Musculoskeletal

• Musculoskeletal system


  Bones, muscles and joints
• Bones


  • Provide structure, protection, serve as storage of calcium and produced blood cells
  • 206 bones: axial and appendicular skeleton
  • Composed of compact (hard and dense, outer layer) and spongy (contains numerous spaces, inner layer) osseous tissue
  • Osteoblasts - bone formers
  • Osteoclasts - bone destroyers
  • Red marrow - produces blood cells
  • Yellow marrow - composed mostly of fats
• Skeletal muscles


  • 650 skeletal (voluntary) muscles, which are under conscious control
  • Assist with posture, produce body heat and allow body to move
• Skeletal muscle movements


  1. Abduction - moving away from midline of the body

  2. Adduction - moving toward midline of the body

  3. Circumduction - circular motion

  4. Inversion - moving inward

  5. Eversion - moving outward

  6. Extension - straightening the extremity at the joint and increasing the angle of the joint

  7. Flexion - bending the extremity at the joint and decreasing the angle of the joint

  8. Pronation - turning or facing downward

  9. Supination - turning or facing upward

  10. Protraction - moving toward

  11. Retraction - moving backward

  12. Rotation - turning head to the right shoulder then back to the midline, next turning the head to left shoulder then back to midline
• Joints (Articulation)


  • Fibrous - joined by fibrous connective tissue and are immovable
  • Cartilaginous - joined by cartilage
  • Synovial - contain a space between the bones that is filled with synovial lubricant fluid, promotes a sliding movement of the ends of the bones
  • Temporo-mandibular Joints - open and closes the mouth, projects and retracts the jaw, moves jaw from side to side
  • Sternoclavicular Joints - junction between the manubrium of the sternum and the clavicle, has no obvious movements
  • Shoulder - Flexion and extension, Abduction and adduction, Circumduction, Rotation (internal and external)
  • Hip - Flexion with knee flexed and with knee extended, Extension and hyperextension, Circumduction, Rotation (internal and external), Abduction and adduction
  • Wrists, Fingers & Thumb - Wrists: flexion, extension, hyperextension and adduction, radial and ulnar deviation
  • Fingers: flexion, extension, hyperextension, abduction and Circumduction
  • Thumb: flexion, extension, opposition
  • Elbow - flexion and extension of the forearm, supination and pronation of the forearm
  • Knee - flexion and extension
  • Ankle And Foot - Ankle: plantar flexion and dorsiflexion
  • Foot: inversion and eversion
  • Toes: flexion, extension, abduction, adduction
  • Vertebrae (Lateral View) - C - 7 concave-shaped, T - 12 convex-shaped, L - 5 concave-shaped, S - 5, Cox - 3-4, flexion, hyperextension, lateral bending, rotation
• Assessment of the musculoskeletal system

  1. Inspection of Muscles for Size - Compare each muscle on one side of the body to the same muscle on the other side, measure any apparent discrepancies

  2. Inspect Muscles for Tremors and Tendons for Contractures - Inspect any tremors of the hands and arms

  3. Palpation - Palpate muscles at rest to determine muscle tonicity, palpate the muscles while the client is active and passive for flaccidity, spasticity, and smoothness of movement

  4. Test muscle strength - Compare the right side with left side

  5. Palpation & Inspection of Bones - Inspect the skeleton for normal structure and deformities

  6. Palpation & Inspection of Joints - Inspect the joint for swelling

  7. Range of Motion (ROM) - Ask the client to move selected body parts, use a goniometer to measure the angle of the joint in degrees
• Grading muscle strength


  • Grade 5 - 100% of normal muscle strength; normal full movement against gravity and against full resistance
  • Grade 4 - 75% of normal strength; normal full movement against gravity and against minimal resistance
  • Grade 3 - 50% of normal strength; normal movement against gravity
  • Grade 2 - 25% of normal strength; full muscle movement against gravity with support
  • Grade 1 - 10% of normal strength; no movement, contraction of muscle is palpable or visible
  • Grade 0 - 0% of normal strength; complete paralysis
• Range of motion of the cervical spine

  • Flexion - touch the chin to the chest
  • Extension - Move the head from the flexed position to the upright position
  • Hyperextension - to look up at the ceiling
  • Lateral Flexion - Move the head laterally to the right and left shoulders
  • Rotation - Move the head laterally to the right and left shoulder
• Range of motion of the shoulder

  • Flexion - raise arms forward
  • Extension - Move each arm from a vertical position beside the head forward and down to a resting position at the side of the body
  • Hyperextension - Move each arm from a resting side position to behind the body
  • Abduction - Move arms laterally from a resting position at the sides up above the head, palm of the hand away from the head
  • Adduction (Anterior) - Move arms from a position at the sides across the front of the body as far as possible, the elbow may be straight or bent
  • Circumduction - Move each arm forward, up, back, and down in a full circle
  • External Rotation - bring the hands together behind the head with elbows flexed
  • Internal Rotation - bring the hands together behind the back
• Range of motion of the elbow

  • Flexion - Move each arm forward, up, back, and down in a full circle
  • Extension - Bring each lower arm forward and downward, straightening
  • Rotation for supination - Turn each hand and forearm so that the palm is facing upward
  • Rotation for pronation - Turn each hand and forearm so that the palm is facing downward
• Range of motion of the wrists

  • Flexion - Bend the wrist downward
  • Extension - Straighten the arm
  • Hyperextension - Bend the fingers of each hand back as far as possible
  • Radial Flexion (Abduction) - Bend each wrist laterally toward the thumb side with hand supinated
  • Ulnar Flexion (Adduction) - Bend each wrist laterally toward the fifth finger with the hand supinated
• Normal range of motion of the fingers

  • Flexion - Bend the fingers down
  • Extension - Straighten the fingers of each hand
  • Hyperextension - Bend the fingers of each hand back as far as possible
  • Abduction - Spread the fingers of each hand apart
  • Adduction - Make a fist with each hand
  • Flexion - Move each thumb across the palmar surface of the hand toward the fifth finger
  • Extension - Move each thumb away from the hand
  • Abduction - Extend each thumb laterally
  • Adduction - Move each thumb back to the hand
  • Opposition - Touch each thumb to the top of each finger of the same hand
• Normal range of motion of the hips

  • Flexion - Move each leg forward and upward, the knee may be flexed
  • Extension - Move each leg straight
  • Hyperextension - Move each leg back behind the body
  • Abduction - Move each leg out to the side
  • Adduction - Move each leg back to the other leg and beyond in front of it
  • Internal and External rotation of the hips with knee flexed
• Normal range of motion of the knee, foot and toes

  • Flexion - Bend each leg, bringing the heel toward the back of the thigh
  • Extension - Straighten each leg, returning the foot to its position beside the other foot
  • Flexion (dorsiflexion) - Point the toes of each foot upward
  • Extension (plantar flexion) - Point the toes of each foot downward
  • Eversion - Turn the sole of each laterally
  • Inversion - Turn the sole of each foot medially
  • Internal Rotation - Turn each foot and leg inward so that the toes point as far as possible toward the other leg
  • External Rotation - Turn each foot and leg outward so that the toes point as far as possible away from the other leg
  • Circumduction - Move each leg backward, up, to the side, and down in a circle
  • Flexion - Curl the toe joints of each foot downward
  • Extension - Straighten the toes of each foot
• Normal range of motion of the thoracic and lumbar spine

  • Flexion - Bend the trunk toward the toes
  • Extension - Straighten the trunk from a flexed position
  • Hyperextension - Bend the trunk backward
  • Lateral Flexion - Bend the trunk to the right and to the left
  • Rotation - Turn the upper part of the body from side to side
• Abnormalities affecting the wrist, hands and fingers

  • Acute Rheumatoid Arthritis - tender, painful, swollen, stiff joints
  • Chronic Rheumatoid Arthritis - chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints, limited ROM, and finger deviation toward the ulnar side
  • Boutonniere and Swan-neck Deformities - flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint, hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint
  • Thenar Atrophy - atrophy of the thenar prominence due to pressure on the median nerve is seen in carpal tunnel syndrome
  • Ganglion - non-tender, round, enlarged, swollen, fluid-filled cyst and commonly seen at the dorsum of the wrist
  • Osteoarthritis - hard, painless, nodule over the distal interphalangeal joints (Heberden's nodes) and over the proximal interphalangeal joints (Bouchard's nodes)
  • Tenosynovitis - painful flexion of a finger (infection of the flexor tendon sheathes)
• Abnormalities of feet and toes

  • Acute Gouty Arthritis - metatarsophalangeal joint of the great toe is tender, painful, reddened, hot and swollen
  • Callus - non-painful, thickened skin that occur at pressure points
  • Corn - painful thickening of the skin that occur over the bony prominences and at pressure points
  • Plantar Wart - painful warts (verruca vulgaris) that often occur under a callus, appearing as tiny dark spots
  • Hallux Valgus - the great toe is deviated laterally and may overlap the second toe