Basics of soft tissue examination
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The document discusses the basics of soft tissue examination for practitioners who treat the human structure using their hands. It emphasizes the importance of functional testing through observation, palpation, and passive and contractile muscle testing to determine the source of soft tissue pain. Dr. James Cyriax developed orthopedic medicine based on examining, diagnosing and treating non-surgical lesions of the musculoskeletal system through assessing soft tissues and their patterns of limitation.
Basics of soft tissue examination
- 1. Basics of SoftBasics of Soft-- Tissue ExaminationTissue Examination
- 2. Basics of Soft Tissue ExamBasics of Soft Tissue Exam For practitioners who primarily use theirFor practitioners who primarily use their hands to treat the human structure:hands to treat the human structure: Examination must include functional testsExamination must include functional tests to determine the type of soft tissueto determine the type of soft tissue creating the pain.creating the pain.
- 3. Use all of your sensesUse all of your senses Observation:Observation: –– With observation of gait and stance, you canWith observation of gait and stance, you can become aware of the abnormal tensionsbecome aware of the abnormal tensions emanating from the patientemanating from the patient
- 4. Observation of Gait (Ex)Observation of Gait (Ex)
- 5. Use all of your sensesUse all of your senses Palpation:Palpation: confirmation of visual tensionsconfirmation of visual tensions –– Becomes an art: should literallyBecomes an art: should literally ““feelfeel”” the patientthe patient’’ss painpain –– ExEx’’s: warm, nodular, lumpy, leathery, doughy,s: warm, nodular, lumpy, leathery, doughy, springy, tautspringy, taut
- 6. ““The hand is the greatest diagnostic andThe hand is the greatest diagnostic and therapeutic tool that has ever been, ortherapeutic tool that has ever been, or will be, inventedwill be, invented”” Karel Lewit
- 7. Dr. James CyriaxDr. James Cyriax The purpose of aThe purpose of a soft tissuesoft tissue examination is toexamination is to
- 8. He was a british physician, widely known as the father of Orthopedic Medicine. Orthopedic Medicine is based on his life's work. Orthopedic medicine is the examination, diagnosis and treatment of non-surgical lesions of the musculoskeletal system. It began in 1929 when Dr James Cyriax observed a number of patients where the diagnosis was vague and the treatment non-specific. There was no satisfactory method for testing the function of soft tissues to achieve a clinical diagnosis. He developed a system of assessment aiming to accurately diagnose lesions of the musculoskeletal system and a non-surgical method of treatment for soft tissue lesions by employing a process of diagnosis by selective tension, which uses passive movements to test the inert structures and resisted movements to test the contractile structures.
- 9. Passive TestingPassive Testing Passive tissue refers to tissue thatPassive tissue refers to tissue that does not have its own contractiledoes not have its own contractile ability.ability. Such as: , , ,Such as: , , , , , and ., , and . By definition, passive testing isBy definition, passive testing is neither active nor spontaneous andneither active nor spontaneous and requires an examiner to performrequires an examiner to perform the movement.the movement.
- 10. Passive TestingPassive Testing Passive motion alsoPassive motion also measures themeasures the andand and is used toand is used to evaluateevaluate
- 11. END FEELEND FEEL 1.1. Bone to bone:Bone to bone: hard end feelhard end feel 2. Soft Tissue:2. Soft Tissue: normal tissue approximationnormal tissue approximation 3. Spasm or3. Spasm or ““twangtwang”” passive movement stresses apassive movement stresses a fracture or inflamed jointfracture or inflamed joint (always abnormal)(always abnormal) 4. Capsular:4. Capsular: firm end feel of normal jointfirm end feel of normal joint 5. Springy Block:5. Springy Block: hard rebound (always abnormal)hard rebound (always abnormal) 6. Empty Feeling:6. Empty Feeling: more movement is possible butmore movement is possible but severe painsevere pain (always abnormal)(always abnormal)
- 12. Hypermobility EvaluationHypermobility Evaluation Hypermobile joints resulting in excessive motionHypermobile joints resulting in excessive motion This condition occurs in:This condition occurs in: Shoulder instabilityShoulder instability Patella dislocationPatella dislocation EhlersEhlers--Danlos syndromeDanlos syndrome Marfan syndromeMarfan syndrome Rheumatoid arthritisRheumatoid arthritis Osteogenesis imperfectaOsteogenesis imperfecta Systemic lupus erythematosusSystemic lupus erythematosus PoliomyelitisPoliomyelitis Myotonia congenitaMyotonia congenita some neurologic conditionssome neurologic conditions
- 13. Hypermobility EvaluationHypermobility Evaluation A hypermobile patient would exhibit threeA hypermobile patient would exhibit three or more of the following tests:or more of the following tests: –– Passive thumb apposition to touch the forearmPassive thumb apposition to touch the forearm –– Passive little finger hyperextension or morePassive little finger hyperextension or more than 90 degreesthan 90 degrees –– Elbow hyperextension of more than 10 degreesElbow hyperextension of more than 10 degrees –– Knee hyperextension of more than 10 degreesKnee hyperextension of more than 10 degrees –– Forward flexion of the trunk with the kneesForward flexion of the trunk with the knees straight and the palms of the hands resting flatstraight and the palms of the hands resting flat on the flooron the floor
- 19. Contractile (Isometric) TestingContractile (Isometric) Testing Contractile tissue refers to theContractile tissue refers to the muscularmuscular component and also tocomponent and also to thethe tendontendon stressed by itsstressed by its contracting muscle.contracting muscle. Includes the following:Includes the following: –– Muscle bellyMuscle belly –– Musculotendinous junctionMusculotendinous junction –– Body of the tendonBody of the tendon –– Tendoperiosteal junctionTendoperiosteal junction
- 22. Contractile (Isometric) TestingContractile (Isometric) Testing Cyriax emphasized testing theCyriax emphasized testing the muscle to elicit maximum strengthmuscle to elicit maximum strength while the joint is in its most ,while the joint is in its most , neutral position to reduce jointneutral position to reduce joint compression.compression. BUT, this can allow extra activityBUT, this can allow extra activity from a synergistic muscle, maskingfrom a synergistic muscle, masking pain you are trying to elicit.pain you are trying to elicit.
- 23. Contractile (Isometric) TestingContractile (Isometric) Testing Muscle testing creates some jointMuscle testing creates some joint stress in any position.stress in any position. For this reason, passive testingFor this reason, passive testing should always be performedshould always be performed firstfirst toto help rule out the passive jointhelp rule out the passive joint structures.structures.
- 24. Contractile (Isometric) TestingContractile (Isometric) Testing When muscles are tested, the patient isWhen muscles are tested, the patient is asked to useasked to use maximum strength for atmaximum strength for at least 2 secondsleast 2 seconds.. After muscle incrimination,After muscle incrimination, palpationpalpation ofof the muscle for areas of tenderness andthe muscle for areas of tenderness and soft tissue abnormalities plus the effect ofsoft tissue abnormalities plus the effect of stretching the muscles on the passivestretching the muscles on the passive examination helps pinpoint the particularexamination helps pinpoint the particular site of contractile tissue at fault.site of contractile tissue at fault.
- 25. Contractile (Isometric) TestingContractile (Isometric) Testing Interpretation of Muscle TestingInterpretation of Muscle Testing
- 26. Contractile (Isometric) TestingContractile (Isometric) Testing Muscle Grading ScaleMuscle Grading Scale –– 55 ““normalnormal”” with full ROM against gravity andwith full ROM against gravity and full resistancefull resistance –– 44 ““goodgood”” with full ROM against gravity andwith full ROM against gravity and some resistancesome resistance –– 33 ““fairfair”” with full ROM against gravity, nowith full ROM against gravity, no resistanceresistance –– 22 ““poorpoor”” with full ROM with gravity eliminatedwith full ROM with gravity eliminated –– 11 ““tracetrace”” with slight contractility and no ROMwith slight contractility and no ROM –– 00 ““zerozero”” with no evidence of contractilitywith no evidence of contractility
- 27. Contractile (Isometric) TestingContractile (Isometric) Testing Clinical pearlsClinical pearls –– Repetitive testing may be necessary to elicitRepetitive testing may be necessary to elicit the painthe pain –– Pain after repetitive testing sometimesPain after repetitive testing sometimes indicates an arterial blockageindicates an arterial blockage –– Pain occurring soon after maximal contractionPain occurring soon after maximal contraction rather than immediately after contraction israther than immediately after contraction is considered a positive resultconsidered a positive result –– Isometric muscle testing is useful inIsometric muscle testing is useful in emphasizing muscle atrophyemphasizing muscle atrophy –– Isometric force generation is greatest at theIsometric force generation is greatest at the end ROMend ROM
- 28. Capsular Pattern
- 29. Capsular PatternCapsular Pattern Knowledge of capsular pattern improvesKnowledge of capsular pattern improves diagnostic abilities.diagnostic abilities. A capsular pattern refers to a particularA capsular pattern refers to a particular sequence of passive limitation of motion insequence of passive limitation of motion in a joint controlled by muscles; this patterna joint controlled by muscles; this pattern affects .affects . Every joint has its own particular patternEvery joint has its own particular pattern of capsular limitation (ex. the earliest signof capsular limitation (ex. the earliest sign of the shoulder capsular pattern isof the shoulder capsular pattern is limitation of external rotation by itself)limitation of external rotation by itself) If only a portion of the capsule is involved (shortened), onlyIf only a portion of the capsule is involved (shortened), only movements that stretch that portion of the capsule are involvedmovements that stretch that portion of the capsule are involved instead of a capsular pattern.instead of a capsular pattern.
- 30. Summation of Capsular Patterns ofSummation of Capsular Patterns of Passive LimitationPassive Limitation Shoulder: most limited external rotation; nextShoulder: most limited external rotation; next glenohumeral abduction, then internal rotation.glenohumeral abduction, then internal rotation. Elbow: flexion usually more limited thanElbow: flexion usually more limited than extension; rotations full and painless except inextension; rotations full and painless except in advanced conditions.advanced conditions. Wrist: equal limitation of flexion and extension;Wrist: equal limitation of flexion and extension; little limitation of ulnar and radial deviation.little limitation of ulnar and radial deviation. Trapezio metacarpal joint: only thumb abduction.Trapezio metacarpal joint: only thumb abduction. Hip: most limited is internal rotation followed byHip: most limited is internal rotation followed by flexion. Some limitation of abduction and little orflexion. Some limitation of abduction and little or no limitation of adduction and lateral rotation.no limitation of adduction and lateral rotation. Sign of the buttock: passive hip flexion moreSign of the buttock: passive hip flexion more limited and more painful than straightlimited and more painful than straight--leg raise.leg raise.
- 31. Summation of Capsular Patterns ofSummation of Capsular Patterns of Passive Limitation (cont)Passive Limitation (cont) Knee: more limitation of flexion than extension.Knee: more limitation of flexion than extension. Ankle: more limitation of plantarflexion than ofAnkle: more limitation of plantarflexion than of dorsiflexion.dorsiflexion. Talocalcaneal joint: increasing limitation of varus untilTalocalcaneal joint: increasing limitation of varus until fixation in valgus.fixation in valgus. Midtarsal joint: limitation of adduction and internalMidtarsal joint: limitation of adduction and internal rotation; other movements full.rotation; other movements full. Big toe: much more limitation of extension and slightBig toe: much more limitation of extension and slight limitation of flexion.limitation of flexion. Cervical spine: equal limitation in all directions exceptCervical spine: equal limitation in all directions except for flexion, which is usually full.for flexion, which is usually full. Thoracic spine: limitation of extension, side bending,Thoracic spine: limitation of extension, side bending, and rotation; flexion is less limited.and rotation; flexion is less limited. Lumbar spine: marked and equal limitation of sideLumbar spine: marked and equal limitation of side bending with limitation of flexion and extension.bending with limitation of flexion and extension.
- 32. Tenderness and PalpationTenderness and Palpation Often, tissues that are embryologicallyOften, tissues that are embryologically related refer to the same area.related refer to the same area. As important as tenderness is, theAs important as tenderness is, the clinician must rely first on a completeclinician must rely first on a complete functional extremity examination of all thefunctional extremity examination of all the areas that can create the tendernessareas that can create the tenderness before tenderness can be accepted as thebefore tenderness can be accepted as the sine qua non.sine qua non. A complete functional examination oftenA complete functional examination often gives the practitioner a working diagnosis.gives the practitioner a working diagnosis.