Lecture 7: Soft tissue assessment Flashcards
what are the two types of assessments?
- on field assessment
- sideline/ clinical assessment
- you must understand both of them and why we are doing it
on field assessment
- concise assessment used to get general idea of how bad it is and how we are going to remove them. (pretty much to see how bad the injury is)
- usually takes 2 minutes
sideline/clinical assessment
- more of a in-depth, routine protocol
- usually takes about 20 minutes
SOAP notes
Subjective
objective
analysis/assessment
plan/program
subjective (SOAP)
- single most important aspect of the evaluation
- includes statements provided by the patient regarding their symptoms
- from this history, you develop your assessment plan/strategy
subjective assessment why?
why:
- interviewing is the “art” in contrast to the “science” of medicine
- most clinicians rate the medical history as having greater diagnostic value than the physical exam or results of lab investigation
subjective assessment how?
- used to develop a strategy for further examination
- asking open ended questions
- active listening (eye contact, non-verbal cues)
(you have to make sure we are not filling our thoughts and not focusing on what we think we will see because then you will miss what you need to or actually see.)
subjective (history)
basic information needed
- primary complaint
- history of injury
- Mechanism of injury (MOI)
- symptoms/pain profile
symptom - organic
manifestation which only the patient is aware of
- patient medical history
- MSK injuries
- medical conditions
- Red flags
Subjective history swelling
fast (<4hr) hemarthrosis(bleeding into a joint cavity)
slow (4-8hrs) capsular swelling
subjective history (describing your pain)
dull = thinking more muscular
sharp = thinking more bone
shooting, bright = thinking more nerve
objective
- observable physical phenomenon indicative of a conditions presence
- planning on what you want to do from there
order of assessment
1: subjective
2: observation/ visual inspection
3: AROM (active range of motion)
4: PROM (passive range of motion)
5: Resisted movements
6: Nero (sensation/reflex)
7: Special tests
8: palpation
all of the above are components of OBJECTIVE information
how do you set up a clinical examination?
doing an order of assessment
observation/visual inspection
- we need to assess their general demeanour
- expression (pain, tired, angry)
- tone of voice
- posture
- protective postures, guarding, stiff, etc
-obvious deformity/asymmetry
- protective postures, guarding, stiff, etc
- signs of inflammation
-swelling, redness, bruising
-quality of movement- how are they moving
- speed, quality (smooth, jerky) amount of movement
what is the best way of observing someone?
- asking them to go walk to a chair and watching them when they do not realize
theory of selective tissue tension
- Dr. James Cyriax developed a method for locating and identifying a lesion by applying tension selectively to each of the structures that might produce pain.
- tissues classified as either contractile or Inert
intert:
- ligaments
- bursa
- capsules
- fascia
- nerve roots
- dura mater
contractile:
- muscles
- tendons
- tenoperiosteal insertion (where the tendon attaches to the bone)
Cyriax theory
- when tension is applied to an injured tissue, it will give rise to pain
- when you pull on it, it is going to hurt
contractile tissue
- increases in tension when the tissue is both contracted or stretched
- active motion in one direction and passive motion in the opposite
how can you apply tension to a muscle?
1: having the patient contact the muscle
2: having the patient stretch the muscle
inert tissues
- increase in tension when they are stretched ONLY
- will elicit pain on active and passive movement in ONE direction only
active range of motion
- movement assessment should begin with Active range of motion (AROM)
- active movements which cause pain do not specifically indicate either an inert or contractile lesion
- muscle tension and joint movement causing contractile and inert tension to both occur!
- agnosit contract
- antagonist stretch
- inert tension in only one direction
active range of motion movements
- give us some important information
- where they are sore
- willingness to move
- quality of movement
- amount of available ROM
these give us clues on how we handle them
passive range of motion
(PROM)
- patient must relax completely and allow therapist to move the extremity
- look for limitation and presence of pain
- specific attention should be paid to how they feel at the end of range of motion
(pain prior to end of range usually signifies inflammation or possibly the presence of a red flag) - can be used to detect lesions in inert tissues
- this stretching of the inert tissue will cause pain
- allows us to assess “end feel”
end feel (normal)
1: soft tissue approximation
2: bony or bone to bone
3: capsular
soft tissue approximation (end feel)
- normal
-elbow/knee flexion - soft spongy gradual painless stop when two muscle bellies meet
bony or bone to bone (end feel)
- normal
-elbow extension - distinct abrupt endpoint/un-yielding
- painless (abnormal if painful)
- this is where you feel the bony stop
capsular (end feel)
- normal
-hip rotation - abrupt firm endpoint with a little give
- a leathery feeling
- if you push past you can stretch it a little more like stretching a belt
end feel (abnormal)
1: springy block
2: spasm/ stretch
3: abnormal capsular
4: empty
springy block (end feel)
- abnormal
-internal issue of the joint (probably a meniscus that has been folded over)
spasm/stretch (end feel)
- abnormal
- hamstrings
- involuntary contraction that prevents motion secondary to pain (guarding)
- more of a rubbery feel prior to expected end of range
abnormal capsular (end feel)
- abnormal
- occurs prior to expected end of range
empty (end feel)
- abnormal
- did not reach the end feel
- when considerable pain is produced by movement
- no mechanical resistance detected (no resistance at all)
- significant soft tissue injury, bursitis or neoplasm
(could be a tumour)
what do we need for resisted testing?
- contraction of only target tissue
- no stretch on antagonist
- no movement through joint or stretch on surround inert tissues
information gained through resisted testing
- will tell us about pain in a contractile tissue
- will also give us an indication of how the nerve is working
how do you just contract the target tissue?
- use isometric contraction
- if you do it mid range then you are just tuning on the muscle
resistance movements
- isometric and neutral mid range
- allows us not to have to worry about inert or antagonist parts
interpreting resisted movements
finding strong - painless (nerve= normal, muscle = normal )
finding strong - painful (nerve = normal, muscle = minor problem)
finding weak - painless (nerve = possible nerve lesion, muscle = old/complete rupture)
finding weak-painless (nerve = possible nerve lesion, muscle = acute/significant tear)
how to test resisted movement?
- position the athlete with the muscle being tested in the neutral position… why? so that nothing else is on stretch
- position yourself to maximize mechanical advantage
- ask them to hold that position (ISOMETIC)
- slowly increase the force in the opposite direction until you feel movement or pain is elicited. slowly decrease force
making a decision
- is it inert, contractile or both?
- pain with PROM only = Inert tissue
- pain/weakness with isometric contraction = contractile tissue
- pain with PROM and isometic contraction could be a combination
pain with PROM only
inert tissue
pain with PROM and isometric contraction
contractile tissue
Neurological testing
1: reflexes
2: sensation
3: key muscles
Neurological testing (Reflexes)
- biceps/braidchoradialis (C5- C6)
- triceps (C7- C8)
- knee jerk (L3)
- achilles (S1)
Neurological testing (sensation)
- dermatomes
- cutaneous area receiving the greater part of its innervation from a single spinal nerve
Neurological testing (Key muscles)
- myotomes
- a muscle receiving the greater part of its innervation from a single spinal nerve
- isometric contraction held for at least 5 seconds
- fatigable weakness vs. no strength for peripheral nerve
C2 (Neurological testing)
Neck flexion
C3 (Neurological testing)
neck side flexion
C4 (Neurological testing)
shoulder shrug
C5 (Neurological testing)
shoulder abduction
C6 (Neurological testing)
elbow flexion, wrist etc
C7 (Neurological testing)
elbow extension wrist flexion
C8 (Neurological testing)
thumb extension
T1 (Neurological testing)
spread fingers
L1 (Neurological testing)
hip flexion
L2 (Neurological testing)
hip flexion
L3 (Neurological testing)
knee extension
L4 (Neurological testing)
ankle dorsiflexion
L5 (Neurological testing)
1st toe extension
S1 (Neurological testing)
plantar flexion
S2 (Neurological testing)
knee flexion
S3 (Neurological testing)
intrinsics of foot
special tests
- “special tests” help in the differential diagnosis of the patients injury
- includes manual muscle testing specific “special” muscle and ligament tests
- these are an indication of “how bad it is”
testing and recording strength of muscle
manual muscle testing (oxford scale)
0 = nothing happens
1- twitch or flicker only. no movement
2 = able to move but not against gravity
3 = able to move the joint fully against gravity
4 = movement with some resistance
5 = full movement with resistance equal to opposite side
what is the difference between resistance and muscle testing
resistance testing is isometric, trying to turn on the muscle and seeing if it is sore (tells you what tissue is most likely at fault)
muscle testing is trying to see how the muscles moves, allows us to grade the injury, and tells you how bad the injury is
