spine may become stressed, leading to lower back pain for many pregnant patients. Older Adults With aging, the equilibrium between bone deposition and bone resorption changes so that resorption dominates. For menopausal women, decreased estrogen increases bone resorption and decreases calcium deposition, resulting in bone loss and decreased bone density. By 80 years of age, a woman can lose up to 30% of her bone mass. The loss of bone density affects the entire skeleton, but the weight-bearing long bones and the vertebrae are particularly vulnerable to fractures. Bony prominences become more apparent with the loss of subcutaneous fat. The cartilage around joints also deteriorates. Initially, the muscle mass also undergoes alteration as increased amounts of collagen collect in the tissues. This is followed by fat deposition within the muscles and fibrosis of connective tissue. Tendons become less elastic. This results in a reduction of total muscle mass, tone, and History of Present Illness Joint Symptoms Character: stiffness or limitation of movement, change in size or contour, swelling or redness, constant pain or pain with particular motion, unilateral or bilateral involvement, interference with daily activities, joint locking or giving way Associated events: time of day, activity, specific movements, injury, strenuous activity, weather Temporal factors: change in frequency or character of episodes, better or worse as day progresses, nature of onset (sudden or gradual) Efforts to treat: exercise, rest, weight reduction, physical therapy, heat, ice, braces or splints Medications: nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, biologic modifiers and other immunosuppressants, corticosteroids, topical analgesics, glucosamine, chondroitin, hyaluronic acid, complementary therapies Muscular Symptoms Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic, spasms, clumsiness, wasting, aching, pain Precipitating factors: injury, strenuous activity, sudden movement, stress Efforts to treat: heat, ice, splints, rest, massage Medications: muscle relaxants, statins, NSAIDs Skeletal Symptoms Character: difficulty with gait or limping; numbness, tingling, or pressure sensation; pain with movement, crepitus; deformity or change in skeletal contour Associated event: injury, recent fractures, strenuous activity, sudden movement, stress, postmenopause Efforts to treat: rest, splints, chiropractic, acupuncture Medications: hormone therapy, calcium, calcitonin, bisphosphonates Injury Sensation at time of injury: click, pop, tearing, numbness, tingling, catching, locking, grating, snapping, warmth or coldness, ability to bear weight M echanism of injury: direct trauma, overuse, sudden change of direction, forceful contraction, overstretch Pain: location, type, onset (sudden or gradual), aggravating or alleviating factors, position of comfort Swelling: location, timing (with activity or injury) Efforts to treat: rest, ice, heat, splints Medications: analgesics, NSAIDs Back Pain Abrupt or gradual onset, better or worse with activity Character of pain and sensation: tearing, burning, or steady ache; tingling or numbness; location and distribution (unilateral or bilateral), radiation to buttocks, groin, or legs; triggered by coughing or sneezing and sudden movements Associated event: trauma, lifting of heavy weights, long-distance driving, sports activities, change in posture or deformity Efforts to treat: rest, avoid standing or sudden movements, chiropractic, acupuncture Medications: muscle relaxants, analgesics, NSAIDs Past Medical History T rauma: nerves, soft tissue, bones, joints; residual problems; bone infection Surgery on joint or bone; amputation, arthroscopy Chronic illness: cancer, arthritis, sickle cell disease, hemophilia, osteoporosis, renal or neurologic disorder Skeletal deformities or congenital anomalies Family History C ongenital abnormalities of hip or foot Scoliosis or back problems Arthritis: rheumatoid, osteoarthritis, ankylosing spondylitis, gout Genetic disorders: osteogenesis imperfecta, skeletal dysplasia, rickets, hypophosphatemia, hypercalciuria Risk Factors Osteoarthritis Obesity Female Family history of osteoarthritis Hypermobility syndromes Aging (older than 40 years) Injury, high level of sports activities Peripheral neuropathy Occupation requiring overuse of joints Data from Blagojevic et al. (2010). Personal and Social History E mployment: past and current, lifting and potential for unintentional injury, repetitive motions, typing/ Musculoskeletal System 545 computer use, safety precautions, use of spinal support, chronic stress on joints Exercise: extent, type, and frequency; weight bearing; stress on specific joints; overall conditioning; sport (level of competition, type of shoes and athletic gear); warm-up and cool-down routines with exercise Functional abilities: personal care (eating, bathing, dressing, grooming, elimination); other activities (housework, walking, climbing stairs, caring for pet); use of prosthesis Weight: recent gain, overweight or underweight for body frame Height: maximum height achieved, any changes Nutrition: amount of calcium, vitamin D, calories, and protein Tobacco or alcohol use Infants and Children B irth history Presentation, large for gestational age, birth injuries (may result in fractures or nerve damage), type of delivery (vaginal vs. cesarean delivery), use of forceps Low birth weight, premature, resuscitation efforts, intrauterine insult or perinatal asphyxia, fetal stroke, maternal infections leading to muscle tone disorders, required ventilator support (may result in anoxia leading to muscle tone disorders) Fine and gross motor developmental milestones, appropriate for chronologic age Overweight or obese Quality of movement: spasticity, flaccidity Arm or leg pain Character: localized or generalized; in muscle or joint; limitation of movement; associated with movement, trauma, or growth spurt Onset: age, sudden or gradual, at night or with rest, after activity Participation in organized or competitive sports, weightlifting Pregnant Patients M uscle cramps: nature of onset, frequency and time of occurrence, muscles involved, efforts to treat Back pain Weeks of gestation, associated with multiple pregnancies, efforts to treat Associated symptoms: uterine tightening, nausea, vomiting, fever, malaise (could signify musculoskeletal discomfort if not from another condition) Type of shoes (heels may increase lordosis) Older Adults W eakness Onset: sudden or gradual, localized or generalized, with activity or after sustained activity Associated symptoms: stiffness of joints, muscle spasms or tension, any particular activity, dyspnea Review of Related History CHAPTER 22 Examination And Findings 546 CHAPTER 22 Musculoskeletal System I ncrease in minor injuries: stumbling, falls, limited agility; association with poor vision Change in ease of movement: loss of ability to perform sudden movements, change in exercise endurance, pain, stiffness, localized to particular joints or generalized Nocturnal muscle spasm: frequency, associated back pain, numbness or coldness of extremities History of injuries or excessive use of a joint or group of joints, known joint abnormalities Previous fractures, bone mineral density screening Medications: steroids, calcium, bisphosphonates, NSAIDs Risk Factors Osteoporosis R ace (white, Asian, Native American/American Indian); northwestern European descent Low body weight Increasing age Family history of osteoporosis, previous fractures Nulliparous Amenorrhea or menopause before 45 years of age, postmenopausal Sedentary lifestyle, lack of aerobic or weight-bearing exercise Constant dieting, inadequate calcium and vitamin D intake, excessive carbonated soft drinks per day Scoliosis, rheumatoid arthritis, cancer, multiple sclerosis, chronic illness Metabolic disorders (e.g., diabetes, hypercortisolism, malabsorption, hypogonadism, hyperthyroidism) Drugs that decrease bone density (e.g., thyroxine, corticosteroids, heparin, lithium, anticonvulsants, antacids with aluminum) Cigarette smoking or heavy alcohol use A B EXAMINATION AND FINDINGS Equipment Skin-marking pencil Goniometer Tape measure Reflex hammer Begin your examination of the musculoskeletal system by observing the gait and posture when the patient enters the examination room. Note how the patient walks, sits, rises from sitting position, takes off a coat, and responds to other directions given during the examination. If it is your preference to shake hands with the patient when you greet them, do so gently. If they have underlying arthritis or injury involving their right hand, your firm handshake may cause them significant discomfort. As you give specific attention to bones, joints, tendons, ligaments, and muscles, expose the body surface and view under good lighting. Position the patient to provide the greatest stability to the joints. Examine each region of the body for limb and trunk stability, muscular strength and function, and joint range of motion. Position the extremities uniformly as you examine and look for asymmetry. Inspection Inspect the anterior, posterior, and lateral aspects of the patient’s posture (Fig. 22.12). Observe the patient’s ability to stand erect, symmetry of body parts, and alignment of the extremities. Note any lordosis, kyphosis C FIG. 22.12 Inspection of overall body posture. Note the even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry and alignment of extremities. (A) Anterior view. (B) Posterior view. (C) Lateral view. The occiput, shoulders, buttocks, and heels should be able to touch the wall the patient stands against. (over- curvature of the thoracic vertebrae), or scoliosis (curved from side to side) of the spine. Inspect the skin and subcutaneous tissues overlying the articular structures for discoloration, swelling, and masses. Observe the extremities for overall size, gross deformity, bony enlargement, alignment, contour, and symmetry of length and position. Expect to find bilateral symmetry in length, circumference, alignment, and the extremity position (see Clinical Pearl, “Bilateral Symmetry”). Inspect the muscles for gross hypertrophy or atrophy, fasciculations, and spasms. Muscle size should approximate symmetry bilaterally. Fasciculation (muscle twitching) occurs after injury to a muscle’s motor neuron. Muscle wasting occurs after an injury as a result of pain, disease of the muscle, or damage to the motor neuron. CLINICAL PEARL Bilateral Symmetry Bilateral symmetry should not be defined as absolute because there is no perfect symmetry. For example, the dominant forearm is expected to be larger in athletes who play racquet sports and in manual laborers. Palpation Palpate any bones, joints, tendons, and surrounding muscles if symptomatic. Palpate inflamed joints last, being aware of the patient’s discomfort. Note any heat, tenderness, swelling, crepitus, pain, and resistance to movement. No discomfort should occur when you apply pressure to bones or joints. Muscle tone should be firm, not hard or doughy. Synovial thickening can sometimes be felt in joints that are close to the skin surface when the synovium is edematous or hypertrophied because of inflammation. Crepitus (a grating sound or sensation) can be felt when two irregular bony surfaces rub together as a joint moves, when two rough edges of a broken bone rub together, or with the movement of a tendon inside the tendon sheath when tenosynovitis is present. Range of Motion and Muscle Tone Examine both the active and passive range of motion for each major joint and its related muscle groups. Muscle tone is often evaluated simultaneously. Allow adequate space for the patient to move each muscle group and joint through its full range. Instruct the patient to move each joint through its range of motion as detailed in specific joint and muscle sections. Pain, limitation of motion, spastic movement, joint instability, deformity, or contracture may suggest a problem with the joint, related muscle group, or nerve supply. Ask the patient to relax and allow you to passively move the same joints until the end of the range of motion is felt. Do not force the joint if there is pain or muscle spasm. Muscle tone may be assessed by feeling the resistance to Musculoskeletal System 547 FIG. 22.13 Use of goniometer to measure joint range of motion. passive stretch. During passive range of motion, the muscles should have slight tension. Passive range of motion often exceeds active range of motion by 5 degrees. The range of motion with active and passive maneuvers should be equal between contralateral joints. Discrepancies between active and passive ranges of motion may indicate true muscle weakness or a joint disorder. No crepitation or tenderness with movement should be apparent. Note the specific location of tenderness when present. Spastic muscles are harder to put through the range of motion. Measurements may vary if the muscle tested relaxes with gentle persistence. When a joint appears to have an increase or limitation in its range of motion, a goniometer (see Chapter 3) can be used to precisely measure the angle. Begin with the joint in the fully extended or neutral position, and then flex the joint as far as possible. Measure the angles of greatest flexion and extension, comparing these with the expected joint flexion and extension values (Fig. 22.13). Muscle Strength Evaluating the strength of each muscle group is an important part of the neurologic examination. However, it is usually integrated with the examination of the associated joint for range of motion. Ask the patient first to contract the muscle you indicate by extending or flexing the joint and then to resist as you apply force against that muscle contraction (Fig. 22.14). Alternatively, tell the patient to push against your hand to feel the resistance. Compare the muscle strength bilaterally. Expect muscle strength to be bilaterally symmetric with full resistance to opposition. Full muscle strength requires a complete active range of motion. Variations in muscle strength are graded from no voluntary contraction to full muscle strength, using the scale in Table 22.1. When muscle strength is grade 3 or less, disability is present; activity cannot be accomplished in a gravity field, and external support is necessary to perform movements. Weakness may result from an underlying muscle disorder, pain, fatigue, or overstretching. Examination And Findings CHAPTER 22 548 CHAPTER 22 TABLE 22.1 Musculoskeletal System Assessing Muscle Strength Specific Joints and Muscles Examination And Findings MUSCLE FUNCTION LEVEL GRADE No evidence of movement 0 Trace of movement 1 Full range of motion, but not against gravitya 2 Full range of motion against gravity but not against resistance 3 Full range of motion against gravity and some resistance, but weak 4 Full range of motion against gravity, full resistance 5 Passive movement. a FIG. 22.14 Evaluation of muscle strength: flexion of the elbow against opposing force. Hands and Wrists Inspect the dorsal and palmar aspects of the hands, noting the contour, position, shape, number, and completeness of digits. Note the presence of palmar and phalangeal creases. The palmar surface of each hand should have a central depression with a prominent, rounded mound (thenar eminence) on the thumb side of the hand and a less prominent hypothenar eminence on the little finger side of the hand. Expect the fingers to fully extend when in close approximation and be aligned with the forearm. The lateral finger surfaces should gradually taper from the proximal to the distal aspects (Fig. 22.15). Deviation of the fingers to the ulnar side and swan neck or boutonnière deformities of the fingers usually indicates rheumatoid arthritis (Fig. 22.16). Palpate each joint in the hand and wrist. Palpate the interphalangeal joints with your thumb and index finger. The metacarpophalangeal joints are palpated with both thumbs. Palpate the wrist and radiocarpal groove with your thumbs on the dorsal surface and your fingers on the palmar aspect of the wrist (Fig. 22.17). Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness. A firm mass over the dorsum of the wrist may be a ganglion. Bony overgrowths in the distal interphalangeal joints, which are felt as hard, non-tender nodules usually 2 to 3 mm in diameter but sometimes encompassing the entire joint, are associated with osteoarthritis. When located along the distal interphalangeal joints, they are Distal phalanx Middle phalanx Distal phalanx Proximal phalanx Metacarpals Proximal phalanx Carpals Radius A Ulna Distal interphalangeal crease Palmar digital crease Proximal interphalangeal crease Distal palmar crease Proximal palmar crease Median crease Ulnar crease Thenar crease Wrist crease B FIG. 22.15 (A) Bony structure of the right hand and wrist; note the alignment of the fingers with the radius. (B) Features of the palmar aspect of the hand; note creases, thenar eminence and hypothenar eminence, and gradual tapering of the fingers. Hypothenar eminence Thenar eminence called Heberden nodes; those along the proximal interphalangeal joints are called Bouchard nodes. Painful swelling of the proximal interphalangeal joints causes spindle-shaped fingers, which are associated with the acute stage of rheumatoid arthritis (Fig. 22.18). Cystic, round, non-tender swellings along tendon sheaths or joint capsules that are more prominent with flexion may indicate ganglia. A B C FIG. 22.16 Unexpected findings of the hand. (A) Ulnar deviation and subluxation of metacarpophalangeal joints. (B) Swan neck deformities. (C) Boutonnière deformity. (Used by permission of the American College of Rheumatology.) A B Musculoskeletal System 549 Examine the range of motion of the hand and wrist by asking the patient to perform these movements: Bend the fingers forward at the metacarpophalangeal joint, then stretch the fingers up and back at the knuckle. Expect metacarpophalangeal flexion of 90 degrees and hyperextension up to 30 degrees (Fig. 22.19A). Touch the thumb to each fingertip and to the base of the little finger; make a fist. All movements should be possible (Fig. 22.19B and C). Spread the fingers apart and then touch them together. Both movements should be possible (Fig. 22.19D). Bend the hand at the wrist up and down. Expect flexion of 90 degrees and hyperextension of 70 degrees (Fig. 22.19E). With the palm side down, turn each hand to the right and left. Expect radial motion of 20 degrees and ulnar motion of 55 degrees (Fig. 22.19F). Have the patient maintain wrist flexion and hyperextension while you apply opposing force to evaluate the strength of the wrist muscles. To evaluate hand strength, have the patient tightly grip two of your fingers. To avoid painful compression from an overzealous squeeze, offer your two fingers of one hand side by side in the handshake position. Finger extension, abduction, adduction, and thumb opposition may also be used to evaluate hand strength. Elbows Inspect the contour of the patient’s elbows in both flexed and extended positions. Subcutaneous nodules along pressure points of the ulnar surface may indicate a rheumatoid nodule (Fig. 22.20) or gouty tophi. Note any deviations in the carrying angle between the humerus and radius while the arm is passively extended, palm forward. The carrying angle is usually 5 to 15 degrees laterally. Variations in carrying angle are cubitus valgus, a lateral angle exceeding 15 degrees, and cubitus varus, a medial carrying angle (Fig. 22.21). Flex the patient’s elbow 70 degrees and palpate the extensor surface of the ulna, the olecranon process, and the medial and lateral epicondyles of the humerus. Then palpate the groove on each side of the olecranon process for tenderness, swelling, and thickening of the synovial C FIG. 22.17 Palpation of joints of the hand and wrist. (A) Proximal interphalangeal joints. (B) Metacarpophalangeal joints. (C) Radiocarpal groove and wrist. Examination And Findings CHAPTER 22 Examination And Findings 550 CHAPTER 22 Musculoskeletal System FIG. 22.18 Unexpected findings of the fingers. (A) Fusiform swelling or spindle-shaped enlargement of the proximal interphalangeal joints. (B) Degenerative joint disease; Heberden nodes at the distal interphalangeal joints and Bouchard nodes at the proximal interphalangeal joints. (C) Telescoping digits with hypermobile joints. (Used by permission of the American College of Rheumatology.) A B FIG. 22.19 Range of motion of the hand and wrist. (A) Metacarpophalangeal flexion and hyperextension. (B) Finger flexion: thumb to each fingertip and to the base of the little finger. (C) Finger flexion: fist formation. (D) Finger abduction. (E) Wrist flexion and hyperextension. (F) Wrist radial and ulnar movement. C 30° Hyperextension 0° Flexion 90° A B C D 0° 70° Extension Radial 20° Ulnar 55° Flexion E 90° F Musculoskeletal System 551 FIG. 22.20 Rheumatoid arthritis involving the elbow. Olecranon bursitis and a rheumatoid nodule are shown. (From Chard et al., 2015.) FIG. 22.22 Palpation of the olecranon process grooves. 0° 15° FIG. 22.21 Expected carrying angle of the arm, at 5 to 15 degrees. membrane (Fig. 22.22). The olecranon bursa is a fluid- filled sac that acts as a cushion between the skin and the olecranon process. Olecranon bursitis results in swelling and tenderness of the bursa. Suspect epicondylitis or tendonitis when a point tenderness exists at the lateral epicondyle or along the grooves of the olecranon process and epicondyles in addition to increased pain with pronation and supination of the elbow. Examine the elbow’s range of motion by asking the patient to perform the following movements: With the elbow fully extended at 0 degrees, bend and straighten the elbow. Expect flexion of 160 degrees and extension returning to 0 degrees or 180 degrees of full extension (Fig. 22.23A). With the elbow flexed at a right angle, rotate the hand from palm side down to palm side up. Expect pronation of 90 degrees and supination of 90 degrees (Fig. 22.23B). Have the patient maintain flexion and extension while you apply opposing force to evaluate the strength of the elbow muscles. Shoulders Inspect the contour of the shoulders, the shoulder girdle, the clavicles and scapulae, and the surrounding musculature. Expect symmetry of size and contour of all shoulder structures. When the shoulder contour is asymmetric and one shoulder has hollows in the rounding contour, suspect a shoulder dislocation (Fig. 22.24). Observe for a winged scapula, an outward prominence of the scapula, indicating injury to the nerve of the anterior serratus muscle (Fig. 22.24B). Palpate the sternoclavicular joint, clavicle, acromioclavicular joint, scapula, coracoid process, greater tubercle of the humerus, biceps groove, and area muscles. To palpate the biceps groove, rotate the arm and forearm externally. Locate the biceps muscle near the elbow and follow the muscle and its tendon into the biceps groove along the anterior aspect of the humerus. Palpate the muscle insertions of the supraspinatus, infraspinatus, and teres minor near the greater tuberosity of the humerus by lifting the elbow posteriorly to extend the shoulder. No tenderness should be noted over the muscle insertions. Examine the range of motion of the shoulders by asking the patient to perform the following movements: Shrug the shoulders. Expect the shoulders to rise symmetrically. Raise both arms forward and straight up over the head. Expect forward flexion of 180 degrees. Extend and stretch both arms behind the back. Expect hyperextension of 50 degrees (Fig. 22.25A). Lift both arms laterally and straight up over the head. Expect shoulder abduction of 180 degrees. Swing each arm across the front of the body. Expect adduction of 50 degrees (Fig. 22.25B). Place both arms behind the hips, elbows out. Expect internal rotation of 90 degrees (Fig. 22.25C). Place both arms behind the head, elbows out. Expect external rotation of 90 degrees (Fig. 22.25D). Have the patient maintain shrugged shoulders while you apply opposing force to evaluate the strength of the shoulder girdle muscles. Cranial nerve XI (the accessory nerve controlling the sternocleidomastoid and trapezius muscles) is simultaneously evaluated with this maneuver (Fig. 22.25E). Examination And Findings CHAPTER 22 CHAPTER 22 Musculoskeletal System Examination And Findings 552 160° Flexion Extension A 180° 90° Supination B 90° Pronation FIG. 22.23 Range of motion of the elbow. (A) Flexion and extension. (B) Pronation and supination. A B FIG. 22.24 (A) At rest, the patient has subtle prominence of the medial border of the right scapula. (B) When the patient flexes his arm forward and pushes against a wall, the medial border of the right scapula protrudes from the posterior chest wall (“winged scapula”). (From Chiu et al., 2018.) Temporomandibular Joint Locate the temporomandibular joints by placing your fingertips just anterior to the tragus of each ear. Allow your fingertips to slip into the joint space as the patient’s mouth opens, and gently palpate the joint space (Fig. 22.26). An audible or palpable snapping or clicking in the temporomandibular joints is not unusual, but pain, crepitus, locking, or popping may indicate temporomandibular joint dysfunction. Examine the range of motion by asking the patient to perform the following movements: Open and close the mouth. Expect a space of 3 to 6 cm between the upper and lower teeth when the jaw is open. Laterally move the lower jaw to each side. The mandible should move 1 to 2 cm in each direction (Fig. 22.27). P rotrude and retract the chin. Both movements should be possible. The strength of the temporalis and masseter muscles may be evaluated by asking the patient to clench the teeth while you palpate the contracted muscles and apply opposing force. This maneuver simultaneously tests cranial nerve V (the trigeminal nerve). Cervical Spine Inspect the patient’s neck from both the anterior and posterior position, observing for alignment of the head with the shoulders and symmetry of the skinfolds and muscles. Expect the cervical spine curve to be concave with the head erect and in appropriate alignment. Palpate the posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles. The muscles should CHAPTER 22 Musculoskeletal System 553 180° 180° Forward flexion Up to 50° 50° Adduction Hyperextension 0° A B 90° 90° C D E FIG. 22.25 Range of motion of the shoulder. (A) Forward flexion and hyperextension. (B) Abduction and adduction. (C) Internal rotation. (D) External rotation. (E) Shrugged shoulders. FIG. 22.26 Palpation of the temporomandibular joint. FIG. 22.27 Lateral range of motion in the temporomandibular joint. Examination And Findings Abduction 554 Musculoskeletal System CHAPTER 22 Extension 0° Flexion Right 45° 40° Examination And Findings Up to 55° A Left 0° 40° B Left rotation 70° 0° Right rotation 70° C FIG. 22.28 Range of motion of the cervical spine. (A) Flexion and hyperextension. (B) Lateral bending. (C) Rotation. A B C FIG. 22.29 Examining the strength of the sternocleidomastoid and trapezius muscles. (A) Flexion with palpation of the sternocleidomastoid muscle. (B) Extension against resistance. (C) Rotation against resistance. have good tone and appear symmetric in size, with no palpable tenderness or muscle spasm. Evaluate the range of motion in the cervical spine by asking the patient to perform the following movements (Fig. 22.28): Bend the head forward, chin to the chest. Expect flexion of 45 degrees. Bend the head backward, chin toward the ceiling. Expect extension of 45 degrees. Bend the head to each side, ear to each shoulder. Expect lateral bending of 40 degrees. Turn the head to each side, chin to shoulder. Expect rotation of 70 degrees. The strength of the sternocleidomastoid and trapezius muscles is evaluated with the patient maintaining each of the above positions while you apply opposing force. With rotation, cranial nerve XI is simultaneously tested (Fig. 22.29). Thoracic and Lumbar Spine Major landmarks of the back include each spinal process of the vertebrae (C7 and T1 are usually most prominent), the scapulae, iliac crests, and paravertebral muscles (Fig. 22.30). Expect the head to be positioned directly over the gluteal cleft and the vertebrae to be straight as indicated by symmetric shoulder, scapular, and iliac crest heights. The curve of the thoracic spine should be convex. The curve of the lumbar spine should be concave (Fig. 22.31A). The knees and feet should be in alignment with the trunk, pointing directly forward. Kyphosis may be observed in aging adults (Fig. 22.31B). Lordosis is common in patients who are obese or pregnant (Fig. 22.31C). A sharp angular deformity, a gibbus, is associated with a collapsed vertebra from osteoporosis (Fig. 22.31D). With the patient standing erect, palpate along the spinal processes and paravertebral muscles (Fig. 22.32). There should be no muscle spasms or spinal tenderness present. Percuss for spinal tenderness, first by tapping each spinal process with one finger and then by percussing each side of the spine along the paravertebral muscles with the ulnar aspect of your fist. No muscle spasm or spinal tenderness with palpation or percussion should be elicited. Ask the patient to bend forward slowly and touch their toes while you observe from behind. Inspect the spine for unexpected curvature. The patient’s back should remain symmetrically flat as the concave curve of the lumbar spine becomes convex with forward flexion. A lateral curvature or rib hump should make you suspect scoliosis (Fig. 22.33). Measure the degree of rotation with a scoliometer (see Chapter 3). Then have the patient rise but remain bent at the waist to fully extend the back. Reversal of the lumbar curve should be apparent. Evaluate the range of motion by asking the patient to perform the following movements: Bend forward at the waist and, without bending the knees, try to touch the toes. Expect flexion of 75 to 90 degrees (Fig. 22.34A). Bend back at the waist as far as possible. Expect hyperextension of 30 degrees (Fig. 22.34B). Bend to each side as far as possible. Expect lateral bending of 35 degrees bilaterally (Fig. 22.34C). Swing the upper trunk from the waist in a circular motion from front to side to back to side while you Spinous process C7 Musculoskeletal System 555 FIG. 22.32 Palpation of the spinal processes of the vertebrae. Spinous process T1 Line between iliac crests crosses spinous process of L4 Paravertebral muscles Posterior superior iliac spine FIG. 22.33 Inspection of the spine for lateral curvature and lumbar convexity. FIG. 22.30 Landmarks of the back. A B C D FIG. 22.31 Deviations in spinal column curvatures. (A) Expected spine curvatures. (B) Kyphosis. (C) Lordosis. (D) Gibbus. Examination And Findings CHAPTER 22 556 CHAPTER 22 Musculoskeletal System Hyperextension 0° 0° Examination And Findings Flexion 30° 75° A B Right Left 0° 35° 35° C D FIG. 22.34 Range of motion of the thoracic and lumbar spine. (A) Flexion. (B) Hyperextension. (C) Lateral bending. (D) Rotation of the upper trunk. stabilize the pelvis. Expect rotation of the upper trunk 30 degrees forward and backward (Fig. 22.34D). Patient Safety Reducing the Risk for Lower Back Pain Counsel patients on how to use appropriate techniques when lifting heavy objects to reduce the risk of lower back injury. Rather than bend over to pick up a heavy object, keep the back straight and flex the knees to get closer to the object. Keep the object close to the body and lift with the knees. Avoid twisting the back during the lift. Hips Inspect the hips anteriorly and posteriorly while the patient stands. Using the major landmarks of the iliac crest and the greater trochanter of the femur, note any asymmetry in the iliac crest height, the size of the buttocks, or the number and level of gluteal folds. Examine the range of motion of the hips by asking the patient to perform the following movements: While supine, raise the leg with the knee extended above the body. Expect up to 90 degrees of hip flexion (Fig. 22.35A). While either standing or prone, swing the straightened leg behind the body without arching the back. Expect hip hyperextension of 30 degrees or less (Fig. 22.35B). While supine, raise one knee to the chest while keeping the other leg straight. Expect hip flexion of 120 degrees (Fig. 22.35C). While supine, swing the leg laterally and medially with the knee straight. With the adduction movement, passively lift the opposite leg to permit the examined leg full movement. Expect up to 45 degrees of abduction and up to 30 degrees of adduction (Fig. 22.35D). Musculoskeletal System 557 Examination And Findings CHAPTER 22 Up to 90° Hip flexion, knee extended Hyperextension, knee extended Up to 30° 0° 0° A B 120° Flexion, knee flexed Abduction 0° 0° Adduction Up to 30° D C 40° Up to 45° 45° Internal rotation F E FIG. 22.35 Range of motion of the hip. (A) Hip flexion, knee extended. (B) Hip extension, knee extended. (C) Hip flexion, knee flexed. (D) Abduction. (E) Internal rotation. (F) External rotation. While supine, flex the knee, keeping the foot on the table, then rotate the leg with the flexed knee toward the other leg. Expect internal rotation of 40 degrees (Fig. 22.35E). While supine, place the lateral aspect of the foot on the knee of the other leg; move the flexed knee toward the table (FABER test—Flex, ABduct, and Externally Rotate). Expect 45 degrees of external rotation (Fig. 22.35F). To test hip flexion strength, apply resistance while the patient maintains flexion of the hip when the knee is flexed and then extended. Muscle strength can also be evaluated during abduction and adduction, as well as by resistance to uncrossing the legs while seated. Legs and Knees Inspect the knees and their popliteal spaces in both flexed and extended positions, noting the major landmarks: tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of the femur, adductor tubercle of the femur, and patella (see Fig. 22.10). Inspect the extended Examination And Findings 558 CHAPTER 22 Musculoskeletal System knee for its natural concavities on the anterior aspect, on each side, and above the patella. Loss of these concavities may suggest a knee effusion. Observe the lower leg alignment. The angle between the femur and tibia is expected to be less than 15 degrees. Variations in lower leg alignment are genu valgum (knock- knees) and genu varum (bowlegs). Excessive hyperextension of the knee with weight bearing (genu recurvatum) may indicate weakness of the quadriceps muscles. An effusion of the knee fills the suprapatellar pouch and the concavity below the patella medially. When this occurs, the usual indentation above and on the medial side of the patella is filled out to be convex rather than concave. Palpate the popliteal space, noting any swelling or tenderness. Fullness in the popliteal space may indicate a popliteal (Baker) cyst. Next, palpate the tibiofemoral joint space, identifying the patella, the suprapatellar pouch, and the infrapatellar fat pad. This joint should feel smooth and firm, without tenderness, swelling, bogginess, nodules, or crepitus (see Knee Assessment for additional assessment procedures). Examine the knees’ range of motion by asking the patient to perform the following movements (Fig. 22.36): Bend each knee. Expect 130 degrees of flexion. Straighten the leg and stretch it. Expect full extension and up to 15 degrees of hyperextension. The strength of the knee muscles is evaluated with the patient maintaining flexion and extension while you apply opposing force. The patient may be sitting or standing for this assessment. Feet and Ankles Inspect the feet and ankles while the patient is bearing weight (i.e., standing and walking) and while sitting. Landmarks of the ankle include the medial malleolus, the lateral malleolus, and the Achilles tendon. Expect to observe smooth and rounded malleolar prominences, prominent heels, and prominent metatarsophalangeal joints. Calluses and corns may indicate chronic pressure or irritation. Observe the contour of the feet and the position, size, and number of toes. The feet should be in alignment with the tibias. Common alignment variations are pes varus (in-toeing) and pes valgus (out-toeing). Weight bearing should be on the midline of the foot, on an imaginary line from the heel midline to between the second and third toes. Deviations in forefoot alignment (metatarsus varus or metatarsus valgus), heel pronation, and pain or injury often cause a shift in weight-bearing position (Fig. 22.37). Expect the foot to have a longitudinal arch, although the foot may flatten with weight bearing (Fig. 22.38A). Common variations include pes planus (Fig. 22.38B), a foot that remains flat even when not bearing weight, and pes cavus, a high instep (Fig. 22.38C). Pes cavus may be associated with claw toes. The toes should be straight forward, flat, and in alignment with each other. Several unexpected deviations of Up to 130° Flexion 15° 0° Hyperextension FIG. 22.36 Range of motion of the knee: flexion and extension. FIG. 22.37 Pronation of heel. Note that weight bearing is not through the midline of the foot. (Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine.) the toes can occur (Fig. 22.39). Hyperextension of the metatarsophalangeal joint with flexion of the toe’s proximal joint is called hammertoe. A flexion deformity at the distal interphalangeal joint is called a mallet toe. Claw toe is hyperextension of the metatarsophalangeal joint with flexion of the toe’s proximal and distal joints. Hallux valgus is lateral deviation of the great toe, which may cause overlapping with the second toe. A bursa often forms at the pressure point and, if it becomes inflamed, forms a painful bunion. Heat, redness, swelling, and tenderness are signs of an inflamed joint, possibly caused by rheumatoid arthritis, gout, septic joint, fracture, or tendonitis. In particular, an inflamed metatarsophalangeal joint of the great toe should make you suspect gouty arthritis. Palpate the Achilles tendon, the anterior surface of the ankle, and the medial and lateral malleoli. A persistently thickened Achilles tendon may indicate the tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia. Use the thumb and fingers of both hands to compress the forefoot and to palpate each Musculoskeletal System 559 Examination And Findings CHAPTER 22 A B2 B1 C1 C2 FIG. 22.38 Variations in the longitudinal arch of the foot. (A) Commonly expected arch. (B1 and B2) Pes planus (flatfoot). (C1 and C2) Pes cavus (high instep). (B2, Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine; C2, from Coughlin et al., 2007.) A C B D E FIG. 22.39 Unexpected findings of the feet. (A) Hallux valgus with bunion. (B) Protruding metatarsal heads with callosities. (C) Hammertoes. (D) Mallet toe. (E) Claw toes. (Courtesy Charles W. Bradley, DPM, MPA, and Caroline Harvey, DPM, California College of Podiatric Medicine.) metatarsophalangeal joint, taking note of discomfort or swelling. Assess the range of motion of the foot and ankle by asking the patient to perform the following movements while sitting: Point the foot toward the ceiling. Expect dorsiflexion of 20 degrees (Fig. 22.40A). Point the foot toward the floor. Expect plantar flexion of 45 degrees. B ending the foot at the ankle, turn the sole of the foot toward and then away from the other foot. Expect inversion of 30 degrees and eversion of 20 degrees (Fig. 22.40B). Rotating the ankle, turn the foot away from and then toward the other foot while the examiner stabilizes the leg. Expect abduction of 10 degrees and adduction of 20 degrees (Fig. 22.40C). Bend and straighten the toes. Expect flexion and extension, especially of the great toes. 560 Musculoskeletal System CHAPTER 22 Advanced Skills Dorsiflexion 20° 30° 20° 0° A 45° Plantar flexion Eversion 0° Inversion B 10° C 0° 20° FIG. 22.40 Range of motion of the foot and ankle. (A) Dorsiflexion and plantar flexion. (B) Inversion and eversion. (C) Abduction and adduction. Have the patient maintain dorsiflexion and plantar flexion while you apply opposing force to evaluate the strength of the ankle muscles. Abduction and adduction of the ankle and flexion, as well as extension of the great toe, may also be used to evaluate muscle strength. For the assessment of gait, see Chapter 23. Evidence-Based Practice in Physical Examination Acute Ankle Injury in Adults In cases of an acute ankle injury, the Ottawa Ankle Rules help identify the characteristics of patients needing an ankle radiograph series. There must be pain in the malleolar zone and one of the following: Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Inability to bear weight for four steps both immediately after the injury and in the emergency department Absolute exclusion criteria for an ankle radiograph series include the following: age younger than 18 years, intoxication, multiple painful (distracting) injuries, pregnancy, head injury, and neurologic deficit. The Ottawa Ankle Rules have 95% sensitivity for detecting an ankle fracture that is present on radiography. Data from Beckenkamp et al. (2017). ADVANCED SKILLS Various other procedures are performed for further evaluation of specific joints of the musculoskeletal system when problems are detected with routine procedures (Table 22.2). Hand and Wrist Assessment Several procedures are used to evaluate the integrity of the median nerve, which innervates the palm of the hand and the palmar surface of the thumb, index and middle fingers, and half of the ring finger. Ask the patient to mark the specific locations of pain, numbness, and tingling on the Katz hand diagram (Fig. 22.41). Certain patterns of TABLE 22.2 Special Procedures for Assessment of the Musculoskeletal System PROCEDURE CONDITION DETECTED Limb measurement Asymmetry in limb size Neer test Shoulder rotator cuff impingement or tear Hawkins test Shoulder rotator cuff impingement or tear Katz hand diagram Median nerve integrity Thumb abduction test Median nerve integrity Tinel sign Median nerve integrity Phalen test Median nerve integrity Straight leg raising L4, L5, S1 nerve root irritation Femoral stretch test L1, L2, L3, L4 nerve root irritation Ballottement Effusion in the knee Bulge sign Effusion in the knee McMurray test Torn meniscus in knee Anterior and posterior drawer test Anterior and posterior cruciate ligament integrity Varus-valgus stress test Medial or lateral collateral ligament instability in knee Lachman test Anterior cruciate ligament integrity Thomas test Flexion contracture of hip Trendelenburg sign Weak hip abductor muscles pain, numbness, and tingling are associated with carpal tunnel syndrome. The thumb abduction test isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve. Have the patient place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength (Fig. 22.42A). Full resistance to this pressure is expected. Weakness is associated with carpal tunnel syndrome. To perform the Phalen test, ask the patient to hold both wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minute (Fig. 22.42B). Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. The CHAPTER 22 Musculoskeletal System 561 Advanced Skills FIG. 22.41 Assessment for carpal tunnel syndrome. (A) Katz hand diagram. (B) Classic and probable patterns of pain, tingling, and numbness using the Katz hand diagram. A Classic pattern Symptoms affect at least two of digits 1, 2, or 3. The classic pattern permits symptoms in the fourth and fifth digits, wrist pain, and radiation of pain proximal to the wrist, but it does not allow symptoms on the palm or dorsum of the hand. Probable pattern Same symptom pattern as classic, except palmar symptoms are allowed unless confined solely to the ulnar aspect. In the possible pattern, not shown, symptoms involve only one of digits 1, 2, or 3. B Numbness Pain Tingling Decreased sensation Advanced Skills 562 CHAPTER 22 Musculoskeletal System A Flexor retinaculum Carpal canal (sulcus carpi) Median nerve B C FIG. 22.42 Additional procedures for assessment of carpal tunnel syndrome. (A) Thumb abduction test. (B) Phalen maneuver. (C) Elicitation of Tinel sign. reverse Phalen test is performed by placing the palms and fingers together with full wrist extension. The Tinel sign is tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament (Fig. 22.42C). A tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign and can indicate carpal tunnel syndrome. Evidence-Based Practice in Physical Examination Carpal Tunnel Syndrome The likelihood that a patient will have a positive electrodiagnostic study for carpal tunnel syndrome is increased by the following: weakened thumb abduction, a classic or probable distribution of symptoms on the Katz hand diagram (see next page), and hypalgesia (decreased pain sensation along the thumb and median nerve distribution compared with the little finger on the same hand). The Tinel and Phelan tests are less accurate. Data from Watson et al. (2010). Shoulder Assessment Several procedures are used to evaluate the rotator cuff for impingement (tendonitis or overuse injury from repetitive overhead activities) or a tear. To perform the passive painful arc maneuver (Neer test), forward flex the patient’s arm up to 150 degrees while depressing the scapula. This presses the greater tuberosity and supraspinatus muscle against the anteroinferior acromion. Increased shoulder pain is associated with rotator cuff inflammation or a tear (Fig. 22.43A). The Hawkins-Kennedy test is performed by abducting the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit. Increased shoulder pain is associated with rotator cuff inflammation or a possible tear (Fig. 22.43B). To test the strength of the rotator cuff muscles, perform the following maneuvers. A normal result is indicated by the absence of pain or weakness with the following maneuvers: To assess the supraspinatus muscle of the rotator cuff, have the patient place the arm in 90 degrees of abduction, 30 degrees of forward flexion, and internally rotated (thumbs pointing down). Apply downward pressure on the arm against patient resistance. To assess the subscapularis muscle, have the patient hold the arm at the side, elbow flexed 90 degrees, and rotate the forearm medially against resistance. To evaluate the infraspinatus and teres minor muscles, have the patient hold the arm at the side, elbow flexed 90 degrees, and rotate the arm laterally against resistance. Pain and weakness with opposing force is an unexpected finding and may be associated with inflammation or a tear. Lower Spine Assessment The straight leg raising test is used to test for nerve root irritation or lumbar disk herniation, most commonly seen at the L4, L5, and S1 levels. Have the patient lie supine with the neck slightly flexed. Ask the patient to raise the leg, keeping the knee extended (see Fig. 22.35A). No pain should be felt below the knee with leg raising. Radicular pain below the knee may be associated with disk A Musculoskeletal System 563 B FIG. 22.43 Assessment for rotator cuff inflammation or tear. (A) Neer test. (B) Hawkins-Kennedy test. herniation. Flexion of the knee often eliminates the pain with leg raising. Repeat the procedure on the unaffected leg. Crossover pain in the affected leg with this maneuver is more indicative of sciatic nerve impingements. The femoral stretch test or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 levels. Have the patient lie prone and extend the hip. No pain is expected. Pain on extension is a positive sign of nerve root irritation (Fig. 22.44). Hip Assessment The Thomas test is used to detect flexion contractures of the hip that may be masked by excessive lumbar lordosis. Have the patient lie supine; fully extend one leg flat on the examining table and flex the other leg with the knee to the chest. Observe the patient’s ability to keep the extended leg flat on the examining table (Fig. 22.45). Lifting the extended leg off the examining table indicates a hip flexion contracture in the extended leg. The Trendelenburg test is a maneuver to detect weak hip abductor muscles. Ask the patient to stand and balance first on one foot and then on the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, this indicates the hip abductor muscles on the weight-bearing side are weak (Fig. 22.46). FIG. 22.44 Femoral stretch test for high lumbar nerve root irritation. FIG. 22.45 Procedures for examination of the hip with the Thomas test. Note the elevation of the extended leg off the examining table. Evidence-Based Practice in Physical Examination Hip Osteoarthritis Simple tests of hip motion and observing for pain during that motion can be helpful in distinguishing patients most likely to have osteoarthritis from those who do not. To identify patients most likely to have osteoarthritis, the most useful physical findings were squat causing posterior hip pain (sensitivity, 24%; specificity, 96%), groin pain on passive abduction or adduction (sensitivity, 33%; specificity, 94%), abductor weakness (sensitivity, 44%; specificity, 90%), and decreased passive hip adduction (sensitivity, 80%; specificity, 81%). A combination of findings efficiently detects those most likely to have severe hip OA. The presence of normal passive hip adduction was most useful for suggesting the absence of OA. Data from Metcalfe et al. (2019). Knee Assessment Ballottement is used to determine the presence of an effusion in the knee from excess fluid. With the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella quickly downward against the femur with a finger of your other hand. If an effusion is present, a tapping or clicking will be sensed when the patella is pushed against the femur. Release the pressure against the patella, but keep your finger lightly touching it. If an effusion is present, the patella will float out as if a fluid wave were pushing it (Fig. 22.47). Advanced Skills CHAPTER 22 Advanced Skills 564 CHAPTER 22 Musculoskeletal System Examination for the bulge sign is also used to determine the presence of excess fluid in the knee. With the patient’s knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella. Observe for a bulge of returning fluid to the hollow area medial to the patella (Fig. 22.48). The McMurray test is used to detect a torn medial or lateral meniscus. Have the patient lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully Trendelenburg test testing the right lower limb Negative ‘normal’ flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position. Extend and then flex the patient’s knee. Any palpable or audible click, pain, or limited extension of the knee is a positive sign of a torn medial meniscus. Repeat the procedure, rotating the foot and knee inward (varus stress) (Fig. 22.49). A palpable or audible click, pain, or lack of extension is a positive sign of a torn lateral meniscus. The anterior and posterior drawer test is used to identify instability of the anterior and posterior cruciate ligaments. Have the patient lie supine and flex the knee 45 to 90 degrees, placing the foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the Positive FIG. 22.47 Procedure for ballottement examination of the knee. FIG. 22.46 Trendelenburg test evaluating the right lower limb. Note any asymmetry in the level of the iliac crests with weight bearing. (From Tillotson et al., 2019) A FIG. 22.49 Procedure for examination of the knee with the McMurray test. Knee is flexed after lower leg was rotated to medial position. B FIG. 22.48 Testing for the bulge sign in examination of the knee. (A) Milk the medial aspect of the knee two or three times. (B) Tap the lateral side of the patella. anterior tibia just distal to the tibial tuberosity. Draw the tibia forward, forcing the tibia to slide forward of the femur. Then push the tibia backward (Fig. 22.50). Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding. The Lachman test is used to evaluate anterior cruciate ligament integrity. With the patient supine, flex the knee 10 to 15 degrees with the heel on the table. Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia. While stabilizing the femur, pull the tibia anteriorly. Attempt to have the patient relax the hamstring muscles for an optimal test. Increased laxity, greater than 5 mm compared with the uninjured side, indicates injury to the ligament. Evidence-Based Practice in Physical Examination Acute Knee Injury In cases of an acute knee injury, the Ottawa Knee Rules identify the characteristics of patients who should have a radiograph of the knee. The rules include any of the following findings: Age older than 55 years Tenderness at head of fibula Isolated tenderness of the patella Inability to flex the knee to 90 degrees Data from Jalili et al. (2010). 565 The varus (abduction) and valgus (adduction) stress tests are used to identify instability in the lateral and medial collateral ligaments. Have the patient lie supine and extend the knee. Stabilize the femur with one hand and hold the ankle with your other hand. Apply varus force against the ankle (toward the midline) and internal rotation. Excessive laxity is felt as joint opening. Laxity in this position indicates injury to the lateral collateral ligament. Then apply valgus force against the ankle (away from the midline) and external rotation. Laxity in this position indicates injury to the medial collateral ligament (Fig. 22.51). Repeat the movements with the patient’s knee flexed to 30 degrees. No excessive medial or lateral movement of the knee is expected. Limb Measurement When a difference in length or circumference of matching extremities is suspected, measure and compare the size of both extremities. Leg length is measured from the anterior superior iliac spine to the medial malleolus of the ankle, crossing the knee on the medial side (Fig. 22.52A). Arm length is measured from the acromion process through the olecranon process to the distal ulnar prominence. The circumference of the extremities is measured in centimeters at the same distance on each limb from a major landmark (Fig. 22.52B). Athletes who use the dominant arm almost exclusively in their activities (e.g., pitchers and tennis players) may have some discrepancy FIG. 22.50 Examination of the knee with the drawer test for anterior and posterior stability. A Musculoskeletal System FIG. 22.51 Valgus stress test of the knee with knee extended. B FIG. 22.52 Measuring limb length (A) and leg circumference (B). Advanced Skills CHAPTER 22 566 CHAPTER 22 Musculoskeletal System Advanced Skills in circumference. For most people, there should be no more than a 1-cm discrepancy in length and circumference between matching extremities. Infants Genetic disorders and fetal conditions can produce musculoskeletal anomalies. The fetus may experience various postural pressures leading to reduced extension of the extremities and torsions of various bones. Fully undress the infant and observe the posture and spontaneous generalized movements. Use a warming table when examining a newborn. No localized or generalized muscular twitching is expected. Inspect the lower back for tufts of hair, dimples, discolorations, cysts, or masses near the spine. A mass near the spine is likely to be a meningocele or myelomeningocele. From about age 2 months, the infant should be able to lift the head and trunk from the prone position, giving you an indication of forearm strength. Assess the curvature of the spine and the strength of the paravertebral muscles with the infant in a sitting position. Kyphosis of the thoracic and lumbar spine will be apparent in the sitting position until the infant can sit without support (Fig. 22.53). Inspect the extremities, noting symmetric flexion of arms and legs. The axillary, gluteal, femoral, and popliteal creases should be symmetric, and the limbs should move freely. No unusual proportions or asymmetry of limb length or circumference, constricted annular bands, or other deformities should be noted. Place the newborn in a fetal position to observe how that may have contributed to any asymmetry of flexion, position, or shape of the extremities. Newborns have some resistance to full extension of the elbows, hips, and knees. Movements should be symmetric. All infants are flat-footed, and many newborns have a slight varus curvature of the tibias (tibial torsion) or forefoot adduction (metatarsus adductus) from fetal positioning. The midline of the foot may bisect the third and fourth toes rather than the second and third toes. The fore- A B foot should be flexible, straightening with abduction. It is necessary to follow tibial torsion and metatarsus adductus variations carefully, but they seldom require intervention. As growth and development take place, the expected body habitus is usually achieved. The hands should open periodically with the fingers fully extended. Observe the palmar and phalangeal creases on each hand. A single crease extending across the entire palm is frequently associated with Down syndrome and other genetic conditions, but it may also be seen in healthy individuals. Count the fingers and toes, noting polydactyly (six or more digits on an extremity) or syndactyly (two or more digits fused together) (Fig. 22.54). Palpate the clavicles and long bones for fractures, dislocations, crepitus, masses, and tenderness. One of the most easily missed findings in the newborn is a fractured clavicle. This may be evident by a lump on the collarbone caused by the callus that forms on the healing clavicle noted in the first weeks after birth. Position the baby with the trunk flexed and palpate each spinal process. Feel the shape of each, noting whether it is thin and well-formed, as expected, or whether it is split, possibly indicating a bifid defect (Fig. 22.55). FIG. 22.53 Kyphosis, expected convex curvature of the newborn’s thoracic and lumbar spine. C FIG. 22.54 Anomalies of the newborn’s hand. (A) Simian crease. (B) Syndactyly. (C) Polydactyly. (A, from Davidson, 2008; B, courtesy Dr. Joseph Imbriglia, Allegheny General Hospital; C, from Chung, 2009.) Palpate the muscles to evaluate muscle tone, grasping the muscle to estimate its firmness. Observe for spasticity or flaccidity and, when detected, determine whether it is localized or generalized. Use passive range of motion to examine joint mobility. The Barlow and Ortolani maneuvers to detect hip dislocation or subluxation should be performed each time you examine the infant during the first year of life. Using little force, test one hip at a time, stabilizing the pelvis with the other hand. With the infant supine, position yourself at the infant’s feet, and flex the hip and knee to 90 degrees. Vertebral body Spinal cord Spinal nerve Defect FIG. 22.55 Bifid defect of the vertebra identified by palpation. A Musculoskeletal System 567 For the Barlow maneuver, grasp the leg with your thumb on the inside of the thigh, the base of the thumb on the knee, and your fingers gripping the outer thigh with fingertips resting on the greater trochanter (Fig. 22.56). Adduct the thigh and gently apply downward pressure on the femur in an attempt to disengage the femoral head from the acetabulum. A positive sign is when a clunk or sensation is felt as the femoral head exits the acetabulum posteriorly. For the Ortolani maneuver, slowly abduct the thigh while maintaining axial pressure. With the fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, you should suspect hip subluxation or dislocation and refer to an orthopedic surgeon for management. High-pitched clicks are common and expected. By 3 months of age, muscles and ligaments tighten, and limited abduction of the hips becomes the most reliable sign of hip subluxation or dislocation (Fig. 22.57). The test for the Allis sign is also used to detect hip dislocation or a shortened femur. With the infant supine on the examining table, flex both knees, keeping the feet flat on the table close to the buttocks and the femurs aligned with each other. Position yourself at the child’s feet, and observe the height of the knees (Fig. 22.58). When one knee appears lower than the other, the Allis sign is positive. B FIG. 22.56 Barlow and Ortolani maneuver to detect hip dislocation. (A) Phase I, adduction. (B) Phase II, abduction. FIG. 22.57 Signs of hip dislocation: limitation of abduction and asymmetric gluteal folds. Advanced Skills CHAPTER 22 CHAPTER 22 Musculoskeletal System Advanced Skills 568 FIG. 22.58 Examination for the Allis sign. Unequal upper leg length would indicate a positive sign. FIG. 22.60 Lumbar curvature of the toddler’s spine. FIG. 22.59 Evaluation of shoulder muscle strength in the newborn. General muscle strength is evaluated by holding the infant in vertical suspension with your hands under the axillae (Fig. 22.59). Adequate shoulder muscle strength is present if the infant maintains the upright position. If the infant begins to slip through your fingers, proximal muscle weakness is present. Children Watching young children play during the history can provide a great deal of information about the child’s musculoskeletal system. Observe the child pick up and play with toys and move around the room. Observe the toddler’s ability to sit, creep, and grasp and release objects during play. Knowledge of the expected sequence of motor development will facilitate your examination. If the child shows no limitation, the musculoskeletal examination may not reveal any additional information. Position the young child to observe motor development and musculoskeletal function. Inspect the child’s spine while they are standing. Young children will have a lumbar curvature of the spine and a protuberant abdomen (Fig. 22.60). As you inspect the bones, joints, and muscles, pay particular attention to the alignment of the legs and feet because developmental stresses are placed on the musculoskeletal system. Remember to observe the wear of the child’s shoes and ask about his or her favorite sitting posture. The W or reverse tailor position places stress on the joints of the hips, knees, and ankles. It is commonly seen in children with in-toeing associated with femoral anteversion (Fig. 22.61). Inspect the longitudinal arch of the foot and the position of the feet with weight bearing. A fat pad obscures the longitudinal arch of the foot until about 3 years of age; after that time, the arch should be apparent when the foot is not bearing weight. Metatarsus adductus should be resolved. The feet of the toddler will often pronate slightly inward until about 30 months of age. After that age, weight bearing should shift to the midline of the feet. Assess for tibial torsion with the child prone on the examining table. Flex one knee 90 degrees and align the midline of the foot parallel to the femur. Using the thumb and index finger of one hand, grasp the medial and lateral malleoli of the ankle; grasp the knee, placing your thumb and index finger on the same side of the leg (Fig. 22.62). If your thumbs are not parallel to each other, tibial torsion is present. Tibial torsion, a residual effect of fetal positioning, is expected to resolve within several years after weight bearing. Assess for bowleg (genu varum) with the child standing, facing you, knees at your eye level. Measure the dis- Musculoskeletal System 569 Advanced Skills CHAPTER 22 FIG. 22.61 Reverse tailor sitting position. FIG. 22.63 Genu valgum (knock-knee) in the young child. Palpate the bones, muscles, and joints, paying particular attention to asymmetric body parts. Use passive range of motion to examine a joint and muscle group if some limitation of movement is noted while the child is playing. Ask the child to stand, rising from a supine position. The child with good muscle strength will rise to a standing position without using the arms for leverage. Proximal muscle weakness is indicated by the Gower sign in which the child rises from a sitting position by placing hands on the legs and pushing the trunk up (Fig. 22.64). FIG. 22.62 Examination for tibial torsion. tance between the knees when the medial malleoli of the ankles are together. Genu varum is present if a space of 2.5 cm (1 inch) exists between the knees. The expected 10-to 15- degree angle at the tibiofemoral articulation increases with genu varum but remains bilaterally symmetric. On future examinations, note any increase in the angle or increased space between the knees. Genu varum is a common finding in toddlers until 18 months of age. Asymmetry of the tibiofemoral articulation angle or space between the knees should not exceed 4 cm (1.5 inches). Evaluate for knock-knee (genu valgum) with the child standing, facing you, knees at your eye level. With the knees together, measure the distance between the medial malleoli of the ankles. Genu valgum is present if a space of 2.5 cm (1 inch) exists between the medial malleoli. As with genu varum, the tibiofemoral articulation angle will increase with genu valgum. On future examinations, note any increase in the angle or increased space between the ankles. Genu valgum is a common finding of children between 2 and 4 years of age (Fig. 22.63). Asymmetry of the tibiofemoral articulation angle or a space between the medial malleoli should not exceed 5 cm (2 inches). Adolescents Examine older children and adolescents with the same procedures used for adults. Specific procedures for the musculoskeletal examination for sports participation are found in Chapter 24. The spine should be smooth, with balanced concave and convex curves. No lateral curvature or rib hump with forward flexion should be apparent. The shoulders and scapulae should be level with each other within.5 inches, and a distance between the scapulae of 3 to 5 inches is usual (see Fig. 22.12B). Adolescents may have slight kyphosis and rounded shoulders with an interscapular space of 5 or 6 inches. Pregnant Patients Postural changes with pregnancy are common. The growing fetus shifts the patient’s center of gravity forward, leading to increased lordosis and a compensatory forward cervical flexion (Fig. 22.65). Stooped shoulders and large breasts exaggerate the spinal curvature. Increased mobility and instability of the sacroiliac joints and symphysis pubis as the ligaments become less tense contribute to the “waddling” gait of late pregnancy. Pregnant patients can often experience pain from the pubic symphysis down 570 CHAPTER 22 Musculoskeletal System Advanced Skills Gower sign FIG. 22.64 Gower sign. Starting from a seated position on the floor, the child uses their hands to “climb up” their legs to achieve a standing position. This is due to weakness in the pelvis, hips, and thighs. (From Heaver et al., 2019.) walking, possibly resulting in lower back pain. Most back pain resolves within 6 months after delivery. Carpal tunnel syndrome (discussed later in the chapter) is experienced by some patients during the last trimester because of the associated fluid retention during pregnancy. Usually, the symptoms abate several weeks after delivery. FIG. 22.65 Postural changes with pregnancy. into the inner thigh when standing and may have a feeling that the bones are moving or snapping when walking. During pregnancy, increases in the lumbosacral curve and anterior flexion of the head in the cervicodorsal region become apparent. To assess for lumbosacral hyperextension, ask the patient to bend forward at the waist toward the toes. Palpate the distance between the L4 and S1 spinal processes. As the patient rises to standing, from full flexion to full extension, note when the distance between L4 and S1 becomes fixed. If it becomes fixed before the spine is fully extended, the patient will be hyperextended when Older Adults The older adult should be able to participate in the physical examination as described for the adult, but the response to your requests may be more slow and deliberate. Fine and gross motor skills required to perform activities of daily living such as dressing, grooming, climbing steps, and writing will provide an evaluation of the patient’s joint muscle agility (see the Functional Assessment box). Joint and muscle agility have tremendous extremes among older adults. The patient’s posture may display increased dorsal kyphosis, accompanied by flexion of the hips and knees. The head may tilt backward to compensate for the increased thoracic curvature (see Fig. 22.31B). The extremities may appear to be relatively long if the trunk has diminished in length due to vertebral collapse. The base of support may be broader with the feet more widely spaced, and the patient may hold the arms away from the body to aid balancing. The reduction in total muscle mass is often related to atrophy, either from disuse, as in patients with arthritis, or from loss of nerve innervation, as in patients with diabetic neuropathy. CHAPTER 22 Musculoskeletal System 571 ACTIVITY TO OBSERVE INDICATORS OF WEAKENED MUSCLE GROUPS Rising from lying to sitting position Rolling to one side and pushing with arms to raise to elbows; grabbing a side rail or table to pull to sitting Rising from chair to standing Pushing with arms to supplement weak leg muscles; upper torso thrusts forward before body rises Walking Lifting leg farther off floor with each step; shortened swing phase; foot may fall or slide forward; arms held out for balance or move in rowing motion Climbing steps Holding handrail for balance; pulling body up and forward with arms; uses stronger leg Descending steps Lowering weakened leg first; often descends sideways holding rail with both hands; may watch feet Picking up item from floor Leaning on furniture for support; bending over at waist to avoid bending knees; uses one hand on thigh to assist with lowering and raising torso Tying shoes Using footstool to decrease spinal flexion Putting on and pulling up trousers or stockings Difficulty may indicate decreased shoulder and upper arm strength; these activities often performed in sitting position until clothing is pulled up Putting on sweater Putting sleeve on weaker arm or shoulder first; uses internal or external shoulder rotation to get remaining arm in sleeve Zipping dress in back Difficulty with this indicates weakened shoulder rotation Combing hair Difficulty indicates problems with grasp, wrist flexion, pronation and supination of forearm, and elbow rotation Pushing chair away from table while seated Standing and easing chair back with torso; difficulty indicates problems with upper arm, shoulder, lower arm strength, and wrist motion Buttoning button or writing name Difficulty indicates problem with manual dexterity and finger-thumb opposition Modified from Wilson and Giddens (2005). Advanced Skills FUNCTIONAL ASSESSMENT Musculoskeletal Assessment ABNORMALITIES MUSCULOSKELETAL Ankylosing Spondylitis A chronic inflammatory disease of the spine, ankylosing spondylitis has a genetic predisposition associated with human leukocyte antigen (HLA)-B27 and may affect the cervical, thoracic, and lumbar spine along with the sacroiliac joints (Fig. 22.66) Abnormalities PATHOPHYSIOLOGY Inflamed intervertebral disks and longitudinal ligaments ossification Leads to eventual fusion and severe deformity of the vertebral column PATIENT DATA Subjective Data Develops predominantly in men between 20 and 40 years of age Begins insidiously with inflammatory low back and buttock pain, also involving hips and shoulders Buttock pain can fluctuate from one side to the other Objective Data Restriction in the lumbar flexion of the patient Limited range of motion of the shoulders, chest wall, hips, and knees may develop Uveitis may be present FIG. 22.66 Gross postural changes in patient affected by ankylosing spondylitis. (From Miller, 2010.) Lumbosacral Radiculopathy (Herniated Lumbar Disk) Herniation of a lumbar disk that irritates the corresponding spinal nerve root PATHOPHYSIOLOGY Generally caused by degenerative changes of the disk Most commonly occurring at the L4, L5, and S1 nerve roots Greatest incidence occurs between 31 and 50 years of age Nerve root L4 L5 S1 PATIENT DATA Subjective Data Can be associated with lifting heavy objects Common symptoms include low back pain with radiation to the buttocks and posterior thigh or down the leg in the distribution of the dermatome of the nerve root Pain relief is often achieved by lying down Objective Data Spasm and tenderness over the paraspinal musculature may be present Potential difficulty with heel walking (L4 and L5) or toe walking (S1) Numbness, tingling, or weakness in the involved extremity (Fig. 22.67) Pain Numbness Motor weakness Screening examination Reflexes Extension of quadriceps Dorsiflexion of great toe and foot Plantar flexion of great toe and foot Squat and rise Heel walking Walking on toes Knee jerk diminished None reliable Ankle jerk diminished FIG. 22.67 Distribution of paresthesia and radiating pain associated with herniated disks at the L4, L5, and S1 nerve roots. (From Thompson et al., 1997.) CHAPTER 22 Musculoskeletal System 573 Lumbar Stenosis PATHOPHYSIOLOGY PATIENT DATA Canal narrowing from bone and ligament hypertrophy may lead to Subjective Data entrapment of the spinal cord as it traverses the spinal canal Pain with walking or standing upright that often seems to originate in the buttocks and may then radiate down the legs Pain relief may occur with sitting or bending forward Pain may be worsened by prolonged standing, walking, or hyperextending the back Objective Data In the early stages, the neurologic examination is frequently normal With progression, the examination may show lower extremity weakness and sensory loss A stooped forward gait may be present Carpal Tunnel Syndrome Compression on the median nerve (see Fig. 22.41) PATHOPHYSIOLOGY Compression of the nerve within its flexor tendon sheath due to microtrauma, local edema or inflammation, repetitive motion, or vibration of the hands Associated with rheumatoid arthritis, gout, acromegaly, hypothyroidism, and the hormonal changes of pregnancy PATIENT DATA Subjective Data Numbness, burning, and tingling in the hands often occur at night Can also be elicited by flexion/extension movements of the wrist Pain may radiate to the arms Objective Data Weakness of the thumb and flattening of the thenar eminence of the palm Reproduction of symptoms with provocation of the Tinel and Phalen maneuvers Gout A form of arthritis resulting from chronically elevated serum uric acid PATHOPHYSIOLOGY Monosodium urate crystal deposition in joints and surrounding tissues results in acute inflammatory attacks PATIENT DATA Subjective Data Sudden onset of a hot, swollen joint; exquisite pain; limited range of motion Primarily affects men older than 40 years and women of postmenopausal age Usually affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved Objective Data The skin over the swollen joint may be shiny and red or purple Uric acid crystals may form as tophi under the skin with chronic gout (Fig. 22.68) FIG. 22.68 Tophi of first and second toe with whitish material seen under the skin of the distal second toe (From Fields, 2019.) Temporomandibular Joint Syndrome Painful jaw movement PATHOPHYSIOLOGY Caused by congenital anomalies, malocclusion, trauma, arthritis, and other joint diseases PATIENT DATA Subjective Data Unilateral facial pain that usually worsens with joint movement May be referred to any point on the face or neck Objective Data Most patients have a muscle spasm, and many have clicking, popping, or crepitus in the affected joint Abnormalities Narrowing of the spinal canal 574 CHAPTER 22 Musculoskeletal System Osteomyelitis Abnormalities An infection in the bone PATHOPHYSIOLOGY Usually results from an open wound or systemic infection Purulent matter spreads through the cortex of the bone and into the soft tissue Decreased blood flow to the affected bone may lead to bone necrosis PATIENT DATA Subjective Data Dull pain develops insidiously at the involved site and progresses over days to weeks Limp or decreased movement in infants and children Objective Data Signs of infection include edema, erythema, and warmth at the site Tenderness to palpation, pain with movement, and signs of inflammation such as fevers Bursitis Inflammation of the bursa PATHOPHYSIOLOGY Due to repetitive movement and excessive pressure on the bursa Can also be due to infection or gout PATIENT DATA Subjective Data Common sites include the shoulder, elbow, hip, and knee, with pain and stiffness surrounding the joint around the inflamed bursa The pain is usually worse during activity Objective Data Limitation of motion caused by swelling; pain on movement; point tenderness; and an erythematous, warm site (Fig. 22.69) Soreness may radiate to tendons at the site A B FIG. 22.69 (A) Olecranon bursitis with (B) full range of elbow extension (From Reilly and Kamineni, 2016.) Paget Disease of the Bone (Osteitis Deformans) A focal metabolic disorder of the bone PATHOPHYSIOLOGY Appears in persons older than 45 years Excessive bone resorption and bone formation produce a mosaic pattern of lamellar bone PATIENT DATA Subjective Data Vertigo and headache as a result of skull involvement Progressive deafness from involvement of the ossicles or neural elements may develop Objective Data Bowed tibias, misshapen pelvis, or prominent skull forehead may be evident Frequent fractures may occur CHAPTER 22 Musculoskeletal System 575 Osteoarthritis The deterioration of the articular cartilage covering the ends of bone in synovial joints PATIENT DATA Subjective Data Pain in hands, feet, hips, knees, and cervical or lumbar spine (most commonly) Onset usually begins after 40 years of age and develops slowly over many years with nearly 100% of people older than 75 years affected Objective Data The joints may be enlarged due to bone growths (osteophytes) (see Fig. 22.18B) May have crepitus and limited, painful range of motion Rheumatoid Arthritis A chronic systemic inflammatory disorder of the synovial tissue surrounding the joints PATHOPHYSIOLOGY Cause is unknown Within the inflamed synovial tissue and fluid, polymorphonuclear leukocytes aggregate Multiple inflammatory cytokines and enzymes are released that can result in subsequent damage to bone, cartilage, and other tissues PATIENT DATA Subjective Data Joint pain and stiffness, especially in the morning or after periods of inactivity Constitutional symptoms of fatigue, myalgias, weight loss, and low-grade fever are common Objective Data Involved joints include the hands, wrists, feet, and ankles, as well as the hips, knees, and cervical spine Synovitis, with soft tissue swelling and effusions, is present on examination Nodules and characteristic deformities can develop (see Fig. 22.16) The Differential Diagnosis table contrasts rheum

Musculoskeletal System Chapter 22

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