Young clinicians often ask me, "how were you able to start your own cash based practice within 3 years of graduating?" While hard work and passion are at the center of this answer, properly positioning myself around the best mentors and educators early in my career was equally important. These mentors largely came from my Orthopedic residency program, the Harris Health System. My residency program taught me pain science education, manual therapy treatments, improved clinical reasoning, differential diagnosis, and improved patient education/ communication. If you combine all of these components into a patient interaction, you hopefully get an efficient and effective Orthopedic clinician.
From opening a cash practice to finding fulfillment, in this post I discuss the need to pursue specialization!
Specializing is Worth It: Your Outcomes Will Improve
Since the majority of physical therapists are caring and compassionate individuals, it is safe to assume that most people who become Doctors of Physical Therapy have a primarily goal of helping others. Furthering this assumption, I would guess that getting patients healthier as fast as possible is even better! For me personally, I know that this is my primarily goal. Going through a residency program and preparing for the Orthopedic Clinical Specialty examination taught me how to quickly improve my patient's pain and function. Additionally, I learned how to become a direct access practitioner. As the entry-point diagnostician, it has always been important for me to know when to treat, but more important to know when NOT to treat. As I studied the clinical practice guidelines and APTA monographs, I learned how to incorporate this evidence into my patient interactions. Instead of passively guessing a patient's prognosis, I learned to actively create a plan of care with a predictable prognosis. As my knowledge improved, my outcomes continued to get better!
Specializing is Worth It: You Will Be More Fulfilled
While I am always developing my practice, my training as an Orthopedic Specialist allows me to view each patient from a different viewpoint. I credit my OCS preparation and residency training for providing me with a deeper understanding of pain science, tissue pathology, and biomechanics. This deeper understanding allows me to provide specific education to each patient based on their individual needs.
As more residencies are being credentialed each year, the awareness and availability of residencies have also increased. With this development, more PT students show interest in pursuing residency, but the question remains, "when is the right time to pursue residency?" There is no correct answer, as each person and situation is different.
Now a residency is not right for everyone. Even with the twelve residency specialties available, the educational pursuit may not be possible or desired. There are some that like to be "generalists" and treat a wide variety of conditions in different settings. While it is not currently a specialty, it may eventually become one. For others, residency may not be financially possible. It can cost income/tuition temporarily and may not lead to an increase in pay upon graduation. There are over 250 credentialed residencies currently and all have different pay and tuition requirements. Some offer very reasonable salary/tuition options compared to "standard local wages," while others are relatively expensive and make it difficult to live off in high cost-of-living regions. With residency pay cuts, it may be easier to manage immediately after graduating PT school (one typically has less expenses immediately after school i.e. may not have a mortgage or kids) or if one has a spouse or family member to help support housing or other living expenses.
As for education and clinical development, timing is different for each individual. Some people, myself included, find that when graduating from PT school, it's easiest to roll right into residency since the mind is still in a "learning state." I knew that I wanted to learn more and specialize in orthopaedics immediately. I felt like I didn't know enough about my area of practice upon graduation. That is not the case for all. Many people do not know right away in what they want to specialize. For those, it may be best to practice (or perform clinicals in various areas) for a few years to solidify interest in a specialty. There isn't necessarily a rush to specialize or complete a residency, so if uncertainty exists, take your time.
All that being said, I still highly recommend residency pursuit. While one learns plenty of clinical knowledge and hands on skills, the two best things that come from residency are clinical reasoning development and how to critically appraise research (and apply it). Clinical knowledge changes with time, as does research. The ability to stay up to date on research an identify study limitations/applications is essential for "evidence based practice." Clinical reasoning skills helps with problem solving, self-reflection, and clinical development. A residency teaches all these things and holds one accountable to certain standards.
-Dr. Chris Fox, PT, DPT, OCS
Over the last year I have seen more and more athletic pubalgia in the clinic. Some of this is because of the population of athletes I have seen and some of this is because of the sports medicine doctors I work with. Athletic pubalgia (also known as sports hernia) is also defined as non-specific referral of groin pain. This injury can be complex to treat or very straightforward depending on the severity. Understanding how to determine if this is a AP and how to effectively treat it to return back to sport is crucial for the sports clinician.
Typical presentation of athletic pubalgia includes:
Other pathologies to consider:
One of the key points to make with AP is that despite the term “sports hernia”, AP is not a hernia. Furthermore, this injury can be chronic in nature. With all that in mind, there are many conservative treatment options.
From a conservative standpoint, treating AP has some non-negotiables. The first phase as many pathologies require, it to control the pain and symptoms. The length of this phase will be determined by severity, sport demands, and previous injury history. However, there are many other things you can do during this phase away from the site of injury to keep the athlete in shape. It is crucial to maintain cardiovascular endurance and strength elsewhere to give the athlete the best chance of returning without another injury later.
Following the first phase you can you can start to work on more advanced core strengthening with “neutral spine”. I say neutral for the purpose of discussion and because most research articles advocate neutral spine but understand that everyone’s “neutral” is different. Another important point to consider during this phase is the influence of the lumbar spine. As with almost all hip injuries, we MUST consider the influence of the lumbar spine. Make sure full ROM is achieved and good control over the stability of the lumbar spine as it will influence the pelvis. More often than not, we can indirectly influence AP with lumbar spine treatment. Lastly, slowly adding adductor specific exercises from isometric in nature to more dynamic is important to add proper strength back to this athlete. I like the Copenhagen plank for a good isometric exercise vs squeezing a ball because it is hard to quantify the “squeeze”. There are many different forms of Copenhagen exercises and I would urge you to watch youtube videos, try them yourself, and determine if and when each variation can assist (or not) with your athlete’s rehabilitation.
Finally, as with all injuries, proper return to sport criteria MUST be measured. While hip return to sport tests are few, there is good research on some tests and more importantly, a proper “battery” of tests must be put together. There is no one approach for return to sport and for those of you who have gone through our “Sports Management for the Orthopedic Clinician” course, you already learned how to put your own battery of tests together for various hip pathologies and how to properly construct return to sport testing.
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
I recently evaluated a patient who came into the clinic with the self- diagnosis of right hip pain. When I asked him where his hip hurt, he pointed to the back of his hip joint, just lateral to his sacroiliac joint. Upon further subjective history, he stated the current pain was very similar to his left hip pain that forced him to have a hip replacement 3 years prior. Needless to say, he was worried his current hip pain would lead to another hip replacement in the future.
During the objective examination, I found this patient to have decreased hip flexion, internal rotation, and extension. While he had limitations in joint mobility, general hip quadrant and scour testing was negative. Looking at regional joints, the patient reported exquisite tenderness to palpation with PA assessment from L4-S1. Additionally he experienced pain with end range lumbar flexion and right rotation as well as various core stability tests. Most notably, his primary report of hip pain was reproduced during the lumbar cardinal plane testing. Since this gentleman had both hip and lumbar impairments, where was the BEST place to start?
Initiate Treatment at the Hip or Low Back?
During any hip examination, I always assess the lumbar spine. Since these body regions are connected via the pelvis, pain or symptoms in one region can directly impact the other. Additionally, I always use the patient's location of symptoms and mechanism of injury to help guide my diagnosis. As a general rule, if the patient reports that their pain is located anteriorly, symptoms are likely coming from the hip joint. From a movement perspective, less motion exists in hip flexion, adduction, and internal rotation, which places the anterior hip joint in a compromised position if pathology, such as hip OA or FAI, is present. If the patient reports their pain is located posteriorly, symptoms are likely coming from the low back region. Both the lumbar facet joints and regional nerves often refer posteriorly. While the L1-2 dermatomes can refer to the anterior hip joint, these nerve roots are less often irritated, which decreases the likelihood that the spine is causing anterior hip pain. There are always exceptions to this rule, but it is a great starting point to help guide your treatment selection.
What Did I Do with My Patient on Day 1?
Since his pain was reproduced with low back cardinal plane testing, I focused FIRST on the lumbar spine, then SECOND on the hip joint. During the initial visit, I did Trigger Point Dry Needling at the L4-5 multifidus and gluteal muscles. Then, I performed L5-S1 joint PA mobilizations to improve lumbar mobility and a hip long axis distraction manipulation. For his exercise prescription, he was given quadruped hand to heel rocks & repeated supine hip internal rotations. These both focused on improving mobility in general and desensitizing the patients pain.
Interested in learning more about the hip?
“An estimated 1.6 to 3.8 million sports-related mild tramatic brain injuries (mTBI), also commonly referred to as concussions, occur each year in the United States.”
The research on concussions has grown exponentially in the last decade. With better information, sports medicine professionals have been equipped with diagnosis and treatment of concussions. While it was once thought that complete rest for 7-10 days would clear up a concussion, we now know that some individuals sustain symptoms longer. We also have learned tools to better handle the post concussive symptoms and assist with treating these athletes.
While concussions are typically not seen in the clinic, in team sports they are much more common. I’ve been fortunate to be side by side with athletic trainers on the field and basketball court for over 600 hours learning about concussions and other acute injuries. During this time I was lucky enough to see the many faces of a concussed athlete. Symptoms such as inability to articulate words, difficulty with memory, and a rash of different emotions were just a few of the symptoms that have stuck with me from some of the concussed athletes I helped off the field/court. Learning to recognize these symptoms was one challenge, but treating them post-concussion was a whole different.
Treatment for concussions ranges. We know that intense exercise too soon can be detrimental to a post concussed athlete. Exercises targeting balance and proprioception are a must. Starting athletes out with simple balancing and progressing to ball tossing is a good start. Working on multi-directional lunge patterns or step-ups can be effective for neuromuscular control. Furthermore, dual tasking can be implemented to help with the cognitive function of a post concussed athlete. Dual tasking also serves the purpose of improving athlete performance as athletics often requires the combination of motor tasks and cognitive functions. Working an athlete in balance with a ball toss and reciting numbers or the alphabet is one example you can use to work dual tasking. You might be surprised how challenging this is in the beginning. Changing variables to progress the athlete is the goal. Moving from stable to unstable surfaces, adding a second ball, or tasking the athlete with a more complicated verbal recital are a few ways to progress. Just remember to continue slowly progressing cardio during this time.
Treating concussions can be a challenge without the right information. Fortunately, we have lots of information and research available to us as sport clinicians. Sideline coverage is a great way to start learning how to recognize the many different faces of concussions. Treatment will vary athlete to athlete but dual tasking can be a very effective way to rehabilitate these athletes.
-Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
The Clinical Practice Guidelines (CPG) have been developed over the last decade with the goal of summarizing best practice methods for various orthopaedic diagnoses. While the utility of CPG's may be debatable, they do an excellent job providing a summary of the evidence for managing the specific conditions. With the hip being the focus of December, I am going to review what the evidence shows for examining a patient with hip osteoarthritis and the appropriate interventions. Before getting started, a quick reminder for the grading system for research: A (strong evidence), B (moderate evidence), C (weak evidence), F (expert opinion).
These patients are over the age of 50 and exhibit the following presentation (A-Level Evidence):
-Moderate anterior or lateral hip pain with weight-bearing
-Morning stiffness less than 1 hour after waking
-Hip IR ROM < 24 deg or IR and Flexion < 15 deg compared to nonpainful side
-Increased hip pain associated with passive hip IR
Outcome Measures for Activity Limitation and Participation Restriction (A):
Activity Limitation/Performance Measures (A):
-6 Minute Walk Test
-30 Second Chair Stand
-4 Square Step Test
Balance Measures (A):
-Berg Balance Test
-Timed SLS Test
Physical Impairment Measures (A):
-Hip Strength Testing
As you can see, there are quite a few very reliable methods of diagnosing Hip OA and then tracking progress in function, balance, performance and impairment. It is in no way necessary to perform all of the above tests and measures. What I recommend from these is to identify your patient's goals and determine what outcome measures and performance measures will best track said progress. It is good to be thorough with the impairment measures in order to track objective changes. Once the patient has been diagnosed with Hip OA, there are several interventions that have shown varying levels of support.
-Education (B): activity modification, exercise, joint unloading, weight-loss
-Functional Gait and Balance Training (C): gait/balance training and use of assistive device
-Manual Therapy (A): thrust/non-thrust manipulation and STM and coupled with exercise
-Flexibility/Strengthening/Endurance Exercises (A)
-Modalities (B): US to ant/lat/post hip and coupled with exercises and heat
-Bracing (F): should only be tried if exercise/manual therapy fail
-Weight Loss (C)
As you can see, the typical trend for PT continues with treatment for this diagnosis: manual therapy and exercise have high level evidence. While education has moderate evidence, it would be interesting to see the benefit of education that was more focused on pain science, graded exposure, and cognitive behavioral therapy. These topics are more pertinent today given the findings of pain science research, especially given how frequently people have "Hip OA" and don't have any pain. Additionally, it was surprising to see that ultrasound had moderate evidence. Even so, I would recommend more focus be placed on exercise, education and manual therapy for these patients.
As a whole, I think that the development of CPG's will help to improve the standard of care. There is far too much varied care due to misdiagnosis. That being said, patients don't present "standardized" and we are moving away from pathoanatomical diagnoses as well. Hip osteoarthritis is so common in people that it is almost surprising that it even has its own CPG. There are so many factors that go into a patient's pain and disability experience: financial situation, relationship stress, past experiences, fear, and more. No two patients present the same. I recommend take the recommendations from the CPG into consideration, but don't hesitate to modify your plan of care based on the patient presentation.
-Dr. Chris Fox, PT, DPT, OCS
The Cervical Spine is Not Scary!
The cervical spine is a sensitive region relative to other parts of the body; however, you should not be scared or less confident performing an evaluation in this region! When performing a cervical examination, it is important to assess for vertebral artery dysfunction, upper cervical instability, and other non-musculoskeletal pathology. Once you have cleared these regional red flags, proceed as you would with any examination. The KEY to creating a reliable cervical examination is to follow the same general steps for every new cervical evaluation you perform. These tests and measures are performed in a systematic, reproducible manner. While the clinician may add or remove testing as needed, the general framework for formulating their diagnosis is consistent. This consistency allows for efficiency and reproducibility.
Cervical Examination Main Points
Cervical Examination Sequence
Cervical Day 1 Interventions (Post-Evaluation)
Similar to my shoulder evaluation post and lumbar evaluation post, my Day 1 cervical interventions heavily focus on desensitizing the painful tissue through graded tissue exposure. Additionally, I spend a significant amount of time educating the patient on pain science and specific postures to temporarily limit due to pain.
Cues and Main Focus Points
Thoracic Extension over Foam Roller
Cues and Main Focus Points
Many physical therapists are hesitant to perform a cervical spine evaluation due to a lack of confidence. Do NOT be one of them! Practice and perform the mental repetitions required to consistent and confident during your cervical examination.
-Jim Heafner PT, DPT, OCS
The temporomandibular joint (TMJ) is one of the least commonly treated regions of the body in outpatient orthopaedics. Due to this infrequency, many will therapists simply refer out to specialists when these patients present. Many are unaware of the fact that the TMJ and cervical spine are connected by more than just proximity. The spinal nucleus of the trigeminal nerve travels down into the upper cervical spine. Because of this relation, dysfunction (even if non-painful) in one can contribute to dysfunction in another. For this reason, among others the TMJ should be considered in management of cervical conditions and vice versa.
One general point to consider regarding TMJ arthrokinematics is that movement of the mandible requires motion in bilateral TMJ's. A restriction in one may force a relative hypermobility in the other. The arthrokinematics of the TMJ require both rotation and translation. Rotation occurs between the superior aspect of the mandibular condyle and the inferior articular disc. Translation occurs as the condyle and disc move on the mandibular fossa/articular eminence.
Protrusion/Retrusion: Relative anterior/posterior translation of disc and condyle on mandibular fossa/articular eminence. The mandible and condyle follow the slope of the articular eminence during the motion, so during protrusion, the mandible slide anteriorly and inferiorly. The opposite is true for retrusion.
Lateral Excursion: Side to side translation of the disc and condyle on the fossa. The ipsilateral condyle has minimal motion, while the contralateral condyle moves anteriorly and medially. The ipsilateral condyle almost acts as a pivot point.
Depression: Made up of two phases. During the early phase (35-50%), the condyle rolls posteriorly on the inferior surface of the disc with slight anterior translation. During the late phase (final 50-65%), it transitions to motion primarily consisting of condyle and disc translating anteriorly on the mandibular fossa and articular eminence. The roll and translation occur with varying degrees but the disc stays between the condyle and eminence to minimize stress between the structures. Protrusion and depression are limited by retrodiskal laminae being stretched by attachment to the disc.
Elevation: The opposite arthrokinematics of depression. Elevation is initiated by tension in the retrodiskal laminae.
When you are assessing an individual referred for TMD and cervicalgia, your examination should include both (along with the rest of the upper quarter). Some standard examination techniques include are ROM, resisted isometrics, segmental mobility, palpation, listening for joint sounds (disc displacement), cotton roll test, and posture. ROM of the TMJ can reveal potential limitations of the capsule. Normal ROM is: 45 mm for depression, lateral excursion is 1/4 of depression, protrusion is 6-9 mm and retrusion is 3 mm (Ho, 2011). Lateral deviation to one side may signify capsular restrictions ipsilaterally, potential muscle dysfunction, or an anteriorly displaced disc without reduction ipsilaterally. This may be represented as a "C-curve" when opening (an "S-curve" is associated with hypermobility). Resisted isometrics can help you to identify a particular muscle that is not functioning properly. Segmental mobility of both the TMJ and upper cervical spine can potentially assist in identifying hyper- or hypomobility in a segment related to the abnormal mechanics. Palpation can be useful for assessing trigger points or tenderness in a capsule. The cotton roll test can help differentiate between muscular and joint involvement. If a patient complains of pain when chewing on one side of the mouth, have the patient bite down on a cotton roll. By doing so, this gaps the ipsilateral TMJ. Thus, if pain is decreased, it would appear the pain is joint related, but if it doesn't change or increases, the pain is muscular (it is still possible that the pain is related to the cervical spine as well). Also, we cannot forget about the cervical posture. Knowing the resting position of the teeth is important to understand the individual's TMJ mechanics and as previously mentioned the impact cervical posture can have on the TMJ. Finally, be sure to check for any poor habits such as bruxism, chewing on ice, grinding teeth, etc. that impact the TMJ.
There are three primary disorders of the temporomandibular joint. Anterior disc displacement with reduction occurs when the disc rests anterior to the condyle. During depression of the mandible, the disc slides into proper position throughout the motion, but as the mandible elevates it slides into its anterior position again. Both of these disc transitions typically are accompanied by a "click." Anterior disc displacement without reduction occurs when the disc rests anterior to the condyle but is unable to slide into proper position during jaw movements. There is typically no clicking occurring with this pathology and depression of the mandible is limited (blocking translation of the condyle). Posterior disc displacement occurs when the jaw has been held widely open for a prolonged period of time or extensive range and the disc gets "stuck" posterior to the condyle, blocking mandibular elevation. With reduction, a closing "click" may occur.
While this article by no means serves as a "how-to" with managing the temporomandibular joint, it will hopefully help to understand the biomechanics of the TMJ and some general concepts regarding TMJ pathology. It is essential to at least consider assessing the TMJ in cervical patients, particularly if their progress is limited. Unfortunately, the research for TMJ management is rather limited at this time.
-Dr. Chris Fox, PT, DPT, OCS
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Low back pain is one of the most prevalent “dx” physical therapists see across the board. So how does low back pain management change with athletes? In some ways it’s exactly the same and others completely different. The important thing is to pay attention to the big picture stuff so you don’t miss a major injury.
Let’s talk about some of the major things we want to look out for and consider with the low back pain athlete. First of all, low back pain is not a normal finding. There is a reason the athlete is experiencing low back pain. For example, when I have a football lineman or gymnast come to me with low back pain my PT senses are automatically heightened. Why? Because these particular sports and positions are more predisposed to having a potential spondylolysis or spondylolisthesis. The reason being is the repetitive hyperextension and vertical loading required in these sports/positions. Therefore, part of my screening process is determining if I need to get these athletes imaging. From there, the management of these athletes with pars defects depend on the degree of slippage. For example, if an athlete has a lower grade slippage than often there is some period of activity restriction until pain subsides and then most importantly a gradual reloading with activity.
Another diagnosis often seen is disc issues. These are more common than one would think and can be another injury that takes an athlete out for some time depending on the severity. Athletes that undergo more axial loading, flexion and rotation in addition to collision sports are often in the higher rate of athletes with lumbar disc herniations. One clinical pearl to offer is that sometimes when there is nerve involvement, the motor function is more affected than the sensory function. Therefore, just because an athlete doesn’t complain of the “common” tingling or numbness in the leg, doesn’t mean you should skip a myotomal exam.
Return to sport following a low back injury in the athlete can be another challenge. While there is no “gold standard” return to sport testing for low back pain, plenty of data exists that athletes can return at a very high level following a low back injury (ex: Tiger Woods, Rob Gronkowski). Instead of the common algorithm like the knee has with hop tests (etc), the lower back is a little more multifactorial. However, similar principles apply. Return the athlete to his/her baseline function, clean up movement abnormalities, re-establish strength levels, and have a gradual return to sport with controlled to uncontrolled practices in the respective sport. There is no one way and we should not make it one way. Instead, understanding the needs analysis of the sport, position, and the athlete’s previous level of function should be our goal.
Low back pain in athletes can be a challenging case to manage. While it starts with a very solid assessment, understanding the biomechanics and positional demands of the respective sport will guide your interventions and eventual return to sport. Make sure you understand each sport and position carefully. For more information on return to sport considerations in the athlete and specific progressions and regressions, check out our Insider Access.
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
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