Performing an assessment before a massage session while the client is standing is the optimal way to evaluate your client, reach an agreement and create a treatment plan.
If a standing assessment doesn’t happen, here are some quick and easy assessment techniques you can perform while the client is on the table in a prone position. You could even do these tests during a relaxing spa massage and gain valuable information while not disturbing the client.
Doing these tests will give you information about where to work to be the most effective, as well as give you and your client something to work toward in future sessions.
With the client prone, use the thenar eminence of your palm to apply a springing pressure to each of the spinous processes of the vertebrae. Do this in about eight spots up the spine to get a quick overview of spinal mobility. Apply quick downward pressure and then release. Start at the lower lumbar and move up the spine all the way to the upper back. Direct pressure straight down toward the table at 90 degrees to the body. (In massage school we are always taught to stay off the spinous processes, but applying this gentle pressure is perfectly safe.)
This is a very general mobility test of each of the vertebrae, and by using this test you can get a quick evaluation of your client’s back health. On a healthy back, each of the vertebrae will move independently. On a back that lacks mobility, multiple vertebrae will move as a column. If the muscles have been tight for a long time, this begins to translate into the facet joints and disks, causing them to become less mobile, and move as a group.
By testing joint movement, you can tell if your muscular work is going to be really effective, or is going to take multiple treatments over a long period of time. For example, if someone has back pain with tight muscles and all the vertebrae move as a column, then you know it is going to take longer to relieve the dysfunction. If you see a client with back pain and tight muscles, but the vertebrae have normal mobility, you know that relieving the muscles will often fix the issue.
After testing about five people, you will start to get a sense of what is normal.
With the client prone, undrape and pick up one ankle, letting the knee bend to 90 degrees. With your other hand on the sacrum, pushing down and stabilizing it so it doesn’t move, pull the leg outward and see how far it will go. Then push the leg across the body and see how far it will go in that direction.
When you pull the leg outward, the front of the femur faces inward. This is hip internal rotation. The leg should be able to go out at about a 40-degree angle. When you push the leg across the body, you are performing hip external rotation. The leg should be able to go to about 45 degrees. Don’t get too caught up in the degree amount. After testing a few people, you will start to get a sense of what is normal. Some people have a greater range, and some less. You really want to pay attention to imbalances between each leg.
If there is a limited internal rotation, you will want to work on the external rotators, which are located under the gluteus maximus and include the piriformis, obturators, gemelli and others.
If there is limited external rotation you will want to work on the hip internal rotators, which are located on the anterior portion of the side of the hip and include the tensor fascia latae and anterior portion of the gluteus medius muscle. After you release the muscles, retest the motion to see if you have increased the range.
With the client prone, pick up the ankle and push it toward the hip. If the ankle does not get close to the hip, it indicates limited knee flexion—a tight quadriceps. If the rectus femoris muscle is tight, doing this motion will cause it to pull the hip downward, and cause the hip to rise off the table a little during the test.
The indication for massage work is the same. In either case, you will want to release the quadriceps muscles. Test both sides. This test is important in cases of back pain because the rectus femoris is a hip flexor, and the position of the hip is of primary concern in cases of back pain. So even though this is mainly a knee flexion test, always include it if someone has back pain.
Shoulder internal and external rotation
With the client prone, bring her arm out so the forearm dangles off the table, with her wrist near the floor. Then swing her wrist upward toward her head and notice how far it will go. Note if it goes above or stays below the level of the table. This tests shoulder external rotation. Then swing it the other direction down by her hip, and notice how far it will go. This tests shoulder internal rotation.
In both directions, the wrist should be able to come up to the level of the table. If it doesn’t, it indicates restriction in the shoulder joint.
If there is limited external rotation, you will need to release the internal rotators, which include the pectoralis major, subscapularis and anterior deltoid. If there is limited internal rotation, you will need to release the external rotators, which include the infraspinatus, teres minor and posterior deltoid.
If releasing the muscles has no effect on range of motion, it indicates the restriction is in the joint capsule itself, and the joint will require slow, deep stretching as long as there is no pain.
Add value with assessment
Performing these assessment techniques can take less than a minute and easily be incorporated into any type of massage flow. With very little effort, you have evaluated for hip internal and external rotation, knee flexion, shoulder internal and external rotation, and spinal mobility in eight spots. That equals 13 areas where you have revealed the function and health of the joint. Knowing this information can guide your session with each client, leading to more personalized work.
After the session, telling the client which areas are restricted can help him understand his body better—and be a good opener for scheduling future sessions to increase the range of motion in all his joints.
About the Author
Sean Riehl, C.M.T., president of Real Bodywork (realbodywork.com), has been teaching massage therapy for over 20 years. He has authored and produced more than 40 massage training DVDs; this article is based on his newest work, Structural Massage. He wrote “A Structural Massage Approach to Easy Assessment” for MASSAGE Magazine’s July 2015 issue.
Neither the author/s nor MASSAGE Magazine assume responsibility for the application of any technique. Readers must ensure they have completed the training necessary to safely and effectively perform any technique mentioned on massagemag.com.