OBJECTIVE DATA PREPARATION The purpose of musculoskeletal examination is to assess function for ADL, as well as to screen for any

abnormalities. A screening for musculoskeletal examination suffices for most people: Inspection and palpation of joints integrated with each body region Observation of ROM as person proceeds through motions described earlier Age-specific screening measures, e.g., ortolanis sign for infants, or scoliosis screening for adolescents

ORDER OF THE EXAMINATION Use the following order for specific joints. Inspection Note the size and contour of the joint. Inspect the skin and tissues over the joints for color, swelling, and any masses or deformity. Presence of swelling is significant and signals joint irritation. Abnormal findings swelling may be due to excess joint fluid, thickening of synovial lining, inflammation of surrounding soft tissue ( burse, tendons) or bony enlargement. Deformities include dislocation, subluxation, contracture or ankylosis. Palpation Palpate each joints, including its skin for temperature, its muscles, bony articulations , and area of joint capsule. Notice any heat, tenderness, swelling, or masses. Joints normally are not tender to palpation. If any tenderness does occur, try to localize it to specific anatomic structures (e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule). Abnormal findings palpable fluid is abnormal because fluid is contained in an enclosed sac, if you push on one side of the sac, the fluid will shift and cause a visible bulging on the other side.

RANGE OF MOTION(ROM) Ask for active ROM while stabilizing the body area proximal to that being moved. If there is a visible limitation, gently attempt passive motion. Anchor the joint with one hand while your other hand slowely moves it to its limit. The normal ranges of active and passive motion should be the same.

Joint motion normally causes no tenderness, pain, or crepitation. Abnormal findings- crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened as with rheumatoid arthritis

TEMPOROMANDIBULAR joint With the person seated, inspect the area just anterior to the ear. Place the tips of your first two fingers in front of each ear and ask the person to open and close the mouth. Drop your fingers into the depressed area over the joint, and note smooth motion of the mandible. An audible and palpable snap or click occurs in many normal people as the mouth opens. Ask the person to perform these motions. Instruction to person Open mouth maximally Motion and expected range Vertical motion, measure space between the upper and lower incisors. Normal is 3 to 6 cm, or three fingers inserted side ways. Lateral motion. Normal extent is 1 to 2 cm. Protrude without deviation.

Partially open mouth, protrude lower jaw, and move it side to side. Stick out lower jaw.

Palpate the contracted temporalis and masseter muscles as the person clenches the teeth. Compare right and left side for size,firmness and strength. Ask the person to move the jaw forward and laterally against your resistence, open mouth against your resistance. This also tests the integrity of cranial nerve V (trigeminal).

CERVICAL SPINE Inspect the alignment of head and neck. The spine should be straight and the head erect. Palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles. They should feel firm, with no muscle spasm or tenderness.

Instruction to person Touch chin to chest. List the chin towards the ceiling. Touch each ear towards the corresponding shoulder. Do not lift up the shoulder. Turn the chin toward each shoulder.

Motion and expected range Flexion of 45 degrees Hyperextension of 55 degrees Lateral bending of 40 degrees Rotation of 70 degrees.

Repeat the motions while applying opposing force. The person normally can maintain flexion against full resistence. This also tests integrity of cranial nerve XI (spinal).

UPPER EXTREMITY Shoulders Inspect and compare both shoulders posteriorly and anteriorly. Check the size and contour of the joints and compare shoulders for equality of bony land marks. Normally , no redness, muscular atrophy, deformity, or swelling is present. Check the anterior aspect of the joint capsule and the subacromial bursa for abnormal swelling. If the person reports any shoulder pain, ask that he or she point the spot with the hand of unaffected side. Be aware that shoulder pain may be from local causes or it may be referred pain due to a hiatal hernia or a cardiac or pleural condition, which could be serious. While standing in front of the person, palpate both shoulders, noting any muscular spasm or atrophy, swelling, heat, or tenderness.start at the clavicle and methodically explore the acromioclavicular joints, scapula, greater tubercle of the humerus, area of the subacromial bursa, the biceps groove, and the anterior aspect of the glenohumaral joint. Palpate the pyramid-shaped axilla, no adenopathy or masses should be present. Test the ROM by asking the person to perform four motions. Cup one hand over the shoulder during ROM to note any crepitation, normally none is present. Instruction to person With arms at sides and elbows extended, move both arms forward and up in wide vertical arcs, then move them back. Rotate arms internally behind the back, place back hands as high as possible towards the scapulae. With arms at sides and elbows extended, raise both arms in wide arcs in the coronal plane. Touch palms together above head. Touch both hands behind the head with elbows flexed and rotated posterirly. Motion and expected range Forward flexion of 180 degrees. Hyperextension up to 50 degrees. Internal rotation of 90 degrees

Abduction of 180 degrees Adduction of 50 degrees External rotation of 90 degrees

Test the strength of the shoulder muscles by asking the person to shrug the shoulders, flex forward and up, and abduct against resistence. The shoulder shrug also tests the integrity of cranial nerveXI, the spinal accessory. Elbow

Inspect the size and contour of the elbow in both flexed and extended positions. Look for any deformity, redness, or swelling. Check the olecranon bursa and normally present hollows on either side of the olecranon process for abnormal swelling. Palpate with the elbow flexed about 70 degrees and as relaxed as possible. Use your left hand to support the persons left forearm and palpate the extensor surface of the elbow- olecranon process and the medial and lateral epicondyles of the humerus- with your right thumb and fingers. With your thumb in the lateral groove and your index and middle fingers in the medial groove, palpate either side of olecranon process using varying pressure. Normally present tissues and fat pads feel fairly solid. Check for any synovial thickening , swelling, nodules, or tenderness. Palpate the area of the olecranon bursa for heat, swelling, tenderness,consistency, or nodules Test ROM by asking the person to do the following:

Instruction to person Motion and expected range Flexion of 150 to 160 degrees, extension at 0. Bend and straighten the elbow Movement of 90 degrees in pronation and Hold the hand midway, then touch front and back sides of hand to table supination While testing muscle strength, stabilize the persons arm with one hand. Have the person flex the elbow against your resistance applied just proximal to the wrist. Then ask the person to extend the elbow against your resistance. WRIST AND HAND Inspect the hands and wrists on the dorsal and palmar sides, noting position, contour, and shape. The normal functional position of hand shows the wrist in slight extension. This way the fingers can flex efficiently, and the thumb can oppose them for grip and manipulation.the fingers lie straight in the same axis as the forearm. Normally, no swelling or redness, deformity, or nodules are present. The skin looks smooth with knuckle wrinkles present and no swelling or lesions. Muscles are full, with the palm showing a rounded mound proximal to the thumb (the thenar eminence) and a smaller rounded mound proximal to the little finger. Palpate each joint in the wrist and hands. Facing the person, support the hand with your fingers undern it and palpate the wrist firmly with both your thumbs on its dorsum. Make sure the persons wrist is relaxed and in straight alignment. Move your palpating thumbs side to side to identify the normal depressed areas that overlie the joint space. Use gentle but firm pressure. Normally, the joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness. Palpate the metacarpophalangeal joints with your thumbs, just distal to and on either side of the knuckles.

Use your thumb and index finger in a pinching motion to palpate the sides of the interphalangeal joints. Normally, no synovial thickening, tenderness, warmth, or nodules are present. Test ROM by asking the person to do the following: Instruction to person Bend the hand up at the wrist Bend hand down at the wrist Bend the fingers up and down at metacarpophlangeal joints With palms flat on table, turn them outward and in. Spread fingers apart; make a fist Touch the thumb to each finger and to the base of little finger Motion and expected range Hyperextension of 70 degrees. Palmar flexion of 90 degrees. Flexion of 90 degrees . hyperextension of 30 degrees Ulnar deviation of 50-60 degrees, and radial deviation of 20 degrees. Abduction of 20 degrees:fist tight. The responses should be equal bilaterally. The person is able to perform, and the responses are equal bilaterally.

For muscle testing, position the persons forearm supinated (palm up) and resting on a table. Stabilize by holding your hand at the persons mid-forearm. Ask the person to flex the wrist against your resistance at the palm. Phalens test Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in normal hand. Tinels sign Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand.

LOWER EXTREMITY

HIP Inspect the hip joint together with the spine a bit later in the examination as the person stands. At that time, note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks. A smooth, even gait reflects equal lengths and functional hip motion. Help the person into a supine position and palpate the hip joints. The joints should feel stable and symmetric, with no tenderness or crepitance.

Assess ROM by asking the person to do the following: Instruction to person Raise each leg with knee extended Bend each knee up to the chest while keeping the other leg straight Flex knee and hip to 90 degrees. Stabilize by holding the thighs with one hand the ankle with the other hand. Swing the foot outward. Swing the foot inward. Swing leg laterally, then medially, with knee straight. Stabilize pelvis by pushing down on the opposite anterior superior iliac spine. When standing swing straight leg back behind body. Stabilize pelvis to eliminate exaggerated lumbar lordosis. The most efficient way is to ask person to bend over the table and to support the trunk on the table. Motion and expected range Hip flexion of 90 degrees Hip flexion of 120 degrees. The opposite thigh should remain on the table Internal rotation of 40 degrees. External rotation of 45 degrees

Abduction of 40 to 45 degrees Adduction of 20 to 30 degrees

Hyperextension of 15 degrees when stabilized

KNEE The person remain supine with legs extended for inspection. The skin normally looks smooth, with even even coloring and no lesions. Inspect lower leg alignment. The lower leg must be extend in the same axis as the thigh. Inspect the knees shape and contour. Normally, distinct concavities, or hollows, are present on either side of the patella. Check them for any signs of fullness or swelling. Note other locations, such as the prepatellar bursa and the suprapatellar pouch, for any abnormal swelling. Check the quadriceps muscle in the anterior thigh for any atrophy. Since it is prime mover of knee extension, this muscle is important for joint stability during weight bearing.

Enhance palpation with the knee in the supine position with complete relaxation of the quadriceps muscle. Start high on the anterior thigh, about 10cm above the patella. Palpate with your left thumb and fingers in a grasping fashion. Proceed down towards the knee, exploring the region of supra-patellar pouch. Note the consistency of the tissues. The muscles and soft tissues should feel solid, and the joint should feel smooth, with no warmth, tenderness, thickening, or nodularity

BULGE SIGN For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. Firmly stroke up on the medical aspect of the knee two or three times to displace any fluid. Tap the lateral aspect. Watch the medial side in the hollow for a distict bulge from a fluid wave. Normally none is present. Ballottement of the patella This test is reliable when larger amounts of fluid are present. Use your left hand to compress the suprapatellar pounch. With your right hand, push the patella sharply against the femur. If no fluid is present, the patella already is snug against the femur. Continue palpation and explore the tibiofemoral joint. Note smooth joint margins and absence of pain. Palpate the infrapatellar fat pad and the patella. Check for crepitus by holding your hand on the patella as the knee is flexed and extended. Check ROM by asking the person to do the following: Instruction to person Bend each knee Extend each knee Motion and expected range Flexion of 130 to 150 degrees A straight line of 0 degrees in some persons; a hyperextension of 15 degree in others.

Check knee ROM during ambulation Check muscle strenghth by asking the person to maintain knee flexion while you oppose by trying to pull the leg forward. Muscle extension is demonstrated by the persons success in rising from a selected position in a low chair or by rising from a squat without using hands for support.

ANKLE AND FOOT Inspect while the person is in a sitting, non-weight-bearing position, as well as when standing and walking. Compare both feet, noting position of feet and toes, contour of the joints, and skin charecteristics. The foot should align with the long axis of the lower leg; an imaginary line would fall from mid-patella to between the first and second toes. Weight bearing should fall on the middle of the foot, from the heel, along the mid-foot, to between the second and third toes. Most feet have a longitudinal arch, although that can vary normally from flat feet to a high instep. The toes point straight forward and lie flat. The ankles are smooth with even coloring and no lesions. Note the locations of any calluses or bursal reactions because they reveal areas of abnormal friction.

Support the ankles by grasping the heel with your fingers while palpating with your thumbs. Explore the joint spaces. They should feel smooth and depressed, with no fullness, swelling, or tenderness. Palpate the metatarsophalangeal joints between your thumb on the dorsum and your fingers on the plantar surface. Using a pinching motion of your thumb and forefinger, palpate the interphalangeal joints on the medial and lateral sides of the toes.

Test ROM by asking the person to do the following:

Instruction to person Point toes toward the floor. Point toes toward your nose. Turn soles of feet out, then in. Flex and straighten toes.

Motion and expected range Plantar flexion of 45 degrees Dorsiflexion of 20 degrees Eversion of 20 degrees Inversion of 30 degrees

Assess muscle strenghth by asking the person to maintain dorsiflexion and plantar flexion against your resistance.

SPINE The person should be standing, draped in a gown open at the back so that you can see the entire back . inspect and note if the spine is straight by following an imaginary vertical line from the head through the spinous processes and down through the gluteal cleft, and by noting equal horizontal positions for shoulders, scapulae, iliac crest, and gluteal folds, and equal spaces between arm and lateral thorax on the two sides. The persons knees and feet should be aligned with the trunk and should be pointing forward. From the side note the normal convex and concave lumbar curve. An enhanced thorasic curve, or kyphosis, is common in aging people. A pronounced lumbar curve, or lordosis, is common in obese people. Palpate the spinous processes. Normally, they are straight and not tender. Palpate the paravertebral muscles; they should feel firm with no tenderness or spasm. Check ROM of the spine by asking the person to bend forward and touch the toes. Look forflexion of 75 to 90 degrees and smoothness and symmetry of movement. Note that the concave lumbar curve should disappear with this motion, and the back should have a single convex C-shaped curve.

If you suspect a spinal curvature during inspection, this may be more clearly seen when the person touches the toes. While the person is bending over, mark a dot on each spinous process. When the person resumes standing, the dots should form a straight vertical line.

Stabilize the pelvis with your hands. Check ROM by asking the person to do the following: Instruction to person Bend sideways. Bend backwards Twist shoulders to one side, then the other Motion and expected range Lateral bending of 35 degrees Hyperextension of 30 degrees. Rotation of 30degrees, bilaterally

Straight leg raising or LaSegues Test These maneuvers reproduce back and leg pain and help confirm the presence of a herniated nucleus pulposus. Straight leg raising while keeping the knee extended normally produces no pain.raise the affected leg just short of the point where it produces pain. Then dorsiflex the foot. Raise the unaffected leg while leaving the other leg flat. Inquire about the involved side.

Measure Leg Length Discrepancy Perform this measurement to determine one leg is shorter than the other. For true leg length, measure between fixed points, from the anterior iliac spine to the medial malleolus, crossing the medial side of the knee. Normally, these measurement are equal or within 1 cm, indicating no true bone discrepancy.