In physical therapy school, therapists are taught a broad spectrum of knowledge. Orthopedic examination, treatment, and prognosis is covered in-depth. For example, we learn more than 50 special tests to diagnose shoulder impingement, rotator cuff dysfunction, biceps pathology, and labral tears. Despite all this knowledge, therapists lack the ability to prioritize these tests. Many therapists gather information without considering ‘why’ we perform each measure. We soon realize that the special tests are not very special! Upon finishing their clinical examination, they are drowning in information that only minimally changes their patient’s prognosis or intervention selection. The therapist has found several secondary and tertiary impairments without identifying the primary cause of the problem. In this post, I am going to discuss how I perform a shoulder evaluation and review some of my regular day 1 shoulder exercises.

For new clinicians, it is important to develop an efficient and reliable examination. This combination of efficiency and reliability will minimize any redundancy of testing while maximizing time for treatment. Below is my template for performing an efficient examination. For the purpose of efficiency, it is divided by patient position. You will notice that only a few special tests are performed and the biggest focus is on assessing regional joint mobility. ​

Upon completion of the shoulder examination, the next step is selecting appropriate interventions. From my clinical experiences, the shoulder joint is typically irritable in the acute stages. Therefore your exercise selection and manual interventions should address the patient's pain. My Day 1 interventions heavily focus on desensitizing the painful tissue through graded tissue exposure. Additionally, I spend a significant amount of time discussing the different mechanisms that impact pain. These exercises often include range of motion exercises and posterior shoulder muscle activation. If the patient has low irritability, further strengthening and mobility exercises can be initiated early in the plan of care.

Questions or comm​ents? 
Let us know what initial interventions you typically use when working with shoulder patients!
-​Jim Heafner PT, DPT, OCS

The shoulder is a complex region of the body as it is comprised of several different joints: glenohumeral, sternoclavicular (SC), acromioclavicular (AC), and scapulothoracic. In this post I will primarily be discussing the AC joint anatomy, joint mobility, and how to address movement restrictions in this region.

Kinematics
The AC joint is primarily responsible for subtle  adjustments of the scapula relative to the clavicle. The scapula upwardly rotates at the AC joint during shoulder flexion and abduction. It downwardly rotates during extension and adduction. With the horizontal plane, the AC joint permits some internal and external rotation. Additionally, the AC joint has slight anterior/posterior titling in the sagittal plane. It is important to remember that the majority of the AC joint kinematics are pretty minimal. Not much motion occurs here at all, but it is still important.

Assessment and Treatment
The AC joint is often responsible for the end-range elevation mobility in the shoulder. While this joint should always be assessed, it should definitely be considered when elevation mobility is restricted. Should there be an actual injury to the AC joint, it typically will present as pain over the joint and possible visual deformity. There are also several tests for AC joint injury, a couple (Active Compression Test and Horizontal Adduction Test) of which are shown below:  

To help improve or retain mobility in the AC joint, I recommend some general mobility exercises or possibly some upper trap/serratus anterior strengthening to facilitate end-range elevation.

For more videos like this one on the AC joint, be sure to subscribe to Insider Access!
-Dr. Chris Fox, PT, DPT, OCS

It's that time of the year again when nerves start to settle in for those who are taking this July's NPTE exam.  I remember very distinctly the days leading up to the exam and I am sure you all share some of the same feelings.  Am I ready? Did I study enough? Can I withstand the long test?  

Don't worry, these feelings are all normal.  Chances are, you are more than prepared.  You finished physical therapy school (which isn't easy) and you completed clinical rotations.  That in itself is great prep for your exam.  On top of that you've been studying for at least the last few weeks (hopefully).  You're not going to be able to memorize or remember everything and thats OKAY.  Nobody can remember everything and there will be some questions that you going to say "WHAT?".   But rest assured, some of those questions are going to be thrown out because they are test questions for future exams.

Still not convinced you did enough?  Let me tell you about my story.  I got into USC's sports residency in May of 2013.  However, because my school's graduation date was after the date to apply for an out of state exam (I had to get finger printed, etc for California) I was not allowed to take the July exam.  Which meant I had to stop studying and wait until October.  Then, in late June I got a call that I'd been approved for the July exam after multiple people called on my behalf.  Which meant that I had less than a month to study for this exam, move to California, get an apartment, and then take the exam!  My final days before the exam were spent flying to Los Angeles, picking up my car 45 minutes away that I had shipped with all my stuff, and studying in between my Dad and I putting my apartment together to be functional.  So trust me, you will be fine! 

Final Tips for the last week:

- Review what you feel least comfortable about
- Go to bed at the same time and wake up at the same time to get your body used to exam times
- Get some good workouts in but don't exhaust your body
- Don't experiment with any new food or drinks
- Find something to take your mind off of the exam the night before (ex: a movie)
- Wake up exam day and commit your mind that no matter what is thrown at you, today you are going to find a way to get the answers correct

Good luck to all that are taking the NPTE! 
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS

The final weeks before the July 2018 NPTE exam are upon us! While this post is not about how to study, I do want to include my TOP piece of advice: As a general rule, I cannot stress enough the importance of taking practice exams and analyzing each question (both incorrect and correct answers). I took five or more practice exams and looked through every question thoroughly. Multiple times I found myself answering questions correctly, but using the wrong clinical reasoning. Other times, I would answer a question incorrectly, but had the proper thought process. These reviews will solidify the information you know and significantly improve your weak points. To read more about how Chris, Brian, and I prepared for the exam, click HERE. 

Whether you have been studying for 3 months, 3 weeks, or 3 days, this post is a friendly reminder to spend a little extra time on 3 important subjects. I break down each one below!

While the direct 'research based' questions are <5% of the examination, it is important to know the difference between sensitivity, specificity, and likelihood ratios. These metrics are commonly seen on various examination techniques, and give practitioners an idea regarding how beneficial that test is clinically.  Sensitivity refers to a test's ability to accurately rule out a disease and is scored between 0 and 1.00. Tests with high Sensitivity, rule Out a disease (SnOut). Specificity refers to a test's ability to accurately rule in a disease and is scored between 0 and 1.00. Tests with high Specificity, rule In a disease (SpIn). Positive and negative likelihood ratios work in a similar way but are not limited to numbers between 0 and 1.00. They act more as "persuasive information" and are more individualized than sensitivity and specificity (Jewell, 2010). Clinicians are required to determine a patient's pretest probability, then incorporate the likelihood ratio for the test and determine how "likely" the patient has the pathology. Keep in mind that the diagnostic accuracy applies to a specific patient population, and will change as other variables change. For example, the sensitivity and specificity of the Lachman's test is largely different in the acute phase of injury versus the chronic phase. Below is an example question from PT Final Exam:

From the rotator cuff to the menisci, there are multiple special test clusters that exam participants must review. While these tests may lack good diagnostic accuracy individually, when clustered together, their ability to diagnosis tissue pathology significantly improves. In addition to the special test clusters, I highly recommend looking at Wells Criteria for a Deep Vein Thrombosis, the Ottowa foot and ankle rules, and hip/ knee arthritis criteria. 

While TSPT blog has a few posts on the cranial nerves, I have referred to our friends over at physiopedia for more in depth information. There will be test questions on the cranial so you must know each one and their function. "There are 12 pairs of cranial nerves and they are numbered according to their position of where they originate in the inferior surface of the brain...The names of the cranial nerves sometimes correspond with their individual function. The cranial nerves are comprised of axons that are either sensory, motor or both."  [Reference: Cranial Nerves]. Watch the video below to learn more! 

Best of luck on your final weeks studying for the NPTE!
​Jim Heafner PT, DPT, OCS

Your athlete comes into see you and has bruising and pain around the lateral ankle, extending down to the foot.  He reports that he was at basketball practice and turned his ankle pretty hard.  He has a history of lateral ankle sprains and presents with increased swelling consistent with a lateral ankle sprain. Yet, he complains of pain along the lateral aspect of his foot and some pain on the plantar side.  

The above scenario is something I have seen many times.  Just last year I had a NBA draft prospect that sprained his ankle during a draft workout but was not getting better and had trouble walking.  By the time I saw him he was 6 weeks from date of injury and struggling to understand why his ankle sprain wasn't better.  There was a slight prominence on the plantar side of his foot about where the cuboid was.  He had lots of pain with walking and weight bearing with pinpoint pain around the cuboid.  I performed a cuboid whip and he immediately had relief of pain.  

Cuboid syndrome is an often overlooked diagnosis with lateral ankle sprains and lateral foot pain.   Cuboid whips are a very effective treatment for these type of injuries.  Signs of cuboid syndrome often go unnoticed because of similarity to ankle sprains.  Some of the more common signs include:

• Sharp pain on the outer and underside of the foot
• Increased pain when weight bearing
• Relief with rest and non-weightbearing on the foot
• Potential mild swelling on the outer side of the foot

Learning to effectively treat ankle sprains and cuboid syndrome with manual therapy can be very beneficial.  Check out the video below to learn how to perform some of mobilizations and manipulations of the foot!

Learn how to perform some of the most beneficial mobilizations and manipulations of the mid-foot/forefoot

Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
​Board Certified Sports Physical Therapist


Learn more at Insider Access

July is here! This means that we are nearing the next National Physical Therapy Examination (NPTE) that is offered quarterly (July 24-25). After going to graduate school for three years to become Doctors of Physical Therapy, your ability to practice is determined by the NPTE. While the purpose of physical therapy school is to prepare clinicians to safely and effectively rehabilitate patients, the direction of school is developed to prepare students to pass the NPTE. Even with three years of schooling, the examination can be intimidating due to its length and significance. In this article, I will review various study methods and recommendations for the examination.

There are many different resources available to make studying for the examination a little less frightening. For starters, the primary prep books include Scorebuilders and TherapyEd. Each of these texts are updated annually to stay in line with the NPTE. They come with overall content summaries (Scorebuilders with various charts is easier on the eyes and TherapyEd is more outline based) and sample tests at the end of the book. The content summaries, while useful, are not typically sufficient by themselves. It is recommended that you take each topic in the book with which you are unfamiliar and expand upon it with either textbooks or notes from school.

The most useful component of the books is the sample examinations and answers. These examinations and answer explanations provide reasoning as to why certain answers are viewed as correct and others are "not as correct" (it is essential to remember that the exam often looks for the best answer available, not necessarily the true best answer). The exams will also give you an idea of how prepared you are overall for the NPTE and which specific areas you are deficient (there is an item analysis and breakdown after you complete each sample test). Both Scorebuilders and TherapyEd exam questions tend to be harder than the NPTE (the PEAT questions are most similar to the NPTE), but TherapyEd has the hardest questions. Because of this, I personally preferred TherapyEd as I like to be over-prepared for exams (I like to approach a difficult test and feel that it ends up being easy by comparison).

There are several supplemental resources available as well. Both Scorebuilders and TherapyEd offer flashcards as a studying tool. If you are a flashcard user typically with studying, these may be useful. These companies also offer study prep courses that can be attended in-person. I attended the TherapyEd course, which while useful for understanding overall components of the exam, did not help in understanding actual content (that studying is left up to the individual). Finally, there are other companies that offer online prep courses and mentoring, such as PT Final Exam. Often these courses provide a timeline for studying the content, regular sample exams and feedback on areas to improve and methods for studying. Whatever resources may be best for you likely depend on your studying habits.

As a general rule, it is recommended that the primary studying focus on the "Big 3." Somewhere around 60-70% of the NPTE questions will be based off the Musculoskeletal, Neuromuscular, and Cardiopulmonary subjects. They may include interventions, foundational information, examination or any other subtopics, but those three subjects comprise the majority of the test. With that said, studying should focus on these areas and add in the other subjects (i.e. modalities, ethics, etc.) as you feel more confident with the major topics. 

Should you feel confident in any specific area, you can spend less time studying that subject. I felt much more knowledgeable with the Musculoskeletal content, so I focused on the other two. The item analysis from the practice exams is perfect for finding those areas of weakness and strength, so it may be beneficial to take a baseline practice test and then at various intervals so you can continue adjusting your studying focus as you move closer to the NPTE. If you are short on studying time, focus primarily on the "Big 3" and touch up with the remaining areas of weakness.

Generally, I recommend using the study tactics that you found successful when going through school. If you did well studying in groups, study in groups. If you did well with using flashcards, use flashcards. If you took longer to study for an exam, start earlier. I recommend starting with a practice exam to establish your baseline strengths and weakness. From that point, make sure you make the "Big 3" strengths and then move onto the other areas. Use the test prep book as your foundation for studying. I recommend working your way through each section and expanding upon a specific diagnosis, intervention, etc. using your class notes or text books. When you go through the practice exams, not only do you want to see why certain answers are wrong and certain answers are correct, but keep a mental log of the type of questions that are asked. This may redirect how you have been assessing and studying each topic.

Finally, I recommend setting a schedule to study the content with more time allotted for the larger areas and some time left over leading up to the exam for final review and "touch up." This will keep you on task and ensure you cover the necessary material. While preparing for the NPTE, it is essential to take time to exercise, reflect/meditate, and relax. Whatever you use for stress relief will only facilitate your studying. The evening before the exam, I recommend taking it easy (don't cram!) and do something enjoyable: go out to eat with some friends, watch a movie, distract yourself from the exam and allow mind to rest as it prepares for the big day. If you have any other specific questions about how to prepare for the NPTE, feel free to reach out to us as we would be more than happy to help you make that transition to a licensed physical therapist!

​-Dr. Chris Fox, PT, DPT, OCS

Understanding hindfoot mechanics is tough! Unlike the shoulder or knee joint, the multiple joints in the foot and ankle complex do not follow standard concave/convex arthrokinematic patterns. Additionally, the complex mechanics change whether or not the individual is in an open or closed kinetic chain. For example, movement at the subtalar joint consists of the triplanar motions of pronation and supination. 

• Open-chain pronation: dorsiflexion, eversion, and abduction of the calcaneous
• Open-chain supination: plantarflexion, inversion, and adduction of the calcaneous
• Closed-chain pronation: calcaneal eversion with plantarflexion and adduction
• Closed-chain supination: calcaneal inversion with dorsiflexion and abduction

For this reason, foot and ankle mechanics are difficult to comprehend!  In this post, I will review hindfoot mechanics of the talocrural and subtalar joints. Additionally, I have included a clinical application video explaining how I incorporate these mechanics in practice! 

The foot and ankle consists of 26 bones and 100 distinct muscles, ligaments, and tendons. The rearfoot (a.k.a hindfoot) primarily refers to the talus and calcaneus bones of the foot. The talus articulates with FOUR seperate bones- the tibia, fibula, calcaneus, and navicular bones. The superior articulation between the talus and tibia/fibula is known as the talocrural joint. The talocrural joint is a uniaxial synovial joint connecting the distal tibia to the talus. While many people view the talocrural joint as only a hinge joint, others authors argue that it is more complex due to the composite internal and external rotation that occurs during dorsiflexion and plantarflexion respectively. For the purpose of this post, the primary movements at the talocrural joint are plantarflexion and dorsiflexion. The average individual has approximately 15-20 degrees of dorsiflexion and 50 degrees of plantarflexion. These motions are often limited due to inadequate stress and load through the joint.   

The subtalar joint (a.k.a. talocalcaneal joint) is comprised of the talus and calcaneus bones.​ As described in the introduction, the primary motion at the subtalar joint is pronation and supination. However, pronation and supination are not simple movements- both consist of 3 distinct movements, which changes depending on the foot's location to the ground. During ambulation, closed chain pronation must occur during the stance phase. This motion consists of calcaneal eversion combined with talus adduction and plantarflexion. This is described nicely in a post from the Gait Guys, "In a perfect biomechanical world, shortly following initial contact with the ground, the calcaneus should evert 4-8 degrees, largely because the body of the calcaneus is lateral to the longitudinal axis of the tibia. This results in plantar flexion, adduction and eversion of the talus on the calcaneus, as it slides anteriorly. At this point, there should be dorsiflexion of the transverse tarsal (calcaneo-cuboid and talo-navicular joints). Due to the tight fit of the ankle mortise and its unique shape, the tibial rotates internally (medially). This translates up the kinetic chain and causes internal rotation of the femur, which causes subsequent nutation of the pelvis and extension of the lumbar spine. [Citation: Gait Guys]" 

The subtalar joint must have adequate mobility to allow for proper structure of the arch. When motion is restricted, mobility issues often arise in the midfoot or at the talocrural joint as a compensatory strategy (see treatment video below). 

After the diagnosis of an ankle fracture has been made, the region is typically immobilized with limited weight-bearing. The severity and location of the fracture contributes to the decision on what level of immobilization is required: open reduction internal fixation, CAM boot, aircast, etc... This timeframe for immobilization typically occurs for 4-8 weeks (factors like osteoporosis and peripheral vascular disease may impact the timeframe). Once radiographic evidence of sufficient healing occurs, the patient often begins skilled physical therapy.

Initially, the primary focus will be on reducing swelling and improving joint mobility. This is often done with ROM and stretching exercises, joint mobilization, soft tissue treatment, and modalities. Open-kinetic chain strengthening exercises are typically started once the patient's fear of movement and activity tolerance improved. During this initial acute phase, gait training may be necessary to train the client on how to use crutches, how to maintain appropriate weight-bearing status, etc. As the patient gains mobility and weight-bearing is progressed (based on bone healing), weight-bearing exercises will be progressed. The patient may initially need to perform AAROM exercises in closed-kinetic chain in order to address any apprehension and improve load tolerance, while restoring mobility. Full ankle motion is not required nor expected before weight-bearing is initiated. Once the patient presents with sufficient tolerance, closed-kinetic chain load is progressed further with shuttle squats and calf raises, to full body versions as well. Exercise progression becomes more typical at this point as various methods of loading (lunges, squats, step-ups/downs, etc.). What likely needs to be addressed is stability training in some form to improve reaction and balance when stability is challenged. This can include standing on unstable surfaces, incorporating mental and upper extremity tasks, agility/plyometric training, etc. 

In physical therapy school, the thoracic spine is often glossed over during the musculoskeletal courses. This may be due to the low incidence and prevalence of thoracic spine pain. The incidence of thoracic spine pain is only ~15-19% across the population. This is relatively low ​compared to lumbar spine pain, which has an 80% prevalence in adults. Additionally, physical therapy schools may choose to emphasize the non-musculoskeletal diagnosis that are important in the thoracic spine. Since many organs are housed in the thoracic cavity, hours are spent on non-musculoskeletal diagnosis. For example, if a patient presents with thoracic spine pain, it is more important to rule-out a myocardial infarction than a thoracic facet restriction. Regardless, there is a gap in student's knowledge regarding thoracic spine anatomy and biomechanics, mobility assessment, and differential diagnosis.
 
In this post, I will be reviewing the active range of motion and segmental mobility assessments for the thoracic spine. Additionally, I have added some clinical pearls for thoracic anatomy and biomechanics! 

Additionally, the thoracic spine houses the sympathetic nervous system. The sympathetic nerve trunk lies anterior to the costotransverse joints. Clinically, this may help explain unusual symptoms  that can be reproduced by neural tension tests such as the SLUMP TEST or Straight Leg Raise Test. Sympathetic innervations of the head arises from T1-T2, the upper extremities from T3-T7, the lower extremities from T8-T12 and the trunk from T1-T12.
​
As Dr. Chris Fox wrote in a previous post on thoracic spine anatomy, "In the thoracic spine, T4-9 is known as the critical zone because the vertebral canal is narrowest here; it also has reduced blood supply (Egan et al, 2011). T6 is a tension point; here motion of the spinal core versus canal converge in different directions." Improving the neural mobility in the thoracic spine can help improve movement and decrease pain in the joints above and below. 

Below are descriptions and pictures of thoracic spine active range of motion assessment. While it is impossible to isolate the thoracic spine, certain pelvis and lumbar spine positions can give the therapist a better idea of thoracic motion. In addition to the pictures below, I also assess thoracic flexion, extension, and rotation range of motion in quadruped. 

Segmental mobility is used to determine how much motion is available at each segment. In theory, this assessment is more specific than an active range of motion assessment as it tries to isolate each segment of the spine. While segmental mobility has been shown to have weak inter-rater reliability, practicing the assessment technique can be useful for improving tissue palpation and improving one's hands-on skills. Additionally, this assessment can help guide interventions when clustered with a patient's other symptoms.    

Golf is a popular sport around the world, especially in our middle aged and older patients.  Due to relatively low contact stresses, the sport is accessible for people of ranging physical capabilities. However, the biomechanics of the golf swing require proper mobility and stability throughout the body, especially at the shoulders, spine, and hips.  Many of our wellness clients are golfers who simply want to perform at a higher level on the course. Most of the time, the missing link is unlocking the thoracic spine.

Having proper mobility in the thoracic spine can improve the mechanics of the shoulders, low back, and hips. Biomechanical studies of the golf swing have shown a direct link between hip and shoulder rotation. From a structural standpoint, the thoracic spine is in the middle of those two joints and needs to be able to move. Additionally, the sympathetic nervous system is housed directly beneath the middle back, playing an important role in neural mobility.
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Many therapists prescribe tennis ball and foam rolling tricks for generalized t-spine mobility, but these are often isolated movements. For proper return to sport, therapists must be incorporating movements that engage the thoracic spine, while using the shoulders and hips. Furthermore, without t-spine rotation, the lumbar spine is required to produce more rotation. While lumbar rotation is not inherently bad, dispersing the rotational stresses throughout the spine is ideal. Using combined exercises for improving hip motion AND thoracic spine motion can useful for both rehab and warming up before golf.

Below are a few effective treatment options to mobilize the thoracic spine.  

Interested in more advanced content for your golfers? Check out our Insider Access!
 
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS