MIDTERM: HEALTH ASSESSMENT LECTURE

HANDOUT 5: MUSCULOSKELETAL SYSTEM

The body’s bones, muscles, and joints compose the musculoskeletal system. Controlled and innervated by
the nervous system, the musculoskeletal system’s overall purpose is to provide structure and movement
for body parts.

BONES
FUNCTIONS:
 provide structure
 give protection
 serve as levers
 store calcium
 produce blood cells
Two hundred and six (206) bones make up the axial skeleton(head and trunk) and the appendicular
skeleton (extremities, shoulders, and hips).

TYPES
1. compact bone- hard and dense and makes up the shaft and outer layers
2. spongy bone- contains numerous spaces and makes up the ends and centers of the bones

SKELETAL MUSCLES
TYPES
1. Skeletal
2. Smooth
3. Cardiac
- is made up of 650 skeletal (voluntary) muscles, which are under conscious control

FUNCTIONS:
assist with posture
produce body heat
allow the body to move.

Abduction: Moving away from midline of the body

JOINTS MAJOR MUSCLES OF THE BODY
The joint (or articulation) is the place where two or more bones meet. Joints provide a variety of ranges of
motion (ROM) for the body parts and may be classified as fibrous, cartilaginous, or synovial
JOINT MOVEMENT

Adduction: Moving toward midline of the body

Circumduction: Circular motion
Inversion: Moving inward
Eversion: Moving outward
Extension: Straightening the extremity at the joint and increasing the angle of the joint
Hyperextension: Joint bends greater than 180 degrees
Flexion: Bending the extremity at the joint and decreasing the angle of the joint
Dorsiflexion: Toes draw upward to ankle
Plantar flexion: Toes point away from ankle
Pronation: Turning or facing downward
Supination: Turning or facing upward
Protraction: Moving forward
Retraction: Moving backward
Rotation: Turning of a bone on its own long axis
Internal Rotation: Turning of a bone toward the center of the body
External Rotation: Turning of a bone away from the center of the body
PREPARING THE CLIENT
1. Be sure the room is at a comfortable temperature and provide rest periods as necessary.
2. Provide adequate draping to avoid unnecessary exposure of the client yet adequate visualization
of the part being examined.
3. Explain that you will ask the client frequently to change positions and to move various body parts
against resistance and gravity.
4. Clear, simple directions need to be given throughout the examination to help the client
understand how to move body parts to allow you to assess the musculoskeletal system.
5. Demonstrating to the client how to move the various body parts and providing verbal directions
facilitate examination.
6. Some positions required for this examination may be very uncomfortable for the older client, who
may have decreased flexibility. Be sensitive to the client’s needs and adapt your technique as
necessary.

EQUIPMENT
• Tape measure
• Goniometer (optional)
• Skin marking pencil (optional)
PHYSICAL ASSESSMENT
• Observe gait and posture.
• Inspect joints, muscles, and extremities for size, symmetry, and color.
• Palpate joints, muscles, and extremities for tenderness, edema, heat, nodules, or crepitus.
• Test muscle strength and ROM of joints.
• Compare bilateral findings of joints and muscles.
• Perform special tests for carpal tunnel syndrome.
• Perform the “bulge,” “ballottement,” and McMurray’s knee tests.

ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS

PROCEDURE
GAIT
Inspection Evenly distributed weight. Client Uneven weight bearing is evident.
Observe gait. Observe the client’s able to stand on heels and toes. Client cannot stand on heels or
gait as the client enters and walks Toes point straight ahead. Equal on toes. Toes point in or out. Client
around the room. Note • Base of both sides. Posture erect, limps, shuffles, propels forward, or
support movements coordinated and has wide-based gait. (See Chapter
• Weight-bearing stability rhythmic, arms swing in opposition, 27, Nervous System, for specific
• Foot position stride length appropriate. abnormal gait findings.)
• Stride and length and cadence of
stride
• Arm swing
• Posture
Client does not fall backward. Falling backward easily is seen with
Assess for the risk of falling Some older clients have an cervical spondylosis and
backward in the older or impaired sense of position in space, Parkinson’s disease
handicapped client by performing which may contribute to the risks of
the “nudge test.” Stand behind the falling.
client and put your arms around the
client while you gently nudge the
sternum.
TEMPOROMANDIBULAR JOINT (TMJ)
Inspection and Palpation Jaw moves laterally 1 to 2 cm. Decreased ROM, swelling,
Inspect and palpate the TMJ. Have Snapping and clicking may be felt tenderness, or crepitus may be
the client sit; put your index and and heard in the normal client. seen in arthritis.
middle fingers just anterior to the
external ear opening (Fig. 26-4).
Ask the client to Mouth opens 1 to 2 inches
• Open the mouth as widely as (distance between upper and lower Decreased muscle strength with
possible. (The tips of your fingers teeth). muscle and joint disease. ROM, and
should drop into the joint spaces as a clicking, popping, or grating
the mouth opens.) Jaw protrudes and retracts easily. sound may be noted with TMJ
• Move the jaw from side to side. The client’s mouth opens and dysfunction.
• Protrude (push out) and retract closes smoothly.
(pull in) jaw.

Test range of motion (ROM). Ask Jaw has full ROM against resistance. Lack of full contraction with cranial
the client to open the mouth and Contraction palpated with no pain nerve V lesion. Pain or spasms
move the jaw laterally against or spasms occur with myofacial pain
resistance. Next as the client syndrome.
clenches the teeth, feel for the
contraction of the temporal and
masseter muscles to test the
integrity of cranial nerve V
(trigeminal nerve).
STERNOCLAVICULAR JOINT
Inspection and Palpation There is no visible bony Swollen, red, or enlarged joint or
With client sitting, inspect the overgrowth, swelling, or redness; tender, painful joint is seen with
sternoclavicular joint for location in joint is nontender inflammation of the joint.
midline, color, swelling, and
masses. Then palpate for
tenderness or pain
 CERVICAL, THORACIC, LUMBAR SPINE
Inspection and Palpation Cervical and lumbar spines are A flattened lumbar curvature may
Observe the cervical, thoracic, and concave; thoracic spine is convex. be seen with a herniated lumbar
lumbar curves from the side then Spine is straight (when observed disc or ankylosing spondylitis.
from behind. Have the client from behind). Lateral curvature of the thoracic
standing erect with the gown spine with an increase in the
positioned to allow an adequate An exaggerated thoracic curve convexity on the curved side is
view of the spine (Fig. 26-5). (kyphosis) is common with aging. seen in scoliosis. An exaggerated
Observe for symmetry, noting lumbar curve (lordosis) is often
differences in height of the seen in pregnancy or obesity
shoulders, the iliac crests and the (Abnormal Findings 26-1). Unequal
buttock creases. heights of the hips suggests
unequal leg lengths.

Nontender spinous processes;

Palpate the spinous processes and welldeveloped, firm and smooth,
the paravertebral muscles on both nontender paravertebral muscles. Compression fractures and
sides of the spine for tenderness or No muscle spasm. lumbosacral muscle strain can
pain. cause pain and tenderness of the
Flexion of the cervical spine is 45 spinal processes and the
degrees. Extension of the cervical paravertebral muscles.
Test ROM of the cervical spine. Test spine is 45 degrees.
ROM of the cervical spine by asking Cervical strain is the most common
the client to touch the chin to the cause of neck pain. It is
chest (flexion) and to look up at the characterized by impaired ROM and
ceiling (hyperextension) (Fig. 26-6). neck pain from abnormalities of the
soft tissue (muscles, ligaments, and
nerves) due to straining or injuring
the neck. Causes of strains can
include sleeping in the wrong
position, carrying a heavy suitcase,
or being in an automobile crash.

Cervical disc degenerative disease

and spinal cord tumors are
associated with impaired ROM and
pain that radiates to the back,
shoulder, or arms. Neck pain with a
loss of sensation in the legs may
occur with cervical spinal cord
compression.

Normally the client can bend 40 Impaired ROM and neck pain
Next test lateral bending. Ask the degrees to the left and 40 degrees associated with fever, chills, and
client to touch each ear to the to the right sides. headache could be indicative of a
shoulder on that side (Fig. 26-7). serious infection such as
meningitis.
Evaluate rotation. Ask the client to About 70 degrees of rotation is
turn head to right and left (Fig. 26- normal.
8).

Ask the client to repeat the cervical Client has full ROM against
ROM movements against resistance.
resistance.

Test ROM of the thoracic and Flexion of 75 degrees to 90

lumbar spine. Ask the client to bend degrees, smooth movement, Decreased ROM against resistance
forward and touch the toes (flexion) lumbar concavity flattens out and is seen with joint or muscle disease.
(Fig. 26-9). Observe for symmetry the spinal processes are in
of the shoulders, scapula, and hips. alignment. Lateral curvature disappears in
functional scoliosis; unilateral
Sit down behind the client, stabilize exaggerated thoracic convexity
the client’s pelvis with your hands, increases in structural scoliosis.
and ask the client to bend sideways Lateral bending capacity of the Spinal processes are out of
(lateral bending), bend backward thoracic and lumbar should be alignment.
toward you (hyperextension), and about 35 degrees (Fig. 26-10A);
twist the shoulders one way then hyperextension about 30 degrees;
the other (rotation). and rotation about 30 degrees (Fig. Low back strain from injury to soft
26-10B). tissues is a common cause of
impaired ROM and pain in the
lumbar and thoracic regions. Other
causes of impaired ROM in the
lumbar and thoracic areas include
osteoarthritis, ankylosing
spondylitis, and congenital
abnormalities that may affect the
spinal vertebral spacing and
mobility.

Test for back and leg pain. If the

client has low back pain that
radiates down the back, perform
Lasègue’s test (straight leg raising) Pain not reproduced. Patient is able
to check a herniated nucleus to raise leg to 90 degree angle. Mild
pulposus. Ask the client to lie flat pain of the hamstring is a common
and raise each relaxed leg finding and does not indicate sciatic
independently to the point of pain. pain.
At the point of pain, dorsiflex the Pain is reproduced. Pain that shoots
client’s foot (Fig. 26-11). Note the and radiates down one or both legs
degree of elevation when pain (sciatica) below the knees may be
occurs, the distribution and due to a herniated intervertebral
character of the pain, and the disc. Continuous, aching pain at
results from dorsiflexion of the foot. night not relieved by rest may be
from metastases. Lower back pain
Measure leg length. If you suspect with tenderness and limited ROM is
that the client has one leg longer Measurements are equal or within 1 common in osteoporosis.
than the other, measure them. Ask cm. If the legs still look unequal,
the client to lie down with legs assess the apparent leg length by
extended. With a tape, measure the measuring from a nonfixed point
distance between the anterior (the umbilicus) to a fixed point
superior iliac spine and the medial (medial malleolus) on each leg. Unequal leg lengths are associated
malleolus, crossing the tape on the with scoliosis. Equal true leg
medial side of the knee (true leg lengths but unequal apparent leg
length) (Fig. 26-12). lengths are seen with abnormalities
in the structure or position of the
hips and pelvis.

SHOULDERS, ARMS AND ELBOWS

Inspection and Palpation Shoulders are symmetrically round, Flat, hollow, or less rounded
Inspect and palpate shoulders and no redness, swelling, or deformity shoulders are seen with dislocation.
arms. With the client standing or or heat. Muscles are fully Muscle atrophy is seen with nerve
sitting, inspect anteriorly and developed. Clavicles and scapulae or muscle damage or lack of use.
posteriorly symmetry, color, are even and symmetric. The client Tenderness, swelling, and heat may
swelling, and masses. reports no tenderness. be noted with shoulder strains,
sprains, arthritis, bursitis, and
Palpate for tenderness, swelling, or degenerative joint disease.
heat. Anteriorly palpate the
clavicle, acromioclavicular joint, sub
acromial area, and the biceps.
Posteriorly palpate the
glenohumeral joint, coracoid area,
trapezius muscle, and the scapular
area. Extent of forward flexion should be
180 degrees; hyperextension, 50 Painful and limited abduction
Test ROM. Explain to the client that degrees; adduction, 50 degrees; accompanied by muscle weakness
you will be assessing his range of and abduction 180 degrees. and atrophy are seen with a rotator
motion (consisting of flexion, cuff tear. Client has sharp catches
extension, adduction, abduction, of pain when bringing hands
and motion against resistance). Ask overhead when he or she has
client to stand with both arms rotator cuff tendinitis. Chronic pain
straight down at sides. Next ask and severe limitation of all shoulder
him to move the arms forward motions are seen with calcified
(flexion), then backward with tendinitis.
elbows straight (Fig. 26-13).

Then have the client bring both

hands together overhead, elbows
straight, followed by moving both
hands in front of the body past the Extent of external and internal
midline with elbows straight (this rotation should be about 90
tests adduction and abduction) (Fig. degrees, respectively.
26-14). Inability to shrug shoulders against
The client can flex, extend, adduct, resistance is seen with a lesion of
In a continuous motion, have the abduct, rotate, and shrug shoulders cranial nerve XI (spinal accessory).
client bring the hands together against resistance. Decreased muscle strength is seen
behind the head with elbows flexed with muscle or joint disease.
(this tests external rotation) (Fig.
26-15A) and behind the back
(internal rotation) (Fig. 26-15B).
Repeat these maneuvers against
resistance.

ELBOWS
Inspection and Palpation Elbows are symmetric without Redness, heat, and swelling may be
Inspect for size, shape, deformities, deformities, redness, or swelling. seen with bursitis of the olecranon
redness, or swelling. Inspect elbows process due to trauma or arthritis.
in both flexed and extended
positions.
Nontender; without nodules. Firm, nontender, subcutaneous
With the elbow relaxed and flexed nodules may be palpated in
about 70 degrees, use your thumb rheumatoid arthritis or rheumatic
and middle fingers to palpate the fever. Tenderness or pain over the
olecranon process and epicondyles epicondyles may be palpated in
epicondylitis (tennis elbow) due to
repetitive movements of the
Normal ranges of motion are 160 forearm or wrists.
Test ROM. Ask the client to perform degrees of flexion; 180 degrees of
the following movements to test extension. 90 degrees of pronation. Decreased ROM against resistance
ROM, flexion, extension, pronation, 90 degrees of supination. Some is seen with joint or muscle disease
and supination. clients may lack 5 to 10 degrees or or injury.
have hyperextension.
Flex the elbow and bring the hand
to the forehead (Fig. 26-16A). The client should have full ROM
against resistance
Straighten the elbow.

Then hold arm out, turn the palm

down, then turn the palm up (Fig.
26-16B). Last have the client repeat
the movements against your
resistance.
WRIST

Inspection and Palpation Inspect Wrists are symmetric without Swelling is seen with rheumatoid
wrist size, shape, symmetry, color, redness, or swelling. They are arthritis. Tenderness and nodules
and swelling. Then palpate for nontender and free of nodules. may be seen with rheumatoid
tenderness and nodules (Fig. 26- arthritis. A nontender, round,
17). enlarged, swollen, fluidfilled cyst
(ganglion) may be noted on the
wrists (Abnormal Findings 26-2).
 No tenderness palpated in
Palpate the anatomic snuffbox (the anatomic snuffbox. Snuffbox tenderness may indicate a
hollow area on the back of the wrist scaphoid fracture, which is often
at the base of the fully extended the result of falling on an
thumb) (Fig. 26-18). Normal ranges of motion are 90 outstretched hand.
degrees, flexion; 70 degrees,
Test ROM. Ask the client to bend hyperextension; 55 degrees, ulnar Ulnar deviation of the wrist and
wrist down and back (flexion and deviation; and 20 degrees, radial fingers with limited ROM is often
extension) (Fig. 26-19A). Next have deviation. Client should have full seen in rheumatoid arthritis.
the client hold the wrist straight ROM against resistance.
and move the hand outward and Increased pain with extension of
inward (deviation) (Fig. 26-19B). the wrist against resistance is seen
Repeat these maneuvers against in epicondylitis of the lateral side of
resistance. the elbow. Increased pain with
flexion of the wrist against
resistance is seen in epicondylitis of
the medial side of the elbow.
Decreased muscle strength is noted
with muscle and joint disease.
Test for carpal tunnel syndrome. No tingling, numbness, or pain After either test, client may report
Perform Phalen’s test. Ask the result from Phalen’s test or from tingling, numbness, and pain with
client to place the backs of both Tinel’s test. carpal tunnel syndrome.
hands against each other while
flexing the wrists 90 degrees Median nerve entrapped in the
downward (Fig. 26-20A). Have the carpal tunnel results in pain,
client hold this position for 60 numbness, and impaired function of
seconds. the hand and fingers (Fig. 26-21).

Optionally test for Tinel’s sign. With

your finger, percuss lightly over the
median nerve (located on the inner
aspect of the wrist) (Fig. 26-20B).

HANDS AND FINGERS

Inspection and Palpation Inspect Hands and fingers are symmetric, Swollen, stiff, tender finger joints
size, shape, symmetry, swelling, nontender, and without nodules. are seen in acute rheumatoid
and color. Palpate the fingers from Fingers lie in straight line. No arthritis. Boutonnière deformity and
the distal end proximally, noting swelling or deformities. Rounded swan-neck deformity are seen in
tenderness, swelling, boney protuberance noted next to the long-term rheumatoid arthritis (see
prominences, nodules or crepitus of thumb over the thenar prominence. Abnormal Findings 26-2). Atrophy
each interphalangeal joint. Assess Smaller protuberance seen of the thenar prominence may be
the metacarpophalangeal joints by adjacent to the small finger. evident in carpal tunnel syndrome.
squeezing the hand from each side
between your thumb and fingers. In osteoarthritis, hard, painless
Palpate each metacarpal of the nodules may be seen over the
hand, noting tenderness and distal interphalangeal joints
swelling (Heberden’s nodes) and over the
proximal interphalangeal joints
(Bouchard’s nodes) (see Abnormal
Normal ranges are 20 degrees of Findings 26-2)
abduction, full adduction of fingers
Test ROM (Fig. 26-22). Ask the (touching), 90 degrees of flexion, Inability to extend the ring and little
client to (A) spread the fingers and 30 degrees of hyperextension. fingers is seen in Dupuytren’s
apart (abduction), (B) make a fist The thumb should easily move contracture. Painful extension of a
(adduction), (C) bend the fingers away from other fingers and 50 finger may be seen in tenosynovitis
down (flexion) and then up degrees of thumb flexion is normal. (infection of the flexor tendon
(hyperextension), (D) move the sheathes; see Abnormal Findings
thumb away from other fingers and The client normally has full ROM 26-2). Decreased muscle strength
then (E) touch the thumb to the against resistance against resistance is associated
base of the small finger. Repeat with muscle and joint disease.
these maneuvers against
resistance.

HIPS
Inspection and Palpation With the Buttocks are equally sized; iliac Instability, inability to stand, and/or
client standing, inspect symmetry crests are symmetric in height. Hips a deformed hip area are indicative
and shape of hips (Fig. 26-23). are stable, nontender, and without of a fractured hip. Tenderness,
Palpate for stability, tenderness, crepitus. edema, decreased ROM, and
and crepitus. crepitus are seen in hip
inflammation and degenerative
joint disease.
Test ROM (Fig. 26-24). With the Normal ROM: 90 degrees of hip
client supine, ask the client to flexion with knee straight and 120 Inability to abduct hip is a common
degrees of hip flexion with the knee sign of hip disease.
Raise extended leg (A). bent and the other leg remaining
straight
Flex knee up to chest while keeping
other leg extended (B).
Move extended leg (C) away from Normal ROM: Pain and a decrease in internal hip
midline of body as far as possible 45 degrees to 50 degrees of rotation may be a sign of
and then toward midline of body as abduction; osteoarthritis or femoral neck stress
far as possible (abduction and 20 degrees to 30 degrees of fracture. Pain on palpation of the
adduction). adduction. greater trochanter and pain as the
client moves from standing to lying
Bend knee and turn leg (D) inward 40 degrees internal hip rotation, down may indicate bursitis of the
(rotation) and then outward 45 degrees external hip rotation. hip.
(rotation).
15 degrees hip hyperextension. Decreased muscle strength against
Ask the client to lie prone (E) and resistance is seen in muscle and
lift extended leg off table. Full ROM against resistance. joint disease.
Alternatively, ask the client to stand
and swing extended leg backward.

Repeat these maneuvers against

resistance.
KNEES
Inspection and Palpation With the Knees symmetric, hollows present Knees turn in with knock knees
client supine then sitting with knees on both sides of the patella, no (genu valgum) and turn out with
dangling, inspect for size, shape, swelling or deformities. Lower leg in bowed legs (genu varum). Swelling
symmetry, swelling, deformities, alignment with upper leg. above or next to the patella may
and alignment. Observe for indicate fluid in the knee joint or
quadricep muscle atrophy. thickening of the synovial
Some older clients may have a membrane.
Palpate for tenderness, warmth, bowlegged appearance because of
consistency, and nodules. Begin decreased muscle control. Tenderness and warmth with a
palpation 10 cm above the patella, boggy consistency may be
using your fingers and thumb to Nontender and cool. Muscles firm. symptoms of synovitis.
move downward toward the knee No nodules. Asymmetrical muscular
(Fig. 26-25). development in the quadriceps may
No bulge of fluid appears on medial indicate atrophy.
Tests for swelling. If you notice side of knee
swelling, perform the bulge test to Bulge of fluid appears on medial
determine if the swelling is due to side of knee with a small amount of
accumulation of fluid or soft tissue joint effusion
swelling. The bulge test helps to
detect small amounts of fluid in the
knee. With the client in a supine
position, use the ball of your hand
firmly to stroke the medial side of
the knee upward, three to four
times, to displace any accumulated
fluid (Fig. 26-26A). Then press on No movement of patella noted.
the lateral side of the knee and look Patella rests firmly over femur.
for a bulge on the medial side of
the knee (Fig. 26-26B).

Perform the ballottement test. It Fluid wave or click palpated with

helps to detect large amounts of large amounts of joint effusion. A
fluid in the knee. With the client in positive ballottement test may be
a supine position, firmly press your present with meniscal tears.
nondominant thumb and index
finger on each side of the patella.
This displaces fluid in the
suprapatellar bursa located
between the femur and patella.
Then with your dominant fingers,
push the patella down on the femur
(Fig. 26-27). Feel for a fluid wave or
a click.

Palpate the tibiofemoral space. As There is no pain on examination. A patellofemoral disorder may be
you compress the patella, slide it Crepitus may be present. suspected if both crepitus and pain
distally against the underlying are present on examination.
femur. Note crepitus or pain.

Test ROM (Fig. 26-28). Ask the Normal ranges: 120 degrees to 130 Osteoarthritis is characterized by a
client to degrees of flexion; 0 degrees of decreased ROM with synovial
• Bend each knee up (flexion) extension to 15 degrees of thickening and crepitation. Flexion
toward buttocks or back. hyperextension. contractures of the knee are
• Straighten knee characterized by an inability to
(extension/hyperextension). extend knee fully.
• Walk normally.
Client should have full ROM against Decreased muscle strength against
Repeat these maneuvers against resistance. resistance is seen in muscle and
resistance. joint disease.

Pain or clicking is indicative of a

No pain or clicking noted. torn meniscus of the knee.

Test for pain and injury. If the client

complains of a “giving in” or
“locking” of the knee, perform
McMurray’s test (Fig. 26-29). With
the client in the supine position, ask
the client to flex one knee and hip.
Then place your thumb and index
finger of one hand on either side of
the knee. Use your other hand to
hold the heel of the foot up. Rotate
the lower leg and foot laterally.
Slowly extend the knee, noting pain
or clicking. Repeat, rotating lower
leg and foot medially. Again note
pain or clicking.

ANKLES AND FEET

Inspection and Palpation With the Toes usually point forward and lie A laterally deviated great toe with
client sitting, standing, and walking, flat; however, they may point in (pes possible overlapping of the second
inspect position, alignment, shape, varus) or point out (pes valgus). toe and possible formation of an
and skin. enlarged, painful, inflamed bursa
Toes and feet are in alignment with (bunion) on the medial side is seen
the lower leg. Smooth, rounded with hallux valgus. Common
medial malleolar prominences with abnormalities include feet with no
prominent heels and arches (pes planus or “flat feet”), feet
metatarsophalangeal joints. Skin is with high arches (pes cavus); painful
smooth and free of corns and thickening of the skin over bony
calluses. Longitudinal arch; most of prominences and at pressure points
weight bearing is on foot midline. (corns); nonpainful thickened skin
that occurs at pressure points
(calluses); and painful warts (verruca
vulgaris) that often occur under a
Palpate ankles and feet for callus (plantar warts; Abnormal
tenderness, heat, swelling, or nodules No pain, heat, swelling, or nodules Findings 26-3).
(Fig. 26-30). Palpate the toes from are noted
the distal end proximally, noting Tender, painful, reddened, hot, and
tenderness, swelling, boney swollen metatarsophalangeal joint of
prominences, nodules, or crepitus of the great toe is seen in gouty
each interphalangeal joint. Assess the arthritis. Nodules of the posterior
metatarsophalangeal joints by ankle may be palpated with
squeezing the foot from each side rheumatoid arthritis. Pain and
with your thumb and fingers. Palpate tenderness of the
each metatarsal, noting swelling or metatarsophalangeal joints are seen
tenderness. Palpate the plantar area in inflammation of the joints,
(bottom) of the foot noting pain or rheumatoid arthritis, and
swelling. degenerative joint disease.
Tenderness of the calcaneus of the
bottom of the foot may indicate
plantar fasciitis. Use the Ottawa ankle
and foot rules (Display 26-3) to
determine need for X-ray referral.

Test ROM (Fig. 26-31). Ask the Normal ranges: Decreased strength against
client to resistance is seen in muscle and
joint disease.

Point toes upward (dorsiflexion) and 20 degrees dorsiflexion of ankle

then downward (plantar flexion) and foot; 45 degrees plantar flexion Hyperextension of the
(A). of ankle and foot. metatarsophalangeal joint and
flexion of the proximal
Turn soles outward (eversion) and 20 degrees of eversion; 30 degrees interphalangeal joint is apparent in
then inward (inversion) (B). of inversion. hammer toe (see Abnormal
Findings 26-3).
Rotate foot outward (abduction)
and then inward (adduction) (C). 10 degrees of abduction; 20
degrees of adduction. Decreased strength against
Turn toes under foot (flexion) and resistance is common in muscle
then upward (extension). and joint disease.
40 degrees of flexion; 40 degrees of
Repeat these maneuvers against extension.
resistance

Client has full ROM against

resistance.
 CALAMBA DOCTORS’ COLLEGE
Virborough Subdivision, Parian, Calamba City, Laguna

Performance Evaluation Checklist

Name: ________________________
Date:_______________
Year and Section: _______________

PERFORMING ASSESSMENT OF THE MUSCULO-SKELETAL SYSTEM

INSTRUCTION: Rate the nursing skill performance of the student based as follows: 5 = Perfect
(91-100) 4 = Very Satisfactory (85-90) 3 = Satisfactory (80-84) 2 = Poor (79-75) 1 = Need Improvement
(74 and below)

ASSESSMENT 5 4 3 2 1 Comments
1. Gather equipment.
2. Explain procedure to client.
3. Ask client to gown.
PROCEDURE 5 4 3 2 1
GAIT
1. Observe gait for base, weight-bearing
stability, feet position, stride, arm swing,
and posture.
TEMPOROMANDIBULAR JOINT
1. Inspect, palpate, and test ROM.
STERNOCLAVICULAR JOINT
1. Inspect and palpate for midline location,
color, swelling, and masses.
SPINE
1. Inspect and palpate cervical, thoracic, and
lumbar spine for pain and tenderness.
2. Test ROM of cervical spine.
3. Test ROM of thoracic and lumbar spine.
4. Test for leg and back pain.
5. Measure leg length.
SHOULDERS
1. Inspect and palpate shoulders for
symmetry, color, swelling, and masses.
2. Test ROM of shoulders.
ELBOWS
1. Inspect and palpate elbows for size, shape,
deformities, redness, or swelling.
2. Test ROM of elbows.
WRISTS
1. Inspect and palpate wrists for size, shape,
sim color, swelling, tenderness, and
nodules
2. Test ROM of wrists.
3. Test for carpal tunnel syndrome
HANDS & FINGERS
1. Inspect and palpate hands and fingers fro
size. symmetry, swelling, color, tenderness,
and knock
2. Test ROM of hands and fingers
 HIPS
1. Inspect and palpate hips for shape and
symmetry.
2. Test ROM of hips.
KNEES
1. Inspect and palpate knees for size, shape,
symmetry, deformities, pain, and
alignment.
2. Test knees for swelling. If small amount of
fluid present, do "bulge test." If large
amount of fluid present, do "ballottement
test.
3. Test ROM of knees.
4. Perform McMurray's test if client complains
of "clicking" in knee.
ANKLES AND FEET
1. Inspect and palpate ankles and feet for
position, alignment, shape, skin,
tenderness, temperature, swelling, or
nodules.
2. Test ROM of ankles and toes.
TOTAL RATING

STUDENT SIGNATURE: __________________________

CLINICAL INSTRUCTORS SIGNATURE: ____________