Learning Objectives

• Perform a musculoskeletal assessment
• Palpate joints for pain, swelling, change in temperature, and range of motion
• Modify assessment techniques to reflect variations across the life span
• Recognize and report significant deviations from norms
• Document actions and observations

The musculoskeletal system gives us the ability to move. It is composed of bones, muscles, joints, tendons, ligaments, and cartilage that support the body, allow movement, and protect vital organs. An assessment of the musculoskeletal system includes collecting data regarding the structure and movement of the body, as well the patient’s mobility. Let’s begin by reviewing the anatomy of the musculoskeletal system and common conditions a nurse may find on assessment.

Skeleton

The skeleton is composed of 206 bones that provide the internal supporting structure of the body. See Figure 13.1^[1] for an illustration of the major bones in the body. The bones of the lower limbs are adapted for weight-bearing support, stability, and walking. The upper limbs are highly mobile with large range of movements, along with the ability to easily manipulate objects with our hands and opposable thumbs.^[2]

Figure 13.1

Skeletal Bones

Bones are connected together by ligaments. Ligaments are strong bands of fibrous connective tissue that strengthen and support the joint by anchoring the bones together and preventing their separation. Ligaments allow for normal movements of a joint while also limiting the range of these motions to prevent excessive or abnormal joint movements.^[3]

Muscles

There are three types of muscle tissue: skeletal muscle, cardiac muscle, and smooth muscle. Skeletal muscle produces movement, assists in maintaining posture, protects internal organs, and generates body heat. Skeletal muscles are voluntary, meaning a person is able to consciously control them, but they also depend on signals from the nervous system to work properly. Other types of muscles are involuntary and are controlled by the autonomic nervous system, such as the smooth muscle within our bronchioles.^[4]

See Figure 13.2^[5] for an illustration of skeletal muscle.

Figure 13.2

Skeletal Muscle

To move the skeleton, the tension created by the contraction of the skeletal muscles is transferred to the tendons, strong bands of dense, regular connective tissue that connect muscles to bones.^[6]

MUSCLE ATROPHY

Muscle atrophy is the thinning or loss of muscle tissue. See Figure 13.3^[7] for an image of muscle atrophy. There are three types of muscle atrophy: physiologic, pathologic, and neurogenic.

Figure 13.3

Muscle Atrophy

Physiologic atrophy is caused by not using the muscles and can often be reversed with exercise and improved nutrition. People who are most affected by physiologic atrophy are those who:

• Have seated jobs, health problems that limit movement, or decreased activity levels
• Are bedridden
• Cannot move their limbs because of stroke or other brain disease
• Are in a place that lacks gravity, such as during space flights

Pathologic atrophy is seen with aging, starvation, and adverse effects of long-term use of corticosteroids. Neurogenic atrophy is the most severe type of muscle atrophy. It can be from an injured or diseased nerve that connects to the muscle. Examples of neurogenic atrophy are spinal cord injuries and polio.^[8]

Although physiologic atrophy due to disuse can often be reversed with exercise, muscle atrophy caused by age is irreversible. The effects of age-related atrophy are especially pronounced in people who are sedentary because the loss of muscle results in functional impairments such as trouble with walking, balance, and posture. These functional impairments can cause decreased quality of life and injuries due to falls.^[9]

Joints

Joints are the location where bones come together. Many joints allow for movement between the bones. Synovial joints are the most common type of joint in the body. Synovial joints have a fluid-filled joint cavity where the articulating surfaces of the bones contact and move smoothly against each other. See Figure 13.4^[10] for an illustration of a synovial joint. Articular cartilage is 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. Articular cartilage can be damaged by injury or normal wear and tear. Lining the inner surface of the articular capsule is a thin synovial membrane. The cells of this membrane secrete synovial fluid, a thick, slimy fluid that provides lubrication to further reduce friction between the bones of the joint.^[11]

Figure 13.4

Synovial Joint

Types of Synovial Joints

There are six types of synovial joints. See Figure 13.5^[12] for an illustration of the types of synovial joints. Some joints are relatively immobile but stable. Other joints have more freedom of movement but are at greater risk of injury. For example, the hinge joint of the knee allows flexion and extension, whereas the ball and socket joint of the hip and shoulder allows flexion, extension, abduction, adduction, and rotation. The knee, hip, and shoulder joints are commonly injured and are discussed in more detail in the following subsections.

Figure 13.5

Types of Synovial Joints

SHOULDER JOINT

The shoulder joint is a ball-and-socket joint formed by the articulation between the head of the humerus and the glenoid cavity of the scapula. This joint has the largest range of motion of any joint in the body. See Figure 13.6^[13] to review the anatomy of the shoulder joint. Injuries to the shoulder joint are common, especially during repetitive abductive use of the upper limb such as during throwing, swimming, or racquet sports.^[14]

Figure 13.6

Should Joint

HIP JOINT

The hip joint is a ball-and-socket joint between the head of the femur and the acetabulum of the hip bone. The hip carries the weight of the body and thus requires strength and stability during standing and walking.^[15]

See Figure 13.7^[16] for an illustration of the hip joint.

Figure 13.7

Hip Joint

A common hip injury in older adults, often referred to as a “broken hip,” is actually a fracture of the head of the femur. Hip fractures are commonly caused by falls.^[17]

See more information about hip fractures under the “Common Musculoskeletal Conditions” section.

KNEE JOINT

The knee functions as a hinge joint that allows flexion and extension of the leg. In addition, some rotation of the leg is available when the knee is flexed, but not when extended. See Figure 13.8^[18] for an illustration of the knee joint. The knee is vulnerable to injuries associated with hyperextension, twisting, or blows to the medial or lateral side of the joint, particularly while weight bearing.^[19]

Figure 13.8

Knee Joint

The knee joint has multiple ligaments that provide support, especially in the extended position. On the outside of the knee joint are the lateral collateral, medial collateral, and tibial collateral ligaments. The lateral collateral ligament is on the lateral side of the knee and spans from the lateral side of the femur to the head of the fibula. The medial collateral ligament runs from the medial side of the femur to the medial tibia. The tibial collateral ligament crosses the knee and is attached to the articular capsule and to the medial meniscus. In the fully extended knee position, both collateral ligaments are taut and stabilize the knee by preventing side-to-side or rotational motions between the femur and tibia.^[20]

Inside the knee joint are the anterior cruciate ligament and posterior cruciate ligament. These ligaments are anchored inferiorly to the tibia and run diagonally upward to attach to the inner aspect of a femoral condyle. The posterior cruciate ligament supports the knee when it is flexed and weight-bearing such as when walking downhill. The anterior cruciate ligament becomes tight when the knee is extended and resists hyperextension.^[21]

The patella is a bone incorporated into the tendon of the quadriceps muscle, the large muscle of the anterior thigh. The patella protects the quadriceps tendon from friction against the distal femur. Continuing from the patella to the anterior tibia just below the knee is the patellar ligament. Acting via the patella and patellar ligament, the quadriceps is a powerful muscle that extends the leg at the knee and provides support and stabilization for the knee joint.

Located between the articulating surfaces of the femur and tibia are two articular discs, the medial meniscus and lateral meniscus. Each meniscus is a C-shaped fibrocartilage that provides padding between the bones.^[22]

Joint Movements

Several movements may be performed by synovial joints. Abduction is the movement away from the midline of the body. Adduction is the movement toward the middle line of the body. Extension is the straightening of limbs (increase in angle) at a joint. Flexion is bending the limbs (reduction of angle) at a joint. Rotation is a circular movement around a fixed point. See Figures 13.9^[23] and 13.10^[24] for images of the types of movements of different joints in the body.

Figure 13.9

Joint Movements

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Osteoporosis

Osteoporosis is a disease that thins and weakens bones, causing them to become fragile and break easily. See Figure 13.11^[1] for an illustration comparing the top right image of normal bone to the bottom right image of bone with osteoporosis. 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.^[2]

Figure 13.11

Osteoporosis

Fracture

A fracture is the medical term for a broken bone. There are many different types of fractures commonly caused by sports injuries, falls, and car accidents. Additionally, people with osteoporosis are at higher risk for fractures from minor injuries due to weakening of the bones. See Figure 13.12^[3] for an illustration of different types of fractures. For example, if the broken bone punctures the skin, it is called an open fracture. Symptoms of a fracture include the following:

Figure 13.12

Types of Fractures

• Intense pain
• Deformity (i.e., the limb looks out of place)
• Swelling, bruising, or tenderness around the injury
• Numbness and tingling of the extremity distal to the injury
• Difficulty moving a limb

A suspected fracture requires immediate medical attention and an X-ray to determine if the bone is broken. Treatment includes a cast or splint. In severe fractures, surgery is performed to place plates, pins, or screws in the bones to keep them in place as they heal.^[4]

Hip Fracture

A hip fracture, commonly referred to as a “broken hip,” is actually a fracture of the femoral neck. See Figure 13.13^[5] for an image of a hip fracture. Hip fractures are typically caused by a fall, especially in older adults with preexisting osteoporosis. Symptoms of a hip fracture after a fall include the following:

Figure 13.13

Hip Fracture

• Pain
• An inability to lift, move, or rotate the affected leg
• An inability to stand or put weight on the affected leg
• Bruising and swelling around the hip
• The injured leg appears shorter than the other leg
• The injured leg is rotated outwards^[6]

Hip fractures typically require surgical repair within 48 hours of the injury. In approximately half of the cases of hip fractures, hip replacement is needed. See more information about hip replacement under the “Osteoarthritis” section below. In other cases, the fracture is fixed with surgery called Open Reduction Internal Fixation (ORIF) where the surgeon makes an incision to realign the bones, and then they are internally fixated (i.e., held together) with hardware like metal pins, plates, rods, or screws. After the bone heals, this hardware isn’t removed unless additional symptoms occur. After surgery, the patient will need mobility assistance for a prolonged period of time from family members or in a long-term care facility, and the reduced mobility can result in additional falls if protective measures are not put into place. Additionally, hip fractures are also associated with life-threatening complications, such as pneumonia, infected pressure injuries, and blood clots that can move to the lungs causing pulmonary embolism.^[7]

Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis associated with aging and wear and tear of the articular cartilage that covers the surfaces of bones at a synovial joint. OA causes the cartilage to gradually become thinner, and as the cartilage layer wears down, more pressure is placed on the bones. The joint responds by increasing production of the synovial fluid for more lubrication, but this can cause swelling of the joint cavity. The bone tissue underlying the damaged articular cartilage also responds by thickening and causing the articulating surface of the bone to become rough or bumpy. As a result, joint movement results in pain and inflammation. In early stages of OA, symptoms may be resolved with mild activity that warms up the joint. However, in advanced OA, the affected joints become more painful and difficult to use, resulting in decreased mobility. 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 OA, joint replacement surgery may be required.^[8]

See Figure 13.14^[9] for an image comparing a normal joint to one with osteoarthritis and another type of arthritis called rheumatoid arthritis. (Rheumatoid arthritis is further explained under the “Joint Replacement” subsection.)

Figure 13.14

Comparison of Osteoarthritis and Rheumatoid Arthritis

Joint Replacement

Arthroplasty, the medical term for joint replacement surgery, is an invasive procedure requiring extended recovery time, so conservative treatments such as lifestyle changes and medications are attempted before surgery is performed. See Figure 13.15^[10] for an illustration of joint replacement surgery. This type of surgery involves replacing the articular surfaces of the bones with prosthesis (artificial components). For example, in hip arthroplasty, the worn or damaged parts of the hip joint, including the head and neck of the femur and the acetabulum of the pelvis, are removed and replaced with artificial joint components. The replacement head for the femur consists of a rounded ball attached to the end of a shaft that is inserted inside the femur. The acetabulum of the pelvis is reshaped and a replacement socket is fitted into its place.^[11]

Figure 13.15

Joint Replacement

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a type of arthritis that causes pain, swelling, stiffness, and loss of function in joints due to inflammation caused by an autoimmune disease. See Figure 13.16^[14] for an illustration of RA in the hands causing inflammation and a common deformity of the fingers. It often starts in middle age and is more common in women. RA is different from osteoarthritis because it is an autoimmune disease, meaning it is caused by the immune system attacking the body’s own tissues.^[15] In rheumatoid arthritis, 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 nonsteroidal anti-inflammatory drugs (NSAIDS), corticosteroids, and antirheumatic drugs such as methotrexate are commonly used to treat rheumatoid arthritis.^[16]

Figure 13.16

Rheumatoid Arthritis in the Hands

Gout

Gout is a type of arthritis that causes swollen, red, hot, and stiff joints due to the buildup of uric acid. It typically first attacks the big toe. See Figure 13.17^[17] for an illustration of gout in the joint of 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, needle-like crystals in joints. Gout is treated with lifestyle changes such avoiding alcohol and food high in purines, as well as administering antigout medications, such as allopurinol and colchicine.^[18]

Figure 13.17

Gout

Vertebral Disorders

The spine is composed of many vertebrae stacked on top of one another, forming the vertebral column. There are several disorders that can occur in the vertebral column causing curvature of the spine such as kyphosis, lordosis, and scoliosis. See Figure 13.18^[19] for an illustration of kyphosis, lordosis, and scoliosis.

Figure 13.18

Vertebral Disorders

Kyphosis is a curving of the spine that causes a bowing or rounding of the back, often referred to as a “buffalo hump” that can lead to a hunchback or slouching posture. Kyphosis can be caused by osteoarthritis, osteoporosis, or other conditions. Pain in the middle or lower back is the most common symptom. Treatment depends upon the cause, the severity of pain, and the presence of any neurological symptoms.^[20]

Lordosis is the inward curve of the lumbar spine just above the buttocks. A small degree of lordosis is normal, especially during the third trimester of pregnancy. Too much curving of the lower back is often called swayback. Most of the time, lordosis is not treated if the back is flexible because it is not likely to progress or cause problems.^[21]

Scoliosis causes a sideways curve of the spine. It commonly develops in late childhood and the early teens when children grow quickly. Symptoms of scoliosis include leaning to one side and having uneven shoulders and hips. Treatment depends on the patient’s age, the amount of expected additional growth, the degree of curving, and whether the curve is temporary or permanent. Patients with mild scoliosis might only need checkups to monitor if the curve is getting worse, whereas others may require a brace or have surgery.^[22]

Dislocation

A dislocation is an injury, often caused by a fall or a blow to the joint, that forces the ends of bones out of position. Dislocated joints are typically very painful, swollen, and visibly out of place. The patient may not be able to move the affected extremity. See Figure 13.19^[23] for an X-ray image of an anterior dislocation of the right shoulder where the ball (i.e., head of the humerus) has popped out of the socket (i.e., the glenoid cavity of the scapula). A dislocated joint requires immediate medical attention. Treatment depends on the joint and the severity of the injury and may include manipulation to reposition the bones, medication, a splint or sling, or rehabilitation. When properly repositioned, a joint will usually function and move normally again in a few weeks; however, once a joint is dislocated, it is more likely to become dislocated again. Instructing patients to wear protective gear during sports may help to prevent future dislocations.^[24]

Figure 13.19

X-ray of Dislocated Shoulder

Clubfoot

Clubfoot is a congenital condition that causes the foot and lower leg to turn inward and downward. A congenital condition means it is present at birth. See Figure 13.20^[25] for an image of an infant with a clubfoot. It can range from mild and flexible to severe and rigid. Treatment by an orthopedic specialist involves using repeated applications of casts beginning soon after birth to gradually moving the foot into the correct position. Severe cases of clubfoot require surgery. After the foot is in the correct position, the child typically wears a special brace for up to three years.^[26]

Figure 13.20

Clubfoot

Sprains and Strains

A sprain is a stretched or torn ligament caused by an injury. Ligaments are tissues that attach bones at a joint. Ankle and wrist sprains are very common, especially due to falls or participation in sports. See Figure 13.21^[27] for an illustration of an ankle sprain caused by eversion or inversion of the ankle. Symptoms include pain, swelling, bruising, and the inability to move the joint. The patient may also report feeling a pop when the injury occurred.

Figure 13.21

Sprained Ankle Ligaments

A strain is a stretched or torn muscle or tendon. Tendons are tissues that connect muscle to bone. See Figure 13.22^[28] for an image of a strained tendon. Strains can happen suddenly from an injury or develop over time due to chronic overuse. Symptoms include pain, muscle spasms, swelling, and trouble moving the muscle.

Figure 13.22

Strained Tendon

Treatment of sprains and strains is often referred to with the mnemonic RICE that stands for Resting the injured area, Icing the area, Compressing the area with an ACE bandage or other device, and Elevating the affected limb. Medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used.^[29]

Contracture

A contracture develops when the normally elastic tissues are replaced by inelastic, fiber-like tissue. This inelastic tissue makes it difficult to stretch the area and prevents normal movement.

Contractures occur in the skin, the tissues underneath, and the muscles, tendons, and ligaments surrounding a joint. They affect the range of motion and function in a specific body part and can be painful. See Figure 13.23^[31] for an image of severe contracture of the wrist that occurred after a burn injury.

Figure 13.23

Contracture

Contracture can be caused by any of the following:

• Brain and nervous system disorders, such as cerebral palsy or stroke
• Inherited disorders, such as muscular dystrophy
• Nerve damage
• Reduced use (for example, from lack of mobility)
• Severe muscle and bone injuries
• Scarring after traumatic injury or burns

Treatments may include exercises, stretching, or applying braces and splints.^[32]

Foot Drop

Foot drop is the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot. As a result, individuals with foot drop often scuff their toes along the ground when walking or bend their knees to lift their foot higher than usual to avoid the scuffing. Foot drop is a symptom of an underlying problem and can be temporary or permanent, depending on the cause. The prognosis for foot drop depends on the cause. Foot drop caused by trauma or nerve damage usually shows partial or complete recovery, but in progressive neurological disorders, foot drop will be a symptom that is likely to continue as a lifelong disability. Treatment depends on the specific cause of foot drop. The most common treatment is to support the foot with lightweight leg braces. See Figure 13.24^[33] for an image of a patient with foot drop treated with a leg brace. Exercise therapy to strengthen the muscles and maintain joint motion also helps to improve a patient’s gait.^[34]

Figure 13.24

Foot Drop Treated with Leg Brace

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MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2019, Feb 7]. Dislocations; [reviewed 2016, Oct 26; cited 2020, Sep 18]. https://medlineplus​.gov/dislocations​.html ↵.

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“813 Clubfoot.jpg” by OpenStax is licensed under CC BY 3.0 ↵.

26.

A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Club foot; [updated 2020, Sep 16; cited 2020, Sep 18]. https://medlineplus​.gov​/ency/article/001228.htm ↵.

27.

“Ankle sprain -- Smart-Servier.jpg” by Laboratoires Servier is licensed under CC BY-SA 3.0 ↵.

28.

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29.

A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Sprains and strains; [updated 2020, Jun 17; reviewed 2017, Jan 3; cited 2020, Sep 18]. https://medlineplus​.gov​/sprainsandstrains.html ↵.

30.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

31.

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A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Contracture deformity; [updated 2020, Sep 16; cited 2020, Sep 18]. https://medlineplus​.gov​/ency/article/003185.htm ↵.

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“AFO brace for foot drop.JPG” by Pagemaker787 is licensed under CC BY-SA 4.0 ↵.

34.

National Institute of Neurological Disorders and Stroke. (2019, March 27). Foot drop information page. https://www​.ninds.nih​.gov/Disorders/All-Disorders​/Foot-Drop-Information-Page ↵.

Subjective Assessment

Collect subjective data from the patient and pay particular attention to what the patient is reporting about current symptoms, as well as past history of musculoskeletal injuries and disease. Information during the subjective assessment should be compared to expectations for the patient’s age group or that patient’s baseline. For example, an older client may have chronic limited range of motion in the knee due to osteoarthritis, whereas a child may have new, limited range of motion due to a knee sprain that occurred during a sports activity.

If the patient reports a current symptom, use the PQRSTU method described in the “Health History” chapter to obtain more information about this chief complaint. If the patient is experiencing acute pain or recent injury, focus on providing pain relief and/or stabilization of the injury prior to proceeding with the interview. Use information obtained during the subjective assessment to guide your physical examination. Sample focused interview questions to include during a subjective assessment of the musculoskeletal system are contained in Table 13.4a. The first question of the musculoskeletal interview is based on the six most common symptoms related to musculoskeletal disease.^[1]

Life Span Considerations

When conducting a subjective interview of children, additional information may be obtained from the parent or legal guardian.

Objective Assessment

The purpose of a routine physical exam 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 during the physical exam.

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 range of motion of joints
• Inspect muscles and extremities for size and symmetry
• Assess muscle strength
• Palpate extremities for tenderness^[2]

While assessing an older adult, keep in mind they may have limited mobility and range of motion 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 such as kyphosis, lordosis, or scoliosis. 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 range of motion (ROM). Active range of motion is the degree of movement the patient can voluntarily achieve in a joint without assistance. See Figures 13.9 and 13.10 as resources for describing joint movement.

Figure 13.10

Joint Movements

Palpation

Palpation is typically done simultaneously during inspection. As you observe, palpate each joint for warmth, swelling, or tenderness. If you observe decreased active range of motion, gently attempt passive range of motion by stabilizing the joint with one hand while using the other hand to gently move the joint to its limit of movement. Passive range of motion is the degree of range of motion demonstrated in a joint when the examiner is providing the movement. You may hear crepitus as the joint moves. Crepitus sounds like a crackling, popping noise that 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.^[3] 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. See Box 13.4 for the muscle strength testing scale.

Box 13.4 Muscle Strength Scale^[4]

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

To assess upper extremity strength, first begin by assessing bilateral hand grip 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 towards them. Finally, ask the patient to place their palms against yours and press while you provide resistance. See Figure 13.25^[5] for images of a nurse assessing upper extremity strength.

Figure 13.25

Assessing Hand Grips and Upper Extremity Strength

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. Secondly, place your hands behind their calves and ask them to pull their legs backwards while you provide resistance. Place your hands on the top of their feet and ask them to pull their feet upwards against your resistance. Finally, place your hands on the soles of their feet and ask them to press downwards while you provide resistance, instructing them to “press downwards like pressing the gas pedal on a car.” See Figure 13.26^[6] for images of a nurse assessing lower extremity strength.

Figure 13.26

Assessing Lower Extremity Strength

To read additional details regarding a full range of motion assessment of the musculoskeletal system, visit the following chapter from Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition: An Overview of the Musculoskeletal System

Video Review of Musculoskeletal Assessment^[7]

See Table 13.4b for a comparison of expected versus unexpected findings when assessing the musculoskeletal system.

Table 13.4b

Expected Versus Unexpected Findings on Musculoskeletal Assessment

View in own window

Assessment	Expected Findings	Unexpected Findings (document and notify provider if a new finding*)
Inspection	Erect posture with good balance and normal gait while walking. Joints and muscles are symmetrical with no swelling, redness, or deformity. Active range of motion of all joints without difficulty. No spine curvature.	Spinal curvature is present. Poor balance or unsteady gait while walking. Swelling, bruising, erythema, or tenderness over joints or muscles. Deformity of joints. Decreased active range of motion. Contracture or foot drop present.
Auscultation	Not applicable	Crepitus associated with pain on movement.
Palpation	No palpable tenderness or warmth of joints, bones, or muscles. Muscle strength 5/5 against resistance.	Warmth or tenderness on palpation of joints, bones, or muscles. Decreased passive range of motion. Muscle strength of 3/5 or less.
*CRITICAL CONDITIONS to report immediately		Hot, swollen, painful joint. Suspected fracture, dislocation, sprain, or strain.

References

1.

Miller, S. B. (1990). An overview of the musculoskeletal system. In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed.). Butterworths. https://www​.ncbi.nlm​.nih.gov/books/NBK266/ ↵. [PubMed: 21250045]

2.

Giddens J. F. A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education. 2007;46(2):83–87. ↵ [PubMed: 17315568] [CrossRef]

3.

This work is a derivative of StatPearls by Naqvi and Sherman and is licensed under CC BY 4.0 ↵.

4.

This work is a derivative of StatPearls by Naqvi and Sherman and is licensed under CC BY 4.0 ↵.

5.

"Neuro Exam image 38.png," Neuro Exam image 41.png," and "Neuro Exam image 39.jpg" by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵.

6.

"Musculoskeletal Exam image 2.png," "Neuro Exam image 6.png," and "Musculoskeletal Exam Image 7.png" by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵.

7.

RegisteredNurseRN. (2017, December 22). Upper & lower extremities assessment nursing | Upper, lower extremity examination. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/1sKnumpKT_Y ↵.

Sample Documentation of Expected Findings

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 5 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 5 out of 5. Patient is able to maintain full resistance of muscle without tenderness or discomfort.

Sample Documentation of Unexpected Findings

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.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: assistive device (i.e., walker, cane, crutches, brace, etc.) based on patient status.

• Check the patient chart for information prior to assessment regarding mobility status, fall risk, and use of assistive devices.

2.

Perform safety steps:

• Perform hand hygiene.
• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient and ask if they have any questions.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

3.

Perform inspection:

• Observe the patient using their arms, legs, gait, ability to sit and stand, and posture.
• Note symmetry; compare each side of the body.
• Inspect overall size, bony enlargement, and alignment of muscles and joints.
• Observe coordination and muscle function and note balance, limping, presence of deformity, or shuffling.

4.

Palpate and assess range of motion (ROM) and muscle strength:

• Gently palpate bones, joints, muscles, and surrounding tissue for heat, swelling, stiffness, tenderness, or crepitation.
• Ask the patient to move major joints (knees, shoulders, hips, and ankles) through the expected ROM movements. Observe the quality and equality of motion bilaterally with the same body parts. Note any limitation, pain, or crepitus with movement. Use passive ROM if indicated and appropriate.
• Assess muscle strength and tone in:
• Hand grips
• Upper extremities
• Lower extremities
• Compare strength of symmetrical muscle groups. Upper and lower extremities on the dominant side are usually stronger. Rate muscle strength on scale of 0 to 5.

5.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

6.

Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

7.

Perform hand hygiene.

8.

Document the assessment findings and report any concerns according to agency policy.

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

1.

During a musculoskeletal assessment, the nurse has the patient simultaneously resist against exerted force with both upper extremities. The nurse knows this it is important to perform this assessment on both extremities simultaneously for what reason?

a.

It measures muscle strength symmetry.

b.

It provides a more accurate reading.

c.

It involves more muscle use.

d.

It decreases assessment time.

2.

The nurse is testing upper body strength on an adolescent. The test indicates full ROM against gravity and full resistance. How does the nurse document these assessment findings according to the muscle strength scale?

a.

4 out of 5

b.

3 out of 5

c.

5 out of 5

d.

1 out of 5

3.

A young adult presents to the urgent care with a right knee injury. The injury occurred during a basketball game. The nurse begins to perform a musculoskeletal assessment. What is the first step of the assessment?

a.

Palpation

b.

Inspection

c.

Percussion

d.

Auscultation