musculoskeletal assessments learner guide€¦ · version control document: hltmsg003...

Musculoskeletal Assessments

Learner Guide

Version Control Document: HLTMSG003 Musculoskeletal Assessment 0617 of 71

UNITS COVERED:

HLTMSG003 Perform remedial massage musculoskeletal assessments: This unit describes

the skills and knowledge required to assess the needs of clients presenting with soft tissue dysfunction, musculoskeletal imbalance or restrictions in range of motion (ROM). It requires the ability to gather client information, conduct specific tests and bring information together to develop a remedial massage treatment plan. There is a strong focus on functional anatomy.

METHOD OF DELIVERY: Each session is of 3 hours duration and is a combination of theory and practical hands on work. There are 10 sessions in total. Hand out notes and session review sheets are provided and students are advised that some note taking is recommended. Two ways sharing of information and experience is encouraged in all classes. RESOURCES REQUIRED: Students are required to bring their own stationary and dress casually to prevent damage to good clothes. Students are also required to bring two towels to each class. All other required resources to facilitate learning will be supplied by MSQ. Recommended reading and references:

1. Musculoskeletal Assessment, 2nd

Ed, Jeffrey Gross, Joseph Fetto, Elaine Rosen, 2002, Blackwell Publishing

2. Orthopaedic Physical Assessment, third edition. David J. Magee, 1997, W.B. Saunders Company 3. Physical examination of the spine extremeties Stanley Hoppenfeld, 1976, Appleton & Lange. 4. Physical Assessment 3rd Edition, Dr. Nikita Vizniak, 2010 5. Professional Health Systems www.prohealthsys.com

http://www.prohealthsys.com/


CONTENT

Session 1: Review of Certificate IV in Massage Therapy Session 2: Medications, Diagnostic Imaging and Assessment Principles Session 3: Client History and Observation Session 4: Assessment – Palpation Session 5: Assessment – Shoulder Session 6: Assessment – Elbow/Wrist Session 7: Assessment – Hip Session 8: Assessment – Knee/Ankle Session 9: Assessment – Vertebral Column Session 10: Core stabilisers and joint stability assessment strategies


SESSION 1 : Introduction to Advanced Assessment

Scope of practice – Certificate IV in Massage

Interview Students are expected to conduct an interview demonstrating good communication skills including

positive body language. They should be able to demonstrate the ability to ask relevant questions

concerning the client’s general overall health and any specific health concerns the client may have.

Relevant questions include

Do you have pain?

If so - where

how long for

was there a cause

what level of pain 1-10 currently, and at worst

what aggravates pain

what alleviates pain

Students must be able to recognize an acute inflamed condition and differentiate from a chronic

condition and recognize contraindicated conditions, e.g. bursitis, acute ankle sprain.

Gait analysis Students should be able to conduct a simple gait analysis to determine any gross dysfunctions in gait

that the client may present with, and to recognize if they represent a contraindication to massage, i.e.

acute ankle sprain

Postural Assessment Students should be able to view the client in the frontal and sagittal position to determine any gross

(obvious) postural anomalies which may be visible and may/may not contribute to the client’s

condition, i.e. Tx kyphosis, forward head posture in a client presenting with chronic headache.

Local assessment Students are to demonstrate an ability to assess a local area of concern to the client for signs of

contraindications to massage such as physical deformation due to possible fractures, acute

inflammation, skin conditions, palpation for sensitivity and tenderness, muscle tightness or

hypertension in tissues.

ROM testing Students are expected to be aware of normal ROM for major articulations and to be able to assess

ROM for Cx, Tx, Lx, and shoulder, elbow, wrist, hip, knee and ankle joints.

Students should be able to conduct 2 global movement tests, the squat test for hips, knees, and ankles,

and the Apley-scratch test for shoulder ROM.


Muscle strength testing Students should be able to conduct simple muscle strength tests for major muscles.

The movements to test include

Shoulder ROM, Elbow flexion-extension, wrist flexion-extension

Hip ROM, knee flexion-extension, ankle dorsiflexion-plantarflexion.

Students should be able to compare these muscle contractions bilaterally to determine if weakness

exists in a given muscle.

Special tests Students must show competence in 3 special tests

The Valsalva test

The vertebral artery test

Supraspinatus impingement test and/or Hawkins Kennedy test

Students are expected to know what a positive test result implies and whether to treat or refer in this

case.

After conduction of a thorough assessment of the client the Cert IV therapists is expected to explain the

probable benefit to the client of the treatment to be provided and also to explain in complex cases that

the massage should not be expected to give the client an improvement in their condition but only to

alleviate tension and/or stress and improve the clients sense of overall well being.

The student is expected to refer the client to a more suitable practitioner for more complex cases if

required.

Bioenergetics Concept Legal and ethical considerations Common Contra-indications for massage The Inflammatory Process Communicating with other health professionals The Aging Process

Bioenergetics Concept

Bioenergetics is the science of energy transfer in living systems. Energy is fundamental to life and is clearly of utmost importance when considering how to optimize training or performance. From an elementary perspective, bioenergetics may be viewed as a simple process of transferring energy.

Here’s an example:

Common food source, such as a potato

Eaten by a human

Undergo digestion and absorption


Blood glucose conversion in the liver

Substrate supplies the muscle with a usable energy, adenosine tri phosphate (ATP)

Enable muscle contraction

Manifest a desired effort or movement for exercise


Legal and ethical considerations 10 rules for professional practice I SHALL:

1. Practice in a competent, caring and responsible manner 2. Keep up to date with developments in clinical techniques and professional and social issues 3. Practice within the scope of my experience and understand and respect my limits 4. Practice from premises and use substances that are safe, legally compliant and conductive to the

healing process 5. Practice in accordance within the ethical precepts of my profession 6. Compile and maintain thorough and legal client records 7. Maintain professional indemnity insurance for the protection of my client and myself 8. Respect the confidence of the therapeutic relationship to promote trust and confidence in my

profession and myself 9. Provide accurate information to my client to allow proper decision-making and consent to treatment 10. Place my client’s interest above my own

Action plan for massage therapists:

Don’t diagnose

Don’t manipulate

Don’t massage where it may cause or aggravate injury or cause adverse skin reactions

Be sensitive to client privacy and the need for careful practices with regard to disrobing

Take great care in advertising to attract genuine clientele

Take precautions for your personal safety Weir, M. (2011) LAW and ETHICS in COMPLEMENTRY MEDICINE 4th edition. Allen and Unwin. Sydney Common Contra-indications for massage Acute injury: RICE – Rest, Ice, Compression, Elevation Acute inflammation: bleeding occurs in tissue fibres that are torn from a trauma. This bleeding causes the skin to feel hotter and appear reddened as well as swollen. Massage at this stage will cause further damage to the torn fibres causing them to bleed even more. The Inflammatory Process Inflammation is a tissue response to damage or the threat of invasion by antigens (non-self items), and is typically caused by :

Physical injury (trauma, chemical burn, hypothermia)

Invasion with foreign bodies (pathogens, splinter, shrapnal)

Hormonal changes

Autoimmune activity The purpose of inflammation is to:

Protect the body from pathogenis invasion

Limit the range of contamination

Prepare for tissue healing


Inflammation leads to:

Complete resolution with no significant tissue changes

Accumulation of scar tissue

Formation of cysts or abscesses

Chronic inflammation Common Signs and Symptoms of inflammation

Pain

Redness

Swelling

Sometimes loss of function (joint range of motion)

In some cases, itching, clotting and pus formation Stages of healing Acute stage (1-3days)

Damaged cells release chemicals causing vasoconstriction and dilation, accumulation of fluid between cells (eodema), and the attraction of platelets and fast moving white blood cells

Subacute stage (2-3weeks) Specific cells accumlate and work to fill in damages cells. Endothelial cells help build new capillaries while fibroblasts spin new collagen fibres to make scar tissue. White blood cells clean up dead pathogens and other cell debris

Postacute stage Remodelling of collegen fibres occurs, and with appropriate rehabilitation, new collegen fibres will lie down in alignment with unijuried fibres


Open wounds: Massage over an open wound will cause further damage to the tissue and encourage infection into the wound and potentially cause harm to the therapist from cross contamination. Bone fractures: Pressure caused by even the smallest manual manipulation of soft tissue or joint joint play mobilising will aggravate the fracture and cause further damage as well as a great deal of pain. If there is a possibility of a fracture, an X-ray should be performed first. Joint Dislocations: If you suspect a dislocation (common is shoulder or fingers) it should first to assessed by a doctor. Soft tissue around the dislocation may be in a acute inflammation and massage should be avoided as mentioned for the reasons above. Joints in the body can be immovable, slightly movable or freely movable. Synovial joints, freely movable joints, are the most vulnerable to injury. Lack of movement in these joints results in lack of synovial fluid, while too much movement can damage cartilage. Excessive force to a joint can cause dislocation

Deep Vein Thrombosis (DVT): A blood clot (common in the calf) can be dislodged with the application of massage techniques causing the clot to travel through the circulatory system, potentially ending in the heart or the lung. This can lead to death. A travelling clot is called an Embolism. If you suspect a DVT, the client must be referred to the hospital. Elderly people with a sedentary lifestyle are most at risk. Varicose veins: Massage is safe for clients with varicose veins, except over the direct site of the varicose veins. These veins are brittle and delicate and damage can occur easy to the vein walls causing sudden severe bleeding. Bleeding Disorders: Conditions where normal blood clotting is affected (Haemophilia), massage may cause trauma and bleeding easily and should be avoided. Contagious conditions: Fever is the most common symptom of these, and clients should be avoided during these times as cross contamination may occur to the therapist themselves.


Contagious skin disorders:

Boils – local bacterial (commonly staphylococcal) infections

Cellulitis – bacterial infection (streptococcal) infection

Fungal infections – tinea most common

Herpes simplex – viral infection resulting in painful blisters common around mouth or genitals

Warts – viral infection in epidermis

Skin cancer

Communicating with other health professionals Effective communication with other health care professionals is very important.

It is potentially helpful in the care of specific clients

It affects your image as a professional health care professional, and helps create the degree of respect you will be accorded in the present and the future

It affects the image of the bodywork profession as a whole and will ultimately determine the degree of acceptance we all achieve

Some good policies to follow for your referral:

Ask clients to tell their own health care providers to feel free to contact you

With the client’s consent, write letters to other health care providers to inform them about your assessment and treatment of the client and the results you obtained

If another health care provider refers a client to you, then write a letter of thanks and includes your report, with your client’s consent.

Health care providers, Community Resources and Support Services

Health Care Professionals General Practitioners (GPs) Physiotherapists Chiropractors Personal Trainers Dietitians Naturopaths Professional Counselors Clinical Psychologists Osteopaths Chinese herbalists Corrective Exercise Specialists Other massage therapists Acupuncturists

Support Services

Domestic violence telephone service

Lifeline

Local child care centre

Local church groups

Local welfare centre


The Aging Process Besides grey hair and wrinkles, there will be many changes occurring to your own body as you age. Cardiovascular system

Slower heart rate

Heart hypertrophy (increase in size)

Blood vessels and arteries become stiffer, making it harder for your heart to pump blood around the body, which can lead to hypertension

What you can do to promote heart health:

Regular moderate physical activity can help you maintain a healthy weight, lower blood pressure and lessen the extent of arterial stiffening

A healthy diet can help you keep your heart and arteries healthy Don't smoke. Smoking contributes to the hardening of your arteries and increases your blood

pressure and heart rate Manage stress. Stress can take a toll on your heart. Take steps to reduce stress — or learn to

deal with stress in healthy ways. Skeletal, Articular and Muscular System

Bones tend to shrink in size and density — which weakens them and makes them more susceptible to fracture. You might even become a bit shorter

Joints become worn out from regular use, particularly load bearing joints such as knees and hips

Muscles generally lose strength and flexibility, and you might become less coordinated or have trouble balancing

What you can do to promote bone, joint and muscle health:

Get adequate amounts of calcium. Dietary sources of calcium include diary products, almonds,

broccoli, kale, canned salmon with bones, sardines and soy products, such as tofu Get adequate amounts of vitamin D. Although many people get adequate amounts of vitamin

D from sunlight, this might not be a good source for everyone. Other sources of vitamin D include oily fish, such as tuna and sardines, egg yolks, fortified milk, and vitamin D supplements

Include physical activity in your daily routine. Weight-bearing exercises, such as walking, jogging, tennis and climbing stairs, and strength training can help you build strong bones and slow bone loss

Avoid substance abuse. Avoid smoking and don't drink more than two alcoholic drinks a day.

Balance and coordination exercises, can help reduce the risk of falls

Physical activity can delay the progression of osteoporosis

Weight-bearing exercise, such as walking or weight training, helps to maintain bone mass

Stretching helps to maintain joint flexibility.


Digestive system

Constipation is more common in older adults. Many factors can contribute to constipation, including a low-fibre diet, not drinking enough fluids and lack of exercise

What you can do to prevent constipation:

Eat a healthy diet. Make sure your diet includes high-fibre foods, such as fruits, vegetables and

whole grains. Limit meats that are high in fat, dairy products and sweets, which might cause constipation.

Drink plenty of water and other fluids. Include physical activity in your daily routine. Regular physical activity can help prevent

constipation and is important for your overall health. Don't ignore the urge to have a bowel movement. Holding in a bowel movement for too long

can cause constipation.

Urinary System

Bones tend to shrink in size and density — which weakens them and makes them more susceptible to fracture

Loss of bladder control (urinary incontinence) is common with aging. Diabetes, menopause and an enlarged prostate might contribute to incontinence.

What you can do to promote bladder and urinary tract health:

Go to the bathroom regularly. Consider urinating on a regular schedule, such as every hour.

Slowly, extend the amount of time between your bathroom trips. Maintain a healthy weight Tighten your pelvic floor muscles Don’t smoke

Nervous System

It might take longer to learn new things or remember familiar words or names as memory tends to becomes less efficient on older we get.

What you can do to keep your memory sharp:

Eat a healthy diet (fruits, vegetables, whole grains, and low-fat protein sources, such as fish, lean meat and skinless poultry), as a heart healthy diet might benefit your brain. What you drink counts, too, so avoid excessive alcohol

Physical activity might help keep your memory sharp as it increases blood flow to your whole body, including your brain.

Stay mentally active (cross words, learn a new language or musical instrument). Mentally stimulating activities help keep your brain in shape and might keep memory loss at bay.

Be social! Social interaction helps ward off depression and stress, which can contribute to memory loss.


Integumentary System

With age, your skin thins and becomes less elastic and more fragile. You might notice that you bruise more easily. Decreased production of natural oils might make your skin drier. Wrinkles, age spots and small growths called skin tags are more common.

What you can do to keep your skin healthy:

Be gentle on older skin. Use milder soaps and moisturiser, sunscreen and wear protective clothing. Get your skin checked!

Don’t smoke as it contributes to skin damage such as wrinkles Physical activity might help keep your memory sharp as it increases blood flow to your whole

body, including your brain. Stay mentally active (cross words, learn a new language or musical instrument). Mentally

stimulating activities help keep your brain in shape and might keep memory loss at bay. Be social! Social interaction helps ward off depression and stress, which can contribute to

memory loss. Musculoskeletal System

Maintaining a healthy weight can be more difficult as you get older because muscle mass decreases and body fat takes its place. You need fewer calories to maintain your weight as fat tissue burns less calories than muscle does.

What you can do to prevent unwanted weight gain and maintain muscle:

Include physical activity with some load bearing exercises, regular moderate activity is the

best combination Eat a health diet (limit sugar and foods high in saturated fat) Watch your portion size, you might not need as many calories as you used to

Reproductive System

Sexual needs, patterns and performance might change with age. Vaginal dryness and impotence can be common.

What you can do to promote your sexual health:

Share concerns and needs with your partner Talk to your doctor


SESSION 2 : Medications, Diagnostic Imaging and Assessment Principles

Medications Diagnostic Imaging: X-RAY CASE STUDY: Adult Spondylolisthesis in the Low Back Principles of assessment Sequential method of assessment Factors that may have a negative impact on assessment

Medications Massage therapists are always encouraged to ask about what medications their client is taking or has taken in the past. The main reasons we do this is:

1. To determine what conditions a client has had or currently has, or 2. To determine possible interactions that massage will have with the client (precautions)

Common medications used by your clients may include: Antianxiety drugs

Effect: Alter sympathetic (flight-or-fight response) nervous system Side effects: CNS depression, poor reflexes, dry mouth, unusual exhaustion Massage: Extra stimulation at end to avoid dizziness and fatigue at the end of the massage

Antidepressants

Effect: Prolong availability of neurotransmitters in brain synapses Side effects: Agitation, increased anxiety, headaches, insomnia, dry mouth, constipation, reduced

sexual function, bladder problems, increases heart rate, dizziness Massage: Extra stimulation at end to avoid dizziness and increase alertness

Anti-inflammatories and analgesics

Effect: Reduce pain Side effects: Altered tissue response, fluid retention, easy bruising Massage: Avoid overtreatment and caution with deep pressure

Cardiovascular drugs

Effect: Minimise sympathetic response or dilate peripheral blood vessels, lower blood pressure, regulate heart rate

Side effects: Dizziness, flushing, hypotension, abdominal pain, Massage: Extra stimulation at end to avoid dizziness, care when sitting up

Clot management drugs Effect: Prevent clot formation, prevent platelet clumping and dissolve pre-existing clots Side effects: Dizziness, flushing, hypotension, abdominal pain Massage: Mostly contraindicated. Light pressure to avoid bruising

An atheroma is a deposit or degenerative accumulation of lipid-containing plaques on the innermost layer of the wall of an artery. Atherosclerosis is a common type of atheroma and is an unhealthy condition, but is found in most humans. Atheroma is the root cause of various cardiovascular diseases such as angina, heart attack, stroke and peripheral vascular disease.


Diabetes management drugs Effect: Insulin supplementation Side effects: Hypoglycemic episode Massage: Avoid injection sites, juice and/or candy available, massage reduces blood glucose

Muscle relaxants

Effect: Reduce spasms by suppressing reflexes Side effects: Reduced muscle protection against stretch Massage: Caution with deep tissue work, range of motion exercises, stretching

Thyroid supplement drugs

Effect: Replace thyroid secretions, boost protein synthesis, increase heart rate Side effects: Nervousness, agitation, insomnia – no long term side effects Massage: Recommended for side effects

Diagnostic Imaging: X-RAY Conventional plain film radiography (also called X-rays) is the primary means of diagnostic imaging for musculoskeletal problems. It offers the advantages of being readily available, being relatively cheap, and providing good anatomic resolution. On the negative side, it does expose the client to radiation, and it offers poor differentiation of soft-tissue structures. Although it is important, radiographic examination is usually used only to confirm a clinical opinion. Radiographs are not taken indiscriminately. Because x-rays have the potential for causing cell damage, there should be a clear indication of need before a radiograph is taken, and the process should not be considered routine. Normally, two projections at 90 deg orientation to each other are taken-most commonly, anteroposterior (AP) and lateral projections. Other views may be obtained, depending on clinical circumstances and specific needs. In the lumbar spine, AP, Lateral, and oblique views are commonly taken. Two views are necessary be-cause X-rays take planar images, so that all structures in the path of the x-ray beam are superimposed on each other and abnormalities may be difficult to evaluate with only one view. X-rays are part of the electromagnetic spectrum and have the ability to penetrate tissue to varying degrees. X-ray imaging is based on the principle that different tissues have different densities and produce images in different shades of grey. The greater the density of the tissue, the less penetration of X-rays there is, and the whiter its image appears on the film. In order of descending degree of density are the following structures: metal, bone, soft tissue, water, fat, and air. These differences give the six basic densities on the x-ray plate. When viewing the x-rays, the therapist must identify the film, noting the name, age, date, and sex of the client, and must identify the type of projection taken (e.g., AP, lateral, tunnel, skyline, weight-bearing, stress type).


CASE STUDY: Adult Spondylolisthesis in the Low Back

In spondylolisthesis, one of the bones in your spine — called a vertebra — slips forward and out of place. This may occur anywhere along the spine, but is most common in the lower back (lumbar spine). In some people, this causes no symptoms at all. Others may have back and leg pain that ranges from mild to severe. Types of Spondylolisthesis Many types of spondylolisthesis can affect adults. The two most common types are degenerative and spondylolytic. There are other less common types of spondylolisthesis, such as slippage caused by a recent, severe fracture or a tumor. Degenerative Spondylolisthesis

As we age, general wear and tear causes changes in the spine. Intervertebral disks begin to dry out and weaken. They lose height, become stiff, and begin to bulge. This disk degeneration is the start to both arthritis and degenerative spondylolisthesis (DS). As arthritis develops, it weakens the joints and ligaments that hold your vertebrae in the proper position. The ligament along the back of your spine (ligamentum flavum) may begin to buckle. One of the vertebrae on either side of a worn, flattened disk can loosen and move forward over the vertebra below it. This slippage can narrow the spinal canal and put pressure on the spinal cord. This narrowing of the spinal canal is called spinal stenosis and is a common problem in patients with DS. Women are more likely than men to have DS, and it is more common in patients who are older than 50. A higher incidence has been noted in the African-American population.


Symptoms of Degenerative Spondylolisthesis

Patients with DS often visit the doctor's office once the slippage has begun to put pressure on the spinal nerves. Although the doctor may find arthritis in the spine, the symptoms of DS are typically the same as symptoms of spinal stenosis. For example, DS patients often develop leg and/or lower back pain. The most common symptoms in the legs include a feeling of vague weakness associated with prolonged standing or walking. Leg symptoms may be accompanied by numbness, tingling, and/or pain that is often affected by posture. Forward bending or sitting often relieves the symptoms because it opens up space in the spinal canal. Standing or walking often increases symptoms.

Spondylolytic Spondylolisthesis

In spondylolysis, a fracture often occurs at the pars interarticularis. One of the bones in your lower back can break and this can cause a vertebra to slip forward. The break most often occurs in the area of your lumbar spine called the pars interarticularis.


In most cases of spondylolytic spondylolisthesis, the pars fracture occurs during adolescence and goes unnoticed until adulthood. The normal disk degeneration that occurs in adulthood can then stress the pars fracture and cause the vertebra to slip forward. This type of spondylolisthesis is most often seen in middle-aged men.

Because a pars fracture causes the front (vertebra) and back (lamina) parts of the spinal bone to disconnect, only the front part slips forward. This means that narrowing of the spinal canal is less likely than in other kinds of spondylolisthesis, such as DS in which the entire spinal bone slips forward.

Symptoms of Spondylolytic Spondylolisthesis Most patients with spondylolytic spondylolisthesis do not have pain and are often surprised to find they have the slippage when they see it in x-rays. They typically visit a doctor with low back pain related to activities. The back pain is sometimes accompanied by leg pain.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include: X-rays. These tests visualize bones and will show whether a lumbar vertebra has slipped forward. X-rays will show aging changes, like loss of disk height or bone spurs. X-rays taken while you lean forward and backward are called flexion-extension images. They can show instability or too much movement in your spine. Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord. It can show more detail of the slippage and whether any of the nerves are pinched. Computed tomography (CT). These scans are more detailed than x-rays and can create cross-section images of your spine.


Treatment

Non-surgical Treatment

Although nonsurgical treatments will not repair the slippage, many patients report that these methods do help relieve symptoms. Physical therapy and exercise - Specific exercises can strengthen and stretch your lower back and abdominal muscles. Medication - Analgesics and non-steroidal anti-inflammatory medicines may relieve pain. Steroid injections - Cortisone is a powerful anti-inflammatory. Cortisone injections around the nerves or in the "epidural space" can decrease swelling, as well as pain. It is not recommended to receive these, however, more than three times per year. These injections are more likely to decrease pain and numbness, but not weakness of the legs.

Surgical Treatment

Surgical candidates with DS - Surgery for degenerative spondylolisthesis is generally reserved for the patient who does not improve after a trial of nonsurgical treatment for at least 3 to 6 months. In making a decision about surgery, your doctor will also take into account the extent of arthritis in your spine, as well as whether your spine has excessive movement. DS patients who are candidates for surgery often are unable to walk or stand, and have a poor quality of life due to the pain and weakness. In spinal fusion, screws are often used to help stabilize the spine. Surgical candidates with spondylolytic spondylolisthesis - Patients with symptoms that have not responded to nonsurgical treatment for at least 6 to12 months may be candidates for surgery. If the slippage is getting worse or the patient has progressive neurologic symptoms, such as weakness, numbness, or falling, and/or symptoms of cauda equina syndrome, surgery may help. Surgical procedures - Surgery for both DS and spondylolytic spondylolisthesis includes removing the pressure from the nerves and spinal fusion. Removing the pressure involves opening up the spinal canal. This procedure is called a laminectomy. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone. Surgical recovery - The fusion process takes time. It may be several months before the bone is solid, although your comfort level will often improve much faster.


Principles of assessment To complete a musculoskeletal assessment of a client, it is important to carry out a proper and thorough systematic examination. A correct assessment depends on a combination of 4 elements:

1. Knowledge of functional anatomy 2. Accurate patient history 3. Diligent observation, and 4. Thorough examination

The differential diagnosis process can involve the use of clinical signs and symptoms, physical examination, knowledge of pathology and mechanisms of injury, provocative tests, and laboratory and diagnostic imaging techniques. It is only through a complete and systematic assessment that an accurate diagnosis can be made. The purpose of the assessment should be to fully and clearly understand the client's problems, from the client's perspective as well as the clinician's, and the physical basis for the symptoms that have caused the client to complain, As James Cyriax stated, is only a matter of applying one's anatomy. Because the examination portion of the assessment involves touching the client and may, in some cases, cause the client discomfort, the therapist must obtain a valid consent to perform the examination before it begins. A valid consent must be voluntary, must cover the procedures to be done (informed consent), and the client must be legally competent to give the consent. The examination is used to confirm or refute the suspected diagnosis, which is based on the client history and observation. The examination must be performed systematically, with the therapist looking for a consistent pattern of signs and symptoms that leads to a differential diagnosis. Special care must be taken if the condition of the joint is irritable or acute. This is especially true if the area is in severe spasm or if the client complains of severe unremitting pain that is not affected by position or medication, severe night pain, severe pain with no history of injury, or non-mechanical behaviour of the joint. In the examination portion of the assessment, a number of principles must be followed.

1. Test normal (uninvolved) side first - Unless bilateral movement is required, the normal side is tested first. Testing the normal side first allows the therapist to establish a baseline for normal movement and shows the client what to expect, resulting in increased client confidence and less client apprehension.

2. Active movements first, then passive movements, then resisted isometric movements - Active

movements are done before passive movements. Passive movements are followed by resisted iso-metric movements. In this way, the therapist has a better idea of what the client thinks he or she can do before the structures are fully tested.

3. Painful movements are done last - Any movements that are painful are done last, if possible, to

prevent an overflow of painful symptoms to the next movement.

4. Apply overpressure with care - If active ROM is not full, overpressure is applied only with extreme care to prevent the exacerbation of symptoms. During active movements, if the ROM is full, over-pressure may be applied to determine the end feel of the joint. This often negates the need to do passive movements.


5. Repeat or sustained movements if history indicates - Each active, passive, or resisted isometric movement may be repeated several times or held (sustained) for a certain amount of time to see whether symptoms increase or decrease, whether a different pattern of movement results, whether there is increased weakness, and whether there is possible vascular insufficiency. This repetitive or sustained activity is especially important if the client has complained that symptoms are altered by repetitive movement or sustained postures.

6. Do resisted isometric movements in a resting position - Resisted isometric movements are done with

the joint in a neutral or resting position so that stress on the inert tissues is minimal. Any symptoms produced by the movement are then more likely to be caused by problems with contractile tissue.

7. With passive movements and ligamentous testing, both the degree and quality of opening are

important - For passive ROM or ligamentous tests, it is not only the degree (i.e., the amount) of the opening but also the quality (end feel) of the opening that is important.

8. With ligametous testing, repeat with increasing stress - When the therapist is testing the ligaments,

the appropriate stress is applied gently and repeated several times; the stress is increased up to but not beyond the point of pain. In this way, maximum instability can be demonstrated without causing muscle spasm.

9. With myotome testing, contractions must be held for 5 seconds - When testing myotomes (groups of

muscles supplied by a single nerve root), each contraction is held for a minimum of 5 seconds to see whether weakness becomes evident. Myotomal weakness takes time to develop.

10. Warn of possible exacerbations - At the completion of an assessment, the therapist must warn the

client that he or she may experience exacerbation of symptoms as a result of the assessment.

11. Refer if necessary - If, at the conclusion of the examination, the therapist has found that the client has presented with unusual signs and symptoms, or if the condition appears to be beyond his or her scope of practice, the therapist should not hesitate to refer the client to another appropriate health care professional.

Sequential method of assessment Regardless of which system is selected for assessment, the therapist should establish a sequential method to ensure that nothing is overlooked. The assessment must be organized, comprehensive, and reproducible. In general, the therapist compares one side of the body, which is assumed to be normal, with the other side of the body, which is abnormal or injured. For this reason, the therapist must come to understand and know the wide variability in what is considered normal. In addition, the therapist should focus attention on only one aspect of the assessment at a time. Common sequential method for assessment (HIP-MNRS)

History (interview & charting)

Inspection / Observation (skin, posture, body language, gait: SHARP – swelling, heat, a loss of function,

redness, pain

Palpation

Motion (functional, AROM, PROM, muscle testing, joint play)

Neuromuscular (reflexes)

Referred pain

Special Tests (including orthopaedic tests)


Factors that may have a negative impact on assessment There are certain factors that can have a negative or detrimental effect on our assessment. These factors may interfere with correct assessment, which means our treatment will not be based on true assessment. These factors may include:

Clothing and/or jewelry Language difficulties Mental or physical disabilities Emotional trauma Lack of privacy or focus due to other parties being present Lack of understanding of assessment process Cultural or gender factors

Potential sensitivities of your client may include:

Gender Cultural heritage Sexuality Ability Personal history/presenting disease state Religious beliefs Ethnicity Phobias


SESSION 3 : Client History and Observation

Client History Pain parameters Observation – Posture and Gait Revision Scanning Observation

Client History A complete medical history should be taken and written to ensure reliability. Naturally, emphasis should be placed on that portion of the assessment having the greatest clinical relevance. Often, the therapist can make the diagnosis by simply listening to the client. No subject areas should be skipped. Repetition helps the therapist to become familiar with the characteristic history of the client's complaints, so that unusual devia-tion, which often indicates problems, can be noticed immediately. Even if the diagnosis is obvious, the history provides valuable information about the disorder, its prognosis, and the appropriate treatment. The history also enables the therapist to determine the type of person the client is, the treatment the client has received, and the behaviour of the injury. In addition to the history of the present illness or injury, relevant past history, treatment, and results should be noted. Past medical history should include any major illnesses, surgery, accidents, or allergies. In some cases, it may be necessary to delve into the social and family histories of the client if they appear relevant. Lifestyle habit patterns, including sleep patterns, stress, workload and recreational pursuits, should also be noted. It is important that the therapist keep the client focused and discourage irrelevant information; this should be done politely but firmly. Questions and answers should provide practical information about the problem. At the same time, to obtain optimum results in the assessment, it is important to establish a good rapport with the client.

The history is usually taken in an orderly sequence. It offers the client an opportunity to describe the problem and the limitations caused by the problem as your client perceives them. To achieve a good functional outcome, it is essential that the clinician pay heed to the client's concerns and expectations for treatment. After all, the history is the client's report of their own condition. The questions asked should be easy to understand and should not lead the client.

For example, the therapist should not say, "Does this increase your pain?" It would be better to say, does this alter your pain in any way?" The therapist should ask one question at a time and receive an answer to each question before proceeding with another question. Open-ended questions ask for narrative information; closed or direct questions ask for specific information. Direct questions are often used to fill in details of information given in open-ended questions, and they frequently require only an one-word answer, such as yes or no.


The 3 areas of client history

1. Chief Concern History (LOC-Q-SMAT)

L Location Where? Accurate location in anatomical terms (superior posterior deltoid) Left or right? Does it radiate? Where to and how far?

O Onset When did it happen? Gradual or sudden? What caused it? Mechanism of injury

C Chronological/Timing Constant or intermittent, episodic Constant (24hrs a day) or majority Time of day? Associated with specific activity Frequency & Duration Worse in the morning? End of day? Night pain? Prevent sleep? Progressive – getting worse? Getting better Has this happened before? When? How long? Previous treatment

Q Quality Subjective symptoms – client’s own words Pain is sharp? Dull?

S Severity/effect ADL Pain is mild? Moderate? Severe? Pain scale 1-10 ADL – can you go to work? Affect hobbies? What activities during daily life can you not do or do with pain – Great functional outcome markers

M Modifying factors What increases the pain? What decreases the pain? Avoiding what? Changing posture? Rest? Medications? Supplements? (dose and frequency)

A Associated symptoms Other symptoms as result of chief concern (neck or back complaint – numbness, weakness in extremities?)

T Treatment previous Who did they see? When? What tests were done? What diagnosis? What treatment? Successful?

2. Past Health History (HAS-MAD)

H Hospitalisations/Surgeries Have you been in Hospital? For what? Surgery? For what?

A Accidents/Injury/Trauma General trauma requiring treatment? MVA? Mechanisms? Residual problems, prolonged side effects?

S Serious Illness Any serious illnesses? Other problems? Residual effects?

M Medications Prescribed medications? Non-prescribed medications? Vitamins? Supplements? Duration? Dosage?

A Allergies Food? Nuts? Seasonal? Medications?

D Diagnosis Imaging X-ray, MRI findings


3. Family & Personal History (FISH-DOSE)

F Family History History of diabetes, HBP, stroke, cancer? Other family health problems

I Interests Hobbies or activities regularly undertaken

S Sleep pattern Hours sleep a night? Quality of sleep? Any recent changes

H Habits Alcohol, smoking, drugs?

D Diet Rate diet – good, fair, poor? Drinking enough water?

O Occupation Describe activities at work Job satisfaction

S Stress Recent stress factors? Death? Divorce? Family? Work?

E Exercise Overall fitness level? Type, intensity & frequency

PAIN Definition of pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms as such damage. Pain Parameters Pain Duration

Acute Pain: generally associated with acute stage of inflammation, or pain that is unbearable, usually first 48-72hrs

Sub Acute Pain: pain after acute stage but not yet chronic, typically >72hrs

Chronic Pain: refers to pain associated with the stages of healing after inflammatory response, typically of long duration >3months

It is not uncommon to also talk about an acute pain during duration of a chronic condition. For example, arthritis sufferers may talk about their condition is in a flared up stage, or acute inflammation of an ongoing chronic condition. This knowledge is also beneficial in terms of how vigorously the client can be examined. For example, the more acute the condition, the less stress the therapist is able to apply to the joints and tissues during the assessment. A full examination may not be possible in very acute conditions. In that case, the therapist must select those procedures of assessment that will give the greatest amount of information with the least stress to the client. Pain Patterns

Dermal Pain: from superficial soft tissues usually well localised (cut in the skin)

Sclertomic Pain: from deep somatic tissues, typically deep, aching and somewhat localised. o Bone pain tends to be deep, boring, very localised and little radiation of pain. o Vascular pain tends to be diffuse, aching, and poorly localized and may be referred to other

areas of the body. o Muscle pain is usually hard to localize, is dull and aching, is often aggravated by injury, and

may be referred to other areas (trigger points). o Muscular, ligament, and bursa types of pain are often indistinguishable


Visceral Pain: from internal organs, or organ capsules, typically deep cramping that may become sharp at times and often poorly localised and may be immobilising (intestinal cramps, PMS)

Radicular Pain: from nerve roots or pressure on the dura mater (outermost covering of the spinal cord) typically shooting or sharp electrical or burning sensation, in a dermal pattern.

o Pressure on the nerve trunk, no pain occurs, but there is paresthesia or an abnormal sensation such as a pins and needles feeling or a tingling.

o If the nerve itself is affected, regardless of where the irritation occurs along the nerve, the pain is perceived by the brain as coming from the periphery. This is an example of referred pain.

Phantom Pain: perception of pain in amputated limb arising from direct changes in neural pathways

Type of Pain Structure

Cramping, dull, aching Muscle

Sharp, shooting Nerve root

Sharp, bright, lightning like Nerve

Burning, pressure-like, stinging, aching Sympathetic nerve

Deep, nagging, dull Bone

Sharp, severe, intolerable Fracture

Throbbing, diffuse Vasculature

Pain Intensity

Visual analogue scale (VAS)

No Pain Mild Pain Moderate Pain Severe Pain Very Severe Pain

Worst Pain possible

Numeric Rating scale (NRS)

0 1 2 3 4 5 6 7 8 9 10 No Pain Moderate Pain Worst Pain Possible

Special Notes:

Pain on activity that decreases with rest usually indicates a mechanical problem interfering with movement, such as adhesions.

Morning pain with stiffness that improves with activity usually indicates chronic inflammation and oedema.

Pain or aching as the day progresses usually indicates increased congestion in a joint.

Pain at rest and pain that is worse at the beginning of activity than at the end implies acute inflammation.

Pain that is not affected by rest or activity usually indicates bone pain or could be related to organic or systemic disorders such as cancer or diseases of the viscera.

Chronic pain is often associated with multiple factors such as fatigue or certain postures or activities.

Intractable pain at night may indicate serious pathology (e.g. a tumour).

Symptoms of peripheral nerve entrapment (e.g., carpal tunnel syndrome) and thoracic outlet syndromes tend to be worse at night.

Pain and cramping with prolonged walking may indicate lumbar spinal stenosis (neurogenic intermittent claudication) or vascular problems (circulatory intermittent claudication).


Intervertebral disc pain is aggravated by sitting and bending forward.

Facet joint pain is often relieved by sitting and bending forward. Functionally, pain can be divided into seven levels, especially for repetitive stress conditions:

Level 1: Pain after specific activity Level 2: Pain after specific activity resolving with warm-up Level 3: Pain during and after specific activity which does not affect performance Level 4: Pain during and after specific activity which does affect performance Level 5: Pain with activities of daily living (ADL) Level 6: Constant dull aching pain at rest which does not disturb sleep Level 7: Dull aching pain which does disturb sleep

ACTIVITIES OF DAILY LIVING (ADLs) This is one of the best functional outcome measures as it directly related to your client’s daily activities as they will easily notice changes in walking, sitting, standing and their ability to perform daily tasks such as cooking and cleaning. They will also notice changes (hopefully improvement) during their leisure activities including playing sport and during any hobbies they may have. Another indicator may be the number of days missed from work.

It is evident that the taking of an accurate, detailed history is very important. With experience, the therapist is often able to make a preliminary diagnosis from the history alone. The observation and examination phases of the assessment are then used to confirm or refute the possible diagnoses.

Observation – Posture and Gait Revision In an assessment, observation is the ‘looking’ or inspection phase. Its purpose is to gain information on visible defects, functional deficits, and abnormalities of alignment. Much of the observation phase involves assessment of normal standing posture. Normal posture covers a very wide range, and asymmetric findings are common. The key is to determine whether these findings are related to the pathology being presented. The therapist should note the client's way of moving as well as the general posture, manner, attitude, and willingness to cooperate. Observation may begin in the waiting room or as the client is being taken to the assessment area. Often the client is unaware that observation is occurring at this stage and may present a different picture. The client must be adequately undressed in a private assessment area to be observed properly. Male clients should wear only shorts, and female clients should wear a bra or halter top and shorts. Because the client is in a state of undress, it is important for the therapist to explain to the client that observation and detailed looking are an integral part of the assessment. This explanation may prevent a potentially embarrassing situation. As the client enters the assessment area, his or her gait should be observed. This initial gait assessment is only a cursory one; however, problems such as drop foot are easily noticed. If there appears to be an abnormality, the gait may be checked in greater detail after the client has undressed. The therapist should be positioned so that the dominant eye is used, and both sides of the client should be compared simultaneously. During the observation stage, the therapist is only looking at the client and does not ask the client to move.


After the client has undressed, the therapist should observe the posture and attempt to answer the following questions. Posture and Gait:


What is the normal body alignment? Anteriorly, the nose, xiphisternum, and umbilicus should be in a straight line. From the side, the tip of the ear, the tip of the acromion, the highpoint of the iliac crest, and the lateral malleolus (anterior aspect) should be in a straight line.

Is there any obvious deformity? Deformities may take the form of restricted ROM (e.g. flexion deformity), misalignment (e.g. genu varum), alteration in the shape of a bone (e.g. fracture), or alteration in the relaxation of two articulating structures (e.g. subluxation, dislocation). Structural deformities are present even at rest; examples include torticollis, fractures, scoliosis, and kyphosis. Dynamic deformities are caused by muscle action and therefore are not usually evident when the muscles are relaxed; these types of deformity are more likely to be seen during the examination phase.

Are the bony contours of the body normal and symmetric, or is there an obvious deviation? The body is not perfectly symmetric, and deviation may have no clinical implications. For example, many people have a lower shoulder on the dominant side or demonstrate a slight scoliosis of the spine adjacent to the heart. However, any deviation should be noted, because it may contribute to a more accurate diagnosis.

Are the soft tissue contours (e.g. muscle, skin, fat) normal and symmetric? Is there any obvious muscle wasting?

Are the limb positions equal and symmetric? The therapist should compare limb size, shape, any atrophy, colour, and temperature.

Does a joint exhibit locking, unlocking, twinges, instability, or giving way? Locking may mean that the joint cannot be fully extended, as is the case with a meniscal tear, or it may mean that it does not extend one time and does not flex the next time (pseudo-locking), as in the case of a loose body moving within the joint. Locking may mean, that the joint cannot be put through a full ROM because of muscle spasm; this is sometimes referred to as spasm locking. Giving way is often caused by reflex inhibition of the muscles, so that the client feels that the limb will buckle if weight is placed on it, or it may be caused by instability of the joint. Inhibition may be caused by anticipated pain or instability.

There are two types of instability: 1. Mechanical (pathological) instability refers to loss of control of the small joint movements that occur

when the client attempts to stabilize the joint during movement. 2. Clinical instability refers to excessive gross movement in a joint and is sometimes referred to as

pathological hypermobility; in non-pathological states, it is called laxity or hypermobility.

Both types of instability can cause symptoms, and treatment centres on teaching the client to develop muscular control of the joint and to improve reaction time and proprioceptive control. Both types of instability may be voluntary or involuntary. Voluntary instability is initiated by muscle contraction, and involuntary instability is the result of positioning.

Skin:

Are the colour and texture of the skin normal? Does the appearance of the skin differ in the area of pain or symptoms, compared with other areas of the body? Trophic changes in the skin resulting from peripheral nerve lesions include loss of skin elasticity, shiny skin, hair loss on the skin, and skin that


breaks down easily and heals slowly. The nails may become brittle and ridged. Cyanosis, or a bluish colour to the skin, is usually an indication of poor blood perfusion. Redness indicates increased blood flow or inflammation.

Are there any changes in colour of the limb? Ischemic changes resulting from circulatory problems may include white, brittle skin; loss of hair; and abnormal nails on the foot or hand.

Are there any scars that indicate recent injury or surgery? Recent scars are red because they are still healing and contain capillaries; older scars are white and primarily avascular. Fibers of the dermis (skin) tend to run in one direction, along so called cleavage or tension lines. Lacerations or surgical cuts along these lines produce less scarring. Cuts across joint flexion lines frequently produce excessive (hypertrophic) scarring. Some individuals are also prone to keloid (very excessive) scarring. Are there any callosities, blisters, or inflamed bursae, indicative of excessive pressure or friction to the skin? Are there any sinuses that may indicate infection? If so, are the sinuses draining or dry?

Is there any heat, swelling, or redness in the area being observed? All of these signs are indications of inflammation or an active inflammatory condition.

Sounds:

Is there any crepitus, snapping, or abnormal sound in the joints when the client moves them? Crepitus may vary from a loud grinding noise to a squeaking noise. Snapping, especially if not painful, may be caused by a tendon moving over a bony protuberance. Clicking is sometimes heard in the temporomandibular joint and may be an indication of early nonsymptomatic pathology.

Behaviour:

What attitude does the client appear to have toward the condition or toward the therapist? Is the client apprehensive, restless, resentful, or depressed? These questions give the therapist some indication of the client's psychological state and how he or she will respond to treatment.

What is the client's facial expression? Does the client appear to be apprehensive, in discomfort, or lacking sleep?

Is the client willing to move? Are patterns of movement normal? If not, how are they abnormal? Any alteration should be noted and included in the observation portion of the assessment.


Scanning Observation The observation described here emphasises the joints of the body, their movement and stability. It is necessary to examine all appropriate tissues to delineate the affected area, which can then be examined in detail. Application of tension, stretch, or isometric contraction to specific tissues produces either a normal or an appropriate abnormal response. This action enables the therapist to determine the nature and site of the present symptoms and the client's response to these symptoms. The observation shows whether certain activities provoke or change the client's pain; in this way, the therapist can focus on the subjective response (the client's feelings or opinions) as well as the test findings. The client must be clear about his or her side of the observation. For instance, the client must not confuse questions about movement associated pain ("Does the movement make any difference to the pain?" "Does the movement bring on or change the pain?") with questions about already existing pain. In addition, the therapist attempts to see whether client responses are measurably abnormal. Do the movements cause any abnormalities in function? A loss of movement or weakness in muscles can be measured and therefore is an objective response. Throughout the assessment, the therapist looks for two sets of data:

1. What the client feels (subjective) 2. Responses that can be measured or are found by the therapist (objective)

The scanning observation may be used when:

There is no history of trauma

There are radicular signs

There is trauma with radicular signs

There is altered sensation in the limb

The client presents with abnormal patterns To ensure that all possible sources of pathology are assessed, the examination must be extensive. This is especially true if there has been no history of trauma leading to symptoms. In this case, a scanning or screen-ing examination is performed to rule out the possibility of referral of symptoms. Similarly, if there is any doubt about where the pathology is located, the scanning examination is essential to ensure a correct diagnosis. In the upper part of the body, the scanning examination begins with the cervical spine and includes the temporomandibular joints, the entire scapular area, the shoulder region, and the upper limbs to the fingers. In the lower part of the body, the examination begins at the lumbar spine and continues to the toes. The goal of the scanning examination is to rule out potential problems in the upper or lower extremities that may have been referred from the spine to other areas; in addition, the therapist can identify areas needing more specific testing. As with all assessments, the scanning examination begins with the history and observation. The scanning examination is a modification of the cervical or lumbar spinal assessment. After the active, passive, and resisted isometric movements of the cervical or lumbar spine have been tested, the peripheral joints are scanned, with the client doing only a few movements at each joint. The movements should include those that may be expected to exacerbate symptoms. In reality, this quick look at the peripheral joints is the only part of the scanning examination that is different from the normal spine assessment. The therapist then tests the upper or lower limb myotomes. After these tests, the appropriate reflexes and cutaneous distributions can be checked or left until later. At this point, the therapist makes a decision or an educated guess as to whether the problem is in the cervical spine, lumbar spine, or a peripheral joint, based on the information gained so far. Once the decision is made, the therapist either continues with the spinal assessment or turns instead to a complete assessment of the appropriate peripheral joint.


Scanning Observation

Observation Description Assesses

1. Seated cervical motion

Seated, bilateral rotation of head Functional cervical ROM, neck and upper trap muscle tightness, vertigo

2. Seated thoracic rotation / Seated thoracic side bending

Seated, bilateral spinal rotation Seated, lateral torso flexion

Lumbar and thoracic rotation and lateral symmetry

3. Apley’s scratch test

Seated or standing, place hand behind back and touch middle back inferiorly, then repeat superiorly

Rotator cuff pathology, GH tightness, labral pathology, capsular/muscular contracture

4. Side bending

Standing, lateral torso flexion sliding arm down leg

Lumbar ROM symmetry

5. Standing flexion test / Seated flexion test

Standing, anterior torso flexion Seated, anterior torso flexion

General lumbar and hamstring flexibility, functional scoliosis test

6. FABERE test (flexion, abduction, external rotation, extension of hip)

Supine, client to cross legs into figure 4 position, examiner stabilises pelvis and applies gentle downward pressure over flexed knee

Hip joint pathology, arthritis, tight hip adductors


SESSION 4 : Assessment – Palpation

Palpation Principles Palpation Levels

Palpation Initially, palpation for tenderness plays no part in the assessment, because referred tenderness is very real and can be misleading. Only after the tissue at fault has been identified is palpation for tenderness used to determine the exact extent of the lesion within that tissue, and then palpation is done only if the tissue lies superficially and within easy reach of the fingers. Palpation is an important assessment technique that must be practiced if it is to be used effectively. Tenderness often does enable the therapist to name the affected ligament or the specific section or exact point of the tearing or bruising. To palpate properly, the therapist must ensure that the area to be palpated is as relaxed as possible. For this to be done, the body part must be supported as much as possible.

OVERVIEW - When Palpating, the Therapist Should Note

Differences in tissue tension, texture and thickness

Abnormalities, Tenderness

Temperature variations

Pulses, tremors and fasciculation (localised subconscious contractions)

Dryness or excessive moisture

Any abnormal sensations

As the ability to perform palpation develops, the therapist should be able to accomplish the following:

1. Discriminate differences in tissue tension (e.g. effusion, spasm) and muscle tone (i.e. spasticity, rigid-ity, flaccidity). Spasticity refers to muscle tonus in which there may be a collapse of muscle tone during testing. Rigidity refers to involuntary resistance being maintained during passive movement and without collapse of the muscle. Flaccidity means there is no muscle tone.

2. Distinguish differences in tissue texture. For example, the therapist can, in some cases, palpate the

direction of fibres or presence of fibrous bands.

3. Identify shapes, structures, and tissue type and thereby detect abnormalities. For example, bony deformity such as myositis ossificans may be palpated.

4. Determine tissue thickness and texture and determine whether it is pliable, soft, and resilient. Is

there any obvious swelling? Edema is an abnormal accumulation of fluid in the intercellular spaces; swelling, on the other hand, is the abnormal enlargement of a body part. It may be the result of bone thickening, synovial membrane thickening, or fluid accumulation in and around the joint. It may be intracellular or extracellular (oedema), intracapsular or extracapsular. Swelling maybe localised (encapsulated), which may indicate intra-articular swelling, a cyst, or a swollen bursa. Swelling that develops immediately or in 2 to 4 hours after injury is probably caused by blood extravasations into the tissues or joint. Swelling that becomes evident after 8 to 24 hours is caused by inflammation and, in a joint, by synovial swelling. Bony or hard swelling may be caused by osteophytes or new bone formation (e.g., in myositis ossificans).


Soft tissue swelling such as edematous synovium produces a boggy, spongy feeling (like soft sponge rubber), whereas fluid swelling is a softer and more mobile, fluctuating feeling. Blood swelling is usually a harder, thick, gel-like feeling, and the overlying skin is usually warmer. Pus is thick and less fluctuant; the overlying skin is warm, and the temperature is usually elevated. Older, long-standing soft-tissue swelling, such as a skin callus, feels like tough, dry leather. Synovial hypertrophy has a hard, thick feeling to it with little give. The more leathery the thickening feels, the more likely it is to be chronic and caused by local symptoms. Softer thickenings tend to be more acute and associated with recent Symptoms. Pitting oedema is thick and slow moving, leaving an indentation after pressure is applied and removed. It is commonly caused by circulatory stasis. Long-lasting swelling may cause reflex inhibition of the muscles around the joint, leading to atrophy and weakness. Blood swelling within a joint is usually aspirated because of the irritating and damaging effect it has on the joint cartilage.

SWELLING

Comes on soon after injury blood

Comes on after 8 to 24 hours synovial

Boggy, spongy feeling synovial

Harder, tense feeling with warmth blood

Tough, dry callus

Leathery thickening chronic

Soft, fluctuating acute

Hard bone

Thick, slow- moving pitted oedema

5. Determine joint tenderness by applying firm pressure to the joint. The pressure should always be

applied with care, especially in the acute phase.

Example of Grading Tenderness on Palpation

Grade I: Client complains of pain Grade II: Client complains of pain and winces Grade III: Client winces and withdraws the joint Grade IV: Client will not allow palpation of the joint

6. Feel variations in temperature. This determination is usually best done by using the back of the

therapist's hand or fingers and comparing both sides. Joints tend to be warm in the acute phase, in the presence of infection, or with blood swelling.

7. Feel pulses, tremors, and fasciculations. Fasciculations result from contraction of a number of muscle

cells innervated by a single motor axon. The contractions are very localized, are usually subconscious, and do not involve the whole muscle. Tremors are involuntary movements in which agonist and antagonist muscle groups contract to cause rhythmic movements of a joint. Pulses are an indication of circulatory sufficiency and should be tested for rhythm and strength if circulatory problems are suspected.


Common Circulatory Pulse Locations

Artery Location

Carotid Anterior to sternocleidomastoid muscle

Brachial Medial aspect of arm midway between shoulder and elbow

Radial At wrist, lateral to flexor carpi radialis tendon

Ulnar At wrist, between flexor digitorum superficialis and flexor carpi ulnaris tendons

Femoral In femoral triangle (sartorius, adductor longus, and inguinal ligament)

Popliteal Posterior aspect of knee (deep and hard to palpate)

Posterior tibial Posterior aspect of medial malleolus

Dorsalis pedis Between first and second metatarsal bones on superior aspect

8. Determine the pathological state of the tissues in and around the joint. The therapist should note any

tenderness, tissue thickening, or other signs or symptoms that would indicate pathology. 9. Feel dryness or excessive moisture of the skin. For example, acute gouty joints tend to be dry,

whereas septic joints tend to be moist. Nervous clients usually demonstrate increased moisture in the hands.

10. Note any abnormal sensation such as dysesthesia (diminished sensation), hyperesthesia (increased

sensation), anaesthesia (absence of sensation), or crepitus. Soft, fine crepitus may indicate roughening of the articular cartilage, whereas coarse grating may indicate badly damaged articular cartilage or bone. A creaking, leathery crepitus (snowball crepitation) is sometimes felt in tendons and indicates pathology. Tendons may snap over one another or over a bony prominence. Loud, snapping, pain-free noises in joints are usually caused by cavitation, in which gas bubbles form suddenly and transiently owing to negative pressure in the joint.

Palpation of a joint and surrounding area must be carried out in a systematic fashion to ensure that all structures are examined. This procedure involves having a starting point and working from that point to adjacent tissues to assess their normality or the possibility of pathological involvement.


The therapist must work slowly and carefully, applying light pressure initially and working into a deeper pressure of palpation, feeling for pathological conditions or changes in tissue tension. The uninvolved side should be palpated first so that the client has some idea of what to expect. Any differences or abnormalities should be noted and contribute to the diagnosis. Assessment by Palpation Palpation is the use of the hands or fingers to examine. Our hands are our most versatile and exquisite assessment tools. Technology does not come close to the sensitivity and accuracy of a trained assessing hand. Our hands need to be trained to interpret what they perceive accurately. For the therapeutic massage professional, palpation is an essential and continuous process, and the hands become skilled with experience. This section provides structure to facilitate learning palpation assessment. When dealing with palpation assessment, the main considerations for basic massage are the ability to differentiate between different types of tissue and the ability to distinguish differences of tissue texture within the same tissue types. Palpation includes assessment for hot and cold and observation of skin colour and general skin condition. Palpation also assesses various body rhythms, including breathing patterns and pulses. The tissues that the massage therapist should be concerned with and should be able to distinguish are skin, superficial fascia, fascial sheaths, tendons, ligaments, blood vessels, muscles, and bone. Mechanisms of Palpation Before discussing actual palpation skill, it is important to understand what mechanism is being used to make palpation an effective assessment tool. The proprioceptors and mechanoreceptors of the hand receive stimulation from the tissue being palpated. This is the reception phase. These impulses are then transmitted through the peripheral and central nervous systems to the brain, where they are interpreted. The somatosensory area of the brain that interprets this sensory information devotes a massive area to the hand. The refined discriminatory sense of the hand can perceive very subtle shifts and changes. The interpretation ability usually is a sense of comparison. This tissue is softer than that tissue, or this feels rougher than that. Because comparison is a necessity the practitioner must be careful to compare apples with apples; for example, it is not logical to compare skin on the back with skin on the feet.

It is this same mechanism that makes self-massage less effective. It is difficult for the brain to decide which signals to pay attention to when the hand is doing the massage and trying to send sensory information, and the body area being massaged is also trying to decide what is happening. Because the hand sensory and motor areas in the brain are so large, it is possible that the information from the hand supersedes the information coming from the part of the body being self-massaged. The body seems to respond to the strongest set of signals. The result is that the brain pays attention to the hand and does not focus enough motor response to the area being massaged. The same area being massaged by another person can respond without conflicting sensory input.

It is important not to limit a palpation sense only to the hand. Movement, heat, and other sensations can be felt with the entire body. It is essential that the massage therapist's entire self become sensitive to subtle differences in the client's body. This is especially true with palpation skills. With palpation, what is going on must be felt and not thought about.


How to Palpate Palpation can begin many different ways. After the skills have been learned, the particular protocol presented in this text need not be followed. It is best to begin with the lightest palpation and move to the deepest levels because after the hands have been used for deep compression, the light-touch sensors momentarily decrease in sensitivity. During palpation varying depths of pressure must be used to reach all the tissue types and layers. Do not stay in one area too long or concentrate on a particular spot. The receptors in the practitioner's hand or body adapt, and what is subsequently felt or perceived is then lost. The practitioner's first impression should be trusted; if the area feels hot, it probably is. Near-touch palpation The first application of palpation does not include touching the body. It detects hot and cold areas. This is done best just off the skin using the back of the hand because the back of the hand is very sensitive to heat. The general temperature of the area and any variations should be noted. It is important to move fairly quickly in a sweeping motion over the areas being assessed because heat receptors adapt quickly. Very sensitive cutaneous (skin) sensory receptors also detect changes in air pressure and currents and movement of the air. This is one reason we can feel someone come up behind us when we cannot see him. The movement and change in the surrounding air pressure alert us; this is a protective survival mechanism. Being able consciously to detect subtle sensations is an invaluable assessment tool. It is important to realize from where the information comes and why it can be sensed to avoid any idea that this ability is of an "extrasensory" origin. We are subconsciously aware of all the sensory stimulation that we have receptor mechanisms to detect. It is possible, with practice, to become consciously aware of these more subtle sensory experiences. Sensitivity or intuition is the ability to work with this information on a conscious level. The information received from near-touch assessment just above the skin feels somewhat similar to putting two poles of a magnet together: a very subtle resistance occurs. Areas that seem thick, dense, or bumpy; or those that tend to push the therapist away are hyperactive. Deeper palpation often reveals muscular hyperactivity or hot spots. Areas that seem thin or feel as though holes are present usually are under-active. Palpation of the surface of the skin The second application of palpation is very light surface stroking of the skin. First, determine whether the skin is dry or damp. Damp areas feel a little sticky, or the fingers drag. This light stroking also causes the root hair plexus that senses light touch to respond. It is important to notice whether an area gets more goose bumps than other areas (pilomotor reflex). This is a good time to observe for colour, especially blue or yellow coloration. The practitioner also should note and keep track of all moles and surface skin growths, pay attention to the quality and texture of the hair, and observe the shape and condition of the nails. Palpation of the skin The third level of palpation is the skin itself. This is done through gentle, small stretching of the skin in all directions, comparing the elasticity of these areas. The skin also can be palpated for surface texture. By applying light pressure to the skin surface, roughness or smoothness can be felt.


Palpation of the skin and superficial connective tissue The fourth application of assessment is a combination of skin and superficial connective tissue. A method such as petrissage, or skin rolling, is used to further assess the texture of the skin by lifting it from the underlying fascial sheath. The skin should move evenly and glide on the underlying tissues. Areas that are stuck, restricted, or too loose should be noted. Any areas of the skin that become redder in comparison with surrounding areas are to be noted as well. Palpation of the superficial connective tissue The fifth application of palpation is the superficial connective tissue, which separates and connects the skin and muscle tissue. It allows the skin to glide over the muscles during movement. This layer of tissue is found by using compression until the fibres of the underlying muscle are felt. The pressure then should be lightened so the muscle cannot be felt, but if the hand is moved, the skin also moves. This area feels a little like a very thin water balloon. The tissue should feel resilient and springy, like gelatine. Superficial fascia holds fluid. If surface oedema is present, it is in the superficial fascia. This water-binding quality gives this area the feel of a water balloon, but it should not feel boggy or soggy or show pitting oedema (i.e., the dent from the pressure stays in the skin). Palpation of vessels and lymph nodes The sixth application of palpation involves circulatory vessels and lymph nodes. Just above the muscle and still in the superficial connective tissue lie the more superficial blood vessels. The vessels are distinct and feel like soft tubes. Pulses can be palpated, but if pressure is too intense, the feel of the pulse is lost. Feeling for pulses helps detect this layer of tissue. In this same area are the more superficial lymph vessels and lymph nodes. Lymph nodes usually are located in joint areas and feel like small, soft gelcaps. The com-pression of the joint action assists in lymphatic flow. A client with enlarged lymph nodes should be referred to a medical professional for diagnosis. Very light, gentle palpation of lymph nodes and vessels is indicated in this circumstance.


Palpation of muscles The seventh application is skeletal muscle. Muscle has a distinct fibre direction that can be felt. This texture feels somewhat like corded fabric or fine rope. Muscle is made up of contractile fibres embedded in connective tissue. Where the muscle fibres end and the connective tissue continues; the tendon develops. This is called the musculotendinous junction. It is a good practice activity to locate this area for all surface muscles and as many underlying ones as possible. Almost all muscular dysfunctions, such as trigger points or micro-scarring from minute muscle tears, are found at the musculotendinous junction. Most acupressure points, often classified as motor points are also are located in these areas. Often three or more layers of muscle are present in an area. Compressing systematically through each layer until the bone is felt is important. The layers usually run cross-grain to each other. The best example of this is the abdominal muscle group. Even in the arm and leg, where all the muscles seem to run in the same direction, a diagonal crossing and spiralling of the muscle groups is evident. Palpation of tendons The eighth application of palpation is the tendons. Tendons have a higher concentration of collagen fibres and feel more pliable and less ribbed than muscle. Tendons feel like duct tape. Tendons attach muscles to bones. These attachments can be directly on the bone, but it is just as common to find tendons attaching to ligaments, other tendons, and fascial sheaths for indirect attachment to the bone. The important thing to remember is that these attachment areas are made of various types of connective tissue. The difference in the connective tissue is the ratio of collagen, elastin, and water. Under many tendons is a fluid-filled bursa cushion that assists the movement of the bone under the tendon. Bursae feel like little water balloons or bubbles. Palpation of fascial sheaths The ninth application of palpation is fascial sheaths. Fascial sheaths feel like plastic wrap. Fascial sheaths separate muscles and expand the connective tissue area of the bone for muscular attachment. Some, such as the lumbodorsal fascia, the abdominal fascia, and the iliotibial band, run on the surface of the body. Others, such as the linea alba and the nuchal ligament, run perpendicular to the surface of the body and the bone. Still others run horizontal through the body. The horizontal pattern occurs at joints, the diaphragm muscle (which is mostly connective tissue), and the pelvic floor. Fascial sheaths separate muscle groups.

The larger nerves and blood vessels lie in grooves created by the fascial separations. Careful comparison reveals that the location of the traditional acupuncture meridians corresponds to these nerve and blood vessel tracts, as do the motor points that correspond to the acupuncture points. Palpating with the fingers can separate the layers. With sufficient pressure, the fingers tend to fall into these grooves, and then they can be followed. These areas need to be resilient but distinct. They serve both as stabilizers and separators. Palpation of ligaments The tenth application of palpation is the ligaments. Ligaments, which are found around joints, are high in elastin and somewhat stretchy. They feel like bungee cords. Some are flat. Ligaments hold joints together and maintain joint space in synovial joints by keeping the joint apart. Ligaments should be flexible enough to allow the joint to move, yet stable enough to restrict movement. It is important to be able to recognize a ligament and not mistake it for a tendon. Palpation of joints The eleventh application of palpation is the joints. Joints are found where two bones come together. Careful palpation should reveal the space between the synovial joint ends. Joints often feel like hinges. Most assessment, at the basic massage level, is with active and passive joint movements. An added source of information is palpation of the joint while it is in motion. The sense should be a stable, supported, resilient, and unrestricted range of motion.


With the joint movements, it is important to assess for end-feel. End-feel is the perception of the joint at the limit of its range of motion. The end-feel is either soft or hard. In most joints it should feel soft. This means that the body is unable to move any more through muscular contraction, but a small additional move by the therapist still produces some give. A hard end-feel is what the bony stabilization of the elbow feels like on extension. No more active movement is possible, and passive movement is restricted by bone. Palpation of bones The twelfth application of palpation is the bones. Those who have developed their palpation skills find a firm, but detectable pliability to bone. Bones feel like young sapling tree trunks and branches. For the massage practitioner, it is important to be able to palpate the bony landmarks that indicate the tendinous attachment points for the muscles and trace the bone's shape. Main bony prominences that can be palpated


Palpation of abdominal viscera The thirteenth application of palpation is the viscera. The abdomen contains the viscera, or internal organs of the body. It is important for the massage professional to be able to locate and know the layering of the organs in the abdominal cavity. A good anatomy text can help with this information. The massage therapist should be able to palpate the distinct firmness of the liver and the large intestine. Although deep massage to the abdomen is not suggested for those trained in basic massage, light to moderate stroking of the abdomen is beneficial for the large intestine. The massage therapist should be able to locate and palpate this organ. Palpation of body rhythms The fourteenth application of palpation is the body rhythms. Body rhythms are felt as even pulsations. Body rhythms, those mentioned and not mentioned, are designed to operate in a coordinated balanced and synchronized manner. In the body the rhythms all entrain. When palpating body rhythms the practitioner should get a sense of this harmony. Although the trained hand can pick out some of the individual rhythms, just as one can hear individual notes in a song, it is the whole connected effect that is important. When a person feels "off" or "out of sync," often he or she is speaking of disruption in the entrainment process of body rhythms. The three basic rhythms are the respiration, circulation, and craniosacral rhythms.

1. Respiration

The breath is easy to feel. It should be even and should follow good principles of inhalation and ex-halation. Palpation of the breath is done by placing the hands over the ribs and allowing the body to go through three or more cycles as the practitioner evaluates the evenness and fullness of the breath.

2. Circulation

The movement of the blood is felt at the major pulse points. The pulses should be balanced on the two sides. Basic palpation of the movement of the blood is done by placing the fingertips over pulse points on both sides of the body and comparing for evenness.

3. Craniosacral rhythm

The craniosacral rhythm, sometimes called the primary respiratory mechanism, and related cranial rhythmic impulse is a subtle but detectable widening and narrowing movement of the cranial bones. A to-and-fro Oscillation of the sacrum should be noted. Specific training for craniosacral therapy focuses on this mechanism. Basic palpation of the craniosacral rhythm is done by lightly placing the hands on either side of the head and sensing for the widening and narrowing of the skull. Also, place a hand over the sacrum and feel for the to-and-fro (back-and forth) movement. These sensations normally occur at a rate of 10 to 14 times per minute? The movement of the cranium and sacrum should feel coordinated and even.


SESSION 5 : Assessment – Shoulder

EXAMINATION OF THE SHOULDER

Info taken from Gross, Fetto and Rosen 1st

Ed, CH 8 pgs 143 - 194

The Shoulder Girdle:

The shoulder girdle includes the following joints:

1. The shoulder joint (glenohumeral).

2. The acromioclavicular joint.

3. The sternoclavicular joint.

The Shoulder Joint:

Is a multi-axial ball and socket joint with a large range of movement. The articulation is between the head of the humerus and the Glenoid fossa of the scapula. It receives little security from its bony construction or ligaments and depends on surrounding muscles to support it. It is however covered from above by the acromion process, the coracoid process and the coraco-acromial ligament.

A fibro cartilaginous rim (glenoid labrum) deepens the glenoid fossa and increases the stability of the joint. Ligaments surrounding the capsule are:

1. The glenohumeral.

2. The coracohumeral.

3. The transverse humeral ligaments. The transverse humeral ligament acts as a retinaculum to hold the long head of biceps tendon within the bicipital groove.


The tendons of the subscapularis, supraspinatus infraspinatus and teres minor muscles are intimately blended with the joint capsule, forming a cuff (rotator cuff). The rotator cuff muscles reinforce the capsule and provide active support for the joint from above, in front and behind.

There are numerous bursae lying around the shoulder joint. The one most commonly involved with injuries is the subacromial bursa which lies between Deltoid and the joint capsule and protrudes under the acromion.

The Acromio-clavicular joint is a planar joint between the acromion and clavicle. Both articular surfaces are covered in fibro cartilage. The coracoclavicular ligament prevents the two from separating.

The sterno-clavicular joint lies between the sternal end of the clavicle, the clavicular notch of the manubrium sterni and the cartilage of the 1st rib. It is a type of saddle joint with strong surrounding ligaments and an articular disc.

Movements:

Movements in the acromioclavicular and sternoclavicular joints are of a gliding nature which usually accompanies all shoulder joint movements.

Movements of the scapular via these joints are: Elevation / Depression. Protraction / Retraction. Forward / Backward rotation.

Main shoulder elevators - Trapezius, Levator Scapulae.

Main shoulder depressors - Serratus Anterior, Pectoralis Minor.

Main shoulder protractors - Serratus Anterior, Pectoralis Minor.

Main shoulder retractors - Trapezius, Rhomboids.

Main shoulder forward rotators - Upper trapezius, lower serratus ant.

Main shoulder backward rotators - Levator Scapulae, Rhomboids.

Shoulder Joint (Glenohumeral) Movement:

There are 3 degrees of freedom: Flexion/Extension. Abduction/Adduction. Internal/External rotation.

Abduction of the shoulder joint involves scapular movement as well. For every 18 degrees of shoulder abduction, 10 degrees is from glenohumeral movement and 5 degrees from the scapula. This is known as Scapulo-humeral rhythm.

Main shoulder flexors: - Pectoralis Major, Deltoid (anterior fibres), coracobrachialis.

Secondary: - Biceps.

Main shoulder extensors - Deltoid (posterior fibres) teres major.

Secondary: - Teres Minor Tricep.

Main shoulder abductors: - Deltoid (middle fibres) supraspinatus.

Secondary: - Deltoid (anterior & posterior) serratus anterior.

Main shoulder adductors: - Pectoralis Major, latissimus dorsi.

Secondary: - Teres Major Deltoid (anterior).

Main shoulder Ext. rotators: - Infraspinatus teres minor.

Secondary: - Deltoid (posterior).


Main shoulder Int. rotators: - Subscapularis, Latissimus Dorsi. Pectoralis Major Teres Major.

Secondary: - Deltoid (anterior fibres).

Examination Of The Shoulder Girdle:

Subjective Objective:

Look at the person walking, note arms swinging their symmetry and rhythm. Watch undressing procedure, note ease of movement, any unnatural movement. Note any scars, muscle wasting, swelling etc. Check contour, compare to other side. Note position of arm and hand. Check scapula, symmetrical, any winging? Look at thoracic spine, Kyphotic?.

Bony Palpation:

Supra sternal notch. Sterno clavicular joint. Clavicle. Coracoid process. Acromion and acromioclavicular joint. Gr tuberosity of humerus and bicipital groove. Spine of scapula and medial border - T3 - T7.

Soft Tissue Palpation:

Rotator Cuff Muscles - supraspinatus, infraspinatus, and teres major. Subacromial Bursa - lies below acromion and under Deltoid, palpable with passive extension. Axilla - contains the nerves and blood vessels supplying the arm. The walls consist of pectoralis major, latissimus dorsi, 2

nd to 6

th ribs covered by serratus anterior and bicipital groove. Biceps,

Deltoid, Trapezius, and Rhomboids.

Quick Tests:

Flexion: Ask patient to raise arms forward over head. Watch the spontaneous action looking at Scapulo-thoracic rhythm, degree of abduction that is used, manner of movement and range. Repeat action but this time you keep arms in the correct forward plane.

Abduction: Ask patient to raise arms sideways above head and repeat with you keeping the arms in the correct plane. Hand behind back, any pain? Or Limited range?

Active Movement: Flexion / Extension

Passive Movement: Abduction / Adduction

Active Resisted: Internal / External rotation.

Special Tests: Refer (Chp 7 Gross et al)

1. Apley Scratch Test ( P. 21 Hoppenfeld, p147 Gross ): Shoulder in external rotation and abduction. Shoulder in internal rotation and adduction. Abduction.

2. Yergason Test: ( P.32 Hoppenfeld, p 174 Gross et al ) For stability of biceps tendon in groove, flex elbow, patient resists external rotation. Pull down elbow. If unstable the tendon will pop out with pain.

3. Drop Arm Test: ( P.33 Hoppenfeld ) For rotator cuff tear. Abduct shoulder then slowly lower. If there is a supraspinatus tear, the arm will abruptly drop from the 90 degree position.

4. Apprehension Test for Shoulder Dislocation: ( P. 34 Hoppenfeld, p172 Gross et al ) This can be a chronic problem. Abduct and externally rotate shoulder. Look for apprehension, patient will begin to resist the movement.

With the passive tests, look for the quality of end feel. Is it bony or soft tissue?. Watch the combination of Scapulo - humeral movement. Limited flexion or extension may indicate bursitis or biceps tendinitis.

Note: Shoulder pain can be referred from the cervical spine. A common area to receive referred pain is the superior angle of the scapula.


The heart can produce pain down the left shoulder and arm during a heart attack.

SESSION 6 : Assessment – Elbow and wrist

EXAMINATION OF THE ELBOW JOINT

Refer Gross et al, Ch 9 pgs 197 - 232

The elbow joint contains two articulations: the humero-ulnar, between the trochlear of the humerus and the trochlear of the ulnar, and the humero-radial, between the capitulum of the humerus and facet on the head of the radius.

It is a Compound Synovial Joint and its complexity is increased by its continuity with the superior radio ulnar joint. The capsule is strengthened by the medial and lateral collateral ligament fibres from Brachialis anteriorly and fibres from Triceps and Anconeus posteriorly.

There are 4 fat pads within the joint: 1. Over the olecranon fossa. 2. Over the coronoid fossa. 3. Over the radial fossa. 4. Between the radius and ulna projecting from the posterior wall of the capsule.

Movement: The elbow is a uni-axial hinge joint with a small degree of screwing and conjunct rotation (similar to knee). There is flexion and extension -

1. Main Elbow Flexors: Brachialis

Secondary: Biceps, Brachioradialis Supinator.

2. Main Elbow Extensors: Triceps

Secondary: Anconeus.

“Carrying Angle”( Hoppenfeld p.36) - when the arm is extended in the anatomical position (forearm supinated) there is a lateral angle - away from the body at the elbow joint. The normal angle is 5 degrees in males and 10 - 15 degrees in females. It is noticeable when carrying something heavy.

The Radio Ulnar Joints:

There are three joints between the radius and ulnar. Two, the proximal and distal radio - ulnar joints are synovial joints whereas the middle joint is fibrous - the interosseus ligament:-

1. The proximal joint is a pivot joint where the radial head rotates in a osseous fibrous ring formed by the radial notch of the ulna and the annular ligament.


2. The distal joint is also a pivot joint between the convex lower end of the ulnar and the ulnar notch of the radius, held together by an articular disc.

Movement:

Pronation and Supination.- The head of the radius rotates within the ring and swings the lower end of the radius around over the ulnar producing a palms down or up movement.

The power of supination is much stronger than that of pronation -

1. Main Forearm Pronators: Pronator Quadratus. Pronator Teres.

Secondary: Flexor Carpi, Radialis.

2. Main Forearm Supinators: Biceps, Supinator.

Secondary: Brachio radialis.

Examination Of The Elbow Joint:

Subject - History of Injury.

Objective:- Look at the “Carrying Angle” when arm is in extension and supination. Is it normal? A supracondylar or epicondylar fracture in childhood may cause an abnormal angle. Observe any swelling, local or diffuse. Check any scars, and deformities.

Bony Palpation:

Medial and Lateral Epicondyles. Supracondylar lines of Humerus. Olecranon and Olecranom fossa, perhaps decraron bursa. Radial Head - pain may indicate O.A. or synovitis. With the elbow in extension the 2 epicondyles and decranon should form a straight line. With the elbow flexed at 90 degrees they should form a triangle.


Ulnar Nerve (p.43 Hoppenfeld) - it lies in a groove between medial epicondyles and olecranon. Scar tissue may lead to Nerve compression tingling in a little finger and ring finger.

1. Common Flexor Origin at Medial Epicondyle gives rise to Pronator Teres, Flexor Carpi Radialis Palmaris Longus and Flexor Carpi Ulnaris.

2. Medial Collateral Ligament.

3. Triceps tendon.

4. Common extensor Origin at Lateral Epicondyle gives rise to Brachioradialis, Extensor Carpi Radialis Longus and Brevis.

5. Lateral Collateral Ligament, a round, cord-like structure.

6. Cubital Fossa, lies between the two epicondyles, brachioradialis and pronator teres. It contains, Biceps tendon, Brachial Artery, Median and Musculocutaneous nerves.

7. Biceps tendon and Belly.

Active movements Flexion / Extension

Passive movements Supination / Pronation

Resisted movement


Ligament Stability Test: (p. 56 Hoppenfeld )

Cup posterior aspect of elbow joint with hand and hold wrist with the other. Patient flexes a few degrees as you push laterally putting a valgus strain on joint - look for gapping on the Medial side. Repeat but put a varus strain on joint and look for gapping on the lateral side of joint.

Tennis Elbow Test: ( P. 57 Hoppenfeld )

This is done to reproduce pain caused by tennis elbow. Stabilize the forearm, instruct patient to make a fist and extend wrist against resistance. If there is a tennis elbow injury, there should be sudden severe pain over the common extensor origin.

*Note: Pain may be referred from the neck or shoulder region.

EXAMINATION OF THE WRIST AND HAND

Gross CH 10 pgs 235 - 291

This is the most active part of the upper limb and the least protected. Thus incidence of injury to this part is high.

Subjective: History of the injury.

Objective: Look at how the patient holds hand at rest and with functional activity. Count fingers. Look at Palmar Aspect - arched framework thenar and hypothenar eminences, callouses , and webbed spaces.

Objective: Look at Dorsal Aspect - Joints and valleys, knuckles, fingers and nails. Palpate skin, temperature? Sweating?. Observe scars and swellings.

Bony palpation:

1. Radial Styloid Process.

2. Scaphoid Bone - is the floor of the anatomical snuff box, most commonly fractured of carpal bones, easier to palpate with ulnar deviation.

3. Trapezium - articulates with 1st

MC. Easier to palpate when thumb flexes and extends.

4. Tubercle of Radius - on dorsum of hand, 1/3 way across.

5. Capitate - lies between the base of 3rd

MC. And radial tubercle.

6. Lunate - lies proximal to Capitate. Is the most frequently dislocated and 2nd

most susceptible to fracture.


7. Ulnar Styloid process.

8. Triquetrum - just distal to the styloid process, easier to feel with radial deviation.

9. Pisiform, is a sesamoid bone which lies on the Antero lateral surface of triquetrum and within the flexor Carpi Ulnaris tendon.

10. Hook of Hamate - lies distally and radially to pisiform, need to press firmly as it is deep to soft tissue structures.

11. Metacarpals (MC5) find bases and palpate up to heads, unusual tenderness suggests possible fracture.

12. Knuckles - metacarpophalangeal joints (MCP jts.).

13. Phalanges - 14 in each hand.

Soft tissue palpation:

The anatomical snuff - box. Borders include Abductor Pollicis Longus, Extensor Pollicis Brevis, Extensor Pollicis Longus. Floor is scaphoid bone.

Extensor Carpi Radialis Longus and Brevis Tendons.

Extensor Pollicis Longus Tendon does a 45 degree turn around radial tubercle and crosses ECRL & B.

Extensor Digitorum and Extensor Indicis Tendons. Extensor Digiti Minimi Tendon. Extensor Carpi Ulnaris.

Flexor Carpi Ulnaris.

Palmaris Longus - absent in 7% of population.

Flexor Carpi Radialis.

Thenar Eminence, composed of Flexor Pollicis Brevis, Opponens Pollicis, and Abductor Pollicis Brevis.

Hypothenar Eminence - Flexor Digiti Minimi, Opponens Digiti, and Abductor Digiti Minimi.

Palmar Aponeurosis, consists of 4 broad bans extending to bases of fingers.

Active 1. Wrist flexion/extension radial/ulnar deviation.

Passive movements 2. Thumb flexion/extension, ab/adduction, opposition.

Resisted 3. Finger flexion/extension, ab/adduction.

The wrist joints:

The Radio Carpal Joint - is a biaxial ellipsoid joint between the distal end of the radius, the articular disc and the proximal row of carpal bones, scaphoid, lunate and triquetral. The joint line is convex up and runs as a curve between the 2 styloid processes. Ligaments surrounding the joint are:- palmar radio and ulnar carpal, dorsal radio carpal, and radial and ulnar collateral.

The carpal joints exist between the 8 carpal bones - scaphoid, lunate triquetral, pisiform, traperium, traperoid capitate and hamate. They are connected by the dorsal, palmar and interossei ligaments and the synovial membrane is extensive and of a very irregular shape.

Movement:

Flexion / Extension, Ulnar deviation / Radial deviation.


1. Main Wrist Flexors:- Flexors Carpi Ulnaris and Radialis Palmaris Longus.

2. Main Wrist Extensors:- Extensors Carpi Radialis Longus and Brevis, Extensor Carpi Ulnaris.

3. Main Wrist Radial Deviators:- Flexor Carpi Radialis, Extensor Carpi Radialis L & B.

4. Main Wrist Ulnar Deviators:- Flexor Carpi Ulnaris, Extensor Carpi Ulnaris.

The carpometatcarpal joints:

The Carpo meta carpal joint of the thumb has a great range of movement due to its structure and lax capsule. It is a sellar joint between the trapezium and base of first metacarpal. The two bones are connected by lateral, anterior and posterior ligaments and a joint capsule.

Movement:

Flexion /Extension, Abduction / Adduction, Circumduction & Rotation.

Flexion is always associated with medial rotation. When Flexion and medial rotation of the cmc joint are combined with abduction the pad of thumb comes in contact with the pads of slightly flexed fingers - opposition.

1. Main Thumb Flexors: Flexor Pollicis Brevis, Opponers Pollicis. Secondary: Flexor Pollicis Longus.

2. Main Thumb Extensors: Extensors Pollicis Longus and Brevis. Secondary: Abductors Pollicis Longus.

3. Main Thumb Abductors: Abductor Pollicis Brevis and Longus.

4. Main Thumb Adductors: Adductor Pollicis.

5. Main Thumb Opposers: Opponens Pollicis, Flexor Pollicis Brevis.

6. Main Thumb circumduction: All muscle groups acting consecutively.

The metacarpophalangeal joints (MCP Joints).

These are ellipsoid joints between the heads of the metacarpals and the bases of the proximal phalanges.

Each joint has a palmar and 2 collateral ligaments. The dorsal surface has a thin capsule which is separated from the extensor tendon by a bursa.

Movements:

Flexion / Extension. Abduction / Adduction. Limited rotation.

The metacarpophalangeal joint of the thumb is exceptional as it has a limited range of movement, especially with abduction.

1. Main MCP flexors:- Flexor Digitorum Superficialis and Profundus Lumbricals and Interossei. Flexor Digiti Minimi, Flexors Pollicis Longus and Brevis.


2. Main MCP extensors:- Extensor digitorum, Extensor indicis. Extensor Digiti minimi, Extensors Pollicis Longus and Brevis.

3. Main MCP abductors:- Only with fingers extended - Dorsal Interossei Abductor Digiti Minimi Abductor Pollicis Brevis.

4. Main MCP adductors:- With fingers extended - Palmar Interossei. With fingers flexed - Long finger flexors, Adductor Pollicis.

The interphalangeal joints:

These joints are uni-axial hinge joints with a palmar and 2 collateral ligaments. Each finger has two interphalangeal joints and the thumb has one.

Movements: Flexion / Extension -

1. Main Finger Flexors:- At proximal Joint - Flexors Digitorum Superficialis and Profundus. At Distal Joint - Flexor Digitorum Prof. Flexor Pollicis Longus.

2. Main Finger Extensors:- Extensor Digitorum, Extensor Pollicis Longus.

Carpal tunnel syndrome: (p.83, Hoppenfeld)

The carpal tunnel lies between the pisiform and hook of hamate and the scaphoid tuberosity and tubercle of Trapezium. The tunnel transports the Median Nerve and finger flexor tendons from the forearm to the hand. Narrowing of the tunnel can cause compression of the Median nerve, resulting in weakness and sensory loss in the hand. The thenar eminence will have atrophied. Tinel Sign - a tap over the middle of the palmar carpal ligament will produce tingling if there is nerve compression.

Tunnel of Guyon:

Lies between the hook of hamate and the pisiform and contains the Ulnar Artery and nerve. Compression of the Ulnar Nerve also causes weakness in the hand and atrophy of the hypothenar eminence.

Dupuytren contracture (p.85, Hoppenfeld )

Nodules in the palmar aponeurosis causing flexion deformities in the fingers.

Boutonniere deformity: (p.87, Hoppenfeld)

The middle slip of the extensor tendon avulses from its insertion on the middle phalanx causing flexion of the proximal joint and extension in the distal.

Mallet finger: (p.87 Hoppenfeld)

The distal insertion of the extensor tendon has been torn off the distal phalanx causing the distal phalanx to remain in a flexed position, unable to extend.

Rheumatoid Arthritis can cause a swan neck deformity where the proximal joints are hyper extended and the distal joint flexed.

SESSION 7 : Assessment – Hip EXAMINATION OF PELVIS AND HIP JOINT


Refer Gross et al, Pg 293 – 334

Steps in Clinical Examination Of Pelvis And Lower Limbs;

Anatomy of the Hip Joint;

The hip joint is a multi axial, ball and socket joint. The head of the femur articulates with the fossa of the acetabulum. The depth of the acetabulum is increased by a fibro cartilaginous rim - acetabular labrum.

A ligament lies within the joint, attached to the head of the femur and either side of the acetabular notch. 3 ligaments surround the capsule - Ilio femoral, ishio femoral and pubo femoral.

The Ilio femoral ligament lies at the front of the joint and is the strongest ligament in the body.

The blood supply to the joint is derived from the obturator, medial circumflex femoral and superior gluteal arteries. The nerve supply comes from the femoral nerve.

Movement:-

The hip joint has a lot smaller range of movement than the other ball and socket joint, the shoulder joint. Mobility has been sacrificed for stability. The acetabular fossa is deep and firmly embraces the head of the femur whereas the Ilio femoral ligament is the strongest in the body.

There are six movements in the hip joint: - Flexion/Extension, Abduction/Adduction, Internal rotation/ External rotation.

Main hip flexor: - Iliopsoas muscle

Secondary: - Rectus femoris, quad, sartorius (largest in the body), pectineus.

Main hip extensors: - Gluteus maximus, hamstrings.

Main hip Abductors: - Gluteus medius and minimus.

Secondary: - Pectineus, gracilis

Main Internal Rotators:- Tensor fascia lata, anterior fibres of gluteus minimus.

Secondary:- Adductors.


Main External Rotators:- Obturator internus and externus, gemellus, quadratus Femoris.

Secondary: - Piriformis, gluteus maximus, sartorius.

Examination of Hip: Ask patient to undress down to underwear - look for any discomfort or unnatural movements.

Look for any skin markings, scars, swelling, obvious deformity.

In standing position check symmetry.

Palpate ASIS, PSIS, Iliac crests, Greater trochanters Ischial Tuberosity.

Check Gluteal Folds and Lumbar Lordosis.

Hip Joint line is too deep to palpate.

Palpate inguinal ligament Femoral Artery, Sciatic Nerve.

Ask patient to walk forwards, backwards, squat.

In supine - Active Movement Test. Compare to other side. Hip flexion, extension, abduction and adduction, internal, external rotation.

Passive Movement Test

Resisted Movements.

Flexion - Iliopsoas: - A weak iliopsoas will make going upstairs and ramps difficult. There will be problems with supine to sitting and sit to stand. A tight iliopsoas will increase lumbar lordosis and the anterior pelvic tilt in standing. When supine with Right hip flexed Left hip will tend to follow. Demonstrate psoas shortness test Thomas Test Patient supine, flexes hip, holding with his hands below knee to deepen the flexion, therapist tests with hand under opposite hamstrings to see if leg lift off bench, if so short psoas that side.

Extension - Gluteus Maximus:- Prone with knee flexed. Weak Glut. Max. will make walking very difficult - need crutches. Also sit to stand - use arms to push up.

Abduction - Gluteus Medius:- is the primary lateral stabiliser of the pelvis on the thigh. A weak Gluteus Medius will produce a Trendelenburg Gait (Hoppenfeld,1976, p.164 ) as the muscle cannot hold the pelvis level when the opposite leg is lifted off the ground. To test ask patient to stand on 1 leg and look for the tilt. Hip drop test done at this time helps differentiate between gluts. and quad. lumb. acting above pelvis.

Adduction - Adductor Longus:- tight adductors will cause pelvis to ride high on side of contracture so that the foot has to plantar flex to reach the floor.

Internal Rotation - Tensor Fascia Lata weakness results in external rotation of hip in standing and walking contracture will result in knock-knees in weight bearing. Unable to sit cross-legged.

External Rotation - Piriformis, Quadratus Femoris, Obturator Internus and Externus. Weakness results in pronation of foot and knock-knees. Tight Ext. Rotators result in toes pointing out.

Setting The Pelvis Square: (Adams, 1995, p284)

This is an important preliminary step to determine leg length.

Determine from the position of the anterior superior iliac spines whether or not the pelvis is lying square with the limbs. If it is not, an attempt is made to set it square. If this is impossible it means that there is incorrectable adduction or abduction at one or other hip: in that event the fact that the pelvis is tilted should be noted and borne in mind during the subsequent steps of the examination.

Measuring the Length Of The Limbs:


Methods of measuring the lower limbs are often confusing to the uninitiated, but it is important that they should be properly understood. Accuracy in measurement is of more than academic significance; it is of practical importance when corrective operations or adjustments to the shoes are contemplated.

It is necessary to measure,

First, the real or true length of each limb.

Secondly, it is necessary to determine whether there is any ‘apparent’ or false discrepancy in the length of the limbs from fixed pelvic tilt.

Whereas it is always necessary to measure the true length, it is necessary to measure ‘apparent’ discrepancy only when there is an in correctible pelvic tilt.

Measurement of True Length:

Ideally it would be desirable to measure from the normal axis of hip movement - that is, the centre of the femoral head, but since there is no surface landmark at that point it is impracticable to do so. The measurement is therefore taken from the nearest convenient landmark - namely, the anterior superior spine of the ilium. Distally, measurement is usually made to the medial malleolus.

The anterior superior spine, be it noted, is well lateral to the axis of hip movement.

This makes no matter if the angle between limb and pelvis is the same on each side. But it will render the measurements fallacious if the angle between limb and pelvis is not the same on each side. It will be seen that abduction of a limb brings the medial malleolus nearer to the corresponding anterior superior spine, whereas adduction of the limb carries the medial malleolus away from the anterior superior spine. Thus if measurements are made while the patient lies with one hip adducted and the other abducted (a common posture in cases of hip disease) inaccurate readings will be obtained: the length will be exaggerated on the adducted side and belittled on the abducted side.

The rule is, therefore, that to obtain an accurate comparison of their true length by surface measurement, the two limbs must be placed in comparable positions relative to the pelvis.

Thus if one limb is adducted and cannot be brought out to the neutral position the other limb must be adducted through a corresponding angle by crossing it over the first limb before the measurements are taken. Similarly, if one hip is in fixed abduction the other must be abducted through the same angle before the measurements of true length are made.

Fixing the tape measure at the anterior superior ischial spine ASIS: A flat metal end (as found on the ordinary tailor’s measure) is essential. The metal end is placed immediately distal to the ASIS and is pushed up and the tape-end together. This gives rigid fixation of the tape measure against the bone.

Taking the reading at the medial malleolus: The tip of the index finger is placed immediately distal to the medial malleolus and pushed up against it, the thumbnail is brought down against the tip of the index finger so that the tape measure is pinched between them, the thumbnail indicates the point of measurement.

A third reading can be taken at the superior margin of the patella.

In summary the 3 points to take Leg Length Discrepancy LLD measurements are, ASIS, superior margin of patella and medial malleolus. If the lengths differ on each side there is a discrepancy. NOTE it is important to begin with a neutral pelvis. Lie the client supine with hips flexed and feet nearer to buttocks, then lift pelvis off the table like a bridge in yoga, and back down to achieve this.

FABERE test (flexion, abduction, external rotation, extension of hip)

Supine, client to cross legs into figure 4 position, examiner stabilises pelvis and applies gentle downward pressure over flexed knee

Hip joint pathology, arthritis, tight hip adductors


Patrick or FABERE test: (Hoppenfeld 1976, p.262) helps to detect hip or sacro iliac problems. The patient flexes, abducts and externally rotates the leg so the foot rests on other knee, this may produce pain in the inguinal region - hip problem. If pressure is now exerted on ASIS and medial aspect of the bent knee to apply pressure to the sacro-iliac joint, if this produces pain could indicate pathology in the SI. Joint

Hip Quadrant or scour test

Definition/ description The Hip Quadrant test is a passive test that is being applied to asses if there is any damage in structure in the inner and outer quadrant of the hip. The hip quadrant test is also known as the quadrant scour test. This test is not to be confused to the quadrant test for the lumbar spine.The purpose of the Hip Quadrant test is to determine if there is a nonspecific hip pathology and a chance of ROM. This test does so by completing the ROM from flexion and

adduction to flexion and abduction. This test is also capable to detect early hip degeneration

Technique

The patient lies supine on the table. The therapist stands on the side of the involved leg. He brings the hip and the knee to 90° flexion, the knee is directed towards the opposite shoulder (figure 1). One hand of the therapist is above the patient’s knee, the other is above the malleolis. Afterwards the therapist puts pressure on the leg by pushing the femur dorsally.

In the first part of the exam the therapist adducts the patient's leg until the pelvis begins to raise off the table. In the second part of the exam the therapist brings the leg of the patient in abduction with the hip still in 90° flexion and goes to abduction until the pelvis almost raises of the table. When he brings the leg to abduction it is

Findings

A positive Hip Quadrant test is an indication that there might be arthritis, an osteochrondral defect, avascular necrosis, joint capsule tightness and an acetabular labrum defect. This test also detects if the patients hip can move in the full range of motion.

Other Tests

Trendelenburg test for gluteus medius weakness.

The patient is asked to stand on one leg for 30 seconds without leaning to one side. The therapist observes the patient to see if the pelvis stays level during the one-leg stance. A positive Trendelenburg Test is indicated if during unilateral weight bearing the pelvis drops toward the unsupported side

SESSION 8 : Assessment – Knee and Ankle EXAMINATION OF THE KNEE


Gross Ch 12 & 13 pgs 337 - 431

Examination of the knee:

Subjective: - What was the mechanism of injury?. Look at gait. Look for asymmetry and abnormal movement. Ask the patient to walk forwards and back. Check for scars, swelling, obvious deformity and wasting. Check line of patellas, the valgus angulation of the tibias. The knees may be slightly hyper extended. Ask the patient to bounce in the squatting position. Ask the patient to take a kneeling upright position and slowly kneel down to heels.

Bony palpation:

Patient sits over edge of bed as the ligaments and muscles are then relaxed and finding joint structures is easier. Palpate joint line and find tibial plateau, tibial tuberosity lateral and medial femoral condyles, adductor tubercle, the lateral tubercle and head of fibula. The patella is easier to palpate with knee in extension.

Soft tissue structures:

Ask patient to contract a quadriceps - compare if asymmetric, measure the circumference of each thigh. Palpate ligamentum Patellae. Look for swollen bursae (prepatellar and infrapatellar bursae are most commonly injured). Palpate joint line for menisci; internally rotate the tibia to produce the medial meniscus, external rotation for lateral. Collateral ligaments. Muscle tendons or Sartorius, Gracilis and Semitendinosus on the medial side of the joint. Biceps Femoris tendon on the lateral. The Ilio tibial tract can be felt with knee extension or flexing the knee against resistance. Popliteal fossa contains popliteal artery - feel for the pulse.

Active movement test:

In Supine test knee flexion and extension - compare with other side. Check for quads lag in the last 10 degrees of extension, test internal and external rotation.

Resisted movement test:

Knee flexion is easier to resist in the prone position. Compare Passive Movement with Active. Compare ROM in the weight bearing position to the non weight bearing position.

Joint stability tests ( p.185-186, Hoppenfeld )

Are designed to evaluate the strength and integrity of certain joint structures such as collateral ligaments cruciate ligaments and menisci.


1. Collateral Ligament Instability - test with knee in slight flexion, put a varus strain on the tibia and look for gapping at the lateral joint line. Then put a valgus strain on the tibia and look for medial instability. It is more common to have instability of the medial collateral ligament which is critical for joint stability.

Main Knee Flexors:- Biceps Femoris, Semitendinosus, Semimembranosus. Secondary: - Gracilis Sartorius Popliteus. Main Knee Extensors: - Quadriceps. Secondary: - Tensor Fascia Lata. Medial Rotation: - Popliteus, Semimembranosus and Semitendinosus. Secondary: - Gracilis, Sartorius. Lateral Rotation: - Biceps Femoris.

EXAMINATION OF THE ANKLE AND FOOT

Refer SET TEXT CH 13 pgs 383 - 431

The ankle and foot are focal points where the entire body weight is transmitted during ambulation.

Ankle joint:

The ankle joint is a uniaxial joint involving the lower end of the tibia, the two malleoli and interior transverse ligament which form a deep recess in which sits the body of the talus. The fibrous capsule is strengthened medially by the medial collateral ligament commonly known as the DELTOID LIGAMENT. This is a strong triangular band with superficial and deep fibres connecting the medial malleolus with the navicular, talus and calcaneal bones.

The Lateral collateral ligament consists of 3 bands:- The Anterior and Posterior talofibular and the calcaneofibular. The Ankle Joint rarely dislocates unless there is a fractured malleolus.

Movements: Plantar Flexion and Dorsi Flexion.

Dorsi Flexion is the initial position from where all thrusting actions are developed such as jumping or running. This is the position of maximum congruence of the articular surfaces, i.e., the most stable. The foot in plantar flexion allows slight side to side gliding and rotation.

Main Ankle Dorsi flexor - Tibialis Anterior Secondary - Extensor Digitorum Longus, Extensor Hallucis Longus Peroneus Tertius. Main Ankle Plantar flexors - Gastrocnemius, Soleus. Secondary - Plantaris Tibialis Posterior, Flexor Hallucis Longus. Flexor Digitorum Longus.

The line of the body weight falls in front of the ankle joint. Soleus is the postural muscle that prevents the body from falling forwards.

Bones of the foot:


Talus, Calcaneus, Navicular (all of the hind foot), Cuboid, Lateral, Medial and Intermediate Cuneiforms (forefoot), and 5 Metatarsals, Phalanges (toes).

The foot is comprised of 26 bones and 78 ligaments. The joints of the foot exist between these bones and there are 6 synovial cavities.

Movement:

The sub talar (Talo calcanean) and the talocalcaneonavicular articulations allow gliding and rotation, moving the navicular and calcaneus medially on the talus (Inversion).

It also includes slight adduction and plantar flexion of forefoot. Eversion is the opposite movement and has less range. These two movements of the whole foot refer to when the foot is off the ground. (Non-weight bearing).

When the foot is on the ground these movements are modified to keep sole in contact with the ground (plantigrade). These movements are called Pronation and Supination.

Pronation: The distal part of tarsus and metatarsus rotates downwards relative to calcaneus and talus.

Supination: The distal part of tarsus rotates upwards.

Main Invertors of Foot: Tibialis Anterior and Posterior.

Main Evertors of Foot: Peroneus Longus and Brevis.

Most of the other tarsal joints allow gliding and rotation associated with inversion and eversion. This increases the suppleness of the joint.

The degree of pronation and supination is different when feet are together or apart.

Movements of metatarsals and toes:

Flexion / Extension. Abduction/Adduction.

These movements are produced by various muscles of the foot and leg. The great toe has its’ own flexors, extensors, abductors and adductors. Thus individual movement of the big toe is more developed than that of the 4 other toes.

Arches:

The foot has two important functions: to support the body weight in standing or progression and to act as a level to propel body forwards. Therefore it must be adequate as a platform to spread out the stresses of weight bearing and also pliable to adapt to uneven surfaces, then to transform into a strong and resilient lever.

This is all possible to its’ arched formation.

The arches are due to the bony configuration and ligaments but muscles also contribute.

The Longitudinal Arch has medial and lateral parts and varies in height from person to person and also in the same person with different phases.

The weight bearing is done through the 5 metatarsal heads, the lateral border of the foot and the calcaneus. Flattening the arch puts a strain on the plantar ligaments and fascia.

The Transverse Arch lies behind the metatarsal heads. Peroneus Longus has a role in maintaining its curvature.

Examination of the ankle and foot.

Subjective examination:


Look at walking - a deformed foot will deform the footwear. Check footwear - areas of wear and tear, creases, nails, rivets. Count toes - look at shape and deformity. Look at arches in standing and sitting. Note any colour change of skin when person sits. Check sole of foot - calluses. Check swelling of ankles - unilateral or both.

Objective examinations:

Bony Palpation: - 1st metatarsal head (MT head)- any bunions?. 1st

MT cuneiform joint. Navicular and head of talus - more evident with flat feet. Medial Malleolus and Sustentaculum tali. Medial tubercle of talus (post to malleolus). 5

th MI

head and joint. Styloid process. Calcaneus, peroneal tubercle. Lateral Malleolus. Sinus Tarsi. Medial tubercle of calcaneum Sesamoid Bones - give assistance with toe off. MT heads.

Soft Tissue: - Head of 1st

MT - site of Hallux valgus and bunion. Deltoid Ligament. Tendons of Tibialis Posterior. Flexor Digitorum Longus and Flexor Hallucis Longus. These are enclosed in sheaths which may be inflamed. Tibialis Anterior, Extensor Hallucis Longus and Extensor digitorum Longus. Peroneus Longus and Brevis. Lateral Collateral Ligament - 3 parts. Achilles Tendon x surrounding Bursae. Plantar Aponeurosis. Toes - ingrown toenails, calluses.

Ankle joint stability tests: Anterior Draw Sign( p.222 Hoppenfeld):- To test anterior instability between talus and tibia. Sit person over edge of bed. Grab calcaneus, there should be no movement.

Lateral Instability Test:- Invert calcaneus and if gapping between calcaneus and talus then both anterior talo fibular and the calcaneofibular ligaments are injured.

It takes massive trauma to tear the deltoid ligament or dislocate the ankle joint.

Active movement tests:

Quick Tests ( p.223 Hoppenfeld ):- Walk on toes, heels, outer borders and inner borders of feet.

Active Movement in sitting Dorsi /Plantar, In/Eversion Passive Movement in sitting Flex/Ext. of toes. Active Resisted Movement

Note:- 35 - 40 degrees extension of the great toes is crucial for toe off.

SESSION 9 and 10: Assessment – Vertebral Column - Spine

Spinal Cord and Nerve Roots Dermatome


Myotome Sclerotome Signs and Symptoms Special Tests

Nerve roots are made up of anterior (ventral) and posterior (dorsal) portions that unite near or in the intervertebral foramen to form a single nerve root or spinal nerve. They are the most proximal parts of the peripheral nervous system. Within the human body, there are 31 nerve root pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each nerve root has two components: a somatic portion, which innervates the skeletal muscles and provides sensory input from the skin, fascia, muscles, and joints, and a visceral component, which is part of the autonomic nervous system. The autonomic system supplies the blood vessels, dura mater, periosteum, ligaments, and intervertebral discs, among many other structures.

Spinal cord, nerve root portions, and spinal nerve in the cervical spine and their relation to the vertebra and vertebral artery.

Somatic

Innervates the skeletal muscles and provides sensory input from the skin, fascia, muscles, and joints

Visceral

Part of the autonomic nervous system that supplies the blood vessels, dura mater, periosteum, ligaments, and intervertebral discs, among many other structures.

The inter-relationship of the spinal nerve roots, plexus, and peripheral nerves, using cervical spine and brachial plexus as an example.


Definitions

Sensory exam terminology Motor exam terminology

Paresthesia: abnormal sensations (pins and needles) Anesthesia: complete loss of touch sensation Analgesia: total loss of pain sensation

Atrophy: loss of muscle tone, size, contour Paresis: muscle weakness Paralysis (flaccid): complete loss of muscle function and tone Spasticity: increased muscular resistance initially felt during quick joint motion Rigidity: involuntary muscle resistance felt when moving a resting joint

Examination To further comprehend and ensure the value of the scanning examination, the therapist must have a clear understanding of signs and symptoms arising from the spinal cord and nerve roots of the body and those arising from peripheral nerves. The scanning examination helps to determine whether the pathology is caused by tissues innervated by a nerve root that is referring symptoms distally.

Client History (subjective)

Observation (objective)

Decision: Spinal or peripheral? (educated guess)

Spinal Peripheral

Special tests (sensory tests) (reflexes) Joint Play Palpation Imaging techniques

Active movements Passive movements Resisted isometric movements Peripheral Joint Movements Special tests (sensory tests) (reflexes) Joint play Palpation Imaging techniques

The nerve root is that portion of a peripheral nerve that connects the nerve to the spinal cord. Nerve roots arise from each level of the spinal cord (e.g., C3, C4), and many, but not all, intermingle in a plexus (brachial, lumbar, or lumbosacral) to form different peripheral nerves. This arrangement can result in a single nerve root supplying more than one peripheral nerve. For example, the median nerve is derived from the C6, C7, C8, and TI nerve roots; the ulnar nerve is derived from the C7, C8, and TI nerve roots; and the radial nerve is derived from the nerve roots of C5, C6, C7, C8, and TI. For this reason, if pressure is applied to the nerve root, the distribution of the sensation or motor function is often felt or exhibited in more than one peripheral nerve distribution. Therefore, although the symptoms seen in a nerve root lesion (e.g., paresthesia, pain, muscle weakness) may be similar to those seen in peripheral nerves, the signs (e.g., area of paresthesia, where pain occurs, which muscles are weak) may be different.


The therapist must be able to differentiate a dermatome (nerve root) from the sensory distribution of a peripheral nerve, and a myotome (nerve root) from muscles supplied by a specific peripheral nerve. In addition, neurological signs and symptoms such as paresthesia and pain may result from irritation of tissues such as facet joints and interspinous ligaments or other tissues supplied by the nerve roots, and they may be demonstrated in the dermatome, myotome, or sclerotome supplied by that nerve root. This irritation can contribute to the referred pain. Dermatome: relationship between the spinal nerve and skin The sensory distribution of each nerve root is called the dermatome. A dermatome is defined as the area of skin supplied by a single nerve root. The descriptions of dermatomes in the following chapters should be considered as examples only, because slight differences occur with each client, and dermatomes also exhibit a great deal of overlap. The variability in dermatomes was aptly demonstrated by Keegan and Garrett in 1948. The overlap may be demonstrated by the fact that, in the thoracic spine, the loss of one dermatome is often not noticed because of the overlap of the adjacent dermatomes.

Spinal nerve roots are poorly developed which makes them more susceptible to compressive forces, tensile deformation, chemical irritants (e.g., alcohol, lead, arsenic), and metabolic abnormalities. For example, compression of the nerve root could occur with a disc herniation, a ‘burner’ or stretching of the nerve roots or the brachial plexus in a football player, alcoholic neuritis in an alcoholic, or metabolic peripheral neuropathy of one or more peripheral nerves in a diabetic. Pressure on nerve roots leads to loss of muscle tone and mass, but the loss is often not as obvious as when pressure is applied to a peripheral nerve. Because the peripheral nerve that innervates the muscle is usually supplied by more than one nerve root, more muscle fibres are likely to be affected if the peripheral nerve itself is damaged. In addition, the pattern of weakness (i.e., which muscles are affected) is different for an injury to a nerve root and to a peripheral nerve, because a nerve root supplies more than one peripheral nerve. Pressure on a peripheral nerve resulting in a neuropraxia leads to temporary non-function of the nerve. With this type of injury, there is primarily motor involvement, with little sensory or autonomic involvement, and although weakness may be demonstrated, muscle atrophy may not be evident. With more severe peripheral nerve lesions, atrophy is evident.


The variability of dermatomes at C8 and SI as found by four researchers. Similar variability is demonstrated in most cervical, lumbar, and sacral vertebrae. (Redrawn from Keegan, I.j., and F.D. Garrett: The segmental distribution of the cutaneous nerves in the limbs of man. Anat. Rec. 101:430, 433, 1948. Copyright 1948. Reprinted by permission of John Wiley & Sons, Inc.)

EXAMINATION OF THE LUMBAR SPINE Gross j, Fetto J, Rosen E, 2002, Musculoskeltal Examination, Blackwell Science, Massachusetts. REFER CH 6 pgs 97 – 139


Review of Anatomy of back:

The lumbar spine:

The Lumbar spine transports the cauda equina to the lower limbs, provides mobility for the back and supports the upper portion of the body and transmits the body weight to the pelvis.

The lumber spine consists of 5 lumbar vertebrae, which articulate with the thoracic spine above, and the sacrum below.

The bodies of the vertebrae are large, wider side-to-side. The vertebral foramina are triangular and smaller than the cervical vertebrae. The pedicles are short the spinous processes are horizontal and quadrangular and the transverse processes are long and thin.

The 5th

lumbar vertebra is the only atypical one, with a massive transverse process and a large body which is markedly deeper in front increasing the sacrovertebral angle.

The thoracic spine:

There are 12 thoracic vertebrae, which show a gradual transformation from the cervical to the lumbar type. The thoracic vertebrae articulate with 12 pairs of ribs which together house and protect the thoracic contents (lungs, heart, and major vessels).

They all have costal facets on the bodies and most on the transverse processes, which articulate with the heads and tubercles of the ribs.

The vertebral foramina are relatively smaller as the spinal cord in the thorax is smaller.

The spinous processes are long and slant down and back. The transverse processes are substantial and club shaped.

The atypical vertebrae are the first, ninth, tenth, eleventh and twelfth. The transitional phase occurs most frequently between T11 and T12. The joints lock intimately preventing all but flexion.

The joints between the vertebrae are synovial planar (gliding) joints. Various ligaments and the articular capsule connect the laminae and transverse processes.

The costo-vertebral joints are between the head of the ribs and bodies of the vertebrae. The costotransverse joints unite the neck and tubercle of ribs to the transverse process.

Fibrous capsules and ligaments surround them.

Movement:

The lumbar spine is more mobile than the thoracic spine as there are no ribs to restrict movement. The length of the spinous processes and the angle of the articular facets also help to decrease the range of movement possible in the thoracic spine, thus reducing interference in respiration.

Rotation is the most free whereas in the lumbar spine there is a large range of flexion and extension. There also exists lateral flexion which entails a degree of lumbar rotation. The hips are involved and contribute to lumbar flexion and extension.

Main trunk flexors:- Rectus abdominis.

Main trunk Extensors:- erector spinae, spinalis.

Main trunk lateral flexors:- intertransversarii, multifidus.

Main trunk rotators:- multifidus, rotators.


Soft tissue palpation: - Supraspinous ligament which connects the spinous processes. The interspinous ligaments connect adjoining spinous processes but are not palpable unless ruptured, then acute tenderness on palpation.

Para spinal muscles, there are three layers, only the superficial one is palpable. Ask the patient to extend head to relax fascia. Feel for spasm or tenderness.

Origin of Gluteus Maximus, under the lip of the iliac crest.

Sacral triangle, common area of low back pain.

Sciatic Nerve passes midway between the greater trochanter and ischial tuberosity and it can be tender when a herniated disc is present.

Rectus Abdominis. Ask patient to do a slight sit up and palpate stomach.

Neurological testing of the lumbar spine: ( Refer set text pg 120 - 131.) Pathology in the lumbar spine can refer pain to the buttocks and lower limbs. Examination of the myotomes, dermatomes and reflexes in the lower limbs can help determine at what level the problem lies.

Neurology of the lower limbs:

Disc Root Reflex Muscles Sensation

L3-L4 L4 Patellar Anterior Tibialis Medial leg and foot

L4-L5 L5 - Extensor Hallucis Longus Lateral leg & dorsum of foot

L5-S1 S1 Achilles Peroneus L & B Lateral Foot

L1 L2 and L3 supply Iliopsoas muscle and the anterior thigh to knee dermatone.

S2, S3 and S4 supply the intrinsic muscles of the foot and the bladder and the dermatome consists of three concentric rings around the anus.

Lumbar Lordosis:- Is an increase in the concavity of the lumbar spine. It may be congenital or compensation for a thoracic kyphosis or an increased pelvic tilt caused by weak abdominal musculature, pregnancy osteoarthritis in the hips or hip flexor contractions.

Thoracic Kyphosis:- Is a increase in the convexity of the thoracic spine. It can be mobile or fixed due to poor posture, muscle weakness, bony and connective tissue, changes in the spine such as, ankylosing spondylitis. The patient cannot correct the fixed kyphosis whereas, with posture muscle re-education the mobile kyphosis can.

Scoliosis:- Is a lateral curvature of the spine associated with the rotation of vertebrae. The ribs protrude on the side of the convexity. 80% of cases are due to unknown causes. 20% are due to conditions such as leg length discrepancy, hemi or missing vertebrae, polio or cerebral palsy.

The scoliosis can be functional or structural and often appear in adolescents after a rapid growth spurt.

It consists of two parts. The primary part if usually lower and more difficult to correct. Scoliosis needs immediate attention as it can cause serious problems due to the abnormal stresses placed on the bones. It causes a restricted lung capacity, right cardiac failure and osteoarthritis of the spine. Examination of the back: It should be noted particularly whether the spinal muscles go into protective spasm when movement is attempted.

Special tests: see SET TEXT pg 131 - 137


Straight Leg Raising Test: - is done to stretch the spinal cord and reproduce the pain. If the SLR does cause pain, lower the leg slightly and dorsi flex the foot to differentiate between hamstring tightness and the sciatic nerve. Sciatic pain will be present with the dorsiflexion and it may extend all the way up the leg.

If the patient complains of back or sciatic pain when the opposite leg is raised then this is further evidence of a herniated disc or space occupying lesion. Holding the knee straight, lift each lower limb in turn to determine the range of pain-free movement (normal = 90 degrees; often more in women). When associated with clearly defined sciatica (and in the absence of gross disease of the hip), marked impairment of straight leg raising by pain suggests mechanical interference with one or more of the roots of the sciatic nerve. The pain is easily explained. Even a normal sciatic nerve is tautened by straight leg raising, though not to the point of causing pain by dragging on the meningeal sheath that encloses the nerve root. If a nerve is already stretched or anchored, as by a protruded piece of an intervertebral disc or a tumour, the further tautening entailed in lifting the limb is sufficient to cause pain. (Adams,1995,p.168) *** When elevating the thigh movement should be smooth and slow, rough movement may rupture axon.

Kernig test: (Hoppenfeld 1976, p.258) is also done to stretch the spinal cord but the muscle is forcibly flexed this time. Patient supine, hands behind his head, ask patient to flex neck. This test is used to help differentiate sciatic pain of lumbar or piriformis origin.

Pelvic rock: (refer page 36 these notes, Hoppenfeld p261.) Shows sacroiliac instability.

Pull the two crests together, compressing the pelvis towards the midline. This may cause pain over the sacroiliac joints. Patrick or FABERE test: (Hoppenfeld 1976, p.262) helps to detect hip or sacro iliac problems. The patient flexes, abducts and externally rotates the leg so the foot rests on other knee, this may produce pain in the inguinal region - hip problem. If pressure is now exerted on ASIS and medial aspect of the bent knee to apply pressure to the sacro-iliac joint, if this produces pain could indicate pathology in the SI. joint. Standard tests:

Active ROM - tested in standing and sitting. Flexion / Extension Lateral Flexion. Rotation. Rotation is tested in sitting to stabilize pelvis.

Passive ROM - tested in supine, moving the lower limbs on the body. Flexion: Instruct the patient to stretch his fingers towards his toes, keeping the knees straight. It is important to judge what proportion of the movement occurs at the spine and how much is contributed by hip flexion. Some patients can almost reach their toes, despite a stiff back, simply by flexing unusually far at the hips. (Normally the hamstrings limit hip flexion

to about 90 when the knees are straight.) The range may be expressed as a percentage of the normal, or as the distance by which the fingers fail to reach the floor. Extension: Instruct the patient to arch the spine backwards, looking up at the ceiling. Judge the range and express approximately as a percentage of the normal. Lateral Flexion: Instruct the patient to slide each hand in turn down the lateral side of the corresponding thigh. Observe the range. Measure finger tips from floor. Rotation:


With the feet fixed, the patient rotates the shoulders towards each side in turn. Note the range of spinal rotation as distinct from that which occurs at the knees and hips. Hold arms out straight to assist visual assessment. Related Joints: The costo-vertebral joints: The mobility of the costovertebral joints is judged from the range of chest expansion. The normal difference in chest girth at full inspiration and full expiration is about 7 or 8 centimetres. ( use tape measure ) A marked reduction of chest expansion is of particular significance when ankylosing spondylitis is suspected. The sacro-iliac joints: It is not practicable to measure the range of sacro-iliac movement. But the joints should be moved passively to determine whether pain is produced, as it will be in arthritic conditions of the joints. A simple method is to grip each iliac crest and compress the pelvis strongly from side to side. ( or p.261 Hoppenfeld- thumbs against lateral edge of ASIS press both medially ) Palpation Of The Iliac Fossae And Groins: Palpation of the iliac-fossa and groins is an essential step in the examination of the back. Its specific purpose is to determine whether or not there is a soft-tissue thickening or abscess. It should be remembered that a ‘psoas’ abscess originating from a tuberculous lesion of the lumbar spine first becomes palpable deep in the iliac fossa. Such an abscess is felt most easily by pressing the flat palmar surface of the hand and fingers against the flat inner aspect of the iliac bone. To do this the therapist must stand at the side of the couch corresponding to the side being examined, that is, he must stand on the right of the patient to examine the right iliac fossa and on the left to examine the left iliac fossa. Neurological Examination of the Lower Limbs: Disorders of the back are so frequently accompanied by radiating pain, paraesthesia, or other manifestations in the lower limb that a neurological survey should be carried out as a routine. Muscular System: Examine the muscles for wasting, hypertrophy, and fasciculation. Note the tone and test the power of each muscle group, comparing it with its counterpart in the opposite limb. Circumferential measurement is a reliable method of comparing the bulk of the calf muscles, the girth being measured at the widest part or ‘equator’. Sensory System: Examine the patient’s sensibility to touch and pin-prick. When indicated, test also the sensibility to deep stimuli, joint position, vibration, and heat and cold. Reflexes: Compare on the two sides the knee jerk (mainly L.4) and the ankle jerk (mainly S.1). It is important to note not only the presence or absence of the response, but also difference of intensity. Test the plantar reflex. Extrinsic Sources of Back Pain and Sciatica: The back offers many pitfalls in diagnosis. Sometimes there are no local symptoms to indicate that the spine is the seat of the disorder, pain being referred entirely to the buttock or to the lower limb. Thus patients often complain only of pain ‘in the hip’ or ‘in the leg’ when the true source of the trouble is the lumbar spine. Conversely, the symptoms may suggest a spinal lesion when in fact they arise from an affection of the abdomen, pelvis, or lower limb, or from occlusion of a major artery or a leaking aortic aneurysm. Finally, it should always be remembered that back symptoms may be no more than a local manifestation of a generalized skeletal disease. Thus the investigation of back or sciatic symptoms must extend further than a study of the spine itself; it must include an examination of the abdomen, pelvis, lower limbs and vascular system, and a general survey of the rest of the body. At this stage of examination the massage therapist must consider whether the patient condition is of sufficient severity to require referral.


EXAMINATION OF THE NECK AND THORACIC SPINE

Refer Set Text CH 4 pg 37 - 81 After the back the neck and shoulders are the next most commonly presenting clinical complaints. The neck:

Cervical Spine: The cervical spine connects the heads of the thorax and consists of seven cervical vertebrae. The first, second and seventh vertebrae present special features whereas the rest conform to a common type.

The Typical Cervical Vertebra features:-

small transversely broad body

large, triangular vertebral foramen.

Pedicles projecting laterally as well as back.

long, narrow laminae markedly angled.

spinous process is short and bifid.

superior and inferior facets form an articular, pillar.

The 1st

Cervical Spine is more commonly known as the Atlas. It:-

supports the globe of the head.


lacks a body.

no true spine.

Unusually long transverse processes (increases power of muscle leverage).

Males have wider atlases than females.

The 2nd

Cervical Vertebra is known as the Axis. It:-

acts as a pivot for the head to rotate on.

has a long, tooth-like process - Dens (odontoid process) which juts vertically up.

has no articular pillar as the superior facet joint lies more anteriorly than the inferior facet joint.

has laminae thicker than other cervical vertebrae.

has long powerful spinous process to take the pull of muscles rotating the head.

has small transverse processes.

The 7th

Cervical Spine features:-

A long spinous process with a single tubercle at its end.

Large transverse processes, especially the posterior part.

Joints Of The Cervical Spine: From the 2nd

cervical vertebra down there are cartilaginous joints between the bodies and synovial joints between the arches.

The vertebral bodies are united by intervertebral discs of fibro cartilage and long anterior and posterior ligaments.

The Discs: Are the chief bond and consist of a jelly-like centre (nucleus pulposus) and an outer fibrous ring (annulus fibrosus). They are thicker in front than behind, contributing to the cervical lordosis. The discs are adherent to a thin layer of cartilage which covers the superior and inferior surfaces of the vertebral bodies. They constitute 1/5 of the vertebral column and proportionally more in the cervical region, making it a more pliant area.

The Facet Joints: Between the vertebrae are synovial planar joints. The laminae, spines and transverse processes are connected by the ligamentum flavum, and the interspinous, the supraspinous and inter-transverse ligaments.

The Atlanto-Axial Joints: Consist of three synovial joints, one on either side of the lateral mass and one between the anterior arch and transverse ligament of atlas and the dens of the axis. This is a pivot joint and allows rotation of the head. The capsules are thin and loose, strengthened by accessory ligaments.

The Atlanto Occipital Joints: Are two joints between the lateral masses of the atlas and the condyles of the occipital bone. They are ellipsoid joints united by fibrous capsules and anterior and posterior atlanto-occipital membranes.

Ligaments extending between the occipital bone and the axis are the membrana tectoria which lies within the vertebral canal, the alar ligaments which lie either side of the dens and the apical ligament which connects tip of dens to occiput. Dislocation of atlas from axis with rupture of the transverse ligament is the cause of death with hanging.

Movements Of The Cervical Spine: Flexion/Extension, Rotation, left and right and Lateral Flexion, left and right are the movements of the neck. The combination of them give the head a wider scope of vision.

50% of rotation occurs at the atlanto-axial joint.


Main neck flexors:- Sternocleidomastoids, in conjunction.

Secondary Scalenus muscles, pre vertebral muscles.

Main neck extensors:- Para vertebral extensor mass. (Splenius, Semi spinalis, capitis) trapezius..

Secondary Various small intrinsic neck muscles.

Main neck rotators:- Sternocleidomastoid - one at a time.

Secondary Small intrinsic neck muscles.

Main lateral flexors:- Scalenus anterior, medius, posterior.

Secondary Small intrinsic neck muscles.

Examination of The Cervical Spine:

The cervical spine has three functions:-

1. To support the head.

2. Provides a large visual field for the head, and

3. House and transport the spinal cord and vertebral artery.

Subjective and Objective Examination:

Watch head position as they walk into the room, see if it is held stiffly as if protecting itself, or if it moves freely in an erect position. Also look for blisters, scars, or swelling.

Bony Palpation:

1. Examine supine to relax muscles.

2. Palpate the hyoid bone, opposite C3 just under chin. Ask patient to swallow. Any pain?

3. Thyroid cartilage opposite C4 - C5. Upper part is Adams Apple.

4. 1st

Cricoid Ring opposite C6 (part of trachea). If too much pressure is exerted, a gag reflex may be initiated.

5. Carotid Tubercle - anterior tubercle of C6 transverse process. Lateral to Ring.

6. C1 Transverse Process - lies between angle of jaw and mastoid process.

7. Mastoid Process - behind ear part of skull.

8. Examine in prone the posterior land marks.

9. Occiput and Inion ( Greater protuberance ) - bump on back of skull..

10. Superior Nuchal Line - runs laterally from inion - a transverse ridge.

11. Spinous processes of cervical vertebrae C2 is first to palpate (C1 is hidden deep). C7 and T1 should be more prominent.


12. Facet joints - move laterally 1 inch from the spinous processes. Apply finger pressure up into TP’s.


Supine position.

1. Sternocleidomastoid muscle. (Frequently stretched in hyper ext. injuries).

2. Lymph nodes - along medial border of SCM. Not normally palpable.

3. Carotid pulse - felt as 6 level near tubercle, feel one at a time.

4. Parotid gland - covers angle of mandible, swells with mumps.

5. Supra Clavicular fossa - palpate for lumps or unusual swellings. Possible cervical rib.

Sitting position.

6. Trapezius - Prominent superior border - frequently stretched in flexion injuries. Also lateral to spinous processes.

7. Greater Occipital Nerves - lie on either side of inion and become palpable if inflamed after acute trauma resulting in headaches.

8. Superior Nuchal Ligament - lies over spinous processes from base of skull to C7.

Active Range of Movement - Test in sitting position.

Flexion/Extension Lateral Flexion Rotation.

Active Resisted Range of Movement - Test in sitting, stabilize body.

Passive R.O.M. - Test in supine.

Special Tests:

Distraction Test (P.126, 127 Hoppenfeld Chp 4 Gross et al)

- Distraction can relieve neck pain if pain is produced by narrowing of the neural foramen, (intravertebral), (with resultant nerve root compression).

Distraction widens the foramen, decreases pressure on joint capsules and alleviates muscle spasm. Therapist hands under chin and nuchal line - lift up with care.

Compression Test also known as Spurling’s Test: (P.126, 127 Hoppenfeld, Chp 4 Gross et al)

Compression may reproduce pain referred to upper limb from, cervical spine by narrowing the foramen and increasing pressure on facet joints. This may help locate the neurological level of and existing pathology. Apply direct pressure down through crown.

Vertebral Artery Test: (Chp 4 Fig 4.70 Gross et al)

Vertebral Artery Insufficiency can cause dizziness when the head is rotated. This is due to stenosis or canal narrowing, allowing insufficient blood flow to the brain. The vertebral A. passes through the foramina in the transverse processes of all the cervical vertebrae except the 7

th and winds around the lateral mass of the atlas to enter the skull, through the

foramen magnum.


Ask the patient to rotate the head to its limit and hold for 10 seconds. If no symptoms of dizziness or faint headedness, rotate the other direction and hold for 10 seconds. Finally fully extent the head for 10 seconds. This test can be done sitting or supine ( hang neck over table – extend and rotate)

Adson Test: ( p.127 Hoppenfeld )

Is used to determine the state of the subclavian artery, which may be compressed by an extra rib or by tight scalenes muscles, which can compress an artery where it passes between them on it’s way to the upper extremities.

Take the patient’s radial pulse at the wrist. As you continue to feel the pulse, abduct, extend and externally rotate his arm. Then instruct him to take a deep breath and to turn his head toward the arm being tested. If there is a compression of the subclavian artery, you will feel a marked reduction or absence of the radial pulse.

Neurological Testing Of Cervical Spine:

Degeneration of cervical discs with subsequent trauma, may cause external derangement of the disc or soft tissue injury to the joints, causing pressure or irritation of the neighbouring spinal nerves which emerge through the intervertebral foramen. This is most common in the C5 - C7 level and motor and sensory effects, with loss of power and reflexes

and sensory changes may result in the areas of supply. The spinal nerves appearing from below the lower four cervical vertebrae and the first thoracic vertebra join and mingle to form the Brachial Plexus which in turn divides into branches and supplies the upper limb.

Specific muscle reflex and sensory testing can help establish at what neurological level the problem is to be found.

Neurology Of Upper Limb.

Disc Root Reflex Muscles Sensation

C4 - 5 C5 Biceps Deltoid / Biceps Lateral arm/

Axillary Nerve.

C5 - 6 C6 Brachioradialis Wrist ext. / Biceps Lateral forearm / Musculocutaneous Nerve.

C6 -G C7 Triceps Wrist flexors / Finger

Extensors/ Triceps.

Middle Finger

C7 - T1 C8 Finger Flexion / Hand

Intrinsic.

Medial Forearm / Med. Ant. Brachial

Cutaneous N.

T1 - T2 T1 Hand Intrinsic Medial Arm / Med. Brachial Cutaneous N.

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