Position, Motion and Resistance Testing
of the Hip and Shoulder

Now, let me make a further distinction. We can use these same terms to describe both the position and motion of the hip or shoulder joint and these are separate considerations. If there is no motion occurring, we just have the static joint position. If there is motion, then we have a dynamic joint position with a motion that can be the same or opposite the position. Thus, we can have the shoulder in mid-range extension and be moving it further into extension or moving it towards neutral and flexion. So we can have a position of extension with a movement of extension or a position of extension with a movement of flexion. Similarly, we can have a position of flexion and a movement of either flexion or extension. The same motions are also available at a neutral position — one that is neither flexion or extension. So, we see that position and motion are separate items.

In the above examples, I have been keeping the position and motion in a single plane. This isn't necessary. We can move the shoulder into a position of abduction and then examine positions of lateral rotation, medial rotation, or neutral rotation. At the same time, we could describe the motion as lateral rotation, medial rotation, or static (no rotation). Sometimes, there are special and even multiple names for movements combining multiple primary positions and motions. Horizontal flexion, moving horizontally from abduction into flexion, and horizontal extension, moving horizontally from flexion into abduction, are common examples at the shoulder. These same movements are also often called horizontal adduction and horizontal abduction, respectively.

Let me make another comment about noting rotation of the hip. We can look at such rotation either with the client supine and the knee and hip both flexed to 90° or with the client prone and the knee flexed to 90° . In either case, imagine a virtual arrow going through the client's thigh from the posterior side to the anterior (i.e. back to front). Please don't use real arrows for this; keep them virtual. If you want to get carried away, use a marker and draw a round circle on the front of your partner's arm and thigh and an X for the feather side of the arrow on their posterior arm and thigh. This is best not done over clothes.

The direction of rotation is the change in the direction in which the head of the arrow points. Thus if the arrowhead move laterally, it is lateral rotation. This is just opposite to the direction that we see the ankle move. When we move the client's ankle medially, the arrowhead moves laterally; when we move the ankle laterally, the arrowhead points more medially. For the shoulder, when we keep the arms at the client's side (i.e. no abduction) and flex their elbow to 90°, the arrowhead and wrist move in the same direction as we rotate the humerus. Keeping this all straight become important as we note limitation in rotational range of motion (ROM), do resistance testing, or use active muscle relaxation techniques (e.g., post-isometric relaxation, muscle energy technique, PNF).

One memory trick I use for a client lying prone with their knee flexed is that moving them into medial rotation or resisting their lateral rotation is like dispensing a glass of ale from a long-handled tap. You just grab the tap handle (their ankle) and apply pressure towards you. This assumes that you are pulling on the leg ipsilateral (i.e. on the same side) to the side on which you are standing. While I'm at it, let me define contralateral, on the opposite side, and bilateral, on both sides.

In summary, we have six primary motions: flexion, extension, abduction, adduction, and medial and lateral rotations. These same names are also used to describe positions. We have the option of no movement (static positioning) but we always have a position. We have to note the positions and motions separately. We obtain the complexity of our positioning and moving by simultaneously combining (superposition of) the primary movements and positions. And finally, we have to be careful of noting hip rotation because the rotation and movement of the ankle are opposite. Now let's move on into thinking about how the motion happens.

I've just spent the last few minutes asking your classmate here on the table to just relax and let me move her arms and legs around for her. Does anyone want to venture what we call that kind of motion?

Passive and active movements

When I'm doing the movement for my client, we call it passive movement. If I get tired of doing all the work and train them to move themselves then we call it active movement. For the client, the motion is passive if I'm doing all the work and active if they are doing it. Note that a second ago I said train them to move rather than ask them. With the average client you are likely to have to run them through a movement passively a few times and then ask them to continue it actively,if that is the desired goal. This is important, because to check ROM you have to keep the movements pure.

Left to themselves, people will cheat on their ROMs by pulling in the compensations that they use to get through day-to-day life. If my shoulder joint can't abduct well, I'll elevate my scapula and flex my torso laterally to the opposite side to move my arm outward from my side. If it hurts to extend my shoulder, I'll cheat by adding in some abduction. So if you keep your eyes open, you can learn a lot about your client's active ranges of motion and their compensations for limitations all at the same time. Also look at the quality of their movements. There may be areas they avoided for a while because of pain and injury and have never relearned smooth neuromuscular patterns (our kinesthetic vocabulary) to move through them. Now, what has to happen for me to passively move a client's should or hip to some range of motion limit?

Passive movements

Right, the joint and surrounding ligaments have to allow the motion; so first we check passive movement to assess the noncontractile structures that guide movement and maintain joint integrity. Full range of motion with normal endfeel requires that the joint capsule be free of motion preventing adhesions. When this isn't true, we call it adhesive capsulitis (to ourselves, so as not to diagnose —that's considered outside our scope of practice). What we can do is note whether we observe characteristic capsular patterns of ROM limitations. Cyriax (1993) and Hammer (1999) discuss capsular patterns of ROM limitation and joint endfeel in some detail. Endfeel refers to the type of sensation we feel in bringing a joint to some physical limitation or pain barrier —is motion stopped bone-to-bone (elbow extension), by soft tissue compression (elbow and hip flexion), spasm or twang (fracture, inflamed joint), a firm capsular feel (like stretching leather), a springy block (meniscus tissue displaced into a knee joint), or an empty feeling (client indicates pain).

Passive movements to the joint barrier will also stretch and compress ligaments, potentially compress bursae, and stretch the muscles that would be antagonists to (oppose) the direction of motion. Some motions that compress adjacent soft tissue, such as combined flexion and adduction of the hip, may also identify the presence (by pain) of adhesions that we can address by direct work. So, with passive movement, we get to evaluate whether all of these structures are allowing a full range of motion without pain. This also bring us to the concept of motion barriers.

Motion barriers

There are several different movement barriers that people use in discussing ROM: anatomical, elastic, physiological, and pathological or restrictive. Greenman (1995) provides an entire chapter on barrier concepts within the larger framework of the diagnostic triad of Asymmetry, Range of motion, and tissue Texture abnormality (ART). There is also some discussion in Lewit (1999) and in a chapter by Lewit within Hammer (1999). The outermost limit is the anatomical barrier. When the anatomical barrier is exceeded, the integrity of the joint is compromised by fracture, dislocation, or tearing of ligaments. In the interest of having return clients, I strongly advocate staying within the anatomical limits. Treating your clients like the pop-beads at a Club Med resort has a strong practice limiting effect.

Just short of the anatomical barrier, lies the elastic barrier, where the joint tissues offer resistance but still have some slight ability to lengthen. Within that, the range of active movement is somewhat less than that for passive movement and the end point of this range is called the physiological barrier. The barrier representing loss of ROM due to dysfunction is the pathological or restrictive barrier. The positional relationships between these different barriers are shown schematically in Figure 1. Associated with a loss of range there is also a shift in the neutral or mid-point of the movement away from the limitation. Our therapeutic goal is to normalize hypertonicity and free adhesive restrictions so that we move the client's pathological barrier outward towards the appropriate physiological barrier. This also returns their neutral point to the correct midrange location.

Figure 1: Schematic diagram of the relationship between various range of motion barriers. Normal neutral is at the midpoint of normal ROM

Active movements

I once heard fitness instructor Joanie Greggains motivate a set of standing leg exercises with “you grew them — you lift them”. Moving into active movements and muscle testing is rather like that; your client doesn't just get to come in and be moved around passively, they have a responsibility to actively participate in their own care. So what gets added when the client does the movement?

With an active movement, the client's muscle has to contract to power the movement. One bit of trivia about muscle contractions is that a particular muscle fiber either contracts or it doesn't. There is none of this “fire a little bit” kind of action. When you need more power, more fibers are fired. So as a first test of active movement, you can have a client go through the different motions and look at ROM and the quality of the movement. If there wasn't any pain doing passive movements, and with active movement there is pain, you also have a strong indication of a lesion (tear or area of dysfunction) in the active muscle-tendon unit. We can take this thought a lot further by adding the concept of resistance.

With resistance, we can think of three different kinds of exercise: isometric, isotonic, and isokinetic. With isometric exercise, the effort and the resistance are kept in balance and no movement occurs. With isotonic exercise, the joint is moved through the range of motion against a fixed amount of resistance, as with free weights or a standard weight machine. Note that the term isotonic is technically a misnomer in that it literally implies that the muscle is kept at the same tension, something that is virtually impossible over a range of movement. While isotonic is likely to be the commonly encountered term, most properly this would be called a dynamic contraction against a fixed resistance. Finally, with isokinetic exercise, which requires a facilitator or special machines, the resistance varies to keep the velocity of motion constant. Finally, for isotonic and isokinetic exercise we can divide the effort further into concentric exercise and eccentric exercise.

For concentric exercise, the muscle that's contracting is also shortening; it's successfully overpowering the resistance. This is what happens when you climb on a weight machine and move the weight as far as you can. But now that you have the weight up there, you've got to lower it again. If you just let it drop suddenly, it's going to make a really loud crash and everyone around you will turn and give you a dirty look. So you keep your muscles working to lower the weight back down, which means that the muscle that is working is simultaneously lengthening and we call that an eccentric contraction. Your muscle is working, but you let it be overcome by the resistance. This is also what happens with your quadriceps when you walk down stairs. If you didn't resist gravity with your quadriceps, you would collapse and fall down the stairs. So resistance isn't futile.

One of the reasons it is important to know about eccentric exercise is that it's associated with delayed onset muscle soreness (DOMS). The idea that muscle soreness is caused by lactic acid and that massage moves it out is one of the great massage myths. This isn't all that likely unless you grab a sprinter or a swimmer and toss them on the table the minute they are done with their event. If you look within most exercise physiology books, you will find a graph that shows blood lactate levels and blood pH (acidity) returning to normal within 30-60 minutes. In fact, one of the largest motivations for anaerobic training is that it increases your ability to do intense exercise and have your blood lactate and pH stay reasonable. It's called increasing your lactate threshold. We have another write-up available on the lactic acid myth.

In contrast, DOMS isn't yet fully understood, but is thought to occur because of micro-damage to muscle tissue. The damage results in calcium ion leakage from the sarcoplasmic reticulum that surrounds each myofibril. This in turn is thought to induce inflammation and nerve-ending irritation. So 24-48 hours after you or your client were a little foolish about the rate of increasing exercise, particularly eccentric exercise, you are reminded of the error or your ways. My personal belief is that deep massage can relieve the soreness because it normalizes muscles that are still hypertonic (i.e. working too hard while they should be resting) and neurologically gates off some of the pain sensitization that has occurred. So the muscle is more relaxed, less active neurologically and, because there is less local pressure on the muscle tissue, enjoying better capillary circulation. Besides, it feels good. So what's to resist?

Resistance testing at its simplest

As it turns out, what the massage therapist resists is the client's muscle contraction. The most basic form is just doing an isometric resistance at different parts of the range of motion. If the resistance is painful, you have a big clue that one of the contracting muscles has a lesion. There are two ways to request this. The first is to say, “I want you to push against my hands and I'm going to resist your motion”. This isn't a really bright thing to say to a bulky macho client. The other way is to say, “I want you to hold your arm (or leg) in place, and I'm going to push against it.” This second way you control the amount of force by how hard you push and they have less temptation to send you sailing across the room.

If your client comes in and says something like, “I get this pain in my hamstrings after running 20 minutes”, what might be going on? One possibility is that they get the pain as their muscles start to tire and new fibers or auxiliary muscles are recruited. So instead of isometric muscle testing, you do isotonic testing a number of times until their muscle starts to fatigue. This requires them to recruit new muscle fibers and simulates what goes on after they have been exercising for a while. It may allow you to duplicate and figure out that furtive pain.

Finally, we do a lot of comparing asymmetries in ROM and muscle strength, since people have different baseline flexibility even before an injury. By the way, if you notice a really marked difference in muscle strength between one side and the other, something beyond the dominant/nondominate variation, consider that they might have a motor neuron impingement worthy of a referral —particularly if you notice atrophy in the corresponding muscles when you palpate them.

Palpation and muscle activation

The next bit I want to cover is using muscle activation as an aid to palpation. If you have the client do the gentlest isometric resistance, it activates the muscles trying to do the motion you are resisting. So if you are palpating inferior to (i.e. below) the spine of the scapula and you ask your client to attempt a very gentle lateral rotation that you resist, you will feel the infraspinatus and teres minor firm up under your fingers. Just inferior to those muscles, for a resisted medial rotation, you will feel the teres major activate. By having a client side-lying and taking their upper leg into abduction with slight extension and lateral rotation, as you press back towards neutral and they resist, you can palpate the gluteus medius. With hip flexion and the rectus femoris, a slight activation can let you palpate the attachment at the AIIS (anterior inferior iliac spine). This simple technique of activating the muscle you are trying to palpate can be really helpful trying to verify that you really are palpating a subscapularis or a psoas. So the reason that you learn muscle anatomy isn't so that you can spew out the names of muscles that don't even know their own names. You learn it so that you know how to play these clever palpation games with your clients.

Note taking

Finally, all of this bring us down to the idea of taking formal notes. There are two basic methods of approach. HOPS stands for History, Observation, Palpation, and Special tests. HOPS and a number of the special tests are covered in your recommended text by orthopedic massage instructor and author Whitney Lowe. That's also the place to continue on from this session into specific functional assessments. The most common method of keeping notes is SOAP — Subjective, Objective, Assessment, and Plan. This is thoroughly covered for massage therapists by Diana Thompson in Hands Heal. Because of the common use of SOAP notes across many different health professions, Whitney Lowe advocates using the HOPS assessment thinking within the context of the SOAP note taking format; this organization is shown in Table 1. As a less formal mode of getting and noting information, you can use a body symptom coloring chart (PDF file). Sometimes you have to inform the client that it isn't particularly helpful when they just color in their entire body as hurting.

Table 1: Use of HOPS assessments within the context of SOAP notes
SOAP	HOPS
Subjective	History
Objective	Observation, Palpation, and Special tests
Assessment	Describe or state your assessment conclusions
Plan	State your plan of treatment and reevaluation

Summary

So we've covered a lot more than you can consciously hold, but it will sound a lot more familiar the next time through it. And my demo person is thoroughly bored with all of these movement and resistance games I've been playing, which is why this doesn't count as a “real” massage demonstration. We've started with the concepts of the primary hip and shoulder movements: flexion, extension, abduction, adduction, and medial and lateral rotation. We've noted that motion and position use the same names but are separate items to note. We've looked at passive movement and range of motion testing and the concepts of endfeel and motion barriers. We've discussed isometric, isotonic, and isokinetic active efforts and how they apply to range of motion and resistance testing. We've differentiated between concentric and eccentric contractions. All of this applies to homing in on asymmetries, range of motion differences, and abnormalities in tissue texture (ART). We've dispelled the lactic acid myth and talked a very little bit about delayed onset muscle soreness. Finally, we've learned how to combine muscle activation and palpation and methods for taking notes. It's time for a break.

Acknowledgments

I wish to thank Whitney Lowe for reviewing this article and for making comments that improved the consistency and technical accuracy of the material presented. I also wish to acknowledge the many McKinnon Institute students who have helped me to refine my thoughts and presentation of this material via their interest and questions.

References