Have massage therapists been putting too much of an emphasis on orthopedic assessment?

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functional assessment
  • What role does orthopedic testing play a role in gathering clinically useful information for massage therapy treatments?
  • Orthopedic assessments can and do rule in or rule out a definable pathology in the acute stage, but what is the role of orthopedic testing in the chronic pain patients? 

What information does orthopedic testing give us about the experience pain?

Traditionally the role of orthopedic testing is to define a treatable pathology (e.g. Lachman's for ACL), this has a role in orthopedic medicine and acute injuries, but as massage therapists we are often seeing injuries in the chronic phase. These injuries cannot as easily be defined solely by tissue damage, patients often suffer from multiple ongoing issues, such as post traumatic arthritis of the knee, anterior hip impingement, disc herniation, which is often compounded with peripheral and central sensitization.

Massage therapists should be aware that there is often there is a disconnect between tissue damage seen on clinical imaging and clinical presentation, this creates confusion for both patients and therapists. Several landmark studies have shown tissue tears revealed on imaging are very common in patients who are completely asymptomatic, these are often part of normal aging and unassociated with pain.

  • Spine - Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age." (Brinjikji 2014)
  • Neck - 87.6% of people WITHOUT neck/arm pain have a disc bulge, usually at C5-6 or C6-7. (Nakashima 2015)
  • Shoulders - In pain free overhead athletes, 40% of dominant shoulders had findings consistent with partial or full thickness tears of the rotator cuff, as compared to 0% of the non-dominant shoulders. (Conner 2003)
  • Hips - 71% of asymptomatic football players have abnormal groin MRI. (Branci 2014)
  • Knees - 60% of people with pain free knees, aged 20-68, showed abnormalities in at least 3 of the 4 regions of the knee. (Beatie 2005)

The current use of clinical tests is focused on a black and white pathoanatomical diagnosis, this often does not determine the source of pain. (Docking 2016). A functional manual assessment focuses on the variables that predict which patients will benefit from massage therapy. It is a reproducible hands on protocol that gives therapists a better understanding of an individual’s adaptive capacity, by assessing for common neurological and biomechanical dysfunctions using range of motion testing and motor recruitment testing, that is blended with static and dynamic palpation to identify specific lines of tension, mechanosensitivity and trophic changes. This information is then used to formulate a clinical hypothesis that does not seek a single source of pain. A functional manual assessment used as an adjunct to standard orthopedic assessments to give massage therapists a better understanding of the patient and to direct the most appropriate intervention based on:

  • Pain presentation
  • Functional limitations
  • Psychosocial factors

Links for the curious

Beatie et al. (2005) Abnormalities identified in the knees of asymptomatic volunteers using peripheral MRI. Osteoarthritis Cartilage. 

Branci, S., Thorborg, K., Bech, B. H., Boesen, M., Nielsen, M. B., & Hölmich, P. (2014). MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. British Journal of Sports Medicine.

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., . . . Jarvik, J. G. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology.

Conner, Banks et al. (2003) MRI of the Asymptomatic Shoulder of Overhead Athletes. A 5-year Follow-up Study. American Journal of Sports Medicine.

Docking, S. I., Cook, J., & Rio, E. (2016). The diagnostic dartboard: Is the bullseye a correct pathoanatomical diagnosis or to guide treatment? British Journal of Sports Medicine.

Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine.

Templehof et al. (1999) Age related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery.