One of the biggest mistakes many novice clinicians make is focusing too heavily on the site of pain. While the site of pain needs to be address for pain management purposes, many times the cause of the dysfunction is not the location of pain. For example if a patient presents with medial sided knee pain, the knee should not be the primary joint addressed. The clinician should rely more heavily on the cause of the problem which is likely at the core, hips, or ankles. In other words, instead of treating the painful region, focus on the region that is not functioning properly.
How do you assess the cause of the dysfunction?
First, perform specific functional movement tests including gait assessment, squat, lunge, and others. Next perform specific local biomechanical assessments of the joints surrounding the pain. Using the knee example above, during the evaluation have the patient perform the functional movements, then perform a gross AROM and strength screening of the lumbar spine, hip, and ankle. If you notice that the patient's knee moves into adduction and internal rotation during the squat & they have a positive trendelenburg while ambulating, you know you want to check the strength of the posterior gluteus medius on that side. If the patient is lacking dorsiflexion range of motion during their squat, assess dorsiflexion AROM and talocrural joint mobility. Using this same principles, if the patient exhibits normal ankle dorsiflexion during the squat, there is likely no need to check dorsiflexion range of motion. They demo'ed normal mobility functionally, it is a waste of time to assess the isolated movement. This leads to over testing and finding minute impairments unrelated to the cause of the dysfunction.
With every functional deficit you see, perform specific local biomechanical tests to triangulate your findings.
Please let me know if you would like more examples of functional deficits I often find that assist with my local testing.
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James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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