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1
Conditions
CONDITIONS
Scar Tissue – a collagen-based tissue that develops as a result of the inflammatory process,
used to mend injury
 No frictions on proud flesh or keloid scar
 Pain free ROM ASAP to avoid excessive scar tissue
 Partial or no nerve innervation – no hair or sweat glands in scar itself (watch using
hydrotherapy)
 HH Q – What was the scar caused from? (injury, surgery)
o How long has the scar tissue been developing?
o Are they taking any anti-inflammatory medication?
o Has the injury been immobilized for a prolonged period of time?
o Has the px been using any hot hydrotherapy to relieve the pain/contractures? (if chronic)
 Palpation – tissue may be hard depending on the age and extent of the scar
 AFROM and PRROM reduced
 AR Test – weakness in affected muscles
 Tx - 1. Pre-heat
o 2. Treat the periphery of the scar first then the centre
o 3. Use fascial techniques or frictions depending on the scar
o 4. Follow treatment with a passive stretch
 Goal – to make a more mobile scar, increase ROM
Wounds and Burns – disruption of the continuity of the skin
 Classifications based on the depth of burn (Superficial, Partial Thickness, Full Thickness)
 Important to know what stage of healing px is at
 At 10-14 days, ROM exercises should start to be incorporated (align fibres, prevent excessive
adhesions)
 Distally – only use techniques that do not increase circulation in acute (mm squeezing, stroking)
 Elevation of affected limbs and lymph techniques (acute)
 One hand may be placed prox to injury site to monitor drag and techniques that do not have
shearing forces should be used (stroking/scooping in early subacute)
 Joint play may be used in chronic – be careful if there is an injured mm crossing joint
 High risk of infection, gloves may be worn, oil not used around wound (avoid direct contact with
blisters)
 Direction of pressure must be modified due to fragility of granulation tissue and pressure is
therefore towards injury
 HH Q – What degree was the burn?
o What percentage of surface area of the patient’s skin was burnt? 1st or 2nd intention
healing?
o Is there any associated infection with the wound/burn?
o Did they seek any medical attention at the time of the injury?
o Is the area still painful or the skin fragile?
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Conditions
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What caused the burn? (electrical [arrhythmias can occur, headaches], heat, chemical,
radiation)
 Wounds
o Observation – obvious wound likely visible, skin grafts with 3rd degree only
o Palpation – use caution close to the wound
o AFROM and PRROM reduced
o AR Test – weakness in affected muscles
 Tx of Wounds - 1. Avoid the area until healed, see note on inflammation
o 2. Do not create drag on the tissue while the wound is healing
 Burns
o Acute and early sub-acute 2nd or 3rd degree burns: There may be swelling, limited
mobility, bandaging, and muscle guarding. Client may be taking pain meds and antiinflammatories. For 2nd or 3rd degree burns, passive ROM is contraindicated for
affected tissues or tissues that will be stretched/moved by ROM.
o Late sub-acute or chronic 2nd or 3rd degree burns, or any stage of 1st degree
burns: Testing can include Active ROM or Passive Resisted ROM of the affected area.
Active Resisted isometric testing begins in the early subacute stage and may reveal
weakness in the affected muscles. ROM and strength will gradually return unless
adhesions or contractures remain, e.g. from superficial or deep scarring.
 Tx of Burns - 1. Treat like a wound/inflammation while still healing
o 2. Treat like a scar once scar tissue is formed
Contusions – crush injury to a mm where there is damage to the mm fibres resulting in bleeding
to the subcutaneous tissue and skin
 Complication – myositis ossificans
 3 degrees – Mild (1st degree), Moderate (2nd degree), Severe (3rd Degree)
 In acute stage, testing of moderate or severe contusions other than pain free AROM is CI
 No on-site work (acute), unless mild – very light onsite work (vibrations, stroking) –
EXCEPTION
 First 7-10 days no aggressive stretching/aggressive massage/heat or contrast hydrotherapy d/t
potential of re-bleed (subacute)
 No techniques to increase circulation distal to contusion (acute, early subacute)
 Watch for hematoma, myositis ossificans or nerve compression
 Be careful of pressure and positioning depending on where contusion is located
 Use PIR or antagonist stretching to regain ROM, or gentle passive ROM (late subacute)
 HH Q – does anything accompany the contusion? Myositis Ossificans (quads or brachialis)?
Fracture? Nerve damage?
o How do they sleep? Is there a comfortable position?
o Has there been a history of injury or contusion to this mm?
o What happened at the time of the injury? Any emergency medical attention?
o Did the limb give way at the time of the injury?
o Swelling in 20 mins – hematoma? Send for medical attention
o Any elastic bandages or crutches?
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Observations – edema, bruising, redness depending on stage and severity
Palpation – local heat, tenderness and spasm depending on stage and severity
AFROM – pain and reduced ROM with stretch or contraction of affected muscle
PRROM – pain with stretch of muscle
AR Test – pain and reduced strength depending on stage and severity
Muscle Length Tests – reveals muscle shortness
Note –only do observation and palpation for acute moderate or severe contusion
Strains – damage to the musculotendinous unit due to overstretch (tendon/muscle)
 3 degrees – Grade 1, Mild (1st Degree), Grade 2, Moderate (2nd Degree), Grade 3, Severe (3rd
Degree)
 Be careful with positioning – make sure the affected joint is comfortable for the patient
 Resisted ROM testing may display weakness is mm affected by injury or immobilization
 In acute stage, testing of moderate or severe contusions other than pain free active free ROM is
CI
 HH Q – what grade is the strain? Were they able to continue the activity after injury?
o What was the MOI? Did they hear a noise or feel snapping sensation? Did the limb give
way during the injury? (grade 3)
o Complications – avulsion? Hematoma? Nerve damage?
o Is the px using crutches? (acute – grade 2-3 strain)
o Have they had surgery? (grade 3)
o Are they using elastic bandage to support the limb to prevent re-injury?
 Observations – local edema, redness, visible gap depending on severity
 Palpation – local heat, local tenderness, palpable gap, depending on severity
 AFROM – pain with contraction or stretch of the muscle (no pain with complete rupture)
 PRROM – pain with passive stretch of the muscle (no pain with complete rupture)
 AR Test – pain with contraction of the muscle (no pain with complete rupture)
 Specific Muscle Strength test – pain and weakness depending on severity and stage
 Specific Muscle Length tests – pain with stretch of muscle
 Gastrocnemius - Thompson Test – positive with grade 3 gastrocnemius strain
 Supraspinatus - Drop Arm Test – positive with grade 3 supraspinatus strain
 Tx – depends on the staging
Sprains – sudden twist or wrench of the joint beyond its normal ROM (ligament)
 Adhesion becomes very important to stop during tx
 In late subacute – joint play if needed – above- below affected joint, be very cautious with
injured joint as well as with frictions and fascia
 Tell px to make sure they are not doing the same action that injured the joint in the first place as
it will continue to micro-tear
 Proprioception and strengthening mm around joint important to prevent re-injury
 HH Q – Do you have a history of sprains at this joint?
o What exactly was the movement causing the injury?
o Did you hear a noise at the time of injury?
o Were you able to continue with the activity? (grade 1-yes, grade 2-with difficulty, grade
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3- no)
o Did you need to immobilize the joint or have surgery to reduce?
o Were there any complications such as nerve damage or avulsion?
o Does the joint “give way”?
o Were they using crutches? Immobilization?
o Is there joint effusion – inflammation within the joint (delayed swelling)
o Edema and swelling are outside the joint capsule?
Observations – local edema, redness, bruising depending on stage and severity
Palpation – local heat, tenderness, spasm, depending on stage and severity
AFROM – reduced due to pain depending on stage and severity
PRROM – pain in the range that stresses the injured ligament and reduced ROM maybe present
due to muscle spasm
Ligamentous Stress Test – positive with sprain when ligament is stretched
Ankle – one of the following will be positive depending on the ligament involved - Anterior Drawer
test, Anterior Talofibular Test, Calcaneofibular Test, Calcaneocuboid Test, Deltoid Ligament
Test
Knee - Collateral Ligament Sprain – one of the following is positive - Valgus Test, Varus Test or
Apleys Distraction Test
Knee – Cruciate Sprain or Meniscal Tear – one of the following is positive – Anterior-Posterior
Drawer, Lachman’s, McMurray’s, Bragards Sign, Apley’s Compression
Wrist – one of the following is positive – radial stress, PR wrist extension, PR wrist flexion, ulnar
stress test, Distal RU Joint Ballotement Test, Piano Key Test
Elbow – one of the following is positive – Varus Stress test (LCL), Valgus Stress Test (MCL)
AC joint – AC shear test positive
SI joint - Sacroiliac Joint Gapping, Sacroiliac Joint Squish Test, Gaenslens Test, Anterior SI
Distraction Test, Sacral Thrust Test, SI Compression Test, Thigh Thrust Test, SI Rocking Test,
Yeoman’s Test, Patrick’s Test, Hibb’s Test, Double Leg Raise - positive
Facet joints – Spinal Percussion, Kemp’s (Quadrant) Test, Double Leg Raise
Note – testing during acute other than pain-free AFROM is CI
Cruciate & Meniscal Injuries – the knee is a frequently injured joint. In addition to the more
superficial medial and lateral collateral ligaments which are covered in the chapter on sprains,
the deeper anterior and posterior cruciate ligaments present clinical concerns, as do the 2
menisci.
 HH Q – did they hear a sound or did the joint give way at the time of the injury?
o Does the knee give way or lock during walking? Is there a clicking noise?
o Was it surgically repaired?
 Cruciate injury
 Observation: antalgic gait – no weight on affected leg
 Palpation: swelling, extreme pain at knee, and even distal to knee – mild tenderness
 AFROM: painful in any direction
 PFROM: restricted, especially knee extension
 Neurological: L3/L4 increased sensation, decreased strength and painful patellar reflex
 Special Tests: positive lachmans/anterior drawer
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Conditions
 Meniscal injury
 Acute: with swelling
 Observations - Swelling(measure the amount of swelling)or there may not be swelling, bruising or
redness over the knee, joint is held in a semi flexed position, client may be on crutches, have
elastic bandages or splints or signs of surgical intervention.
 Gait - limping
 Rule out Hip and Ankle
 Palpation - tibial/femoral joint line
 AF ROM - limited in extension and flexion (normal resting position 25 degrees)
 PR ROM - may have muscle guarding end feel or a springy block end feel due to meniscal
involvement
 AR strength tests - should be painless and indicate normal strength. If there is pain there is an
accompanying muscle injury
 Special Tests - Brush wipe test, Minor Effusion Test?, Ballottable Patella
 Early and Late Subacute and Chronic Knee Injury
 AF ROM - limited in extension with AC injury >10 degrees significant
 limited in flexion with PC injury> 125 degrees significant
 PR ROM - limited when a joint locking is present-knee doesn’t fully extend
 AR Strength - Quads may be reduced due to atrophy
 Special Tests - McMurrays Test, Bragard’s Sign, Apley’s compression Test, Helfet’s test? may
also be positive: stand on affected leg, px will try to stabilize knee with opposite foot.
 Tx – Do assess or get diagnosis for exactly which structure is injured.
o If acute, do refer out for initial diagnosis before treating.
o 1. Best position may be prone, with leg slightly elevated.
o 2. If acute or sub-acute, check for edema and maybe do drainage.
o 3. Check for facial restrictions along quads and hamstrings.
o 4. Primary focus of massage is compensatory structures. Treat trigger points and
hypertonicity in quads, hamstrings, popliteus, gastrocs.
o 5. Treat the low back and gluteals.
o 6. Gently stretch knee; don't push it to the limit. Full-range stretch hip and ankle.
Dislocations – a complete disassociation of the articulating surfaces of a joint
Subluxation – occurs when the articulating surfaces of a joint remain in partial contact with
each other
 Hypermobility may be a cause or result of the dislocation/subluxation
 If surgically repaired, must be aware of new limited ROM and do not force
 Any other structure crossing the joint or within the joint area will be affected as well (strains and
contusions are common)
 Assessment in acute and subacute – AROM at proximal and distal joints – everything else CI
 Be aware px may be apprehensive!!
 Post TrP techniques on mm that cross affected joint – repetitive petrissage
 Maintain ROM – gentle JP during late subacute – not in direction of injury
 In acute, Rem Ex CI – when you start to provide RemEx, avoid position of injury
 HH Q – Do you have any joint pathologies causing ligamentous instability or laxity?
o Has this happened before?
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o Did you feel something pop out of place?
o Are you using a sling or anything else to support the joint or crutches?
o Is there any swelling or bruising near or distal to the area?
o Did any blood vessel damage or bone fractures occur?
o What is the most painful activity/movement for you to do?
o Has the joint been surgically repaired? Pins, screws, plates?
o Complications such as nerve or mm damage or fracture?
Observations – edema, redness, bruising, sulcus sign
Palpation – local heat, tenderness, protective spasm
AF Apprehension Test – positive with unstable joint (PR testing is then CI)
PR Apprehension Test – positive with unstable joint
AR Test – some muscles crossing the joint could show weakness
Patella Dislocation – positive Patellar Apprehension Test
Glenohumeral Dislocation – Apley’s Scratch reveals reduced ROM
Lunate Dislocation – positive PR wrist extension test
AC joint Dislocation – positive AC shear test
Note – testing other than pain-free AFROM is CI in acute and subacute
Tx – strengthen mm surrounding, no JP in direction of dislocation if joint capsule is not surgically
reduced, be careful when stretching mm that cross the joint, avoid removing mm splinting, only
do JP to new ROM, do not overstretch (if joint has been surgically reduced)
Fractures – break in the bone (closed/simple, open/compound – soft tissue damage and bone
through skin, complete & incomplete)
- Types: Colles (wrist – fracture of radius prox to wrist), Galeassi (fracture of radial shaft and
dislocation of inferior RU joint – ulnar nerve injury may occur), Pott’s (ankle fracture – affects
one or both malleoli – distal fib breaks close to malleolus), Dupuytren’s (fib fracture higher up,
med malleoli avulses and talus pushed superior btwn tib and fib), Greenstick, Other
- Complete: transfers, oblique, spiral, comminuted (shattering of broken bone), avulsion (tearing
off bone by lig/tendon) and osteochondral (complete break of bone)
- Incomplete: compression, greenstick, perforation and stress
- Stages: hematoma formation, cellular proliferation, callus formation, ossification, remodelling
 Bone may be immobilized for some time – may have disuse atrophy – can use light tapotement
to stimulate
 No forces on limb until completely healed
 HH Q – Is the patient seeing a physio, if so, what instructions have they been given?
o How long ago was the injury? (It is important to note that full consolidation of the bone
may take months and that upper limb and non-weight bearing casts may be removed
before full consolidation occurs leaving the site still weak.)
o Did the patient receive bolts, pins or metal plates? Permanent or degradable?
o What type of immobilization was used?
o Is the patient using any other supports? (crutches)
o Did the patient perform any movement/exercise while injury was immobilized?
o Does the patient experience any increased levels of pain, edema, bruising, paresthesia
or temperature local to the fracture? (Could be experiencing complications with healing
and should consult their physician.)
o When was the cast removed? (Consider sensitive skin, atrophy, CT contractures)
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Is the patient still experiencing pain after the cast has been removed? (Possible
malunion, delayed union, non-union present.)
 Immobilized:
o Observations – distal edema and bruising possible depending on stage
o Palpation – hypertonicity in surrounding muscles
o ROM - all testing of muscles and joints involved is a CI
 Post-immobilization:
o Observations – local chronic edema, possible bruising, local atrophy, dry flaky skin
o Palpation – possible local heat or coolness, local tenderness, hypertonicity and TPs in
surrounding muscles
o AFROM – all ranges reduced depending on stage
o PRROM – reduced ROM with tissue stretch
o AR Test – reduced strength due to atrophy of immobilized muscles
o Percussion Test – positive with stress fracture, vertebral fracture, facet irritation
o Stress Fracture (Fulcrum) Test – positive with femoral neck stress fracture
o Heel tap/Bump/Anvil test – foot fracture
Whiplash – the cause of whiplash is an acceleration-deceleration of the head and neck relative
to the body resulting from MCV/MVA, contact sports or theme-park rides
 Tissues affected: Posterior - suboccipitals, rotatores, multifidi, semispinalis cervicis,
longissimus cervicis, upper trapezius, levator scapulae
 Anterior – rectus capitis anterior, longus capitis, longus colli/cervicis, SCM, the hyoid mm,
platysma
 Lateral – rectus capitis lateralis, scalenes
 Mm of mastication, intercostals, posterior spinal mm and diaphragm can also be affected
 May feel burners or stingers – radiating pain on the affected side
 Facet joint radiates into the neck and shoulder of affected side
 Pain and stiffness can begin to develop 24-48 hours after the incident – may also experience
deafness, dizziness, dysphagia, headache, memory loss, nausea, TMJ pain, TOS, tinnitus &
difficulty swallowing
 In acute (Grade 2 and up) – any testing other than AROM, neurological testing and swallowing
test are CI
 Avoid mobilizing hypermobile vertebrae, usually at C4-C6 levels
 Avoid overly aggressive techniques in subacute/chronic stages – may provoke flare-up of acute
 Avoid extreme stretches of cervical mm, especially SCM and larger post. cervical mm in
acute/subacute stages
 In subacute – TrP work is followed by PIR that only partially lengthens the affected mm
 HH Q – where were you sitting in the vehicle?
o Was there an airbag deployed? Were you wearing a seatbelt?
o Where were you sitting? What was head position during accident?
o Have you been injured in an MVA previously?
o Was there a headrest on the seat?
Plantar Fasciitis – an overuse condition resulting in inflammation of plantar fascia
 Signs and sx – pain, decreased function and HT of plantar fascia, mm weakness
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Can/will lead to injuries in other compensating structures
Usually caused by biomechanical factor – px must change that to allow complete healing
Pain upon rising in the am or after periods of sitting, pain lessens with 30-45 mins of activity,
then intensifies 2-3 hrs later with continued activity and is usually relieved by rest
Positioning is prone at first and then supine to work on compensating structures
Arch in foot allows us to absorb force of walking, etc. and pain can stem up rest of body
Make sure you tx fascia as one of the options – if acute may not be able to work on locally
Heat pre-tx may be beneficial, be careful of direction of pressure (work towards if painful)
HH Q – when is the foot most painful?
o What shoes do you wear? Not adequate arch support?
o Are you pregnant? Or have you gained weight?
o Do you have any heel spurs?
o Pes planus/cavus and Achilles tendonitis may be present
Postural exam - Excessive pronation (flat feet), Signs of swelling in the medial arch, High
arches, Knock-knees, Possible uneven leg length, Wear and tear marks on shoes = more wear
at heel and inside edge of the sole
Gait - Pain in the toe-off phase (pre-swing), Excessive external rotation at the hip during gait
(abducted gait)
Palpate - Pain at anteromedial aspect of calcaneous (plantar surface), Adhesions may be
present at medial tubercle of the calcaneous, Tenderness and hypertonicity along plantar fascia,
Adhesions in the fascia under the heel through to forefoot, Possible hypertonicity in
gastrocnemius/soleus, Tight Achilles Tendon
AROM - Pain with plantarflexion, Decreased ROM and pain with dorsiflexion, Decreased ROM
and pain with extension of toes, Decreased ROM and pain with eversion
PROM - Decreased ROM and pain with dorsiflexion, Decreased ROM and pain with extension
of toes, Decreased ROM and pain with eversion
RROM - Pain with plantarflexion
Neurological, If parathesia is present, neurological and Tinel’s Test are performed to rule out
Tarsal Tunnel Syndrome.
Special Tests - Palpation mostly, Hop on forefoot to recreate symptoms, Tinel’s Test (rule out)
Muscle Strength - Decreased strength in plantarflexion
Muscle Length - Decreased length in dorsiflexion. (gastrocnemius & soleus)
Tx - 1. Acute flare up- avoid frictions
o 2. Fascial techniques to gastrocnemius and soleus
o 3. Frictions on adhesion on plantar fascia and Achilles tendon
o 4. Treat TrPS in gastrocnemius, soleus, and flexor digitorum longus, TrPS may also be
present in abductor halluciis longus, flexor digitorum brevis and abductor digiti minimi
o 5. Joint play of subtalar joint and navicular bone
o 6. Home care: Ice applied 3-4 times daily for inflammation
o Use cold/frozen water bottle to roll under the foot to stretch and reduce inflammation
Periostitis & Compartment Syndrome – “shin splints” – inflammation of the periosteum that
develops at the insertion of the leg mm of the tibia (usually posterior medial) and may be
referred to “medial tibial stress syndrome”, “tenoperiostitis” and “soleus syndrome”
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Posteromedial periostitis occurs with excessive pronation, varus knee, and excessive ext rot of
hip – feel pain in the am or at beginning of exercise, goes away with rest
Anterolateral periostitis occurs with forefoot varus, tight gastrocnemius and soleus
Predisposing factors of compartment syndromes: anatomical configuration, mm imbalance or
tightness, improper footwear - feel pain during the activity, pressure in compartment
Positioning is the px in prone to work on compensating structures and then supine
If a patient has an acute compartment syndrome is referred for emergency medical attention
HH Q –
Periostitis
Postural exam - Excessive pronation (flat feet), Signs of swelling in the medial arch, High
arches, Knock-knees, Possible uneven leg length, Wear and tear marks on shoes = more wear
at heel and inside edge of the sole
Gait - Pain in the toe-off phase (pre-swing), Excessive external rotation at the hip during gait
(abducted gait)
Palpate - Pain at anteromedial aspect of calcaneous (plantar surface), Adhesions may be
present at medial tubercle of the calcaneous, Tenderness and hypertonicity along plantar fascia
Adhesions in the fascia under the heel through to forefoot, Possible hypertonicity in
gastrocnemius/soleus, Tight Achilles Tendon
AROM - Pain with plantarflexion, Decreased ROM and pain with dorsiflexion, Decreased ROM
and pain with extension of toes, Decreased ROM and pain with eversion
PROM - Decreased ROM and pain with dorsiflexion, Decreased ROM and pain with extension
of toes, Decreased ROM and pain with eversion
RROM - Pain with plantarflexion
Neurological - If parathesia is present, neurological and Tinel’s Test are performed to rule out
Tarsal Tunnel Syndrome.
Special Tests - Palpation mostly, Hop on forefoot to recreate symptoms, Tinel’s Test (rule out)
Muscle Strength - Decreased strength in plantarflexion
Muscle Length - Decreased length in dorsiflexion. (gastrocnemius & soleus)
Compartment syndrome – anterior, posterior, lateral
Observations - Swelling in lower leg, with or without hypoxia, where the foot colour takes on a
purplish colour due to reduced vascular function, Excessive external rotation of the hip joint,
Abducted gait or knee varus may be present.
Palpations - Inflammation and tenderness along the medial border of the tibia or in the area of
posterior muscles especially attachments of soleus and gastrocs, Bony irregularities may be
present with chronic periostitis or compartment syndrome, Redness, heat and pitting edema can
all be present.
AFROM - restricted by pain and/or edema
PRROM - reduced by edema.
ARTEST - most commonly reveal weakened posterior and anterior compartment muscles
caused by any combination of nerve and/or arterial compression.
Special Tests
o Compartment syndrome can generally be diagnosed by the three preceding categories;
however, there are three tests used to differentiate the presenting leg pain.
o 1). Tibialis posterior tendinitis. This pain is worse on activity than at rest. Pain is along
the course of the tendon, just posterior to the medial malleolus and along the proximal
tibia. AR testing for tendinitis is positive.
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2). Tibial stress fracture pain is sharp and localized to the fracture site. The medial
aspect of the tibia is a common location. Pain is initially worse with activity and is
relieved with rest. The progression of the condition makes it impossible to “run through”
the pain. A stress fracture test using a tuning fork is positive. The patient is referred to a
physician for diagnostic imaging.
o 3). DVT. Deep vein thrombosis is also a possibility. The Homan’s sign is the special test
for this. Because a blood clot could be dislodged during this procedure it is not
recommended.
Tx – Acute
o 1. Lymph Drainage to proximal injured area – avoid local area
o 2. Effleurage & Petrissage compensating muscles (neck, back, glutes, hamstrings,
quads, opposite leg)
o 3. Stroking, vibrations, muscle squeezing distal leg.
o 4. Cold hydrotherapy
Chronic
o 1. Fascial Techniques
o 2. Effleurage & Petrissage shortened contracted muscles (gastrocs, soleus, tib. post.)
o 3. Joint Play (subtalar, superior tib/fib joint)
o 4. Passive stretching of soleus and gastrocs
o 5. Frictions to adhesions on soleus, tib post, and flexor digitorum longus
o 6. Hydrotherapy – hot before applying fascial techniques – cold after frictions.
Tendinitis – inflammation of a tendon – chronic overload of a tendon leads to micro-tearing and
inflammatory response – Grades 1-4
 Types: Paratendinitis – inflammation of the paratendon or tendon sheath, Tenosynovitis –
irritation of inner surface of tendon sheath, tenovaginitis – irritation and thickening of the sheath
itself, tendinosis – degenerative changes that occur with chronic overuse tendon injures
 Test with resisted ROM – px will experience pain
 Make sure other mm have full ROM to not put additional stress on injured area
 Do not work locally in acute – stretch within the inner range
 May have to change the direction of techniques once you are closer to the tendon
 Can only start strengthening when: local tenderness on palpation is absent, no pain on activity,
full pain-free stretch is obtained (px progresses from isometric to isotonic )
 Make sure to check mm belly – HT, TrPs, atrophy
 GTO (on unaffected end of mm) and agonist stretching is good to use
 Achilles tendon – tx while mm is on stretch
 HH Q – What movement causes the most pain?
o What is your recreational or occupational posture?
o What type of occupation do you have? (i.e. Assembly line or Factory worker).
o Do you engage in overhead types of sports such as tennis, swimming, etc?
o Have you started a new activity recently or changed a particular activity?
o Have you previously injured this area?
o Are you using any support or braces?
o Are you doing any stretching and or strengthening for this area?
 Tx - Acute:
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Elevate and comfort. Hydrotherapy cold, lymphatic drainage first, unidirectional
effleurage, stationary circles.
Use local techniques proximal to the tendon. Treat proximal limb for hypertonicity use
effleurage and muscle stripping
Treat trigger points that refer to the area and treat the antagonist with segmental
techniques (avoid circulation to the area),
Use Passive relaxed pain-free ROM
Use muscle squeezing and stroking used on distal limb
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 Chronic:
o Hydrotherapy: proximal and on the lesion site deep moist heat not prolonged
o Fascial treatment: crossed hands and ulnar boarder spreading
o Treat adhesions with skin rolling, fascial spreading and muscle stripping first before
using Frictions which are applied across the tendon
o Use joint play on hypo-mobile joints and passive relaxed ROM
Bursitis – inflammation of a bursa, common to be a secondary issue
 Heals on its own but px must rest, boggy feel, not point tender
 RROM – the harder px contracts, no change in pain
 No local tx – avoid compressing the bursa or applying techniques that place a drag on the
surrounding tissues
 Be careful treating mm overlying bursa (may need to manual stretch)
 Be mindful of positioning so that there is no additional pressure on the bursa
 HH Q – Have you had a direct traumatic blow to the area?
o Do you have to climb stairs on a regular basis for your job or other reasons? (knee)
o Does your occupation require frequent kneeling? (i.e. Carpet installer). (knee)
o Does your job or a sport involve repetitive movements at this joint?
 All bursa, generally:
 Observations - tenderness, swelling, redness, guarding. Postural assessment may be performed
to determine sources of muscle imbalance.
 Palpation - will not be palpable unless inflamed. Adhesions in chronic bursitis may be felt. In
acute, avoid any technique that applies pressure or places drag on the affected area.
Conversely, applying pressure and drag may help to by provoking pain for a differential
diagnosis. May be accompanied by hypertonicity and trigger points.
 AFROM - reduced in most directions due to pain and swelling. In chronic, pain may exist only at
single positions or specific joint angles.
 PRROM - in acute, empty end feel due to pain. Limited ROM.
 ARROM - any motion that activates the agonist motions of the muscles crossing the joint will be
positive
 Notes - may be accompanied by tendinitis. Contributing factors include muscle or postural
imbalances, inflexibility, poor biomechanics. Pain will be deep and burning, and may disturb
sleep if bursa is compressed. ROM will be decreased.
 Shoulder
 Palpation - feel for it through the anterior deltoid near the acromion. To palpate rotator cuff bursa,
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Conditions
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extend the arm backwards and internally rotate it. This brings the bursa anteriorly where it can
be better palpated by resting your hand on their shoulder, thumb behind, index finger over the
acromion.
AFROM - may be provoked by raising arm above head. Use overpressure.
AR Test - pain may be provoked by any movement of muscles crossing the joint
Other - may be diagnosed as impingement syndrome or bicipital tendinitis
Special tests - empty-can and Hawkins-Kennedy to test impingement.
Olecranon
Observation - will be quite obvious and swollen when inflamed
Palpation - easily provoked by pressure even when not inflamed
AFROM - may be normal ROM, save at end range or in acute.
PRROM - Restricted ROM due to empty end feel may indicate fracture.
AR Test - Elbow extension should provoke.
Other - can be caused by trauma, e.g. fracture, or prolonged pressure, "student's elbow"
Trochanteric
Palpation - two bursa are here, one between glute max and trochanter, the other between glute
med and trochanter. Find them by palpating through these tendons. Pain will be local to the
lateral hip, may present similar to a "hip pointer" (impact trauma). (New term to cover both
injuries is greater trochanteric pain syndrome, GTPS.)
AFROM - may be provoked by Trendelenberg test, contracting glut med
PRROM - IT band stretches to provoke
AR Test - provoked by IT band contraction
Other - can be caused by trauma, e.g. impact
Ischial
Palpation - localized pain over ischial tuberosity. Pain may refer down posterior leg, imitating
sciatica
AFROM - Posterior tilt of the pelvis may relieve pain; e.g., when driving, the client may find that
braking relieves pain because that rotates the ischial tuberosity up away from the seat
PRROM - flex hip to provoke
AR Test - Toe-walking may provoke, as will any hamstring contraction
Other - can be caused by prolonged irritation, e.g. "weaver's bottom"
Knee and Baker's Cyst
Palpation - Of the many knee bursa, three are most prone to bursitis: pes anserine at the medial
tibia; infrapatellar above the tibial tuberosity, which may present as Osgood-Schlatter's, and
prepatellar, or "housemaid's knee," directly over the kneecap. Baker's cyst may be an
extracapsular bursitis and will be palpable at lateral knee
PRROM - may be provoked by end-range knee flexion
Active ROM test: all provoked by resisted knee extension and may be provoked by active free
extension
Special tests - can do knee effusion test, aka Ballottement test, to check for edema; all knee
ligament tests for differentials (anterior drawer, lachman, pivot shift, posterior drawer, posterior
sag, valgus/varus stress tests); meniscal tests for differential (apprehension test, McMurray's,
bounce-home test)
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Conditions
 Retrocalcaneal
 Palpation - common cause of pain at back of heel.
 PRROM - may be painful on full dorsiflexion
 AR Test - provoked by toe-walk or calf-raise
 Other - can be caused by prolonged irritation, e.g. wearing high heels
 Iliopectineal
 Palpation - flex hip to 90°, feel 1-2cm inferior to the middle of the inguinal ligament, between
iliopsoas muscle and iliofemoral ligament. Pain may radiate down anterior leg due to
pressure on femoral nerve.
 AR Test - provoked by hip flexion and external rotation
 Bunion
 Palpation - hallux valgus deviation may be mild to severe. Client may notice that shoes aren't
fitting. Rule out gout; gout will have swelling but less deviation. Bunions are bony enlargements
of the head of the first metatarsal, so it will likely be tender but won't
necessarily have
swelling.
 ROM - bunion will reduce mobility of the joint
 Other - only medical diagnosis can specifically differentiate: joint aspiration to test for gout,
or x-ray to test for bunion.
 Tx – 1. No on site work - stroking and muscle squeezing applied distal.
o 2. Work towards the bursa - not away, The techniques used should not drag the bursa
o 3. Acute - Cold towel hydrotherapy - application should not be heavy to avoid
compressing the bursa
o 4. Chronic - Deep Moist Heat before stretching
o 5. Treat compensating structures, referring trigger points, and secondary conditions
(tendinitis)
Frozen Shoulder – a painful, significant restriction of active and passive ROM at the shoulder,
most frequently in abduction and external rotation
 Causes are idiopathic, TrPs in Subscapularis, postural dysfunction, intrinsic musculoskeletal
trauma/disorder, disuse, extrinsic disorders
 Stages: Acute (freezing phase/painful phase), Subacute (frozen phase/stiffening) and Chronic
(thawing/resolution phase)
 Rarely occurs in those under 40 or over 70
 Home care extremely important
 Aggressive stretches and joint play mobilizations greater than Grades 1-3 are CI in acute stage
 If hyperkyphosis present, place 2 towel rolls under shoulders retracting them, in prone position
 HH Q –What ROM is limited? Abduction, external rotation and internal rotation?
o Are you going to physiotherapy?
o Any history of injury, rotator cuff tears or impingement syndromes?
o Minor trauma like a twisting stretch to the shoulder while the arm was abducted and
extended (i.e. reaching into the back seat of a car)?
o Occasionally major trauma such as fracture, myocardial infarction or surgery to the
shoulder?
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Conditions
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Does the client have hyperkyphosis?
Are you diabetic? Are you an insulin user? (users for >10 years likely to develop)
More frequently this condition may appear without cause.
What stage is the client? (freezing; frozen; or thawing phase)
Freezing Phase (can last 2-9 months)
Is the pain and severe at night; does it keep you up at night or unable to lie on the
affected side?
o Is the pain on the outer aspect of the shoulder, deltoid insertion, referring to the elbow?
o When did stiffness start? (usual starts 2-3 weeks after initial pain begins)
o Is it your dominant limb?
o Frozen Phase (can last 4-12 months)
o Has the severe pain begin to diminish? Is pain at the end range of motion?
o Shoulder more stiff and interfering in daily activities? Unable to brush/wash hair, put on
coat or a top that goes over the head, fasting a bra, reaching into back pocket?
o Atrophy of muscles?
o Thawing Phase (spontaneous resolve in 2 years; or can last as long as 5-10yrs)
o Diminish pain and is able to sleep through the night?
o Motion is gradually returning? What is new full range of motion?
Presentation will depend on stage of condition
Acute phase: inflammatory stage
o moderate to severe pain that limits all shoulder movement
o Pt. cannot recall event that triggered pain
o Pain interferes w/ sleep & pt. often takes prescribed pain meds
Middle phase: stiffening stage, months to years later
o pt. presents w/ past history of acute phase
o Pain is less, but has difficulty w/ abduction & lateral rotation
Final phase: thawing phase
o slow increase in ROM, but still has significant reduction
o Cause: unknown - Adhesion development b/w or within capsule
 Begins as inflammatory process that resolves with fibrosis
Signs/Symptoms - Depends upon stage of dysfunction; may or not be painful, ROM limited in
capsular pattern, Overall joint stiffness, Unable to sleep on shoulder, Pain may refer distally.
Testing - Significant & equal loss of AROM & PROM  abduction & external rotation affected
most; flexion least affected, Loss of abduction compensated w/ shoulder shrugging and/or trunk
leaning, Muscle testing: strong within available range
Special Tests - Apley’s Test
Extra info - During 180° abduction, there is 2:1 ratio of mvmt of humerus to scapula
o 120° occurs at GH joint
o 60° occurs at scapulothoracic joint
Scapulohumeral Rhythm - 3 phases (
o 1st 30°: abduction of GH joint, little-no motion of scapula
o Next 60°: humerus abducts 40°, scapula rotates 20°
o Final 90°: humerus abducts 60°, scapula rotates 30°
Reverse scapulohumeral rhythm: scapula moves more than humerus; seen in frozen shoulder
Torticollis – abnormal positioning of the head relative to the body
 Acute acquired torticollis – do not passively stretch the spasmodic mm
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Conditions
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Congenital torticollis – if working with infants, use reduced pressure when treating contractures
Spasmodic torticollis – painful techniques, joint play and local direct mx are CI, as they make
spasm more pronounced
Don’t work directly on mm when in acute – use relaxation techniques
Positioning would be supine for comfort of px
HH Q –
Observations - Look for other postural dysfunctions like scoliosis, With typical torticollis there is
a cervical scoliosis convex to the unaffected side, L side torticollis, Neck side bends to left, Face
rotates to the right, Left shoulder is elevated, R cervical scoliosis, Apex usually at C4
Acute acquired torticollis
o Neck stuck flexion or extension, Movement is painful and restricted when trying to take
head out of that position, Perform AR once the spasm has reduced
Congenital
o Active free mov’t away from the affected side is very restricted, Passive relaxed
movement away from the affected side is very restricted with a leathery end feel, May
reveal weakness in the contralateral anterior or anterolateral neck, and ipsilateral
Posterolateral neck extensors
Spasmodic
o AF movement is painful and restricted when trying to take head out of that position
Special tests
o Compression and Cervical distraction- differential a cervical nerve root that may
underline an acute acquired
o Vertebral artery test- rules out cerebral vascular insufficiencies one spasm is reduced
o Spurlings- after spasm has reduced
Tension Headache – mm contraction type of headache, mm in origin and are associated with
Trps and other myofascial pain syndromes
 SCM, utrap, temporalis tend to refer and cause tension headaches
 Types: primary, secondary, cervicogenic, spinally mediated, chronic daily
 No deep techniques during a tension headache
 Avoid vigorous techniques or deep pressure when treating hyper-irritable TrPs, since “kick back”
pain may occur
 Kick back pain may result fi IC are applied to quickly and deeply, released too quickly and not
followed by either passive stretching and heat or slow full active free ROM and heat
 HH Q – Do you have a headache now?
o Location and type of pain? Bilateral, diffuse, one side
o Any trauma? To head neck or spine
o Do you have a high temp, rash or rigid neck? Meningitis - red flags
o Do you have any other symptoms or referral pain? Weakness, ataxia, confusion, nero sx
o What relieves or aggravates?
o Onset? New, chronic, is it different or the ‘worst’ ever? (Age over 50) red flags
o What is the frequency and duration?
o Are you on any medications?
 Palpation – hypertonicity
 AFROM and PRROM likely reduced
 AR Test – may be some weakness in neck muscles
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Conditions
 Special Tests – Use Spurlings compression and cervical distraction test to rule out facet joint
irritation as underlying causes of the headaches
 Tx - During Headache:
o 1. Diaphragmatic Breathing
o 2. Supine, towel over eyes
o 3. Soothing GSM techniques on the pectorals, face, neck, upper shoulders.
o 4. Essential oils- lavender, peppermint, blue chamomile (Be aware of CI's)
o 5. Petrissage on muscles of mastication, face, and scalp.
o 6. Trp's treated with GENTLE ischemic compressions or stripping.
o 7. GTO release of the occiput.
o 8. Gentle stretching and passive cervical ROM.
 Between Headaches:
o 1.The tx is similar to that which is performed during a headache except therapist can use
more vigorous techniques
o 2. Areas of restricted ROM are addressed using joint play and fascial work.
o 3.Trigger points can be treated more aggressively.
Migraine Headaches – paroxysmal neurological disorder with may signs and sx
 Primary headaches – headache is condition
 Secondary headaches – result of underlying pathology (only 0.004% due to serious pathology)
 High-risk headaches – report to a physician: onset of new headache after age 50, onset of new
or different headache, client reports the “worst” headache ever experienced, recent history of
acute head trauma, onset of headache that steadily worsens with exertion, coughing or
straining, the headache is associated with changes in neurological status, such as drowsiness,
confusion, weakness, ataxia and loss of coordination and deep tendon reflexes or Babinski
response, there is a new headache in a person with cancer or HIV, the headache is associated
with fever and neck rigidity, the headache is associated with hypertension
 During a migraine, mx may be CI depending on the client’s sx
 Avoid the use of heat on the neck or head during migraine as heat causes painful vasodilation
 Do not work deeply during a migraine
 Avoid music or bright lights if the client is sensitive to them during the headache
 Either during or between attacks, avoid the use of fragrances with those whose migraine
triggers are perfumes; these may include essential oils
 Positioning during an attack may be supine or side lying – prone may be painful
o HH Q – Location and type of pain? Bilateral, diffuse, one side
o Any trauma? To head neck or spine
o Do you have a high temp, rash or rigid neck? Meningitis - red flags
o Do you have any other symptoms or referral pain? Weakness, ataxia, confusion, neuro
sx
o What relieves or aggravates?
o Onset? New, chronic, is it different or the ‘worst’ ever? (Age over 50) red flags
o What is the frequency and duration?
o Are you on any medications?
 Tx - During an Attack
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Diaphragmatic Breathing
No painful or vigorous work
Supine, towel over eyes
Cold hydro to the head and/or neck
If direct HNS work is NOT tolerable to px, apply cold hydro to head while addressing the
hands and feet
o If px can tolerate direct HNS work, apply MLD, soothing GSM, and gentle pressure point
work to frontal, maxillary, temporal and occipital areas.
o Trp's treated with GENTLE ischemic compressions or stripping.
Between Attacks
o The tx is similar to that which is performed during a headache except therapist can use
more vigorous techniques
o Areas of restricted ROM are addressed using joint play and fascial work.
o Prone position now appropriate to tx thoracic and lumbar areas
o Hot hydro may now be used if needed
o Essential oils listed above may be used if the scents do not trigger attacks
o TMJ dysfunction may now be addressed.
Pes Planus – decreased medial longitudinal arch and pronated hind foot
 Leads to internal rotation of tibia when standing – altered hip/knee biomechanics, overuse
 Do not mobilize the hypermobile joints on the medial longitudinal arch
 Do not passively stretch Tib Ant and Tib Post since this will allow increased pronation of foot
 Avoid using heat on the plantar surface of the foot in the presence of an inflammatory process
such as plantar fascia
 Positioning in prone to start then supine
 HH Q –
 Observations - Helbing’s sign is visible posteriorly at the Achilles tendon, Internal rotation at the
tibia and possible also the hip, Medial arch of the foot is either reduced or not present at all
causing “touch down” of medial foot bones normally supported by ligaments
 Palpations - Tenderness at the spring ligament, the navicular, the calcaneal attachment of the
long plantar ligament and plantar fascia, Tenderness in the muscles and tendons of the lower
leg, Trigger points are commonly found in peroneus longus and brevis.
 AFROM - reduced with dorsiflexion in severe cases, Increased internal rotation may be present
with femoral anteversion
 PRROM - assessed in the foot, ankle, superior tibiofibular joint and hip. The tarsal joints and the
other joints of the medial longitudinal arch are hypermobile. Plantar flexion and dorsiflexion are
both reduced with a restricted ankle joint. Low grade inflammation of the ligaments or plantar
fascia will cause passive eversion to be restricted.
 ARTEST could show weakness in tibialis anterior, tibialis posterior and extensor halluciis
longus.
 Special Tests - Patient is standing barefoot on a hard surface. Two fingers are slid underneath
the medial arch of the foot. Fingers should touch the lateral aspect without the DIPs of those
fingers being visible, Functional or structural pes planus test is positive, Morton’s neuroma test
may also be positive.
 Tx - 1. Treat compensating structures with effleurage, petrissage and trigger points
o 2. Reduce fascial restrictions in shortened gastroc
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3. Effleurage & Petrissage gastrocs, soleus, peroneus longus, brevis and tertius
4. Brisk petrissage, tapotement of tib. ant., tib. post, flexors and intrinsic foot muscles
5. Treat trigger points
6. Stretch gastrocs and soleus without stressing plantar arch – use distal calcaneous as
lever.
Iliotibial Band Contracture – contracture or thickening of the IT band – IT band friction
syndrome is inflammation and pain where the IT band crosses the later femoral condyle
 Worse with activity – pain felt along lateral thigh and into lateral aspect of knee
 Valgus or hyperextension orientation of the affected knee may be present
 Secondary trochanteric bursitis may develop
 Do not randomly stretch fascia – assess the fascia and only treat areas of restriction
 Positioning may be best side lying on the unaffected side
 HH Q –
 Tx - 1. Positioning it important - side lying, easiest to access entire length of ITB.
o 2. Hydrotherapy - pre-treatment application of deep moist heat.
o 3. Fascial techniques to entire length of ITB.
o 4. Adhesions treated with frictions, specifically distal end of ITB.
o 5. Treat TFL and Vastus Lateralis with GSM and stretching techniques.
o 6. After fascial work, cool or contrast is used to increase local circulation.
Patellofemoral Syndrome – aka patellofemoral tracking disorder – describes various painful
degenerative changes to the articular cartilage on the underside of the patella
 Associated conditions- chondromalacia patella (softening of the cartilage of patella) and plica
syndrome (synovial folds at knee that cause clicking or swelling)
 Contributing factors: abnormal biomechanics, small high patella, tight lat/ant/post structures,
weakness (VMO, glute med), knee injury/overuse, arthroscopic procedures
 If any inflammation is present avoid using hot local hydrotherapy or local techniques, such as
frictions, at the lesion site
 Walking down stairs, squatting and running downhill painful, crepitus, disuse atrophy, difficulty in
sitting for long periods of time
 Full flexion passive relaxed ROM with overpressure is CI if it produces pain
 If Q angle is greater than 18 degrees when the client is standing
 HH Q –
 Observation – patella will not be in line with femur
 Palpation – tenderness at anterior knee, hypertonic quadriceps group, swelling
 AFROM – grinding sensation during knee flexion
 Neurological – L3/L4 increased sensation, decreased strength and painful patellar reflex
 Special Tests - brush wipe test: for swelling, valgus/varus stress tests to rule out ligaments,
medial/lateral McMurrays to rule out meniscus
 Tx - 1. GSM - low back, gluteals, surrounding structures.
o 2. Fascial techniques on the ITB and hamstrings.
o 3. Mobilize patella in a medial direction.
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Conditions
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4. Petrissage on TFL, glut med, hamstrings, and gastrocnemius.
5. TrP in quadriceps can refer pain to the knee. TrP in Vastus medialis can cause knee
to be weak and buckle.
Hyperkyphosis – an increase in the normal thoracic kyphotic curve, with protracted scapulae
and head-forward posture
 Would make sense to loosen the shortened part first and then stimulate the back
 heat before and contrast therapy at the end or for home care
 Mm shortened with med rotated shoulders, mm shortened with forward head posture
 Degenerative disc disease can contribute in the elderly
 Consider positioning for comfort of the px
 Swayback – hyperkyphosis combined with hyperlordosis
 Flatback – (post pelvic tilt) includes tight hamstrings and ab mm with accompanying
hyperkyphosis
 See Rattray for which mm are shortened and which are lengthened
 HH Q – How long has it been present?
o Painful areas?
o Postural habits?
o Any other conditions related to the problem? TOS, Frozen shoulder, Head neck or jaw
pain?
 Observations - increased thoracic curve and cervical lordotic curve, scapulae are protracted and
often winged, slight ankle plantarflexion with knee hyperextension, increase in lumbar lordotic
curve with anterior pelvic tilt, head forward posture
 Palpation - pecs, SCM, upper traps, suboccipitals, levator scapulae, scalenes are tender and
hypertonic, may contain trigger points, thickened pectoral fascia
 AFROM - decrease in extension
 PRROM - reduced in cervical spine during forward and lateral flexion. Reduced external rotation
of the GH joint with shoulder protraction
 AR Test - weakness in middle trapezius and rhomboids
 Note - only treat areas of actual fascial restriction, important to assess where those areas are
first, avoid lengthening techniques on weak, overstretched tissues
Hyperlordosis – an increase in the normal lumbar lordotic curve with increased anterior pelvic
tilt and hip flexion
 Short and tight mm – iliopsoas, rec fem, TFL, quadratus lumborum and lumbar erectors,
adductors and piriformis
 Stretched, weak and taut mm – rectus abdominius, internal abdominal obliques, gluteus
maximus and hamstrings
 If LBP is present, rule out potential pathological sources before tx – refer to Dr. if necessary
 Positioning is supine with pillows under their knees to reduce the hyperlordosis
 HH Q –
 Observation - Muscles imbalances, increased lumbar lordosis with associated bilateral anterior
pelvic tilt and hip flexion, possible pes planus, knee hyperextenson, bilateral iliotibial band
contracture , Hyperkyphosis may be noted
 Palpation - Tenderness, Hypertonicity and trigger points may be present in the lumbar erector
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spinae, QL's, Illiopsoas, TFL, and rectus femoris, the texture of the lumbar and iliotibial tract
fascia is thickened and reinforced
PF ROM - hip ROM is reduced in extension
AR ROM - Reveals that both iliopsoas are strong while the abdominal are weak.
Special Tests
o Thomas test - Positive bilaterally for tight iliopsoas and Rectus femoris
o Ely's - Positive bilaterally, indicating rectus femoris shortness
o Obers test - Positive, indicating adductor muscle shortness
o Piriformis Test - likely positive
o Straight leg test likely positive : shows increase in hamstring length
o In the lumbar and thoracic spine, anterior and lateral spinous challenge tests may reveal
areas or hyper / hypomobility
Scoliosis – lateral rotary deviation of the spine
 May be in response to pain, compensation may cause scoliosis,
 Functional – postural/non-structural curves, may be voluntarily altered or reversed by positional
changes or mm action
 Structural - curves are fixed due to bony changes and cannot be corrected by positional
changes or voluntary effort – usually have since childhood and req surgery
 ROM reduced away from the concave side; rib mobility restricted
 Do shorter techniques on side with rib hump (convex)
 Have the px lie on the opposite side if they are ok with that position (can put a towel under their
side to stretch further while treating) – positioning and stretching is the main focus
 HH Q – Surgically repaired? Wires, rods??
o Any history of bone fractures in lower extremities?
o General health? When did it become noticeable?
 Observations - must determine if it is an S or C curve, functional or structural. Postural
observations will be dependent on curve type. Assess level of occiput, AC joint levels, humeral
lengths, scapula distances to each other, iliac crest levels, PSIS levels, heights of the malleoli
 Palpation - Will depend on shape of curve. Palpate for hypertonicity and trigger points at the
erector spinae, quadratus lumborum, intercostals, trapezius and gluteus medius
 AFROM - decreased range of the spine towards the convex side of the curve in flexion and
lateral bending
 PRROM - at the hip there is decreased range in extension with an anterior pelvic tilt. At the
protracted shoulder, decrease in external rotation, may also have decreased cervical spine
ROM
 AR Test - weakness in abdominals and muscles on the concave side of the curve
 Note - only treat areas of actual fascial restriction, important to assess where those areas are
first, do not stretch or use longitudinal work on muscles on the convex side of the curve since
these muscles are already overstretched.
Hypermobility – increased degree of motion at a joint
 HH Q  AFROM – increased
 PRROM – increased
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Conditions
 9 Point Scoring – score of 4-6 indicates hypermobility syndrome
 Special Testing
o Ligamentous Stress Tests – positive with specific joint laxity
o AC Joint - Acromioclavicular Shear Test – positive with AC joint laxity
o SI Joint - Sacroiliac Joint Gapping, Sacroiliac Joint Squish Test – positive with SI joint
laxity, Gaenslens Test – positive with SI joint laxity
 NO JP on hypermobile joints!!
 Do not stretch muscles that cross a hypermobile joint past the accepted range for that joint
Hypomobility – is loss of motion at a joint, including the loss of normal joint play mvts
 HH Q –
 AFROM – reduced, possible capsular or bony end feel
 PRROM – reduced, possible capsular or body end feel
 Special Testing - SI Joint - Sacroiliac Joint Gapping, Sacroiliac Joint Squish Test, Gaenslens Test
– indicate SI hypomobility
 Do not attempt to mobilize a hypomobile joint that was surgically repaired with metal appliances
 Where ligs have been surgically shortened, do not restore full ROM of affected joint in direction
that will stretch repaired lig
TMJ dysfunction – disorder of the mm of mastication, the TMJ and associated structures
 Stress, chewing on one side,
 Mm involved: Temporalis, Masseter, medial/lateral pterygoid, digastric, mylohyoid, geniohyoid,
infrahyoids
 Head-forward posture may be present
 Avoid deep work over the styloid process of the temporal bone, as it is potentially fragile
 Do not use techniques that compress the mandible superiorly against TMJ
 Differentials: tension headache, migraine, sinusitis, trigeminal neuralgia, toothache, fibromyalgia
 Position chosen for comfort
 HH Q – Was there any trauma?
o When do you feel pain?
o Open/close mouth, chewing, protruding or lat deviate jaw
o Any noises?
o Has the jaw ever locked?
o Are there any other symptoms?
o Headache, sensitive to hot/cold, dizzy, ringing in ear
o Do you overwork your jaw? (Gum, smoke, grind, lean on jaw, dental work, stress)
o Any inflammation? Any medication?
 Observations - Postural
o Anterior- shoulders may be elevated or one higher than the other, look at symmetry of
the face observing external auditory meatus, frontal ridges, angles of the mandible and
alignment of the jaw and teeth
o Lateral- habitual antalgic head forward posture, increased in the cervical lordotic curve.
Asses for mandibular protraction/ retraction
o With head forward posture- SCM assumes a more vertical position
22
Conditions
o
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In normal posture these muscle angles posteriorly from the inferior to superior
attachments
o Pained or medicated facial expression, Masseter or temporalis muscles may be
obviously clenched, Ridging on the inside of the cheek, and lateral tongue scalloping
due to jaw clenching.
Palpation - Tenderness in muscles of mastication, pain anterior to TMJ itself or inside external
auditory meatus, Inflammation of TMJ, Popping or clicking of the condyles, Hypertonicity and
trigger points in muscles of mastication
AROM- of mandible/cervical spine reduced due to pain
PROM- mandible/cervical reduced and painful
ARROM- isometric testing of mandible,
Depression, lateral motion, protrusion- lateral/medial pterygoid or supra- or infrahyoid muscles
Special Test - Three knuckle test, Passive relaxed anlanto-occipital and antlano-axial
articulation test, TMJ AF- rom
Tx - Reduce pain
o Decrease but not fully remove SNS firing,
o tx compensating structures
o Maintain local circulation.
o Relaxation is key to treatment.
o Reduction of edema and facial restrictions is also benefit to tx.
o Joint play for immobile joints
o Trigger point therapy can also be done.
o Muscles included are temporalis, masseter, med and lat pterygoid, digastric, mylohyoid,
geniohyoid, infrahyoids.
o Three things need to be present in order to cause TMJ problems including;
predisposition, tissue alteration, and stress.
o This is a very complex joint and TMJ is more common to find that most individuals think.
Degenerative Disc Disease – degeneration of the annular fibres of the intervertebral discs
 Acute rupture of the disc can occur and most common btwn 30-45 – affect more men
 Herniation at L4-L5-S1
 Stages: Dysfunction, Instability, Stabilization
 Acute scoliosis – 90% shift away from pain (lateral to nerve root), 10% shift toward (medial to
nerve root)
 If protrusion (ant/post) be aware of positioning – if prone, may not be able to lay on the
abdominal pillow (post) – may be painful to flex
 Not tx disc itself but tx the sx – give extension exercises for home-care
 Work on mobilizing hypomobile joints as long as no permanent fusion or osteophyte formation is
present
 Work on correcting anterior pelvic tilt & stretching tight fibres
 If no position can be found that relieves pain, tx is CI until px is referred to Dr for assessment
 Positions that aggravate sx are avoided
23
Conditions
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Pressure and direction of techniques are modified and deep or longitudinal techniques are not
used on areas of mm atrophy
HH Q –
Observations - FHP, Hyperlordosis (APT) or flatback may be present, Muscle atrophy, Signs of
torticollis, LLI or acute scoliosis may be observed
Palpation - point tenderness, TrP’s, fascial restrictions, fibrosed and HT mm’s crossing the
affected level… possible muscle atrophy
Testing - AF & PR ROM (PR having more range), AF Flexion may be limited and may have a
deviation to one side
o Protrusion: Flexion peripheralize w mmt, ext is also limited and symptoms centralize w
mmt
o Complete rupture or sequestration: mmt cannot relieve the s/s
Special Tests (C / L spine) - SLR, Well Leg, Braggard’s, Valsalva’s, Slump, Kemp’s, Kernig’s,
ULLT, Spurlings, Neuro testing (true positive = motor weakness specific to the level of lesion
and specific dermatomal sensory changes i.e.: numbness)
Differentials Neck & Arm Pain - Facet joint irr, TOS, scalene TrP’s, CTS, tendinitis, OA, visceral
pathologies
Differentials Low back & Leg Pain - Facet joint irr, SI mobility, SI joint dysfunction, hip
pathologies, Spondylolisthesis, visceral pathologies
Refer if: Saddle anesthesia and bladder weakness (emergency), if no position relieves the pain. tx
is CI’d.
Modifications - do not mobilize hypermobile joints, do not remove protective spasming, pressure
and direction of techniques are modified and deep or longitudinal techniques are not used on
areas of mm atrophy
Osteoarthritis – group of chronic, degenerative conditions that affect joints, specifically
articular cartilage and subchondral bone
 Primary OA – idiopathic and either (1 or 2 jts) or generalized (involving 3 or more jts)
 Secondary OA – result of known cause, such as joint trauma or an underlying pathology
 some joints more common that you will see it, cannot cure, but can help
 avoid using heat with acute inflammation
 exercise caution when applying overpressure with osteophyte formation
 Joint play is helpful, Average age is older people
 Heberden’s nodes (DIP joints), Bouchard’s nodes (PIP)
 HH Q – What joints are affected?
o Is there a history of previous injury to the joint?
o Is there pain? Stiffness? In the morning? After a period of immobility?
o Has the condition been diagnosed by a physician?
o What medications, if any, is the client taking, including self-medication and over the
counter drugs?
o Is the client seeing a chiropractor, physiotherapist or other practitioner for treatment?
 Observation – joint swelling and enlargement may be evident
 AFROM – reduced and painful
24
Conditions
 PRROM – reduced and may have a leathery or bony/osteophyte end feel
 AR Test – weakness and possibly pain in muscles crossing affected joint
 Note – it is important to rule out other sources of joint pain such as bursitis, tendinitis, space
occupying lesion, facet joint irritation
 Tx - 1. Reduce stiffness - edema, spasm, trigger points, fascial restriction
o 2. Relieve compressive forces on the joint if possible
o 3. Maintain ROM and strength
o 4.Later stages be cautious of joint play with osteophyte formation
Pregnancy – is a state of wellness associated with many interrelated changes that occur
throughout the woman’s body as the fetus develops
 HH Q – General health? Is there a history of maternal cardiac, renal, thyroid, pulmonary, GI or
hepatic diseases or diabetes placing the fetus or mother at some risk for complications ranging
from low or high birth weight to potential early labor?
o Any health conditions posing risk to this pregnancy?
o Stage of pregnancy
 1st trimester – 0-12 wks
 2nd trimester – 13-26 wks
 3rd trimester – 27-40 wks
o Previous pregnancies? Complications?
o Family history of complications?
o Current symptoms?
o Blood pressure at each treatment? If signs of pre-eclampsia or eclampsia are present
the woman is immediately referred to her midwife or physician.
 Assessment testing is likely pertaining to a particular presenting condition related to pregnancy
such as sciatica
 Certain testing could present a challenge depending on stage of pregnancy
 Deep mx and fascial techniques are CI over low back during 1st trimester
 In 2nd and 3rd trimesters px must be carefully positioned on her back to avoid compression of
aorta and inferior vena cava. If nausea or discomfort experienced, position is changed to sidelying or seated or tx discontinued.
 Pre-eclampsia warning signs:
o In 2nd trimester, mistiness, blurring or change in vision may signal pre-eclampsia or
elevated BP. Bedrest and notification of MD are necessary.
o Continuous severe headache usually over the front or back of head accompanied by
visual disturbances may be sx of severe pre-eclampsia or HT. This is a headache that is
not relieved by the usual remedies
 Tx - 1. Pay close attention to comfort of patient, there is no specific rule for when prone lying is
no longer possible
o 2. Avoid work on the low back in the first trimester
o 3. Typical concerns are gluteal/sciatic pain, upper back pain late stages of pregnancy,
o 4. Edema in limbs may be an issue
o 5. Left side lying may be the best position towards the late stages of pregnancy
Communication issues – visual, hearing, sight
 HH Q -
25
Conditions
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Visual: client may need to be guided by voice or by touch to the assessment area, and made
aware of the assessment space: where the chair is, the table, obstructions. Ask first: something
like "may I guide you to the clinic space?" or "may I touch your elbow or shoulder to indicate to
you which way to go?" How will the client be giving formal consent? Ask them how they sign
forms or otherwise grant legal consent. Client will not be able to see you demonstrate special
tests, so describe them verbally, and ask for permission to touch them to place their body in the
appropriate positions for each test. Tests requiring balance will also be altered, e.g. the client
may experience vertigo when performing Kemp's or Trendelenberg, and will be more likely to
appreciate some help getting on and off the table. Finally, be more detailed in describing the
treatment than you would with a seeing patient, so there will be no surprises for them.
Hearing: Make use of writing or an iPad/laptop to show the special tests you'll be performing,
describe the treatment, and elicit their feedback. Client will probably have their own pad of
paper or communication device. Before giving them a massage treatment in which they'll be
lying face-down, make sure you both agree on a way of communicating pain scale, comfort, etc.
E.g. write on their notepad "if this pressure is too much, if anything hurts, or if there's anything
you'd like to communicate with me during the treatment, raise your hand or tap me, and I'll
pause what I'm doing so you can sit up and communicate with me." Then be sure they
understand and agree.
Speech: Similar to above, client will probably have their own method of communicating, e.g. a
notepad or iPad. Make sure you're getting full feedback from them, e.g. ask "is there anything
I've neglected to ask you which you'd like to share with me, or that you think I might not be
understanding?"
Comprehension: This is trickier. If they're having difficulty comprehending, they might not
legally be "competent" to provide consent, they might not understand how to communicate a
pain scale or their comfort, and they might not give expected responses during assessment.
See Rattray p. 664 for a number of specific guidelines, e.g. limit distractions like background
music, speak slowly and clearly, elicit a response to make sure they understand everything
you're saying, use visual aids, have them repeat back to you any directions it's crucial they
understand (e.g. "just to make sure we understand each other, please summarize for me the
pain scale I've just described to you"), etc. If they do not seem mentally competent, be sure they
have a legally authorized representative or caregiver present.
Tx - 1. set up signals to assist with treatment ie. tap patient on shoulder
o 2. ensure they understand what you will be doing before you do
Ambulation issues – cane, walker, wheelchair
 HH Q  Information regarding functional ability may be gathered by observing the ambulation aids used
by a client. These include canes, walkers, wheelchairs and scooters.
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Observations o Canes and Walkers: used to support lower limbs or assist with balance (Compression
and overuse syndromes, HT in HNS and arms, unaffected leg)
o Wheelchairs: Used when ambulation is difficult or impossible. Upper body strength is
required.
26
Conditions
o
Motorized: Due to inadequate strength and coordination of upper body. (HT in HNS,
arms and hands), Lymph drainage and elevation of lower limbs, Hyperkyphosis,
compressed diaphragm, decubitus ulcers from prolonged sitting (lower lumbar spine,
sacrum and ischial tuberostities)
 Tx - Keep the “aid” near the table for when the patient is getting off the table after the treatment
Decubitus ulcers – also called “pressure sores”, are skin lesions caused by an external
pressure, shearing or friction force that is sufficient to locally impair circulation and
lymphatic flow in susceptible individuals. The lesions may result in ulcerations.
 HH Q –
 Categorized into 4 stages. 4th stage being the most severe type lesion.
 Observations
o Pressure sores: (prolonged immobilizations; wheelchair) most common over bony
prominences, most common: sacrum, ischial tuberosity, greater trochanter, spinous
processes, calcaneus and elbow.
o Friction sores: (prolonged bed rest) less serious initially but area is more susceptible to
pressure.
 Tx – See note on wound, inflammation
Spasm – an involuntary, sustained contraction of a mm. A cramp is a common or lay term for a
painful, prolonged mm spasm
 HH Q - Has the patient had an injury to the spasm site before?
o Has the patient had this type of spasm previously? Have they discussed it with their
physician?
o Have they made any changes to their dietary or eating habits?
 Palpation – local heat or cool, tenderness
 AFROM – pain on contraction and stretch of the muscle
 PRROM – pain and decreased range with stretch of affected muscle
 AR Test – (submax testing only) pain on contraction and decreased strength
 Note – strength testing of an acutely spasmodic muscle is CI
 Tx – GTO, origin and insertion technique, and mm approximation
o Once spasm has decreased – on site work such as : vibrations, shaking, mm squeezing,
petrissage and JP, repetitive effleurage and petrissage applied to affected mm and
surrounding tissue
Seizures – characterized by the spontaneous, uncontrolled, abnormal discharge of neurons in
the brain
 HH Q –
 During an assessment for someone that suffers from seizures there wouldn’t be many findings.
 Observations - Depending on severity and proximity of seizures a client might have some postural
asymmetries from muscle guarding. Active ROM might also be limited for similar reasons.
 During a treatment if a client has a seizure the telltale signs will be that they will have a blank
stare, a potential loss of consciousness, increase or decrease in postural muscle tone (may last
for a few seconds to almost a minute). For a more serious, grand mal seizure a client will have
27
Conditions
tonic contraction of their muscles, loss of consciousness and bladder/bowel incontinence and
then bilateral, rhythmic contraction and relaxation of limbs
 Tx – 1. be aware of triggers
o 2. be aware of what to do for that specific patient if they have a seizure ie. who to call
o 3. avoid vigorous techniques in case this could trigger a seizure due to excessive
stimulation
Hemiplegia – non-progressive condition of paralysis on one side of the body as a result of a
brain lesion
 HH Q –
 Observations
o unilateral paralysis (depending on side of brain lesion), L lesion - right sided paralysis, R
lesion - left sided paralysis
o Spasticity pattern on affected side - circumducted gait. Ability to balance and shift weight
may be impaired - can or walker may be used
o Edema, muscle bulk differences, postural asymmetries and altered biomechanics
 Palpation - Hypertonicity in muscles affected by spasticity, Hypotonicity and flaccidity in muscles
on affected side, Shoulder pathologies on affected limb
 AF and PR ROM - decrease in ROM if spasticity is present, in most extreme cases then no
movement is possible. Flaccidity will result in decreased ROM in joint crossed by those
muscles.
 AR strength testing - n/a if spasticity is present
 Special Test - sensory; light touch, temp, pain, 2-point discrimination and proprioception may be
affected.
o Less accurate in arm and hand than in the leg and foot, Orthopedic tests are performed for
secondary conditions.
 Tx - 1. Postural issues are likely
o 2. Tissue and joint health is a concern – use ROM for joint health, drainage, effleurage,
petrissage for tissue health
o 3. Contractures may be a concern – use petrissage and stretch
o 4. Spasticity may be a concern – use slow rhythmical movements
o 5. Very important to integrate both sides of the body
o 6. Position and movement of patient on table may be a challenge to weak muscles or
non-functioning limbs
Multiple Sclerosis – a condition in which demyelination of the nerves occur
 HH Q –
 Observations – No typical MS client. General Observations for CNS lesions are: Altered gait
(circumducted or festinating) Posture observed for spasticity (flexion or extension pattern?) or
rigidity (Lead pipe or cog wheel rigidity?), which limbs are affected? Upper or lower body?
Muscle bulk differences between sides or btwn upper or lower body. Functional ability, ie.
removing coat, holding pen, sitting down, standing up, using a cane vs wheelchair? Trophic
changes to skin, edema, skin may be pale, dry or oily. Decubitus ulcers (px wheelchair use or
prolonged bed rest).Red areas over bony prominences (recorded and reported to client)
28
Conditions
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Palpations- No typical MS client. General Observations for CNS lesions are: Assess hypertonicity of spastic or rigid muscles and hypo-tonicity of flaccid mm. Contractures in agonist mm
present w/ spasticity, both agonist and antagonist w/ rigidity, and unopposed antagonist w/
flaccidity. Edema possible in distal tissues, with tissue coolness, and in cases of long-standing
edema overlying tissue fragility, possible pitting edema. Tender or painful areas d/t altered
sensation. Secondary changes d/t altered posture or mm imbalance or soft tissue, joint
pathology or trauma may result in tenderness, adhesions or signs of inflammation.
AF and PRROM- Usual ROM protocols are attempted. Decreased ROM is affected by spasticity
and weakness. Severity of motor dysfunction is revealed by degree of compromised ROM
ARROM- will reveal diminished strength on muscles of “weak side” of body. Limbs affected by
spasticity will not yield useful results.
Special Tests – Sensory testing for light touch, deep pressure, pain and temperature perception,
two point discrimination and proprioception. There may be a variety of sensory changes from
anesthesia to paresthesia. All other Special Orthopedic Tests are performed for secondary
conditions. If spasticity is present, tests may not yield viable results.
Tx – 1. Avoid too much deep work – could trigger spasticity
o 2. Avoid application of heat over large area – fatigues px
o 3. Address muscle rigidity with petrissage, stretch, fascial techniques
o 4. Address joint rigidity with joint play
o 5. Address spasticity with long, relaxing strokes
Parkinson’s – a progressive disorder involving diminishing basal ganglia function. The
disorder results in slow, increasingly difficult movement, accompanied by resting tremors and
muscular rigidity.
 HH Q –
 Observations – Typical posture includes forward flexion and bowing down of the head, frwrd
flexion and lat. tilt of trunk, flexion of elbows, hips and knees and inversion of the feet w/ big
toes dorsiflexed. Measure degree of hyperkyphosis and head forward posture, look for presence
of scoliosis and pelvic tilt (ant. or post.). Gait abnormalities will be observed. Resting tremors
may be in hand or foot, unilateral or bilaterally. Px’s difficulty in maintaining an upright posture
(d/t loss of righting reflex). Movement generally appears stiff and rigid. Frozen facial expression
may be accompanied by lack of eye blinking and an increase in drooling. Also see above for
general CNS observations.
 Palpations – Rigidity in muscles throughout the body d/t increased tone in agonist and
antagonist muscles. Skin may be oily on face, but dry on the rest of the body. Also see above
for general CNS palpations.
 AFROM - Usual ROM protocols are attempted. Decrease in ROM w/ rigidity w/ severity
measured by degree of ROM compromised.
 PRROM – Uniform resistance in the flexor and extensor groups acting on the affected joint
resulting in decreased ROM. AKA “Lead pipe rigidity”. Intermittent interruptions of muscle rigidity
creating a ratchet-like movement is referred to as “cog wheel rigidity”, which usually occurs in
the elbow and wrist.
 ARROM – Tests will not yield useful results in w/ rigidity.
 Special Tests – Bradykinesia Test, Sensory Testing for light touch, deep pressure, pain and
29
Conditions
temperature perception, two point discrimination and proprioception. Results will vary depending
on the client; there may be sensory impairment or facilitation. All other Special Orthopedic Tests
are performed for secondary conditions. If rigidity is present, tests may not yield viable results
 Tx - 1. Avoid too much deep work – could trigger spasticity
o 2. Address muscle rigidity with petrissage, stretch, fascial techniques
o 3. Address joint rigidity with joint play
o 4. Address spasticity with long, relaxing strokes
o 5. Postural imbalances are likely – hyperkyphosis, forward head posture etc.
Cerebral Palsy – a term used for motor function disorders that result from damage to the
immature brain
 HH Q –
 Precautions/Modifications: Some ppl will be reluctant to take part in testing b/c of childhood
experiences with continual physical examinations. Be respectful, and clear consent to the
testing process will often help the client overcome this possible reluctance. Testing should be
completed over a series of txs.
 Specific orthopedic tests are performed for secondary conditions… If spasticity or athetoid mmts
are present in limbs to be tested, the tests may not yield viable results. Modify position if
hypertension is present. Do not increase SNS firing. Altered sensations may be present,
therefore, may produce inaccurate findings.
 Tx - 1. Address contractures with petrissage and stretch, gentle fascial work
o 2. Address flaccid tissue with stimulating tapotement, stimulating petrissage
o 3. Watch for decubitus ulcers if individual uses a wheelchair
o 4. Postural changes are a likely concern – ie. Scoliosis
Spinal Cord injury – quadriplegia, paraplegia – is an injury to the vertebral column, spinal cord
or both due to a direct or indirect trauma
 HH Q –
 Quadriplegia = All 4 limbs, trunk & pelvic organs affected
 Paraplegia = affects lower limb – trunk & pelvic organs may be affected
 Symptoms depend on area of spinal cord injured
o Upper motor neuron lesion = spasticity
o Lower motor neuron lesion = flaccidity
 Hypertonicity in unaffected muscles – overcompensation
 Diaphragm – due to poor posture & being compressed from being in a wheelchair
 Neck, shoulder, arm & supportive muscles (may also be painful)
 Thermoregulation may be lost - Use only cool or warm hydrotherapy if desired to be used
 Risk of bone formation in muscle, bed sores and DVT – be careful with pressure and observe
skin prior to massage
 Sensory & motor function may both be compromised
 Tx - 1. Address contractures with petrissage and stretch, gentle fascial work
o 2. Address flaccid tissue with stimulating tapotement, stimulating petrissage
o 3. Watch for decubitus ulcers if individual uses a wheelchair
30
Conditions
o
4. Postural changes are a likely concern – ie. scoliosis
Poliomyelitis – is an acute viral infection specifically affecting the motor neurons in the spinal
cord and brain stem
 HH Q –
 Muscle Length Tests – reveal shortened muscles due to contractures
 Muscle Strength Tests- reveal weakness due to contractures
 Tx – 1. Address contractures with petrissage and stretch, gentle fascial work
o 2. Address flaccid tissue with stimulating tapotement, stimulating petrissage
o 3. Postural changes are a likely concern – ie. scoliosis
Neuritis – inflammation of the nerve
 HH Q - Has the client had blood work done? chronic acidosis is a chief cause of neuritis
o Diet? Nutritional deficiencies may cause neuritis (B12, B6, B1, pantothenic acid and B2
and general toxemia.)
o A blow, a penetrating injury a bad bruise or heavy pressure over a nerve trunk and or
dislocation and fractures of the bones?
o Any violent muscular activity or over-extension of the joint as in sprains may injure the
nerves and cause neuritis?
o The condition may also result from certain infections such as tuberculosis, diphtheria,
tetanus, leprosy and diabetes mellitus, poisoning with insecticides, mercury, lead,
arsenic and alcohol?
 use caution with assessment as the is very locally painful
Neuralgia – nerve pain
 HH Q – Was there Chemical irritation?
o Presence of kidney dysfunction? Diabetes? Infections, such as herpes zoster (shingles),
HIV, Lyme disease, and syphilis?
o Are you taking any medications such as cisplatin, paclitaxel, or vincristine?
o Is there known pressure on nerves by nearby bones, ligaments, blood vessels, or
tumors?
o Any recent trauma (including surgery)?
 use caution with assessment as the is very locally painful
Trigeminal neuralgia – aka tic douloureaux or painful tic. It affects the trigeminal nerve, which is
cranial nerve V (CNV). The nerve supplies sensory awareness to the face and motor function to
the mm of mastication and the tensor tympani of the middle ear. The nerve consists of 3
divisions: ophthalmic, maxillary and mandibular.
 HH Q - Is there any history of a systemic disorder, such as diabetes mellitus, hypertension or
kidney disease? Multiple sclerosis?
o Are you taking any medications where this could be a side effect?
o Where exactly does the client feel the pain in their face?
o Do you have any vision problems?
o Has the pain progressed?
 Observations – facial tics (look like grimaces), loss of hearing, paralysis or muscles of
mastication
 Palpation – light palpation may bring on an attack
31
Conditions
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AFROM – lock jaw or muscle spasm when opening mouth
Intercostal neuralgia – this condition affects the intercostal nerve that travels between the
internal and innermost intercostal mm. The nerve travels as a neurovascular bundle from the
spine to the sternum for ribs 1-6 and from the spine to the abdomen for ribs 7-11.
 HH Q - Are you diabetic?
o Do you currently have any viral infections?
o Do you know exactly what the trigger zone is? Can you show me?
o Is there any position that may be uncomfortable for you?
 Use caution with assessment as the is very locally painful
Causalgia – severe pain syndrome. Sudden onset of an intense persistent, usually burning
pain, most often associated with a traumatic injury to a peripheral nerve.
 HH Q - What was the original injury that led to this?
 Did that injury heal well?
 caution with assessment as the is very locally painful
Reflex sympathetic dystrophy – pain syndrome. While this term is ofent used interchangeably
with causalgia, it actually refers to a different pain syndrome. Some authors refer to the
condition as minor causalgia - spontaneous burning pain in the limb beyond the area of a nerve
injury.
 HH Q – Was there Injury directly to a nerve
o Was there injury or infection in an arm or leg?
o Rarely, sudden illnesses such as a heart attack or stroke can cause reflex sympathetic
dystrophy. The condition can sometimes appear without obvious injury to the affected
limb
o What stage is the client?
o Stage 1 (lasts 1 - 3 months):
 Are there changes in skin temperature, switching between warm or cold?
 Faster growth of nails and hair?
 Muscle spasms and joint pain?
 Severe burning, aching pain that worsens with the slightest touch or breeze?
 Skin that slowly becomes blotchy, purple, pale, or red; thin and shiny; swollen;
sweatier?
o Stage 2 (lasts 3 - 6 months):
 Continued changes in the skin?
 Nails that are cracked and break more easily?
 Slower hair growth?
 Stiff joints and weak muscles?
o Stage 3 (irreversible changes can be seen)
 Limited movement in limb because of tightened muscles and tendons?
(contracture)
 Pain in the entire limb?
 caution with assessment as the is very locally painful
Neuroma – tumor composed of nerve cells
 HH Q – Where is the neuroma exactly
o When did the neuroma develop?
32
Conditions
o
o
Has the symptoms progressed?
Has there been previous irritation in the area? (nerve tissue thickens in response to
irritation)
 caution with assessment as the is very locally painful
Klumpke paralysis – Injury involves the lower brachial plexus and results from compression or
stretching of the lower nerve roots (C8, T1). Atrophy and weakness are evident in the muscles
of the forearm and hand as well as in the triceps. The obvious changes are in the distal aspects
of the upper limb. The resultant injury is a functionless hand. Sensory loss occurs primarily on
the ulnar side of the forearm and hand.
 HH Q - Is a traction injury to the lower brachial plexus; resulting in a combination median and
ulnar nerve lesion? Birth –breech or forceps? Fall from height and grabbing something to break
the fall causes traction as the force stretches C8 and T1 nerve root?
o When and how did the lesion occur?
o Under care of neurologist? What prognosis? Doctor is aware you’re seeking massage?
o What functions most affected?
o Is there lose sensation or changes from the inside elbow down to the pinky finger (C8
and T1 dermatomes)
o Is their burning pain? Was it immediately following injury or within a few weeks of the
trauma?
o Client receiving other treatment? Physio? Electrical muscle stimulation? Passive
movements?
o Are there signs of a claw hand or ape hand? Muscle wasting at the hypothenar
eminence, or thenar eminence; and/or the forearm (FCU, FDP). Edema in the forearm
and hand?
 Assessment - Observations, look for signs of atrophy.
 Testing - Resisted ROM testing, Weakness on C8 and T1 testing, Dermatomes , May have
abnormal sensations with C8 and T1, DTR for Triceps
 Special Tests
o ULTT 4: tests for Radiculopathy from irritation of: ulnar n, C8, T1
o 1. patient abducts arm with elbows fully extended
o 2. stop short of symptoms
o 3. pt then externally rotates arm
o 4. examiner maintains this position
o 5. then patient flexes elbows & places palms on occiput
o TINEL’S AT THE C SPINE - tests for compression of compression/ irritation of: brachial
plexus
o .Examiner taps area above clavicle (at scalene triangle) with a reflex hammer or finger
o Roo’s\ Adsons
Horners syndrome – which manifests on the affected side (associated with Klumpke’s paralysis)
with constriction of the pupil (miosis), drooping of the eyelid (ptosis), loss of sweating to the
face and neck (anhydrosis) and recession of the eyeball into the orbit (enophthalmos)
 HH Q - Have you been diagnosed with a condition called Klumpke’s paralysis? (Horners
syndrome is an additional complication to KP)
o Have or when did you noticed, on the affected side, the constricted pupil? Drooping
eyelid? Loss of sweating to the face and neck (anhydrosis)? Recession of your eyeball
33
Conditions



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into the orbit?
Observations are very clear, the person will present with constriction of the pupil, dropping of
the eyelid, loss of sweating on the face and neck and recession of the eyeball into the orbit. This
will all be on the affected side.
It’s also an additional complication to having Klumpke’s paralysis which involves a lower
brachial plexus injury and lesion of the median and ulnar nerve lesion.
Therefore in other observations this will present with “claw hand”.
Atrophy and functional loses of muscles in the hand with severe edema are other observations
that will appear if they also have Klumpke’s paralysis.
And for neurological findings sensory loss of the c8 and t1 dermatomes.
Erb’s paralysis – a traction injury that involves the upper brachial plexus, namely C5-C6 nerve
roots. Symptoms: “waiter’s tip”, shoulder adducted and int rot, elbow extended, forearm
pronated and wrist/fingers flexed
 HH Q – Is there lose sensation or changes to the outside of your arm (C5 and C6 dermatomes)?
o When and how did the lesion occur?
o Is it a complete or partial lesion? Was surgery performed, nerve graft or suturing of the
nerve?
o Under care of neurologist? What prognosis? Is Doctor aware you’re seeking massage?
o What functions most affected?
 Causes of injuries when the person is an adult can be from falling on the head and shoulder,
vehicle accident, or sports accidents. The person would have had to strongly separate their
neck and head.
 It’s an injury to the upper brachial plexus on the c5 and c6 nerve roots.
 The observations will be that the person will present with “waiter’s tip”. Shoulder will be
adducted and internally rotated, the elbow will extended, the forearm pronated and the wrist and
fingers will be flexed. There will also be wasting on the muscles of the above the elbow. Also
found motor dysfunction.
 For neurological findings there will be loss of sensory on the C5 and C6 dermatomes.
Radial Nerve Lesion
 HH Q - Where is the lesion exactly?
o How did the lesion develop? When?
o Is it both motor and sensory functions affected? (above the elbow both; below the elbow
one or the other)
o Is it a complete or partial lesion? Was surgery performed, nerve graft or suturing of the
nerve?
o Under care of neurologist? What prognosis? Is Doctor aware you’re seeking massage?
 Observations – atrophy, edema, “wrist drop”
 Palpation – muscle wasting in certain muscles, contractures in other
 AFROM – reduction ranges from slight impairment to loss of function depending on extent of
injury
 PRROM – leathery end feel, do not perform PRROM in ranges that stretch the nerve
 AR Test – reduction in strength ranges from slight impairment to loss of function depending on
extent of injury
 Neuro – dermatome and myotome and reflex will be reduced in the specific distribution (C5-T1)
 Flaccid muscles – wrist extensors
 Note – use caution to avoid stretching the damaged/healing nerve
34
Conditions
Ulnar Nerve Lesion
 HH Q –
 Observations – atrophy, edema “claw hand”
 Palpation – muscle wasting in certain muscles, contractures in other
 AFROM – reduction ranges from slight impairment to loss of function depending on extent of
injury
 PRROM – leathery end feel, do not perform PRROM in ranges that stretch the nerve
 AR Test – reduction in strength ranges from slight impairment to loss of function depending on
extent of injury
 Neuro – dermatome and myotome and reflex will be reduced in the specific distribution
 Flaccid muscles – finger flexors
 Note – use caution to avoid stretching the damaged/healing nerve
 Tx - Acute
o Do not traction the nerve or interfere with the healing process
o If surgically repaired, no mx for up to 3 weeks
o Light stroking & gentle compressions (distal)- to promote health of denervated tissue
 Chronic
o Segmental GSMT & TrP’s proximal & distal to lesion- to promote tissue health of
unaffected & newly innervated tissue
o Fascial techniques to the unaffected mm’s- to prevent contracture formation of the
unopposed antagonists (flexor carpi ulnaris, Guyon’s canal, abductor and flexor digiti
minimi)
o Eventually frictions to lesion- to reduce scar tissue
o Gradually introduce joint play and rhythmic techniques- to maintain and improve tissue
health & ROM
o AA & Passive mmt introduced to joint affected- to maintain health & awareness of
affected limb
Sciatic Nerve Lesion
 HH Q –
 Observations – atrophy, edema possible in leg, “foot drop”, “claw toe”
 Palpation – muscle wasting in certain muscles, contractures in others
 AFROM – reduction ranges from slight impairment to loss of function depending on extent of
injury
 PRROM – leathery end feel, do not perform PRROM in ranges that stretch the nerve
 AR Test – reduction in strength ranges from slight impairment to loss of function depending on
extent of injury
 Neuro – dermatome and myotome and reflex will be reduced in the specific distribution
 Tibial division– altered sensation on posterior leg, heel, sole
 Peroneal division – altered sensation lateral and anterior leg, dorsal foot (not toes)
 Flaccid muscles – hamstrings, Common Peroneal division - peroneals, tibialis anterior, toe
extensors, Tibial division – gastrocnemius, soleus, intrinsic foot muscles affected
35
Conditions
 Note – use caution to avoid stretching the damaged/healing nerve
Bell’s palsy – a condition involving a lesion on the facial nerve (CN VII). It results in flaccid
paralysis of the mm of facial expression on the same side as the lesion.
 HH Q – Prognosis, type of lesion, treatment
 Is there any sensory loss or change?
 Any history of diabetes, hypertension, kidney disease, cold sores, pregnancy?
 What facial functions are most affected?
 Any pain?
o Describe, type, where, when
 Observations: Unilateral weakness followed by flaccid paralysis of the mm’s of facial expression.
Sagging of the face and facial expressions will appear distorted. Loss of control of lacrimation
and decrease of saliva. Pain
 Palpation: Flaccidity is palpated in the affected mm’s over forehead, around the eye, nose &
mouth, and in the platysma, stylohyoid and posterior belly of the digastric mm’s. Edema may be
palpated if the condition is caused by systemic or local edema as the result of trauma.
 Testing: AF ROM of facial expressions, if px is unable to close an eyelid and the eye rolls upward
and inward so sclera is seen, AR strength testing is +ve of the orbicularis oculi mm
 Precautions: eye infections, pressure modified on flaccid mm’s, long dragging strokes are CI on
the affected side.
 Tx – always work toward the affected side (start on opposite side and work lateral to medial and
then on the affected side from medial to lateral)
o Use tapotement to stimulate nerve regeneration on the affected side
o Do retraining exercises with the px on the affected side
Thoracic Outlet syndrome – cervical rib, anterior scalene syndrome, costoclavicular syndrome,
Pectoralis minor syndrome – condition that involves the compression of the brachial plexus and
its accompanying artery
 HH Q –
 Observations: Tenderness on thumb pressure over the ipsilateral supraclavicular area, lateral to
the sternocleidomastoid muscle just above the clavicle. The patient’s nonverbal response,
particularly facial grimaces and withdrawal should be observed.
 Possible poor posture (hyperkyphosis and scoliosis)
 Atrophy in hypothenar and Interossei muscles
 Possible edema in hand, especially dorsal surface
 Swollen arm, bluish or white colour of forearm, hand
 Palpation: Recreation of tingling in pinky and ring fingers, Compression of nerve root causing
tingling in neck and shoulders, Cold hands, Swollen arm
 AROM and PROM (limited in neck and shoulder)
 Pain w/ abduction and flexion of arm
 RROM - Weakness of abduction and adduction of 5th finger
 Neuro: Weakness in C8-T1 nerve roots
 Special Tests:
o Adson’s Test, Reverse Adsons, Phalens, Roos, Allen’s Test
 Tx - 1. Consider the actual cause of the compression and treat accordingly
36
Conditions
o
o
o
o
2. Modify positioning, hydrotherapy and techniques if compression is the result of a
pathology
3. Address entire shoulder girdle, neck and any postural contributors
4. Treat fascia on the neck, shoulder and anterior chest to decrease compression of the
neurovascular bundle
5. Treat SCM, scalenes and pectoralis minor and major for hypertonicity and trigger
points
Carpal tunnel syndrome – results from the compression of the median nerve as it passes
through the carpal tunnel at the wrist. This results in numbness and tingling in the medial
distribution – that is, the lateral 3 ½ digits
 HH Q –
 Observations - Px may be wearing a splint., Edema may be present in the hand, wrist, forearm,
Thenar atrophy
 Palpation - Cardinal signs of inflammation local to the wrist, Tenderness local to CT,
Hypertonicity, Trps in the forearm muscles, Tissue texture may be boggy local to the wrist.
 Testing - AF, PR ROM= decreased flexion and extension, possibly with ulnar deviation, End
feels are often empty.
 AR strength testing of the Abd Poll Brev is positive for weakness if CTS is chronic.
 Special Tests - Phalens and Reverse Phalens=positive, Tinnell's Sign=positive.
 Tx – 1. Use fascial work to decrease compression on the median nerve
o 2. Treat trigger points that refer to thumb and lateral hand: scalenes, brachialis,
brachioradialis, opponens pollicis, adductor pollicis, palmaris longus, and trigger points
that refer to the wrist: subscapularis, flexor carpi radialis, pronator teres
o 3. Apply myofascial stretching to flexor retinaculum
o 4. Maintain ROM to elbow, carpal bones and metacarpal joints
o 5. Do not perform frictions or vigorous joint play if CTS is the result of rheumatoid
arthritis
Piriformis syndrome – compression of the sciatic nerve by the piriformis mm
 HH Q –
 Observation – antalgic gait, hip torsion may be likely, with patient supine, excessive external hip
rotation
 Palpation – hypertonicity in piriformis, TPs, gluteals also and all surrounding muscles
 AFROM and PRROM – reduced internal hip rotation and may be painful
 AR Test – weak piriformis
 Special Tests – pace abduction test, piriformis length test positive, SI motion palpation reveals
reduced movement
 Differentiate from other sources of radiating gluteal pain – nerve root compression, lumbar spinal
stenosis, facet joint irritation, inflammatory arthritides
 Tx - 1. Treat trigger point/stretch piriformis – to allow muscle to lengthen
o 2. Use facial techniques on gluts and down hamstrings – release pressure on nerve
o 3. Sacral joint play – to restore movement through entire pelvis
o 4. Avoid direct compression of sciatic nerve
37
Conditions
o
5. Address all leg muscles with petrissage/facial techniques
Sinusitis – an acute or chronic inflammation of the paranasal sinuses
 HH Q – Are you on any meds?
o Does pain increase when you bend your head forward?
o Where do you feel the pain/pressure?
o Above eyes, across cheeks, side or back of head, toothache like
o Do you have a fever
o Is it acute or chronic? onset
 Observations – yellow/green nasal discharge
 Pain – directly over sinuses, may cause a headache and increases when Px bends forward
 Palpation – tenderness & heat over sinuses, lymphatic nodes in neck enlarged
 Tests – transillumination of sinuses reveal blockage
 Tx – ½ hour on the face/sinuses, positioning could be used as a technique, but be careful
because it could be painful if they are prone for a long time, mx the whole upper body, focus on
accessory mm of respiration, diaphragmatic breathing, PROM, c-spine mobs, stretching
Chronic bronchitis – Chronic bronchitis: Chronic bronchitis is characterized by a productive
(wet) cough that is persistent. The mucus that is produced by the inflamed airways eventually
causes scar tissue to form in the lungs, making breathing difficult. Symptoms include:
wheezing; shortness of breath; ankle, feet, and leg swelling.
 HH Q – Do you Smoke; how much and frequency?
o Onset?
o What times of day is the cough worse? Morning or night?
o Are you taking medication for this?
 Observations - Patient may present with forward rounded shoulders, as well as high tone in
scalene and upper traps, May demonstrate signs of apical type breathing
 May present with redness in the lower extremities due to swelling
 “blue bloater” swollen look to them, chronic cough – worse in morning and evening and in the
winter
 Range of Motion - Shoulder ROM may be limited due to forward rounded shoulders, ROM of the
neck may be limited in all directions, Rib expansion will be decreased due to shortness of
breath, ROM will be decreased in the lower extremities due to swelling
 Palpations - May present with pitting edema, Skin may feel warm to touch
 Tx – tapotement on the back to loosen mucus, JP to the ribs to increase breathing (may not be
expanding enough), diaphragmatic breathing, treat all upper body mm – all of these will help to
maintain what they have – it will not “cure” their chronic bronchitis, work on chronic posture
(kyphosis), long stretching techniques (active inhibition), PROM, local circulation important
Emphysema – Emphysema: progressive disease of the lungs that primarily causes shortness of
breath due to over-inflation of the alveoli (air sacs in the lung). Treatment includes teaching
proper breathing techniques.
 HH Q – Smoke?
o Do you have dyspnea? When does this happen
o Cause?
38
Conditions


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
Observations - Patient may present with forward rounded shoulders, as well as high tone in
scalene and upper trap, May demonstrate signs of apical type breathing, barrel chest possible,
“pink puffer”, kyphosis and forward head posture, cough can be productive or shallow and dry
Range of Motion - Shoulder ROM may be reduced, rib mobility and breathing reduced
Palpation – hypertonic respiratory muscles
AFROM and PRROM – reduced and indicate areas of joint hypomobility in thoracic spine
AR Test – shoulder muscles and abdominal may be weak
Special Test – vocal fremitus and mediate
Tx -
Hypertension – the elevation of BP above the normal rane for a prolonged period of time. It can
increase the risk of stroke or heart attack
 be limited due to forward rounded shoulders, ROM of the neck may be limited in all directions,
Rib expansion will be decreased due to shortness of breath
 Palpations - May present with pitting edema, Skin may feel warm to touch
 Tx - 1. Avoid long strokes especially on limbs, which increase circulation - use small strokes
o 2. Avoid excessive stimulation of SNS (painful techniques) as this may increase BP
o 3. Pressure on abdominal aorta from abdominal pillow in prone, may be uncomfortable
and lead to increased BP, side lying or seated may be best
o 4. Avoid neck rotation for a prolonged period (caution with carotid artery)
o 5. Check in to ensure patient is feeling ok several times during treatment
Asthma – chronic inflammatory disorder characterised by bronchospasm (narrowing of the
airways in the lungs), which is reversible over time either spontaneously or following treatment
 HH Q - What triggers an attack?
o Smoke?
o If you have an inhaler, where is it and what should I do if you have an attack?
 Observations – barrel chest possible
 Palpation – hypertonic respiratory muscles
 AFROM and PRROM – reduced and indicate areas of joint hypomobility in thoracic spine
 AR Test – shoulder muscles and abdominal may be weak
 Special Test – vocal fremitus and mediate percussion test positive with mucus congestion
 Pectoralis Major and Minor may be short
 Positioning is what is most comfortable for the px
 May not be able to have them prone for too long – semi prone/supine may be good
 No hard forced inspiration of the px, no large scale heat applications
 Tx – careful of vigorous techniques if the person is prone to having attacks – increase in SNS
may trigger, work on accessory mm of respiration (scalenes, SCM, QL, intercostals,
diaphragm), diaphragmatic breathing, work on upper body mm, maybe have a humidifier in the
room, restrictions in the upper back, thoracic mobilizations (isolated or general down whole
spine), scapular ROM, stretching mm attaching onto ribs, towel roll under the spine for kyphosis
39
Conditions
Congestive heart failure – Occurs when the heart muscle is weakened and doesn’t pump with
enough force. CHF can also arise when the valves within the heart do not function properly, or
when the heart muscle is thick and stiff. For these individuals, the heart is unable to pump
sufficient blood to meet the body’s metabolic requirements. When the blood is not pumped
forward to the body, it can back up into the lungs causing difficulty breathing. This shortness of
breath may become worse with exertion such as walking or climbing stairs. Patients may wake
at night with coughing spells or difficulty breathing
 HH Q – Questions to ask with left-sided heart failure
o Do you have any breathing difficulties?
o Do you have any feeling of suffocation when lying on your back?
o Would you be comfortable in a semi-supine position with the trunk and head elevated by
pillows?
 Questions to ask with right-sided heart failure
o Do you have edema in anywhere below your heart, especially in your legs?
o Do you have an abdominal pain or any intestinal problems?
o Do you experience coldness of the limbs?
o Did you gain weight?
 Signs and Symptoms - Dyspnea (shortness of breath), Breathlessness is often worse during
exertion or while laying down, Orthopnea (waking up breathless at night), Shortness of breath
experienced while lying flat is a sign of a weakened heart, Coughing- buildup of fluid in the lungs
(pulmonary edema) can result in a nagging cough that may worsen when lying down, Edema,
weight gain. Fatigue
 Treatment - early: rest, change in, diet, modify physical, activity to not overload heart,
medications, surgery
 May not be able to lie face down for long, shorter treatments
 Tx – 1. Avoid long strokes especially on limbs, which increase circulation - use small strokes
o 2. It may be best to treat only the limbs, head, neck, and avoid the trunk
o 3. No full body lymphatic drainage
o 4. Check in to ensure patient is feeling ok several times during treatment
o Get clearance from Dr. before treating to make sure it’s ok
Raynaud’s phenomenon/disease – The difference between phenomenon and disease is that
when is phenomenon the vessels outside the heart and the thorax will be affected. When it is
disease the vessels appear to be normal
 HH Q - Are you diagnosed with Raynaud’s Phenomenon or Disease?
o Do you have any other underlying diagnosed condition? (arterial, connective tissue
disease, frostbite, trauma)
o Are you taking any vasodilators?
o How frequent are the attacks?
o What specifically triggers attacks? (cold, stress)
o Do you have ulcers or gangrene around the nail or fingertip?
 Health history and observation - Raynaud’s comes secondary to various conditions such as:
occlusive arterial disease, arteriosclerosis, systemic scleroderma, lupus erythematous, thoracic
outlet syndrome and other compression syndromes, pulmonary hypertension, myoedema,
40
Conditions
buergers disease, and previous vessel injury through frostbite or trauma.
 More physical observations - the digits will appear white and shiny and will often go numb. Over
time tissue health is affected resulting in atrophy. The nails can become brittle and the skin at
the fingertips will thicken.
 Stay away from COLD hydrotherapy applications
 Tx – 1. Use vigorous techniques cautiously to avoid stimulating SNS
o 2. Intersperse deeper technique with light relaxing techniques
o 3. Avoid cold hydrotherapy
o 4. Fascial with smaller areas, esp. when moving closer to affected tissue
Varicose veins – Varicose means distended or dilated. Therefore, varicose veins are abnormally
large and bulging veins. They are caused by the impaired function of the venous valves
 HH Q – Do you have dull achy pain in that area?
o Do you experience leg cramps?
o Would you be comfortable to lay on your back or stomach with legs elevated?
o Do you wear support stockings?
 Observation – redness is possible, edema distal to the affected veins is possible
 Palpation – local tenderness (alter pressure when working on them)
 Testing – Ramirez Test and Homan’s sign could be positive as this could be related to a deep
vein thrombosis
 Tx - 1. Avoid too much direct pressure on varicose veins
o 2. Use lighter pressure
o 3. Elevate legs
Constipation – the slow, difficult or infrequent movement of feces through the bowel
 HH Q –
 Observations - Abdominal bloating
 Palpations - abdominal tenderness depending on severity of constipation
 AFROM - discomfort with back extension
 Tx – abdominal massage, work on trigger points in low back and rectus abdominius, diaphragm
work, diaphragmatic breathing
Irritable bowel syndrome – aka spastic colon, spastic constipation, irritable colon and nervous
indigestion. It is a motility disorder which is strongly associated with anxiety. Stress or
depression in over half the cases
 HH Q –
 Observations - Abdominal bloating (if constipated) possible cramping (note ataxic posture)
 Palpations - abdominal tenderness
 AFROM - Discomfort with any ranges that move the abdomen
 PRROM - Discomfort with any ranges that move or strain the abdomen
 Tx – abdominal massage is CI if the person is having diarrhea
Inflammatory bowel disease – ulcerative colitis (broad area of ulceration in the mucosa of the
left colon and rectum) and Crohn’s disease (results in multiple, patchy ulcerative lesions which
41
Conditions
may affect any part of the gastrointestinal (GI) tract. These cause scaring and thickening of the
bowel)
 Contributing factors can include stresses and food intolerances.
 Altered bowel function incl constipation, diarrhea and the feeling as though there has only been
partial elimination.
 HH Q –
 Assessment - HH questions, testing including the rebound test (which will be negative for those
with IBS).
 Precautions - If px presents with diarrhea, mx is contraindicated.
Ankylosing spondylitis – a form of chronic inflammation of the spine and the sacroiliac joints.
The sacroiliac joints are located in the low back where the sacrum (the bone directly above the
tailbone) meets the iliac bones (bones on either side of the upper buttocks). Chronic
inflammation in these areas causes pain and stiffness in and around the spine. Over time,
chronic inflammation of the spine (spondylitis) can lead to a complete cementing together
(fusion) of the vertebrae, a process referred to as ankylosis. Ankylosis leads to loss of mobility
of the spine.
 HH Q – How long have you had pain?
o Where specifically is the pain in your back or neck? Are other joints affected?
o What position are you most comfortable?
 Observations - loss of lumbar lordosis, increase in thoracic curve as a result of decreased
lumbar lordosis, the chest becomes fixed, flattened and the thoracic muscles atrophy, Chest
expansion is reduced, breathing is primarily diaphragmatic, during later stages neck movement
are lost and a head forward posture develops, muscle wasting due to disuse atrophy maybe
present
 Palpation - pain in low back, buttock, and occasionally down the posterior thighs, flexion
contractors in the hips, muscle spasm in back muscles for stability
 AFROM / PRROM - decrease ROM starting at the sacroiliac joint and lumbar spine,
progressively moving up towards the cervical spine in extreme cases due to fusion, of ligament
and vertebra
 Special tests - Chest expansion test, SCHOBER’S TEST
 Tx – deal with postural issues (hyperkyphosis, forward head posture, rounded shoulders), work
on rib mobility and breathing
 Smaller strokes along the erectors (lat/med), stimulatory techniques along erectors, stretch the
anterior mm, maintenance of what they have a slow down the postural issues, strengthen the
posterior back mm and work on ROM to maintain the mvt they have
 Towel roll under their back – can also do while they are sleeping
Gout – a kind of arthritis that occurs when uric acid builds up in blood and causes joint
inflammation. Acute gout is a painful condition that typically affects one joint. Chronic gout is
repeated episodes of pain and inflammation, which may involve more than one joint.
 HH Q  Observations - Swelling at MTP joint of great toe (most common), Possible swelling at tarsal
area and ankle, Affected joint is red, hot swollen, and skin is shiny and taut, Patient unable to
bear even the slightly weight on the area affect (even the weight of bed sheets), Antalgic gait,
Pseudogout is similar however commonly affects ankles, knees, shoulders, wrists and less
42
Conditions
commonly the great toe (rule out).
 Palpate - Extreme tenderness at affected joint
 AROM - Reduced ROM due to swelling
 PROM - Not suggested due to pain / empty end feels
 RROM - Unremarkable, results skewed due to tenderness
 Neurological - Depends on location of swelling, but typically unremarkable and unnecessary
 Special Tests - Observation and palpation only
 Tx - Once under control:
o gentle passive movements of the affected joints are indicated
o gentle Joint play used with caution on affected joint capsule to reduce adhesions
o Between flare ups- heat is used on affected joints.
 During flare up:
o cool hydrotherapy
o affected joint is red, hot swollen, and skin is shiny and taut.
o unable to bear even the slightly weight on the area affect (even the weight of bed
sheets)
Infectious arthritis – joint inflammation resulting from infection by bacteria, viruses or fungi
- HH Q – Do you have any chronic illness?
o Did you lately have any trauma, surgery, abscesses or wounds?
o Are you taking antibiotics or any antifungal medication?
 Observations - Hot, red and swollen joint, Possible shaking and chills
 Palpation - Possible local tenderness, heat, swelling, possible fever
 AROM, PROM - Reduced ROM with pain @ affected joint
 Neuro - Normal, could be affected depending on what time of infection present
 Special Tests - Pain on active, passive and resisted ROM
 ***treated medically with antibiotics
 Tx - 1. Treatment is based on reducing compensatory hypertonicity, postural changes and joint
stiffness due to occasional joint pain flare-ups
o 2. During an acute flare, no work on inflamed area, no heat, no joint play
o 3. Between flare-ups, do vigorous work near joints that would cause a flare up.
o 4. All techniques are ok, just not aggressively.
o 5. Petrissage and stretch/fascial work – to reduce joint compression
o 6. ROM, gently JP – to lubricate joints and maintain joint health
Lyme disease – (rheumatic disease) – complex rheumatic disease that affects many systems of
the body
 HH Q - Do you receive any treatment for disease?
o Do you experience headaches, fever, chills?
o Do you have ache in your muscles or joints? Where exactly?
o Do you have any other related neurological abnormalities or cardiac involvement?
 Observations - you may notice a "bulls eye" rash, swollen lymph nodes may be palpable, in
serious cases, bilateral facial palsy may be observed
 Tx – see infectious arthritis
43
Conditions
Reiter’s syndrome – A triad of arthritis, non-gonococcal urethritis and conjunctivitis, following
inflammation of the intestine or urinary tract
 HHQ - are you in a flare up at this time?
o what areas/joints are inflamed at this time?
o how long has it been since it started?
o are you on any medication for it right now? (NSAIDs)
o have you had any infections recently? I.e. salmonella, chlamydia, herpes,
gastroenteritis?
 Observations - Possible skin irritation/redness due to inflammation, may also present with
decreased integrity of the skin
 Range of Motion - ROM may be limited due to inflammation in joints, Pain may be felt during
ROM, End feel may be soft
 Palpations - May present with pitting edema, Skin may feel warm to touch
 Special Tests - Crank test may produce pain in shoulder and crepitus may be heard,
Compression tests to hip, knee may produce pain
 Tx - see infectious arthritis
Rheumatoid arthritis – an inflammatory, destructive, chronic autoimmune disease of multiple
joints and connective tissue throughout the body
 HH Q - are you stiff for about an hour after getting out of bed?
o are there any joints that are swollen or deformities?
o how long have you had it?
o what joint or joints are affected?
o where did it start? (wrists/hands/fingers most common)
o is it bilateral or just on the one side?
o are you in a flare up now?
o are you on any medications for it? (NSAIDs, gold salts, penicillamine, Corticosteroids)
 Observations - Bouchard’s nodes (PIP), Swan Neck deformities - flex MCP, extend PIP, flex
DIP, Boutonnière - Ext MCP, flex PIP, ext DIP, Seen BL - as it is systemic, Ulnar Drift, Might be
experiencing weight loss, rashes or fevers associated with the systemic arthritis, Discoloured
finger nails (blackened), Z deformity of thumb, Subcutaneous nodules at elbow
 Palpation - Extensor Tendons displaced to ulnar side of MCP, Phalanges – tender, Ulnar styloid
tender, Nodules, Redness, heat and swelling at fingers, Trigger Finger,
 Special Tests - Bracelet Test (test bilaterally)
 Tx – alter the pain scale – depending on the patient, no joint plays or aggressive techniques on
the affected joints because they have already been compromised, relaxation is key
Scleroderma – a systematic disorder affecting collagen, characterized by slowly spreading
fibrosis and collagen deposits throughout the body
 HH Q - do you get finger swelling or puffiness occasionally? (Reynaud’s Phenomenon usually
1st symptom)
o does temp affect symptoms, esp. cold?
o was there a sudden or gradual onset of the symptoms? (categories-sudden indicates
DIFFUSE and gradual indicates LIMITED)
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Conditions
o
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do you notice any changes in how the joints feel when moving? (can develop a leathery,
rubbing sensation with ROM)
o do you have any Cardiac complications, Renal failure G/I or Respiratory issues?
o are you on any meds? (penicillamine to slow progression, NSAIDs for pain
Scleroderma causes- occupational exposure to vinyl, chloride, and organic solvents. Higher prominence in men, between ages 30-50
This particular disease affects the skin and the collagen within the skin, as well as muscles and
the fascia within.
Symptoms - Raynaud’s (loss of circulation in the tips of the digits), swelling and puffiness within
the digits also, Can be localized or generalized, loss of ROM can also occur, as well as a
hardening of the skin, causing contractures
o localized scleroderma can present with hard oval shapes of hardened skin on the
surface. Reduced ROM, and if present on the px's face can cause the lips to pucker,
and difficulty in opening the mouth.
o generalized scleroderma can present in multiple systems throughout the px's body.
Generally beginning with the skin and then progressing throughout the px's body,
Possible fractures of vertebrae, or wedging, which can cause compression of the nerves,
Hyperkyphosis “dowagers hump”, Client may not be aware that they have this condition,
unless it has been diagnosed by physician
Special Tests - AF ROM and PR ROM testing; as well as weight bearing are painful in groin and
hip region if fracture is present. Accompanied by shortening of the external rotators on the
affected side
Tx – see infectious arthritis
Still’s disease – (same as JRA but with fever, anemia and/or rashes. Affects 10% of those with
JRA) – chronic synovial inflammation in children
 HH Q - do you get frequent fevers or rashes?
o have you been diagnosed by your doctor with any other conditions like anemia or
hepatosplenomegaly?
o are you on any treatments or meds for those conditions?
 aka systemic-onset juvenile idiopathic arthritis
 Of all patients with Still's disease, 100% have high intermittent fever, and 100% have joint
inflammation and pain, muscle pain with fevers, and develop persistent chronic arthritis.
Approximately 95% of Still's disease patients have a faint salmon-colored skin rash, 85% have
swelling of the lymph glands or enlargement of the spleen and liver, 85% have a marked
increase in the white blood cell count, 60% have inflammation of the lungs (pleuritis) or around
the heart (pericarditis), 40% have severe anemia, and 20% have abdominal pain.
 Consider : Px may present with fatigue - try and limit on/ off / turning of px on table, Active
movements maybe painful due to muscle and joint pain, Muscles and organs may be tender
with palpation, Px may have shortness of breath, Px may break out with a fever during
assessment
 Tx - see infectious arthritis
Juvenile rheumatoid arthritis – chronic synovial inflammation in children
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Conditions
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HH Q - when was onset?
o is there a family history of this condition?
o how often do the symptoms flare up?
o when was last flare up?
o what are the areas affected?
o how do you feel first thing in the morning?
o are you on any meds?
Observations - muscle guarding, pained expression, gait or postural dysfunctions depending on
location, taut/shiny skin, joint deformities, joints red and swollen
Palpation - heat and tenderness around joints (esp. during flare up), joints have spongy end
feel, possible muscle spasm in muscles crossing affected joints, hypertonicity, trigger points and
crepitus in between flare ups
AFROM - reduced range due to swelling and pain, possible crepitus
PRROM - restricted due to pain
AR Test - weak and possibly painful
Note - only use AFROM during flare ups
Tx see infectious arthritis
Systemic lupus erthematosus – one type of chronic, attack-remitting autoimmune inflammatory
disease that can affect any system or organ in a variable manner
 HH Q – how is your general health?
o what areas are affected? And symptoms?
o how long since the onset?
o how frequent are the flare ups? When was last one?
o are you on any meds for symptoms?
 AFROM and PRROM may be limited due to pain
 AR Test may be weak for various muscles
 Tx - see infectious arthritis
Fibromyalgia – painful non-articular rheumatic condition of at least 3 months duration,
characterized by widespread muscular achiness and specifically the palpation of tender points
at 11 of 18 prescribed locations on the body
 HH Q - have they been diagnosed by a Dr.? What method of diagnosis?
o Has px received mx since diagnosis? How did they respond?
o Is the px taking medication for pain, depression or sleep disturbances?
 Palpation would be inaccurate because of body wide tenderness. Patient may not be in a good
mood. Patient will also display an antalgic posture
 DO NOT OVERFATIGUE PX
 Avoid deep work or techniques that overstretch px mm, tx should not be so long vigorous as to
fatigue of px
 Frequently mm relaxants, analgesics and antidepressants will be prescribed to help the client
cope with the symptoms
 Tx - Relaxation, overall health (exercise, stretching, eating),
Chronic fatigue syndrome – A condition distinguished by persistent fatigue that does not
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Conditions
resolve and severely reduces activity levels for at least six months.
 HH Q –
 Assessment - Since the cause of CFS is not well understood, HH questions come into place.
 No special tests or precautions. Goal is to reduce stress to increase total hours of sleep while
reducing stress and anxiety
Dupuytren’s contracture – is a contracture of the palmar fascia, resulting in a flexion deformity
of the fingers
 HH Q – does anyone in the client’s family have this condition?
o When was the onset?
o What is the type and location of the pain? Tenderness or achiness in the palm
o What activity aggravates this condition: use of tools? Walking with a cane?
 Observations - Possible hyperkyphosis and forward head posture, The affected flexor tendons
may be raised
 Palpation - Discrete, palpable nodules in the palmar fascia and possibly over the proximal
phalange, Thickening of the palmar skin, Tenderness around the nodules and contracture
 Diffuse tenderness in the palm, Palpation may be done for trigger points that refer into the palm,
May be increased tone in the intrinsic hand muscles, Coolness in the palm and affected fingers
 Testing - Px will be unable to fully extend the affected wrist and fingers, Pain on extension may
be present
 PR ROM of the affected wrist=decreased extension w/ a leathery end-feel, possible pain on
forced extension.
 AR testing= possible reduced strength of the wrist and finger flexors and extensors.
 Tx - 1. Use facial techniques on forearm flexors – to help increase movement through the wrist
o 2. Treat trigger points in the forearm flexors – that developed due to shortened muscles
o 3. Treat adhesions in palm with frictions – this should free up movement in the tendons
of the palm that are affected
o 4. Passively stretch fingers into extension
Osteoporosis – a progressive disease in which the bones become gradually weaker and thinner,
causing changes in posture and posing an increased risk of fractures
 HH Q  make sure patient is comfortable, be aware of positioning
o prone: pillow lengthwise under trunk
o supine: pillow lengthwise under spine and another under Csp
 no overpressure, incorporate gentle passive movements of the joint, no aggressive joint play
(ex. rib springing), should be a relaxation treatment, with diaphragmatic breathing
Diabetes Mellitus – a chronic condition that results in problems with carbohydrate, protein and
fat metabolism
 HH Q – type 1 or type 2? Controlled? Using insulin?
o do they have any sensory/motor deficits?
o Last time they checked their blood sugar level?
o How is the tissue health? Gangrene risk?
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Conditions
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Is fainting or postural light-headedness experienced that may be a concern for the
client?
o Do they have hypoglycemia? Should they have something to eat with them in case they
are feeling unwell
Type 1 - onset is often abrupt with extreme symptoms
o Possible Observations - Frequent urination, excessive thirst(dry mouth, licking lips?),
unusual weight loss, extreme fatigue, sweet-smelling breath, nausea, vomiting(gagging,
pale complexion)
Type 2
o Observations - age over 45years, slow-healing cuts and bruises, skin, gum
infections(particularly on the feet)
ROM - may be reduced in hands and fingers(flexor tenosynovitis and Dupuytren’s contracture are
common)
RROM -weakness may begin in the most distal muscles such as the toe dorsiflexors or intrinsic
hand muscles and then progresses proximally
Considerations - decreased peripheral sensation due to nerve damage, infection and tissue
breakdown
neuropathy affects 40-50% of those with diabetes(affecting distal peripheral nerves and cranial
nerves)
Diabetic radiculopathy and polyradiculopathy common in long standing diabetes-may be confused
with nerve root compression (usually thoracic and lumbar roots are affected) Acute burning
pain and super sensitivity of the skin occur
Cancer – a general term used for the abnormal, uncontrolled growth of cells
 HH Q  Skin may have burns or other lesions from treatments such as radiation, so be conscious of this
while performing observations for skin conditions and when performing dermatome testing in the
neurological portion of assessment, as normal skin sensations could be altered.
 Scars from surgery can cause secondary fascial restrictions that lead to reduced ROM. For
example, frozen shoulder may occur secondary to a mastectomy.
 Patient’s pain tolerance could become lessened in the advanced, or end stages, which would
need to be taken into consideration.
 Edema is also a common issue to be aware of during observations and ROM testing. This could
be the result of either having a patient. that is confined to a bed or wheelchair, or because there
were lymph nodes removed as part of treatment causing congestion distal to that site.
 One of the most important points is that disuse atrophy and/or cancer medications could leave
soft tissue, bones and joints vulnerable to further injury if any aggressive techniques or
stretching is used.
HIV & AIDS – (human immunodeficiency virus) – the virus that causes AIDS (acquired immune
deficiency syndrome)
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HH Q –
Fatigue, irritability, depression, weakness, weight loss are all common symptoms and issues for
those dealing with asymptomatic HIV through to AIDS.
Tissue health may be good, or wasting and atrophied (disuse if bedridden) depending on patient
condition.
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Conditions
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Edema may be present in limbs.
Depending on opportunistic infections and diseases, patient may present with other issues.
Considerations - Peripheral neuropathies in hand and feet – possibly leading to paralysis, HIV
(asymptomatic) – 6-8% only
o AIDS – much more common
o HIV-associated Arthritis in knees, shoulders and elbows.
o HIV-induced transient muscle pain is common.
o Fibromyalgia
o Medications may be causing muscles aches, parathesia, physical illness or other
symptoms.
o Patient may go through bouts of good health and bad health.