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Chapter 7 / Assessment 311
realize that AROM is not a test or a competition. After
the evaluation has been made on the unaffected side, you
can evaluate the involved side, looking for any limitations,
hesitation, fluidity, compensation, recruitment, and facial
expressions.
Always ask clients to let you know if there is any
restriction, discomfort, or pain during AROM. Clients
perceive pain at different levels or may have a diminished
awareness of pain. They may not use the word “pain” or
“weakness” to describe a restriction of movement, instead
thinking of it as “pressure,” “tension,” or a feeling of being
“stuck.” Be sensitive to this terminology and watch for
any abnormal movement, unusual facial expressions, or
movement-created sensations. Any findings can be recorded as a positive test result on the general assessment form
or in the Objective section of the SOAP note. For a client
who complains of pain in the right shoulder when demonstrating AROM, you can record: Cl c/o (P) in ® shoulder
w/AROM.
Passive Range of Motion
PROM evaluates passive tissues including ligaments, joints,
and joint capsules. Using PROM can give you a better idea
of whether the client’s area of concern can benefit from
massage or whether the client should be referred out for
further evaluation. Clients relax during PROM while you
do the work. You hold and support their body parts, slowly
and gently moving their body through the individual joint
ROMs. If they feel that you might drop their arm or leg,
they will “help” you by holding up their own body part
to prevent it from being dropped. When clients “help”
you hold their body, they introduce muscular tension that
interferes with the PROM evaluation. By holding clients
securely and using a gentle and knowledgeable tone of
voice, clients are more likely to relax their body (Fig. 7-9B
illustrates the gentle but secure way to hold a client during PROM). PROM requires a certain amount of trust from
your client and must be performed carefully to avoid injuring yourclients.
Before you evaluate PROM, clients should demonstrate
AROM for the same joint movement because it gives you
a good idea of the limits of the range. With AROM, the
actively contracted muscles can impede movement, but with
PROM, those muscles are relaxed and can be compressed to
allow a greater ROM.
Evaluating PROM follows a series of steps similar to
the AROM procedure (see general assessment Procedure
Box7-1). Starting with the client’s area of concern, you determine the joint that may be affected, determine the movements of that joint, and observe the client’s AROM of the
joint to get a general idea of the limits to the ROM. Explain
the PROM process to your clients, demonstrating passive
elbow flexion on your own arm if they need clarification.
Express the importance of being relaxed, encourage clients to
tell you if there is any pain or discomfort, and provide sufficient stabilization.
Gently and slowly guide the client’s joint through its
range, watching and feeling for glitches or hesitations in
movement, resistance, changes in breathing patterns, and
variations in fluidity of movement. Test the uninvolved side
first to determine the client’s normal PROM for the joint
and then test the affected side. Record any differences you
notice from side to side and note any pain or discomfort as
a positive test result on the general assessment form and in
the Objective portion of the SOAP chart.
Alert
If passive ROM elicits pain or discomfort, the
client may have a condition outside the scope of
massage therapy.
Massage therapists do not treat joint or joint capsule injury,
and clients with those conditions should be referred to the
appropriate healthcare professional. If PROM results are
negative, meaning that there is no pain or discomfort with
passive movement, massage therapy is indicated.
End Feels
When moving any joint through an ROM, you need to
know when to stop pushing or pulling. It is possible to
injure a client with PROM if the joint is moved past its safe
stopping point. It requires practice to be able to feel the limitation of a joint’s ROM. An end feel is a sensation of hesi-
tation, tightness, or resistance as a joint reaches the end of
its PROM and the client’s body resists further movement.
Specific structures that stop the ROM have a unique end
feel. Normal end feels are created by normal anatomical
structures that stop the movements and determine the full
ROM. Normal end feels are classified as hard, soft, or firm.
Abnormal end feels are the result of abnormal anatomical
conditions or some kind of problem in or around the joint.
Abnormal end feels are classified as hard, soft, firm, springy
block, empty, or spasm. More important than learning the
difference between the abnormal end feels, which takes a lot
of practice, is being able to recognize an end feel as normal
or abnormal. Table 7-1 describes the normal and abnormal
end feels and gives examples of each. You should learn the
normal end feels and get comfortable with determining a
firm end feel. The firm end feel is caused by muscular or
fascial tension, which is within the scope of practice for
massage therapy. When PROM is limited by a firm end feel,
312 INTRODUCTION TO MASSAGE THERAPY
Normal (Physiological) End Feels
End Feel Description Example
Hard (Bony) When movement comes to an abrupt, hard
stop and bone contacts bone
Soft (Soft
apposition)
Firm (Soft tissue
stretch)
(Capsular stretch) When joint capsule or ligaments are
Abnormal (Pathological) End Feels
End Feel Description Example
Hard When bone contacts bone or there is
Soft When movement is stopped with a squishy
Firm When there is a springy sensation or hard
When two exterior body surfaces come
together and a soft compression of tissue
is felt
When muscles are stretched and elicit a firm
or springy sensation that has some give
stretched and provide a hard arrest with
some give
a grating sensation like rough articular
surfaces moving past each other, there will
be an abrupt, hard stop to movement
or yielding sensation
stop with a little give
Passive elbow extension: the olecranon
process contacts the olecranon fossa
Passive knee flexion: the posterior aspects
of the calf and thigh come together
Passive ankle dorsiflexion with the knee in
extension: tension from the gastrocnemius
muscle
Passive external rotation of humerus
A joint with loose components, degenerative
joint disease or bone fracture
Presence of synovitis or soft tissue edema
Muscular, capsular, or ligamentous
shortening
Springy block When the client jumps or withdraws with
discomfort (a rebound) to the end feel
Empty When the therapist cannot reach the end feel
because the client experiences considerable
pain and requests to stop ROM
Spasm When PROM comes to a hard, sudden stop
the client often suffers pain
massage is indicated to relieve the muscular tension and soft
tissue restrictions. You must learn and practice these end
feels with a qualified instructor to avoid injuring a client.
When a joint is put through PROM, the position at
the end of the range passively contracts the muscle that is
responsible for that movement. In other words, a muscle
in passive contraction is in a shortened position but is not
actively contracting. Passive contraction brings the muscle’s
origin and insertion closer together and puts the muscle in a
relaxed, soft position that is especially helpful for massaging
deep tissues.
Torn meniscus of the knee
Acute bursitis, joint inflammation, or a
fracture
Acute or subacute arthritis or a fracture
Direction of Ease
There are a lot of clients who want to “help,” but encouraging these clients to relax by saying, “Just relax,” is not
always effective. The direction of ease concept can be a
good tool in these situations. This concept uses the direction in which the tissues move with least resistance. Let
clients position themselves the way they want to (in the
direction that “eases” their pain or discomfort); you can
even encourage them to display that position and then
slowly but gently move them into the position you prefer
Chapter 7 / Assessment 313
or ask them to actively move themselves into that position. Clients who continue to tense their muscles despite
your requests and suggestions to relax during PROM may
respond to the direction of ease concept. You can firmly
hold their body in a fixed position and ask them to gently push or pull against your resistance, giving them the
Once clients are on your massage table, visual assessments
provide information regarding the condition of their soft
tissues. Look for variations of skin coloration, differences
in bilateral symmetry of tissues, and any kind of marks or
wounds on the skin.
Areas of redness often indicate a localized area of
increased circulation. Areas that appear paler than the rest
of the skin can result from ischemia, which is a localized
area of reduced blood supply. Either condition indicates
some kind of dysfunction that may affect the condition of
the client’s soft tissues.
Sometimes you notice differences in the fullness or
thickness of soft tissues or bilateral asymmetry of soft tissues. If your client’s left gastrocnemius is smaller than the
right one, they likely have some compensation patterns to
maintain balance. Differences in the size and fullness of soft
tissues can be caused by hypertonicity, a difference in muscle
opportunity to activate their muscles, which is what their
body wants to do. After 5 seconds or so, you can ask them
to relax slowly and gently, which again gives them control
over their body. The muscles will likely be more relaxed
than before they pushed against you, and you can attempt
the PROM evaluation again.
mass, or edema (swelling caused by accumulated interstitial tissue fluids that are not drained by the lymph system).
Checking the fullness of muscles and comparing the left to
right can point out hypertonic muscles or compensation
patterns, which gives you more information on where you
might focus your massage techniques.
Visual assessments should also include open wounds,
rashes, bruises, moles, varicose veins, and scars. You may
notice changes on a client’s skin before he or she does.
Remember that any open skin wounds, bruises, or varicose
veins are local contraindications for massage. Visible scars are
important because the skin and underlying tissues are usually
pulled toward the scar in the healing process and they can even
lead to compensation patterns. All of these visual findings are
recorded on the general assessment form and the Objective
portion of the SOAP note. For a client with a bruise on the
right gastrocnemius, you could record “bruised ® gastroc.”
Palpation is the skillful art of touching and exploring the
body, locating different structures, and assessing the quality
of structural characteristics. It requires a thorough knowledge of the functional anatomy of the body and continually improves with practical experience. With practice, you
will learn to use all of your senses with increased awareness and become more sensitive to what is underneath your
hands. Good palpation skills are critical for massage therapy.
Massage therapists with good palpation skills become soft
tissue experts. Working with relaxed hands will help you
gain even the subtlest sensory information about the client’s
soft tissues. There are more nerve endings in the skin than any
other body part—600,000 overall in an adult; 50,000 per square
inch in the fingertips.
A single touch receptor in a fingertip can
detect pressure of less than 1/1,400 of an ounce, or the weight
of an average housefly.
The saying “Less is more” can be applied to palpation
and treatment of soft tissues. People tolerate being poked,
prodded, and invaded, but nobody is particularly comfortable with such intrusions. Moving too fast and too deep can
activate the body’s protective response to push the intrusion back out by contracting muscles. You can test this phenomenon by slowly poking yourself in a relaxed muscle
such as the masseter, which is located in the lower cheek.
Notice how your finger sinks into the relaxed muscle tissue.
Now, actively contract the muscle by clenching your teeth
and feel the contraction of the muscle push your finger
out. This protective mechanism is activated subconsciously
by the sympathetic nervous system in situations of potential and perceived danger. When you quickly jab a finger
into someone’s arm, they can respond with surprise, pain,
discomfort, and recoil. If you very slowly push your finger
314 INTRODUCTION TO MASSAGE THERAPY
into their relaxed arm, your finger can penetrate deeper
and you might be able to feel the muscle relax and soften.
This approach is less intrusive and less painful for clients and
gives you a better feel for the condition of the soft tissues.
Your palpation assessment evaluates and notices differ-
ent temperatures, textures, and movements of soft tissues:
• Temperature—localized areas of heat or cold, or a
noticeably elevated body temperature
• Textures—hypertonic muscles, scar tissue, restricted
fascia, trigger points, and tissue edema (swelling)
• Movements—fascial adhesions or restrictions, which
can be localized or cover large areas of the body,
sometimes feel stuck, sticky, or resist movement;
hypertonic muscles limit ROM
• Rhythms—breathing, pulse, craniosacral
Assessment of Skin Temperature
Skin temperature can be an indicator of circulation.
Excessive heat can be caused by a fever or by the increased
circulation of an inflammatory process that is the body’s
response to an injury. Fever is a systemic contraindication for
massage, meaning you should not massage clients who have
a fever. If the inflammatory process is causing the elevated
temperature, you need to know how long the pain and discomfort have been present. An acute injury that has existed
less than 72 hours is a local contraindication for massage,
but general massage will help the rest of the body relax and
may decrease the likelihood of the formation of compensation patterns.
Cold skin temperatures can indicate decreased circulation. Ischemia is a condition of reduced blood supply that
is sometimes caused by fascial adhesions and hypertonic
muscles. These conditions restrict circulation and prevent
adequate blood supply. Massage is especially beneficial for
ischemia caused by restricted soft tissues because it can
relax and create more space in them or normalize them and
restore their blood supply.
Textures and Movement of Soft Tissues
As you gain experience with palpation and massage, you will
easily notice the different textures associated with soft tissues. Scar tissue and restricted fascia can feel as if the tissues
are bound down and stuck together, and sometimes they
have a grainy texture. Hypertonic muscles feel tight and
resistant when they are in a relaxed position or are passively
contracted. Trigger points feel like little knots within a muscle, and they elicit pain or discomfort upon palpation, which
radiates to another part of the body. Without the radiating
pain, these localized areas of hypertonic muscle tissue are
considered tender points. Tissue edema (swelling) can feel
spongy or full and squishy.
Texture and Movement of
Muscles
Normal, healthy muscles feel warm and pliable; they open
up to receive additional pressure, they slip smoothly past
neighboring tissues, and they are not painful. When muscles lack nutrition, are injured, or are chronically contracted
or overstretched, they will not feel like healthy muscle tissue. Tissues suffering from poor nutrition feel deteriorated
and nonsubstantial, as if they are falling away or dissolving
under the palpation pressure. Tissue that seems to dissolve
under pressure feels different from tissue that opens up to
receive additional pressure. The difference is subtle at first,
but with experience, you can easily differentiate between
thetwo.
Injured muscle tissue that develops fascial adhesions
and scars has a ropelike feel that may elicit pain or discomfort with applied pressure and force. When your massage
stroke travels across fascial restrictions, your hand or forearm may slow down or bounce over the tissue with a skidding or jumpy movement.
Muscles used for repetitive motions and muscles that
are posturally shortened can become hypertonic, or excessively tight. Hypertonic muscles can create trigger points,
areas of pain and hypersensitivity, and fascial adhesions.
They feel tight upon palpation, even in a passive contraction,
and can feel resistant, tough, inelastic, and sticky.
Rhythms
There are different body rhythms you can learn to distinguish and evaluate. These rhythms can provide you
with more information about your client’s overall condition. Once you recognize the normal range of the different rhythms, you can recognize aberrations. The repeated
inhalation and exhalation of breathing produces a rhythm
that you can feel. The regular contractions of the heart ventricles that create the cardiac pulse can be detected along
the arteries. The craniosacral rhythm is a subtle ebb and
flow of cerebrospinal fluid (CSF) that, with practice, can be
felt in different parts of the body, but most easily on the
cranium.
Chapter 7 / Assessment 315
Breathing Rhythm
By placing your hands lightly on the back of a prone client or
on the shoulders of a supine or seated client, relaxing your
hands and using a light touch, you should be able to detect
the breathing rhythm. The movement of the rib cage may
feel easy and fluid, freely movable, restricted, hesitant, or difficult. The more freely the rib cage moves, the more deeply
and effectively the client can breathe. Slow, deep breathing
usually indicates relaxation and parasympathetic nervous system activity. Shallow, fast breathing generally indicates stress
or sympathetic nervous system activity, and it usually involves
upper chest breathing. You may notice the shoulders moving
up and down, indicative of shallow breathers who use their
scalenes, the accessory muscles that raise the rib cage, instead
of the diaphragm muscle to pull air into the lungs. Upper
chest breathing overworks the scalene and anterior neck muscles and can lead to neck and shoulder tension and headaches.
The muscular involvement in breathing is a good topic for
client education and self-care because getting oxygen into the
body not only helps the soft tissue but also the overall health
and well-being. (Remember that without oxygen, cells will
eventually die.) A number of resources are available to explain
breathing techniques, which you may suggest to clients.
Cardiac Pulse Rhythm
Your palpation observations can include assessment of the
client’s heartbeat or cardiac pulse. The pulse is the rhythmic
throbbing felt along the arteries, and it indicates the rate at
which the heart is pumping oxygenated blood through the arterial system. More common places to detect and evaluate the
pulse are the radial artery (at the distal end of the anterior radius), carotid artery (anterolateral aspect of the neck), and temporal artery (anterior aspect of the temporal bone). Use your
middle and index fingers to firmly compress the artery and
then relieve the pressure gradually to feel the pulse. The average pulse rate is about 75 beats per minute, but for massage,
you will be checking more for differences in the strength of the
pulse from side to side. Hypertonic muscles and fascial adhesions can restrict the blood vessels and thus reduce the blood
flow to an area. For example, if you detect a stronger radial
pulse on the right than on the left, you could use ROM evaluations to see if some soft tissue restrictions near the shoulder
might be constricting blood flow through the brachial artery.
Craniosacral Rhythm
You may notice the extraordinarily subtle craniosacral (KRAYnee-oh-SAY-krahl) rhythm, which is an ebb and flow of CSF,
while you perform massage. The CSF surrounds the brain
and spinal cord, acting as a source of protection and nourishment. It is produced in the brain, is contained within the
dural tube as it bathes the spinal cord, and is reabsorbed in the
brain. The CSF is released and reabsorbed in a slow rhythm,
and the flow creates a wavelike pulsation that is almost imperceptible, but the rhythm can be palpated on thebody.
positioning your relaxed fingertips so that they touch different bones of the cranium. For example, you could touch
the occipital, parietal, and temporal bones. With a very light
touch, you might feel those bones move outward very slightly
(1 to 2 mm) over a period of about 4 seconds, which feels like
the entire cranium is expanding ever so slightly, and then a
short pause that is followed by all the bones moving inward
a similar distance and at a similar rate. Feeling the craniosacral rhythm depends on a delicate, refined technique that can
be learned with advanced training in the field of craniosacral
therapy. This rhythm can be evaluated for quality, quantity,
and fluidity. The parasympathetic nervous system arises from
the cranial and sacral sections of the spinal cord and is sometimes referred to as the craniosacral system. Restricted CSF
flow, which can be caused by soft tissue restrictions, may hinder the parasympathetic nervous system response. Massage
can relieve soft tissue restrictions and restore the parasympathetic response, which involves the activities of resting and
digesting, relaxing, and restoring energy. Without these activities, a body cannot resolve stresseffectively.
For the entry-level student, using massage techniques to
reduce pain and tension and restore muscle balance can help
minimize or eliminate functional limitations over time. The
general assessments you use before the initial and subsequent massage sessions help you determine the soft tissues
that might be involved with your clients’ areas of concern,
the techniques you should use or avoid, and a treatment
plan that is focused on achieving treatment goals. FA tests
specifically evaluate the client’s area of concern to discover
the likelihood of specific dysfunctions and conditions that
require medical diagnosis. These tests, which include manual
muscle tests, manual resistive tests, and special orthopedic
tests, are more definitive than general assessments. Some
resources refer to active and passive ROM evaluations as FA.
Manual muscle tests require clients to perform isometric muscle contractions against your counterforce. The test
316 INTRODUCTION TO MASSAGE THERAPY
results help you determine whether muscles are functioning abnormally because they are shortened, overstretched,
or weak. Manual resistive tests are similar, involving active
isometric muscle contractions, but they help you determine
whether there may be problems with a muscle or a tendon, a
breakdown in the neuromuscular communication, or a more
severe neurological condition. There are orthopedic tests
that are designed to discover the likelihood of specific medical conditions related to fascia, ligaments, nerves, and joints.
For instance, there are orthopedic tests that examine symptoms of carpal tunnel syndrome, tendinitis, ankle sprain, and
sciatica to indicate whether or not these conditions are likely.
Following the massage treatment, you need to analyze progress with posttreatment assessments or reassessment observations. These assessments are the same ones you used before
the treatment, but they help you analyze the massage. For
a client who begins the session complaining of a tight left
shoulder, your initial assessment may discover bilateral hypertonicity in the upper trapezius and levator scapula muscles,
left shoulder elevation, and reduced AROM and PROM upon
left shoulder flexion and abduction. Posttreatment assessment would reevaluate your original findings to look for any
changes in the hypertonic muscles, shoulder elevation, or
ROMs. Tightness can be assessed during the massage after
The concepts of these FAs are introduced so you know
that they are available as assessment tools. Once you have
an established practice and find that many of your clients
come to you with health conditions that may need further
evaluation, or if you want to work specifically with clients
who have injuries, you might want to take additional training on FA techniques so you can deliver safe and effective
massage treatments and continue to keep the clients’ health
and well-being at the center of your care. Performing good
FA tests requires good technique and supervised practice to
elicit valid test results that can be incorporated into your
treatment plan.
you apply techniques to this area. Assess the shoulder elevation and ROMs after the client is off the table and dressed.
Document these changes in the Activity and Analysis portion
of the SOAP note. For this sample client, you could record:
• A moderate change that reduced hypertonicity in
the bilateral upper trapezius and levator scapula
muscles: mod. ⌬ ↓≡ (BL) up trap ⫹ lev scap
• After a full-body relaxation massage, the left shoulder
elevation was reduced: FBRM → ↓(L) shoulder elev.
(See SOAP notes with posttreatment assessment find-
ings documented in Figs. 7-11 and 7-14.)
Case Studies
This section highlights the documentation of objective
information.
Progressive Case Study 1:
Rob Blackwell
Rob Blackwell’s health history
form and intake interview provide the starting point for your
assessment process. His goals
are to restore sleep, reduce
pain, and restore his previous
abilities to lift weights and play
golf. Your questions determine that he especially likes
golf and is frustrated because
his shoulder pain has significantly affected his game.
The anterior postural assessment shows some extra
wrinkles in his shirt at the right axilla and elevation of the
right shoulder. From the posterior aspect, you confirm
right shoulder elevation. The lateral view of Rob’s posture
indicates that his right shoulder is rolled forward and his
head is forward.
His gait pattern is smooth and symmetrical with no
noticeable abnormalities.
To sort through the different areas of pain, you
determine Rob’s compensation patterns (see Procedure
Box7-3). Both active and passive ROM for flexion of the left
knee are reduced and painful. You find reduced active and
passive ROM upon left hip flexion, extension, and abduction. AROM shows lateral flexion of the spine is greater
to the left than to the right. AROM is reduced for bilateral
shoulder abduction and neck rotation to the left and right.
During the massage, you do not notice any visual
differences. You feel a number of hypertonic muscles
Chapter 7 / Assessment 317
on the right: sternocleidomastoid, pectoralis major,
levator scapula, and rhomboids. The upper trapezius,
deltoids, and tensor fascia lata muscles are hypertonic
bilaterally. Quadratus lumborum is hypertonic on the
left. You feel fascial adhesions around the right levator
scapula, right rhomboids, and bilateral iliotibial bands.
All of these general assessments are recorded in the
Objective section of the SOAP note. You also use a general assessment form, as shown in Figure 7-10.
You perform the appropriate massage, analyze the
results, prioritize functional limitations, and determine
treatment goals. You determine a treatment plan, including recommendations for future treatment and self-care
activities to help him maintain the progress made during
the first massage (Fig. 7-11).
Progressive Case Study 2:
Timothy Roberts
Timothy has made a
first-time appointment
for relaxation massage.
To assess the general
condition of his health
and soft tissues, you
look over the HxTxC
form he filled out, looking for any specific
complaints to confirm
that he does not want
therapeutic treatment.
He states impatiently
that he just wants a
massage and asks if all the paperwork is really necessary. To strike a balance between gaining his trust and
remaining professional, your assessments are brief.
You quickly ask if there are any specific areas he wants
you to work on, or if there are any areas he wants you
to avoid. He says no and starts taking off his shoes. As
he is sitting in front of you and begins to stand up, you
look for any obvious postural deviations. While he is
getting onto the table, you use your office references to
determine that the combination of relaxation massage
and blood pressure medication could lower blood pressure further. You know to be especially careful when he
gets off the table.
During the massage, you notice some fascial adhesions around his left ankle and that PROM is limited for
that ankle. Like many seniors, Timothy may have hypertonic areas where ROM is reduced without associated pain.
Following the massage, you make recommendations for future treatment and self-care. Your assessments and recommendations are recorded on the HxTxC
form (Fig.7-12).
Progressive Case Study 3: Kirsten Van Marter
Kirsten’s information
from the history and
intake interview provides the basis for your
assessment process.
She wants to reduce
her back, hip, neck,
and shoulder pain;
restore sleep; restore
her previous fitness
level; and lift her child.
She has been receiving
massage regularly for
years, and she knows
that massage cannot deliver all of these benefits at once.
She says that she is especially concerned that she cannot lift her child without pain and is afraid it will only get
worse as the pregnancy progresses.
Postural assessments show that both shoulders
are rolled forward and her left hip is elevated. When
you evaluate her gait, you notice that she is starting
to compensate for the growing fetus by widening her
stance and pulling her shoulders back. AROM is limited
with pain upon bilateral shoulder flexion, but PROM is
not painful.
During the massage, you notice hypertonicity in a
number of areas: bilateral pectoralis major and minor,
rhomboids, and upper trapezius muscles and left quadratus lumborum and left tensor fascia latae muscles.
You feel adhesions in the superior erector spinae muscles and bilateral iliotibial bands. She has trigger points
in her bilateral pectoralis minor muscles and many
tender points in her trapezius and rhomboid muscles.
You do not notice any visual differences in tissue color,
but you do notice some swelling around her ankles. All
of your observations are recorded as objective information on the SOAP note or on a general assessment form
(Fig. 7-13).
Following the massage, you and she prioritize her
functional limitations, determine treatment goals, and
come up with a treatment plan that is feasible for her
(Fig.7-14).
318 INTRODUCTION TO MASSAGE THERAPY
BOX 7-3
1. Primary areas of concern are neck, back, and knees.
2. Rob’s right shoulder is elevated and rotated (rolled) forward.
3. The right shoulder elevation and roll could cause the neck and back pain, but the knees do not fit into the local pain pattern.
4. Rob indicates that his bilateral knee pain has been with him the longest, for about 10 years. He was diagnosed with
osteoarthritis in both knees over 10 years ago but remembers badly twisting his left knee playing basketball before then.
5. Assume that the knee is the joint originally involved in the imbalance.
6. Evaluate AROM and PROM for flexion and extension of the left knee.
a. You find reduced AROM with discomfort.
b. PROM is reduced and painful, indicating that passive structures are involved in addition to active structures.
Treating passive structures is outside our scope of practice.
7. Evaluate AROM and PROM for all movements of the left and right hips, spine, and shoulders.
a. You find reduced AROM and PROM of left hip flexion, extension, and abduction.
b. You find greater AROM for lateral flexion of the spine to the left than to the right.
c. AROM for neck rotation is reduced to both sides.
d. You find reduced AROM upon bilateral shoulder abduction.
His right shoulder elevation and roll could be compensation for the original left knee injury.
8. Document your general assessment findings, including the compensation pattern, in the Objective portion of the
SOAP note, and/or on the general assessment form.
a. R shoulder elev + roll, ↓ ROM + P w/ L knee flex text, ↓ ROM L hip flex text + abduct, AROM lat flex spine
L > R , ↓ AROM
BL neck rot + shoulder abduct
b. R shoulder compensation for L knee?
9. Because there was pain upon PROM of left knee, refer Rob to a medical doctor for a more current diagnosis to
make sure massage is not contraindicated. Document your referral in the Plan section of the SOAP note.
Although we cannot avoid stress completely, we can
learn to cope with it. Holding onto tension and stress
Relaxation massage often provides temporary relief from
pain and tension, but determining the underlying cause of
the problem and using therapeutic techniques when they
are indicated is more beneficial and offers longer lasting
results. Clients should be evaluated for their chief complaints to determine the condition of their soft tissues as
well as their overall health. A new mother complaining
of tight shoulders, for example, probably suffers fatigue,
guilt, lack of rest, and insufficient aerobic exercise. These
other factors can affect her overall health as much or
more than the hypertonic shoulders and associated fascial
restrictions.
requires a lot of energy, which then depletes the body’s
resources for functioning properly. Compensation pat-
terns require a part of the body to work excessively to
compensate for a dysfunction or imbalance in another
part of the body, and they can increase the potential for
injury. By relieving compensation patterns, we can facili-
tate the client’s ability to relax and experience more ener-
gy and vitality. Compensation patterns should always be
suspected and, when they exist, treated to restore opti-
mal function and movement.
hurts, where it is compensated, and at the ends of the fascial
restriction.
As a guideline, treat where it
Chapter 7 / Assessment
319
Figure 7-10. General assessment form for Rob.
320 INTRODUCTION TO MASSAGE THERAPY
Figure 7-11. SOAP note for Rob, highlighting Objective information. (Modified with permission from Thompson
DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 2nd ed. Baltimore:
Lippincott Williams & Wilkins, 2002.)