Objective

The massage therapist working with athletes, physical rehabilitation, and those involved with fitness has an expanded assessment responsibility. Assessment identifies the structures that need to be worked with, creates a clear intention about treatment goals, provides a baseline of objective information to measure the effectiveness of the treatment, and helps identify conditions that are contraindicated. When working with a client who is striving for optimal performance or who has pain, dysfunction, or disability, the massage therapist needs to gather information about both long-term and short-term treatment goals and relevant data about activities and training activity, as well as about pain or decreased function.

Information from the athletic trainer, coaches, or other professionals is important. The massage therapist must understand and apply assessment information provided by the trainer. If at any time you do not understand, ask clarifying questions. Information gathered by the massage therapist should be shared with the athletic trainer or other appropriate member of the sport and/or medical team in a concise and intelligent manner.

A massage treatment plan based on efficient biomechanical movement should focus on reestablishing or supporting effective movement patterns. Biomechanically efficient movement is smooth, bilaterally symmetric, and coordinated, with easy, effortless use of the body. Functional assessment measures the efficiency of coordinated movement. During assessment, noticeable variations need to be considered.

Once the treatment plan has been determined, the massage therapist needs to develop strategies for achieving the goals pertaining to the therapeutic massage. Teamwork is essential, with cooperation and consensus among the various professionals attending to the client. It is important for the massage therapist to maintain an appropriate scope of practice and not infringe on the professional responsibilities and expertise of others.

Objective

As the volume of knowledge pertaining to massage increases, and as soft tissue modalities such as massage are integrated into the areas of sport fitness and physical rehabilitation, it is becoming increasingly important to be able to think or reason through an intervention process and justify its effectiveness. Therapeutic massage practitioners must be able to gather information effectively, analyze that information to make decisions about the type and appropriateness of an intervention, and evaluate and justify the benefits derived from the intervention.

Effective assessment, analysis, and decision making are essential in meeting the needs of each client. Routine or a recipe-type application of therapeutic massage does not work for this population because each person’s set of presenting circumstances and outcome goals is different. An experienced sports massage professional possesses effective clinical reasoning skills targeted to this complex population.

Fact gathering is an initial part of the clinical reasoning process. Each unique client situation needs to be thoroughly researched. This text provides only a portion of the information needed. Additional research is almost always necessary.

Every massage professional who works with athletes needs to have a medical dictionary and comprehensive texts on athletic training, kinesiology, and pathology, as well as resources on the particular sport and references on medication and nutritional supplements. See the resource list in this text for recommendations. The Internet is also a vast resource.

Each sport has its ideal performance requirement and common injuries; however, a sprain in a football player, a soccer player, or a skate boarder is still a sprain. The sprain should be addressed according to the recommendations in this text. Understanding the demands of the sport is important. However, it is not necessary for the massage professional to be an expert in the sport activity. The sport activity is the context that the massage outcomes support.

Subjective and objective assessments are also sources of facts and are the major focus of this chapter. Analysis of factual data in the assessment leads to treatment plan development.

Objective

Outcome goals need to be quantified. This means that they are measured in terms of objective criteria such as time, frequency, 1 to 10 scales, measurable increase or decrease in ability to perform an activity, and/or measurable increase or decrease in sensation, such as relaxation or pain.

Outcome goals also need to be qualified. How will we know when the goal is achieved? What will the client be able to do after the goal has been reached that he or she is not able to do now? For example, How fast will the client be able to run? What performance skills will the client be able to perform?

After the analysis of history and assessment data is complete and problems and goals have been identified, a decision needs to be made about the care or treatment plan. Depending on the situation, the massage treatment plan may need to be approved by appropriate supervising personnel.

Short-term goals typically support a session-by-session process and are dependent on the current status of the client. Long-term goals typically support recovery, performance, or rehabilitation. Long-term goals focus on what is being worked toward. Short-term goals focus on what currently is being worked on, as well as incremental steps toward achieving long-term goals. Short-term goals should not be in conflict with long-term goals.

For example, a golfer is involved in a conditioning program in preparation for going on tour. She has been working with the strength and conditioning coach on core strength and cardiovascular fitness. She has also been working with the golf coach on swing mechanics. Long-term goals for this client are to maintain range of motion (ROM) and manage a chronic tendency for low back pain. During this particular session, the client has indicated that she has a headache and delayed-onset muscle soreness. The focus of the current massage must consider both short-term and long-term goals. Short-term goals are to reduce headache pain and fluid retention as part of the existing long-term treatment plan.

How much time is allocated to each set goal depends on the adaptive capacity of the client. For example, massage targeting connective tissue application as part of the long-term goals plan may be reduced or eliminated in the areas where delayed-onset muscle soreness exists. Muscle energy application may require more effort than the client is willing to expend because of the headache.

It is this ever-changing dynamic of past history, current conditions, and future outcomes that makes any sort of massage routine useless. Each and every session is uniquely developed and applied on the basis of multiple factors. Many influencing factors must be considered when one is treating athletes or those in physical rehabilitation of any type. Assessment is the identification of all of these influences. Clinical reasoning is the sorting and developing of an appropriate treatment session.

Objective

As the treatment plan is implemented, it is recorded sequentially, session by session, in some form of charting process such as SOAP (subjective, objective, assessment [analysis], and plan). The plan is reevaluated and adjusted as necessary. This process should have been learned in entry level massage training.

Various charting methods are used in the sport and fitness realm. Regardless of the particular style, the basic SOAP plan is easily modified to other charting styles. Be very clear with supervisory personnel, usually the trainer, about the type and depth of information included on the client’s chart.

Good record keeping provides the therapist with the information necessary to communicate with health care and other personnel and furnishes accurate details about what treatment goals are specified, the methods of massage used, and the effectiveness of treatment.

Objective

How extensive the assessment is depends on whether you are working under the direction of a doctor, a trainer, or another health care provider or are working independently. It is the responsibility of the primary care provider to take a thorough history, perform a complete examination, and inform the massage therapist regarding the client’s condition and desired outcomes for the massage. If you are working independently, it is your responsibility to perform the appropriate comprehensive assessment, especially to note contraindications and to clarify treatment goals.

This text assumes that the reader already has completed a comprehensive therapeutic massage course of study that included assessment procedures such as history taking, physical assessment, treatment plan development, and charting.¹

The following procedures are recommended for targeting this specific population.

History

The history interview provides subjective information pertaining to the client’s health history, the reasons for massage, a history of the current condition, a history of past illness and health, and a history of any family illnesses that may be pertinent. It also contains an account of the client’s current health practices.

Targeting this information to the athlete or person in physical rehabilitation is the focus of this text. In addition to the general history, anyone who is working with an athlete or a person in physical rehabilitation needs to explore the following for each client:

The client’s history may vary depending on whether the problem is the result of sudden trauma or is chronic. The following questions should be addressed if the athlete has an acute injury. Usually it is the doctor or trainer who performs the initial injury assessment:

For an athlete with a chronic condition, ask the following:

Additional questions address when the client first noticed this condition to help to identify any previous incident or injury that occurred before the current condition:

Typically, a gradual onset suggests an overuse syndrome, postural stresses, or somatic manifestations of emotional or psychological stresses common in athletes.

Ask the client to point to as well as explain the area of complaint.

It is also important to know whether the client has had massage therapy before, whether it was helpful, and the type of massage application.

If the client has taken pain medication within 4 hours of assessment and treatment, the medication may be giving the client a false sense of comfort during assessment and during massage. Be aware of antiinflammatories, muscle relaxers, and so forth.

Is the client getting better, worse, or is the client in need of a referral?

Gestures

Pay attention to gestures used by the client. The general guidelines for gestures listed here are not written in stone. Professional experience indicates that those listed here are fairly dependable starting points when interpreting an individual’s body language.

It is the professional’s responsibility to understand what a gesture means for a particular individual.

The following are common gestures:

Symptoms

It is important to determine how often the client notices the dysfunction or disability. Is it once a day, 2 or 3 days a week, once a week, or constant? Grade 1 and 2 sprains and strains to the muscles, tendons, and ligaments usually hurt when they are being used, and are relieved with rest. Constant pain may be associated with severe injury or underlying pathology. A client with constant pain should be referred to a physician.

The more serious the condition, the longer it will last.

Typical words used by the client to describe the symptoms are “stiff,” “achy,” “tight,” “stuck,” and “heavy.” These words are associated with muscles, tendons, ligaments, and joint capsules and their associated connective tissue and usually describe simple tension or mild overuse of the soft tissue or edema. If an ache is more than mild, is frequent, and lasts a long time, it is more serious and represents inflammation. A referral is required to rule out a more serious condition.

Typically, tight means an increase in neuromuscular activity. Achy and fat often indicate fluid retention or swelling. Stiff sensations often indicate a connective tissue pliability issue. Heavy sensation of the limbs indicates a firing pattern or gait reflex problem. Stuck sensations often mean a joint problem.

Other terms used to describe symptoms include the following:

The client can choose from the following descriptors:

Irritation or injury to the soft tissue can refer to the extremities, with diffuse pain and aching. Nerve entrapment and trigger point pain can radiate. Sharp well-localized pain in the extremities felt even at rest typically indicates a nerve root problem and requires a referral.

Ask the client to rate his or her pain on a 0 to 10 scale, with 10 being the worst pain ever experienced (incapacitating pain) and 0 being no pain. Moderate pain (5 to 9) interferes with a person’s ability to perform sport-related activities. Mild pain (1 to 4) does not interfere with a person’s activities of daily living but may interfere with sport performance.

The most simple strains and sprains of the musculoskeletal system are irritated by too much movement and are relieved by rest. When a condition hurts more with rest, this indicates either inflammation or pathology.

As the soft tissue heals, it feels good to move the injured area. Stretching tight muscles, shortened ligaments, and joint capsules feels good, despite some mild discomfort. Acute injuries involving the soft tissue are painful with large movements and are relieved with rest. Muscle guarding makes stretching painful.

Pain caused by inflammation and tumors is worse at night. Constant, gripping pain that is worse at night requires immediate referral to a doctor. An area that hurts at night but is relieved with movement usually indicates inflammation. Joint pain and stiffness with fascial shortening are usually worse in the morning.

Clarifying assessment questions to ask include the following:

The client should demonstrate for the massage therapist. Trust the client’s impressions. They usually are right. Then translate what the client is saying into a massage application.

The client should draw a picture of his or her condition. When the client draws the picture, give as few directions as possible. Evaluate the drawing for location and intensity of the symptom. Does the client use hard zigzag lines or small or large circles? Then ask the client to explain.

All the history information should be consolidated and considered when treatment plans and session outcomes are documented.

 See the Evolve website that accompanies this book for an example of a history taking form.

Objective

After the history is complete, the physical assessment is performed. The objective data are obtained during physical assessment.

Accurate assessment is best achieved using a sequence to ensure that all relevant information has been gathered. A major aspect of a massage session is palpation assessment.

In general, physical assessment includes the following:

Identify any scars or muscle atrophy. Scars may indicate prior surgery or prior injury and reveal that the area is compromised. Ask the client to describe how he or she received the scar.

An area of atrophy may have been deconditioned owing to lack of use, or this may indicate neurologic involvement. Simple atrophy can be a result of immobilization caused by prior fracture or lack of use due to pain.

Physical Assessment of Posture

Note the posture of the client in standing and seated positions, as well as the posture or position of the area of complaint. Look for areas of asymmetry. Asymmetry usually results when overly tense muscles or shortened connective tissue pulls the body out of alignment.

Direct trauma pushes joints out of alignment. Weak stabilizing mechanisms, such as overstretched ligaments or inhibited antagonist muscles, contribute to the problem. In these situations, a chiropractor, an osteopath, or another trained medical professional skilled in skeletal manipulation is needed. Often a multidisciplinary approach to client care is necessary.

First, observe the client during general movement as opposed to formal assessment to identify natural function. Then, perform the following structured standing assessment and compare the findings.

Assessment of Joint and Muscle Function

The more the fascia muscle tissue structure is researched, the more we understand that the concept of individual muscles is flawed. It is necessary to rethink the functional and structural aspect of contractile tissues—muscle tissue—as a continuum of function within spans of connective tissues such as fasciae, ligaments, and tendons. The idea of individual muscles and specific attachments is ingrained and it will take a long time to shift the paradigm. Throughout this text, the functional unit has been emphasized; however, knowledge of individual muscle names and locations remains valuable and will be used. Although the muscular system looks highly complicated, it is important to realize that the actual mechanics involved in movement are simple. A muscle can do only two things: it can contract and shorten, and it can relax and lengthen. The system is a complex pattern of movement composed of many simple levers and pulleys. Movement is created by muscle shortening, which pulls together bones that are connected at the joint.

Many muscles working in functional units provide the widest variety of movements and the ability to do them with stability, control, and efficiency. For example, the knee is basically a hinge joint capable of moving on only one plane, and so, theoretically, it should need only one pulley (muscle) to flex it and one to extend it. However for extension, there are the four quadriceps muscles, each of which pulls across the joint in a slightly different direction. During flexion, three hamstrings accomplish the same thing. This muscle interaction stabilizes the joint and enables it to adapt to variations in movement and to the random direction of forces from the outside environment. The whole of the muscular system works in unison to enable the body to cope with the stresses caused by gravity when movement takes place. It is important to see movement in terms of patterns of activity (movement strategies) taking place within a system rather than as the action of individual muscles. Almost all movement strategies involve the gait (walking) process.

Overuse problems develop in parts of a system that are put under greater stress, or repetitive use, compared with the rest of the system. The running action, for instance, does not involve just the leg muscles. Many muscles work to create a complicated pattern of rotation and spiral movements throughout the entire body. If this did not happen, and if movement is confined to the legs, then all the stress of impact and push-off will be absorbed by the ankle, knee, and hip joints, and the forces on these joints will cause damage. The spiraling movement up the body absorbs the stress and distributes the impact through many joints. Because no individual structure absorbs too much stress, the human body is able to function for many years.

Coordinated movement involves many muscles working together in a pattern to create the power and control needed to accomplish a task. Each muscle has a preferred function within a movement pattern; therefore, a particular movement will involve greater effort from certain individual muscles. For example, kicking a soccer ball involves a strong effort from the quadriceps muscles. Each of the four muscles within the group acts on the joint from a different angle; therefore, depending on the degree of rotation in the lower leg and the angle of force, one muscle may have to keep working slightly more than the rest.

The muscular system develops according to how the body is used. Each individual has unique patterns of muscle function adaptation, many of which are beneficial and are in harmony with the person’s activities and lifestyle, although some will be negative or excessive. Assessment provides information about beneficial or detrimental function.

For example, a midfield soccer player who often has to pass the ball with the inside of the foot will tend to use the vastus medialis, and the adductors may be involved. Therefore, the soccer player would naturally develop increased strength in the vastus medialis and adductors while training. Although this may appear to create an imbalance within the other quadriceps muscles, it could be natural for the individual; therefore, this may not be a situation requiring remedial treatment. The same imbalance found in a distance runner complaining of patellofemoral syndrome or groin pain would be a treatment priority.

Microtrauma

A muscle can suffer acute strain with its fibers being torn, if overused or overloaded. The same can occur on a microscopic level, even if just a few fibers are overused. When this breakdown occurs on a microscopic level, the pathologic changes that take place are the same as with any soft tissue tear: bleeding, swelling, muscle tension, guarding in surrounding tissues, and scar tissue formation. The delayed-onset muscle soreness experienced in muscles after hard exercise is due in part to this type of trauma (microtrauma).

Scar tissue can continue to build up gradually with repetitive activity. Adhesions can form, affecting the elasticity within that particular area of the muscle and making muscles vulnerable to further microtrauma. This process results in fibrotic changes in the muscle.

As function deteriorates in a small part of the muscle, it can create imbalance within a functional muscle unit (a group of muscles working together). As the condition builds up gradually, it may develop unnoticed in the early stages. Increased tension can then put excessive stress on adjoining structures such as the tendons, which can become more vulnerable to acute trauma. Biomechanical alterations develop as natural movement patterns compensate. In the long run, the overuse syndrome can lead to many problems, both locally and in other parts of the body. Several muscle dysfunctions can develop.

Massage is possibly the most effective way of identifying this type of problem. Palpation assessment identifies fibrotic changes in a muscle. This is the most important benefit of general preventive massage.

These areas should be treated in much the same way as any chronic muscle injury. Mechanical force is applied to break down scar tissue to improve flexibility and to realign tangled fibers.

Static positions, such as standing at attention in the military for long periods of time, put stress on specific tissues, causing microtrauma in a way similar to the active type of overuse, but from isometric overload instead of eccentric or concentric function. Lack of movement in the muscles also slows blood and lymph flow through the area, which can increase congestion and add to the problem.

Active Movements

General understanding of biomechanics is especially important for the massage professional who works with athletes. The assessment question “What do you want your body to do?” will result in answers such as “run,” “ride,” “throw,” “catch,” “jump,” “bend,” “rotate,” “lift,” and “press.” The massage professional needs to break down the movements of the activity, assess for soft tissue changes that interfere with these movements, and then identify massage applications that can support these movements. For example, in response to the assessment question, “What do you need to do that you are having problems with?” I will often hear something like “run backward” or “swing.” Then I will ask the athlete to show me, and while I observe the movements, I can begin to target the specific outcomes.

Perhaps the athlete says, “I can’t stand on my left foot with the same balance as my right foot” (which is important for many sport activities). I ask the athlete to stand on the right foot, and I observe and palpate to determine the “normal” activity that he or she can perform. This is a general assessment and treatment principle. The least affected movement pattern or structure becomes “normal” for evaluation and comparison purposes. Regardless of the situation, in practical application this works. I then ask the athlete to stand on the left foot, where the problem exists, and I compare it with the more normal function. Then I assess for the difference between the two—tissue texture and pliability, ROM, and firing patterns. Choices about what treatments to use are based on the assessment information.

The next part of the examination is divided into two sections. In active movement assessment, the massage therapist asks the client to perform movements in specific directions in all planes of movement. The squat assessment is particularly beneficial. In passive movement assessment, the massage therapist moves the client.

Injuries and dysfunctions of the musculoskeletal system are symptomatic when the injured area is actively moved. More complex conditions such as inflammation of the nervous system, systemic conditions such as heart disease, and pathologies such as tumors are not significantly affected by movement. If an area does not hurt at rest, but it does hurt with movement, soft tissue dysfunctions are indicated.

Remember that each individual joint movement pattern is part of an interconnected aspect of the neurologic and fascial coordination pattern of muscle movement called the kinetic chain. The support system involves the tensegric nature of the body’s connective design. Posture and movement dysfunctions identified in an individual joint pattern must be assessed and treated in broader terms of kinetic chain interactions, muscle tension/length relationships, and the effects of stress and strain on the entire system.

 Log on to your Evolve website to watch Video 10-1: Multiplanar Assessment (Functional Assessment).

Range of Motion

Remember that each person is unique, and many factors influence available range of motion. Just because a joint does not have the textbook range of motion (ROM) does not mean that what is displayed is abnormal. Abnormality is indicated by nonoptimal function. This can be seen as a limitation or an exaggeration in the “textbook normal” range of motion (Box 10-2).

ROM is measured in degrees. Joint movement is measured from the neutral line of anatomic position. Movement of a joint in the sagittal, frontal, or transverse plane is described as the number of degrees of flexion, extension, adduction, abduction, and internal and external rotation (Figure 10-6). For example, the elbow has approximately 150 degrees of flexion at the end range and 180 degrees of extension. Anything less than this is hypomobility, and anything more is considered hypermobility. Massage therapists typically estimate degrees of movement, and other professionals use specific equipment to obtain precise information. The normal ROM of joints is found in anatomy texts such as Mosby’s Essential Sciences for Therapeutic Massage.