BIOE221. Session 11. Musculoskeletal System. Bioscience Department. Endeavour College of Natural Health endeavour.edu.au

Transcription

1 BIOE221 Session 11 Musculoskeletal System Bioscience Department

2 Session Objectives o Review the major structures and functions of the musculoskeletal system system in order to be able to assess its motor functions o Identify the common symptoms relating to musculoskeletal disorders o Demonstrate examination of the musculoskeletal system by use of various techniques o Recognise abnormal findings with these techniques

3 Musculoskeletal System o Functions Support to stand erect Movement To encase and protect inner vital organs To produce red blood cells in the bone marrow As a reservoir for storage of essential minerals e.g. calcium, phosphorus

4 o Nonsynovial joints Joints bones united by fibrous tissue or cartilage immovable e.g. sutures in the skull slightly moveable e.g. vertebrae o Synovial joints freely movable - bones separated from each other enclosed in a joint cavity/ cavity filled with synovial fluid

5 Joints Synovial Joints: Commonly affected by inflammatory conditions such as arthritis Non-synovial Cartilaginous Joints Commonly affected by injury or trauma (Jarvis, 2016, p.577 & 580)

6 o 3 types of muscle Muscles Skeletal (striated and voluntary) Smooth (non-striated and involuntary) Cardiac (striated and involuntary) (The primary focus of this lecture will be on skeletal muscle) o Tendons attach muscle to bone (origin and insertion) o Ligaments attach bone to bone (to form joints) o Prime mover (agonist) The muscle that flex s (contracts) to produce movement o Antagonist The opposing muscle to the prime mover that relaxes (extends)

7 Case History Questions o Joints pain/ stiffness/ limitation of movement swelling/ heat/ redness/ sprains o Muscles Pain (cramps) Weakness/ atrophy o Bones Pain/ deformity Trauma (fractures/ dislocations) o Functional assessment (ADLs) o Self care behaviours Occupational hazards/ exercise/ weight/ medications

8 Order of Examination o Head to toe/ proximal to distal Inspection Palpation Range of Motion active passive Muscle Testing active resisted

9 Preparation for Examination o Screening Musculoskeletal (M/S) exam (General) Inspection and palpation of joints in each body region Observation of ROM o Complete M/S exam (Specific to affected joint) If person has articular (joint) disease History of M/S symptoms Problems with ADLs Drape for full visualisation of area being examined o Compare Bilaterally Expect symmetry of structure and function/ ROM

10 Gait It is important to assess gait in all persons who present with back, hip or lower limb complaints. Need to differentiate between a neurological gait and an antalgic gait. Antalgic Gait: Gait that is altered due to pain and/or may be associated with reduced range of motion.

11 Joint Examination - Inspection o Note size, contour of the joint o Inspect the skin & tissues over the joints for colour, swelling, any masses or deformity Swelling may be due to Excess joint fluid (effusion) Thickening of the synovial lining Inflammation of surrounding soft tissue Bony enlargement Deformities include Dislocation Subluxation (partial dislocation) Contracture (shortening of muscle / limited ROM of joint) Ankylosis (stiffness or fixation of a joint)

12 Joint Examination - Palpation o Palpate each joint for Temperature Muscles Bony articulations Area of the joint capsule o Note Heat Tenderness Try to localise to structure Swelling Palpable fluid abnormal Masses

13 Range of Motion (ROM) o Perform active ROM, in the direction of the prime mover first. You may stabilize the area proximal to that being moved if necessary o If any limitation or increase in ROM Gently attempt passive ROM Normal active & passive ROM should be similar o Note Tenderness/ pain Crepitation audible/ palpable crunching/ grating on movement

14 Muscle Testing o Muscle strength Test using active resisted ROM in the direction of the prime mover 5 Full ROM against gravity, full resistance 100% 4 Full ROM against gravity, some resistance 75% 3 Full ROM with gravity (no resistance) 50% 2 Full ROM with gravity eliminated (Passive ROM) 1 Slight contraction (slight voluntary movement) 25% 10% 0 No contraction (no voluntary movement) 0% (Adapted from: Jarvis, 2016, p.590)

15 Musculoskeletal Pain o Joint Pain and loss of function are the most common M/S symptoms (assess pain according to session 1) o Rheumatoid arthritis (RA) usually affects symmetric synovial joints causing chronic inflammation and pain interspersed with acute flare ups. Pain is usually worse in the morning o Osteo-arthritis (OA) can be unilateral or affect multiple joints causing chronic inflammation and pain. Pain is usually worse at the end of the day or following rigorous activity.

16 Musculoskeletal Pain Muscle pain o Usually felt as cramping or aching o Viral illness often includes myalgia o Weakness may involve M/S or nervous systems Bone pain o Fractures cause sharp pain that increases with movement o Other bone pain is described as dull or deep and is unrelated to movement

17 o Flexion o Extension o Abduction o Adduction Synovial Joint Movements bending a limb at a joint straightening a limb at a joint moving a limb away from the midline of the body moving a limb towards the midline of the body o Circumduction moving the distal end of a body part in a circle. Not routinely a part of clinical assessment (Functional) o Pronation o Supination turning the forearm so the palm is down. turning the forearm so that the palm is up

18 Synovial Joint Movements o Inversion moving the sole of the foot inward at the ankle o Eversion moving the sole of the foot outward at the ankle o Rotation moving the head around a central axis o Protraction moving a body part forward and parallel tot he ground o Retraction moving a body part backward and parallel to the ground o Elevation upward movement of a body part o Depression lowering a body part

19 Joint Movements (Jarvis, 2016, p.578)

20 Temporomandibular Joint Normal ROM Open/ close mouth Normal space between upper & lower teeth 3 fingers inserted sideways Lateral motion 1-2cm Protraction without deviation Abnormal Swelling - looks like a round bulge over the joint, although it must be marked to be visible Crepitus and pain occur with TMJ dysfunction Lateral motion may be lost earlier and more significantly than vertical

21 Temporomandibular Joint (Jarvis, 2016, p.579)

22 Temporomandibular Joint (Jarvis, 2008)

23 Temporomandibular Joint (Tortora & Derrickson, 2005)

24 Spine o 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused) and 3-4 coccygeal vertebrae (fused) o Posterior View Vertical alignment of the spine from the atlantooccipital point, through C7 (Vertebra prominens) to the gluteal cleft. Shoulder elevation and scapula should be symmetric Iliac crests should be horizontally aligned o Lateral view has 4 curves cervical and lumbar Lordotic curve thoracic and saccrococcygeal - Kyphotic curve

25 Cervical Spine Range of Motion (Jarvis, 2012)

26 Lumbar Spine Range of Motion (Jarvis, 2016, p )

27 Abnormal findings of Spine Head tilted to one side Asymmetry of muscles Tenderness/ hypertonic muscles with muscle spasm Limited ROM Pain with movement The person cannot hold the movement against resistance o Kyphosis pronounced thoracic curve o Lordosis pronounced lumbar curve o Scoliosis lateral curvature of the spine

28 Scoliosis (Jarvis, 2012)

29 Straight Leg Raise Test o These manoeuvres reproduce back and leg pain and help confirm the presence of a herniated disk o Straight leg raising while keeping the knee extended normally produces no pain o Raise the affected leg just short of point where it produces pain, then dorsiflex the foot The test is positive if it reproduces sciatic pain (Jarvis, 2016, p.609)

30 Shoulder Joint (Tortora & Derrickson, 2012)

31 Shoulder Joint o Glenohumeral joint articulation of humerus with glenoid fossa of scapula o Rotator cuff 4 powerful muscles and tendons that support and stabilize joint Abnormal findings o Limited ROM o Asymmetry of bony landmarks/ muscle mass o Pain +/- crepitus with motion o Rotator cuff lesions may cause limited ROM/ pain/ muscle spasm during abduction forward flexion stays fairly normal o Swelling from excess fluid best seen anteriorly swelling of the subacromial bursa is localized under the deltoid muscle and may be accentuated when the person tries to abduct the arm.

32 Shoulder Joint Range of Motion (Jarvis, 2016, p )

33 Elbow Joint Three bony articulations occur at the elbow joint involving the: Humerus Radius Ulna Formation of a hinge joint allows flexion and extension. Formation of a pivot joint allows pronation and supination. (Tortora & Derrickson, 2009)

34 Elbow Joint When testing the ROM of the elbow it is important to isolate the movement to the elbow joint. For flexion and extension be sure to keep the shoulder still For pronation and supination have the elbow bent at 90 o to isolate the radioulnar joint. (Jarvis, 2016, p.595)

35 Elbow Abnormal Findings o Subluxation of the elbow shows the forearm dislocated posteriorly o Swelling and redness over olecranon olecranon bursitis o A bulge or fullness in groove on either side of the olecranon process synovial thickening due to gouty arthritis o Epicondyles, head of radius, and tendons are common sites of inflammation and local tenderness tennis elbow/ golfers elbow (medial/lateral epichondylitis) o Soft, boggy or fluctuate swelling in both grooves synovial thickening or effusion o Subcutaneous nodules occur with RA raised firm, non tender nodules, overlying skin moves freely

36 Olecranon bursitis & rheumatoid nodule (Jarvis, 2008)

37 Wrist and Hand o Radiocarpal joint articulation of the radius and carpal bones o Movement in two planes at a right angles flexion and extension side to side deviation o The metacarpophalangeal and interphalangeal joints finger flexion and extension Abnormalities: o Ulnar deviation - fingers list to ulnar side o Ankylosis - wrist in extreme flexion o Dupuytren s contracture - flexion contracture of finger(s) o Swan-neck or Boutonniere deformity of fingers o Atrophy of thenar prominence o Heberden and Bouchard nodules occur at interphalangeal joints with OA hard/ non tender

38 Hand & Wrist Movements (Jarvis, 2016, p.598)

39 Special Upper Limb Movements (Tortora & Derrickson, 2009)

40 Wrist and Hand Special Test Phalen s Test o Ask the person to hold both hands back to back while flexing the wrists 90 o Normal = no symptoms with acute flexion of the wrist for 60 sec. o Induction of numbness and burning is suggestive of carpal tunnel syndrome. Carpal tunnel syndrome Compression of the median nerve within the carpal tunnel causing numbness, tingling and pain in the median nerve distribution (Kumar & Clark 2009, p.508)

41 Phalen s Test (Jarvis, 2008)

42 Ulnar Deviation Drift in Rheumatoid Arthritis (Jarvis, 2008)

43 Dupuytren s Contracture (Jarvis, 2008)

44 Hand joint changes (RA) (Jarvis, 2008)

45 OsteoArthritis - hand joint manifestations (Jarvis, 2008)

46 Sub Cutaneous Nodules (Jarvis, 2008)

47 Hip Joint (Tortora & Derrickson, 2009)

48 Hip Joint o The hip joint is the articulation between the acetabulum and the head of the femur ball and socket action permits a wide range of motion and weight bearing Abnormal Findings: o Pain with palpation o Crepitation o Pain with motion o Limited motion limited internal rotation of hip early & reliable sign of hip disease limited abduction of the hip while supine hip disease

49 Hip Range of Motion (Jarvis, 2008)

50 Knee Joint (Tortora & Derrickson, 2012)

51 Knee Joint o Knee joint: articulations of femur, tibia, patella hinge joint flexion and extension o Landmarks large quadriceps muscles tibial tuberosity bony protuberance in the midline of the tibia patella anteriorly lateral and medial condyles of the tibia

52 Knee Range of Motion (Jarvis, 2008)

53 Knee Abnormal Findings o Bulge Sign for swelling in the suprapatellar pouch presence of small amount of fluid o Irregular bony margins osteoarthritis o Pronounced crepitus degenerative disease of the knee o Contracture o Pain with motion/ limp o Sudden locking torn cartilage o Sudden buckling/ giving way ligament injury

54 Ankle and Foot o Tibiotalar joint articulation of tibia, fibula, and talus hinge joint flexion and extension o Two bony prominences, one on either side medial malleolus lateral malleolus Abnormal Findings: o Hallux valgus Lateral deviation of the great toe o Hammer toes/ claw toes o Swelling or inflammation o Calluses/ ulcers o Tenderness

55 Ankle Range of Motion (Jarvis, 2008)

56 Resources Jarvis, C. (2016). Physical Examination & Health Assessment (7 th ed.). Sydney: Elsevier. Tortora, G.J., & Derrickson, B. (2014) Principles of Anatomy & Physiology (14 th ed.). Hoboken, NJ: John Wiley & Sons. Kumar, P., & Clark, M. (2009). Clinical Medicine (7 th ed.). London: Saunders Elsevier.

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