Orthopedic Tests used by Massage Therapist

When a client comes to see us with complaints of muscle pain or soreness there are certain tests we can use to assess the situation. These tests will give us an idea of what treatments may be best for the client or if we need to refer them to a specialist. The active range-of-motion (AROM) test gives us an insight to the client's available range of motion, how much muscle strength they have and any pain associated with the movement.

During this test the client does all the motions by themselves while only being verbally guided by the instructor. This test is performed first so we can gauge the client's pain tolerance with the performed motions before further stressful tests can be used. Doing this test first also lets us rule out having to do passive range-of-motion (PROM) tests. The reason being if the client experiences no pain doing the motion by themselves then chances are high they won't experience any pain when assisted in doing the movements.

Passive range-of-motion tests (PROM) where the client is assisted in movements focuses more on the inert tissues since contractile tissues are not used during the passive movements. As the practitioner assists the client in the movements it allows them to palpate the area being moved and to evaluate any possible restrictions being applied in that area. The restrictions that can affect the ROM are items such as muscle binding, crepitus and various other factors. If pain with PROM is detected determining which inert tissues are to blame is the next step. Common causes of pain with passive motion are fibrous scar tissue restrictions, ligamentous injury, joint capsule injury, impingement of soft tissues such as bursa or nerves, osteoarthritis or other joint pathologies. (Lowe) If a client experiences no pain during PROM testing then it's possible that no inert tissue injury exists or the testing did not stress the tissue on the correct plane. Further testing should be done to fully identify the source of the pain and to allow for proper treatment.

Manual resistive tests also known as resisted isometric movements require an isometric muscle contraction. This test will evaluate the proper functions of contractile tissue during its movement. It also gives a confirmation of the findings from our previous AROM and PROM testing. Since this test has no movement occurring at the joint during isometric contraction no inert tissue is involved. The reason this test is done last is because of the exerted stress it requires to perform it. The client is asked in some form or manner to place resistance against certain types of movement so the therapist can further evaluate the situation. If pain is associated with this type of movement it may be an indicator that injury has occurred within the muscle-tendon unit. Common causes can include any type of muscle strain, tendinosis and tenosynovitis. Neuromuscular pain may also be present in the form of chronic muscle spasms.

When we look at our results after each test has been thoroughly performed it gives us a platform to cross reference our data in determining the cause and a treatment plan. If a client had no associated pain during AROM testing then it would be likely that no damage or minimal injury existed to the structure be it contractile or inert. The client may also not have any pain if there were not enough muscle fiber involved to trigger the pain. However if the client has pain during PROM testing and none with AROM then we are able to figure out some form of inert tissue injury exists. If the client presented with pain during AROM but no pain with MRT testing the pain may be caused by inert tissues but since no pain was involved during MRT we can possibly rule out the contractile tissue injury.

Each of these tests performed gives us a specific insight as to what the cause of the pain may be, the client's ability to perform the requested task at hand and what path of treatment is needed. These tests are not end all but through their use we are given valuable information that will allow us to help and treat our clients.

Ankle Drawer Test

This test is used to test the integrity of the talofibular ligament on the anterior portion. You perform this test by stabilizing the anterior distal tibia with one hand and pulling on the calcaneus in an anterior direction with the other hand. When performing this test on a client who may have a 1st or 2nd degree sprain they may experience some pain. If the client presents with a 3rd degree sprain there will be a good amount of movement but limited pain because of a rupture in the affected ligament. Some clients are more flexible in certain areas and you can determine if that client is flexible or injured by testing the unaffected side to see if you get the same results. If the ligament is damaged but not fully torn, then the tensile stress on the injured ligament fibers will cause pain. Treatment with this type of injury is best done using the P.R.I.C.E. method and can be managed with conservative treatment. More severe cases may require surgery and physical therapy treatment that includes ROM exercises, and muscle stretches around the ankle joint to help strengthen it. I would expect the client to be in pain when performing this test with the exception of a non injured client or someone who has a complete rupture.

Squeeze Test

When performing a squeeze test the practitioner will squeeze the mid-calf region together to determine if pain is felt within the distal tibiofibular joint. When the tibia and fibula get squeezed together it causes them to be separated at the distal syndemosis. If pain is present it may indicate a syndesmotic injury. However you need to be weary that some fractures or compartment syndromes also produce pain when performing this test so you need to take this into consideration. I would expect a client to have some mild discomfort when performing this test and experience pain should when an injury exists. Treatment for syndesmosis sprains can be handled similar to medial and lateral ankle sprains using the P.R.I.C.E. method while in the acute stage. Once you have determined the severity of the ligament sprain proper treatment can be determined. Bracing will help improve the stability and enhance weight-bearing activities. Massage may help reduce any muscle spasms and hypertonicity but since ligament fibers are hard to reach the treatment may be only superficial.

Dorsiflexion-Eversion Test

This test is done with the client lying in a supine or on their back position. Then the ankle is passively moved into maximum dorsiflexion and eversion while the toes are hyper extended throughout the test. The position is held between 5 and 10 seconds. Tapping directly over a region of expected neuropathy may reproduce symptoms known as Tinel's sign. If a short, sharp neurological sensation happens with each tap this may indicate tarsal tunnel syndrome. When the irritated nerve gets compressed it becomes highly sensitive to even light pressure and that will produce these symptoms. If TTS is present a conservative treatment approach can be taken first. If the primary problem involves over pronation, which stretches the tibial nerve in the tunnel, an orthotic can be built for the medial side to prevent the foot from rolling into excessive eversion. (Lowe) Massage may be helpful but needs to be performed carefully as it can put excessive pressure on the nerve endings triggering more pain.

Achilles Tendon Pinch Test

This test is performed with the client laying in the prone position or on their stomach. The practitioner then squeezes the sides of the tendon superior to the calcaneus to attempt to reproduce the client's primary complaint. (Lowe) When you squeeze the dysfunctional tendon it causes pain in response. All tendon fibers would be affected so squeezing from the sides puts pressure on the tendon, but decreases the chance that pain originates from the structures directly posterior to the calcaneus, such as the retrocalcaneal bursae. (Lowe) Treatments for the types of injuries associated with this test are best controlled with rest and activity modification. Anti-inflammatory medications and cold applications can be used to reduce any inflammatory activity. Massaging the calf muscles may reduce tension and decrease the forces placed on the tendon.

Reference:

Lowe, Whitney. Orthopedic Assessment in Massage Therapy. Daviau Scott, 2006.

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