David A. Zulak M.A., R.M.T.
Comprehensive Assessment
therapists who want to learn to assess the structures and functions
involved in the musculoskeletal system of the human body.
As a digital textbook –
• Pages can be projected onto a screen for classroom use. When projecting
instructions for a specific test, the instructions and the accompanying images are
all on the same page.
• Notes can be written on Adobe ‘post-its’ and saved with the document you
have downloaded. Short notes or several pages worth of notes can be stored, on
any page, even at a specific word on the page.
• Though the text still lacks an index, as a PDF it is searchable by word or phrase.
• As an Adobe PDF there is a free reader available from Adobe so that the text can
be used with tablets.
For a fuller discussion on how this book can be used by instructors, students and
practicing therapists see the Introduction: “How to use this book.”
This textbook covers all of the basic or “classic” orthopaedic testing that is required
of massage therapists. It further includes instruction in many forms of motion
palpation and assessment techniques that come from the osteopathic tradition,
especially as the source of testing for the spine and sacrum. Hence, the removal of the
word orthopaedic from the title of the book, as it may misrepresent the full scope of
the intent of this textbook and of the comprehensiveness of testing presented herein.
This digital textbook has been revised since the printed version:
• Addition of a detailed Table of Contents for the textbook as a whole, with page
numbers. This also includes an index for the "classic orthopaedic" tests. Further,
there are revised and corrected list of contents for each chapter, and again, now
with page numbers.
• Newly revised and reorganized Introduction (formally the Preface)
• Addition to Introductory Lectures (formerly the Introduction) with an
introductory lecture on Spinal Motion: Structure & Function.
Comprehensive Assessment for Massage Therapists
An Instructional Textbook for Students, Instructors & Massage Therapists
Written, researched & organized by
David Zulak M.A., R.M.T.
© 1997-2010
The author accepts no liability with respect to the testing procedures discussed or
demonstrated in this book, nor for any treatment suggestions. Please refer to your
regional or national scope of practice guidelines when considering performing any
of the tests in this book.
.
This textbook is dedicated
to my wife, Anne Wilson.
Without her support, love
and inspiring example of determination,
this book would never have seen the light of day.
It is also dedicated to
my extraordinary children,
Katie and James,
for their sustaining love
thanking all of my wonderful students, who over the years taught me so much, who were so patient
with me, and who encouraged me to pursue this project.
My greatest gratitude to any one person, without question, goes to Johan Overzet. Since meeting at
the Sutherland-Chan School of Massage & Teaching Clinic in 1992, we have studied together,
practiced our craft, debated and advanced together. We both attended osteopathic courses together
in Canada and helped each other survive the experience and be better manual therapists for it. The
results of many of our debates over the years are scattered through this book. Johan has always been
honest with me, whether for approval or criticism. That, above all, proves he is the truest of friends.
I owe much to Bruno Ruberto, who did the layout for the book, providing so much to its readability,
through both his artistic eye and help with editing. A special thank you to Marcia Mrochuk for her
invaluable editing skills. Also, I appreciate the help of Jackie Guanzon RMT and Ashley Marcos RMT for
their efforts in serving as proof readers for various parts of the book. Jackie, who is featured
extensively throughout the book, also served as the principal model, assisted by Antonella Licata,
Darryl Hoogendam RMT and Justin Doherty RMT. Bart Vallecoccia, an anatomical artist, created the
wonderful anatomically detailed drawings that are found throughout the text.
I am grateful to my instructors at Sutherland-Chan for their dedication to the profession, and their
students. I wish to thank Debra Curties and Trish Dryden for their support and encouragement in my
first attempts at teaching, which also occurred at Sutherland-Chan. My first co-teachers also helped
me greatly. Geoff Harrison, who as a certified athletic therapist, was instrumental in bringing a wealth
of information to my attention, and the late Earl O’Neal, who so generously shared his wealth of
experience with me.
I wish also to thank Naomi Baker RMT, owner and operator of Therapeutic Massage Counsel, for her
support and friendship. I have worked for many years in her wonderful multi-therapist clinic. A former
student of mine, Naomi has, with nary a complaint, let me disappear for days at a time for teaching,
studying or writing, over the years. The outstanding staff at the clinic has coddled me to the point that
I am now absolutely spoiled. My fellow therapists at the clinic have all been so generous and kind and
I greatly appreciate their camaraderie and enthusiasm while working in an environment that focuses
on therapeutic massage.
Last, but not least, I owe much to the instructors at the Canadian Academy of Osteopathy & Holistic
Health Sciences in Hamilton, Ontario, Canada. I am especially thankful to Dr. Todd Bezilla (DO, USA)
and Robert Johnston (DOMPT, Canada) for allowing me to occupy so much of their time with
answering my endless questions. The depth of their knowledge and the breadth of their thinking keep
me humble. As great teachers and as thoughtful, meticulous and compassionate health care
providers, both of them have provided me with an ideal to strive for.
David Zulak
General Table of Contents
Detailed Table of Contents ii
,QWURGXFWLRQ +RZWR8VHWKLV%RRN p1
Introduct
DU\/HFWXUHV i1
Chapter IV: Comprehensive
List of “Classic” Special Orthopaedic Tests ix
Chapter I: Ankle & Foot 1
Chapter II: Knee 33
Chapter III: Hip & Innominate 79
Examination of the Spine 137
Chapter V: Sacroiliac Joint & Pelvis
149
Chapter VI: Lumbar Spine 203
Chapter VII: Thoracic Spine & Ribs 267
Chapter VIII: Cervical Spine 309
Chapter IX: Thoracic Outlet 387
Chapter X: Shoulder
p 403
Chapter XI: Elbow 447
Chapter XII: Wrist & Hand 477
References 519/ (r1)
How to use this book p1
How this book is comprehensive p3
When Learning too much is not enough p4
Introductory Lectures
The Spirit of Assessment i1
The Procedure for Assessment i7
Pain i13
Observations i24
Overview of Assessment Protocol i25
Intake: Forms, Interviewing & Case History Taking
i28
• Case History Form i29
Pain and Impairment i33
• Active Listening i39
Rule Outs i42
Range of Motion Testing i42
Differential Tissue Testing i45
Assessment & Treatment Planning i46
Postural Assessment i48
• Muscle Balance and Posture i48
• Common Postures i52
• Postural Examination i54
• Palpating Landmarks i60
• Rotations i69
Gait Analysis(Classic) i75
Gait Analysis: Alternative View i80
Charting & Recording i86
Spinal Motion: Structure & Function i99
Chapter I ANKLE & FOOT Page 1
Clinical Implications of Anatomy & Physiology 3
Case History (Specific Questions) 5
Observations 5
Rule Outs 7
Active Free Range Of Motion (AF-ROM) 9
Passive Relaxed Range Of Motion (PR-ROM) 11
Active Resisted Range of Motion (AR-ROM) 13
Special Tests 16
Differential Muscle Testing 16
Talar-Tilts 19
Anterior Draw Test 20
Wedge Test 21
Homans’ Sign 24
Metatarsal-Phalangeal & Phalangeal Joints 25
AF-ROM
25
PR-ROM
26
AR-ROM
28
Ankle & Foot Conditions/Pathologies 29
Chapter II KNEE 33
Clinical Implications Of Anatomy & Physiology 35
Case History (Specific Questions) 40
Observations 41
Rule Outs 45
Fractures 47
Wipe Test for minor effusion 47
Fluctuation Test for moderate effusion 49
Patellar Tap Test for major effusion 50
Active Free Range Of Motion (AF-ROM) 51
Quadriceps Inhibition Test 53
Passive Relaxed Range Of Motion (PR-ROM) 55
Active Resisted Range Of Motion (AR-ROM) 59
Special Tests 60
Differential Muscle Testing 60
Modified Helfet Test 63
Valgus Stress Test 64
Varus Stress Test 65
Apley Distraction Test 65
Anterior Draw Test 66
Posterior Draw Test 68
Lachman’s Test 68
Apley Compression Test 70
McMurray’s Meniscus Test 71
Patellar Apprehension Test 75
Patellofemoral Compression Testing 75
Clark’s Test 76
Noble’s Compression Test 77
Bounce Home Test 77
Chapter III: HIP & INNOMINATE 79
Clinical Implications of Anatomy & Physiology 80
i
Comprehensive Assessment for Massage Therapists
Passive Relaxed Range Of Motion (PR-ROM) 108
Testing Joint Play 112
Active Resisted Range Of Motion (AR-ROM) 114
Special Tests 118
Differential Muscle Testing 118
Thomas Test 123
Ober’s Test 126
Piriformis Test 128
Trendelenburg’s Test 130
Scouring Test 131
FABER Test 132
Ely’s Test 133
Leg Length Discrepancy Test 133
Stork Test 135
Chapter IV Comprehensive
Examination of Spine 137
Comprehensive Structural Examination
of the Spine & Pelvis 139
1. Standing Postural Views 140
2. Checking Symmetry Of Landmarks 141
3. Checking Symmetry During AF-ROM 142
4. Assessing Postural Stability 144
5. Checking Postural Symmetries & AF-ROM Sitting 145
6. Checking Postural Symmetries While Supine 145
7. Checking Rotation In The Body 147
8. Checking Landmarks Prone 148
Chapter V: Sacroiliac Joint & Pelvis 149
Note to Reader 151
Chapter Organization 152
Part I: Clinical Implications of Anatomy & Physiology 153
Anatomical Structures & Landmarks 153
S.I. Joints and Impairments 154
Terminology & Types of Movements 155
Some Points to Consider 156
Definitions of Sacroiliac Movements 157
Part II: Innominate Motions & Impairments 164
Movements of the Lumbopelvic Girdle 164
Unilateral and Bilateral Pelvic Tilts 167
Physiological Motions of the Innominates
during Gait 168
Symptoms of Innominate Impairments 168
Part III: Testing For Innominate Impairments 169
Observation & Inspection 170
Testing for Leg Length Discrepancy 172
Assessing for Inflares & Outflares 173
Placing Innominate Orientation in Context
Of the Trunk & Head 174
Stork Test 175
Standing Flexion Test 176
Standing Extension Test177
Palpation & Inspection of Sacral Motion 178
Four-Point Test 178
Spring Test 179
Gapping Test 179
Pelvic Challenge for Pubic Symphysis
Impairments 180
Interpreting Results of Motion Testing
& Palpatory Findings 181
Part IV: Introduction to Sacral Dysfunctions 182
Gait: The Innominates & Sacroiliac Joints182
Physiological Motions Where the Sacrum Can
Other Non-Physiological Impairments Of The S.I.
Become Fixed 183
Non-Physiological Motions Where the Sacrum
Can Become Fixed 184
Joints 185
Part V: Testing for Sacral Dysfunctions 186
Observations 186
Seated Flexion Test 186
Prone Palpation of Sacrum 187
Torsion Lesions 189
Sacral Shears, Summary of Findings 189
Bilaterally Nutated Or Counter-Nutated Sacrum,
with Summary of Findings 190
Part IV: Orthopaedic Assessment
of the Sacroiliac Joints 192
Rule Outs 192
Differential Muscle Testing 193
Special Tests 197
Compression Test of S.I. Joints 197
Posterior Displacement Test 198
Anterior Displacement Test 198
FABER Test 199
Ganslen’s Test (Caution) 199
Appendix 200
Gait & Sacral Motion 200
Walking/Running 200
Rules of Movement for the Sacrum & L5 202
Chapter VI: Lumbar Spine 203
Clinical Implications of Anatomy & Physiology 205
Fryette’s Rules of Spinal Motion 206
Lumbar Intervertebral Disc (IVD) 208
Note on Causes of Low Back Pain 208
The IVD & Low Back Pain 208
Levels of Degenerative Disc Disease 209
Suspected Sources of Intermittent
& Chronic Low Back Pain 210
Are X-rays, CT Or MRIs Really Better
Than Hands-On Testing? 211
Facet Joint Dysfunction & Pain 212
Group & Segmental Impairments 213
Comprehensive Examination 215
Case History (Specific Questions) 216
Observations 216
Common Postures & How
Exceptions for Range of Motion (ROM) Testing
& Use of Motion Palpation Testing 223
Active Free Range of Motion (AF-ROM)
224
Measuring Amount of Lumbar flexion 225
Pain on Flexion 226
AF Flexion with Over-Pressure 227
Extension 228
Pain on Extension 228
Sidebending 229
Pain on Sidebending 229
AF Sidebending with Over Pressure 230
Hip-Drop Test 231
Lumbar Rotation 232
Over Pressure to lumbar Rotation 233
Motion Testing for Facet Joint
Dysfunctions in the Lumbar Spine 234
Palpation in Neutral 235
Basic Rules & Findings of Motion
Testing in the Spine 236
Palpating in Flexion & Extension 236
Findings, Explanations & Examples 238
Palpatory Findings Chart 239
Alternative Motion Palpation
Testing in Prone 240
A Common Clinical Finding:
The Disappearing Scoliosis 241
Lumbar Curves & Segmental
Dysfunctions 242
Passive Relaxed Range Of Motion
Introductory Note 242
Passive Range of Motion 243
Insight – Assessing Lumbopelvic
Motion in Supine 245
Joint Mobilization 246
Resisted Isometric Testing & Strength Testing 249
Special Tests 251
iv
Straight Leg Raise Test
for Neurological Signs 252
Well Leg Raise 254
Slump Test 254
Bowstring Sign 255
Valsalva’s Test 256
Hoover’s Test 256
Group 2 – Specific Neurological Tests 257
Myotome Testing 257
Dermatome Testing 260
Deep Tendon Reflexes 263
Excluded Classic Tests 265
Femoral Nerve Stretch (Nachlas Test)
Quadrant Test (Kemps’ test)
Milgram’s Test
Chapter VII: Thoracic Spine & Ribs 267
Clinical Implications of Anatomy & Physiology 269
Fryette’s Rules of Spinal Motion 269
Motion impairments 270
Thoracic Intervertebral Disc 270
“Rules of Three” for Land-marking T-Spine 271
Comprehensive Examination 272
Observations 274
Note on Testing Range of Motion 276
Insight - Isolating Thoracic Spine
from Rest of Spine: What To Do? 276
Active Free Range Of Motion (AF-ROM) 277
Notes on Scoliosis 278
Passive Relaxed Range of Motion 280
Testing End-of-Range Motion of Ribs 281
Motion Palpation of the Upper T-Spine 282
Basic Rules & Findings of Motion
Testing in the Spine 282
Review of Findings & What
They Mean 284
Palpation of Ligaments of the Thoracic Spine 295
Thoracic Spine Neurological Symptoms 296
Introduction to the Ribs
Musculature & Joints 297
Palpation of First Rib 299
Palpation of Second Rib 300
The Sternomanubrial Joint & Its Palpation 301
The Sternoclavicular Joint & Its Palpation 302
General Motion of the Ribs & a Quick
Scanning of Rib Motions 303
Possible Findings during Testing 304
Palpation of Rib Motion 305
Chapter VIII: Cervical Spine 309
Clinical Implications of Anatomy & Physiology 311
Sub-occipital Recti Muscles
& Eye Movements 311
Definitions & Rules of Motion
for the Cervical Spine 312
Clinical Considerations & More
on the OA & AA Joints
More on Anatomy of the Upper Quadrant 314
The Lower Quadrant 315
Presentation of Pain & Segmental
or Group Dysfunctions 316
Insight – Migraines can be a Pain
in the Neck 318
Comprehensive Examination 319
Case History (Specific Questions) 321
Observations 321
Upper Cross Syndrome 323
Light Inspection Palpation 324
Rule Outs 324
82
Shoulder 324
Insight – Observing OA Joint Impairment 329
Motion Palpation Testing of the Cervical Spine 331
Motion Palpation Testing of
the Occipito-Atlantal (OA) Joints 332
First Method 333
Second Method 334
Third Method 335
Diagonal Glides 336
Motion Palpation Testing of
the Atlanto-Axial (AA) Joints 337
Calculating ROM Loss in the AA Joint,
v.s. from Lower Cervical Joints 339
Insight – Rotated C1 Impairment 339
Alternate Hand Positioning
for Testing of AA Joint 340
Motion Palpation of Lower Cervical Spine 341
Joint Mobilizations 341
What Type of Lesions are We Finding
with Lateral Translations 344
Insight – Further Comments
On Translation Movements 344
Discovering Which Side is Impaired 345
Insight – Don’t Make Assumptions 346
Insight – What We may have Seen
in AF-ROM 349
Summary of Testing the Cervical Spine
by Translations 350
Other Impairments and Red Flags 351
Passive Relaxed Range of Motion 352
Active Resisted Range of Motion .356
Insight – Shortfalls of Some Orthopaedic Testing
of the Cervical Spine 357
Special Tests 358
Compression Test 358
Decompression Test 359
Quadrant Testing 360
Lower Quadrant Test 361
Spurling’s Test 362
Tinel’s Sign At The Neck 365
Bakody’s Sign 365
Introduction to Specific Neurological Testing 366
Dermatome Testing 368
Sensory Testing Of the Face 369
Peripheral Nerve Testing 370
Myotome Testing 371
Motor Testing of Peripheral Nerves 373
Upper Limb Tension Testing (ULTT) 376
(See Thoracic Spine chapter, TOS Testing)
Deep Tendon Reflex (DTR) Testing 376
Pathological Nerve Impairment Testing 378
Spastic Paralysis Versus
Flaccid Paralysis 378
Temporal Mandibular Joint Testing: Introduction 379
Insight - Chewing: More Than Just Opening
& Closing the Jaw 380
Active-Free Range of Motion Testing
381
Passive Relaxed Range of Motion
& Joint Mobilization for TMJ 384
Chapter Nine: Thoracic Outlet 387
Clinical Implications of Anatomy & Physiology 389
Observations Prior To Specific TOS Testing 392
Rule Outs 393
Thoracic Outlet Tests 394
Adson’s Test
& Variations 394
Insight - Travell’s Variation,
and the Halstead Manoeuvre 395
Costoclavicular Syndrome Test 395
Pectoralis Minor Syndrome Test 396
Cervical Rib 397
Introduction to Upper Limb Tension
Tests (ULTT) 397
Cautions & Considerations 398
General ULTT 399
Median Nerve Bias ULTT 400
vi
Clinical Implications Of Anatomy & Physiology 405
Case History (Specific Questions) 407
Observations 408
Rule Outs 411
Insight – Why we need to Test both Sides Bilaterally 412
Active Free Range Of Motion 413
Scapulothoracic Articulation 416
Apley’s Scratch Test 417
Passive Relaxed Range of Motion 418
Assessing the Acromioclavicular
& Sternoclavicular Joints 420
Joint Play Inspection of the
-Glenohumeral Joint 421
Sternoclavicular Joint 423
Acromioclavicular Joint 424
Scapula 425
Three Interrelated Motion Tests for
the Scapula & Glenohumeral Joint 426
Active Resisted Range of Motion 429
Special Tests 432
Differential Muscle Testing 432
Yergason’s Test 438
Speed’s Test 439
Supraspinatus Tendonitis Tests 440
Empty Can Test 440
Hawkens-Kennedy/Impingement Test 441
Apprehension Sign/Crank Test 441
Winging Scapula Test 442
Acromioclavicular Shear Tests 442
Shoulder Muscle Length Testing 443
Shoulder Pathologies 445
Chapter XI: ELBOW
447
Elbow Chapter Overview 448
Clinical Implications Of Anatomy & Physiology 449
Case History (Specific Questions) 451
Observations 451
Rule Outs 452
Special Tests 460
Differential Muscle Testing 460
Ligamentous Stability Tests 466
Valgus Stress Tests 466
Varus Stress Tests 467
Tests For Epicondylitis 468
Tendonitis vs. Tendonosis 468
Lateral Epicondylitis/Tennis Elbow 469
Medial Epicondylitis/Golfer’s
or Pitcher’s Elbow 470
Tests for Nerve Compression Syndromes 471
Ulnar Nerve Tinel’s Sign at Elbow 471
Ulnar Nerve Stretch Test at Elbow 471
Pronator Teres Syndrome Test
or Anterior Interosseous Syndrome 472
Compression of the Median Nerve at
the Ligament of Struthers Test 472
Supinator Radial Nerve Syndrome Test 473
Tinel’s Sign for Radial Nerve At Elbow 473
Source Of Neurological Symptoms Not Found? 474
Pathologies and Conditions of the Elbow 475
Chapter XII: Wrist & Hand 477
Wrist & Hand Chapter Overview 478
Clinical Implications of Anatomy & Physiology 479
Case History (Specific Questions) 480
Observations 481
Observing, Inspecting and Palpating 482
Rule Outs 485
Neurological Issues 486
Active Free Range of Motion 487
Capsular Patterns of Restriction
& Position of Rest 487
Passive Relaxed Range Of Motion 488
Joint Play Inspection of the Wrist 489
Active Resisted Range Of Motion 490
(Mouse Hand) 497
Intersection Syndrome 498
Conditions of the Phalanges (The Fingers) 498
Fracture Of The Scaphoid 498
Extensor Expansion Test (Bunnel-Littler Test) 499
Ligamentous Tests of MCP, PIP & DIP Joints 499
Skier’s Thumb 499
Trigger Finger 500
Nerve Compression Syndromes at the Wrist 500
Tests for Median Nerve Impingement
Motor Testing for the Median Nerve
-Tinel’s Sign & Phalen’s Tests 501
Pinch Test 502
Tests for Ulnar Nerve Impingement
-Ulnar Nerve Tinel’s Sign 502
Frommet’s Sign/Test 503
Vascular Compression Tests at the Wrist
Allen’s Test at the Wrist
for Ulnar and Radial Arteries 504
Appendix A:
General Testing of the Hand & Fingers 505
Appendix B:
Testing Of Fingers & Thumb 510
Active Free Range of Motion 510
Passive Relaxed Range Of Motion 513
General Joint Mobilization
Testing 512
Active Resisted Range Of Motion
of the Thumbs and Fingers 514
References r1 (519)
viii
Adson’s Test Variation Halstead Manoeuvre 395 Adson’s Test Variation Travell’s Variation 395 Allen’s Test at the Wrist 504
Ankle Ligament Tests – see Talar Tilts 19 Anterior Displacement Test of the Hip 198 Anterior Draw Test for the Ankle 20 Anterior Draw Test for the Knee 66 Apley Compression Test 70 Apley Distraction Test 65 Apley’s Scratch Test 417
Apprehension Sign/Crank Test 441 Bakody’s Sign 365
Bounce Home Test 77 Bowstring Sign 255 Bunnel-Littler Test 499 Cervical Rib 397
Clark’s Patellar Test Excluded* 76
Compression Test for the Cervical Spine 358 Compression Test of S.I. Joints 197 Costoclavicular Syndrome Test 395
De Quervain’s Syndrome (Finkelstein’s Test) 497 Decompression Test for the Cervical Spine 359 Ely’s Test 133
Empty Can Test 440
Excluded Classic Tests - Lumbar 265
Extensor Expansion Test (Bunnel-Littler Test) 499 FABER Test 132, 199
Femoral Nerve Stretch/Nachlas Test Excluded * 265 Finkelstein’s Test 497
Fracture of the Scaphoid 498 Ganslen’s Test (Caution) 199 Golfer’s Elbow 470
Hawkens-Kennedy/Impingement Test 441 Hoover’s Test 256
Intersection Syndrome 498
Kemps’ test for the Lumbar Spine Excluded * 265 Lachman’s Test 68
Lateral Epicondylitis/Tennis Elbow 469 Leg Length Discrepancy Test 133 Lower Quadrant Test Cervical Spine 361 McMurray’s Meniscus Test 71
Medial Epicondylitis/Golfer’s/ Pitcher’s Elbow 470
Noble’s Compression Test 77 Ober’s Test 126
Patellar Apprehension Test 75
Patellofemoral Compression Testing 75 Pectoralis Minor Syndrome Test 396 Phalen’s Tests 501
Piriformis Test 128 Pitcher’s Elbow 470
Posterior Displacement Test of the Hip 198 Posterior Draw Test for the Knee 68 Quadrant Testing 360
Scouring Test 131
Shoulder Impingement Test 441 Skier’s Thumb 499
Slump Test 254 Speed’s Test 439 Spurling’s Test 362 Stork Test 135 Straight Leg Raise Test
Supraspinatus Tendonitis Tests 440 Swallowing Test 364
Talar-Tilts (Ankle Ligament Tests) 19 Thomas Test 123
Thompson’s Test 22 Tinel’s Sign at the Ankle 23 Tinel’s Sign at the Elbow 471 Tinel’s Sign at the Neck 365 Tinel’s Sign at the Wrist 501 Trendelenburg’s Test 130 Trigger Finger 500
Valgus Stress Test Elbow 466 Valgus Stress Test Knee 64
Valsalva’s Test: lumbar 256; cervical 364 Varus Stress Test Elbow 467
Varus Stress Test Knee 65 Wedge Test 21
Well Leg Raise 254 Winging Scapula Test 442 Yergason’s Test 438
*Excluded tests are still described, but are not recommended for use with clients. However, they are still taught to students as their clients may have had them done with other health care practitioners.
- For Students
2. How this Book is “comprehensive.”
3. When “learning too much” is not enough.
Abstract: Many massage therapy school directors and students alike believe that students have
to learn way too much information for what their future practice will entail. A principle cause of this misbelief is a result of the incomplete and fractured curriculums. If the right five or ten percent of information is added to the curriculum, information that connects, links, and re-enforces their other learning, this ‘larger’ amount is, in fact, not too much at all, but makes the total more useful, memorable, and practical.
1. How to Use This Book
This is an assessment text written by a massage therapist specifically for massage therapists.
Both students in massage therapy schools and those already in the profession need such a text
in order to fulfill their goals. In other words, to be as effective and efficient as possible when
treating injuries and dysfunctions, while insuring that the application of techniques and
modalities remains appropriate and safe for the client.
For Instructors of Massage Therapy, or any manual therapy:
This digital version provides some extra benefits over a hard copy. This digital version works extremely
well with projectors in the class room. Why? Because every test has the written description of how to
do the test with the photos – all on the same page! If a test runs more than a page the instructions and photos stay in sync.
New topics start on a new page – the presentation has been specifically designed to avoid looking overwhelming for the students/readers.
The book is based on the structure & function of the joints and tissues being tested. Knowing the anatomy is not enough for a student to make the necessary connections to see how assessing and treating guide each other, and re-enforce the recall of each, along with linking the other courses of their program together for them. Understanding how the joints function helps the student understand those tissues better, understand how they work and how they can become impaired, how and why the test works, and enables the student/therapist to see and understand the results of testing.
The book is also based on an impairment model of assessment & treatment. If the student now sees what the testing is meant to tell them, about which tissues are injured and to what degree, then they know what needs to be treated. They understand the acuity of the injured tissues and what indications and contraindications to treatment exist. Taking this knowledge and adding it to the treatment
modalities they have learned, the student can create their own treatment plan. A safe and effective treatment plan!
p1 Comprehensive Assessment for Massage Therapists
For Instructors, Students and Massage Therapists: Other advantages of this digital textbook – The Adobe PDF version of the textbook allows you not only to download to laptops, but Adobe has a reader that is suitable for tablets. Further, all Adobe reader (free) programs now allow the reader to insert notes into the document via a ‘post-it note’ button. The note or comments can be very long, if necessary, and they can be saved by you in your downloaded PDF. As well, adobe documents are searchable – you can look up topics by word or phrase. Bookmarks can be inserted so that you can quickly access specific sites in the book.
For Students of Massage Therapy:
Students in massage therapy schools will need their instructors to help them deal with most of the material. To what degree and concerning which matters will be dependent on where and when their clinical assessment courses are situated within the school’s curriculum.
• The introduction to this book will be of most use to students. It does cover the main topics that are associated with assessment skills and understanding.
• In approaching each chapter, students can be guided in different ways by their instructors. • Many massage therapy students are kinaesthetic learners, which means they need to do first, to
perform the testing and then they are more likely to understand theories and rationales for the testing. The kinaesthetic learner can move right to the instructions regarding testing. In general, this will start in the observations section of each chapter. They should also initially skip the insights. In this way, they can go through the protocol suggested for each region of the body. They can then return to the anatomy review and the clinical implications of anatomy and physiology in each chapter in order to fill out their understanding. The insights throughout the chapter will fulfill this need as well.
• On the other hand, some students like to have a good grasp of why and what they are doing before they can learn the manual skills. The present of the book will suit them just fine.
For Students getting 1200 Or Less Hours Of Training: For massage therapists who have 1200 hours of
training or less, they should start with the clinical implications of anatomy and physiology sections and look through these, at least to insure that their knowledge of anatomy and joint physiology is sufficient to help them appreciate how the tests work and what they are telling them. Otherwise, they risk doing a test that they are not taking full advantage of with respect to what that test can tell them about the client’s chief complaint.
Therefore, for these readers, they too can go to a specific test if all they need is to review how it is done. Nonetheless, deepening their understanding by reading the clinical implications of anatomy and
physiology sections, as well as through reading the insights will only help them expand their understanding of what is going on with each client.
For Massage Therapists With 2200+ Hours of Training: For massage therapists of 2200+ hour programs,
this text becomes a resource that helps them to review specific tests, to review protocols of testing, and give some clues about anatomy topics they may wish to pursue in order to keep providing the highest quality care for their clients. However, even for many therapists with such training, the chapters on the sacroiliac joints, pelvis and parts of the spinal chapters may well exceed what they learned in school.
A. It Is Comprehensive In Scope:
• It will test all principal joints, muscles and ligaments that comprise the soft tissue and joint structures that are commonly impaired.
• The text is not just to cover the testing of the extremities and some cervical and some lumbar testing which is primarily neurologically focused. Rather, it intends to cover all the joints of the spine–including the facet joints – and the ribs. In addition, it will cover these all comprehensively, yet concisely,
efficiently.
• However, unlike some texts, it is not an encyclopaedia containing all possible tests, regardless of their efficiency or usefulness. It is not designed as a resource for all medical professionals. This text is
designed for massage therapists and written by a massage therapist in order to fulfill our scope
ofpractice: to assess and treat a client’s soft tissue and joints. In other words, it is comprehensive for our profession.
B. It Is Comprehensive For Clinical Use:
• It employs an impairment-based model to organize the protocol of assessment. The goal of such an assessment is to find the impairments a client presents with. The unique pattern of injury or
impairments that is unique to that individual.
• In finding the impairments that are unique to each individual client, the treatment for that client also becomes very specific.
• This organization of assessment includes finding the unique way that client is compensating for the dysfunction(s):
a) Instead of confirming someone else’s diagnosis, this textbook is organized so that each therapist finds the impairments they need in order to treat their client.
b) This book provides a protocol rather than suggesting specific tests for specific conditions. c) It is comprehensive because it is designed so that the therapist sees the client’s chief complaint as a set of impairments occurring within the context of the whole body.
C. It is comprehensive in that its protocol goes back to the basics, and covers as much as is reasonable for
our profession:
• It goes from case history taking, to range of motion (ROM) testing, to special testing. All the while explaining what each type of testing is revealing about the client and how each type of testing builds upon one another, leading to an understanding of that specific client’s chief complaint at that specific time and within the context of that person as a whole being.
• It is not just a textbook that makes a list of tests to learn for some examination. It is not a manual of orthopaedic tests.
• Rather it is designed to help the student/therapist understand why they are doing the testing that is required of them, and how to get the maximum information from this testing protocol in a clearand orderly manner.
• This protocol, this organized and efficient ordering of testing, has been designed to meet the needs of any massage therapist’s general practice.
• And, it provides a firm base upon which a therapist can then seek specialized training in assessment for sports massage, gerontology, or rehabilitative focused therapy.
• Further, with this firm base, a massage therapist can then successfully incorporate specialized techniques into their treatments, such as cranial osteopathy, reiki, visceral manipulation, or
acupuncture. With this comprehensive view, and with the addition of these specialized forms of testing,
p3 Comprehensive Assessment for Massage Therapists
protocol that is meant to provide a firm basis for a clear and transparent consent by the client.
Therefore, in all the ways mentioned above, the text is comprehensive:
• By ensuring the completeness and thoroughness of the assessment protocol; • By finding all that ails the client;
•By being designed to further both the therapist’s and the client’s understandings of what ails theclient, and how to mutually establish the goals of treatment;
•By ensuring the highest quality of care that massage therapy can provide the client.
All of this enables the therapist to treat the client appropriately, effectively, efficiently, and so with maximum benefit and safety.
3. When Is Learning Enough Too Little:
Making Training in Massage Therapy Comprehensive
Very few massage therapists, who have gone through a 2200+ hour program, would feel as though they were given too little information to learn while in school. Yet, many do not have the knowledge and skills to comprehensively treat the soft tissue and joints of the body. What is missing?
From my perspective, an important omission in the education of a large number of therapists is the lack of training they receive in assessing the synovial joints of the spine and the sacroiliac joints. Without these skills, how are we expected to actually treat neck, upper-, mid- and low-back pain and restrictions in motion? After all, three quarters of people who come to massage therapists for treatment do so for neck or back pain. If we do not understand how the spine and sacrum works, and also how those structures become impaired, then I believe we are left lacking as therapists. Without this knowledge how can we use the techniques we spent so much time honing to help rebalance a spine with a functional scoliosis? – to restore motion to a painful and locked sacrum?
Without the knowledge of how the joints of the spine are structured and how they are in motion in the living body, we are actually prevented from adequately treating almost all of our clients. Now, I know that what I have said is not true of all massage therapists, nor are all schools of massage remiss in teaching the basic principles of spinal or sacral motion. However, there are many schools, probably the majority of schools, which do not provide this knowledge and training. Why is that?
One reason, I expect, is historical. In many provinces the length of time given to the training and education of massage therapists, the modification to curriculum and even the methods of education have changed and evolved over many decades. The spine and sacrum was seen as the territory of chiropractic and physiotherapy, and it was too complicated for a massage therapist to safely treat. Why would those professions, especially chiropractors, who were recruited to teach the expanding courses in anatomy, neurology, pathology, and clinical assessment, teach us to assess and treat an area of the body that they considered to be their specialty? Why would they contribute to making us into their competitors in the field of manual therapy?
It appears that historically the assessment and treatment of the spine and sacrum was just considered not to be part of the set of skills belonging to massage therapists. In fact, at times it was even
volume of information they receive in the classroom, it is because they have not been shown how the information fits together. They have not been given various “hooks” on which to hang the reams of facts and information in anatomy and physiology that they are getting. The student has not learned to use the knowledge and, thus, cannot retain it for long.
If the student is not shown how to assess and treat the spine, why and how would they retain the otherwise disparate facts about the spine, its musculature and its pathologies? I often tell students, especially practicing massage therapists, that they have already learned 95 per cent of what is needed, to learn how to assess the spine and sacrum while in school; all those “facts” about the spine’s
anatomy. But that last 5 per cent that would speak to how it all fits together, how the spine functions and how it dysfunctions, was held back from them as students. So, of course, therapists forget “the facts” as soon as they graduate, because so much of the information, the anatomical, physiological, and pathological “facts” cannot be applied in their treatments. To coin a phrase, if we do not use it, we lose it.
This crucial information, the missing link, is the knowledge of how the spine works and how to assess it. Unfortunately, this information is withheld from a large number of students of massage. This relatively small amount of information is not the “final straw” that will break the proverbial camel’s back, which will leave the student crushed under the burden of all those “facts.” Rather, I believe that when the student understands how something about the body works and how they can see it, feel it and how to affect that aspect of the body in their practice, they have little trouble remembering the details. In other words, this is the missing link that holds all of that knowledge together. This is the role the subject of assessment should play; namely to be a teaching and learning tool, and not be just another subject in a curriculum. What do I mean?
First: Assessment is thinking through anatomy – thinking through the implications of the structure and function of the musculoskeletal system. Clinical assessment is not really another distinct subject to be learned, but rather, it is a way to take the information from other subjects, such as anatomy and physiology, and see these tissues and structures, that may have been only been previously memorized facts, come to life. Something as basic to orthopaedic testing as a postural assessment now becomes away to see how all those facts of anatomy and physiology seek balance, successfully or unsuccessfully. The student begins to use their knowledge like a pair of glasses: as something that they can use to help them see better with than without.
Second: In many ways we can think of much of orthopaedic testing as a way to palpate tissues that might otherwise be inaccessible. How so? As noted by James Cryiax, when you place tension through a tissue and it complains (by being painful, and/or by being dysfunctional), then you can assume that the tissue is part of the client’s problem. From this, Cryiax, and those since, have created what we call orthopaedic testing. Example: a meniscus test for the knee, or a scouring test for the hip or
glenohumeral joint, allows us to palpate those deep tissues. We can feel the tension, or laxity of deep muscles or of the otherwise inaccessible ligaments. I know from my experience, as both a student and as a teacher, that when you can touch and recognize a tissue, you can more easily remember its name and its ‘facts.’
Palpating (feeling the tissue) becomes another way of remembering information by storing it in yet another part of the brain. Using one more of the numerous pathways the brain has of recalling
information. You learn to use your knowledge to feel, to palpate so much more deeply and accurately.
p5 Comprehensive Assessment for Massage Therapists
“informed hand” is able to receive from the client’s body the information it needs to assess the client’s impairments.
Third: With the knowledge organized and learned through assessment – the skill to see and palpate structures and tissues so clearly – the therapist can now make an accurate assessment. By combining that assessment with the knowledge concerning the mechanical and reflex effects of Swedish and other massage manipulations, the therapist can always provide a safe and effective treatment for the client. This would make it difficult for a therapist to forget how to treat a musculoskeletal problem.
In summation: The added basic knowledge of how the spine and sacrum function is not really piling on even more facts to an already tottering tower of knowledge, that the student has to strain to memorize, but rather such knowledge as this provides structure and organization to the student’s knowledge. Comprehensive training in assessment skills is what changes endless lists of discrete bits of information into a living body of knowledge.
In conclusion: Do we have the techniques to treat spinal dysfunction? It may be true that the reason some educators feel it is best not to learn to fully assess the spine and sacrum, is that they believe that we do not have the techniques to treat spinal dysfunctions. This could not be further from the truth. Many dysfunctions of the spine and/or sacrum can be addressed through Swedish massage itself. They may also be treated through the application of stretching techniques such as Post Isometric
Relaxation(PIR), or with simple joint play oscillations as learned in school – once the therapist
understands how the structures and tissue work and how they dysfunction. Yes, there are some flashy special techniques that can be used to treat the spine, and certainly there are a few that are out of our scope of practice, but the techniques learned in massage schools across this country can be used effectively to treat many dysfunctions of the spine and sacrum. Yes, we do possess the necessary skills! Massage therapy is a still-evolving profession. The more comprehensive our knowledge, understanding and assessment skills are with respect to spinal and sacral dysfunctions, the more likely massage therapy will develop new and innovative ways of addressing these dysfunctions using techniques that remain within our scope. We are, in fact, rapidly becoming one of the last truly manual therapies. We rely on our hands as the primary source of information regarding our clients’ impairments.
The Procedure for Assessment i7
Pain i13
Observations
Overview of Assessment Protocol i25
Details of Protocol i29
Case History Form i29
Pain and Impairment i33
Active Listening i39
Rule Outs i42
Range of Motion Testing i42
Differential Tissue Testing i45
Treatment Planning i46
Postural Assessment i48
Muscle Balance and Posture i48
Common Postures i52
Postural Examination i54
Palpating Landmarks i60
Rotations i69
Gait Analysis(Classic) i75
Gait Analysis (Alternative) i80
Charting i86
Assessing Joint Play With Joint Mobilization i92
Spinal Motion: Structure & Function i97
Comprehensive Assessment for Massage Therapists © 1997-2011 David Zulak MA, RMT
• The Spirit Of Assessment
• The Procedure For An Assessment
• Pain
• Observations
• Overview Of Assessment Protocol
• Details Of Protocol For Clinical Assessment
- Intake, Interviewing & Health History Taking
- A Short History of Pain and Impairment
- Interviewing the Client: Employing Active Listening and Funnel Sequencing
- Ruling Out the Joints above and below
- More on Range of Motion Testing: Testing Function, Narrowing the Options
for Tissue Involvement and Differentiating between Types of Tissue.
• Postural Assessment
• Gait Analysis
• Charting
Required Tools Of The Trade:
1. Health History Forms, Assessment Forms, and/or pads of paper; 2. Cloth measuring tape (retractable is best);
3. Plumb line; 4. Reflex hammer;
5. Shims: i.e., several magazines of varying thickness, ranging from 1/4 inch to 1/2 inch, used to place under a foot to level a hip, for example.
The Spirit Of Assessment
For many years I have seen assessment as a holistic, meaningful and positive growth process as well as a solid medical procedural technique. This first came about by an almost religious experience, a “conversion experience” if you will, just a few short weeks into my new profession as a massage therapist. It was mid-afternoon and I was taking a case history from a new client – nothing unusual. Also not unusual, my confidence as a therapist was being tested by my recent entry into the real world. I was missing that comfort of having a supervisor around (public clinic at school) from whom I could always get assistance with assessing a client. Assessment still sounded scary. However, I am one of those people who likes to have a complete picture of what is going on before I proceed.
So, the client and I got down to discussing her chief complaint and, in brief, I heard: “I had a skiing accident last winter, injuring my shoulder, which the doctor at the hospital, an orthopaedic specialist, said was a rotator cuff tear. I have been through two bouts of physiotherapy and it really is not any better. I sometimes have my doubts about whether they got it right.” When asked to point to where the pain had been coming from, she pointed to the back of her right shoulder around the area of her infraspinatus, teres major and teres minor tendons.
Comprehensive Orthopaedic Assessment For Massage Therapy
go through all active ranges of motion for the shoulders, bilaterally (all the time thinking that I was not going to have anything else to tell her), as well as passive range of motion (assuming no joint involvement), and then proceed to isometric resisted testing. I was 10 minutes or so into this assessment (thinking she probably is becoming impatient and just wants to get on the table) but I could not seem to stop myself from at least finishing the resisted testing.
Then, confusion and surprise! Resisted external rotation that should have bothered an injured or dysfunctional infraspinatus and the teres muscles. To my further surprise, resisted extension of the shoulder caused discomfort. When asked to point out where she felt the pain, she pointed to that same area of the tendons. Confusion led to internal babbling in my head, and an idea popped into my head: “test long head of triceps.” So I did. I had the client hold her upper arm in slight extension and resist my pushing her upper arm into flexion, and at the same time resist my attempt to abduct the upper arm. I was just beginning with gentle pressure and building slowly when the client shouted: “That’s it! That’s where it hurts! That’s what I injured.” She pointed to what I now know is the insertion of the long head of the triceps at the inferior tubercle of the glenoid fossa, which lies deep under the tendons of the infraspinatus and teres muscles (as these pass over to insert on the humerus).
I was standing beside her thinking, “has her rotator cuff injury resolved, to be replaced by this other injury?” (I can be a bit thick, or so I have been told, having brilliant, complex, flights of analytical thinking that take a little time to land me somewhere near the obvious). All the while, the client was telling me: “No one has ever done any of this testing with me. In fact, all anyone ever did was ask me a few questions and tell them where it hurt.” I was quite surprised (I have been told I am quite naive, as well). After some further discussion with the client (since I was reluctant to believe that an orthopaedic physician and two separate physiotherapists missed the mark), I eventually had to bow to the probability that my client originally suffered a severe strain of the long head of the triceps, with the expected concomitant involvement of other tissues nearby and involved with the shoulder joint. While I may have sounded matter of fact and confident when giving and explaining my assessment to the client, this did not cause my head to swell, rather I realized that by following the basic rules of orthopaedic assessment the answer had just popped out at me. No need for feats of awesome intuition or analysis was required on my part. After the first treatment (she had 35 minutes left to her original hour), the client felt a great deal of relief, and by the fourth visit she was pain-free. By following some simple strengthening exercises she went skiing that winter with no problem. A convert was born. The client was extremely happy that I took the time with her. She felt that I had listened to her and that, by being thorough, I had her best interests at heart. It was good for business; I have received literally dozens of clients who have been referred to me by her. This experience was also good for relationship building with other health professionals. The client’s family physician was impressed and has, in turn, sent clients my way. My treatment was specific to her, specific to her injury, and the acuity or state of the tissue at the time I saw her. Though I specifically focused on her right triceps and particularly the long head and its attachment onto the scapula, I also dealt with all the surrounding tissue and related structures, in light of what all of my testing told me. Her injury was unique simply because it was hers. Because the treatment was specific to her, it was the most effective treatment she had received for her injury.
INTRODUCTION
Assumptions Can Be Misleading
Follow the basic protocol: Case history taking followed (when appropriate) by range of motion testing; followed, in turn, by any special or differential testing. Follow it from beginning to end. Assumptions along the way can be misleading; leave them aside until the testing is completed. One should not go about doing just the testing that would support one’s guess or assumption. Do not rely on another’s assessment concerning soft tissue injury. Find out for yourself. Orthopaedic assessment skills help give knowledge that is useful regardless of the techniques employed.
Of late, I have come to see the impact of these lessons, in one of those “Aha!” experiences. I used to tell students that clinical assessment was 50 per cent of our scope of practice: “… to assess and treat …” Truthfully, it is not any percentage at all. To assess and treat is one and the same, united and melded into one when working with a client.
What Do We Think We Are Doing?
Over the last several decades in North America, massage therapy has been on a path toward becoming an integral part of the health care system. In doing so, more and more emphasis has been placed on developing and refining treatments for “soft-tissue” injury or dysfunction. Though relaxation massage and stress management will always be a part of our scope of practice, you just need to look at the curriculum of a school to see the growing list of conditions that we, as massage therapists, can treat. This direction in the profession (which in many ways is taking off from where the profession was during the early part of the century) has seen a number of terms bandied about to describe it: medical massage, therapeutic massage, and treatment massage, to name a few. In turn, massage therapists have toyed with different terms to describe themselves: body-workers, deep tissue specialists or soft tissue specialists. This process of trying to define what we do and the role we are to play within the health care environment has resulted in a pithy statement regarding our “scope of practice,” the kernel of which is contained in the phrase: To assess and treat soft tissue injury and dysfunction.
How To Be A Therapist
In order to be therapists, to truly be treating people helping them recover from injury and to help them with their pain or provide palliative care, we need to know more than how to apply the diverse techniques such as Swedish Massage, Muscle Energy, Polarity or Craniosacral Therapy. We also need to know when to apply these techniques. In order to treat a wide variety of conditions, we cannot rely on others to provide us with a pre-done assessment, or diagnosis (or one that is necessarily correct, or thorough enough), so that we just need to perform some memorized routine.
In order to use the techniques and the types of manipulations, along with other treatment modalities that we have learned, we need, above all, to be able to assess for ourselves the injury or dysfunction that the client presents to us. All too often, a client comes to us with an assessment that is vague and of little help: e.g., sciatica, a pinched nerve, whiplash, etc. Proper clinical assessment procedures in no way hinder or prevent a massage therapist from using whatever techniques they wish to explore; if anything, it provides the sure footing upon which specific techniques (e.g., Craniosacral, Reiki, Shiatsu, Aromatherapy, Muscle Energy) can be applied effectively, making you a better therapist. If anything, a strong grounding in physical orthopaedic assessment helps us unite and focus our “intention,” that mysterious ability or attitude that somehow allows us into the tissue. If we cannot focus our intention we are often unable to be invited into the tissue, and hence are left unable to assist the client with their healing.
Comprehensive Orthopaedic Assessment For Massage Therapy
INTRODUCTION
Many of the “specialized techniques” come with their specific form of assessment: craniosacral rhythms, energy evaluation, Traditional Chinese Medicine pulse diagnosis, and Hara palpation, to name a few. But often they are dependent on either the technique, or a specific model of human health or both. However, no matter what techniques you use, clinical assessment can bring focus to client treatment. Understanding what soft tissue and structures are involved can only help to bring to bear all of our techniques into a cohesive whole and maximize our effectiveness as therapists. Further, assessment techniques from osteopathic to traditional Chinese medicine need not be seen as outside of classic orthopaedic assessment. They can be employed as “Special Tests” or procedures. Indeed, that is what they are: tests designed to test specific structures, energies or balances within the body. The Core Of Clinical Assessment
The basis of the hands-on portion of clinical assessment is active, passive and resisted testing, all done with a keen sense of palpation: these are grouped together as range of motion testing. They are to assessment like effleurage, kneading and muscle stripping are to massage technique. Range of motion testing needs to be part of every assessment. Yes, it’s true that they are not as flashy as “Special Tests” or “Advanced Techniques” that get all the attention when we spend hundreds of dollars learning them. Range of motion testing is like meditation; practice until it is second nature and the reality of our client appears right before our eyes, appearing as the obvious.
There is a danger when making an assumption about the client’s injury during case history taking and testing only for that assumed condition. So, even though a client’s subjective report implies a rotator cuff tear, do not just do the tests specific to a rotator cuff tear. If you only do a test specific to a tear you may well get a “positive,” but that could be secondary to some other tissue or structure that is the “real” primary cause of their pain or problem. Even if it is principally a rotator cuff tear, you do not want to lose the opportunity to see how all of the surrounding or compensatory tissues are involved or responding.
Further, by being thorough you may discover postural or muscle balance issues that may have set the client up for injury in the first place and which, if left untreated or unaddressed, may leave the client prone to re-injury. Alarms should go off in your head every time you think, “I’ve heard/seen this before” … and “it’s always been …” You need to resist the temptation to only do the tests that would confirm your guess, or skip the testing altogether.
Isn’t Imaging Technology Better Than Manual Assessment?
In the face of technology, health professionals have often acquiesced to employing or relying on a machine, especially in the field of assessment. Are not X-rays, CT-scans, or MRIs the truly objective base for judgments about soft-tissue pain and dysfunction? The short answer is yes – and no. For acute trauma-based injury, the answer may be yes. For chronic or recurring injury, the answer is actually no. In a 1998 article in Scientific American, Dr. Richard A. Deyo brought together some interesting studies about assessment when addressing the issue of low back pain.
Deyo concluded: “that at least for adults under age 50, X-rays added little diagnostic value to office examinations …” Further, referring to epidemiological research it was “revealed that many conditions of the spine that often received blame for pain were actually unrelated to the symptoms … and multiple studies determined that many spine abnormalities were common in asymptomatic people as in those with pain. X-rays can, therefore, be quite misleading.” And lastly, “even highly experienced radiologists interpret the same X-rays differently, leading to uncertainty and even inappropriate
treatment.” (Deyo, Scientific American)
