The nurse is teaching a nursing student about various deformities of the spine

The musculoskeletal system consists of the muscles, bones, cartilage, and joints. This system provides the body with support and movement. Also, the musculoskeletal system protects major organs, produces red blood cells and store important minerals such as calcium and phosphorus.

A properly functioning musculoskeletal system is important for a patient to perform activities of daily living (ADLs). The techniques for the assessment of the musculoskeletal system are inspection, palpation, and observing the range of motion of the joints. This article contains 13 tips for Performing a Nursing Health Assessment of the Musculoskeletal System.

Tip #1 – Gather Information about the Patient’s History.

Ask the following questions.

1. Have you had any recent trauma?
2. Have you had any past surgeries?
3. Do you have any problems with mobility?
4. Have you noticed a change in your gait or the way you walk?
5. Have you been diagnosed with any health condition related to your musculoskeletal system?
6. Do you have a diagnosis of osteoarthritis or rheumatoid arthritis?
7. Do you have any bone or joint deformities?
8. Have you ever had a diagnosis of any congenital deformities?
9. What medications do you take? (Some medications can affect the gait)

Tip #2 – Gather Information on Chief Complaints or Symptoms.

Some major complaints of the musculoskeletal system include pain, swelling, stiffness, and inflammation. The most common areas of pain include the neck, the back, and the joints.

Ask the following questions about general pain.

1. How long have you had the pain?
2. Did the onset of pain happen all of a sudden or over a period of time?
3. If the pain came on all of a sudden, was there an injury related to the pain?
4. Has the pain steadily increase in severity over a period of time?
5. Do you have pain constantly or off and on?
6. Where in the body is the pain located? (Have the patient point to the pain.)
7. Is the pain worst at certain times? (Morning? Evening)?
8. How long does the pain last? (Hours? All day? At night?)
9. Does the pain keep you from performing your usual activities?
10. Is the pain related to certain activities?
11. Do you become easily fatigued when performing usual activities?
12. Do you have any other symptoms related to the pain?
13. Is there anything that relieves the pain?
14. On a scale of 0-10, how severe is your pain?

Ask the following questions about neck pain.

1. Do you have any pain in your neck?
2. Does the pain radiate to your arms?
3. Is there any numbness in your arms?
4. Does the pain radiate to your legs?
5. Is there any numbness in your legs?

Ask the following questions about joint pain.

1. Do you have pain in any of your joints?
2. Where is the pain located? (Have the patient point to the joint that has pain.)
3. Do you have pain in more than one joint?

Assess for Back Pain

According to the American Chiropractic Association, approximately 80-85% of the population will experience back pain at some point in their lives. Most of the time back pain will not have any underlying cause.
https://www.acatoday.org/Patients/Health-Wellness-Information/Back-Pain-Facts-and-Statistics.

When assessing for back pain use open-ended questions.

Ask the following questions about back pain.

1. Do you have any pain in your back?
2. Does the pain radiate to the lower extremities?
3. Is there any numbness in the lower extremities?
4. Does the pain radiate to the buttock area?

Assess for swelling, stiffness, and inflammation.

Usually, with swelling or stiffness, the patient will have a loss of range of motion. Swelling is normally associated with an articular joint. Stiffness is normally associated with pain in the joints especially with movement. Inflammation can be associated with systemic disorders.

Ask the following questions about swelling and stiffness.

1. Do you have stiffness early in the morning?
2. Do you have stiffness or swelling after strenuous activity?
3. Does the swelling or stiffness affect your ability to walk, run, stand from a sitting position, climb stairs, or use your hands?
4. Do you have pain in your joints associated with movement?

Ask the following questions about inflammation.

1. Asses the area of swelling or stiffness for redness, warmth, and tenderness.
2. Ask the patient if they have a fever, chills, rash, or weakness. These symptoms can be associated with conditions such as rheumatoid arthritis.

Tip #3 – Perform Inspection of the Musculoskeletal System.

A nursing health assessment of the musculoskeletal system involves inspection of the joints. Use inspection to assess the joints for symmetry. A problem in one joint can mean trauma. A problem in more than one joint can mean a systemic condition. Note the patient’s movements when performing the range of motion maneuvers. The movements should be smooth.

1. Check for joint deformities, muscle atrophy or abnormal positioning of the limb.
2. Assess for immobility in all joints.
3. Inspect the surrounding tissue and muscle for swelling,
4. Inspect the area for redness.
5. Assess the joint area for any skin abnormalities. (Different color, or protruding bony prominences.)
6. Listen for an audible crunching sound resonating from the joint. This sound indicates crepitus. Crepitus can also be palpated.
7. Observe the patients posture.
8. Note the position of the patients head and neck.
9. Assess the patient’s gait. A waddling gait could indicate a hip problem.
10. Note how the patient bears weight on each side as they walk.
11. Note the swing of the leg that is not bearing the weight as the patient walks.
12. Assess the knee as the patient walks. The knee should be extended when the heel strikes the ground and flexed when the leg is swinging.
13. Note how far the patient’s feet are apart while standing. The normal width is between 2-4 inches.

Tip #4 – Perform Palpation of the Musculoskeletal System.

Also, a nursing health assessment of the musculoskeletal system involves palpation of the joints. Palpate the joints and assess the temperature of the skin and the muscles. Palpate for warmth, tenderness, swelling or masses. If pain or tenderness are noted, further assess to specify the joint or structure involved. If there is any pain proceed carefully.

1. Use the back of the hand to palpate for warmth.
2. Compare the affected area with an unaffected area.
3. Palpate the bony landmarks of each joint.
4. Assess each area for pain.
5. Palpate each area for swelling especially in the synovial joint area.

If you need a list of the synovial joints click here for the article 7 Facts About the Skeletal System Every Nursing Student Should Know.

Tip #5 – Assess Range of Motion (ROM) – Shoulder.

Assess the shoulder joint for six (6) different movements. Those movements include extension, flexion, adduction, abduction, internal rotation, and external rotation. While the patient is performing theses movements observe the smoothness of the patient’s movements. Have the patient stand in front of you with their hands at their sides and follow your instructions. Make sure that the movements are performed on each side.

1. To test for flexion:
   With the elbows extended, have the patient to raise their arms forward to 90 degrees and over their head to 180 degrees.  
   
2. To test for extension:
   With the elbows extended, have the patient raise their arms backward 80 degrees.  
   
3. To test for adduction:
   With the elbows extended and at the patient’s side, have them move their arm across the front of their body to 90 degrees.  
   
4. To test for abduction:
   With the elbows extended and at the patient’s side, have the patient move their arms out to the side 90 degrees and then over their head 180 degrees. 
   
5. To test for internal rotation:
   With the elbows extended and at the patient’s side, have the patient move their arms behind their back, bend at the elbow and attempt to touch the opposite shoulder blade. 
   
6. To test for external rotation:
   With the elbows extended and at the patient’s side, have the patient raise their arm, bend the elbow and clasp the hands behind the head. 
   

Tip #6 – Assess Range of Motion (ROM) – Elbow.

Assess the elbow joint for four (4) different movements. Those movements include extension and flexion of the elbow. Also, additional movements include supination and pronation of the forearm.

1. To test for extension of the elbow:
   Have the patient straighten the elbow.
2. To test for flexion of the elbow:
   Have the patient bend the elbow.
3. To test for supination of the forearm:
   Have the patient extend the arms forward in front of them and turn the palms up as if to carry something.
4. To test for pronation of the forearm:
   Have the patient extend the arms forward in front of them and turn the palms down.

Tip #7 – Assess Range of Motion (ROM) – Wrist and Fingers and Thumb.

Assess the wrist for four (4) different movements. Those movements include extension, flexion, ulnar deviation, and radial deviation. Also, test the fingers for four (4) different movements. Those movements include flexion, extension, abduction, and adduction. Test the thumb for flexion, extension, abduction, and adduction, and opposition.

ROM in the wrist.

1. To test for extension:
   Have the patient extend one arm in front of them with the palm down. Then, have them point their fingers to the ceiling bending at the wrist.
2. To test for flexion:
   Have the patient extend one arm in front of them with the palm down. Then, have them point their fingers to the floor bending at the wrist. 
   
3. To test for ulnar deviation:
   Have the patient extend one are in front of them with the palm down on a surface. Then, have them move their entire hand from midline toward the fifth finger. The movement should be up to approximately 45 degrees.
4. To test for radial deviation:
   Have the patient extend one arm in front of them with the palm down on a surface. Then have them move their entire hand from midline toward the thumb. The movement should be up to approximately 20 degrees.  
   

ROM in the fingers.

1. To test for flexion:
   Have the patient extend their arm and make a fist with the thumb over the knuckles.
2. To test for extension:
   Have the patient straighten the fingers out from the fist position.
3. To perform abduction:
   Have the patient extend the arm and the hand, then spread their fingers apart.
4. To perform adduction:
   Have the patient bring the fingers back together

ROM in the thumb.

1. To test for flexion:
   Have the patient hold out their hand with their fingers together. Then, have them move their thumb across the palm and touch the base of the fifth finger (toward the ulnar side).
2. To test for extension:
   Have the patient hold out their hand with their fingers together.  Then, have them move their thumb away from the hand as far as possible.
3. To test for abduction and adduction:
   Have the patient hold out their hand with the palm up. Next, have them move their thumb away from the rest of the hand upwards (abduction) and back down with the hand (adduction).
4. To test for opposition:
   Have the patient hold out their hand in front of them and the palms up. Next, have the patient touch their thumb to each of the fingertips.

Tip #8 – Additional Assessments of the wrist, fingers, and thumb.

Hand Grip Test.

Assess the strength of a patient’s hand by performing the Hand Grip test. This is also a great assessment to perform during a neurological assessment. This movement tests the function of the muscles and joints of the fingers and wrist.

To perform the hand grip assessment, have the patient grasp two of your fingers on each hand and squeeze. When a patient has decreased grip, the results are positive. A positive result means weakness of the muscles of the hand and or wrist. Further assessment is necessary to find the cause.

Finkelstein’s Test.

The Finkelstein’s test assesses thumb movement and function. When performing this movement assess for any pain in the wrist on the thumb side of the hand. Pain when performing this maneuver can be an indication of a repetitive movement problem such as Quervain’s tenosynovitis.

To perform the Finkelstein’s test have the patient bend their thumb to the palm of the hand and grasp the thumb with the fingers of that hand (make a fist). The test is positive if there is any pain in the wrist.

Tinel’s sign.

The Tinel’s sign is used to test for nerve irritation. It is commonly used to test for Carpal Tunnel Syndrome although the test is not always definitive.

To perform the Tinel’s sign, with your fingers lightly tap over the area you which to test. For Carpal Tunnel Syndrome this is usually the median nerve which is located in the inner wrist. A positive test will elicit numbness or tingling along the distribution of the median nerve which will usually be the thumb, index finger, and middle finger.

Phalen’s Test.

The Phalen’s test is another test used to determine Carpal Tunnel Syndrome. Like the Tinel’s sign, it is not always definitive for diagnosis. The Phalen’s test assesses for median nerve compression.

To perform the Phalen’s Test have the patient place the back of their hands together in front of their body with the wrist flexed. Have the patient hold this position for at least one (1) minute. The test is positive if the patient complains of numbness or tingling in the thumb, index finger, or middle finger.

Tip #9 – Assess Range of Motion (ROM) – Cervical Spine.

Assess the cervical spine for mobility. Note the movements of the neck. Assess for flexion, extension, rotation, and lateral bending of the cervical spine.

ROM of the cervical spine.

1. To test the neck for flexion:
   Have the patient stand in front of you with the head facing forward. Next, have the patient bend the head forward and touch their chin to their chest.
2. To test the neck for extension:
   Have the patient stand in front of you with the head facing forward. Next, have the patient look at the ceiling.  
   
3. To test the neck for rotation:
   Have the patient stand in front of you with their head facing forward. Next, have the patient look over their shoulder toward one side then the other.
4. To test the neck for lateral bending:
   Have the patient stand in front of you with their head facing forward. Next, have the patient bring their ear to their shoulder on one side then the other ear to the other side.  
   

Tip #10 – Assess Range of Motion (ROM) – Spinal Column.

ROM of the spinal column.

Assess the mobility of the spinal column. Assess the movements of flexion, extension, rotation, and lateral bending.

1. To test for flexion:
   Have the patient bend forward and touch their toes without bending the knees. The movement should be smooth and symmetrical. Assess the lumbar spine are any deformities. Assess to see if the curvature in the lumbar spine flattens out.
2. To test for extension:
   Have the patient bend backward from a standing position as far as possible. Support the patient while performing this maneuver. Assess for decreased mobility or pain with movement.  
   
3. To test for rotation:
   Have the patient rotate the spine by turning side to side without moving their feet. Support the patient while performing this maneuver. Have the patient turn to one side then the opposite side as far as possible for that patient.
4. To test for lateral bending:
   Have the patient bend from side to side at the waist. Support the patient while performing this maneuver. Assess for decreased mobility.  
   

Do not force the patient further than they are capable of bending with any of these movements.

Tip #11 – Assess Range of Motion (ROM) – Hip.

Assess the range of motion of the hips. Test the movements of flexion, extension, abduction, adduction, external rotation, and internal rotation. To perform an assessment of the hip, place the patient in a lying position. Begin with the patient in a supine position or lying on their back.

1. To test for flexion:
   Place the patient in a supine position (on their back). Place your hand under the patients back at the lumbar spine. Have the patient raise the leg with the knee extended or a straight leg. This is hip flexion of 90 degrees. Observe the opposite knee to see if it remains extended. The opposite knee should remain flat. 
   
2. To test for extension:
   Place the patient in a prone position (on their stomach). Assist the patient in lifting their leg posteriorly. Assess the amount of extension in the hip.
3. To test for abduction:
   Place the patient in a supine position or have the patient in a standing position. Have the patient move their leg away from midline to the side. Limited abduction could indicate a problem with arthritis of the hip.
4. To test for adduction:
   Place the patient in a supine position or have the patient in a standing position. Have the patient move their leg toward the midline.  
   
5. To test for internal rotation:
   Place the patient in a supine position and have them bend their knee. Have the patient move their foot away from the midline as the knee moves toward the midline.
6. To test for external rotation:
   Place the patient in a supine position and have them bend their knee. Have the patient move their foot toward midline as the knee moves away from the midline.

Tip #12 – Assess Range of Motion (ROM) – Knee.

Assess the range of motion of the knee. Test the movements of flexion, extension, internal rotation, and external rotation.

1. To test for flexion:
   Have the patient bend the knee or squat. A problem with bending the knee could indicate arthritis or an injury.
2. To test the extension:
   Have the patient straighten the knee from a bent position or rise up from the squat. A problem with moving from a bent position to an extended position can also indicate arthritis or an injury.  
   
3. To test the internal rotation:
   Place the patient in a sitting position. Have the patient swing the lower leg toward the midline.
4. To test for external rotation:
   Place the patient in the same sitting position. Have the patient swing the lower leg away from the midline.

Tip #13 – Assess Range of Motion (ROM) – Ankle and Foot.

Assess the range of motion of the ankle and foot. Assess the movements of plantar flexion, dorsiflexion, inversion, and eversion.

1. To test the plantar flexion:
   Have the patient point their toes.
2. To test the dorsiflexion:
   Have the patient raise their toes toward the ceiling.  
   
3. To test for inversion:
   Have the patient bend their heel inward toward the midline.
4. To test for eversion:
   Have the patient bend their heel outward away from the midline.  
   

Conclusion

In conclusion, the tips above will help you with a nursing health assessment of the musculoskeletal system. For this nursing assessment, you will use the skills of inspection, palpation, and the assessment of range of motion. Assessment of the musculoskeletal system will help you identify any problems a patient may have with movements and performing activities of daily living. Also, for more information about the musculoskeletal system read the articles 7 Facts About the Musculoskeletal System Every Nursing Student Should Know and 9 Facts About the Skeletal System Every Nursing Student Should Know. 

Reference

Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins.

Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc.

Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc.

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