Presentation by Professor Rebecca Jester for Clinical History Taking and Examination Course 2013

1. Assessment of the
musculoskeletal system
Professor Rebecca
Jester 2013

2. Aims of the day
 Recap on applied anatomy and physiology
 History taking practice
 Principles of MSK examination
 Practice of MSK examination
 Falls risk assessment

3. 3 elements essential for mobility
 The ability to move
 The motivation to move
 The environment to permit and facilitate
mobility.

4. Causes of impaired mobility
 Intolerance to activity, decreased strength
and endurance.
 Pain/discomfort
 Perceptual/cognitive impairment
 Musculoskeletal impairment
 Psychological impairment
(Davis, 2005)

5. What is involved in mobility –
musculoskeletal system
 Axial skeleton (skull, VC, ribs, sternum) &
appendicular (upper and lower limbs, pelvic
and pectoral girdles).
 Cartilage – hyaline covers articulating
surfaces, fibrocartilage – shock absorber,
elastic cartilage e.g. larynx & epiglottis

6. musculoskeletal system (contd)
 Joints – fibrous, cartilaginous, synovial
 Types of synovial-hinge, ball and socket,
plane, pivotal, condyloid, saddle
 Tendons – connect muscle to bone
 Ligaments – join bones together at joints
 Muscles – insertion and origin

7. Bone is living tissue
 Osteocytes, osteoblasts, osteoclasts
 Haversian systems
 Compact and cancellous bone
 Diaphysis
 Epiphyses
 periosteum

8. Nervous system
 Function to coordinate and control all parts of
the body.
 Central nervous system (brain and spinal
cord)
 Peripheral system (spinal and cranial nerves)
 Voluntary (somatic) and Involuntary
(autonomic)

9. Stages of Assessment
 History – 10 steps
 Examination – observation, inspection,
palpation, auscultation, percussion,
measurement e.g. ROM, limb length, muscle
strength, gait analysis
 PROMS
 Clinical Investigations

10. ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM
HISTORY TAKING
 Pain is the commonest orthopaedic complaint
 Pain is a symptom and is not the same as
tenderness, which is a physical sign
 Pain is often referred – eg pain in the hands may be
referred from the neck (cervical spondylosis or
prolapsed cervical disc) or knee, hip pain from
lesions in the lumbo-sacral spine. Therefore
examination of joints above and below is essential

11. ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM
Assessment – Nature of Pain
 Localised or diffuse
 Unilateral or bilateral
 Aching or sharp
 Present only with use
 Present constantly
 Worse at night or at rest
 Associated with sensory symptoms
 Use of pain assessment tools

12. Other chief complaints
 Loss of or reduced function, mobility, range
of movement.
 Joint stiffness, joint instability, joint laxity
 Inflammation of joints, deformity

13. ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM
Landmarks
 Limbs and joints can be grossly distorted by trauma
or disease. So identification of known landmarks is
essential.
Examples – ant. Sup,Iliac spine, greater trochanter,
ischial tuberosity and symphysis pubis for the hip.
 Range of active and passive movement
 Temperature of joints
 Measurement of limbs
 Muscle power- MRC scale
 Neurological – reflexes, sensitivity to sharp/blunt

14. ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM
Examination
Both limbs should always be compared
Gait
 Common gait abnormalities include:- Trendelberg,
toe catching due to drop foot, stiff legged gait (knee
disorders)
 Muscle wasting local or generalized eg wasting of
thena muscles associated with median nerve
compression

15. Gait abnormalities
 Common gait abnormalities include:-
Trendelberg, toe catching due to drop foot,
stiff legged gait (knee disorders).
 Observation of patients’ gait, stride pattern
and their footwear are important.

16. Goniometry
 Comes from two Greek words – gonia (angle) and metron
(measure)
 If performed correctly goniometry provides a very accurate
measure of joint motion.
 The movement should be free of any muscle contraction.
 The measurement of ROM of a particular patient should be
taken 3 times and the average ROM recorded to 5 degree
increments.
 The measurements are obtained by placing the parts of the
measuring instrument along the proximal and distal bones
adjacent to the joint concerned.

17. Assessing muscle power
MRC Scale for Recording Muscle Power
0 No muscle power
1 Flicker of activity
2 Movement with effect of gravity eliminated i.e. in a place at
right angles to gravity but not against resistance
3 Movement against gravity but not against applied resistance
4 Movement against applied resistance but less than full power
5 Normal power

18. ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM
Measuring Leg Length
 Measure from the anterior superior iliac spine to the
medial malleolus, then extend the measurement
down to the bottom of the heel with the ankle in the
neutral position.
 Remember to check that the patients pelvis is flat
and square on the bed before measuring.

19. The Bony Spine
 Back pain is extremely common and if it
becomes chronic and unrelieved can lead to
significant psychological and social issues for
the patient and their family. It is therefore
important to include assessment of patients'
stress, coping and depression status, social
circumstances as well physical examination.

20. The Bony Spine
 Back pain may be localized to the back, but
often radiates into the buttocks, legs and feet
due to sciatica. Back pain may also be
indicative of problems not associated with
the bony spine such as lower intestine,
genitourinary or renal problems and these
should be excluded during the assessment
process.

21. The Bony Spine
 Areas of the spine included in the
assessment will depend on the patient's
presentation and history. Causes include:
sprains and strains, osteoarthritis,
spondylosis, spinal stenosis, ankylosing
spondylitis, osteoporotic fractures and less
commonly tumours/spinal metastases and
infection

22. Bony Spine
 Detailed history of what specific movements,
activities and positions bring on or
exacerbate the pain e.g. sitting or standing
for long periods, occupational activity,
coughing or sneezing, bowel movements.
Also determine what alleviates the pain.

23. Bony spine
 Elicitif there is a history of trauma does the
patient report twisting their spine, whiplash or
any locking. Its important to elicit if there is
any neurological symptoms such as sciatica,
erectile dysfunction or loss of bladder or
bowel sensation which if reported require
urgent investigation (MRI)by a spinal
specialist.

24. Bony spine
 The symmetry of the spine should be
observed and any abnormal curvature such
as lordosis, scoliosis or kyphosis noted.
Observe for limb length inequality when
standing and gait pattern should be noted.
Check for protrusions, redness, swelling and
any scars which indicate previous surgery or
trauma.

25. Bony spine
 Palpation and Percussion - The spine
should be palpated with the patient in the
sitting and standing positions and any
tenderness, heat, misalignment, protrusions
noted. The spine should also be gently
percussed with the patient bending forward
from the root of the neck to the sacrum
noting any pain.


26. Bony spine
 Specific assessment of motor and sensory
function will depend on the level of the
presenting spinal problem and if the patient
reports any altered sensation or motor
function during the history. E.g. patients
presenting with lumbar/sacral pain who
report sciatica will need to have the
sensation and motor function of their lower
limbs assessed.

27. Bony spine
 Movement - The amount of
flexion/extension, lateral bend and rotation of
the spine should be measured. If prolapsed
intervertebral disc is suspected then the
patient's ability to straight leg raise should be
included in the assessment.

28. Bony spine- clinical investigations
 NICE guidelines for management of non-
specific LBP(2009) recommend not to offer
X-ray of the lumbar spine for the
management of non-specific low back pain
and only to consider MRI when a diagnosis
of spinal malignancy, infection, fracture,
cauda equina syndrome or ankylosing
spondylitis or another inflammatory disorder
is suspected.

29. Bony spine- clinical investigations
 If ankylosing spondylitis is suspected blood
tests for inflammatory markers should be
taken (CRP, ESR,PV and HLA-B27 antigen)

30. Psyco/social aspects of
assessment
 There are a number of valid and reliable
indices to assess depression and anxiety
including Becks Depression Inventory (BDI)
and Hospital Anxiety and Depression Score
(HADS). The nurse should also ascertain
how the patient's back pain is impacting on
their social and occupational activities.

31. Disease specific measures
 There are a number of assessment indices
specifically designed for assessing back pain
including the Oswestry low back pain score
(full and modified versions) and the Back
Pain Index see orthopaedic.scores.com for
further detail.

32. Examination of the Shoulder
 Total shoulder movement comprises 2 separate
movements: 1 at the gleno-humeral joint and 1
between the scapula and chest wall. You should fix
the scapula before assessing ROM of GH joint.
 External rotation and adduction by asking patient to
touch the back of the head.
 Internal rotation and adduction by asking patient to
reach as high up his back as possible.
 Normal – patient can touch fingertips of both hands
together. Record any limitation due to pain.

33. ROM of the Shoulder
 Circumduction (200 )
 Elevation through abduction (180)
 Elevation through forward flexion (160-180)
 External/lateral rotation (90)
 Internal/medial rotation (60-90)
 Adduction (50-75%)
 Horizontal adduction/abduction (cross-flexion/cross
extension 130)
 Extension (50-60)
 Elevation through the plane of the scapula (170-180)

34. Examination of the hip
 Range of active movement should include:
 Flexion (110-120° )
 Abduction (30-50°)
 Aduction (30°)
 Extension (10-15°)
 Lateral rotation (40-60°)
 Medial rotation (30-40°)

35. HIP
 A patient with tight adductors or weak abductors will
have a +ve Trendelburg sign. Stand on good leg, the
pelvis tilts up on the opposite side appropriately.
When standing on bad leg not possible to tilt the
pelvis so opposite side sags down.
 Fixed flexion deformity of hip – often hidden by
exaggerated lumbar lordosis, Fully flexing opposite
hip flattens lordosis and the fixed flexion contracture
becomes apparent (Thoma’s test)

36. Examination of the Knee
 Flexion 0-140 degrees / Hyperextension possible 5-
0-90. There should not be a great deal of
internal/external rotation of the knee.
 Anterior Draw Test – tibia is pulled forward on the
femur to check the integrity of the anterior cruciate –
knee should be in 90 degree flexion (sit on foot to
stabilise).
 Lachman Test – still for anterior cruciate instability –
knee is not flexed (suitable for acutely injured knee).
Pull tibia forward on the femoral condyle.

37. Radiography
 Radiographic images are created by short bursts of
radiation which pass through the body and interact
with photographic film or a fluorescent screen. The
extent to which the film is blackened depends on the
number of x-rays reaching the film which, in turn,
depends on the densities of the tissue. X-rays pass
easily through soft tissue but are less able to pass
through bone which is more dense.

38. Radiography
 Radiographs provide images of bony
structures, the density of bones, the
relationships between bones, their continuity
and contour and the shape of spaces within
joints. They are used in all cases of
suspected fracture and are commonly used
in the diagnosis of musculo-skeletal
conditions such as osteoarthritis.

39. Radiography
 Long shot. A general overview of the radiograph,
standing well back, considering the shape, size and
contour of the bones and joints as a whole.
 Medium Shot. Noting bone texture, areas of new
bone or bone destruction and deformity
 Close-up. Tracing methodically around the contours
of the bone and noting any abnormalities of the
continuity of the outline and structure of the bone.

40. CT scans
 CT scans are created using radiation beams passing
through the tissue from different angles of rotation to
provide cross-sectional slice images of a segment of
the body. This enables more detailed views of bony
structures from many angles as well as greater
definition of different types of tissue. In most
situations CT scans have now been superseded by
MRI. The risks of CT are the same as those for
normal radiographs although the scan will take much
longer so the dose of radiation may be greater.

41. MRI
 MRI is increasingly being used to diagnose
musculo-skeletal problems
 No radiation is involved and the process is
harmless to the patient (although can be
quite lengthy and noisy)

42. Suggested Reading
 Jester R, Santy J & Rogers J (2011) Oxford Handbook of
Orthopaedic & Trauma Nursing. OUP. Oxford
 Magee D (2006) Orthopaedic Physical Assessment. 4th Ed.
Saunders Elsevier. St Louis
 McRae R (2005) Clinical Orthopaedic Examination. 5 th ed.
Churchill Livingstone. Edinburgh