Musculoskeletal

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, antiinflammatory) 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

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II.

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

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

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 OF

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: 1 = 2 = 3 = 4 = 5 =

0 = no evidence of movement trace movement FROM, but not against gravity (passive movement) FROM against gravity but not against resistance FROM against gravity and some resistance, but weak 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. positions

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

- 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

ANKLES – inspect while pt is bearing wt and while sitting - ankle landmarks include medial and lateral malleolus and Achilles

AND

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. ligaments

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

- 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