Musculoskeletal Structures (how to distinguish)

BONE  —  Provides Structure
·         Point Tenderness to Percussion
·         Radiating Tenderness to remote percussion
 
JOINT  —  Space Between Bones
·         Tender with any Passive ROM
 
LIGAMENT  —  Attach Bone-to-Bone
·         Tender to Passive ROM that stretches the injury
 
MUSCLE  —  Power Source to Move Distal Part of Limb
·         Tender to Palpation
·         Tender to Strength-Against-Resistance at site of Muscle
 
TENDON  —  Connect muscle to distal bone (across a joint)
·         Tender to strength-against-resistance (across joint, at site of tendon)
 
BURSA  —  Protect muscle and tendon from bony prominences
·         Tender to Palpation
·         Tender to all Active ROM, not Passive ROM
·         May be Painful at Rest
 
FASCIAL  COMPARTMENTS  —  Separate & organize anatomic structures
·         Pain & Tenderness of Involved Area
·         Distal Deficits of Sensation, Motor Strength, or Circulation
·         Compartment Syndrome is Limb-Threatening !!!
 
SKIN  /SUBCUTANEOUS TISSUE  —  Protection & Beauty
·         Tender to Superficial Palpation

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HOW TO PROCEED

1.  R/O Bone Disease.  Palpate, then percuss & pound, for tenderness.  If none, no bone disease (no X-Ray).

2.  Passive ROM for joint disease or ligament injury.  If non-tender (except perhaps at full flexion), there’s no Inflammatory Arthritis.

  • PROM tender in only one direction, suspect a Ligament, especially if also tender to palpation.
  • Osteoarthritis may not cause pain with PROM until a certain point in the range.

3.  Motor Testing (Strength-Against-Resistance)  —   Immobilize the joint & test strength in all the possible directions of joint ROM.  If one movement brings out the patient’s pain, that’s a Tendon strain or Tendonitis.

  • If pain with motor testing is over a Muscle, then that’s the source of symptoms.

4. Active ROM  —  If several AROMs of a joint hurt, but not PROM, & also not Motor Testing, it’s probably a Bursitis.  Tenderness to palpation over the bursa confirms it.

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