Clinical Nursing Skills: Musculoskeletal Assessment PDF

25.2 Physical Assessment 1169 Interview Follow-up Example Questions Are you Describe your concern today. “My lower back...

25.2 Physical Assessment 1169 Interview Follow-up Example Questions Are you Describe your concern today. “My lower back has been hurting for the past experiencing any How is it affecting your ability to week.” current complete daily activities? “I can barely walk, as I feel I have to lean over and musculoskeletal P: Does anything bring on the my legs are awkward. I have trouble leaning over symptoms such symptom, such as activity, weight- when I brush my teeth.” as muscle bearing, or rest? If activity brings on P: “I don’t remember anything specific that I did weakness, pain, the symptom, how much activity is that made my back start hurting, but one morning swelling, required to bring on the symptom? a week ago, I woke up and could barely get out of redness, warmth, Does it occur at a certain time of bed. The only thing that helps is a hot shower.” or stiffness? day? Is there anything that makes it Q: “When I’m just lying down, my back aches, but better or go away? when I try to walk, I’d say throbbing and Q: Describe the characteristics of sometimes a sharp jab.” the pain (aching, throbbing, sharp, R: “My lower back, just above my butt. It hurts dull). more on the left.” R: Is the pain localized or does it S: “Most of the time, like right now, 4, maybe 5. radiate to another part or area of But when I feel that sharp jab of a knife, it’s 8 to the body? 10.” S: How severe is the pain on a T: “It started a week ago, when I tried to get out of scale of 0 to 10? bed, it was bad. It’s continual pain at a 4 or 5, and T: When did the pain first start? Is it then those jabs of really bad pain—they come and constant, or does it come and go? go. I took some ibuprofen when the constant pain Have you taken anything to relieve was like a 7 one day, and it took it to a 3 but never the pain? went away. I never know when the stabbing pain will happen, so I can’t know when to take something.” Have you ever Please describe the conditions and “No, I haven’t. But I don’t see a doctor very often.” been diagnosed treatments. with a chronic musculoskeletal disease such as osteoporosis, osteoarthritis, or rheumatoid arthritis? Have you ever Please describe. “No. Nothing like that.” been diagnosed with a neurological condition that affected the use of your muscles? TABLE 25.4 Focused Interview Questions Related to the Musculoskeletal System 1170 25 Assessment of the Musculoskeletal System Interview Follow-up Example Questions Have you had Please describe. “I broke my right arm when I was a kid. Wore a any previous cast for a couple months. Nothing with my back or surgeries on your legs.” bones or muscles, such as fracture repair or knee or hip surgery? Are you currently Please describe. “I take a water pill for my blood pressure. I’ve taking any never had something like this happen before, so medications, no, I don’t take anything for my back. Well, I did herbs, or try some ibuprofen a couple days ago, like I said.” supplements for your muscles, bones, or the health of your musculoskeletal system? Have you ever Please describe. “My broken arm, when I was a kid. That’s the only had a broken thing.” bone, strain, or other injury to a muscle, joint, tendon, or ligament? TABLE 25.4 Focused Interview Questions Related to the Musculoskeletal System LIFE-STAGE CONTEXT Musculoskeletal Assessment Questions for the Older Adult When assessing older adults, it is important to assess their mobility and their ability to perform ADLs: Do you use any assistive devices, such as a brace, cane, walker, or wheelchair? Have you fallen or had any near falls in the past few months? If so, was there any injury or did you seek medical care? Describe your mobility as of today. Have you noticed any changes in your ability to complete your usual daily activities such as walking, going to the bathroom, bathing, doing laundry, or preparing meals? If so, do you have any assistance available? Medications also should be explored, to include prescriptions, over-the-counter medications, vitamins, and herbals, as all these sources have chemical properties that affect the human body. Effects may be intended and desired or undesired and accidental; interactions between drugs of all types should be noted in the patient’s medical record. Objective Data The purpose of a routine physical examination of the musculoskeletal system by a registered nurse is to assess function and to screen for abnormalities. Most information about function and mobility is gathered during the patient interview, but the nurse also observes the patient’s posture, walking, and movement of their extremities Access for free at openstax.org  25.2 Physical Assessment 1171 during the physical examination. During a routine assessment of a patient during inpatient care, a registered nurse typically completes the following musculoskeletal assessments: Assess gait. Inspect the spine. Observe the ROM of joints. Inspect muscles and extremities for size and symmetry. Assess muscle strength. Palpate extremities for tenderness. While assessing an older adult, keep in mind they may have limited mobility and ROM due to age-related degeneration of joints and muscle weakness. Be considerate of these limitations, and never examine any areas to the point of pain or discomfort. Support the joints and muscles as you assess them to avoid pain or muscle spasm. Compare bilateral sides simultaneously and expect symmetry of structure and function of the corresponding body area. Inspection General inspection begins by observing the patient in the standing position for postural abnormalities. Observe their stance and note any abnormal curvature of the spine. Ask the patient to walk away from you, turn, and walk back toward you while observing their gait and balance. Ask the patient to sit. Inspect the size and contour of the muscles and joints and if the corresponding parts are symmetrical. Notice the skin over the joints and muscles and observe if there is tenderness, swelling, erythema, deformity, or asymmetry. Observe how the patient moves their extremities and note if there is pain with movement or any limitations in active ROM. Active ROM is the degree of movement the patient can voluntarily achieve in a joint without assistance. Palpation Palpation is typically done simultaneously during inspection. As you observe, palpate each joint for warmth, swelling, or tenderness. If you observe decreased active ROM, gently attempt passive ROM by stabilizing the joint with one hand while using the other hand to gently move the joint to its limit of movement. The passive range of motion is the degree of ROM demonstrated in a joint when the examiner is providing the movement. During palpation, a feeling of popping accompanied by a crackling noise is considered normal as long as it is not associated with pain. As the joint moves, there should not be any reported pain or tenderness. Assess muscle strength. Muscle strength should be equal bilaterally, and the patient should be able to fully resist an opposing force. Muscle strength varies among people depending on their activity level, genetic predisposition, lifestyle, and history. A common method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale (Naqvi & Sherman, 2023). This method involves testing key muscles from the upper and lower extremities against gravity and the examiner’s resistance and grading the patient’s strength on a 0 to 5 scale (Table 25.5). 0—No muscle contraction 1—Trace muscle contraction, such as a twitch 2—Active movement only when gravity eliminated 3—Active movement against gravity but not against resistance 4—Active movement against gravity and some resistance 5—Active movement against gravity and examiner’s full resistance TABLE 25.5 Muscle Strength Scale (Source: Naqvi & Sherman, 2023.) To assess upper extremity strength, first begin by assessing bilateral handgrip strength. Extend your index and second fingers on each hand toward the patient and ask them to squeeze them as tightly as possible. Then, ask the patient to extend their arms with their palms up. As you provide resistance on their forearms, ask the patient to pull their arms toward them. Finally, ask the patient to place their palms against yours and press while you provide resistance. Figure 25.10 shows images of a nurse assessing upper body strength. 1172 25 Assessment of the Musculoskeletal System FIGURE 25.10 A nurse tests a patient’s (a) handgrip, (b) ability to pull toward themselves, and (c) ability to push away from themselves. (credit: “Neuro Exam image 38.png,” Neuro Exam image 41.png,” and “Neuro Exam image 39.jpg” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0) To assess lower extremity strength, perform the following maneuvers with a seated patient. Place your palms on the patient’s thighs and ask them to lift their legs while providing resistance. Second, place your hands behind the patient’s calves and ask them to pull their legs backward while you provide resistance. Place your hands on the top of their feet and ask them to pull their feet upward against your resistance. Finally, place your hands on the soles of their feet and ask them to press downward while you provide resistance, instructing them to “press downward like pressing the gas pedal on a car” (Figure 25.11). FIGURE 25.11 A nurse assesses lower body strength by having the patient (a) lift their legs, (b) push their legs back, and (c) push up their feet against resistance. (credit: "Musculoskeletal Exam image 2.png," "Neuro Exam image 6.png," and "Musculoskeletal Exam Image 7.png" by Meredith Pomietlo/Chippewa Valley Technical College, CC BY) LINK TO LEARNING This video demonstrates an adult musculoskeletal assessment (https://openstax.org/r/77mskelassess) in about six minutes. A comparison of expected versus unexpected findings when assessing the musculoskeletal system is summarized in Table 25.6. Access for free at openstax.org  25.2 Physical Assessment 1173 Assessment Expected Findings Unexpected Findings (document and notify provider if a new finding) Inspection Erect posture with good balance Spinal curvature present and normal gait while walking Poor balance or unsteady gait Symmetrical joints and muscles while walking with no swelling, redness, or Swelling, bruising, erythema, or deformity tenderness over joints or muscles Active ROM of all joints without Deformity of joints difficulty Decreased active ROM No spine curvature Contracture or foot drop present Auscultation Not applicable Crepitus (a grating or crackling sound) associated with pain on movement Palpation No palpable tenderness or Warmth or tenderness on warmth of joints, bones, or palpation of joints, bones, or muscles muscles Muscle strength 5/5 against Decreased passive ROM resistance Muscle strength of 3/5 or less CRITICAL Hot, swollen, painful joint CONDITIONS to report Suspected fracture, dislocation, immediately sprain, or strain TABLE 25.6 Expected Versus Unexpected Findings on Musculoskeletal Assessment LIFE-STAGE CONTEXT Age-Related Musculoskeletal Differences Patients at the extremes of age, neonates and older adults, have some age-related musculoskeletal differences based on their age. The normal newborn skull bones are not fused, and assessment includes the fontanelles: depression or puffiness provides data about the baby’s fluid balance. Muscle development and strength are immature, but the normal neonate is able to move the head and all extremities; ROM is assessed passively. The spine is assessed, including inspection for the presence of a dimple and/or tuft of hair, which are associated with spina bifida occulta (Mayo Clinic, 2022). Changes associated with advanced age include sarcopenia (muscle loss), degenerative joint disease (DJD) or degenerative disk disease, a tendency of the tendons to lose elasticity, calcification of joint capsules, possible osteoporosis, and arthritis-related changes. These alterations to normal structure and function may lead to reduced flexibility and strength that may cause slower movement and impaired mobility and, in many cases, may place patients at increased risk for falls. While sarcopenia is common in older adults, it actually begins in about the third decade. There are steps that can be taken to prevent frailty and injuries, including exercise and proper nutrition. Resistance exercises show the most positive effect in the prevention of sarcopenia. Abnormalities of the Musculoskeletal Assessment The number of potential abnormalities that may present in the musculoskeletal assessment is vast and beyond the scope of this book and chapter. To narrow the range of possibilities, the focus herein is primarily on some of the most common aberrations, to assist the student and generalist nurse in identifying deviations from the normal 1174 25 Assessment of the Musculoskeletal System assessment. Diagnosing the specific cause of abnormal findings is within the scope of the advanced practice nurse and other such healthcare providers. In addition to the common abnormalities, exposure to a serious complication of musculoskeletal injury—compartment syndrome—is presented. Prompt recognition of signs and symptoms of compartment syndrome is essential to reduce development of more extensive injury and possible limb loss. Change in Bone Alignment Normal musculoskeletal function relies on bones to be aligned appropriately. Alterations to the alignment of bones can be genetic or occur from injury, infection, neoplasm, or metastasis. Even with medical or surgical intervention, fractures may heal with misalignment in bone structure, from location of the injury, abnormal healing process, or subsequent infection or inflammation. Dislocations also cause misalignment in bone structure, at least temporarily. Some dislocations, like many fractures, are urgent or emergent, requiring prompt or immediate intervention and realignment. Some other changes in bone alignment include the following: Intoeing: Commonly referred to as “pigeon-toed,” is when the feet turn in; this is especially notable when walking. Spinal disorders: Degenerative disk disease, osteoarthritis, herniated disk, spondylolisthesis, and spina bifida are all disorders that can affect spinal alignment. Neoplasms and metastases: Certain cancers can cause misalignment of bone structure either by primary tumors or metastases from other regions. Blount disease: Also called “tibia vara,” Blount disease is not a very common finding. It is a C-shaped bowing of the legs after toddlerhood caused by a growth disorder at the proximal epiphyseal plate of the tibia. It may be unilateral or bilateral. Accessory navicular bone: Not a particularly common finding, an accessory navicular bone is an extra bone in the center of the inner arch of the foot. Change in Shape of Bone Similar to bone alignment, bones are particular shapes for particular reasons—structurally and/or functionally. Because bones interact with other bones and connective tissues like cartilage, ligaments, and tendons, abnormal shapes can impact these related tissues and surrounding tissues. Changes in bone shape may lead to dysfunctions or, in mild cases and depending on where the shape change is, may not be symptomatic or apparent. There are a variety of causes for changes in the shapes of bones throughout the life span. Following are some examples: Bone spurs may develop. Osteoarthritis may cause changes. Unicameral bone cysts, cavities filled with fluid, change the shape of (primarily) long bones in children. Certain cancers affect the shape of bones, including multiple myeloma and primary bone marrow lymphoma. Skeletal surgeries may have resultant shape changes—bone grafts, repair of fractures, and joint replacements have this potential. Change in Length of Bone According to Boston Children’s Hospital (2005–2023) and Nationwide Children’s Hospital (2023), the chief causes of discrepancies in bone length are congenital, injury or infection, or neoplasm. The impact of impaired growth on the length of bones is reduced in adulthood, as once the epiphyses calcify, growth is halted. Adults can still be affected by changes in the length of bones from residual effects of traumatic injuries, infections, or neoplasms. Symptomatic discrepancies in bone length are most apparent in long bones, most commonly the femur and tibia (OrthoInfo, 1995–2023). The bearing of injuries, infections, or cancers on bone growth are especially significant when the epiphysis of the bone is impacted, as this is the source of long bone growth. Healing after fracture is commonly associated with slower growth; however, childhood fracture of the femur may lead to growth acceleration after the break, causing that leg to be longer than the uninjured side (OrthoInfo, 1995–2023). More than 50 percent of people have discrepancies in leg length (OrthoInfo, 1995–2023), but when the difference is less than 1.5 centimeters, it is often not apparent, is often without symptoms, and may not even be measured and Access for free at openstax.org  25.2 Physical Assessment 1175 confirmed. When the discrepancy between limbs is approximately 1.5 to 2 centimeters (or more), patients are likely to seek care and are evaluated for treatment (Figure 25.12). FIGURE 25.12 Discrepancy in leg length: this patient’s left leg is shorter than the right, with a missing fibula and notable bowing of the tibia. (credit: "Radiographic presentation of a 6 years old patient with fibular hemimelia type II" by National Library of Medicine, CC BY 2.0) Surgical interventions include shortening the longer leg or lengthening the shorter leg (Boston Children’s Hospital, 2005–2023). The following are three methods for shortening a leg: Resection of bone: This involves removal of a piece of bone from the longer leg; this is done after reaching adult height. Stapling the epiphysis: Both sides of the epiphysis are temporarily stapled; when length is equalized, the staples are removed. Epiphysiodesis: In epiphysiodesis, the epiphysis of the longer extremity is temporarily or permanently fused. Crepitus The term crepitus refers to a grating or crackling sound, or a finding with palpation that is described as akin to feeling crisped puffed rice under the fingers. In relation to the musculoskeletal system, it is associated with the sound of bones rubbing together. This is often apparent with joint movement. Crepitus can be a normal finding, but it is considered abnormal when accompanied by pain. In such circumstances, ROM may also be limited, and complete assessment of the joint may require passive instead of active ROM. Pain Many musculoskeletal issues can cause the patient to feel pain. Examples include the result of arthritis, injury, infection, joint dislocation, surgery, and some of the misshapes or misalignments previously discussed. Pain results from acute events and may also become chronic. Chronic musculoskeletal pain is a major contributor to worldwide disability (El-Tallawy et al., 2021). The most common regions of musculoskeletal pain include the low back, neck, and shoulders. Patients are affected by pain in various ways and in their abilities to perform self-care activities, work, and maintain an acceptable quality of life. With increasing age, the potential for experiencing musculoskeletal pain increases. 1176 25 Assessment of the Musculoskeletal System LIFE-STAGE CONTEXT Older Adults and Joint Pain Osteoarthritis (OA) is a degenerative disorder with repeated episodes of inflammation and joint damage leading to loss of cartilage within joints. Pain results as bones move within the joint without the cushion normally provided by cartilage. Limited movement may follow as pain and deterioration advance. Older adults are more prone to OA as it is known as a disorder of use; therefore, advancing age shows the results of years of use and perhaps overuse. Chronic pain also places a burden on healthcare systems and costs, which can be seen in the number of visits to healthcare providers, surgeries, assistive devices, and disability (El-Tallawy et al., 2021). Use of over-the-counter (OTC) and prescription medications are another example of high use and high impact on healthcare costs. When patients are prescribed medications to treat musculoskeletal pain, prescription may focus strictly on pain, as is apparent with opioids, or aim to treat inflammation as the source of pain. Because musculoskeletal pain often involves muscle spasms, a medication regimen may include a drug for pain, an anti-inflammatory, and a muscle relaxant. It is important for nurses to assess a patient’s pain before and after administering medications. Commonly, a numeric scale is used for adults who are able to comprehend a 0 to 10 scale of pain from none through severe (Figure 25.13). Alternatively, there are pain scales with faces showing different expressions denoting levels of pain—these are helpful for pediatric patients and adults who do not understand a number-based scale. FIGURE 25.13 This example of a pain scale includes numbers, expressive faces, and verbal descriptions, which can be used with different patient populations. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) Nurses must use different techniques for assessing pain in patients who are unconscious or otherwise unresponsive. Those nurses who work with such patients rely heavily on their assessment skills relative to nonverbal cues to evaluate patients’ pain and their responses to varied interventions. The critical-care pain observation tool (CPOT) allows nurses to score such patients objectively through four parameters: facial expression, body movements, ventilator compliance, and muscle tension. LINK TO LEARNING This video details the assessment of a nonverbal, intubated patient (https://openstax.org/r/77nonverb) using the CPOT. Watch the video to learn how to use the CPOT to assess pain in critically ill patients who are unable to verbalize or point to a number or image. Decreased Range of Motion Limitations to ROM can fall anywhere along a spectrum from mild decrease of ROM to a total lack of movement. Such immobility may be physiological, as in the case of residual damage after an injury or a cardiac event like myocardial infarction or stroke. Decreased ROM may also reflect treatment as in the case of certain internal or external fixation devices, braces, and supports. Inflammation, pain, wounds, stiffness, muscle spasm, and contracture can all limit ROM, as can the neurological system. Because movement begins with a neurological signal, anything impacting the transmission of such signals can impact movement and ROM. Access for free at openstax.org  25.2 Physical Assessment 1177 Assessment of a decrease in ROM may be diagnostic on its own or contributory to diagnosis, as certain traits direct advanced practitioners to differential diagnoses. Treatments prescribed may also contribute to limitations in ROM; examples are varied and may include muscle relaxants and/or analgesics. There are multiple subclassifications of drugs used to treat muscle spasm and pain, and selection by the prescriber is often based on the mechanism of action (MoA) of the drug. Pain medicines may be focused purely on analgesia, or the MoA may be anti-inflammatory. Therefore, identifying the cause or mechanism of injury or restriction is important for the most effective treatment plan and results. Compartment Syndrome The condition known as compartment syndrome occurs when increased pressure in a confined body space compromises blood flow to muscles and nerves, causing tissue ischemia (lack of blood and oxygen). If not treated promptly, this has the potential to cause tissue death. Compartment syndrome tends to occur following an injury and subsequent inflammation of the limbs or torso. This inflammation increases the pressure in these compartments leading to ischemia. Compartment syndrome can be acute or chronic. Acute compartment syndrome is an emergency and is most often seen after traumatic injuries (penetrating, crush, fractures), with tight-fitting casts, and after revascularization procedures (Torlincasi et al., 2023). Chronic compartment syndrome is caused by pressure from swelling of muscle during exercise but usually resolves with rest. Signs and symptoms of compartment syndrome include the following: Positive findings for the five P’s: ◦ pain out of proportion to extent of injury, worsened by the passive stretch of the muscle ◦ pallor, poor/pale skin color, and delayed capillary refill in distal extremity ◦ pulselessness, lack of palpable pulse in distal extremity ◦ paresthesia, loss of sensation or tingling in the extremity ◦ paralysis, inability to move, or loss of function of the limb, a late sign indicating muscle damage Tightness or fullness in the compartment affected Difficulty moving the affected compartment Coolness felt distal to the area When caring for a patient who is at risk for developing compartment syndrome, frequent assessment of the affected limb should be performed. This should include measurement of the diameter of the limb with a tape measure, in addition to frequent inspection and palpation of the affected area for any change in appearance or temperature. The location of measurement should be marked upon the first measurement, and subsequently, the same site should be used in order to ensure measurement comparisons are accurate. These serial measurements are extremely important. Comparison of the limb with the other limb is also helpful. The appearance of any of these symptoms is urgent, and the provider should be notified immediately for medical and/or surgical intervention. Validating and Documenting Findings After completion of the nursing assessment, whether it be initial or a follow-up, the nurse should promptly document the data collected. It is recommended for charting to be done as soon as possible after the assessment or event, to avoid forgetting key details. Another reason for prompt documentation is to avoid confusing the details of one patient with another. Remember to include any interventions performed during your assessment. CLINICAL JUDGMENT MEASUREMENT MODEL Take Action: Postoperative Total Hip Replacement Patient The nurse is assisting and educating a patient who has had total hip replacement surgery with positioning and mobility. Priority interventions are focused on avoiding dislocation of the operative joint. This involves avoiding adduction of the operative leg. The following points should be followed and explained to the patient: Avoid twisting or adduction of the operative leg; do not cross legs. Use the abduction pillow for proper positioning while in bed. Do not bend more than 90 degrees forward. Use raised seats (including toilets) to maintain knees lower than hips. 1178 25 Assessment of the Musculoskeletal System When ambulating, use rolling walker and remember, “nose over toes”: Slide the operative leg forward first, followed by the nonsurgical leg forward. Here is sample documentation of expected findings after a musculoskeletal assessment: Patient reports no previous history for bone trauma, disease, infection, injury, or deformity. No symptoms of joint stiffness, pain, swelling, limited function, or muscle weakness. Patient is able to perform and manage regular daily activities without limitations and reports consistent exercise consisting of walking 2 miles for five days a week. Joints and muscles are symmetrical bilaterally. No swelling, deformity, masses, or redness upon inspection. Nontender palpation of joints without crepitus. Full ROM of the arms and legs with smooth movement. Upper and lower extremity strength is rated at five out of five. Patient is able to maintain full resistance of muscle without tenderness or discomfort. Here is sample documentation of unexpected findings after a musculoskeletal assessment: Patient reports, “I felt a pop in my right ankle while playing basketball this afternoon” and “My right ankle hurts when trying to walk on it.” Pain is constant and worsens with weight-bearing. Patient rates pain at 4/10 at rest and 9/10 with walking and describes pain as an “aching, burning feeling.” Ibuprofen and ice decrease pain. Right ankle is moderately swollen laterally and anteriorly with tenderness to palpation but no erythema, warmth, or obvious deformity. Color, motion, and sensation are intact distal to the ankle. ROM of the right ankle is limited and produces moderate pain. Minimal eversion and inversion demonstrated. Patient is unable to bear weight on the right ankle. Dr. Smith notified, and an order for an ankle x-ray received. The right ankle was elevated and ice applied while the patient waits for the x-ray. 25.3 Recognizing Common Musculoskeletal Disorders LEARNING OBJECTIVES By the end of this section, you will be able to: Examine musculoskeletal disorders affecting the spine Recognize musculoskeletal disorders affecting the wrists, hands, and fingers Identify musculoskeletal disorders affecting the feet and toes The spine offers support for the body, allowing humans upright posture. The structure of the spine also offers protection for the delicate spinal cord. Muscles and other tissues assist the spine with strength and support as well as foster some flexibility and movement. Because the spine provides protection for the delicate spinal cord, it is important for nurses to keep this in mind when assessing patients with any symptoms or deviations from normal spinal structure and/or function. Disorders, deformities, and injuries lead to varying levels of pain and dysfunctions ranging from minor to life threatening. Variations from the normal curvature of the spine can cause mild, moderate, or severe changes in posture and may lead to pain as muscles and other structures accommodate alterations; limited or absent ability to stand or walk may be or become apparent. The neurological impacts of the spinal cord being moved or squeezed may include paresthesia, pain, or movement limitations, from minimal to total. Patients may be unable to complete ADLs, and have increasing reliance on others for daily care. Changes in tone may become evident, with resultant flaccidity or spasticity associated with the impaired structure and function. In addition to spinal disorders, there are disorders that affect wrists, hands, and fingers of the upper extremities, and feet and toes of the lower extremities. Some of the common diagnoses affecting these specific regions are important to be explored as they need to be considered as the nurse performs a musculoskeletal assessment. Again, knowing normal conditions and having an awareness of some of the potential abnormal conditions can be very important for the bedside nurse’s contribution to patient care. Disorders Affecting the Spine The vertebral, or spinal, column is composed of a sequence of vertebrae, each pair joined by intervertebral disks. The spinal column has flexibility, allowing for movement as well as providing support for the head, neck, and body. The spinal cord runs through openings in the posterior of the vertebrae; the bony structure of the spine protects the Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1179 spinal cord. There are normally four curves along the length of the spinal column in adults (Figure 25.14). These curves increase strength, flexibility, and ability of the spinal column to dissipate shock. With certain efforts, like lifting and carrying heavy loads, the spine is under more pressure and accommodates by an increase in the depth of the spinal curves. When the pressure is relieved, for example, by putting the heavy load on the ground, the normal curvature is restored. FIGURE 25.14 This is the normal curvature of the spine. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) LINK TO LEARNING C1, or the atlas, is thusly nicknamed because Atlas was the Greek Titan who held the sky above the earth for eternity (GreekMythology.com [1997–2021]). C1, C2 (axis), and C7 are each uniquely shaped vertebrae, with C3 through C6 structurally similar. See diagrams and descriptions of the cervical vertebrae (https://openstax.org/r/ 77cervvert) in this video. There are several disorders that can occur in the vertebral column that affect its normal motion and curvature, causing pain and decreased quality of life. Common conditions seen include flattening of the lumbar curvature, hyperlordosis, kyphosis, scoliosis, and ankylosing spondylitis. Flattening of the Lumbar Curvature The lumbar spine normally displays a mild lumbar lordosis, or inward curve above the buttocks, which allows for normal, upright posture, with accompanying ability to look straight ahead. If the lordotic curve is absent, this manifests by a flattened lumbar curve, or “flatback syndrome.” Patients adjust in order to stand upright, which may be subconscious or conscious, as hips and C-spine are extended, and knees flexed (Burhan et al., 2020). These adjustments are tiring, and by days’ end, patients are often fatigued, and forward stooping is more pronounced (Asher, 2023; Cedars-Sinai, 2023). Pain is also frequently associated with this disorder, also increasing throughout a 1180 25 Assessment of the Musculoskeletal System day of postural adjustments while the patient attempts to complete ADLs and perhaps activities associated with a job and other extended daily activities. A common cause of flatback syndrome is surgical correction of other spinal disorders, (Figure 25.15). Other associated causes include congenital disorders, degenerative disk disease, trauma, osteoporosis, and compression fractures. FIGURE 25.15 (a) A skeleton and body in normal alignment and posture, and (b) a body with flattening of the lumbar curve (flatback syndrome). (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) Hyperlordosis Just as a lack of curve in the lumbar region can cause problems and symptoms, an excessive lordotic curve (hyperlordosis) can become an issue (Figure 25.16). The posture of hyperlordosis is characterized by a protrusion forward of the stomach, and rearward of the bottom—this exaggerates the C of the lumbar curve and can cause pain, especially in the neck and perhaps the lower back (Hecht, 2018). Hyperlordosis may also be referred to simply as lordosis, or by the nickname “swayback.” The situation is often temporary and reversible; if the patient maintains flexibility, the impact on mobility is expected to be minor. As stiffness becomes apparent, however, restriction of movement is possible. Some of the causes of hyperlordosis include obesity and advanced pregnancy, injury to the spine, long-term sitting or standing or wearing high-heel shoes, a weakened core, rickets, or some neuromuscular disorders (e.g., osteoporosis, osteosarcoma, spondylolisthesis, muscular dystrophy) (Cleveland Clinic, 2023; Hecht, 2018). The provider may use radiographic testing such as x-ray, computed tomography, or magnetic resonance imaging, along with physical examination, to assist in diagnosing the cause of hyperlordosis. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1181 Once the diagnosis and likely cause are identified, treatment may include a combination of physical therapy with exercises to increase strength and flexibility and a brace for back support. If the patient has been experiencing pain, anti-inflammatory drugs may be recommended. In extreme circumstances, surgery may be necessary to fuse and straighten the spine (Cleveland Clinic, 2023). Nurses are involved in assessing interventions, including patient willingness and compliance and response to prescribed treatments. FIGURE 25.16 Spine disorders, such as (a) hyperlordosis, (b) kyphosis, and (c) scoliosis can cause mild to extreme function and mobility problems. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) Kyphosis An exaggeration of the curvature of the thoracic spine is called kyphosis, though it has been referred to by the nicknames “hunchback” and “dowager’s hump” (Figure 25.16). The nicknames are not flattering or scientific and are therefore discouraged. A currently accepted nickname is more descriptively, “roundback.” Like other spinal disorders, causes are varied and include congenital defects, spinal trauma and healing, degenerative disease (e.g., arthritis), osteoporosis, and less frequently, disorders of connective tissue, tumors in the spine, polio, and muscular dystrophy. Depending on the severity of curvature, symptoms may be absent or mild or may be extreme. During assessment, the nurse may notice unequal shoulder height and shoulders that are rounded; the upper back may have a visible and palpable hump. With these physical alterations from normal, the patient may notice stiffness and/or pain in the upper back or shoulders, and the hamstrings may not be flexible. The patient may tire easily. In severe cases, the patient may notice paresthesias or numbness, urinary or bowel incontinence, or dyspnea from restricted chest expansion (Gabbey & Cohen, 2023). Patients with kyphosis also suffer from poor body image. Treatment for kyphosis is based on symptoms and limitations relative to mobility and ability to perform ADLs. Nurses interact with patients in outpatient settings while noninvasive interventions are attempted. This may include assessment of pain control measures; strength and flexibility improvement from physical therapy; and ongoing exercises for the core, back, and posture. Some patients may benefit from a back brace, and success or lack of improvement should be evaluated and noted. Surgery is not common, but in cases of respiratory compromise or incontinence, surgery may be necessary. Scoliosis A horizontal curvature of the spine is diagnosed as scoliosis (Figure 25.16). This is a common disorder and is often diagnosed during adolescence, although some cases occur and are diagnosed much younger. When a nurse is assessing a patient’s spine, it is routine to have the patient stand facing away from the nurse. This provides an opportunity to inspect the spine while the patient is upright. To further the assessment with scoliosis in mind, the nurse asks the patient to bend forward at the waist, and the nurse observes for shoulder placement. Uneven shoulders in this position are a sign of scoliosis (Mayo Clinic, 2023). Other signs include an uneven waist and hips, a shoulder blade more prominent than the other, or a side of the rib cage that is more forward than the other. 1182 25 Assessment of the Musculoskeletal System LINK TO LEARNING Watch this demonstration of a scoliosis assessment (https://openstax.org/r/77scoli) that provides steps and descriptions of normal and abnormal findings. Think about the findings as if you were the examiner. Scoliosis may be mild, with only a small spinal curvature and mild or no symptoms, or it can be severe, and the patient may be required to use a wheelchair. Symptoms can be anywhere between the two ends of the spectrum. Once diagnosed, healthcare providers usually follow patients on a regular basis, with radiographs and examination, to evaluate any progression of the curvature and symptoms. Scoliosis is sometimes considered hereditary, with appearances within family lines. Often, the occurrence of scoliosis is idiopathic, with no specific cause identified. In some cases, a diagnosis like muscular dystrophy or cerebral palsy is the cause of the spinal curvature. Other potential causes include spinal infection or trauma, congenital deformity affecting bone development, and diagnosis of a spinal cord disorder. Girls tend to be at increased risk for development of scoliosis, and symptoms tend to appear in adolescence (Mayo Clinic, 2023). LIFE-STAGE CONTEXT Scoliosis in the Adolescent An assessment of the spine for curvature associated with scoliosis is a frequent part of a routine physical examination for an adolescent patient. Manifestations of scoliosis that the examiner looks for include a visible horizontal deviation from the normal straight spinal column, uneven shoulders while standing erect and as seen from behind while bending forward at the waist, prominence of one scapula in comparison to the other, an uneven waist, asymmetrical rib cage, and hip deviation with leg length discrepancy (Mayo Clinic, 2023). Severe cases of scoliosis may impact respiratory function, as expansion of the lungs may be reduced by size and shape of the thoracic cage. Signs and symptoms are prone to worsening as the spinal curve increases over time. Treatment depends on severity, as mild cases often require no treatment and are simply monitored for changes. Once bone growth is complete, progression is slow; with this in mind, treatments tend to be more effective in growing children (Mayo Clinic, 2023). Application of a brace is helpful in prevention of worsening of the curvature, so this is a common treatment for the growing child, and individual patient response should be assessed at each healthcare visit. Surgery is an option used to straighten the spinal curve, with hopes of preventing it from worsening over time. Of course, surgery is not without potential complications, including some of the spinal deformities already discussed. Surgeries for treatment of scoliosis include use of a rod (or two) that is adjusted in length with the patient’s growth, every few months (Mayo Clinic, 2023). Another option is spinal fusion, which connects multiple vertebrae to prevent individual movement; this may be done with rods, screws, or pins. Tethering of the vertebral body is another method in which screws are utilized on the outer part of the curve of the spine, and a cord is inserted through them. The spine is straightened as the tether is made taut. Nurses are involved in educating the patient and family throughout diagnosis and treatment, and during postoperative care, frequent assessment of neurological and musculoskeletal function is critical. Additionally, the postoperative patient should be assessed for bleeding at the surgical site. Infection is a risk with any invasive procedure. Ankylosing Spondylitis The chronic inflammatory disease ankylosing spondylitis is within the category of arthritis, primarily of the spine and sacroiliac joint (Figure 25.17). The inflammatory process causes abnormal formation of new bone, which leads to fusion (permanently joining together) of involved vertebrae. This produces a flattening of the affected area of the spine, limits movement in the region, and alters posture (Mayo Clinic, 2023). Ankylosing spondylitis may affect other joints as well, and interestingly, it may affect eyes, specifically with a condition called anterior uveitis (Doherty, 2021). The most common symptom is lower back pain; other symptoms include kyphosis, stiffness, heel and other joint pain (enthesitis—inflammation of the area of attachment of ligament or tendon to bone), and malaise or fatigue, as systemic inflammatory symptoms. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1183 FIGURE 25.17 The processes of inflammation, bone formation, and fusion are involved in ankylosing spondylitis. (credit: "Blausen 0037 AnkylosingSpondylitis.png" by "BruceBlaus"/Wikimedia Commons, CC BY 3.0) Symptoms may demonstrate differences based on sex, although men and women may experience any or all symptoms (Doherty, 2021). Back pain tends to occur in both sexes as the most common symptom; neck, knee, hip pain, fatigue, and depression are experienced more often in women. Men present more often with foot pain. Nurses should be alert for certain common characteristics of inflammatory back pain, including chronicity, with typically slow onset in patients under 40 years old. Symptoms tend to improve with exercise and not by resting. As a matter of note, symptoms may be even worse at night, severe enough to wake the patient. Because the disorder is inflammatory, drug therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) is often effective. While rare, a potential neurological emergency for patients with ankylosing spondylitis is compression of the spinal cord. Symptoms the nurse may notice on assessment include a burning pain from buttocks to arms and legs, numbness in extremities, a loss of coordination of the hands, or foot drop (Johns Hopkins, 2023). The cauda equina syndrome may cause loss of bladder or bowel function, increasing leg numbness, and pain. Most spinal cord compression is treated conservatively, with anti-inflammatory drugs (e.g., steroids or powerful NSAIDs) and physical therapy for strength enhancement of the legs and core. Surgery may be indicated for severe situations, and cauda equina syndrome may require emergent surgical intervention (Johns Hopkins, 2023). 1184 25 Assessment of the Musculoskeletal System LINK TO LEARNING A discussion guide about ankylosing spondylitis (https://openstax.org/r/77anky) designed for patients to use in anticipation of an appointment with a healthcare provider gives ideas for questions patients may have. Consider how these can be helpful for nurses who are interviewing and assessing patients with musculoskeletal concerns. Degenerative Joint Disease The degenerative joint disease (DJD), also known as osteoarthritis, is a common disease that occurs with age. Joints, especially those that bear the body’s weight or move in chronic repetitive motion, are prone to inflammation and structural joint damage (American Academy of Physical Medicine and Rehabilitation [AAPM&R], 2024). The constant cycle of inflammation and joint damage leads to a loss of the articular cartilage cushion, creating pain, inflammation, and limited joint movement. In addition to advancing age, other risk factors for DJD are obesity, a family history of DJD, and joint injury or overuse. Women are more prone than men to experience DJD, especially after age 50 years (Centers for Disease Control and Prevention, 2023). While weight-bearing joints (spine, knees, and hips) are more prone to development of DJD, fingers can also be affected. There is no cure for osteoarthritis, but several treatments can help alleviate the pain. Treatments may include weight loss, low-impact exercise, and medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and celecoxib. For severe cases of DJD, joint replacement surgery may be required. LINK TO LEARNING The videos provided here are of the hip and knee, but the degenerative pathophysiology of osteoarthritis (https://openstax.org/r/77osteo) is explained here and is the same wherever the joint. Osteoporosis The disease osteoporosis causes thin and weakened bones that become fragile and break easily (Figure 25.18). Osteoporosis is common in older women and often occurs in the hip, spine, and wrist. To keep bones strong, patients at risk are educated to eat a diet rich in calcium and vitamin D, participate in weight-bearing exercise, and avoid smoking. If needed, medications such as bisphosphonates and calcitonin are used to treat severe osteoporosis. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1185 FIGURE 25.18 (a) This is normal bone compared with (b) bone with osteoporosis. (credit: "Blausen 0686 Osteoporosis 01.png" by "BruceBlaus"/Wikimedia Commons, CC BY 3.0) PATIENT CONVERSATIONS Osteoporosis Scenario: Miss Nilsen is 60 years old and postmenopausal. She is meeting with the nurse after seeing her primary care provider about her bone density scan results. The nurse has been asked to provide education about osteopenia, osteoporosis, and Miss Nilsen’s next steps. Nurse: Miss Nilsen, I’m Luisa, I think we’ve met before. I’ve been asked to talk with you about your bone density scan results. Patient: Dr. Rand says I have weak bones but I don’t have osteoporosis? What’s the difference? Nurse: Your situation is some bone loss or weakening, called osteopenia. This has not progressed to osteoporosis; the nice thing about finding out now is you can take some steps to prevent it from worsening. Patient: What do I need to do? Dr. Rand mentioned a medicine. 1186 25 Assessment of the Musculoskeletal System Nurse: Yes, your healthcare provider is considering starting you on a prescription for alendronate. You had lab work done recently, and your calcium level is fine, but like so many people, your vitamin D is low. Before you can start the alendronate, you should have normal vitamin D, so let’s talk about how much vitamin D to take. Because vitamin D and calcium work together to strengthen your bones, I’ll show you how much calcium to take too. In three months, we’ll have you come to have a retest. Patient: I can’t start the osteoporosis drug now? I sure don’t want this to get worse. Nurse: Not until your vitamin D is normal so you have the right building blocks for it to work. First, vitamin D is dosed in international units—you’ll see it on the bottle as IU. Because you are past menopause, the recommendation is for you to have 800 IU of vitamin D every day. Calcium is dosed in milligrams, which on the bottle will be mg. Every day you should take in 1,200 mg. This is between food and fluid intake, and the supplement. I have a list of food and drinks and their usual amounts of calcium and vitamin D; we can circle those you eat regularly and come up with the right amount you need from the supplements. Patient: Okay, I’m sure glad you’ve got this written down, and we’ll write down the foods and stuff too. This is all a bit confusing. Nurse: Absolutely! It’s a lot to remember, so you’ll get to take these with you. Do you get any sun? How about exercise? Patient: I’m so pale, I try to avoid the sun and put on a high number sunscreen, like SPF50, which almost blocks all ultraviolet rays—98 percent (MacGill, 2018). I like to swim, I do that a few times a week. Nurse: Yes, you are fair, so sunscreen is good to prevent skin cancer. But twenty or thirty minutes of sun daily can help your body produce and use vitamin D. You don’t have to expose your whole body to get the benefit—maybe alternate limbs and expose one at a time for ten minutes, three times a day? Instead of swimming, or in addition to it, could you could do some walking? Exercises that put weight on your bones helps more for making and keeping strong bones. Patient: Maybe I can walk on my lunch break, so I can get sun and make my bones stronger at the same time. Nurse: That should help, along with the supplement. Do you think you can add the vitamin D supplement and walking at least three times a week? For three months—until you come in for a repeat blood test? Patient: I can try. I’ll pick up the supplements on my way home and start tonight. Disorders Affecting the Wrists, Hands, and Fingers The small and specialized bones of the wrists, hands, and fingers are prone to disorders, some unique to their locations and some common with other regions. Other musculoskeletal structures, muscles, tendons, and ligaments, can also be impacted by injuries and disorders, whether specific to the region or broader in occurrence. Rheumatoid arthritis, for example, is a systemic autoimmune disorder, so effects can be anywhere and in multiple places. Osteoarthritis is common in the hands (especially fingers) and also the spine, hips, and knees. Similarly, tenosynovitis can occur with tendons around the body. But, De Quervain tenosynovitis is localized to the wrist, with tendon inflammation at the base of the thumb. Carpal tunnel syndrome is another disorder specific to the palm side of the hand. These conditions are further examined in this section. Rheumatoid Arthritis In rheumatoid arthritis (RA), pain, swelling, stiffness, and loss of function in joints is due to inflammation caused by an autoimmune disease. See Figure 25.19 for an illustration of RA. It often starts in middle age and is more common in women (AAPM&R, 2024). Rheumatoid arthritis is different from osteoarthritis because it is an autoimmune disease, meaning it is caused by the immune system attacking the body’s own tissues. In RA, the joint capsule and synovial membrane become inflamed. As the disease progresses, the articular cartilage is severely damaged, resulting in joint deformation, loss of movement, and potentially severe disability. There is no known cure for RA, so treatments are aimed at alleviating symptoms. Medications such as NSAIDs, biologics, corticosteroids, and antirheumatic drugs such as methotrexate are commonly used to treat RA. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1187 FIGURE 25.19 (a) This shows a normal knee joint and (b) joint changes associated with rheumatoid arthritis, including inflammation, loss of cartilage, and erosion of bone. (credit: modification of work "Rheumatoid-Arthritis.png" by National Library Of Medicine US/Wikimedia Commons, Public Domain) CLINICAL JUDGMENT MEASUREMENT MODEL Analyze Cues: Patient with Rheumatoid Arthritis Mrs. Jackson is a 52-year-old female who visits her primary care provider for swollen, sore hands. The nurse, Marcus, interviews Mrs. Jackson and discovers the following: Personal history of hyperlipidemia, hypertension, obesity, and prediabetes. Family history of hypertension and coronary artery disease in both parents; mother with stiff hands she called “rheumatism.” Mrs. Jackson describes always being stiff in the mornings and that for the past three days she has had no appetite, felt extra tired, and had a bit of fever. Marcus’s assessment includes vital signs: HR 88, BP 140/92, T 99.3°F (37.4°C), SaO2 95 percent on room air. He notices both hands are warm, with bilateral edema and erythema at the metacarpal phalangeal (MCP) and proximal interphalangeal (PIP) joints; her fingers hurt when touched, and ROM of the fingers is limited by pain. Marcus’s analysis of cues leads to his conclusion that those cues valuable for the next steps of nursing care include the mother’s “rheumatism,” or RA, the patient’s morning stiffness, flu- like syndrome (malaise, low-grade fever, anorexia), and inflamed MCP and PIP joints. CLINICAL SAFETY AND PROCEDURES (QSEN) QSEN Competency: Evidence-Based Practice and Postoperative Care of the Musculoskeletal Surgery Patient Definition: The nurse incorporates clinical skills, current evidence, and preferences of the patient and family in professional nursing care. Knowledge: The nurse explains the importance of a professional practice based on evidence. 1188 25 Assessment of the Musculoskeletal System Assessment of pain and readiness to ambulate are both essential for recovery and are interrelated. Adequate pain control is necessary for patients to reposition, sit and dangle at the bedside, and feel ready to stand and walk. Protocols such as the Enhanced Recovery After Surgery (Zhang et al., 2018) guide practice through evidence relative to the importance of pain control through medication as prescribed, proper positioning, and application of ice packs, and the value of early ambulation in prevention of complications (e.g., deep vein thrombosis [DVT], pneumonia, constipation, and ileus). Skill: The nurse will maintain a professional practice that includes current evidence-based materials. Maintaining currency in practice through continuing education (CE) Reading peer-reviewed journal articles relative to professional practice Reading and following new protocols as they are established Attitude: The nurse recognizes the significance of ongoing evidence-based clinical practice development. Ganglion Cyst A ganglion cyst is a fluid-filled lump that most often occurs at the back of the wrist, over tendon sheath or joint (Figure 25.20). They can also develop on the end joint or base of a finger. The exact cause is unknown, but they are most common in women, younger people between ages 15 and 40 years, and gymnasts who repeatedly apply stress to the wrist. FIGURE 25.20 This shows a ganglion cyst as it appears at the wrist. (credit: modification of work "Cyst Profile2.JPG" by “GEMalone”/Wikimedia Commons, CC BY 3.0) Some ganglion cysts disappear on their own with joint rest or splinting of the wrist. In some cases, where there is pain, aspiration of the fluid may help to relieve pain, but the cyst may grow back. Surgical removal can also be done to remove the root of the cyst and the tendon sheath involved (Pidgeon & Jennings, 2022). Tenosynovitis Inflammation of a tendon is termed tendonitis; tenosynovitis is a term for inflammation of not only the tendon but also the surrounding sheath. Such inflammation often affects extensor and flexor tendons of the wrists. It can be caused by autoimmune disorders such as RA or overuse of the tendon. It can also be caused by infection, such as from animal bites, a skin commensal (organism that normally resides on our skin), Staphylococcus aureus, or methicillin-resistant S. aureus (MRSA). Two common types of tenosynovitis seen are De Quervain tenosynovitis and stenosing tenosynovitis. De Quervain tendonitis occurs on the thumb side of the wrist. Patients feel pain when turning their wrist, grasping, and making a fist (OrthoInfo, 1995–2023). The cause is not known, but repetitive hand and wrist movements can make the pain worse. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1189 Treatments for De Quervain tendonitis include splinting the wrist and hand, NSAIDs, and avoidance of painful activities and positions. Corticosteroid injection is a possible treatment, as is surgical intervention involving release of the tendon sheath. In stenosing tenosynovitis, nicknamed “trigger finger,” the flexor tendons of a finger or thumb freeze in the bent position (Figure 25.21). The patient may report clicking when bending and/or straightening the finger, as well as pain and stiffness. This type of tenosynovitis is common in patients with diabetes, and the risk for development increases with advanced age. FIGURE 25.21 This shows the clicking or catching involved in trigger finger. The flexor tendons of the finger are frozen in the bent position. (credit: modification of work "Surgical decompression of trigger finger" by National Library of Medicine, CC BY 2.0) LINK TO LEARNING Learn about the distinctive movements of trigger finger (https://openstax.org/r/77triggfing) in this article. Treatment includes rest, splinting, NSAIDs, and stretching exercises. Like De Quervain syndrome, steroid injection may be beneficial. Surgery to release the pulley to allow the flexor tendon to glide freely may be performed. Postoperative assessment by the nurse for treatments of tenosynovitis will be the same as for ganglion cyst postprocedure care. Carpal Tunnel Syndrome In the wrist, the carpal bones and the flexor retinaculum form a passageway called the carpal tunnel, with the carpal bones forming the walls and floor and the flexor retinaculum forming the roof of this space. The tendons of nine muscles of the anterior forearm and the median nerve pass through this narrow tunnel to enter the hand. Overuse of the muscle tendons or wrist injury can produce inflammation and swelling within this space. This produces compression of the nerve, resulting in carpal tunnel syndrome, which is characterized by pain or numbness and muscle weakness in those areas of the hand supplied by the median nerve. Classic symptoms of median nerve compression include pain that may be described as burning, numbness, and tingling, which may involve the forearm or entire arm, as it is relative to the sensation of the median nerve. The hand may lose fine motor skills and the ability to grasp and carry things. Being awakened at night with severe arm pain is common, especially if the patient’s wrists are bent forward when sleeping. Carpal tunnel syndrome happens more often in women, and its occurrence increases with advancing age (AAPM&R, 2024). While repetitive use of the hands has made this common with cashiers and assembly-line workers for many years now, keyboard typing has become a common source of the syndrome. There is also a hereditary component to 1190 25 Assessment of the Musculoskeletal System carpal tunnel syndrome, and as mentioned, position of the wrist (especially flexion) can contribute to the disorder and its symptoms. PATIENT CONVERSATIONS Carpal Tunnel Syndrome Scenario: A 50-year-old female, Mrs. Eldridge, talks to the nurse, LaTonya, prior to a visit with her primary care provider for a painful wrist and thumb. Nurse: Mrs. Eldridge, how long has this pain been bothering you? Patient: About three months now. Nurse: What sort of work do you do? Patient: Medical coding; I work from home. Nurse: Nice. That’s computer work, right? Lots of typing? Patient: Oh yes. Nurse: Let me see your hand. The one that hurts. [pause] I notice the pad at the base of your thumb, it’s nearly gone. Has that been three months too? Patient: Yes, it wasted away. Nurse: Does the pain ever wake you up? Patient: Every night, I jump up from a deep sleep shaking my hand, it hurts so much! What’s going on with me? Nurse: Well, the doctor will do a test to be sure, but you might be experiencing carpal tunnel syndrome. At least that’s a starting point. The doctor will be in shortly, and we’ll have a better idea. Treatment commonly begins with NSAIDs and a wrist and hand brace, which maintains the wrist in a neutral—not flexed—position, which is especially helpful while sleeping. Patients may also choose to wear the brace during activities that tend to cause pain. Corticosteroid injection may help relieve symptoms, at least temporarily; surgery to enlarge the tunnel by dividing the carpal ligament may be recommended (OrthoInfo, 1995–2023). Postoperatively, patients wear an immobilizing brace. Disorders of the Feet and Toes There are some musculoskeletal disorders that are naturally associated with the feet, including toes. These may only occur in connection with the feet, or commonly strike feet and toes, but also have the potential to happen elsewhere. This chapter’s exemplars include gout, which can appear in any joint, but is very common in the feet, especially the great toe. Other disorders specific to the feet and toes include pes planus (flat feet), hallux valgus (bunion), and hammertoe. Gout A type of arthritis that causes swollen, red, hot, and stiff joints due to the buildup of uric acid is termed gout (Figure 25.22). It typically first attacks the big toe. Uric acid usually dissolves in the blood, passes through the kidneys, and is eliminated in urine, but gout occurs when uric acid builds up in the body and forms painful, needlelike crystals in joints. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1191 FIGURE 25.22 This is a great toe with classic signs of gout-related inflammation. (credit: modification of work "Gota" by “John Cush”/Public Domain Pictures, Public Domain) Gout is treated with lifestyle changes such as avoiding alcohol and food high in purines as well as administering antigout medications, such as allopurinol and colchicine. Nurses are often involved in patient education, and with gout there may be complicated comorbidities, polypharmacy, and diet and exercise teaching to be done to maximize the patient’s care plan. In extreme cases, especially with frequent exacerbations of gout, surgery may be indicated and may involve joint fusion or replacement (Petrie, 2023). Related nursing assessment will be based on location but includes pain assessment and regional focused assessment. REAL RN STORIES Patient with Gout Nurse: Monica, RN Clinical setting: Home environment Years in practice: 7 Facility location: Columbus, Ohio A 58-year-old patient has just been diagnosed with an acute exacerbation of gouty arthritis. He told me this was the third acute episode he has experienced in four months, then said, “Both my big toes hurt so bad!” As I followed up for more information, I found his father is Italian and his mother German. His father worked the family farm, and his mother was a homemaker. His wife is Irish; she works as a receptionist. He is an accountant and sometimes works long hours, especially at tax time; he doesn’t feel he has time to exercise. I asked about his involvement in his diet, whether he plans meals, shops for groceries, or cooks meals. He told me that when he was single, his mother did all that, and now his wife does. He tells me his father always enjoyed some red wine in the evenings, and he inherited that habit, usually having three to five glasses. When his wife cooks Italian food from his grandmother’s recipes, she is sure to include plenty of cheese, especially mozzarella and parmesan. He told me his wife sometimes packs him a lunch; his favorite is a summer sausage and blue cheese sandwich, with pickles and sauerkraut, but he’ll eat any lunchmeat-and-cheese combination. I was pretty concerned about his dietary intake and his lack of exercise. Clearly, his habits have been formed over many years and were well established within his family. I thought about the particular foods he enjoys and, of course, the wine. I knew if I criticized him or his family for their dietary choices, he might be resistant to any suggestions I made, especially since his parents are both still alive, and while they are older, the active lifestyles involved with running a farm may have contributed that. But his lifestyle includes very little physical activity, with 1192 25 Assessment of the Musculoskeletal System excessive food and wine, especially high-purine foods, which are the likely contributors to the rather frequent exacerbations of gout. I asked him if his wife should join us to talk about food choices and such. He welcomed that idea. With both of them, I outlined foods and beverages that are high in purine and therefore lead to hyperuricemia. I described the pathophysiology of hyperuricemia and its relationship to gout. We talked about some different ways of meal planning. Then I told him he should try to not drink more than two glasses of wine per evening. That was a huge education session, with a lot of information for both of them. In many cases, it is hard for patients to remember details, so I gave them some written information as well. This included the list of high-purine foods, recommended foods, and some simple recipes for the patient and his wife to try. We scheduled a follow-up appointment in a month to see how he is doing, and whether the new ideas have been successfully incorporated. Pes Planus (Flat Feet) Flat feet, termed pes planus, is a common foot deformity characterized by the loss of the medial longitudinal arch of the foot (Figure 25.23). Most babies and toddlers have flat feet and develop a normal arch by age 5 or 6 years. Pes planus is often associated with obesity, posterior tibial tendon dysfunction, excessive tension in the area, or tight Achilles tendon or calf muscle (Raj et al., 2023). FIGURE 25.23 Pes planus, or flat foot, is characterized by the lack of a normal arch. (credit: "Flat foot in proband's sister" by National Library of Medicine, CC BY 2.0) Symptoms are pain noted in the back, leg, ankle, or foot (Raj et al., 2023). The patient will have a visibly flat foot when weight-bearing and may have an abnormal gait. Treatment may include prescribed NSAID therapy, foot orthotics, and motion control shoes. Patients with higher weight are given weight loss counseling. Surgery to essentially build an arch by moving tendons and fusing other bones into position is done when other interventions have been unsuccessful. Hallux Valgus A hallux valgus, or bunion, is a bony protrusion on the medial side of the foot, next to the first metatarsophalangeal joint, at the base of the big toe (Figure 25.24). Over time, this causes inward alignment of the great toe, angling it toward the next toe. Bunions can be hereditary, can be caused by certain autoimmune disorders, such as RA, or can be caused by wearing tight, restrictive shoes. Access for free at openstax.org  25.3 Recognizing Common Musculoskeletal Disorders 1193 FIGURE 25.24 Bunions cause a deformation of the metatarsophalangeal joint and realignment of the toes. (credit: modification of work "How to Prevent A Bunion from Getting Worse" by Daniel Max/Flickr, CC BY 2.0) Assessment findings include the deformed joint and toe(s), erythema, edema, presence of calluses, hammertoes, and difficulty walking. The patient may relay pain and numbness in the affected joint. Osteoarthritis and bursitis may result from bunions, with added symptomatology from these disorders added to the bunion itself. Treatments include NSAID therapy, orthotics, well-fitting footwear, and application of ice to the region. Physical therapy and corticosteroid injections may be helpful for some patients. In severe cases, bunionectomy may be surgically performed. Hammertoe A hammertoe is a deformity where the toe bends at the second joint, causing a hammer-type shape (Figure 25.25). This is most common in the second toe but can also occur in other toes. Women tend to experience hammertoe more frequently than men (Petrie, 2023). Causes include traumatic injury, hallux valgus, arthritis, and poorly fitting shoes. In some cases, hammertoe can be congenital. A corn may be seen on the top of the toe, along with a callus on the sole of the foot. Hammertoe can make it painful to walk. FIGURE 25.25 This is a hammertoe deformity of the second and third toes. (credit: modification of work "Human foot with mallet toe.jpg" by “Bprender22”/Wikimedia Commons, Public Domain) Physical therapy for specific exercises and taping or splinting the toe straight can prevent the deformity from becoming permanent. Applying an ice pack intermittently, taking NSAIDs, or receiving cortisone injections may help 1194 25 Assessment of the Musculoskeletal System with pain and inflammation. In some cases, surgery may be required to straighten the toe joint. Access for free at openstax.org  25 Summary 1195 Summary 25.1 Structure and Function The structure and function of the musculoskeletal system has been a focus of this section. Bones, muscles, tendons, ligaments, collagen, and other connective tissue are the major structures of this body system. These interact with the neurological system in order to provide movement. There are five musculoskeletal system functions: structure and support, movement, protection of vital organs, storage and supply of calcium and phosphate, and hematopoiesis. Under normal circumstances and with normal abilities, the musculoskeletal system is a fine-tuned machine, delivering on its many functions flawlessly. However, with any impairment of the intricate workings of the system, any of the five functions may be affected, with an assortment of potential disorders and diagnoses. Effects may be apparent in both physical and psychological signs and symptoms experienced by the patient. 25.2 Physical Assessment Nursing assessments are relied on by healthcare teams and patients, in all sorts of settings. Such data provide baseline information as well as ongoing documentation of changes in a patient’s status, whether positive changes as the patient heals or otherwise improves or negative and concerning alterations. Assessments may be comprehensive and complete or focused on a particular body system and situation. They are compared and reviewed, and updates are frequently provided to show dynamic and ongoing care. These past paragraphs and pages have explored some general concepts about bedside nurses and assessments, and the musculoskeletal assessment in particular. Additionally, one system does not exist in isolation, so connections as to how this system fits and functions with other systems have also been discussed. The nursing process initiates nursing care through assessment and on through diagnosis/analysis, planning, implementation, and evaluation. A newer model, the clinical judgment measurement model (CJMM), includes four phases: recognize cues to start the process; analyze cues, prioritize hypotheses, and generate solutions; take action; and evaluate outcomes (National Council of State Boards of Nursing [NCSBN], 2023). As generalist nurses are educated and prepared for practice, nursing programs introduce students to the normal assessment. Nursing education also introduces a multitude of disorders through varied teaching and experiential methods, helping learners to make connections between potential patient presentations and possibilities as to what is happening physiologically. The bedside nurse is typically tasked not with differential diagnosis but with identifying normal findings and recognizing those that are abnormal. Therefore, an introductory look at some abnormalities associated with the musculoskeletal system is included in this section. Finally, this section offers some details as to frequently expected documentation to be done by nurses. Whether a nursing assistant or the individual nurse has obtained certain assessment data (e.g., vital signs, point-of-care glucose), the RN is responsible for validation of results, typically made by reviewing and acknowledging the information. Healthcare settings have different expectations about documentation, including format and frequency requirements. It is important for nurses to be aware of expectations and requirements, as well as evidence-based best practice, in order to maintain quality care and communication among members of the interdisciplinary healthcare team. 25.3 Recognizing Common Musculoskeletal Disorders There are certain musculoskeletal disorders that are associated most frequently with particular regions. These include certain diagnoses that are common in the spine; those common to upper extremities, specifically wrists, hands, and fingers; and those typified as ankle, foot, and toe problems. It is important to realize that while some of these are commonly recognized in relationship to one area, they may occur elsewhere. An example is DJD, most commonly OA, which has been explored as both a spinal disorder and that which can occur in other joints. Several disorders have been exemplified for each musculoskeletal area, focusing on the nursing assessment as the primary angle. Nursing is not practiced in isolation; an interdisciplinary approach is needed for holistic patient care, and some mention of that is included in this section and chapter. Also, drug therapies may need to be incorporated, if briefly, and patient responses to such treatment are assessed as part of nursing care. 1196 25 Key Terms Key Terms ankylosing spondylitis a chronic inflammatory disease primarily of the spine and sacroiliac joint articular cartilage smooth, white tissue that covers the ends of bones where they come together and allows the bones to glide over each other with very little friction bone (also, osseous tissue) a hard, dense connective tissue that forms most of the adult skeleton, the support structure of the body bone marrow the softer connective tissue that fills the interior of most bones carpal tunnel syndrome pain, numbness, and muscle weakness caused by compression of the median nerve that runs through the carpal tunnel in the wrist cartilage a semirigid form of connective tissue, provides flexibility and smooth surfaces for movement cauda equina syndrome a condition of symptoms including loss of bladder or bowel function, increasing leg numbness, and pain compartment syndrome occurs when increased pressure in a confined body space compromises blood flow to muscles and nerves, causing tissue ischemia crepitus a popping or crackling sensation when the skin is palpated; it is a sign of air trapped under the subcutaneous tissues De Quervain tendonitis condition that occurs on the thumb side of the wrist degenerative joint disease (DJD) (osteoarthritis) the constant cycle of inflammation and joint damage that leads to a loss of the articular cartilage cushion, creating pain, inflammation, and limited joint movement enthesitis inflammation of the area of attachment of ligament or tendon to bone flatback syndrome characterized by missing lumbar lordosis of the spine, creating a flat spine ganglion cyst a fluid-filled lump that most often occurs at the back of the wrist, over tendon sheath or joint gout a type of arthritis that causes swollen, red, hot, and stiff joints due to the buildup of uric acid hallux valgus (bunion) a localized swelling on the medial side of the foot, next to the first metatarsophalangeal joint, at the base of the big toe hammertoe a deformity where the toe bends at the second joint, causing a hammer-type shape hematopoiesis the production of blood cells hyperlordosis excessive lordotic curve of the spine joint the location where bones come together kyphosis an exaggeration of the curvature of the thoracic spine ligament band of tissue that connects bones to one another, provides support and stability, and enhances joint movements lumbar lordosis inward curve above the buttocks musculoskeletal system composed of bones, muscles, joints, tendons, ligaments, and cartilage that support the body, allow movement, and protect vital organs ossification bone development osteoporosis a decrease in bone mass and density that thins and weakens bones causing them to become fragile and break easily paralysis inability to move paresthesia loss of sensation, or tingling, in an extremity passive range of motion the degree of range of motion demonstrated in a joint when the examiner is providing the movement pes planus (flat feet) a common foot deformity characterized by the loss of the medial longitudinal arch of the foot pulselessness lack of palpable pulse red marrow tissue that produces red and white blood cells and platelets; where hematopoiesis takes place rheumatoid arthritis (RA) a type of arthritis that causes pain, swelling, stiffness, and loss of function in joints due to inflammation caused by an autoimmune disease scoliosis horizontal curvature of the spine skeletal muscle produces movement, assists in maintaining posture, protects internal organs, and generates body heat skeletal system the body system composed of bones and cartilage skin commensal organism that normally resides on our skin Access for free at openstax.org  25 Assessments 1197 stenosing tenosynovitis involves the flexor tendons of the fingers and causes the flexor tendons of a finger or thumb to freeze in the bent position synovial fluid a thick, slimy fluid that provides lubrication to further reduce friction between the bones of the joint synovial joint has a fluid-filled joint cavity where the articulating surfaces of the bones contact and move smoothly against each other tendon band of fibrous collagenous tissue that provides a continuation of the muscle sheath to enable muscle attachment to the periosteum of bones tendonitis inflammation of a tendon tenosynovitis inflammation of the tendon and the surrounding sheath yellow marrow tissue that produces fat, cartilage, and bone and contains adipose tissue; the triglycerides stored in the adipocytes of the tissue can serve as a source of energy Assessments Review Questions 1. Tendons provide what component of musculoskeletal structure? a. joining of two or more muscles b. connection of ligaments and muscles c. attachment of bone to muscle d. linking vertebrae together 2. The hip has what type of joint? a. plane joint b. saddle joint c. pivot joint d. ball-and-socket joint 3. A nurse is caring for a 6-year-old child who has a history of bleeding, bruising, and fatigue. The child may have what type of disorder? a. electrolyte b. bone marrow c. cardiovascular d. adrenal 4. The new graduate nurse recalls what number of cardinal signs of inflammation? a. three b. four c. five d. six 5. A nurse notices a patient’s knees creak with bending. This will be documented as what finding? a. dislocation b. crepitus c. impaired ROM d. asymmetry 6. An older woman has experienced spontaneous fractures. The nurse associates what disorder as a probable contributor to her bone weakness? a. hip dysplasia b. scoliosis c. sarcopenia d. osteoporosis 7. A nurse recommends what action for a patient concerned about sarcopenia-related frailty? 1198 25 Assessments a. reducing protein intake b. swimming more often c. thrice weekly stair-stepper d. high-carbohydrate diet 8. A nurse is caring for a patient who has had surgical repair of a fractured right radius. The nurse notices the right forearm is edematous and firm. What should be the nurse’s first action? a. Notify the charge nurse immediately. b. Call the surgeon about possible infection. c. Document the normal findings. d. Palpate for a radial pulse. 9. When reviewing a student nurse’s planned documentation of a postoperative hip replacement patient, the nurse will reassure the student the CMS assessment includes what item? a. bowel sounds b. capillary refill c. level of consciousness d. urinary output 10. The atlas rests on what spinal structure? a. spinous process b. intervertebral disk c. vertebral foramen d. second cervical vertebra 11. Flatback syndrome is characterized by a loss of what normal spinal curve? a. kyphotic curve b. lordotic curve c. cervical curve d. sacral curve 12. The occurrence of gout is associated with what abnormal laboratory test? a. hyperuricemia b. hypophosphatemia c. hypernatremia d. hypomagnesemia 13. Ankylosing spondylitis is an inflammatory arthritic disorder with a potential for causing what diagnosis of the eye? a. macular degeneration b. retinal detachment c. anterior uveitis d. astigmatism Check Your Understanding Questions 1. What musculoskeletal structures are involved in enhancing mobility? 2. Describe abnormal findings that may be found on inspection during a musculoskeletal assessment. 3. Describe the different manifestations of OA and RA, as noted in the hands. 4. Explain the relationship between weight-bearing and the electrolytes calcium and phosphorous in the prevention of osteoporosis. Access for free at openstax.org  25 Assessments 1199 Reflection Questions 1. Consider the protective function of the musculoskeletal system and a traumatic injury affecting multiple ribs. Compose at least four examples of the potential impacts on underlying organs. 2. Examine at least two possible results a patient may experience from a primary or metastatic neoplasm occurring in the femur. 3. A patient with kyphosis may experience any combination of body image disturbance, self-care deficit, ineffective coping, and acute and/or chronic pain. Compose a nursing care plan and include at least one therapeutic measure for each nursing diagnosis. What Should the Nurse Do? 1. A nursing instructor is reviewing results of a skeletal quiz taken by a group of second-semester nursing students. A true/false item included the following statement: “The primary purpose of the skull’s bony structure is to facilitate movement.” Ninety percent of the students selected “true.” What should the nurse do? a. Score the students’ selection of “true” as correct. b. Review the protective function of the skull again. c. Explain the role of bone marrow in blood cell production. d. Review the skull’s facilitation of body movement. 2. A patient who has injured the right foot has a weight-bearing prescription for toe-touch weight-bearing. What should the nurse do to position the patient? a. The unaffected leg cannot bear weight or touch the floor. b. The unaffected toes are on the floor with 25 percent weight on the affected leg. c. Both feet are on the floor with up to 50 percent of body weight placed on the affected leg. d. Toes of the unaffected leg are on the floor for balance, and no weight is on the affected leg. 3. A 16-year-old patient comes to the clinic because of bilateral foot and ankle pain and states that his mother was told when he started school that he had flat feet. What should the nurse do to assess pes planus? a. Have the patient sit in a chair and straighten both feet in the air. b. Ask the patient to lie prone and flex both legs at the knees. c. Request that the patient stand up with both feet on the floor. d. Ask the standing patient to alternate weight-bearing one leg at a time. Competency-Based Assessments 1. A patient who has had surgical repair of a tibial fracture states, “My leg hurts more now than it did before the pain medicine!” The nurse assesses the leg; what assessment finding further supports the possibility of compartment syndrome? a. The leg is warmer than the nonsurgical leg. b. The nurse can easily feel pulses on the surgical foot. c. The stapled incision is well approximated. d. The lower leg is cooler than the upper leg. 2. A nurse explains to a patient that crepitus in the knee when kneeling or squatting is of concern if accompanied by what symptom? a. grinding in the knee b. pain in the knee c. redness of the knee d. limited knee ROM 3. Assess another person’s feet for pes planus. 4. A patient seeks care for a painful right wrist that is described by burning pain with intermittent numbness and 1200 25 References tingling. The patient is frustrated by dropping items when trying to carry them. The nurse suspects what diagnosis? a. trigger finger b. osteoarthritis c. carpal tunnel syndrome d. rheumatoid arthritis References American Academy of Physical Medicine and Rehabilitation. (2024). Degenerative joint disease. https://www.aapmr.org/about-physiatry/conditions-treatments/pain-neuromuscular-medicine-rehabilitation/ degenerative-joint-disease Asher, A. (2023) Flat back syndrome: What it is and how to treat it. https://www.verywellhealth.com/flat-low-back- posture-296885#Summary Boston Children’s Hospital. (2005–2023). Limb length discrepancy. https://www.childrenshospital.org/conditions/ limb-length-discrepancy Breeland, G., Sinkler, M. A., & Menezes, R. G. (2023). Embryology, bone ossification. In StatPearls [Internet]. 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Spinal cord compression. https://www.hopkinsmedicine.org/health/conditions- and-diseases/spinal-cord-compression MacGill, M. (2018). Which sunscreen should I use? https://www.medicalnewstoday.com/articles/306838#what-is- sun-protection-factor Mayo Clinic. (2022). Spina bifida. https://www.mayoclinic.org/diseases-conditions/spina-bifida/symptoms-causes/ syc-20377860 Access for free at openstax.org  25 References 1201 Mayo Clinic. (2023). Ankylosing spondylitis. https://www.mayoclinic.org/diseases-conditions/ankylosing- spondylitis/symptoms-causes/syc-20354808 Mayo Clinic. (2023). Scoliosis. https://www.mayoclinic.org/diseases-conditions/scoliosis/symptoms-causes/ syc-20350716 Military.com. (2023). Medical conditions that can keep you from joining the military. https://www.military.com/join- armed-forces/disqualifiers-medical-conditions.html Naqvi, U., & Sherman, A. I. (2023). Muscle strength grading. In StatPearls [Internet]. 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