Musculoskeletal System

Prepared by:Dr. H.EL Sharkawy

To review the general anatomy of musculoskeletal system .

To know how to assess musculoskeletal system .

To know the common posture deformities & its rehabilitation .

Objectives

The Skeletal System

· Parts of the skeletal system· Bones (skeleton)· Joints· Cartilages· Ligaments (bone to bone)(tendon=bone to

muscle)

· Divided into two divisions· Axial skeleton- skull, spinal column· Appendicular skeleton – limbs and girdle

SkinMusclesBonesTendonsLigamentsCartilage

Musculoskeletal Structures

Holds all structures together Barrier function Protects underlying structures Subcutaneous tissue

◦ Fat◦ Fascia

Musculoskeletal Structures - Skin

Composed of specialized cells with ability to contract

Voluntary (Skeletal)◦ Conscious control◦ Allows mobility

Smooth (Bronchi, GI tract, blood vessels)◦ Controlled by ANS◦ Able to alter inner lumen diameter

Cardiac◦ Contracts rhythmically on its own

Musculoskeletal Structures -Muscle

Can only contract Skeletal muscle causes movement by

shortening resulting in pulling on bones through cord like bands

Musculoskeletal Structures -Muscle

Tendons◦ Bands of connective tissue binding muscles

to bones Cartilage

◦ Connective tissue covering the epiphysis◦ Surface for articulation

Ligaments◦ Connective tissue supporting joints◦ Attach bone ends to each other

Musculoskeletal Structures

Functions of Bones

· Support of the body

· Protection of soft organs

· Movement due to attached skeletal muscles

· Storage of minerals and fats

· Blood cell formation

Bones of the Human Body

· The skeleton has 206 bones· Two basic types of bone tissue

· Compact bone· Homogeneous

· Spongy bone· Small needle-like

pieces of bone· Many open spaces

Figure 5.2b

Classification of Bones on the Basis of Shape

Figure 5.1

Types of Bone Cells

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

· Osteocytes· Mature bone cells

· Osteoblasts· Bone-forming cells

· Osteoclasts· Bone-destroying cells· Break down bone matrix for remodeling and release

of calcium· Bone remodeling is a process by both osteoblasts

and osteoclasts

The Axial Skeleton

Slide 5.20a

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

· Forms the longitudinal part of the body· Divided into three parts

· Skull· Vertebral Column· Rib Cage

The Vertebral Column

· Vertebrae separated by intervertebral discs made of cartilage

· The spine has a normal S curvature

· Each vertebrae is given a name according to its location

A joint, or articulation, is the place where two bones come together.

Fibrous- Immovable:connect bones, no movement. (skull and pelvis).

Cartilaginous- slightly movable, bones are attached by cartilage, a little movement (spine or ribs).

Synovial- freely movable, much more movement than cartilaginous joints. Cavities between bones are filled with synovial fluid. This fluid helps lubricate and protect the bones.

Joints

Occur in 70-80% of all multi-trauma patients Blunt or Penetrating Upper extremity rarely life-threatening

◦ may result in long-term impairment Lower extremity associated with more severe

injuries◦ possibility of significant blood loss◦ femur, pelvic injuries may pose life-threat

Incidence/Mortality/Morbidity

Problem is not just the bone injury◦ Other injuries caused by the injured bone

Soft tissue Vascular Nervous system Decreased function

Incidence/Mortality/Morbidity

Sports Training Seat Belt use Child Safety Seat use Airbag use Gun Safety and Education Motorcycle education and protective

equipment Fall prevention Can you think of others?

Prevention Strategies

Look for asymmetry between sides Swelling Deformities Atrophy Erythema

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Inspection of Specific Area

Have patient range the joints Watch for decreased or increased movement

of the joint compared to the other side. Watch for pain with movement Listen for crepitus or “popping” Watch for abnormal movements

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Range of Motion (Active)

Next range the joints passively, comparing the end points to the active

Again note any decreased or increased movement

Pain with the movement Crepitus or “popping”

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Range of Motion (Passive)

When palpating a structure, you need to know the anatomy of that structure

Palpate for swelling Palpate for warmth Palpate each area of the structure in turn

evaluating for pain, and abnormalities as compared to the other side

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Palpation

Check the following comparing one side to the other:◦ Grade strength (0-5)◦ Grade reflexes (0-4)◦ Sensory exam( Types ) .

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Muscular and Neurological

Health History

Subjective Data -Chief Complaints – pain, altered sensation, limited motion

Family history, personal history, dietary history, socioeconomic status

Medications (steroids); Current health problems – obesity

Objective Data - Physical Exam Objective Data - Diagnostic Tests Special Assessment Techniques

◦ Ballottement◦ Bulge Sign◦ Phalen◦ Tinel’s

MusculoskeletalAssessment

History of injury? Any previous back or neck pain? Any positions of comfort? Family history? Previous illnesses, surgeries, or severe

injuries? Hx of other conditions (connective tissue

diseases such as Marfan’s Syndrome)?

Patient History

Footwear? Patient age? Growth spurt? In females, related to menarche/menses? In males, related to voice change Deformity progressive or stationary?

Patient History

Neurologic symptoms? Nature, extent, type, and duration of pain? Exacerbating activities or positions? Difficulty breathing? Previous treatment? Did it help?

Patient History

◦ Mental Status◦ General inspection◦ Head and neck: temporomandibular joint; crepitus◦ Height, weight, nutritional status, skin, spine –

lordosis, scoliosis, posture, joint function, upper and lower extremities

◦ Posture, gait, ROM ex., deep tendon reflexes, bone integrity, muscle strength and tone, neurovascular, MS injuries

Physical Exam

X-ray- determine density of the bone. Arthrogram- visualization of joint structure & movement. Diskogram- visualization of intervertebral disk abnormalitiy. Sinogram- visualizes course of sinus & tissues involved. CT- to identify soft tissue & bone abnormalities, and various

MS trauma. MRI- to view soft tissue- useful in the dx. Of ligament

tears, osteomyelitis, disk disease. Bone and Muscle Biopsy Ultrasonography

Musculoskeletal System Diagnostic tests

Body type◦ Ectomorph◦ Mesomorph◦ Endomorph

Observation

Assessment of Posture

Definition of posture Postural development Common spinal deformities HIPS

Overview

◦ Defined: “The position of the body at a given point in time.”

(Starkey) “A set of muscle contractions that place the body

in the necessary location from which a movement is performed.” (Enoka)

“The situation or disposition of the several parts of the body with respect to each other for a particular purpose.” (Webster)

What is posture?

What is good posture? Ideal posture serves as a

reference point. Ideal posture…

◦ Distributes gravitational stress for balanced muscle function.

◦ Allows joints to move in their mid range to minimize stress on ligaments and articular surfaces.

◦ Effective for the individual’s activities of daily living.

◦ Allows the individual to avoid injury.

Factors affecting posture◦ Bony contours◦ Laxity of ligamentous structures

Fascial & musculotendinous tightness

◦ Muscle tonus◦ Pelvic angle◦ Joint position & mobility

Postural Development

Good Spinal Posture

Any position that deviates from “good posture”◦ Static

Standing Sitting Sleeping

◦ Dynamic Running Throwing, etc.

What is bad posture?

Shoulder/Scapula◦ FSP Forward shoulder

posture ◦ Winging Scapula

Head and C-Spine◦ FHP(Forward Hip

posture

Commonly Seen Postural Deviations

History

Inspection

Palpation

Special (Functional) Tests

HIPS

Identify factors that influence posture

◦ Overuse◦ Neurological

Problems◦ Pain◦ Lack of awareness◦ Ms weakness/

Imbalance

Relevant History

◦ Hypermobile Jts◦ Hypomobile Jts◦ ST Flexibility◦ Bony Abnormality◦ Leg Length Disc.

◦ Use of a plumb line Anatomical reference 3 views

Lateral (sagittal plane movements)

Anterior (frontal/ transverse plane movements)

Posterior (frontal/ transverse plane movements)

Inspection

Look for:◦ @ ankle?◦ @ knee?◦ @ hip?◦ @ shoulder?◦ @ neck?◦ @ head?

Lateral View

Anterior view◦ Head straight on

shoulders◦ Shoulders level◦ Clavicles/AC joints◦ Sternum & ribs◦ Waist angles & arm

positions◦ Carrying angles◦ Iliac crests◦ ASIS◦ Patellae◦ Knees◦ Fibular heads

◦ Malleoli level◦ Arches◦ Foot rotation◦ Bowing of bones◦ Diastematomyelia (hairy

patches)◦ Pigmented lesions

Café au lait spots

Anterior view

Look for:◦ @ heel?◦ @ pelvis?◦ @ lumbar spine?◦ @ scapulae?◦ @ neck?◦ @ head?

Posterior View

In assessment position (i.e., standing), palpate:◦ Laterally

ASIS vs. PSIS◦ Anteriorly

Patellae Iliac Crests ASIS heights Lateral Malleolar heights Fibular Head heights Shoulder heights

Palpation

Posteriorly PSIS positions Spinal alignment Scapular positions

Slump Test Romberg Tandem walking Others designed to:

◦ Rule out bony restrictions

◦ Rule out soft tissue restrictions

◦ Assess muscular length ROM Resting muscle length

Functional Tests

Video Analysis 3D Motion Analysis REBA Rapid Entire

BodyAssessment (REBA)Posture assesment.

Sway Measurement Tools( posture sway measurment) .◦ Force Plate◦ Biodex Stability System◦ NeuroCom

Other Technology

Postural development Common spinal deformities Patient history Observation Examination

Overview

Correct posture◦ “Position in which

minimum stress is placed on each joint.” (Magee)

Faulty posture◦ Any position that increases

stress on joints

Postural Development

Birth› Entire spine concave

forward (flexed)› “Primary curves”

Thoracic spine Sacrum

Developmental (usually around 3 mos.)› Secondary curves› Cervical spine› Lumbar spine

Postural Development

Causes of poor posture› Positional factors

social factors . Muscle

imbalances/contractures Pain Respiratory conditions

› Typically can be managed conservatively through ex & education.

Postural Development

Causes of poor posture◦ Structural factors

Congential anomalies Developmental problems Trauma Disease

◦ Not typically easily managed .

Postural Development