NR 509 Week 3: The Musculoskeletal
System
Table of Contents
Note
For learning purposes in this course, the weekly lessons are divided by body systems
and focused on specific objective physical examination techniques. The lessons are
adjunct to the assigned reading and by no means a substitution. Therefore, it is
incumbent upon you to fully comprehend the associated subjective health
history, health promotion, and anatomy and physiology as outlined in each
textbook chapter. By the end of the course, you will be proficient with conducting a
complete physical examination.
Advanced Practice Assessment Techniques
Assessment of the musculoskeletal system involves evaluating for issues of the bones,
joints, skeletal muscles, ligaments and tendons, and cartilage throughout the body. As a
clinician, you need to be aware of the expected anatomy and physiology of each
structure within the musculoskeletal system, including the expected range of motion
(ROM) of each joint. When abnormalities or limitations are discovered on assessment,
diagnostic reasoning skills must be applied to determine how to best utilize the data.
Your examination should be systematic. Include inspection, palpation of bony structures
and related joint and soft tissue structures, assessment of range of motion, and special
maneuvers to test specific movements. Recall that the anatomical shape of each joint
determines its range of motion. There are two phases to range of motion: active (by the
patient) and passive (by the examiner). There are specific differences in approach to
assessment, as well as expected findings, across the lifespan. As you review the
required readings this week, be alert for special considerations that relate to special
patient populations.
Review the videos below which demonstrate examination of the entire musculoskeletal
systems and then practice your assessment skills. Continue to practice your skills until
you can comfortably repeat a return demonstration of the entire assessment.
The Hip Examination
The hip joint is deeply embedded in the pelvis and is notable for its strength, stability,
and wide range of motion. The stability of the hip joint, essential for weight bearing,
, arises from the deep fit of the head of the femur into the acetabulum, its strong fibrous
articular capsule, and the powerful muscles crossing the joint and inserting below the
femoral head, providing leverage for movement of the femur.
Often, the examiner must assist the patient with movements of the hip, so further detail
is provided below for flexion, abduction, adduction, and external and internal rotation.
Meta-analyses suggest that no single test discriminates specific hip pathology.
Flexion: With the patient supine, place your hand under the patient's lumbar spine.
Ask the patient to bend each knee in turn up to the chest and pull it firmly against the
abdomen. Note that the hip can flex further when the knee is flexed because the
hamstrings are relaxed. When the back touches your hand, indicating normal flattening
of the lumbar lordosis, further flexion must arise from the hip joint itself.
Extension: With the patient lying face down, extend the thigh toward you in a posterior
direction. Alternatively, carefully position the supine patient near the edge of the table
and extend the leg posteriorly.
Abduction: Stabilize the pelvis by pressing down on the opposite anterior - superior
iliac spine with one hand. With the other hand, grasp the ankle and abduct the
extended leg until you feel the iliac spine move. This movement marks the limit of hip
abduction.
Adduction: With the patient supine, stabilize the pelvis, hold one ankle, and move the
leg medially across the body and over the opposite extremity.
External and internal rotation: Flex the leg to 90° at hip and knee, stabilize the thigh
with one hand, grasp the ankle with the other, and swing the lower leg medially for
external rotation at the hip, and laterally for internal rotation. Although confusing at first,
it is the motion of the head of the femur in the acetabulum that identifies these
movements.
The Knee Examination
The knee joint is the largest joint in the body. It is a hinge joint involving three
bones: the femur, the tibia, and the patella (or knee cap), with three articular
surfaces, two between the femur and the tibia and one between the femur and
the patella. Note how the two rounded condyles of the femur rest on the relatively
flat tibial plateau. There is no inherent stability in the knee joint itself, making it
dependent on four ligaments to hold its articulating femur and tibia in place. This
feature, in addition to the lever action of the femur on the tibia and the lack of
padding from overlying fat or muscle, makes the knee highly vulnerable to injury.
Learn to examine "the seven structures of the knee": the medial and lateral
menisci, the LCL and MCL, the ACL and PCL, and the patellar tendon. The ACL
and PCL are not palpable but are tested by specific maneuvers. Palpation and
special maneuvers of these structures are especially helpful in primary care
diagnosis.
System
Table of Contents
Note
For learning purposes in this course, the weekly lessons are divided by body systems
and focused on specific objective physical examination techniques. The lessons are
adjunct to the assigned reading and by no means a substitution. Therefore, it is
incumbent upon you to fully comprehend the associated subjective health
history, health promotion, and anatomy and physiology as outlined in each
textbook chapter. By the end of the course, you will be proficient with conducting a
complete physical examination.
Advanced Practice Assessment Techniques
Assessment of the musculoskeletal system involves evaluating for issues of the bones,
joints, skeletal muscles, ligaments and tendons, and cartilage throughout the body. As a
clinician, you need to be aware of the expected anatomy and physiology of each
structure within the musculoskeletal system, including the expected range of motion
(ROM) of each joint. When abnormalities or limitations are discovered on assessment,
diagnostic reasoning skills must be applied to determine how to best utilize the data.
Your examination should be systematic. Include inspection, palpation of bony structures
and related joint and soft tissue structures, assessment of range of motion, and special
maneuvers to test specific movements. Recall that the anatomical shape of each joint
determines its range of motion. There are two phases to range of motion: active (by the
patient) and passive (by the examiner). There are specific differences in approach to
assessment, as well as expected findings, across the lifespan. As you review the
required readings this week, be alert for special considerations that relate to special
patient populations.
Review the videos below which demonstrate examination of the entire musculoskeletal
systems and then practice your assessment skills. Continue to practice your skills until
you can comfortably repeat a return demonstration of the entire assessment.
The Hip Examination
The hip joint is deeply embedded in the pelvis and is notable for its strength, stability,
and wide range of motion. The stability of the hip joint, essential for weight bearing,
, arises from the deep fit of the head of the femur into the acetabulum, its strong fibrous
articular capsule, and the powerful muscles crossing the joint and inserting below the
femoral head, providing leverage for movement of the femur.
Often, the examiner must assist the patient with movements of the hip, so further detail
is provided below for flexion, abduction, adduction, and external and internal rotation.
Meta-analyses suggest that no single test discriminates specific hip pathology.
Flexion: With the patient supine, place your hand under the patient's lumbar spine.
Ask the patient to bend each knee in turn up to the chest and pull it firmly against the
abdomen. Note that the hip can flex further when the knee is flexed because the
hamstrings are relaxed. When the back touches your hand, indicating normal flattening
of the lumbar lordosis, further flexion must arise from the hip joint itself.
Extension: With the patient lying face down, extend the thigh toward you in a posterior
direction. Alternatively, carefully position the supine patient near the edge of the table
and extend the leg posteriorly.
Abduction: Stabilize the pelvis by pressing down on the opposite anterior - superior
iliac spine with one hand. With the other hand, grasp the ankle and abduct the
extended leg until you feel the iliac spine move. This movement marks the limit of hip
abduction.
Adduction: With the patient supine, stabilize the pelvis, hold one ankle, and move the
leg medially across the body and over the opposite extremity.
External and internal rotation: Flex the leg to 90° at hip and knee, stabilize the thigh
with one hand, grasp the ankle with the other, and swing the lower leg medially for
external rotation at the hip, and laterally for internal rotation. Although confusing at first,
it is the motion of the head of the femur in the acetabulum that identifies these
movements.
The Knee Examination
The knee joint is the largest joint in the body. It is a hinge joint involving three
bones: the femur, the tibia, and the patella (or knee cap), with three articular
surfaces, two between the femur and the tibia and one between the femur and
the patella. Note how the two rounded condyles of the femur rest on the relatively
flat tibial plateau. There is no inherent stability in the knee joint itself, making it
dependent on four ligaments to hold its articulating femur and tibia in place. This
feature, in addition to the lever action of the femur on the tibia and the lack of
padding from overlying fat or muscle, makes the knee highly vulnerable to injury.
Learn to examine "the seven structures of the knee": the medial and lateral
menisci, the LCL and MCL, the ACL and PCL, and the patellar tendon. The ACL
and PCL are not palpable but are tested by specific maneuvers. Palpation and
special maneuvers of these structures are especially helpful in primary care
diagnosis.
