MUSCULOSKELETAL

DEVELOPMENTAL VARIATIONS
INFANTS AND CHILDREN
- increased length of long bones results from proliferation of cartilage at growth
plates (epiphyses)
- ligaments are stronger than bone until adolescence - - injuries to long bones
and joints are more likely to
result in fractures than in sprains

ADOLESCENTS
- rapid growth results in decreased strength in epiphyses
- general decreased strength and flexibility leading to greater potential for
injury
- bone growth is completed by about age 20 yrs

PREGNANT WOMEN
- increased levels of circulating hormones lead to elasticity of ligaments and
softening of cartilage in pelvis
- progressive lordosis (abnormal forward curvature of spine in lumbar region)
in effort to shift center of gravity
- painful muscle cramps, more likely to occur at night or after awakening with
an unknown cause

OLDER ADULTS
- menopausal women have decreased estrogen which increases bone
resorption and decreases calcium
deposition resulting in bone loss and decreased bone density
- bony prominences due to loss of subcutaneous fat
- cartilage around joints deteriorates
- muscle mass changes due to increased amt of collagen collected in tissues
and fibrosis of connective tissues
- tendons become less elastic leading to reduction of total muscle mass, tone,
and strength
- decrease in reaction time, speed of movements, agility and endurance
- sedentary lifestyle and any health problems contribute to reduced physical
activity
- routine exercise and well-balanced diet help slow progression

I. SUBJECTIVE ASSESSMENT
- try to differentiate between muscle or bone and joint pain
- have pt rate pain on a scale of 0 – 10
- ~30 min. after administering pain meds, have pt re-rate pain
- steroids close growth plates (epiphyses)

A. REVIEW OF PRESENT ILLNESS

joint complaints – stiffness or limitation; change in size or contour; swelling or
redness; constant pain or pain
 with particular motion; interference with ADL; efforts to treat (exercise,
rest, wt reduction, physical
therapy, heat, ice, braces or splints); medications (anti-inflammatory,
corticosteroids)

muscular complaints – limitation; weakness or fatigue; paralysis; clumsiness;

wasting; aching or pain;
precipitating factors (injury, strenuous activity, sudden movement,
stress); efforts to treat (heat, ice,
splints, rest, massage); medications (muscle relaxants, anti-
inflammatory)

skeletal complaints – difficulty with gait or limping; numbness or tingling; pain

with movement; crepitus;
deformity or change in skeletal contour; associated events (injury, recent
fractures, strenuous activity,
postmenopause); efforts to treat (rest, splints, chiropractic); medications
(hormone replacement
therapy, calcium)

injury – sensation at time of injury (click, tearing, numbness, tingling, catching,

locking, grating, snapping);
mechanism of injury (direct trauma, sudden, forceful, overstretch);
location, type, onset of pain;
swelling; efforts to treat

B. PAST MEDICAL HISTORY

- trauma, surgery, chronic illness (cancer, arthritis, osteoporosis), skeletal
deformities

C. FAMILY HISTORY
- congenital abnormalities, scoliosis or back problems, arthritis
(rheumatoid, osteoarthritis, gout),
genetic disorders (dwarfing, rickets)

D. PERSONAL AND SOCIAL HISTORY

Employment – lifting and potential for unintentional injury; spinal support,
chronic stress, repetitive motions
Exercise – extent, type, and frequency; stress on specific joints; overall
conditioning; sports
Functional Abilities – personal care, housework, walking, climbing stairs, use of
prosthesis
Weight – recent gain or loss, overweight or underweight, sedentary lifestyle
Nutrition – amt of calcium, vitamin D, calories and proteins
Tobacco and Alcohol Use

OSTEOPOROSIS RISKS
- light body frame, thin
- family history, gene for decreased bone density
- menopause before age 45, postmenopausal
 - lack of aerobic or weight-bearing exercise
- constant dieting, inadequate calcium intake, excessive soft drinks
- scoliosis, rheumatoid arthritis, cancer, chronic illness
- metabolic disorders
- poor teeth; previous fractures
- cigarette smoking or heavy alcohol use

II. OBJECTIVE ASSESSMENT

- begin examination by observing the gait and posture when pt enters the
room
- note how pt walks, sits, rises from sitting position
- examine ea. region of the body for limb and trunk stability, muscular
strength and function, and joint
function
- look for symmetry

A. INSPECTION - observe alignment of extremities noting any lordosis (abnormal

forward curvature of spine in
lumbar region), kyphosis (abnormal rearward curvature of spine,
resulting in proturbence of upper
back – hunchback), or scoliosis (abnormal lateral curvature of spine)
- observe extremities for overall size, gross deformity, bony enlargement,
alignment, contour, and
symmetry of length and position
- expect to find symmetry in length, circumference, alignment
- inspect for gross hypertrophy or atrophy

***Learn to practice palpation, ROM, testing of movement, testing of strength, and

screening all together****
B. PALPATION – palpate all bones, joints, and surrounding muscles
- note any heat, tenderness, swelling, fluctuation of joint, crepitus, and
resistance to pressure
- no discomfort should occur
- muscle tone should be firm, not hard or doughy
- palpate inflamed joints last
- crepitus can be felt when two irregular bony surfaces rub together
as a joint moves, when
two rough edges of a broken bone rub together, or with the
movement of a tendon
inside the tendon sheath when tenosynovitis (inflammation)
is present
- keep one hand on the joint being palpated, testing strength at the same
time

C. RANGE OF MOTION (ROM) – examine both active and passive

- ask pt to actively move ea. muscle group and joint through full range
- pain, limitation of motion, spastic movement, joint instability,
deformity, and contracture
 suggest a problem w/ joint, related muscle group or nerve
supply
- ask patient to relax and allow you to passively move same joints until
end of range is felt
- do not force the joint if there is pain or muscle spasm
- no crepitation or tenderness with movement should be apparent

goniometer – measures joint ROM angle; greatest flexion and extension

values

D. MUSCLE STRENGTH – ask pt to first contract muscle indicated by extending or

flexing the joint, then to resist as
you apply force against that muscle contraction
- do not allow pt to move the joint
- expect muscle strength to be bilaterally symmetric with full resistance
to opposition
- full muscle strength requires complete active ROM

Grading Scale: 0 = no evidence of movement

1 = trace movement
2 = FROM, but not against gravity (passive movement)
3 = FROM against gravity but not against resistance
4 = FROM against gravity and some resistance, but weak
5 = FROM against gravity, full resistance

- disability is present with grade 3 or less; activity cannot be

accomplished in a gravity field;
external support is necessary to perform movements
- weakness may result from disuse, atrophy, pain, fatigue, or
overstretching

E. SPECIFIC JOINTS AND MUSCLES

1. TEMPOROMANDIBULAR JOINT – located by placing fingertips just anterior to
tragus of ea. ear
- allow fingertips to slip into joint space as pt’s mouth opens
- audible or palpable snapping or clicking is not usual
- pain, crepitus, locking, or popping may indicate
temporomandibular joint dysfunction

2. THORACIC AND LUMBAR SPINE – major landmarks include ea. spinal process of
vertebrae, scapulae,
iliac crests, paravertebral muscles
- expect head to be positioned directly over gluteal cleft and
vertebrae to be straight as
indicated by symmetric shoulder, scapular, and iliac crest
heights
- curves of cervical and lumbar spines should be convex
- knees and feet should be in alignment with trunk, pointing directly
forward
- percuss for spinal tenderness
 - no spasms or spinal tenderness with palpation or percussion
should be elicited
- back should remain symmetrically flat as concave curve of lumbar
spine becomes convex
with forward flexion
- lateral curvature or rib hump should make you suspect
scoliosis
- reversal of lumbar curve should be apparent
3. SHOULDERS – inspect contour of shoulders, should girdle, clavicles and
scapulae, and area muscles
- should have symmetry of size and contour
- observe for winged scapula, outward prominence of scapula,
indicating injury to the nerve of
the anterior serratus muscle

4. ELBOWS – inspect contour of pt’s elbow in both flexed and extended

positions
- subcutaneous nodules along pressure points may indicate
rheumatoid arthritis
- palpate groove on ea side of olecranon process for tenderness,
swelling, and thickening of
synovial membrane
- boggy, soft, or fluctuant swelling; point tenderness at lateral
epicondyle or along
grooves; increased pain indicates epicondylitis or
tendonitis

5. HANDS AND WRISTS – inspect dorsal and palmar aspects, noting contour,
position, shape, number, and
completeness of digits
- palmar surface should have central depression with prominent,
rounded mound on thumb
side and less prominent hypothenar eminence on little finger
side
- deviation of fingers on ulnar side, and swan neck or boutonniere
deformities of fingers
usually indicates rheumatoid arthritis
- joint surfaces should be smooth, without nodules, swelling,
bogginess, or tenderness
- firm mass over dorsum of wrist may be a ganglion
- bony overgrowths, felt as hard, nontender nodules sometimes
encompassing entire joint are
associated with osteoarthritis
Heberden Nodes - when located along distal
interphalangeal joints,
Bouchard Nodes - those along proximal interphalangeal
joints
- painful, fusiform swelling of proximal interphalangeal joints causes
spindle-shaped fingers,
which are associated with acute stage of rheumatoid arthritis
 6. HIPS – inspect anteriorly and posteriorly using major landmarks of iliac
crest and greater trochanter of
femur
- note any asymmetry in iliac crest height, size of buttocks, or
number and level of gluteal folds
- palpate hips and pelvis with pt supine
- no instability, tenderness or crepitus is expected
- evaluate muscle strength during abduction and adduction, as well
as resistance to
uncrossing legs while seated

7. LEGS AND KNEES – inspect knees and popliteal spaces both flexed and
extended, noting major
landmarks: tibial tuberosity, medial and lateral tibial condyles,
medial and lateral epicondyles
of femur, adductor tubercle of femur, and patella
- observe lower leg alignment
- variations are genu valgum (knock-knees), genu varum
(bowlegs), and excessive
hyperextension of knee with wt bearing (genu
recurvatum)
- usual indentation above patella is filled out to be convex
rather than concave
- palpate popliteal space, noting any swelling or tenderness
- joint should feel smooth and firm, without tenderness,
bogginess, nodules or
crepitus

8. FEET AND ANKLES – inspect while pt is bearing wt and while sitting

- ankle landmarks include medial and lateral malleolus and Achilles
tendon
- expect smooth and rounded malleolar prominence,
prominent heels, and prominent
metatarsopharlangeal joints
- calluses and corns indicate chronic pressure or irritation
- observe contour of feet and position, size, and number of toes
- feet should be in alignment with tibias
- pes varus (in-toeing) and pes valgus (out-toeing) are
common variations
- deviations in forefoot alignment, heel pronation, and pain or
injury often cause a shift
in wt bearing position
- expect foot to have longitudinal arch
- variations include pes planus (foot that remains flat even
when not bearing wt) and
pes cavus (high instep)
- toes should be straight forward, flat and in alignment with each
other
 - heat, redness, swelling, and tenderness are signs of inflamed
joint, possibly caused by
rheumatoid arthritis, septic joint, fracture, or tendonitis

F. ADDITIONAL PROCEDURES
1. THUMB ABDUCTION TEST – isolates strength of abductor pollicis brevis
muscle, innervated only by
median nerve
- pt places hand palm up and raises thumb perpendicular
- apply downward pressure on thumb to test muscle strength
- full resistance to pressure is expected
- weakness is associated with carpal tunnel syndrome

2. TINEL SIGN – tested by striking pt’s wrist w/your index or middle finger
- tingling sensation radiating from wrist to hand in distribution of
median nerve is a positive
result and suggestive of carpal tunnel syndrome

3. PHALEN TEST – ask pt to hold both wrist in fully palmar flexed position
w/dorsal surfaces pressed
together for 1 min
- numbness and paresthesia in distribution of median nerve is
suggestive of carpal tunnel

4. BALLOTTEMENT – used to determine presence of excess fluid or effusion in

knee
- w/knee extended, apply downward pressure then push patella
sharply downward against
femur
- if effusion is present, tapping or clicking will be sensed when
patella is pushed
- release pressure against patella, keep finger lightly touching it
- if effusion is present, patella will float out as if a fluid wave
were pushing it

5. BULGE SIGN – used to determine presence of excess fluid in knee

- w/knee extended, milk medial aspect of knee upward 2 – 3 times,
then tap lateral side of
patella
- observe for bulge of returning fluid to hollow area medial to
patella

6. MCMURRAY TEST – used to detect torn medial or lateral meniscus

- pt in supine position w/one knee flexed completely and foot flat on
table near buttocks
- stabilize knee on either side of joint space and hold heel
w/other hand
- rotate foot and lower leg to lateral position
- extend knee to 90° angle noting any palpable or audible
click, grinding, pain, or
 limited extension

7. DRAWER TEST – used to identify instability of anterior and posterior cruciate

ligaments
- pt in supine position w/knee flected to angle between 45 - 90°,
placing foot flat on table
- draw tibia forward, forcing tibia to slide forward of femur, then
push tibia backwards
- anterior or posterior movement of knee greater than 5 mm
in either direction is an
unexpected finding

8. LACHMAN TEST – used to evaluate anterior cruciate ligament integrity

- pt in supine position, flex knee 10 - 15° w/heel on table
- stabilize femur and place other hand around proximal tibia, pull
tibia anteriorly
- have pt relax hamstring for optimal test
- increased laxity, greater than 5 mm compared to uninjured
side indicates injury

9. TRENDELENBURG TEST – used to detect weak hip abductor muscle

- w/pt standing, have them balance first on one foot then the other
- note any asymmetry or change in level of iliac crest
- when iliac crest drops on side of lifted leg, hip abductor
muscles on wt-bearing side
are weak

III. DEVELOPMENTAL VARIATIONS

A. INFANTS – fully undress infant and observe posture and spontaneous generalized
movements (most flexible)
- no localized or generalized muscular twitching is expected
- inspect back for tufts of hair, dimples, discolorations, cysts, or masses
near spine
- kyphosis of thoracic and lumbar spine will be apparent in sitting position
until infant can sit w/out
support
- note symmetric flexion of arms and legs
- axillary, gluteal, femoral, popliteal creases should be symmetric
and limbs freely movable
- no unusual proportions or asymmetry of limb length or
circumference, constricted annular
bands, or other deformities should be noted
- newborns have some resistance to full extension of elbows, hips, and
knees
- movements should be symmetric
- all babies are flat-footed
- Simian crease (single crease extending across entire palm) is associated
with Down syndrome
- palpate clavicles and long bones for fractures, dislocations, crepitus,
masses and tenderness
 - feel shape of each spinal process, noting whether it is thin and well
formed, as expected
- split, possibly indicates bifid defect
- muscle strength is evaluated by holding infant upright w/your hands
under axillae
- adequate should muscle strength is present if infant maintains
upright position
- weakness is present if infant begins to slip through fingers

BARLOW-ORTOLANI MANEUVER – used to detect hip dislocation or subluxation

- test one hip at a time, stabilizing pelvis with other hand
- position yourself at supine infant’s feet, flex hip and knee to 90°
- adduct thigh and gently apply downward pressure on femur in
attempt to disengage femoral
head from acetabulum
- clunk or sensation may be felt if femoral head exits
acetabulum posteriorly as a
positive result
- high-pitched clicks are common and expected

ALLIS SIGN – used to detect hip dislocation or shortened femur

- w/infant in supine position, flex both knees, keeping feet flat on
table and femurs aligned
w/ea. other
- observe height of knees - - positive sign is when on knees appears
lower than the other

B. CHILDREN – function of joints, ROM, bone stability, and muscle strength can be
adequately evaluated by
observing child climb, jump, hop, rise from sitting position, and
manipulate toys or other objects
- young children will have lumbar curvature of spine and protuberant
abdomen
- observe toddler’s ability to sit, creep, and grasp and release objects
during play
- remember to observe wear of child’s shoes and ask about his/her
favorite sitting posture
- W or reverse tailor position places stress on joints of hips, knees,
and ankles (commonly
seen in children with in-toeing associated with femoral anteversion)
- tugging on child’s arm while removing clothing, or lifting child by
grabbing hand can lead to
dislocation
- relatively easy injury to cause, easy to reduce, better to prevent it
from happening
- generalized muscle weakness is indicated by GOWER SIGN (child rises
from sitting position by placing
hands on legs and pushing trunk up)
 genu varum (bowleg) – evaluated w/child standing, facing you, knees
at your eye level
- present if space of 2.5 cm (1”) is between knees
- common finding in toddler until 18 mos.

genu valgum (knock-kneed) – evaluated w/child standing, facing you,

knees at your eye level
- present if space of 2.5 cm (1”) is between medial malleoli
- common finding of children between 2 and 4 yrs

C. ADOLESCENTS – spine should be smooth w/balanced concave and convex curves

- no lateral curvature or rib hump w/forward flexion should be apparent
- shoulders and scapulae should be level w/ea other
- may have slight kyphosis and rounded shoulders

D. PREGNANT WOMEN – growing fetus shifts center of gravity forward, leading to

increased lordosis and
compensatory forward cervical flexion
- stooped shoulders and large breasts exaggerate spinal curvature
- increased mobility and instability of sacroiliac joints and ligaments
become less tense contribute to
waddling gait
- expected increases in lumbosacral curve and anterior flexion of head
- carpal tunnel syndrome is experienced during last trimester because of
associated fluid retention

E. OLDER ADULTS – response to movement requests may be slow and deliberate

- head may tilt backward to compensate for increased thoracic curvature
- extremities may appear to be relatively long if trunk has diminished in
length due to vertebral collapse
- base of support may be broader w/feet more widely spaced and arms
held away from body to aid
balancing

IV. COMMON ABNORMALITIES

A. ANKYLOSING SPONDYLITIS – hereditary, chronic inflammatory disease, initially
affecting lumbar spine and
sacroiliac joints
- larger joints of shoulders, hips, and knees may be affected later
- inflamed intervertebral disks become infiltrated w/vascular connective
tissue that ossifies, leading to
eventual fusion and severe deformity of vertebral column
- develops predominantly in males between 20 – 40 yrs

B. CARPAL TUNNEL SYNDROME – compression on median nerve caused by thickening of

flexor tendon sheath often
resulting from microtrauma, repetitive motion of arms and hands, or
vibration
- symptoms of numbness, burning, and tingling in hands
 - pain may radiate to arms
- weakness of hand and flattening of thenar eminence of palm
- 3 times more common in women

C. GOUT – disorder of purine metabolism that results in serum uric acid

concentrations
- symptoms include sudden onset of red, hot, swollen joint; exquisite
pain; limited ROM; and mild fever
- primarily affects men over 40, and only 10 – 20% have family history

D. TEMPOROMANDIBULAR JOINT SYNDROME – (TMJ) painful jaw movement caused by

congenital anomalies,
malocclusion, trauma, arthritis, and other joint diseases
- unilateral facial pain that usually worsens w/joint movement and may
be referred to any point on face
or neck
- muscle spasms, clicking, popping or crepitus in affected joint

E. BURSITIS – inflammation of bursa resulting from constant friction between skin

and tissue around joint
- common sites are shoulder, elbow, hip and knee
- signs include limitation of motion caused by swelling; pain on
movement; point tenderness; and
erythematous, warm site
- soreness may radiate to tendons

F. FIBROMYALGIA – painful, nonarticular condition that primarily affects muscles

- symptoms include widespread pain and aching, persistent fatigue,
generalized morning stiffness,
multiple tender points
- may be accompanied by headaches, irritable bowel, dysmenorrheal,
cold sensitivity, Raynaud
phenomenon, restless legs, atypical patterns of numbness and
tingling, and exercise
intolerance and weakness
- commonly affects women over 50 yrs

G. OSTEOARTHRITIS – noninflammatory disorder of movable joints

- results in deterioration and abrasion of cartilage and formation of new
bone at joint surfaces
- hands, feet, hips, knees, and cervical or lumbar spine are most
commonly affected

H. RHEUMATOID ARTHRITIS – chronic, systemic, inflammatory disorder of joints that can

occur between 3 – 80 yrs
and affects 1% of population
- unknown cause but may be associated w/infection, autoimmunity,
trauma, stress or familial
predisposition
 - joint inflammation results from infiltration of joint synovial fluid by
immune cells
- onset is characterized by unremitting fever, maculopapular rash, and
arthritis
- joints most commonly affected are wrists, hips, knees, ankles, and
cervical spine

I. MUSCLE STRAIN – caused by excessive stretching or forceful contraction beyond

functional capacity
- associated w/improper exercise warm-up, fatigue, or previous injury
- signs include temporary weakness, spasm, pain, and contusion

J. SPRAIN – stretching or tearing a supporting ligament of a joint by forced

movement beyond normal range
- signs include pain, marked swelling, hemorrhage, and loss of function

K. DISLOCATION – complete separation of contact between two bones in a joint, often

caused by pressure or force
pushing bone out of joint
- signs include deformity and inability to use extremity or joint as usual

L. FRACTURE – partial or complete break in continuity of bone resulting from trauma

(direct, indirect, twisting,
crushing)
- muscle contractions and spasms lead to shortening of tissues around
bone
- other signs include edema, pain, loss of function, color changes, and
paresthesia

M. TENOSYNOVITIS – inflammation of synovium-lined sheath around tendon

- results from repetitive actions associated w/occupational or sports
activities
- common sites include shoulder, knee, heel, and wrist
- signs include point tenderness, edema, pain w/movement, and weak
grasp

N. LEGG-CALVE’-PERTHES DISEASE – avascular necrosis of femoral head

- commonly seen in males between 3 – 11 yrs
- may have limp that is painless or antalgic (painful w/shortened time on
extremity); loss of internal
rotation; loss of abduction; decreased ROM on affected side
- pain is often referred to medial thigh or knee

O. OSGOOD-SCHLATTER DISEASE – traction apophysitis (inflammation of bony

outgrowth) of anterior aspect of tibial
tubercle
- presents w/limp, knee pain, and swelling that is aggravated by
strenuous activity, especially involving
quadriceps
 - most common in males between 9 – 15 yrs

P. MUSCULAR DYSTROPHY – group of genetic disorders involving gradual degeneration

of muscle fibers
- characterized by progressive symmetric weakness and muscle atrophy
or pseudohypertroyphy from
fatty infiltrates
- skeletal muscles and those of organs such as the heart may be involved
- cause mild disability with expected normal life span; others produce
severe disability, deformity,
death
- early signs may include clumsiness, difficulty climbing stairs, frequent
falls, waddling gait, and
positive Gower Sign

Q. SCOLIOSIS – physical deformity w/concave curvature of anterior vertebral bodies,

convex posterior curves, and
lateral rotation of thoracic spine
- severe deformities result in uneven shoulder and hip levels
- rotational deformities cause rib hump and flank asymmetry on forward
flexion
- physiologic alteration occur in spine, chest, and pelvis
- structural scoliosis most commonly affects girls
- functional scoliosis may occur because of leg length discrepancy

R. OSTEOPOROSIS – silent progressive disease in which a decrease in bone mass

occurs because bone resorption
is more rapid than bone deposition
- bones become fragile and susceptible to spontaneous fractures;
presenting symptom is usually loss
of height or acute, painful fracture
- most common fracture sites are hips, vertebrae, and wrists
- affected persons lose height and waistline, have bent spine, decreased
abdominothoracic space,
and appear to sink into their hips
- women are more commonly affected, especially postmenopausal

S. DUPUYTREN CONTRACTURE – affects palmar fascia of one or more fingers and tends
to be bilateral
- unknown cause, but appears to be hereditary component
- gradual increase incidence occurs with age, diabetes, alcoholic liver
disease, and epilepsy