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Chapter 7 / Assessment
Figure 7-1. Fascia photo showing fascial lines. (A) Representation
of unrestricted fascia. (B) Representation of fascial restriction;
notice the fascial lines created by the fascial restriction.
Compensation patterns are postural offsets that attempt to
protect a primary dysfunction or injury or correct an imbalance. Some examples of injury compensation patterns are
a limp for a sore ankle, the excessive use of one arm because
the other is in a cast, and turning the entire thorax to look over
your shoulder because neck rotation is limited and painful.
Sustained postures and repetitive motions can also cause
compensation patterns. When muscles continually hold the
body in place or are continually used to perform the same
movement, they are actively contracted on a regular basis
without being lengthened regularly by their antagonists. As a
result, the muscles that repeatedly contract or hold contractions for extended periods of time adopt a shorter resting
length (they are posturally shortened), and their antagonists
develop longer resting lengths (they are overstretched). The
body must make up for the imbalance between the antagonistic muscles by adjusting the posture in other areas with functional compensation patterns. Sitting at a computer all day
using a mouse requires your body to hold a single position
for an extended period of time. Cashiers repetitively turn to
their left and sweep products from right to left. Musicians are
especially prone to functional compensation patterns because
they have to hold their bodies in asymmetric positions for
extended periods while they perform repetitive motions with
their hands and fingers. All of these activities result in functional compensation patterns that show up as postural asymmetries or deviations. See Procedure Box 7-2 for the steps to
determine compensation patterns.
Compensation patterns begin when the imbalance or
injury occurs. Ideally, as balance is restored and the injury
heals, the compensation patterns work themselves out.
Unfortunately, a lot of compensation patterns do not go
away completely and can develop areas of chronic hypertonic
muscles and restricted fascia. A sprained ankle ligament that
occurred a week ago will have an associated compensation
pattern that could dissipate over several months, as long as
the ligament healed well and the ROM was restored safely and completely. On the other hand, a 40-year-old man
who has had flat feet all his life and has never been medically treated for them will have developed and reinforced a
301
compensation pattern over several decades. Restoring the
shortened and overstretched muscles to their normal resting lengths and breaking up the fascial adhesions that have
settled into the tissues could take years, especially if the man
continued to go without medical corrective treatment and
continued to reinforce the source of the imbalance.
The body’s compensation is registered not only in the
muscles but also in the nervous system via nerve tracks,
which are discussed in the nervous system section of the
Body Systems chapter. The longer a compensation pattern
has existed, the more the compensated body positions and the
functionally shortened and overstretched muscles are locked
into these figurative grooves in the nervous system. Imagine
drawing a circle in the sand with a stick. The more circles you
draw, the deeper the groove becomes. Over time, compensations are reinforced and become more difficult to change.
Implications for Massage
Once you discover compensation patterns in your postural
assessment, you can determine which muscles are functionally shortened or overstretched. Postural deviations, imbalances, or restrictions in movement can be documented with
symbols and abbreviations on body diagrams or in the text
of your massage treatment records.
Your findings can determine the type of techniques to
use and the length of time it may take to restore the most
functional balance for the client. Several factors affect massage treatment and the time it will take for healing and restoration of balance and functional movement to occur:
• Lifestyle
• General health
• Length of time the client has been compensating
• Number of planes involved in the compensation
• The client’s continuation to repeat any activity that
reinforces the imbalance or compensation pattern
• Reinjuring the affected muscles
Assessment Documentation
Your initial observations of postural symmetry, gait, ROM,
soft tissue appearance, and soft tissue textures can be
recorded as objective information in the SOAP note or on
specific forms that only include general assessment data.
Figure 7-2 shows an example of a general assessment form.
If you use a general assessment form for the client’s initial
visit, you can record general assessments made in subsequent massage sessions in the Objective portion of the SOAP
chart. See Chapter 6, Communication and Documentation,
for more in-depth coverage of documentation.
302 INTRODUCTION TO MASSAGE THERAPY
BOX 7-2
1. Identify the client’s primary area(s) of complaint.
2. Identify the client’s postural deviations as noted on the general assessment form and/or the objective portion of the
SOAP chart.
3. Consider relationships between the postural deviations, the area(s) of concern, and pain patterns.
4. Determine the original imbalance or primary dysfunction or injury that caused the postural offsets:
a. Ask if there is an area that has been painful longer than the others.
b. Ask if there was an event (such as an injury, trauma, fall, twisted joint, prolonged period in one position,
extended period of repetitive motion) that started the pain pattern.
5. Identify the joint(s) involved in the original imbalance or primary dysfunction.
6. Evaluate AROM and PROM of the movements of those joints, looking for restrictions or limitations, and for pain
upon PROM, suggesting problems with the passive structures that require a medical referral.
7. Evaluate AROM and PROM of the movements of nearby joints, looking for restrictions that may have resulted from
the original imbalance.
For example, an injury to the right foot could be compensated by a limp to relieve pressure on the right foot.
The limp could require extra work from the hamstring muscles to flex the knee, the rectus femoris muscle to flex
the right hip, the right quadratus lumborum to elevate the right side of the pelvis, and the left levator scapula and
upper trapezius to elevate the left shoulder. The muscles that are overworked will likely be posturally shortened and
will restrict ROM of the joints they move.
8. Document compensation patterns in the Objective section of the SOAP chart.
9. Document any medical referrals in the Plan section of the SOAP chart.
Posture is the position of the upright, relaxed body. Although
many people pay little attention to posture, it can significantly affect a person’s health and well-being. The efficiency
of the entire organism, or person, depends on cooperation
of all the separate anatomical structures working efficiently,
with little friction and minimal energy. Any interference can
create muscular and soft tissue strain, extra energy requirements, and reduced efficiency in movement. These interferences can result in stress, exhaustion, and health problems
that affect the circulatory and digestive systems, spleen,
liver, and kidneys. Correct posture provides the best conditions for the bones, joints, muscles, and organs. Incorrect
posture can lead to discomfort, pain, organ dysfunction, and
disability.
You can evaluate posture to see how “straight” clients
stand by looking at how surface landmarks and bony landmarks are positioned, relative to vertical and horizontal reference lines. Your vertical reference can be a plumb line, a
line that hangs perfectly vertically as the result of gravity. It
can be fashioned with a small weight at the end of a string
that hangs from a level higher than the client’s head. The
client’s stance is positioned such that the line falls exactly
between the feet. (Fig. 7-3 shows a plumb line relative to a
client’s posture.) As simple as it is to hang a plumb line, most
Chapter 7 / Assessment
303
Figure 7-2. Blank general assessment form. (Modified with permission from Thompson DL. Hands Heal: Communication,
Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 2002.)
304 INTRODUCTION TO MASSAGE THERAPY
massage therapists do not have one in their office. Instead,
you can use a door frame, which is readily available in every
massage treatment room, as a vertical reference. Some door
frames are not perfectly vertical, but they still give you a reference line to work with.
Ideal Posture
Ideal posture minimizes stress and strain while maximizing
efficiency. To evaluate posture for massage, you will look
at the anterior, posterior, and lateral aspects of your client
and check the alignment and position of surface landmarks.
Figure 7-3 illustrates anterior, posterior, and lateral views of
ideal posture.
Looking at the anterior aspect of ideal posture, there
are a number of surface and bony landmarks that fall on the
midsagittal line, which runs vertically down the center of
the body: nose, chin, sternum, spine, and navel.
Looking at the anterior or posterior view of ideal posture, there are a number of bilateral landmarks that are both
at the same horizontal level: ears, shoulders (acromion process), pelvis (anterior superior iliac spine [ASIS], posterior
superior iliac spine [PSIS], and iliac crest), hands (fingertips),
and knees (patella).
When you evaluate the lateral aspect of your clients,
your reference is a vertical line that runs just anterior to the
A
Figure 7-3. Ideal posture. (A) Anterior view. (B) Posterior view. (C) Lateral view.
B
C
Chapter 7 / Assessment 305
lateral malleolus (ankle). In ideal posture, the vertical line
will run through the center of the ear, through the center of
the glenohumeral joint, through the bodies of the lumbar
vertebrae, through the center of the greater trochanter of
the femur, and through the center of the knee joint.
Anterior Postural Assessment
To view the client’s anterior postural alignment, ask clients
to stand comfortably, shoes off, arms hanging at the sides,
and heels about 3 inches apart. Make sure that your vertical
reference line falls midway between the heels and that the
client’s body does not touch the line. Using the position of
bony landmarks in ideal posture as a comparison, evaluate
the position of the client’s:
• Ears (both ears at the same level)
• Nose (on the midsagittal line)
• Chin (on the midsagittal line)
• Shoulders (both clavicles at the same level and the
same distance from the midsagittal line)
• Sternum (on the midsagittal line)
• Navel (on the midsagittal line)
• Pelvis (ASIS and iliac crests at the same level)
• Hands (fingertips at the same level, same amount of
space between the body and each hand)
• Knees (patellae at the same level)
• Feet (even arches) (see Fig. 7.3A)
If bilateral landmarks are higher on one side than on the
other, the landmarks are said to be located off the transverse
plane (Chapter 4 describes planes of division). For example, a
right shoulder that is noticeably higher than the left shoulder
exhibits a deviation off the transverse plane. Another way to
recognize bilateral landmarks at different levels is to use the
term elevation. Using the previous example, the right shoulder is elevated. This can be documented on the SOAP note or
general assessment form with a diagonal line on the body diagram at the shoulders that is higher on the right. (Figs. 7-10,
7-11, 7-13, and 7-14 show how to document elevation.)
If left and right landmarks are at the same horizontal
level but farther to the left or the right, they are said to deviate off the sagittal plane. Some examples of deviations off
the sagittal plane include a body part that is abducted or
adducted more on one side than the other or a body that
leans to one side. These can be recorded on the body diagram with an arrow at the location of the deviation, pointing in the direction of the deviation.
When evaluating the anterior view of your client’s
standing posture, consider symmetry. Determine whether
the client’s landmarks are in similar positions on both sides,
as described earlier, but also look for side-to-side differences
in fullness, space, and body surface curves. There are sometimes differences in the fullness of tissues from side to side.
For instance, one arm might be noticeably larger than the
other. The space between the arms and body should also be
about equal, but occasionally one arm will hang much closer to the body than the other. You might notice symmetrical differences in the curves, such as the curve at the waist,
or the creases of the body such as at the axilla (armpit).
(Fig.7-6, illustrating scoliosis, shows a difference in symmetry.) These observations can be noted on the general assessment form and the Objective portion of the SOAP note.
Posterior Postural Assessment
To evaluate the client’s postural alignment in the posterior
view, clients should stand in the same, relaxed position and
not touch the vertical reference line, but instead of facing you,
their back is to you. Using the ideal posture in Figure7-3B for
comparison, evaluate the position of the client’s:
• Cranium (ears at the same level)
• Shoulders (scapular spines at the same level and
angles)
• Spine (along the midsagittal line)
• Pelvis (PSIS and iliac crest at the same level)
• Hands (fingertips at the same level, same amount of
space between the body and each hand)
• Scapula (space to spine, angles)
Check for bilateral symmetries when evaluating the posterior view of your client’s standing posture, just as you did with
the anterior view: positions of landmarks, fullness, space, and
body curves. The differences can be recorded on the general
assessment form and the Objective portion of the SOAP note.
Lateral Postural Assessment
When you evaluate the side view, the client’s feet maintain
the same kind of positioning, but the vertical reference line
should run just anterior to the lateral malleolus. You can use
Figure 7-3C, lateral view of ideal posture, as a comparative
standard when evaluating your clients for:
• Cranium (line through the ear)
• Shoulder (center of the glenohumeral joint should
be on the line)
306 INTRODUCTION TO MASSAGE THERAPY
• Hands (palms should be directed medially)
• Pelvis (greater trochanter should be on the line)
• Knee (center of the knee joint should be on the line)
If a landmark is found more toward the anterior or
posterior of the client’s body, the deviation is off the frontal plane. A client whose head and shoulders are anterior
appears to stand slightly bent forward in what is sometimes
called a forward posture. The deviation can be documented
on a body diagram with an arrow located at the area that is
noticeably deviated, with the arrow pointing in the direction
of the deviation. (Figs. 7-10 and 7-11 show how to document
deviation off the frontal plane.) Clients who wear shoes with
a heel are shifted forward, off the frontal plane, and their
bodies have to compensate by pulling the head and shoulders posteriorly. In fact, the higher the heel, the farther forward the shift, and the more the body has to compensate.
Postural Deviations
Sometimes posture contributes to, or is the source of, soft
tissue dysfunction. Seemingly minor postural deviations
can cause major problems in some clients, yet significant
postural deviations may not be accompanied by any symptoms. Generally, however, incorrect posture is learned and
reinforced from soft tissue imbalances that occur over time
and lead to discomfort, pain, and compensation patterns.
A deviated angle of the sacrum can distort the symmetry
and balance of the body, causing rounded shoulders, spinal
curve deviations, and abdominal deformations, which can
affect internal organs. In animals that walk on four legs, the
ventral wall of the abdomen supports the organs. In people, however, organs rest on each other and are suspended
by ligaments and the mesentery. Abnormal positioning of
the organs can interfere with the circulatory and digestive
systems. Because all body systems are functionally interrelated, even the spleen, liver, and kidneys can be affected.
Massage therapists may relax the soft tissue surrounding
the postural deviation, and although that may not cure
symptoms, it allows the body to use its energetic resources where they are best needed, rather than to fight against
posture-created strain.
Abnormal Spinal Curvature
There are a number of postural deviations your clients may
have, often accompanied by excessive spinal curvature:
Figure 7-4. Sway-back posture.
• Flat-back posture—easiest to see from the lateral
view: reduced lordotic curve, head is anterior, pelvis
is anterior, knees are posterior and often hyperextended (Fig. 7-5).
• Scoliosis (lateral curvature of spine)—easiest to see
from the posterior view: ears may not be at the same
level, shoulders may not be at the same level, spine
is not directly along midsagittal line, iliac crests are
not at the same level, PSIS are not at the same level,
space between hands and body differs from side to
side (Fig. 7-6).
• Kyphosis–lordosis (excessive lordosis and kyphosis)—
easiest to see from the lateral view: head anterior,
shoulder posterior, pelvis anterior, knees posterior and
slightly hyperextended (Fig. 7-7). In this case, the musculature will compensate for the abnormal curvature
with shortened neck extensors and hip flexors as well
as elongated, weakened neck flexors, upper sections of
the erector spinae group, and external obliques.
• Sway-back posture—easiest to see from the lateral
view: excessive kyphosis, head is anterior, shoulder is
slightly anterior, palms of hands are directed posteriorly, pelvis is anterior, knees are often hyperextended
(Fig. 7-4).
Many clients have a forward posture, with the head anterior to the spine. Their scalenes, sternocleidomastoid, and
other neck flexor muscles might be hypertonic, or excessively
tight. As a result, the antagonistic neck extensor muscles are
overstretched, creating tension on the musculotendinous
Chapter 7 / Assessment 307
Figure 7-5. Flat-back posture.
juncture or the tenoperiosteal juncture. This tension often
causes pain because the overstretched muscles are continually
attempting to bring the head back into balance, over the spine.
Clients commonly feel pain in their upper back because of
overstretched neck extensors resulting from chronically tight
neck flexor muscles associated with their forward posture.
The massage therapy scope of practice includes
manipulation of soft tissue but not bony structures. In
other words, we do not attempt to realign the skeleton.
Sometimes, in our attempt to normalize the soft tissues of
the body to restore function, the client’s posture and skeletal
alignment improve.
Alert
Do not make it your intent to manipulate skeletal
structures.
Chiropractors and osteopathic physicians perform spinal
manipulations (adjustments) to realign the spine and bony
structures of the body. Their work is very complementary
to massage because the skeletal structures and soft tissue
structures are so interactive in maintaining posture and creating movement.
Figure 7-6. Scoliosis.
Rotation
Rotation, or torque, occurs around the vertical or longitudinal
axis. This is an imaginary axis that runs straight up and down
through the center of the body or through the center of a long
bone. For example, if a client is standing up, facing forward
with feet parallel, and the shoulders appear to be turning to
face another direction, the client is exhibiting rotation of the
thorax. The left and right acromion processes are both on the
same horizontal level, but one is anterior to the frontal plane
and one is posterior. In another example, a person standing
in the anatomical position has a patella that is directed more
laterally than anteriorly, possibly indicating a laterally rotated
femur. Rotation is a significant factor in soft tissue compensation, although it is unfortunately often ignored. Document
your initial observations on the general assessment form as
well as in the Objective section of the SOAP chart.
A complex movement at the glenohumeral joint that
rolls the structures of the shoulder joint forward and down
is sometimes called shoulder rotation, but it is not a true
rotation. A more appropriate description is an anterior roll,
which is recorded as “shoulders rolled forward.” You can
document a shoulder roll by drawing a curved line in the
direction of the roll on the body diagram. (Figs. 7-10, 7-11,
7-13, and 7-14 show documentation for rolled shoulders.)
308 INTRODUCTION TO MASSAGE THERAPY
not relieved (rebalanced) within a month or two, muscles
develop shorter resting lengths and fascial restrictions are
established.
Postural assessment is performed with shoes off,
giving you an opportunity to take a look at your clients’
feet. You can check the height of their arches, see if the
feet are deviated medially (toes point in, or commonly,
duck footed) or laterally (toes point out, or commonly,
pigeon toed), and observe the wear pattern on the soles
of their shoes. The arch affects how people stand on
their feet, as does the wear pattern on the soles of the
shoes, and the deviation can indicate rotation of the
femur.
Arches and wear patterns can provide information
about stance. Pronation causes wear on the medial edge
of the sole, and supination wears the lateral edge of the
sole. If the client’s feet pronate, the peroneus muscles will
develop a shorter resting length, and the antagonistic muscles will be overstretched. As a result of this imbalance
starting at the feet, compensation patterns can develop all
the way up the body as we try to maintain balance. If you
judge that supination or pronation may be causing compensation patterns throughout the body, you may refer
the client to a podiatrist (poh-DAHY-ah-trist), chiropractor, or other healthcare professional. There are some medical devices and treatments that can rectify pronation and
Figure 7-7. Kyphosis–lordosis.
Feet
As the foundation for our balance, the feet are important
to healthy posture. If you have ever stepped on something
sharp or injured a toe, you know how your body compensates to keep you from putting any pressure on the injury.
Imbalances of the feet can result in the development of multiple compensation patterns because our structure balances
on top of our feet.
When the compensation patterns are
supination. Massage therapy can provide temporary relief
for these compensation patterns, but unless the client can
walk and stand in a new, balanced state, the compensation patterns will be perpetuated. Wearing old, worn-out
shoes is one of the worst things a client suffering from
foot imbalances can do, because those shoes reinforce the
imbalance and can even make the situation worse. Proper
stance and muscle balance, on the other hand, facilitate
good health. This information can be used to educate
clients and is a source of good self-care. Once you make
observations of the feet, record your findings on the general assessment form and in the Objective portion of the
SOAP note. For example, supination of both feet can be
recorded as (BL) foot sup.
Observing the body in motion is another assessment tool
you can use. Evaluating gait , or the walking pattern, is a
process of observing how the client walks. Pay attention to
the following aspects:
• Quantity, quality, fluidity, and evenness of steps
• Alignment of the head over the spine
• Position of the shoulders
• Shoulders and shoulder girdle movement is even and
fluid
• Arm swing is equal from side to side
• Medial or lateral deviation of the feet
• Extent of knee flexion upon a step and the amount
of bounce in the step
• Hip movement is even and fluid
Chapter 7 / Assessment 309
Stance phase
Initial contact
(heel strike)
Figure 7-8. Gait pattern.
Load response
(foot flat)
Step length
Midstance
(push off)
Terminal stance
(acceleration)
The proper, normal gait pattern is shown in Figure 7-8. Some
clients will swing one arm less than the other, some will walk
with their head anterior to the spine, and others will use their toes
Swing phase
Preswing
(toe off
leading into
initial swing)
Stride length
Midswing
(swing through)
Terminal swing
(deceleration
leading into
initial contact)
to absorb the shock of a step instead of their knees. Document
any deviations from the normal gait pattern on the general assessment form and in the SOAP note’s Objective section.
Evaluating ROM is another way of assessing the body
in motion. When your clients tell you what their primary
area of concern is, you use that information to determine
which joint movements are affected, how they are affected,
and which soft tissues might be involved. The first joint
you check is the one closest to the client’s area of concern.
Assess each movement of that joint for limitations and the
quality of movement and use the information for your analysis of the massage session.
Each joint can move in specific directions to varying
extents. The range of motion (ROM) is the end-to-end dis-
tance of a specific joint movement that is structurally possible. It can be quantitatively measured in degrees by a device
called a goniometer (GOH-nee-AH-meh-ter), but massage
therapists generally evaluate the quality and restriction of
a client’s joint movement instead of measuring the actual
quantity of movement.
There are two kinds of ROM: active and passive.
Active range of motion (AROM) is joint movement
that requires clients to actively use their own energy to
demonstrate how much of the full range can be completed comfortably and without restriction. It provides
information regarding condition of the active structures of movement, such as the muscles and tendons.
Passive range of motion (PROM) is joint movement that
requires the therapist to move the relaxed client through
a ROM to determine how much of the full range can be
completed comfortably and without restriction. PROM
evaluations can help determine the likelihood that there
is a dysfunction in anatomical structures that are passively involved in movement, such as ligaments and joints.
AROM assesses active structures and PROM assesses pas-
sive structures.
Massage therapists work with muscles and soft tissues,
not bones and structures of the joints. Pain and discomfort
caused by PROM can suggest problems with the ligaments
and joint structures, which are outside the massage scope
of practice. If you suspect that a client’s area of concern
could be a contraindication for massage, you can use ROM
evaluations to help you make the determination and refer
to the appropriate healthcare professional. Medical, osteopathic, and chiropractic doctors can diagnose medical conditions and prescribe treatment for injuries to bones and joint
structures.
310 INTRODUCTION TO MASSAGE THERAPY
Active Range of Motion
AROM assesses the muscles and tendons actively involved
in the joint movement. The following factors are critical to
evaluating AROM and gathering useful information:
• Movement should be slow.
• Movement should be performed at a steady speed.
• Movement must be isolated, and the rest of the body
must be still.
• Movement should continue through the normal
range until the client feels restriction, tightness, or
discomfort.
When the movement is not slow and steady, you will
not easily notice hesitations, glitches, facial expressions,
changes in breathing patterns, variations in speed or fluidity, recruitment of other muscles to complete the range, or
limitations to the ROM. Isolating the movement is a finer
point of the evaluation. Clients often recruit other muscles
to perform AROM, partly because of their natural compensation patterns and sometimes because of a desire to successfully “pass the test.” For example, neck rotation is easily
and commonly altered with lateral flexion of the neck, and
shoulder flexion is often accompanied by shoulder elevation. Keeping the body still, except for the movement of the
joint being evaluated, helps reveal any recruitment of other
muscles to accomplish the whole range of joint movement
(Fig. 7-9A).
To evaluate AROM, there are a series of steps to
follow (see Procedure Box 7-1). You should always demonstrate the movement before asking your client to perform the movement. During your demonstration you can
point out the slow, steady speed and the stillness of your
body that helps isolate the joint movement. Let clients
know that if there is any restriction, pain, or discomfort,
they should tell you. Clients then slowly move one joint
through the specified range and back to anatomical position, minimizing any other body movement during the
evaluation, while you look for compensation and recruitment activities. Then they demonstrate AROM for the
joint on other side and you compare the quality and quantity of the two sides.
When AROM is evaluated to rule out the possibility of a condition that would contraindicate massage, the
uninvolved or unaffected side should be observed first
to determine the client’s normal ROM. Explain this concept to clients, emphasizing that you are only comparing their left and right sides. Sometimes this helps clients
Figure 7-9. (A) Active range of motion. (B) Passive range of motion.