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Musculoskeletal System Write-Up

Musculoskeletal System Write-Up

Consent: The patient, ADM, is a 28-year-old male. An informed consent was sought from the patient before beginning the assessment. He was also told that the assessment process would be recorded and the video uploaded to YouTube for educative purposes.

Musculoskeletal System Write-Up

The objective of this activity is to assess the strength, mobility, and function of the musculoskeletal system to identify structural and functional impairments that may affect the patient’s ability to perform activities of daily living. The activity will demonstrate assessment techniques for all parts of the musculoskeletal system, including visual inspection and bilateral palpation, and also compare the expected and actual findings.

Hands and Fingers

Inspection:

The patient assumed a seated upright position, with his hands on a pillow. Both hands, elbows, and wrists were adequately exposed. The hands were symmetrical, consistent in color, and warm. There were no visible scars or wasting of muscles. The nails were translucent. There were no signs of nail pitting, Lindsay’s nails, or Beau’s lines.

Close inspection of the dorsal aspects of the hand revealed no swelling on the hands and redness. Redness may be suggestive of cellulitis. There was an interphalangeal joint symmetry on both hands. There were no signs of skin bruising or thinning, psoriatic plagues, or muscle wasting. There were no signs of Heberdeen’s and Bouchard’s nodes, Boutonnière’s deformity, Swan neck deformity, and Z-thumb. Notably, Heberdeen’s and Bouchard’s nodes are associated with osteoarthritis. Swan neck deformity usually occurs at the distal interphalangeal joints and is associated with rheumatoid arthritis. Z-thumb, a hyperflexion of the thumb, is also associated with rheumatoid arthritis. Inspection of the hands also revealed no signs of hand posture abnormalities. Hand posture abnormalities such as ulnar deviation.

Palpation:

The hands were palpated, one after another, starting distally at the distal interphalangeal joint towards the proximal interphalangeal joint and the metacarpophalangeal joint. There were no signs of pain, tenderness, or discomfort on palpation of the distal and proximal interphalangeal joints. There were also no signs of pain, tenderness, discomfort, or crackling sound on palpation of the metacarpophalangeal joint. There was also no Palmer thickening.

Range of Motion:

Bilateral finger flexion and extension were noted, as evidenced by the patient’s ability to make a fist and splay his fingers upon opening his fist. The patient was also able to abduct and adduct his fingers without any discomfort, pain, or notable contractures.

Wrists

Inspection:

The wrist joints were symmetrical. There were no signs of swelling, lumps, redness, or muscle wasting on the skin above the wrists.

Palpation:

There were no signs of nodules, discomfort, pain, crepitus, or swelling on palpation of carpal and metacarpal bones. The radial and ulnar pulse were felt on palpating the radial.

Range of Motion:

There were no signs of pain or discomfort on a 90-degree downward flexion and upward extension of the wrist. Pain on extension or flexion of the wrist may be suggestive of tendinitis. There was also no ulnar deviation on adduction or abduction of the wrist. Ulber deviation may be suggestive of rheumatoid arthritis.

Specialty Tests:

Tinel’s Test – Slight percussion of the area proximal to the median nerve in the wrist did not produce a tingling sensation in the thumb, middle, index finders, and parts of the ring finger. A negative Tinel’s test reveals the absence of nerve damage or nerve irritation. A positive test is suggestive of conditions that cause nerve damage, such as carpal tunnel syndrome (Fujita et al., 2023).

Phalen Test – There were no reports of a tingling sensation on the middle and index fingers, as well as in the thumb and parts of the ring finger, after completing the Phallen test. In this test, the patient was asked to hold his palms together and bend them as far as he could go. He then held in this position for 60 seconds. The absence of a tingling sensation revealed no nerve irritation or damage (Fujita et al., 2023).

Elbows

Inspection:

With the patient relaxed, shoulders adducted, and the left and right elbows relaxed, the medial, lateral, anterior, and posterior aspects of both elbows were examined. The elbow joint symmetry was noted on a contralateral comparison of the joint. There were no visible signs of edema, swelling, nodules, redness, or muscular atrophy. No skin color changes were also noted.

Palpation:

The elbow joint was warm. There were no signs of nodules, discomfort, tenderness, edema, or pain on palpating the bicep tendon, ulnar extensor surface, radial head, lateral epicondyle, olecranon process, or medial epicondyle. Pain in the lateral epicondyle is suggestive of lateral epicondylitis, also known as the Tennis elbow. Contrarily, Golfer’s elbow manifests as pain in the inner aspects of the elbows, which is suggestive of medial epicondylitis.

Range of Motion:

The elbows’ range of motion was assessed from a starting position, where the arms were supinated and abducted to the shoulders at 90 degrees. There was no sign of discomfort or pain on the bilateral flexion and extension of the elbow joint. The patient has a flexion and extension range of about 140 degrees. With the elbows flexed to 90 degrees and the shoulders adducted, supination and pronation movements were assessed. The patient had a supination range of about 80 degrees and a pronation range of about 70 degrees.

Shoulders

Inspection:

With the patient in an upright position and relaxed, the anterior, lateral, and posterior aspects of the shoulders were inspected bilaterally. The shoulder joint was symmetrical. There were no signs of skin color changes, scars, swelling, muscular atrophy or hypertrophy, or scapula winging. There were also no signs of nodules, redness, or shoulder joint deformity.

Palpation:

There were no signs of tenderness, edema, or pain on palpating the acromioclavicular joint, coracoid process, acromion, scapular spine, the tubercle of the humerus, biceps groove, subdeltoid bursa, and the sternoclavicular joint. There was also no pain or tenderness on palpating the deltoid, paraspinal muscles, and periscapular region.

Range of Motion:

There were no signs of discomfort, pain, or intolerance when the shoulder was flexed to 180 degrees above the head. There was also no pain or discomfort reported when the shoulder was extended backward to 60 degrees, with the arms straight behind. Abduction was performed bilaterally, with the arms at the side and the scapula stabilized by the examiner. The abduction range was 180 degrees. There were no signs of movement restriction on abduction. No discomfort was noted when the shoulder was adducted across the midline to 90 degrees. The patient could internally rotate his shoulder to 90 degrees. He could also externally rotate his shoulders to about 90 degrees while placing his hands behind his neck with the elbows out to the side.

Specialty Test

The Crank Test – In this test, the patient’s arms were held in an abducted position, and a passive and axial rotation was applied on the shoulders. There were no reports of pain or clincking on the glenohumeral joint. The crack test has a 91% sensitivity in identifying glenoid labral tears and unstable superior labral anterior-posterior (SLAP) lesions (Chiou et al., 2022).

Head and Neck

Inspection:

With the patient in an upright position, all aspects of the head and neck were inspected from the head down to the neck. The patient had an appropriate posture. There were no signs of deformities, head malformations, or posture abnormalities. The hair on the head was evenly distributed and even in texture. There were no signs of hair loss or excessive hair growth. The skin color around the head and neck was consistent, with no signs of skin color changes, patches, lesions, scars, or swelling. No glandular masses or nodal enlargement was seen on inspecting the neck. The trachea was midline.

Palpation:

There was no pain or tenderness on performing the temporomandibular joint (TMJ) test. In this test, the first two fingers of each hand were placed in front of the tragus of the ear, and the patient was asked to open wide and close his mouth. The presence of pain or clicks on jaw movements is indicative of a TMJ disorder. There was no pain or discomfort on palpation of the cervical spine, the para clavicular, sternoclavicular, trapezius, paracervicular, and rhomboid muscles.

Range of Motion:

The patient was able to perform the chin-to-chest flexion test without discomfort or intolerance. The approximate flexion range of the patients was about 80 degrees. The patient was also able to extend his head backward without any difficulty, revealing intact cervical extensor capabilities.

The patient was able to rotate his neck from side to side without any difficulty or discomfort. The reported axial rotation was about 90 degrees. Difficulties in neck rotation may be suggestive of injury to the neck muscles.

The patient was able to touch his right shoulder with his right ear and left shoulder with his left ear without pain or discomfort. This is indicative of his ability to move his neck laterally. The presence of pain or discomfort is suggestive of an underlying neck injury.

The patient was able to insert three of his vertically-placed fingers in his mouth upon maximal opening. This is indicative of a normal range of maximum mouth opening. The inability to open the mouth maximally can be suggestive of a TML disorder and an inflammatory condition, such as rheumatoid arthritis.

With his mouth wide open, the patient was able to move his jaws from side to side. The inability to move jaws side to side with an open mouth may be suggestive of dental issues such as malocclusion.

Specialty Tests:

The Spurling Test With the head fully extended and laterally bent, no radiating pain was reported when a slight compression was applied to the head. A negative Spurling test shows the absence of compression on the cervical nerve root. The presence of radiating pain on compression is highly suggestive of cervical radiculopathy.

Feet and Toes

Inspection:

The feet were inspected bilaterally. The feet were symmetrical. The standing flat feet was detected on the patient. He, however, denied feeling any pain, tenderness, or discomfort. He also reported that he can still walk without any fatigue or stiffness. There were no signs of edema, skin thickening, color inconsistencies, gross deformities, bunions, corns, plantar warts, or nodules.

Palpation:

The feet were warm. There were no signs of pain or discomfort after conducting the Morton’s test. In this test, the medial and lateral aspects of the forefoot are squeezed, and the tender area is palpated. The presence of aggravated pain is suggestive of a Morton’s neuroma.

There was no pain or discomfort on palpation of the distal and proximal interphalangeal joints and the metatarsal joints. Also, no cysts, nodules, or heaviness were detected in the interphalangeal and metatarsal joints.

Range of Motion:

The patient was able to extend and flex his toes. The reported great toe extension was approximately 70 degrees, with a flexion of about 45 degrees. The patient was also able to invert and evert both the right and the left foot.

Ankles

Inspection:

The ankles were symmetrical on bilateral inspection. There were no signs of scars, muscle wasting, nodules, or skin color inconsistencies. There were also no visible ankle deformities.

Palpation:

The ankles were warm. There were no signs of pain or discomfort, nodules, tenderness, or swelling on palpating the medial malleolus, the Achilles, and the lateral malleolus. There were also no signs of localized pain around the Achilles. The anterior and posterior talofibular and fibulocalcaneal ligaments were all normal on palapation.

Range of Motion:

The patient’s passive range of motion was tested via dorsiflexion, plantar flexion, and eversion and inversion movements. The patient was able to move his feet in a backward-bending motion, suggestive of a full range of dorsiflexion, moving the feet downward away from the body (plantar flexion). He was also able to tilt the sole of his foot outwards, away from the midline (eversion), and roll his foot inward (inversion) without difficulty. The active range of motion was tested via dorsiflexion, eversions, and plantar flexion movements.

Knees

Inspection:

The knees were inspected bilaterally. The knee joint was symmetrical. There were no signs of swelling, skin color inconsistencies, nodules, or redness on the knee joint. There was also no sign of muscle wasting on the skin around the skin or scars on the knees. No valgus deformity or varus deformity was detected. In varus deformity, the distal segments of the bone at the knee joint are angled inward, while in valgus deformity, the bone is angled outwards.

Palpation:

The knee joint was warm. There were no signs of pain, tenderness, nodules, or swelling felt on palpating the sides of the patella, the suprapatellar pouch, and the suprapatellar bursa. There were palpable Baker’s cysts on examining the popliteal fossa. Baker’s cysts are often suggestive of a torn cartilage or an inflammatory condition on the knee.

Range of Motion:

The patient’s knee flexed to about 130 degrees and barely extended on performing passive ROM. The patient was able to flex his knee to about 130 degrees without difficulty and extend the knee to 0 degrees on active ROM.

Specialty Tests

Valgus Stress Test – With the patient in a supine position, his knee bent slightly, and the thigh moved laterally to about 30 degrees while the knee kept steady. The patient denied any pain or discomfort when the ankle was pulled to the side. Pain sensation on the Valgus stress test may be suggestive of a compromise to the integrity of the medial collateral ligament(Graef et al., 2022).

Varus Stress Test – There were no reports of pain or discomfort on grasping and adducting the lower leg of the patient with one hand, with the other on the patient’s medial femur.

Lachman’s Test – Test for ACL tear. With the femur stabilized medially, the knee flexed to about 15 degrees, and the tibia grasped medially using one hand, there was no discomfort noted on pressing down the femur.

Anterior And Posterior Drawer Test – (Test For ACL And PCL Tears)

With the patient in a lying position and the knee flexed to about 90 degrees, and hips about 45 degrees, and with the examiner sitting in the patient’s feet, there was no discomfort or pain when the examiner attempted to displace the knee joint anteriorly or posteriorly.

McMurray – There were no reports of discomfort when the patient rotated her tibia or bent and strengthened his knee joint.

Hips

Inspection:

With the patient in a supine position and the legs straight together, the hip was visually inspected from one side to another. The hips were symmetrical. There was no sign of hip misalignment, deformity, swelling, or nodules.

Palpation:

There was no tenderness or reports of pain, discomfort, or soreness when palpating the anterior superior iliac spine, posterior superior iliac spine, or the greater trochanter. The anterior superior iliac spine and the pubic tubercle were felt on palpation.

Range of Motion: Knee flexion to around 45 degrees was attained. The patient could also rotate both his legs externally and internally, with the leg returning to the original position without difficulty. Hip flexion was also attained as the patient could passively and actively move his bent knee to his chest. A hip extension was also achieved as the patient, in a face-down position, could passively and actively extend both of his legs. His adduction was attained as the patient, in a supine position, could passively and actively recline and move his legs across the midline to about 30 degrees. Hip abduction was also attained as the patient, lying on the side, could passively and actively abduct his hips bilaterally to 60 degrees.

Specialty Tests

Thomas Test – The patient was able to bend his knee toward his chest without any pain or discomfort.

Patrick’s Test – With the patient in a supine position, the hip flexed and abducted, and the lateral ankle resting on the contralateral thigh above the knee, the full range of motion was attained, with no pain or discomfort felt when external rotational, posterior, and abduction force was applied to the knee.

Spine

Inspection:

With the patient in an upright position, the spine alignment was inspected on the anterior, posterior, and lateral aspects. There are signs of spinal curvatures, such as cervical or lumbar lordosis or dorsal kyphosis. The shoulders were symmetrical and perfectly aligned with the body. The iliac crest was also symmetrical. There were no signs of skin creases, asymmetry, or wrinkles under the buttocks. There were no signs of scoliosis. The height of the shoulder and the hips and the spinal curvature were also symmetrical.

Palpation:

The spinous processes and the intervertebral spaces were felt on palpation of the spine, with no nodules, tenderness, or pain felt. Percussion of the pine using the ulnar surface of the fist revealed no compression fractures.

Range of Motion:

The patient was able to attain a 35-degree lateral bending, as demonstrated by his ability to bend to the right and the left by approximately 35 degrees. He was also able to bend forward by up to 90 degrees. The patient was also able to attain a spine extension as he was able to bend back by up to 35 degrees. The patient was also able to attain a lateral shoulder rotation, demonstrated by his ability to rotate the shoulders by about 30 degrees to the left and the right.

Specialty Test

Straight Leg Raise – Each leg was tested in isolation. With the patient in a supine position, his knee was placed in full extension, and the hip flexed passively; there was no sign of pain or discomfort. This is suggestive of the absence of lumbosacral radiculopathy.

References

Chiou, S. Y., Clarke, E., Lam, C., Harvey, T., & Nightingale, T. E. (2022). Effects of arm-crank exercise on fitness and health in adults with chronic spinal cord injury: A systematic review. Frontiers in Physiology13. https://doi.org/10.3389/fphys.2022.831372

Fujita, S., Tojyo, I., Suzuki, S., & Tajima, F. (2023). Application of Tinel’s test combed with clinical neurosensory test distinguishes spontaneous healing of lingual nerve neuropathy after mandibular third molar extraction. Maxillofacial Plastic and Reconstructive Surgery45(1). https://doi.org/10.1186/s40902-023-00389-3

Graef, F., Rühling, M., Gwinner, C., Hommel, H., Tsitsilonis, S., & Perka, C. (2022). Increasing grades of frontal deformities in knee osteoarthritis are not associated with ligamentous ankle instabilities. Knee Surgery, Sports Traumatology, Arthroscopy31(5), 1704–1713. https://doi.org/10.1007/s00167-022-07021-3

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Question 


Musculoskeletal Write-Up

Objectives:

  1. Assess function, mobility, and strength, as well as screen for abnormalities that may impair their ability to conduct daily tasks.

    Musculoskeletal System Write-Up

  2. When analyzing the musculoskeletal system, inspect, palpate, and compare bilaterally expected versus unexpected findings.
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