Issue link: https://www.massageandbodyworkdigital.com/i/230373
Brachial plexus Coracoacromial ligament Pectoralis minor Subacromial bursa Biceps tendon long head and its surrounding synovial sheath Joint capsule 2 Deeper structures that may be involved. Image is from 3D4Medical's Essential Anatomy application available on the App Store. As massage therapists, our lens of bias may be slanted toward muscular problems because those are what we mainly address. Yet, other tissues such as bursae, joint capsules, ligaments, nerves, or tendons could also be involved. Investigating the potential role these tissues might play in Melvin's complaint is important. In Melvin's situation, we need to investigate key structures such as the pectoralis major and minor, coracoacromial ligament, joint capsule, biceps tendon, and nerves of the brachial plexus, because they are all located in the primary region of his pain (Images 1 and 2). ASSESSMENT AND EVALUATION The first and most important physical examination procedure is palpation. Your palpation should never feel like poking or prodding, but gentle and compassionate investigation of the superficial and deep tissues. Palpation is most effective when you visualize the underlying anatomical structures as you evaluate the tissues. Make note of any pain that is reproduced and in what tissues. When palpating Melvin's shoulder, we find he has the greatest discomfort on the anterior aspect of his shoulder. The tenderness does not seem to be in the superficial tissues because it is not reproduced with moderately light pressure. The pain does not occur until greater pressure is applied, thereby suggesting it is originating in deeper tissues as opposed to the more superficial anterior deltoid. The next step is to focus on specific range-ofmotion (ROM) evaluations. Active movements are performed first, followed by passive movements, and then resisted actions (manual resistive tests). While 3 Biceps tendon long head. Image is from 3D4Medical's Essential Anatomy application available on the App Store. it might be helpful to include every motion of the shoulder in each test, that may not be necessary. It will be more efficient to focus primarily on motions Melvin has already described that cause pain and look at motions that stress other key structures in the anterior shoulder. In his initial history, Melvin described pain associated with reaching overhead; this motion emphasizes forward flexion or abduction of the shoulder. Paying particular attention to these motions as they are performed with the various active, passive, and resisted procedures will provide more information to work from. Most of the shoulder evaluation procedures reproduce very little of the pain Melvin was experiencing. He does, however, have pain at the far end of active and passive flexion of the shoulder. The pain is more significant with active movement than passive. There is also some pain felt with resisted shoulder flexion. After noting which of these tests causes a reproduction of his pain, we can cross-reference these findings with what does not produce pain to see if a clear pattern emerges based on anatomy and biomechanics in the area. It pays to be ABMP Certified: www.abmp.com/go/certifiedcentral 101