When is an Injury not an Injury?

The following article, as seen in Massage Therapy Today covers some of the facts behind structural and anatomical issues, and may make a lot of sense for those of you who have been told that you’re “falling apart”, “bone on bone” or “out of alignment”

Sports injuries; what’s in an assessment?

For many of us, sports injuries are a common part of our practice. We regularly see people who depend on their bodies to perform to a certain standard, who have higher than average physical expectations, and who regularly test and increase their limits. Our assessments protocol assumes too many universal beliefs; it needs more flexibility to better reflect the commonality of “outliers”. It lacks context.

In my mind, there’s a simple rule that all of our assessments need to follow: they should be meaningful. This means that they’re relevant to the stressors our patients encounter.

Before getting to that; however, I’d like to touch on some generally accepted concepts.

A couple of established norms:

  • Hypermobility is a pathology.
  • Misalignment is abnormal, and leads to injuries.
  • Asymmetry is an example of poor posture, which is abnormal, and leads to injuries.
  • If something is torn, worn, or narrowed, it’s anatomically abnormal, which is a pathology, and is probably going to hurt.

So what is normal?

Look at yourself. Are you in alignment? Are you in pain because of your current lack of alignment?

During daily movement, we rarely if ever maintain alignment. Seriously, just watch anybody walking around and see how often their knees valgate, or they hunch or rotate through their trunk. Misalignment is normal. You may be thinking “well duh”, but that’s just the little bit that you can casually observe. What’s fascinating is when we take into account outlier variables, and extreme forces, such as in sports-specific movements.

When assessing sports injuries, we need to be aware that altered mobility and alignment may be normal. Among high school baseball players, for example, pitchers demonstrate a general shift to greater external rotation range through the glenohumeral joint (up 10 degrees external, and less 15 degrees internal).1, 2 In sports like basketball and volleyball, athletes regularly demonstrate a significantly higher than average peak knee valgus angle on landing.3

Our provocative tests need to be modified to reflect that these altered limits may be normal.

Sports-specific training often results in greater tolerance to misalignments such as knee valgus. Certainly we want to aim for alignment in training, especially at load and at velocity, but given these increased tolerances, our measure for a positive special test needs to be adjusted to reflect those increases in order to more accurately reflect patient norms.

What about symmetry?

While discussing alignment, we should cover symmetry. We have this whole narrative based on the idea that people should be symmetrical: front to back, side to side, we’re supposed to be balanced. I’ve been given different explanations for this, ranging from irregularities in joint changes over time, to excess stress to maintain vertical posture. I don’t know what universal truth there may be there, but I remember learning that asymmetry is a bad thing.

One of my go-to tests used to be the Adams forward bend test: a standing, forward-bending test to look for evidence of scoliosis (manifesting as pseudohypertrophy, or unevenness in the paraspinal region from right to left). It’s reasonably simple, plainly visible, and doesn’t require any special tools. It’s by no means a perfect test, but it’s accessible and easy to monitor over time.

But how uncommon is asymmetry? An often quoted study by William P. Bunnell tested one thousand high school students for spinal symmetry, and found that less than 2% actually demonstrated it, with 80% of them demonstrating 3 degrees of rotation or greater in forward bend.4 So here I was, using this special test that I thought was great, but the numbers just didn’t justify it; I had to reconsider my approach.

Okay, so asymmetry is a thing, and it’s common, whereas normal ranges of motion are commonly abnormal, and safe limits to alignment are incredibly variable. This is giving me a headache.

Let’s consider structural norms

Probably the most common complaints I see in my office involve shoulder pain. I’ve classically followed textbook assessments protocols, including looking for structural dysfunction under the assumption that structural changes are pathological. But what if they’re not?

In a study of volleyball players from the US Women’s and Men’s national indoor teams, 26 players underwent MRI imaging of their dominant shoulders. About 2⁄3 of them presented with tears of their rotator cuff muscles, and almost half of them presented with labral tears or labral fraying.5 Every player was asymptomatic, and all were performing at a high level, with extreme demand on range of motion, speed and strength. These athletes were high functioning, explosive movers, and yet the majority of them are injured according to our assessment criteria.

Maybe these injuries aren’t actually injuries, but are instead adaptations to training demands. We can clearly consider a soft rule that no stress is too much, so long as it stays within reasonable anatomical limits and we allow for adaptation. Over time, this results in structural adaptation (yes, even tearing) and neurological optimization. This fills a functional niche, but isn’t necessarily pathological.

Anatomical irregularities may not be injurious; they may be adaptive.

Let’s stop and step back…

Why is your patient here? They’re experiencing a thing: pain, weakness, decreased range of motion or tightness, the list goes on. That doesn’t automatically mean that their body is damaged, nor does it mean that it’s not, it just means that they’re experiencing a thing and that they want to change that experience.

Trying to accurately determine what’s happening in a patient’s body is daunting. We rely on our experience, their precedent/health history, and protocol and special tests to create an index of suspicion. Our special tests depend largely on the assumptions that the anatomy is consistent (it isn’t) and that perception of dysfunction is accurate (it isn’t) as their basis for reliability. In a systematic review of orthopaedic tests for the spine by Simpson and Gemmell, most single tests demonstrated either poor specificity, poor sensitivity, or both.6 We can offset single test unreliability with test clusters, but it’s far from perfect: false positives and negatives can still skew the entire index of suspicion. This isn’t to say that we shouldn’t perform special tests, but it is to say that overreliance on them can be detrimental.

We have to consider that a person’s lifestyle and experiences contribute to what they perceive as normal, both neurologically and physically. Stressors such as valgus deviation, hypermobility, or tears may be normalized to them, and may not be the cause for either alarm or pain.

Coming back to context…

A person’s complaint is often obvious (pain/tightness, etc), and we focus our assessment on that; it represents the “foreground” of the assessment. Their general movement capacity not including dysfunction represents the “background”. Putting the foreground and background together gives us a complete trackable assessment, and the basis for our treatment plan to calm the warnings and build tolerances. I personally like to break down my movement and injury assessments in terms of 3R’s (range, resistance, and rate of movement), including my tests. The following descriptions are simplified, but the concept is sound:

  • Range is the available range of motion required for the movement to occur. This is active range, and includes mechanical factors, as well as neurological.
  • Resistance refers to the idea that we can generate enough muscle energy to perform our task. This includes sufficient motor unit recruitment, and perceived safety to allow for that.
  • Rate takes into consideration time to apply muscle energy, to start, stop and control our movements with appropriate timing.

This may sound needlessly complex, but it actually simplifies things a lot. The movement portion of the assessment can cover one or multiple joints, and many of the simple and combined movements overlap with our special tests. We have to have enough movement, strength, and speed in order to perform a task, and if dysfunction is present, we can break it down along these lines.

Consider reaching for a cup of coffee. You require sufficient range of motion through your joints, sufficient muscle energy to lift your arm against gravity, and finally sufficient control over timing and accuracy so as not to spill your drink. Your nervous system needs to decide that the movement is safe enough so as not to require a warning, in order to succeed painlessly.

When we assess our patients for injuries (sport or mundane), we are essentially questioning what is impacting their ability to perform a task. The cause may be mechanical (like a broken bone) or perceived risk (like kinesiophobia).

Your patient has a complaint, but that doesn’t mean that they’re necessarily injured. It just means that challenging those movement variables in some way or other is causing them to experience dysfunction. Breaking down our general range of motion testing, and asking what feels apprehensive/painful/meaningful to them will give us a much more complete picture of what they’re experiencing.

For consideration:

A couple of years back I was treating one of my circus performers, the primary complaint was right-sided shoulder pain in performance (cyr wheel, hand balancing, and tumbling). Full range, full resistance, full rate control with no positive special tests. According to most testing criteria, he was pain free and perfectly functional, and it wasn’t until we tested his hand balancing while walking up stairs, down stairs, and in static single arm holds that we found meaningful symptoms. My standard testing criteria was all but useless, so we had to get creative and find a testing method that was meaningful to him. Walking into an assessment with unquestioning confidence in our dogma is just us setting our own narrative; assessments are about discovering the narrative. It’s all about context.


  1. Wendy J. Hurd et al., “A Profile of Glenohumeral Internal and External Rotation Motion in the Uninjured High School Baseball Pitcher, Part I: Motion,” Journal of Athletic Training 46, no. 3 (May/Jun 2011): 282-288.
  2. Wendy J. Hurd, and Kenton R. Kaufman, “Glenohumeral Rotational Motion and Strength and Baseball Pitching Biomechanics,” Journal of Athletic Training 47, no. 3 (May/Jun 2012): 247–256. https://doi.org/10.4085/1062-6050-47.3.10.
  3. Komsak Sinsurin et al., “Altered Peak Knee Valgus during Jump-Landing among Various Directions in Basketball and Volleyball Athletes,” Asian Journal of Sports Medicine 4, no. 3 (Sept 2013): 195-200. https://doi.org/10.5812/asjsm.34258.
  4. William P. Bunnell, Outcome of Spinal Screening (Loma Linda: Mizuho Osi, 2010). https://pdfs.semanticscholar.org/e5d0/493ac4da7ef545cdcf9464419393d32d52d2.pdf.
  5. Christopher Sy Lee et al., “Shoulder MRI in asymptomatic elite volleyball athletes shows extensive pathology,” Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 5 (Jan 2020):10-14. https://jisakos.bmj.com/content/5/1/10.
  6. Rob Simpson, and Hugh Gemmell, “Accuracy of spinal orthopaedic tests: a systematic review,” Chiropractic & Osteopathy 14 (Oct 2006). https://doi.org/10.1186/1746-1340-14-26.