Lecture 7: Soft tissue assessment

Question 1

what are the two types of assessments?

Answer 1

1. on field assessment
2. sideline/ clinical assessment

• you must understand both of them and why we are doing it

Question 2

on field assessment

Answer 2

• 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

Question 3

sideline/clinical assessment

Answer 3

• more of a in-depth, routine protocol
• usually takes about 20 minutes

Question 4

SOAP notes

Answer 4

Subjective
objective
analysis/assessment
plan/program

Question 5

subjective (SOAP)

Answer 5

• 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

Question 6

subjective assessment why?

Answer 6

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

Question 7

subjective assessment how?

Answer 7

• 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.)

Question 8

subjective (history)

Answer 8

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

Question 9

Subjective history swelling

Answer 9

fast (<4hr) hemarthrosis(bleeding into a joint cavity)
slow (4-8hrs) capsular swelling

Question 10

subjective history (describing your pain)

Answer 10

dull = thinking more muscular
sharp = thinking more bone
shooting, bright = thinking more nerve

Question 11

objective

Answer 11

• observable physical phenomenon indicative of a conditions presence
• planning on what you want to do from there

Question 12

order of assessment

Answer 12

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

Question 13

how do you set up a clinical examination?

Answer 13

doing an order of assessment

Question 14

observation/visual inspection

Answer 14

• we need to assess their general demeanour
  
  • expression (pain, tired, angry)
  • tone of voice
• posture
  
  • protective postures, guarding, stiff, etc
    -obvious deformity/asymmetry
• signs of inflammation
  -swelling, redness, bruising
  -quality of movement
  
  • how are they moving
  • speed, quality (smooth, jerky) amount of movement

Question 15

what is the best way of observing someone?

Answer 15

• asking them to go walk to a chair and watching them when they do not realize

Question 16

theory of selective tissue tension

Answer 16

• 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)

Question 17

Cyriax theory

Answer 17

• when tension is applied to an injured tissue, it will give rise to pain
• when you pull on it, it is going to hurt

Question 18

contractile tissue

Answer 18

• increases in tension when the tissue is both contracted or stretched
• active motion in one direction and passive motion in the opposite

Question 19

how can you apply tension to a muscle?

Answer 19

1: having the patient contact the muscle
2: having the patient stretch the muscle

Question 20

inert tissues

Answer 20

• increase in tension when they are stretched ONLY
• will elicit pain on active and passive movement in ONE direction only

Question 21

active range of motion

Answer 21

• 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

Question 22

active range of motion movements

Answer 22

• 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

Question 23

passive range of motion
(PROM)

Answer 23

• 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”

Question 24

end feel (normal)

Answer 24

1: soft tissue approximation
2: bony or bone to bone
3: capsular

Question 25

soft tissue approximation (end feel)

Answer 25

- normal -elbow/knee flexion - soft spongy gradual painless stop when two muscle bellies meet

Question 26

bony or bone to bone (end feel)

Answer 26

- normal -elbow extension - distinct abrupt endpoint/un-yielding - painless (abnormal if painful) - this is where you feel the bony stop

Question 27

capsular (end feel)

Answer 27

- 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

Question 28

end feel (abnormal)

Answer 28

1: springy block 2: spasm/ stretch 3: abnormal capsular 4: empty

Question 29

springy block (end feel)

Answer 29

- abnormal -internal issue of the joint (probably a meniscus that has been folded over)

Question 30

spasm/stretch (end feel)

Answer 30

- abnormal - hamstrings - involuntary contraction that prevents motion secondary to pain (guarding) - more of a rubbery feel prior to expected end of range

Question 31

abnormal capsular (end feel)

Answer 31

- abnormal - occurs prior to expected end of range

Question 32

empty (end feel)

Answer 32

- 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)

Question 33

what do we need for resisted testing?

Answer 33

- contraction of only target tissue - no stretch on antagonist - no movement through joint or stretch on surround inert tissues

Question 34

information gained through resisted testing

Answer 34

- will tell us about pain in a contractile tissue - will also give us an indication of how the nerve is working

Question 35

how do you just contract the target tissue?

Answer 35

- use isometric contraction - if you do it mid range then you are just tuning on the muscle

Question 36

resistance movements

Answer 36

- isometric and neutral mid range - allows us not to have to worry about inert or antagonist parts

Question 37

interpreting resisted movements

Answer 37

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)

Question 38

how to test resisted movement?

Answer 38

- 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

Question 39

making a decision

Answer 39

- 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

Question 40

pain with PROM only

Answer 40

inert tissue

Question 41

pain with PROM and isometric contraction

Answer 41

contractile tissue

Question 42

Neurological testing

Answer 42

1: reflexes 2: sensation 3: key muscles

Question 43

Neurological testing (Reflexes)

Answer 43

- biceps/braidchoradialis (C5- C6) - triceps (C7- C8) - knee jerk (L3) - achilles (S1)

Question 44

Neurological testing (sensation)

Answer 44

- dermatomes - cutaneous area receiving the greater part of its innervation from a single spinal nerve

Question 45

Neurological testing (Key muscles)

Answer 45

- 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

Question 46

C2 (Neurological testing)

Answer 46

Neck flexion

Question 47

C3 (Neurological testing)

Answer 47

neck side flexion

Question 48

C4 (Neurological testing)

Answer 48

shoulder shrug

Question 49

C5 (Neurological testing)

Answer 49

shoulder abduction

Question 50

C6 (Neurological testing)

Answer 50

elbow flexion, wrist etc

Question 51

C7 (Neurological testing)

Answer 51

elbow extension wrist flexion

Question 52

C8 (Neurological testing)

Answer 52

thumb extension

Question 53

T1 (Neurological testing)

Answer 53

spread fingers

Question 54

L1 (Neurological testing)

Answer 54

hip flexion

Question 55

L2 (Neurological testing)

Answer 55

hip flexion

Question 56

L3 (Neurological testing)

Answer 56

knee extension

Question 57

L4 (Neurological testing)

Answer 57

ankle dorsiflexion

Question 58

L5 (Neurological testing)

Answer 58

1st toe extension

Question 59

S1 (Neurological testing)

Answer 59

plantar flexion

Question 60

S2 (Neurological testing)

Answer 60

knee flexion

Question 61

S3 (Neurological testing)

Answer 61

intrinsics of foot

Question 62

special tests

Answer 62

- "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"

Question 63

testing and recording strength of muscle

Answer 63

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

Question 64

what is the difference between resistance and muscle testing

Answer 64

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