Somatic dysfunction tenderness

T denotes tenderness. Although not an objec five finding, tenderness is produced during palpation of the tissues where it should not occur if there was no somatic dysfunction. 

Tenderness is the subjective sensation of pain or soreness that is reported by the patient in response to palpation of tissues by the physician. Tenderness is the most likely subjective finding. This sensation is almost always present in tissues surrounding a somatic dysfunction when the physician exerts no more than normal pressure. Pressing too firmly on soft tissues will almost always cause pain or tenderness. Pressure that should not normally cause pain will do so in tissues around a dysfunctional joint. 

It is important to be aware that because tenderness is a subjective finding, not all patients report it as such at the site of somatic dysfunction. Some other subjective sensation may be reported, or none at all may be reported. If the other criteria are present, they are sufficient for the diagnosis to be made. Tenderness and other subjective sensations indicate the likelihood of a problem but are not a diagnosis in and of themselves. The physician must use these findings as part of a larger picture when making the diagnosis of somatic dysfunction. 

In counterstrain, the diagnosis is made by finding reflex "tender points." Each involved ligament, joint, or muscle has its own specific tender points, anterior or posterior, depending on the joint somatic dysfunction. The point may he in the shortened muscle or in a more distant area to which it has been referred reflexively. It is a palpable tissue texture change and comprises a tense, fibrotic area approximalely the size of a dime. It is tender to an amount of pressure that would not normally cause pain. The tender points may very well be related to trigger points (Travell points) and acupuncture points there are marked similarities in distribution. 

The patient is cautioned that some muscle soreness may result, but because this is not a somatic dysfunction, the muscle will return to normal quickly. A contraindication to use of this teclmique may include an iirflammatory process at the location of the tender point indicating the presence of other possible problems. 

C3 Create flexion with rotation away and side-bending toward the tender point (STAR). Occasionally C 3 will require extension. This tender point may be present with either a flexed or an extended somatic dysfunction. Flexion is used most commonly. 

The cervical region musculature is commonly involved in stress-related reactions. During times of stress, individuals tend to tense the neck and upper back muscles, elevate the shoulders, and as a result have pain and stiffness of the neck and upper back. Some patients tend to "carry the weight of the world on their shoulders, and the trapezius tenses. Often, tender points and trigger points develop in this muscle. Trigger points in the trapezius usually refer pain to the head. Teaching the patient techniques to cope with stress is important in the treatment of stress-related somatic dysfunctions. 

Physical examination revealed a blood pressure of 13 8/86, with heart sounds and rhythm normal. A few crackles on exhalation were noted scattered throughout the lung fields. The thoracic spine was mildly kyphotic. There were several somatic dysfunctions found T1FS,R, T4FSiRt and TIOESlRl- The paravertebral muscles were hypertonic and tender throughout the thoracic region. 

She was treated with gentle myofascial, soft-tissue teehniques to the paravertebral muscles and all tender points were treated with counterstrain techniques. She was given gentle stretching and flexibility exercises. She was given instructions on care of the back, especially how and what she could lift, and how to prevent falls. She was given a prescription for alendronate. She was treated with osteopathic manipulation weekly for 3 weeks, then every 2 weeks for 2 months. The somatic dysfunctions resolved and she had less back pain. 

The counterstrain tender points of the lumbar spine are named for the dysfunctional lumbar vertebrae. Anterior tender points are treated with the patient supine and posterior tender points are treated with the patient prone. Many of the counterstrain techniques for lumbar somatic dysfunctions are facilitated by slight rotation of the patient s thighs and pelvis, and by resting some part of the patient s leg on the physician s thigh or knee. 

On examination, the left buttocks was lender to palpation and there were tender points at the mid-pole of the sacrum on the lateral border and one deep to the gluteus maximus, where a lense piriformis could be palpated. There was a unilateral sacral flexion (sacral shear) present on the left. No lumbar somatic dysfunctions were present. There was mild tenderness at the sciatic notch of the ischium. Deep tendon reflexes were normal and muscle strength of the ihigh was normal. There was some pain on internal rotation and adduction of the left hip. 

Physical examination revealed a slightly obese woman in obvious discomfort. She preferred to stand rather than sit on the examination table. The sacrum was freely movable and no somatic dysfunctions of the lumbar spine were noted. The coccyx was markedly lender to palpation and ihe soft tissues around il were tense and lender. There was a high flare-out tender point on the posterior surface of ihe sacrum. Rectal examination confirmed tenderness of the coccyx, but it was not severe enough to indicate a fracture and the coccyx was not dislocated. 

Palpation along the sternal border anteriorly will reveal ribs that have moved anteriorly (anterior ribs), a common cause of anterior chest wall pain. The patient may mistake rib dysfunction on the left side for cardiac pain. Tenderness and tissue changes may be palpated along the sternal border and at the costochondral junction in the case of somatic dysfunction. 

Palpation of the costochondral junction elicits tenderness. There seldom is swelling. It must be differentiated from Tietze syndrome, which is similar in symptomatology. However, Tietze syndrome is generally more localized and swelling is usually present. Costochondritis must also be differentiated from somatic dysfunction, another cause of anterior chest wall pain. Evaluation of rib motion will usually allow a diagnosis however, motion may be restricted in the presence of costochondritis as well. 

Somatic dysfunction can occur between any of the carpal or hand bones. Tender points lie over the dorsal and volar surfaces of the wrist A common tender point ofthe hand is found in the thenar eminence. 

The bursitis has as its cause trauma to the area, acute or chronic, as well as any dysfunction affecting the ischium or the structurai integrity of the knee joint. The patient reports pain at the medial aspect of the knee, but careful palpation will elicit point tenderness below the knee joint that is very specific and localized in its nature. The pain will be made worse with contraction of the semitendinous, sartorius, and gracilis muscles. An evaluation for somatic dysfunctions of the pelvis, sacrum, and lumbar region, as well as the postural balance of the lower extremity, must be performed. Treatment can be a local injection of a steroid, a prescription for a NS AID, ice, exercises, and osteopathic manipulative treatment (OMT) of all somatic dysfunctions, including knee, hip. and pelvic region. 

Examination revealed normoactive bowel sounds and tenderness to palpation in all four quadrants. There were type 11 somatic dysfunctions in the lower thoracic spine, with Chapman s points on the lateral right thigh. There was no abdominal rebound and the patient was afebrile. 

Osteopathic structural examination revealed marked tenderness in the upper left thoracic area with somatic dysfunction of T2, T3, T4, and the third rib. The first ribs were elevated bilaterally and there was marked tension and tenderness in the trapezius bilaterally. Cervical somatic dysfunctions were aiso found OA F SiRi, C2 F SlRl, and C3 F S R . 

On reassessment, somatic dysfunctions and tenderness had been reduced, rotations normalized, and range of motion had become more symmetric during gait. She stated that her headache had resolved. She showed mood improve-... 

The osteopathic physician will frequently find tenderness to palpation of the facial and cervical muscles, including the sternocleidomastoid and scalene muscles, on the ipsilateral side. There is often a somatic dysfunction at the level of C3. There may be occipitomastoid compression with an internally rotated temporal bone on the involved side. 

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