10.3 General Musculoskeletal System Assessment

Risk Factors

Several risk factors can affect the health of the musculoskeletal system^{[1],[2],[3],[4]}:

• Age: With aging, the risk of musculoskeletal problems increases due to natural wear and tear on joints, decreased bone density, and reduced muscle mass. As individuals age, muscle fibers decrease in size and number. As a result, the muscle tissue can atrophy and deteriorate from a lack of use. As individuals age, they also experience the loss of minerals within the bones, specifically calcium and phosphorus.
• Genetics: Family history of conditions such as osteopenia, osteoporosis, arthritis, or scoliosis can increase risk for musculoskeletal disorders.
• Gender: Women are prone to musculoskeletal conditions like osteoporosis, especially after menopause, due to hormonal changes.
• Nutrition: Inadequate intake of essential nutrients like calcium and vitamin D can weaken bones, leading to conditions such as osteoporosis.
• Concurrent medical conditions: Conditions like lupus and other autoimmune diseases can affect the musculoskeletal system. Chronic conditions like cardiovascular or respiratory diseases can cause activity intolerance that affects an individual’s ability to exercise and maintain muscle strength and bone density. Chronic endocrine disorders or medications affecting hormone levels can also contribute to decreased bone density.
• Obesity: Excess body weight puts extra strain on the joints, particularly in the knees, hips, and spine, leading to increased risk of arthritis and other joint-related issues.
• Sedentary lifestyle: Lack of regular physical activity contributes to muscle weakness, reduced flexibility, and decreased bone density, all of which increase the risk of musculoskeletal problems.
• Smoking: Smoking is linked to decreased bone density and can impair the body’s ability to heal from musculoskeletal injuries.
• Occupational factors/Repetitive movements/Previous injuries: Jobs that involve repetitive movements, heavy lifting, or poor ergonomics can increase the risk of musculoskeletal injuries or conditions. Previous musculoskeletal injuries can also increase the risk of recurrent issues or chronic conditions.

Cultural Factors

Several cultural factors can impact musculoskeletal health. Dietary intake of calcium and vitamin D can be affected by cultural preferences for certain foods or dietary restrictions due to religious beliefs. Some cultures value intense physical training regimens, high-impact exercises, or martial arts that may increase risk for musculoskeletal disorders such as fractures, sprains, or strains. Additionally, cultural beliefs and stigmas about health care can impact musculoskeletal health if treatment is delayed.^[5],[6]

Socioeconomic Factors

Several socioeconomic factors may influence musculoskeletal health. Access to health care services plays a crucial role, as individuals with limited access may experience delays in diagnosis and treatment, leading to exacerbated musculoskeletal conditions. For example, individuals with limited health care resources may not seek treatment for a fracture or injury, allowing it to heal on its own and potentially resulting in limitation in function.

Socioeconomic status can impact access to nutritious food sources. Calcium, vitamin D, and adequate protein sources play a significant role in muscle and bone health and healing, but economic limitations can impact the ability to purchase foods with these nutrients. Additionally, physically demanding occupations can cause muscle strain or injury. For example, nurses are at risk for back injuries related to repositioning clients. Addressing socioeconomic determinants of health is vital for promoting improved musculoskeletal health across diverse populations.^[7],[8]

General Assessment of the Musculoskeletal System

Nurses and other health professionals assess factors that impact the musculoskeletal system, as well as signs and symptoms of disorders that affect movement and function.

Health History

Completing a detailed health history can provide cues for areas of potential concern in the musculoskeletal system, including obtaining a history of chronic musculoskeletal disorders and other illnesses, fractures, dislocations, sprains, and surgeries related to bones, joints, or muscles.

Assessing a client’s family history also contributes cues for potential musculoskeletal risks. For example, many musculoskeletal disorders like osteoporosis or scoliosis can have a genetic link.

Medications can also impact musculoskeletal health. For example, antibiotics such as fluoroquinolones increase the risk of tendonitis or tendon rupture. Additionally, prolonged use of corticosteroids also impacts musculoskeletal health by decreasing bone density and increasing risk for bone fracture.

Other important health history factors include exercise habits, occupation and repetitive stress, and dietary factors (specifically calcium and vitamin D intake). Additionally, congenital or developmental factors must be considered that affect musculoskeletal growth patterns.

If a musculoskeletal disorder is identified, a comprehensive pain assessment is completed, as well as a functional assessment to determine its impact on the ability to complete activities of daily living. This data is used to plan appropriate interventions and restore function.^[9]

Physical Examination

Conducting a thorough examination of body systems provides the nurse with cues regarding potential musculoskeletal disorders. Early identification of abnormal findings and notification of the health care provider can lead to prompt intervention and reduce long-term impact. Table 10.3 summarizes potential manifestations of musculoskeletal disorders.

Table 10.3. Manifestations of Musculoskeletal Disorders^[10],[11]

Life Span Considerations

Nurses consider characteristics of the pediatric and older adult populations during assessment.^[12]

Pediatric Considerations

• Infants lack muscle tone, power and coordination; they rely on the support and supervision of others to keep them stable and safe.
• Bones are soft until puberty and break and bend more easily. As a result of bones being more flexible, serious internal injuries can be present without fractures present.
• Infants and children have growth plates located between the middle and the end of the long bones. Fractures may occur that affect these growth plates and require medical care by a specialist.
• Children are physically active and typically require casts and splints to protect healing fractures.
• As infants and children grow, some bones fuse together. For example, the bones of the skull fuse during infancy and later. During the teenage years the ilium, ischium and pubis fuse together.
• Additional information may be obtained from the parent or legal guardian regarding the child’s history, such as history of hip dysplasia or previous fractures or difficulties with walking, jumping, or playing.

Older Adult Considerations

• With aging, the risk of musculoskeletal problems increases due to natural wear and tear on joints, decreased bone density, and reduced muscle mass.
• As individuals age, muscle fibers decrease in size and number. As a result, the muscle tissue can atrophy and deteriorate from a lack of use.
• As individuals age, they also experience the loss of minerals within the bones, specifically calcium and phosphorus.
• During subjective assessment of older adults, additional questions include use of assistive devices, recent falls/injuries, and ability to accomplish activities of daily living with or without assistance.
• Older adults may have limited mobility and range of motion due to age-related degeneration of joints and muscle weakness.

Diagnostic Assessment

When diagnosing and/or monitoring potential musculoskeletal disorders, blood tests and diagnostic imaging are often ordered by the health care provider. Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

Blood Tests

• Serum Calcium (Ca): Calcium is vital for preserving bone health. Abnormalities in calcium levels can indicate conditions such as osteoporosis. Decreased calcium levels can reduce bone strength and density.
• Vitamin D: Vitamin D works to facilitate calcium absorption. Low levels of vitamin D may impede calcium absorption.
• Phosphorus (Phos): Phosphorus has an inverse relationship with calcium to enhance bone mineralization. Low phosphorus levels reduce bone strength.
• Alkaline Phosphatase (ALP): Alkaline phosphatase is an enzyme that contributes to bone formation. Elevated levels of alkaline phosphatase can indicate the presence of bone tumors or conditions that impact bone growth and healing.
• Creatine Kinase (CK-MM): Creatine kinase is an enzyme found predominantly in skeletal muscle. Increased levels of creatine kinase indicate signs of muscle damage or injury.

Diagnostic Studies

• X-rays (Radiography): X-rays visualize bones and detect fractures, bone deformities, joint dislocations, and disorders affecting bone density.^[13],[14]
• Computed Tomography (CT Scan): CT scans create detailed, cross-sectional, three-dimensional images of bones, joints, and soft tissues that are useful for detecting complex fractures and evaluating bone tumors, joint abnormalities, and spinal conditions.^[15]
• Magnetic Resonance Imaging (MRI): MRI uses magnet and radio waves to generate detailed images of bones, joints, ligaments, tendons, and soft tissues. MRIs are very effective in diagnosing soft tissue injuries, cartilage damage, ligament tears, spinal cord injuries, and joint-related conditions. An MRI is particularly useful for assessing signs of inflammation/injury in tissue.^[16]
• Bone Density Scans (Dual-Energy X-ray Absorptiometry - DEXA or DXA): DEXA scans are specialized X-ray tests that measure bone mineral density. DEXA scans are primarily used to diagnose osteoporosis and assess fracture risk by evaluating bone density in the hip, spine, or other areas prone to fractures.^[17],[18]
• Ultrasound Imaging: Ultrasound imaging uses sound waves to create images of soft tissues, tendons, and muscles. Ultrasounds are commonly used to diagnose soft tissue injuries, tendon tears, and conditions affecting muscles and ligaments. Ultrasound is also useful in guiding certain musculoskeletal procedures, such as joint injections.^[19]
• Nuclear Medicine Scans (Bone Scans): Bone scans involve injecting a radioactive tracer into the bloodstream, which accumulates in areas of increased bone turnover or damage. These scans are useful for detecting bone infections, metastatic bone disease, stress fractures, and assessing overall bone health.^[20],[21]
• Electromyogram (EMG): An EMG is a diagnostic procedure that assesses the function of nerve cells that control muscles. Electrodes, either attached to the skin or inserted into the muscle, record electrical impulses. An EMG can identify functional problems with the peripheral nerves, muscles, or with the signals between the nerves and the muscles. During a needle EMG, a needle electrode inserted directly into a muscle records the electrical activity in that muscle. A nerve conduction study, another part of an EMG, uses surface electrodes applied to the skin to measure the speed and strength of signals traveling between two or more points. EMG results are used to diagnose muscle and nerve disorders.
• Arthrocentesis: A surgical puncture to aspirate fluid from a joint, such as the knee, for lab analysis and symptom relief. Lab analysis of the fluid can help determine the cause of swollen, painful joints. After aspiration of joint fluid, the health care provider may inject medications into the joint to temporarily ease pain and inflammation.
• Arthroscopy: A common procedure performed by orthopedic surgeons to view the inside of a joint to diagnose and/or to repair joint problems. After a local anesthetic is administered, the surgeon inserts a narrow tube attached to a fiber-optic video camera through a small incision. The view inside the joint is transmitted to a video monitor. Arthroplasty, surgical repair of a joint, may also take place during the procedure.