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However, when performing musculoskeletal assessment, you rarely know what type of pain or injury complaint you are dealing with at the outset. In that case, another framework can be used to help gather information about what might be causing your client's existing pain complaint. This next evaluation framework is far more detailed and helps the practitioner consider multiple causes of pain or discomfort when performing the client evaluation. Each row of this comprehensive evaluation framework will look at: • One particular joint region • One motion at a time (flexion, extension, abduction, etc.) • One type of motion at a time (active, passive, or resisted) • Which specific tissues are exposed to either compressive or tensile loads in the above scenario Anterior Knee Pain Let's see what a more comprehensive evaluation would look like for a client with anterior knee pain during the physical examination process. We will explore several knee movements to evaluate if they reproduce the client's pain. Here's what one of those movement patterns would look like if we plug it into this evaluation framework. Note that the framework shows which tissues are subjected Manual Resistance Manual resistance puts an increased load on the affected muscle and is likely to reproduce pain if a muscle strain is present. Note: A full copy of this evaluation framework (which we call the Assessment Cheat Sheet), with references to muscle, tendon, ligament, nerve, cartilage, and bursa injuries, can be downloaded for free at Thinking about various soft-tissue injuries in categories like this helps manage and organize the load of information you may gather during the assessment process. I have repeatedly found that when teaching assessment, most people learned how to perform range-of-motion evaluations in their basic training, but they didn't get a firm grasp of how to interpret the information derived from those procedures. This visual representation helps make sense of all the information and organizes it so you can use it effectively. PERFORMING A MORE COMPREHENSIVE EVALUATION The framework presented in the five different evaluation scenarios is helpful for confirming the involvement of specific tissues, or type of tissue, when you already have an idea of the tissues at play. 94 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 9 force, not enough fibers are recruited to reproduce the pain of the muscle strain. Active Lengthening With a muscle strain, the fibers of the muscle are pulled during active lengthening. The tensile load will be greatest near the end range when the muscle is being fully stretched. Eccentric loads usually produce enough tensile force on the muscle to reproduce pain with a muscle strain, and pain will likely increase as the muscle further lengthens. Passive Shortening During passive shortening there is no load on the muscle, and any tensile forces decrease as the muscle length reduces. For that reason, pain decreases as the strained muscle further shortens if the movement is passive. Passive Lengthening Similar to active lengthening, pain is likely to increase as the muscle is further stretched. There is no eccentric load on the muscle since the movement is passive, so pain is usually less than with active lengthening, but pain is still likely as the muscle length increases. Pain generally increases near the end range of available movement. The available range of motion may be significantly less than normal due to pain limiting the motion. 2 Flexion Tissues Actively Shortening Tissues Passively Slackening Tissues Compressed Tissues Pulled (Mostly at End Range) Active Range of Motion Muscles that produce flexion during concentric contraction, such as: • Semitendinosus • Semimembranosus • Biceps femoris • Sciatic nerve • Posterior knee • Joint capsule • Cruciate ligaments The following tissues or structures could be slightly compressed at the very end range of knee flexion: • Distal end of hamstring muscles • Proximal plantaris • Popliteus muscles • Gastrocnemius: superior portion • Patellofemoral contact surface Muscles that produce extension when contracting concentrically, such as: • All four quadriceps muscles • Patellar tendon • Patellar retinacular fibers Mechanical Responses During Active Knee Flexion

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