• Any problems with your joints? Any pain?

 • Location: Which joints? On one side or both sides?

• Quality: What does the pain feel like: aching, stiff, sharp or dull, shooting? Severity: How strong is the pain?

 • Onset: When did this pain start?

• Timing: What time of day does the pain occur? How long does it last? How often does it occur?

• Is the pain aggravated by movement, rest, position, weather? Is the pain relieved by rest, medications, application of heat or ice?

• Is the pain associated with chills, fever, recent sore throat, trauma, repetitive activity?

• Any stiffness in your joints?

• Any swelling, heat, redness in the joints?

• Any limitation of movement in any joint? Which joint?

 • Which activities give you problems? (See Functional Assessment below and on p. 605.)

Joint pain and loss of function are the most common musculoskeletal concerns that prompt a person to seek care.

Rheumatoid arthritis (RA) involves symmetric joints; other musculoskeletal illnesses involve isolated or unilateral joints.

Exquisitely tender with acute inflammation.

RA pain is worse in morning when arising; osteoarthritis is worse later in the day; tendinitis is worse in morning, improves during the day.

Movement increases most joint pain except in RA, in which movement decreases pain.

Joint pain 10 to 14 days after an untreated strep throat suggests rheumatic fever. Joint injury occurs from trauma, repetitive motion.

RA stiffness occurs in morning and after rest periods

Suggests acute inflammation.

Decreased ROM may be due to joint injury to cartilage or capsule or to muscle contracture.f

muscles

 • Any problems in the muscles, such as any pain or cramping? Which muscles?

• If in calf muscles: Is the pain with walking? Does it go away with rest?

• Are your muscle aches associated with fever, chills, the “flu”?

 • Any weakness in muscles?

• Location: Where is the weakness? How long have you noticed weakness?

• Do the muscles look smaller there?

Myalgia

Suggests intermittent claudication (see Chapter 20).

Viral illness often includes myalgia.

Weakness may involve musculoskeletal or neurologic systems (see Chapter 23).

Atrophy.

• Any bone pain? Is the pain affected by movement?

• Any deformity of any bone or joint? Is the deformity due to injury or trauma? Does the deformity affect ROM?

 • Any accidents or trauma ever affected the bones or joints: fractures; joint strain, sprain, dislocation? Which ones?

• When did this occur? What treatment was given? Any problems or limitations now as a result?

• Any back pain? In which part of your back? Is pain felt anywhere else, like shooting down leg?

 • Any numbness and tingling? Any limping?

Fracture causes sharp pain that increases with movement.

Other bone pain usually feels “dull” and “deep” and is unrelated to movement.

4. Functional assessment (ADL).

• Bathing—getting in and out of the tub, turning faucets?

• Toileting—urinating, moving bowels, able to get self on/off toilet, wipe self?

 • Dressing—doing buttons, zipper, fasten opening behind neck, pulling dress or sweater over head, pulling up pants, tying shoes, getting shoes that fit?

 • Grooming—shaving, brushing teeth, brushing or fixing hair, applying makeup?

 • Eating—preparing meals, pouring liquids, cutting up foods, bringing food to mouth, drinking?

• Mobility—walking, walking up or down stairs, getting in/out of bed, getting out of house?

 Communicating—talking, using phone, writing?

Functional assessment screens the safety of independent living, the need for home health services, and quality of life

Impaired physical mobility.

Impaired verbal communication.

5. Self-care behaviors.

• Tell me about your exercise program. Describe the type of exercise, frequency, the warm-up program.

• Any pain during exercise? How do you treat it?

 • Have you had any recent weight gain? Please describe your usual daily diet.

(Note the person's usual caloric intake, all four food groups, daily amount of protein, calcium.)

• Are you taking any medications for musculoskeletal system: aspirin, anti-inflammatory, muscle relaxant, pain reliever?

• If person has chronic disability or crippling illness:

How has your illness affected:

  Your interaction with family

  Your interaction with friends

  The way you view yourself

Assess risk for back pain or carpal tunnel syndrome.

exercise, frequency, the warm-up program.

Self-care behaviors.

Assess for:

 • Self-esteem disturbance

 • Loss of independence

 • Body image disturbance

 • Role performance disturbance

 • Social isolation

Additional History for the Aging Adult

Use the functional assessment history questions in Chapter 4 (pp. 49 to 70) to elicit any loss of function,

self-care deficit, or safety risk that may occur as a process of aging or musculoskeletal illness. (Review the complete functional assessment in Chapter 30.)

1. Any change in weakness over the past months or years?

2. Any increase in falls or stumbling over the past months or years?

3. Do you use any mobility aids to help you get around: cane, walker?

Inspection

Note the size and contour of the joint.

Inspect the skin and tissues over the joints for color, swelling, and any masses or deformity.

Presence of swelling is significant and signals joint irritation.

Swelling may be excess joint fluid (effusion),

thickening of the synovial lining,

inflammation of surrounding soft tissue (bursae, tendons),

or bony enlargement.

Deformities include dislocation (complete loss of contact between the two bones in a joint);

subluxation (two bones in a joint stay in contact but their alignment is off);

contracture (shortening of a muscle leading to limited ROM of joint), or

ankylosis (stiffness or fixation of a joint).

Palpation

Palpate each joint, including its skin for temperature, its muscles, bony articulations, and area of joint capsule.

Notice any heat, tenderness, swelling, or masses. Joints normally are not tender to palpation.

If any tenderness does occur, try to localize it to specific anatomic structures (e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule).

The synovial membrane normally is not palpable.

When thickened, it feels “doughy” or “boggy.”

A small amount of fluid is present in the normal joint, but it is not palpable.

Warmth and tenderness signal inflammation.

Palpable fluid is abnormal.

Because fluid is contained in an enclosed sac,

if you push on one side of the sac, the fluid will shift and cause a visible bulging on another side.

Range of Motion (ROM)

Ask for active (voluntary) ROM while stabilizing the body area proximal to that being moved.

Familiarize yourself with the type of each joint and its normal ROM so that you can recognize limitations.

If you see a limitation, gently attempt passive motion with the person's muscles relaxed and with you moving the body part.

Anchor the joint with one hand while your other hand slowly moves it to its limit.

The normal ranges of active and passive motion should be the same.

Limitation in ROM is the most sensitive sign of joint disease.^15a

The amount of limitation may alert you to the cause of disease.

Articular disease (inside the joint capsule [e.g., arthritis]) produces swelling and tenderness around the whole joint,

and it limits all planes of ROM in both active and passive motion.

Extra-articular disease (injury to a specific tendon, ligament, nerve) produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM,

especially during active (voluntary) motion.

ROM

Joint motion normally causes no tenderness, pain, or crepitation.

Do not confuse crepitation with the normal discrete “crack” heard as a tendon or ligament slips over bone during motion,

such as when you do a knee bend.

Crepitation

Table 22-1, Abnormalities Affecting Multiple Joints, p. 608

Muscle Testing

Test the strength of the prime mover muscle groups for each joint.

Repeat the motions you elicited for active ROM.

Now ask the person to flex and hold as you apply opposing force.

Muscle strength should be equal bilaterally and should fully resist your opposing force.

(Note: Muscle status and joint status are interdependent and should be interpreted together.

Chapter 23 discusses the examination of muscles for size and development, tone, and presence of tenderness.)

TEMPOROMANDIBULAR JOINT

With the person seated, inspect the area just anterior to the ear.

Place the tips of your first two fingers in front of each ear and ask the person to open and close the mouth.

Drop your fingers into the depressed area over the joint, and note smooth motion of the mandible.

An audible and palpable snap or click occurs in many healthy people as the mouth opens (Fig. 22-15).

Then ask the person to:

• Open mouth maximally.

• Partially open mouth, protrude lower jaw, and move it side to side.

• Stick out lower jaw.

Swelling looks like a round bulge over the joint, although it must be moderate or marked to be visible.

Crepitus and pain occur with temporomandibular joint dysfunction.

Vertical motion. You can measure the space between the upper and lower incisors. Normal is 3 to 6 cm, or three fingers inserted sideways.

Lateral motion. Normal extent is 1 to 2 cm (Fig. 22-16).

Lateral motion may be lost earlier and more significantly than vertical.

Protrude without deviation.

TMJ

Palpate the contracted temporalis and masseter muscles as the person clenches the teeth.

Compare right and left sides for size, firmness, and strength.

Ask the person to move the jaw forward and laterally against your resistance and to open mouth against your resistance.

This also tests the integrity of cranial nerve V (trigeminal).

CERVICAL SPINE

Inspect

Palpate

Head tilted to one side.

Asymmetry of muscles.

Tenderness and hard muscles with muscle spasm

UPPER EXTREMITY

Shoulder

Inspect

Redness.

Inequality of bony landmarks.

Atrophy, shows as lack of fullness.

Dislocated shoulder loses the normal rounded shape and looks flattened laterally.

Swelling from excess fluid is best seen anteriorly.

Considerable fluid must be present to cause a visible distention because the capsule normally is so loose

shoulder cont.

If the person reports any shoulder pain, ask that he or she point to the spot with the hand of the unaffected side.

Be aware that shoulder pain may be from local causes or it may be referred pain from a hiatal hernia or a cardiac or pleural condition,

which could be potentially serious.

Pain from a local cause is reproducible during the examination by palpation or motion.

shoulder cont.

While standing in front of the person, palpate both shoulders,

noting any muscular spasm or atrophy, swelling, heat, or tenderness.

Start at the clavicle and methodicallyexplore the acromioclavicular joint, scapula, greater tubercle of the humerus, area of the subacromial bursa, the biceps groove, and the anterior aspect of the glenohumeral joint.

Palpate the pyramid-shaped axilla; no adenopathy or masses should be present.

Swelling.

Hard muscles with muscle spasm.

Tenderness or pain.

Test ROM

• With arms at sides and elbows extended, move both arms forward and up in wide vertical arcs and then move them back.

Forward flexion of 180 degrees. Hyperextension up to 50 degrees (Fig. 22-18, A).

Limited ROM.

Asymmetry.

Pain with motion.

shoulders ROM

• Rotate arms internally behind back, place back of hands as high as possible toward the scapulae.

Internal rotation of 90 degrees (Fig. 22-18, B).

Crepitus with motion.

Rotator cuff lesions may cause limited ROM,

pain,

and muscle spasm during abduction,

whereas forward flexion stays fairly normal.

Elbow

Inspect the size and contour of the elbow in both flexed and extended positions.

Look for any deformity, redness, or swelling.

Check the olecranon bursa and the normally present hollows on either side of the olecranon process for abnormal swelling.

Subluxation

Swelling and redness of olecranon bursa are localized and easy to observe because of the close proximity of the bursa to skin.

Effusion or synovial thickening shows first as a bulge or fullness in groove on either side of the olecranon process, and it occurs with gouty arthritis.

Palpate

elbow cont.

With your thumb in the lateral groove and your index and middle fingers in the medial groove, palpate either side of the olecranon process using varying pressure.

Normally, present tissues and fat pads feel fairly solid.

Check for any synovial thickening, swelling, nodules, or tenderness.

Soft, boggy, or fluctuant swelling in both grooves occurs with synovial thickening or effusion.

Local heat or redness (signs of inflammation) can extend beyond synovial membrane.

elbow cont.

Palpate the area of the olecranon bursa for heat, swelling, tenderness, consistency, or nodules

Subcutaneous nodules

Table 22-3, Abnormalities of the Elbow, p. 610

Wrist and Hand

Inspect

Subluxation (partial dislocation) of wrist.

Ulnar deviation; fingers listto ulnar side.

Ankylosis; wrist in extreme flexion.

Dupuytren contracture;

flexion contracture of finger(s).

wrist and hand cont.

The skin looks smooth with knuckle wrinkles present and no swelling or lesions.

Muscles are full, with the palm showing a rounded mound proximal to the thumb (the thenar eminence) and a smaller rounded mound proximal to the little finger.

Swan-neck or boutonnière deformity in fingers.

Atrophy of the thenar eminence

wrist and hand cont.

Palpate each joint in the wrist and hands.

Facing the person, support the hand with your fingers under it and palpate the wrist firmly with both your thumbs on its dorsum. 

Make sure the person's wrist is relaxed and in straight alignment.

Move your palpating thumbs side to side to identify the normal depressed areas that overlie the joint space.

Use gentle but firm pressure.

Normally, the joint surfaces feel smooth, with no swelling, bogginess, nodules, or tenderness.

Ganglion cyst in wrist (see Table 22-4).

Synovial swelling on dorsum.

Generalized swelling.

Tenderness.

wrist and hand cont.

Palpate the metacarpophalangeal joints with your thumbs, just distal to and on either side of the knuckle (Fig. 22-24).

Use your thumb and index finger in a pinching motion to palpate the sides of the interphalangeal joints (Fig. 22-25).

 Normally, no synovial thickening, tenderness, warmth, or nodules are present.

Phalen Test.

Fig. 22-28

Tinel Sign.

In carpal tunnel syndrome,

percussion of the median nerve produces burning and tingling along its distribution,

which is a positive Tinel sign.

Hip

Wait to inspect the hip joint together with the spine a bit later in the examination as the person stands.

At that time, note symmetric levels of iliac crests, gluteal folds, and equally sized buttocks.

A smooth, even gait reflects equal leg lengths and functional hip motion.

Help the person into a supine position and palpate the hip joints.

The joints should feel stable and symmetric, with no tenderness or crepitus.

Pain with palpation.

Crepitation.

Knee

The person should remain supine with legs extended, although some examiners prefer the knees to be flexed and dangling for inspection.

The skin normally looks smooth, with even coloring and no lesions.

Shiny and atrophic skin.

Swelling or inflammation (see Table 22-5, Abnormalities of the Knee, p. 613).

Lesions (e.g., psoriasis).

Inspect lower leg alignment.

The lower leg should extend in the same axis as the thigh.

Angulation deformity:

 •Genu varum (bowlegs) (see p. 601)

 •Genu valgum (knock knees)

 •Flexion contracture

Inspect the knee's shape and contour.

Normally, distinct concavities, or hollows, are present on either side of the patella.

Check them for any sign of fullness or swelling.

Note other locations, such as the prepatellar bursa and the suprapatellar pouch, for any abnormal swelling.

Hollows disappear;

then they may bulge with synovial thickening or effusion.

Check the quadriceps muscle in the anterior thigh for any atrophy.

 Because it is the prime mover of knee extension, this muscle is important for joint stability during weight-bearing.

Atrophy occurs with disuse or chronic disorders.

First, it appears in the medial part of the muscle, although it is difficult to note because the vastus medialis is relatively small.

Enhance palpation with the knee in the supine position with complete relaxation of the quadriceps muscle.

 Start high on the anterior thigh, about 10 cm above the patella.

Palpate with your left thumb and fingers in a grasping fashion (Fig. 22-31).

Proceed down toward the knee, exploring the region of the suprapatellar pouch.

Note the consistency of the tissues.

The muscles and soft tissues should feel solid, and the joint should feel smooth, with no warmth, tenderness, thickening, or nodularity.

Bulge Sign.

Ballottement of the Patella.

Continue palpation and explore the tibiofemoral joint (Fig. 22-34).

Note smooth joint margins and absence of pain. Palpate the infrapatellar fat pad and the patella.

Check for crepitus by holding your hand on the patella as the knee is flexed and extended.

Some crepitus in an otherwise asymptomatic knee is not uncommon.

Irregular bony margins occur with osteoarthritis.

Pain at joint line.

Pronounced crepitus is significant, and it occurs with degenerative diseases of the knee.

Special Test for Meniscal Tears

McMurray Test

Fig. 22-36

Ankle and Foot

Inspect

Weight-bearing should fall on the middle of the foot, from the heel, along the midfoot, to between the second and third toes.

 Most feet have a longitudinal arch, although that can vary normally from “flat feet” to a high instep.

The toes point straight forward and lie flat. The ankles (malleoli) are smooth bony prominences.

Normally, the skin is smooth, with even coloring and no lesions.

Note the locations of any calluses or bursal reactions because they reveal areas of abnormal friction.

Examining well-worn shoes helps assess areas of wear and accommodation.

In hallux valgus,

the distal part of the great toe is directed away from the body midline (Fig. 22-37).

Hammertoes.

Swelling or inflammation.

Calluses.

Ulcers

Support the ankle by grasping the heel with your fingers while palpating with your thumbs (Fig. 22-38).

Explore the joint spaces.

They should feel smooth and depressed, with no fullness, swelling, or tenderness.

Swelling or inflammation.

Tenderness.

Swelling or inflammation.

Tenderness.

SPINE

The person should be standing, draped in a gown open at the back.

Place yourself far enough back so that you can see the entire back.

Inspect and note whether the spine is straight

(1) by following an imaginary vertical line from the head through the spinous processes and down through the gluteal cleft and

(2) by noting equal horizontal positions for the shoulders, scapulae, iliac crests, and gluteal folds and equal spaces between the arm and lateral thorax on the two sides (Fig. 22-41, A).

The person's knees and feet should be aligned with the trunk and should be pointing forward.

From the side, note the normal convex thoracic curve and concave lumbar curve (Fig. 22-41, B).

An enhanced thoracic curve, or kyphosis, is common in aging people.

A pronounced lumbar curve, or lordosis, is common in obese people.

Palpate the spinous processes.

Spinal curvature.

Tenderness. Spasm of paravertebral muscles.

Chronic axial skeletal pain occurs with Fibromyalgia Syndrome

Check ROM of the spine by asking the person to bend forward and touch the toes (Fig. 22-42).

Look for flexion of 75 to 90 degrees and smoothness and symmetry of movement.

Note that the concave lumbar curve should disappear with this motion and the back should have a single convex C-shaped curve.

If you suspect a spinal curvature during inspection, this may be more clearly seen when the person touches the toes.

While the person is bending over, mark a dot on each spinous process.

When the person resumes standing, the dots should form a straight vertical line.

Straight Leg Raising or Lasègue Test.

Raise the unaffected leg while leaving the other leg flat. Inquire about the involved side.

Lasègue test is positive if it reproduces sciatic pain.

If lifting the affected leg reproduces sciatic pain, it confirms the presence of a herniated nucleus pulposus.

If lifting the unaffected leg reproduces sciatic pain, it strongly suggests a herniated nucleus pulposus.

Measure Leg Length Discrepancy.

true leg length,

fixed

Sometimes the true leg length is equal but the legs still look unequal.

For apparent leg length, measure from a nonfixed point (the umbilicus) to a fixed point (medial malleolus) on each leg.

unequal

True leg lengths are equal, but apparent leg lengths unequal—

this condition occurs with pelvic obliquity or adduction or flexion deformity in the hip.

The Aging Adult

Postural changes include a decrease in height, more apparent in the eighth and ninth decades (Fig. 22-54).

“Lengthening of the arm-trunk axis” describes this shortening of the trunk with comparatively long extremities.

Kyphosis is common, with a backward head tilt to compensate.

This creates the outline of a figure 3 when you view this older adult from the left side. Slight flexion of hips and knees is also common.

Contour changes include a decrease of fat in the body periphery and fat deposition over the abdomen and hips.

The bony prominences become more marked.

For most older adults, ROM testing proceeds as described earlier.

ROM and muscle strength are much the same as with the younger adult, provided no musculoskeletal illnesses or arthritic changes are present.

This is a chronic, systemic inflammatory disease of joints and surrounding connective tissue.

Inflammation of synovial membrane leads to thickening; then to fibrosis, which limits motion; and finally to bony ankylosis.

The disorder is symmetric and bilateral and is characterized by heat, redness, swelling, and painful motion of the affected joints.

RA is associated with fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy.

Associated signs are described in the following tables, especially Table 22-4.

Chronic, progressive inflammation of spine, sacroiliac, and larger joints of the extremities, leading to bony ankylosis and deformity.

A form of RA, this affects primarily men by a 10 : 1 ratio, in late adolescence or early adulthood.

Spasm of paraspinal muscles pulls spine into forward flexion, obliterating cervical and lumbar curves.

Thoracic curve exaggerated into single kyphotic rounding.

Also includes flexion deformities of hips and knees.

Noninflammatory, localized, progressive disorder

involving deterioration of articular cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces.

Aging increases incidence; nearly all adults older than 60 years have some radiographic signs of osteoarthritis.

Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine.

Affected joints have stiffness, swelling with hard, bony protuberances, pain with motion, and limitation of motion (see Table 22-4).

Decrease in skeletal bone mass occurring when rate of bone resorption is greater than that of bone formation.

The weakened bone state increases risk for stress fractures, especially at wrist, hip, and vertebrae.

Occurs primarily in postmenopausal white women.

Osteoporosis risk also is associated with smaller height and weight, younger age at menopause,

lack of physical activity, and lack of estrogen in women.

Decrease in skeletal bone mass occurring when rate of bone resorption is greater than that of bone formation.

The weakened bone state increases risk for stress fractures, especially at wrist, hip, and vertebrae.

Occurs primarily in postmenopausal white women.

Osteoporosis risk also is associated with smaller height and weight, younger age at menopause, lack of physical activity, and lack of estrogen in women.

Chronic disabling pain at lateral epicondyle of humerus, radiates down extensor surface of forearm.

Pain can be located with one finger.

Resisting extension of the hand will increase the pain.

Occurs with activities combining excessive pronation and supination of forearm with an extended wrist (e.g., racquet sports or using a screwdriver).

Medial epicondylitis is rarer and is due to activity of forced palmar flexion of wrist against resistance.

Round, cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist.

Flexion makes it more prominent.

 A common benign tumor; it does not become malignant.

Atrophy occurs from interference with motor function from compression of the median nerve inside the carpal tunnel.

Caused by chronic repetitive motion; occurs between 30 and 60 years of age and is five times more common in women than in men.

Symptoms of carpal tunnel syndrome include pain, burning and numbness, positive findings on Phalen test, positive indication of Tinel sign, and often atrophy of thenar muscles.

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.

 Note the bands that extend from the midpalm to the digits and the puckering of palmar skin.

The condition occurs commonly in men older than 40 years and is usually bilateral.

It occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait.

 The contracture is painless but impairs hand function.

[image]

Swan-Neck and Boutonnière Deformity

Flexion contracture resembles curve of a swan's neck.

Note flexion contracture of metacarpophalangeal joint, then hyperextension of the proximal interphalangeal joint, and flexion of the distal interphalangeal joint.

It occurs with chronic rheumatoid arthritis and is often accompanied by ulnar drift of the fingers.

In boutonnière deformity, the knuckle looks as if it is being pushed through a buttonhole.

It is a relatively common deformity and includes flexion of proximal interphalangeal joint with compensatory hyperextension of distal interphalangeal joint.

Acute episode of gout usually involves first the metatarsophalangeal joint.

Clinical findings consist of redness, swelling, heat, and extreme tenderness.

Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid.

It occurs primarily in men older than 40 years.

Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies.

Functional

Structural