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HEALTH HISTORY
Ask about past problems with sprains, strains, fractures, dislocations, arthritis, gout, backache, bursitis, osteomyelitis, scoliosis, or flat feet. Is there a family history of arthritis, gout, or muscular dystrophy? Are there current problems with muscle twitches, cramps, spasms, involuntary movements, pain, or weakness; muscle atrophy; joint pain, stiffness, swelling, redness, deformity, or limited movement; crepitation (noise or grating with joint movement); backache; spinal deformity; limitation in walking, gait, running, sports activities, or activities of daily living? Has the client had tests involving the musculoskeletal system such as skeletal radiographs or electromyography (results)? RISK FACTORS Lack of exercise Low Calcium intake Excessive caffeine or alcohol consumption Smoking Steroids Low Estrogen SKELETAL MUSCLE MOVEMENTS Abduction (^) Adduction Circumduction Inversion Eversion Extension Flexion Pronation Supination Protraction Retraction Rotation CLIENT PREPARATION Room should be comfortable and well-lighted Provide adequate draping Explain to the client that frequent position changes will be demonstrated Provide verbal directions and demonstrations as necessary PRINCIPLES TO REMEMBER (^) 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 GUIDELINES FOR ASSESSING JOINT AND MUSCLE STRENGTH Joints: Inspect size, shape, color, and symmetry. Note any masses, deformities, or muscle atrophy Palpate for edema, heat, tenderness, pain, nodules, or crepitus Test each joint’s ROM Muscles: (^) Test muscle strength Document muscle strength by using a standard scale If the client can’t move the parts against resistance, ask the client to move the part against gravity MUSCLE STRENGTH GRADING TABLE RATING EXPLANATION STRENGHT CLASSIFICATION 5 Active motion against full resistance Normal 4 Active motion against some resistance Slight weakness
3 Active motion against gravity Average weakness 2 Passive ROM (gravity removed and assisted by examiner) Poor ROM 1 Slight flicker of contraction Sever weakness 0 No muscular contraction Paralysis ASSESSMENT TECHNIQUES Assessment Outline: Gait Temporomandibular Joint (TMJ) Sternoclavicular Joint Cervical, Thoracic, and Lumbar Spine Shoulder, arms and elbows Wrists Hands and Fingers Hips Knees Ankles and Feet GAIT INSPECTION ASSESSMENT ABNORMAL FINDINGS Observe the gait, and note the following: Base of support Weight-bearing stability Foot position Stride and length and cadence of stride Arm swing Posture Uneven weight bearing; cannot stand on heels or toes; toes point in or out; limps, shuffles, propels forward, or has wide-based gait Perform the “ NUDGE TEST” for the elderly and the handicapped falling backward easily (cervical spondylosis; Parkinson’s disease) GAIT PROBLEMS Scissors gait Spastic lower limbs, and movement on stiff, jerky movements Knees are together and the legs cross in front of one another Parkinsonian Gait Shuffling gait, very stiff manner Stooped over posture with flexed hips and knees Steppage Gait Foot drop walk Flexes and raises the knee higher than usual Spastic Hemiparesis Flexed arm held close to body while client drags toe of leg TEMPOROMANDIBULAR JOINT (TMJ) INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS Have the client sit; put your index and middle fingers just anterior to the external ear opening. decreased ROM, swelling, tenderness, crepitus (arthritis) Ask the client to: Open the mouth as widely as possible Move the jaw from side to side Protrude and retract jaw decreased muscle strength & ROM, clicking, popping, or grating sound (TMJ dysfunction) Test ROM Lack of full contraction
(cervical disc degenerative dse.) Pain with loss of sensation in the legs (cervical spinal cord compression) impaired ROM and neck pain with fever, chills and headache (meningitis) TESTING THE THORACIC AND LUMBAR SPINE ROM ASSESSMENT ABNORMAL FINDINGS Flexion Lateral Bending Rotation Lateral curvature disappears (functional scoliosis); Unilateral exaggerated thoracic convexity increases (structural scoliosis) impaired ROM and pain (low back strain, osteoarthritis, congenital abnormalities) TESTING FOR BACK AND LEG PAIN ASSESSMENT ABNORMAL FINDINGS Lasegue’s Test -pain reproduced
- sciatica (herniated interverterbral disc)
- continuous pain, nor relieved by rest (metastases)
- low back pain, tenderness, limited ROM (osteoporosis) MEASURING LEG LENGTH ASSESSMENT ABNORMAL FINDINGS Measuring Leg length Unequal leg length (scoliosis) SHOULDERS AND ARMS INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS Inspect and palpate shoulders and arms Palpate for tenderness, flat, hollow, or less rounded shoulders (dislocation); muscle atrophy
swelling or heat (nerve/muscle damage, lack of use); tenderness, swelling, heat (strain, sprain, arthritis, bursitis, degenerative joint dse.) TESTING SHOULDER AND ARM ROM ASSESSMENT ABNORMAL FINDINGS Flexion - Extension Adduction - Abduction External - Internal Rotation painful, limited abduction with muscle weakness and atrophy (rotator cuff tear); sharp pain (tendinitis) Inability to shrug shoulders – CN XI lesion ELBOWS INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS Inspect for size, shape, deformities, redness, or swelling With the elbow relaxed and flexed about 70 degrees, use your thumb and middle fingers to palpate the olecranon process and epicondyles -Redness, heat and swelling (bursitis) -Firm, nontender subcutaneous nodules ; -Tenderness/pain over epicondyles TESTING ELBOW ROM ASSESSMENT ABNORMAL FINDINGS Flexion - Extension Pronation - Supination
- decreased ROM against resistance (joint/muscle disease, injury) WRISTS INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS Inspect wrist size, shape, symmetry, color, and swelling. Ganglion Osteoarthritis Then palpate for tenderness and nodules Tenderness (scaphoid fracture) PALPATING THE ANATOMIC SNUFFBOX TESTING WRIST ROM ASSESSMENT ABNORMAL FINDINGS Flexion - Hyperextension Radial - Ulnar Deviation -limited ROM on ulnar deviation (rheumatoid arthritis)
- increased pain (epicondylitis) TESTING FOR CARPAL TUNNEL SYNDROME ASSESSMENT ABNORMAL FINDINGS Phalen’s Test Tinel’s Test Tingling, numbness,pain (carpal tunnel syndrome) HANDS AND FINGERS INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS Inspect size, shape, symmetry, swelling, and color Palpate the fingers from the distal end proximally, noting tenderness, swelling, boney prominences, nodules or crepitus of each interphalangeal joint Assess the
ACUTE / CHRONIC
RHEUMATOID ARTHRITIS
Abduction - Adduction Internal and External Rotation Hyperextension -decreased muscle strength against resistance KNEES INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS With the client supine then sitting with knees dangling, inspect for size, shape, shape, symmetry, swelling, deformities, and alignment. Palpate for tenderness, warmth, consistency, and nodules. knock knees; bowed legs
- swelling above or next to patella (knee joint fluid, synovial membrane thickening)
- tenderness and warmth with boggy consistency (synovitis) ABNORMALITIES AFFECTING THE LEG AND KNEES Genu Varum (Bow- leggedness) Deformity in which one or both legs are bent outward at the knee Genu Valgum (Knock- Knees) A deformity in which the legs are curved inward, so that the knees are close together & strike each other as the person walks, & the ankles are widely separated. TESTS FOR KNEE SWELLING TEST FOR PAIN AND INJURY Abnormal Finding: Pain or clicking (torn knee meniscus) ANKLES AND FEET INSPECTION AND PALPATION ASSESSMENT ABNORMAL FINDINGS With the client sitting, standing, and walking, inspect the position, alignment, Acute Gouty Arthritis
shape, and skin Palpate ankles and feet for tenderness, heat, swelling, or nodules. Flat Feet (Pes Planus) Callus Hallux Valgus Corn Hammer Toe Plantar Wart (Verruca Vulgaris) TALIPES EQUINOVARUS (CLUBFOOT) TESTING ANKLE AND FEET ROM Abnormal Finding: hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint (hammer toe)
