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NSG 3160 · Jarvis Ch. 23 · Quick Reference
Chapter 23: Musculoskeletal System
Normal vs. Abnormal Findings
Jarvis & Eckhardt (2024) 9th Ed. · pp. 573–627 · Unit 10
n Normal Finding n Abnormal Finding n Rationale / Clinical Note
n GENERAL EXAMINATION PRINCIPLES — ALL JOINTS
n NORMAL FINDINGS n ABNORMAL FINDINGS
Inspect: size, contour, skin color, swelling, masses, deformity — compare contralateral side.
Swelling = excess joint fluid (effusion), synovial lining thickening, bursae/tendon inflammation, or bony enlargement. Deformities: fracture, dislocation, subluxation, contracture, ankylosis.
Palpation: skin temperature, muscles, bony articulations, joint capsule — normally NOT tender.
Warmth + tenderness = inflammation. Palpable fluid = abnormal (push one side → visible bulge other side). Thickened synovial membrane feels "doughy" or "boggy."
ROM: active ROM first. If limited, attempt passive ROM. Normal active and passive ROM should be equal.
Limitation in ROM = most sensitive sign of joint disease. Articular disease (arthritis) = swelling/tenderness around whole joint, limits ALL planes in both active and passive. Extra-articular (specific tendon/ligament) = one spot, certain planes only, especially active motion.
Crepitation: discrete "crack" as tendon/ligament slips over bone during motion = NORMAL.
Crepitation = audible/palpable crunching or grating = articular surfaces roughened (RA).
Muscle Strength: equal bilaterally, fully resists opposing force. Grade 5 = 100% normal.
Grade < 5 = weakness. Grade 0 = no contraction. Grade 1 = trace contraction only.
Exam order for EVERY joint: Inspect → Palpate → ROM → Muscle Testing. Head-to-toe, proximal to distal. Always compare paired joints.
n JOINT-BY-JOINT NORMAL vs. ABNORMAL FINDINGS
TEMPOROMANDIBULAR JOINT (TMJ)
n NORMAL FINDINGS n ABNORMAL FINDINGS
Smooth motion of mandible into depression anterior to tragus of ear. Swelling: round bulge — must be moderate to be visible.
Audible/palpable snap or click as mouth opens = normal in many healthy people.
Crepitus + pain with movement/chewing = TMJ dysfunction. Malocclusion → palpable crepitus or audible click.
Vertical ROM: 3–6 cm (3 fingers sideways). Lateral ROM: 1–2 cm. Protrusion without deviation.
Decreased ROM = TMJ inflammation or arthritis. Lateral motion lost earlier than vertical.
Temporalis + masseter muscles firm and symmetric bilaterally on clenching.
Tenderness with palpation = TMJ dysfunction. Asymmetry of muscle strength.
n RATIONALE / CLINICAL NOTE
Tests CN V (trigeminal) integrity — jaw movement against resistance. Temporalis and masseter palpated with clenched teeth.
CERVICAL SPINE
n NORMAL FINDINGS n ABNORMAL FINDINGS
Spine straight, head erect. Spinous processes, sternomastoid, trapezius, and paravertebral muscles firm — no spasm or tenderness.
Head tilted to one side. Asymmetry of muscles. Tenderness + hard muscles = spasm. ~15% of population has neck pain; 80–90% have cervical disc degeneration.
ROM: Flexion 45°, Hyperextension 55°, Lateral bending 40°, Rotation 70°.
Limited ROM = arthritis. Pain with movement = arthritis or muscle overuse.
Maintains flexion against resistance (CN XI intact). Cannot hold flexion against resistance = CN XI (spinal accessory) dysfunction. n Do NOT attempt ROM if neck trauma suspected.
n RATIONALE / CLINICAL NOTE
Shoulder shrug + flexion against resistance also tests CN XI. RA: worse in morning, relieved by movement. OA: worse later in day.
SHOULDER
n NORMAL FINDINGS n ABNORMAL FINDINGS
No redness, atrophy, deformity, or swelling. Equal bony landmarks bilaterally. No crepitation on ROM.
Redness. Inequality of bony landmarks = scoliosis. Atrophy (lack of fullness) = rotator cuff problem or disuse. Dislocated shoulder = loses rounded shape, looks flattened laterally.
ROM: Forward flexion 180°, Hyperextension 50°, Internal rotation 90°, External rotation 90°, Abduction 180°, Adduction 50°.
Limited ROM, asymmetry, pain with motion, crepitus. Rotator cuff lesion = limited abduction + pain + spasm (forward flexion stays fairly normal). Positive drop arm test = rotator cuff tear.
Axilla: no adenopathy or masses. Subacromial area nontender. Swelling anteriorly = joint effusion (large amount needed). Subacromial bursa swelling under deltoid. Frozen shoulder (adhesive capsulitis) = stiffness, progressive limitation, unilateral nocturnal pain, unable to reach overhead.
n RATIONALE / CLINICAL NOTE
Shoulder pain may be referred from hiatal hernia, cardiac, or pleural condition — SERIOUS. Local cause reproduces pain with palpation or motion. SITS muscles = Supraspinatus, Infraspinatus, Teres minor, Subscapularis (rotator cuff).
ELBOW
n NORMAL FINDINGS n ABNORMAL FINDINGS
No deformity, redness, or swelling. Hollows present on either side of olecranon process. Tissues and fat pads feel fairly solid.
Subluxation = forearm dislocated posteriorly. Swelling/redness of olecranon bursa = olecranon bursitis (trauma, gout, RA). Effusion/synovial thickening = bulge or fullness in groove on either side of olecranon.
ROM: Flexion 150–160°, Extension 0° (some lack 5–10° or hyperextend 5–10°). Pronation/supination 90° each.
Soft, boggy/fluctuant swelling in both grooves = synovial thickening or effusion. Subcutaneous nodules at olecranon = RA (raised, firm, nontender, skin moves freely). Local heat or redness extends beyond synovial membrane.
Full extension after fall = usually rules out fracture. Epicondyle tenderness = "tennis elbow" (epicondylitis) — pain at lateral epicondyle, radiates down extensor surface of forearm, pain increases when resisting hand extension.
n RATIONALE / CLINICAL NOTE
Palpate with elbow flexed ~70°, as relaxed as possible. Ulnar nerve runs between olecranon and medial epicondyle — sensitive. Epicondylitis from excessive pronation/supination with extended wrist (racquet sports, screwdriver use).
WRIST & HAND
n NORMAL FINDINGS n ABNORMAL FINDINGS
Wrist in slight extension (functional position). Fingers straight, in same axis as forearm. No swelling, redness, deformity, or nodules. Knuckle wrinkles present. Rounded thenar and hypothenar eminences.
Ulnar deviation = fingers list to ulnar side (RA). Ankylosis = wrist in extreme flexion. Dupuytren contracture = flexion of 4th, 5th, 3rd digits (men > 40 yrs; DM, epilepsy, alcoholic liver disease). Atrophy of thenar eminence = carpal tunnel syndrome.
Foot aligned with long axis of lower leg. Weight bearing on middle of foot. Toes point forward and lie flat. Malleoli are smooth bony prominences. Smooth, even skin. ROM: Plantar flexion 45°, Dorsiflexion 20°, Eversion 20°, Inversion 30°.
Hallux valgus = great toe deviated away from midline + bunion. Hammertoes = hyperextension MTP + flexion PIP. Calluses, ulcers. Swelling/inflammation. Tenderness = arthritis or ligament trauma.
No calluses at abnormal sites. Joint spaces smooth and depressed — no fullness, swelling, or tenderness.
Plantar fasciitis = localized tenderness under heel; worse in morning or after rest; "throbbing, searing, or piercing." Risk: obesity, high arch, running, long standing. Achilles tenosynovitis = linear swelling along tendon sheath.
Normal shoe wear: more on outside of heel and inside of toe. Acute gout = redness, swelling, warmth, extreme pain at MTP of great toe; tophi = sodium urate crystals (hard nodules) with chronic gout. Ingrown toenail. Plantar wart = painful, tender side-to-side (callus = tender to direct pressure).
n RATIONALE / CLINICAL NOTE
Ottawa Ankle Rule: x-ray needed if pain near malleoli/midfoot AND inability to bear weight (4 steps) or bone tenderness. Plantar fasciitis self-limiting (6–12 months); treatments: rest, oral pain meds, steroids, stretching, orthotics, night splints.
SPINE
n NORMAL FINDINGS n ABNORMAL FINDINGS
Spine straight — vertical line from head through spinous processes to gluteal cleft. Equal levels of shoulders, scapulae, iliac crests, gluteal folds. Normal convex thoracic + concave lumbar curves on side view.
Scoliosis = lateral curvature with rotation. Functional (flexible) = disappears on bending. Structural (fixed) = present on standing and bending; rib hump on forward flexion. Unequal shoulder/scapula/iliac crest levels.
Spinous processes straight, not tender. Paravertebral muscles firm, no spasm. On forward bending: concave lumbar curve disappears → single convex C-curve. Dots on spinous processes form straight vertical line when standing.
Kyphosis = enhanced thoracic curve (common in aging and adolescent poor posture). Lordosis = pronounced lumbar curve (obesity, pregnancy). Lateral tilting + forward bending = herniated nucleus pulposus. If dots form S-shape = spinal curve present.
ROM: Flexion 75–90°, Hyperextension 30°, Lateral bending 35°, Rotation 30°. Straight leg raising causes no pain.
Low back pain + paravertebral muscle spasm. Limited ROM = OA, ankylosing spondylitis. Positive Lasègue (straight leg raising) test = sciatica / herniated disc — refers sciatic pain, patient resists further elevation. Fibromyalgia = chronic axial pain.
n RATIONALE / CLINICAL NOTE
Ankylosing spondylitis: inflammatory back pain, morning stiffness ≥30 min decreasing with activity, onset ≤45 years, more common in males. Herniated disc: >70% occur at L4-L5 or L5-S1. Sciatic pain (radicular) is the presenting complaint.
n SPECIAL TESTS — POSITIVE vs. NEGATIVE
Test Negative (Normal) Positive (Abnormal) Indicates
Phalen Test No symptoms after 60 sec wrists flexed 90° back-to-back
Numbness + burning in thumb/index/middle finger
Carpal Tunnel Syndrome
Tinel Sign No symptoms on percussion of median nerve at wrist
Burning + tingling along median nerve Carpal Tunnel Syndrome
McMurray Test Leg extends smoothly, no pain with external rotation + valgus stress
Audible or palpable "click" Torn Meniscus → refer to orthopedics
Bulge Sign No bulge seen on medial side after lateral tap
Visible bulge on medial side = fluid wave 4–8 mL knee effusion; high risk for OA progression
Ballottement of Patella Patella already snug against femur — no tap felt
Patella bounces off femoral condyles with a tap
Large amount of knee fluid
Ortolani Maneuver (Infant)
Smooth, no sound during hip abduction
Clunk as femoral head pops back into acetabulum
Developmental dysplasia of the hip → REFER
Allis Test (Infant) Both knees at equal elevation when feet flat
One knee significantly lower Hip dislocation
Thomas Test Opposite thigh remains flat on table during hip flexion
Opposite thigh rises off table Flexion deformity in the opposite hip
Straight Leg Raising / Lasègue
No pain when raising leg with extended knee
Reproduces/worsens sciatic pain; patient resists further elevation; dorsiflexion increases pain
Herniated disc / sciatica → refer
Drop Arm Test Person sustains abducted arm position
Cannot sustain position; shrugs or hitches shoulder forward
Rotator cuff tear
Get Up and Go Test (Aging)
Completes rise-walk-turn-return-sit in < 12 seconds
≥ 12 seconds ↑ Risk of falls in adults > 60 years
n DEVELOPMENTAL FINDINGS — NORMAL vs. ABNORMAL
n NORMAL FINDINGS n ABNORMAL FINDINGS
INFANTS — Feet in varus/valgus (residual fetal positioning). If flexible = self-correctable. Metatarsus adductus at birth — usually resolves by age 3. Single C-curve spine. Clavicles smooth/regular. Normal palmar creases bilateral.
INFANTS — Fixed deformity (not correctable). Tibial torsion > 20°. Positive Ortolani sign (hip clunk) = dislocation → REFER. Positive Allis sign (unequal knee height) = hip dislocation. Fractured clavicle = irregularity, crepitus, limited ROM, unilateral Moro. Tuft of hair over dimple in midline = spina bifida. Dermoid sinus. Polydactyly (extra digits). Syndactyly (webbing). Single palmar crease = Down syndrome. Baby "slips" when lifted by axillae = shoulder weakness.
CHILDREN — Lordosis throughout childhood. Genu varum normal for 1 year after walking. Genu valgum normal ages 2–3.5 years. Flatfoot normal until age 3. Pigeon toes usually self-correct if flexible. Normal gait: broad-based ages 1–2, narrows by age 3.
CHILDREN — Genu varum > 2.5 cm persistent (also with rickets). Genu valgum > 2.5 cm (rickets, polio, syphilis). Pes planus after age 3 (Marfan, Down, CP, obesity). Severe or asymmetric in-toeing with femoral anteversion. Limp (trauma, fatigue, hip disease). Osgood-Schlatter disease = tibial tubercle enlargement + tenderness. Subluxation of radial head (ages 2–4 = nursemaid's elbow). Inability to supinate + elbow pain = nursemaid's elbow.
ADOLESCENTS — Proceed with adult musculoskeletal exam. Kyphosis from poor posture is common. USPSTF does NOT support routine scoliosis screening of asymptomatic adolescents.
ADOLESCENTS — Scoliosis: rib hump on forward bend, unequal shoulder/scapula/iliac crest levels. Idiopathic scoliosis most common in adolescent females during peak growth spurt. Sports-related injuries peak in this age group.
PREGNANCY — Progressive lordosis (normal). Anterior cervical flexion + slumped shoulders (normal compensation). Increased joint mobility. Waddling gait at term.
PREGNANCY — Low back pain from lordosis and muscle strain. Upper extremity aching, numbness, weakness (ulnar/median nerve pressure in 3rd trimester).
AGING ADULTS — Decreased height 3–5 cm (disc thinning, vertebral loss). Kyphosis with backward head tilt. Slight hip and knee flexion. ↓ Muscle mass. Bony prominences more marked.
AGING ADULTS — Get Up and Go ≥ 12 seconds = ↑ fall risk. Osteoporosis (especially postmenopausal White women). ↑ Falls → fractures (wrist, hip, vertebrae). Muscle tremors (hands, head, jaw). Dyskinesias. Sedentary lifestyle hastens changes.
n MAJOR CONDITIONS — MULTI-JOINT ABNORMALITIES
Condition Key Features Joint Pattern Report/Refer
Rheumatoid Arthritis (RA)
Autoimmune, chronic inflammation. 2.5× more in women. Ages 30–60. Morning stiffness > 1 hr (improves with movement). Fatigue, low-grade fever, lymphadenopathy, weight loss. ↑ CV risk.
SYMMETRIC, bilateral. Heat, redness, swelling, painful motion. Ulnar deviation, swan-neck, boutonnière, RA nodules, crepitus.
YES — Refer. Anti-inflammatory treatment needed.
Osteoarthritis (OA) Noninflammatory, progressive. Articular cartilage deterioration + osteophyte formation. Worse later in day. Hard bony enlargements (Heberden/Bouchard nodes). Pain with motion, stiffness.
ASYMMETRIC. Hands (DIP/PIP), knees, hips, spine. Affects one or few joints.
Manage symptoms. Refer if ROM severely limited.
