MuscoSkeletal
создатель Toni Zappulla
1. Inspection
1.1. Inspection
1.2. Note size and contour of joint; inspect skin and tissues over joints for color, swelling, and any masses or deformity
1.3. Presence of swelling signals joint irritation. Use contralateral side for comparison.
1.4. Abnormal Findings: Pain, tenderness, crepitus, Swelling maybe excess joint fluid (effusion), Thickening of a synovial lining, inflammation of surrounding soft tissue(bursae or tendons), or bony enlargements. deformities include a fracture, or dislocation. Contractures which is a shortening of the muscle leading to limited range of motion of the joint. Or Ankylosis stiffening or fixation of a joint.
2. Palpation
2.1. Palpation
2.2. Palpate each joint, including skin for temperature, muscles, bony articulations, and area of joint capsule; notice any heat, tenderness, swelling, or masses which signal inflammation
2.3. Joints normally not tender to palpation
2.4. If tenderness occurs, localize to specific anatomic structures, for example, skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule. The synovial membrane is normally not palpable. When thickened, it feels Joey or baaghi. A small amount of fluid is present in the normal joint but it is not possible.
2.5. Abnormal: Warmness and tenderness signal inflammation. Palpable fluid is abnormal because fluid is contained in a closed sac, if you push one side of a sack and the fluid will shift and cause a visible bulging on another side this would be abnormal.
3. Range of Motion
3.1. Range of Motion (ROM)
3.2. Ask for active voluntary ROM while stabilizing the body area proximal to that being moved
3.3. Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations
3.4. For limitations, gently attempt passive motion; anchor joint with one hand while other hand slowly moves it to its limit; normal ranges of active and passive motion should be same
3.5. Joint motion normally causes no tenderness, pain, or crepitation
3.6. Do not confuse crepitation with normal discrete “crack” heard as tendon or ligament slips over bone during motion
3.7. Abnormal: Limited range of motion is the most sensitive sign of joint disease. The amount of limitation May alert you to the cause of the disease. Articular disease which is inside the joint capsule, as an example arthritis, produces swelling and tenderness around the whole joint and it limits all planes of range of motion in both active and passive range of motion. Articular disease which is injury to a specific tendon, ligament or nerve, produces the swelling and tenderness to that one spot in the joint that affects only certain planes of range of motion, especially during active voluntary motion.
4. Hand and Wrist
4.1. Inspect and Palpate, ROM
4.1.1. Testing for Carpal Tunnel
4.1.1.1. Phalen’s test
4.1.1.2. Ask person to hold both hands back to back while flexing wrists 90 degrees
4.1.1.2.1. Acute flexion of wrist for 60 seconds produces no symptoms in the normal hand
4.1.1.2.2. Test reproduces numbness and burning in person with carpal tunnel syndrome
4.1.1.3. Tinel’s Sign
4.1.1.4. Direct percussion of location of median nerve at wrist produces no symptoms in normal hand
4.1.1.4.1. Percussion of median nerve produces burning and tingling along its distribution, which is a positive Tinel’s sign for carpal tunnel syndrome
4.2. Abnormal: Pain, Redness, tenderness, swelling, ulnar deviation, Ankylosis, Contractures, deformity of fingers. ganglion cyst, nodules, Limited ROM.
5. Knee
5.1. Inspect, Palpate, ROM
5.1.1. Inspect lower leg alignment
5.1.2. Inspect knee’s shape and contour:
5.1.3. Check quadriceps muscle for any atrophy
5.1.4. Check ROM
5.1.5. Check muscle strength
5.2. Abnormal: Redness, swelling, inflammation, contracture, Atrophy, crepitus
6. Ankle and Foot
6.1. nspect while person is sitting, standing and walking
6.2. Compare both feet, noting contour of joints;
6.3. Test ROM
6.4. Assess muscle strength by dorsiflexion and plantar flexion against resistance
6.5. Abnormal: Pain, tenderness, swelling, crepitus. Hammertoe, callus, ulcers. Plantar fasciitis results in tenderness under heel where the fascia is torn. Limited range of motion, unable to hold flexion.
7. Rheumatoid Arthritis
7.1. RA is a chronic inflammatory pain condition that is possibly started by an autoimmune response. symptoms include fatigue, weakness, anorexia, weight loss, low grade fever. Worse in the morning, improves with activity.
7.2. Swan-neck and boutonniere deformities- flexion contracture resembles the curve swans neck. In boutonniere deformities- Knuckle looks as if it is being pushed in through a button hole. RA
7.3. Ulnar deviation or drift- Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance. RA
8. Abnormalities Affecting Multiple Joints
8.1. Atrophy-Loss of muscle mass, lack of fullness, rounding the deltoid muscle.
8.2. Dislocated shoulder- It occurs from trauma. Shows obvious deformity. Complete dislocation.
8.3. Joint effusion- Swelling from excess fluid in the joint capsule. RA
8.4. Tear of the rotator cuff- Characterized hunched position, and limited abduction, while arm is held in abduction or from fall on shoulder, throwing or heavy lifting.
8.5. Frozen shoulder, adhesive capsulitis- Fibrous tissue form in the joint Capsule, causing stiffness, Progressive limitation of motion, and pain especially unilateral, nocturnal pain. Limited motion in abduction and external rotation unable to reach overhead.
8.6. Abnormalities of Elbow
8.7. Olecranon bursitis- Large, soft knob or goose egg, and redness from swelling and inflammation of the olecranon bursa. Occurs with gout and rheumatoid arthritis
8.8. Epicondylitis, tennis elbow- Chronic, disabling pain at the lateral epicondyle of humerous, radiates down the forearm. Pain can be located in one finger. Occurs from overuse, excessive pronation or supination of the forearm examples: tennis, using a screwdriver.
8.9. Ganglion cyst- Round, cystic, non-tender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist. Fluid filled mass is more common in women ages 30 to 60. is it compresses the median or ulnar nerve it may cause numbness, tingling, or weakness.
8.10. Colles’ fracture- Non articular fracture of the distal radius, with or without fracture of the ulna at styloid process. usually from a fall on an outstretched hand occurs in older women. Wrist looks puffy with silver fork deformity, a characteristic hump when viewed from the side.
8.11. Carpal tunnel syndrome- Pain Along thumb and index and middle fingers and a trophy occur with interference with motor function from compression of the median nerve inside the carpal tunnel. caused by chronic repetitive motion, occurs between ages 40 to 60 more common in women. Symptoms of carpal tunnel include nighttime pain, burning and numbness, positive findings on the Phalen test and positive tinel's test.
8.12. Ankylosis-Wrist in extreme flexion with ruptures of wrist and finger extensors caused by severe rheumatoid arthritis.
8.13. Dupuytren’s contracture- Chronic hyperplasia of the Palmar fascia causes flexion contractures of the digits, first in the 4th digit, then the 5th digit, and then the 3rd digit. Common in men older than 40 and is usually bilateral. It occurs with diabetes, epilepsy, and alcoholic liver disease. Also from an inherited trait. The contraction is painless but impairs hand function.
9. Temporomandibular Joint (TMJ)
9.1. TMJ
9.1.1. Articulation of mandible and temporal bone
9.1.1.1. Can feel it in depression anterior to tragus of ear
9.1.1.1.1. TMJ permits jaw function of speaking and chewing
9.1.2. Allows three motions:
9.1.2.1. Gliding action for protrusion and retraction
9.1.2.2. Hinge action to open and close jaws
9.1.2.2.1. Gliding for side-to-side movement of lower jaw
9.1.3. Abnormal Findings
9.1.3.1. Swelling or bulging or over the joint. Crepitus. Malocclusion of the teeth may also cause crepitus. Tenderness to palpation. Decrease range of motion.
10. Movements
10.1. Skeletal muscles produce following movements:
10.2. Flexion: bending limb at joint
10.3. Extension: straightening limb at joint
10.4. Abduction: moving limb away from midline of body
10.5. Adduction: moving limb toward midline of body
10.6. Pronation: turning forearm so that palm is down
10.7. Supination: turning forearm so that palm is up
10.8. Circumduction: moving arm in circle around shoulder
10.9. Inversion: moving sole of foot inward at ankle
10.10. Eversion: moving sole of foot outward at ankle
10.11. Rotation: moving head around central axis
10.12. Protraction: moving body part forward, parallel to ground
10.13. Retraction: moving body part backward, parallel to ground
10.14. Elevation: raising a body part
10.15. Depression: lowering a body part
11. Muscle Testing
11.1. Against Gravity- means they can move the muscle on its own. Example: Kicking out of the knees.
11.2. Against Resistance- means they can move them against the force of the examiner. Example: Kicking out the knees while someone is holding them down, against resistance.
11.2.1. Grade 5: Full range of motion Against Gravity, full resistance = normal 100%
11.2.2. Grade 4: Full range of motion Against Gravity, some resistance=good 75%
11.2.3. Grade 3: Full range of motion with gravity.= 50 % fair
11.2.4. Grade 2: full range of motion with gravity eliminated passive motion = poor 25%
11.2.5. Grade 1: Slight contraction= trace 10%
11.2.6. Grade 0: No contraction = zero%
12. Spine
12.1. Abnormal: A difference in shoulder elevation and in level of scapula and iliac crest occurs with scoliosis.
12.1.1. Kyphosis
12.1.1.1. With age
12.1.1.1.1. Poor posture