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.

 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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A good clinician ​will follow the same general steps when performing any Physical Therapy Evaluation. 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. For example, in the lumbar evaluation the examiner assesses the function of the core muscles in supine; however this should only be completed after a thorough examination of the functional testing of the core in standing. It would not be an efficient use of time to take an acute low back pain patient from standing, to supine, back to standing, to prone. The entire session would be disrupted with positional changes. Additionally, the goal of any physical therapy session is to maximize the patient's functional ability so we must assess function first. 

Similar to my shoulder evaluation post, my Day 1 lumbar 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. 

General Cues

• Position yourself so that your hands are directly under your shoulders and knees are directly under your hips
• Rock backwards as far as you can before your lower back starts to round
• Make sure that your head does not start to look up or drop down and that your lower back does not round during the exercise

​I like to use a foam roller or dowel along the lower back to ensure the neutral position.

There are no single set of exercises for every patient. Their individualized pain triggers and tolerance to exercise will heavily dictate what they can do! 

Jim Heafner PT, DPT, OCS

Last year I wrote an article about neurogenic inhibition testing. Neurogenic Inhibition is the concept that the muscle's ability to produce resistance and contractile force is limited by the neural input, not the true muscle strength. It is indicated when either a muscle became weaker with repetitive resistance testing or if the strength improved when resistance was gradually increased. In the past, I addressed these conditions with focusing on improving mobility along the path of the nerve and with strengthening the affected muscles.

I'm not saying that I agree with the theory, or that there is even any research to support this assessment method; however, I have noted regularly that strength changes can occur with changes in spinal positioning. The method that my mentor treats these cases is that he works on increasing strength and activation of the spine in the deficient region and then supplementing that activity with exercises that work the affected myotomal levels. For example, I evaluated a patient this past week that had 4-/5 strength of his R glutes, ankle DF and ankle eversion, all of which became 5/5 with lumbar bias into extension (complaints of drop foot for 4 years after cervical spine surgery). Some exercises we went over included ones that bias the lumbar spine into extension (APT) and work the glutes, toe extensors, and ankle eversion.

Proposed Theories 
It may be that the patients improve because of increased "stability" in the dysfunctional direction, it may instead be due to improving mobility in the dysfunctional direction, or it may be something else altogether. However, because there is so little research in the area, we don't even know how effective the method is in the long-term; however, it is worth exploring due to the immediate changes that can occur. I like to implement Neurogenic Inhibition Testing to help direct my treatment direction. I have found that this same assessment method tells me which direction a patient may respond to repeated motions. Using the same previous example, if the strength improves with lumbar extension bias, I would have the patient perform repeated lumbar extensions (or a variation of it) and recheck the strength. In most cases, the strength is improved afterwards without doing the same biasing. In fact, the patient I described came back from the evaluation with a HEP of press-ups with a R bias and his ankle DF/eversion and hip abduction strength were all 4+/5 without any lumbar spine bias. It is far too early to tell if any long-term or practical changes will occur however the testing may still play a role. It can be useful when a patient is so acute that they may not be ready for a full repeated motions assessment. In general, my treatment method is going to stay the same as discussed in the previous article: improve mobility of the nervous system along the entire path, wherever restricted, and strengthen the affected muscles. I may get there differently with this alternative testing method and I may incorporate some of the treatment theories as well.

-Dr. Chris Fox, PT, DPT, OCS

​I was recently working with a 16 year old, active young man who injured his knee while playing rugby 6 days prior. During the initial evaluation, he reported quickly decelerating on the field while pivoting his body. He only had minimal pain, and his swelling was quickly improving with each day following his injury. Additionally, he had a rugby tournament overseas in 2 weeks that he needed to be in good athletic condition to play.

As I continued to the examination, I performed the Lachman's Test, which was positive, as well as a positive Anterior Drawer Test. Despite the positive finding, he denied any buckling, locking, or catching. His clinical examination was negative for meniscal pathology and other ligament insufficiency. At this point, I was confronted with the ethical dilemma: Do I tell him his ACL is likely torn or not? On one hand he was making good progress with rest and gradual return to activity. Would the diagnosis of a torn ACL create thought viruses that would hinder his progress with conservative treatment? On the other hand, if he had a torn ACL, does he potentially have other associated injuries? Segund fractures are present in 75-100% of ACL tears. Lateral meniscus tears occur in 54% of acute ACL injuries. 

The following week, he travelled with his rugby team and played in several matches. Upon his surgeon's recommendation, he would have surgery after the tournament to reconstruct his ACL and repair the meniscal tear. In this case, should surgery have been avoided? Was his ACL surgery really necessary? 

For many many, a torn ACL was synonymous with surgery. However recently, the optimal management of ACL injuries has been placed under question. Recent research, 'A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears,' identified that ACL reconstructive surgery was NOT superior to conservative management of ACL tears in young active adults. A second study by Meuffels et al, found similar outcomes between surgical and non-surgical groups at 10-year follow. The authors concluded, "we found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome."

If the outcomes are similar, why are surgeons still being performed at an alarming rate? As with most questions in physical therapy, the answer depends on a variety of factors. Clinically, I try to identify if the patient is a 'coper' or a 'non-coper.' Copers are individuals who can function at their desired level despite having a torn ACL. Non-copers are individuals who are unable to function at their prior level following an ACL injury. Copers will demonstrate good quadriceps strength, no buckling or giving way in their knee, and strong, pain free hop tests following conservative rehabilitation. Non-copers will continue to have giving way of their knee, pain that limits function, and subjective reports of decreased quality of life. Regardless, whether someone is a coper or non-coper, it is important to educate them on the pro's and con's of both surgery and rehab. 

References:
1. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med2010;363:331-42.
​
2. Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures: a matched-pair analysis of high level athletes. Br J Sports Med2009;43:347-51.

​Did the title of this post catch your eye? Articles with similar titles have caught my eye for years in my quest to understand proper sports rehabilitation and return to sport. Yet, despite completing a sports physical therapy residency with USC in 2014 and becoming a board certified sports physical therapist, I still find myself searching for more answers every day. I end up with more questions most of the time (which I think means I’m on the right track?).  
 
Regardless of my current quest to continue to improve my knowledge and ultimately application of knowledge in return to sport, there are a few things I have learned that are worth sharing.  Return to sport is a big buzz word and I feel confident saying that not one person has all the answers.  I’ve been lucky to be in a residency class that boasts two NFL physical therapists (Rams & Eagles) and every conversation I’ve had with them (in the past and recently) demonstrates to me that they too are constantly searching for ways to improve these processes.  Which is pretty crazy because they have great track records.  
 
My interest in ACL return to sport stems from my love for basketball and my years of special interest in treating the basketball athlete.  Unfortunately, too many basketball players suffer from ACL injuries. This sparked my interest in understanding why this happens, how we can better prepare these athletes (prevention), and what we can do to successfully return them to sport at the highest level. I say return to sport at the highest level because too often I see players return to practice level but not full game level.  
 
Currently, literature has focused on more objective criteria and milestones based progressions. However, as we know, it does take the literature time to catch up to what we see anecdotally.  Functional tests are good but do not take into consideration reactive measures.  I find myself using these tests but often adding in different movement testing with reactive components to try to mimic sports.  After all, almost all movements in sports are unplanned.  Training our athletes during their rehab or injury prevention in reactive environments can be very useful. 
 
How can we start to train “reactive” components?  I find it best not to overthink this and I often use auditory commands or visual commands. For example, when training a basketball player with shuffling in a defensive stance, I will say “Right!” or “Backwards!” or “Left!” continuously for a specified time to signal to the player to shuffle in that particular direction. Using your hands to point in specific directions is another way to do it by challenging a different sensory input. Lastly, using props such as a foam roller, tennis ball, basketball, etc to throw or drop it in a particular direction can be very effective in training reactive first steps.  It’s important to note that I often like to record these drills to look at movement both in the moment and afterwards to see what I missed with their preferred movement strategies.  
 
ACL return to sport needs to be a multifactorial approach.  As this literature article suggests, there are many ways to start preparing our athletes for their eventual return to sport.  Understanding the particular athletes sport is something that is also absolutely crucial.  Adding psychosocial components, fatigue testing, reactive testing, and sport specific movement based testing is just as important.  If you have ACL athletes and do not understand the biomechanics of their sport, take a look through the literature and check out our resources here and here.  Most importantly, continue to ask questions to yourself with each athlete you have to find continued ways to improve their outcomes. 
 
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS 
Board Certified Sports Physical Therapist 

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What if this same tool reduced errors? And was easy to use, low-tech, and cost $0?
Would you use it? What if I told you that tool was a checklist…

​When you are first learning how to perform orthopedic evaluations as an SPT, the demands on your attention can be overwhelming. Within your evaluation time frame- say you have 20-30 minutes, you must: take a subjective history, perform comprehensive testing (range of motion, strength, joint play, palpation, and special tests), as well as move the patient efficiently through multiple body positions (supine, prone, standing, sitting, etc.), and finally you must distill all of this information into a differential diagnosis. Whew! It is a lot to think about when you first start off! Any tips and tricks to improve efficiency, accuracy, and consistency of your physical therapy (PT) evaluation are truly valuable. ​

One tool that I have come to rely upon in learning how to perform a consistent and effective evaluation, in a timely manner is The Checklist. As I’ve written about before (Can A Checklist Make You A Better PT?), checklists have been used in various medical settings with positive outcomes (improving patient outcomes, reducing medical errors, and guiding treatment decisions). The checklist does not only function to reduce errors, but I believe it can be an effective learning tool for guiding appropriate practice when learning how to perform PT orthopedic evaluations.

If you want to get good at the evaluation process, it is not enough to just practice evaluations. You must take a hard look at HOW you practice evaluations. There has been a lot written about this concept in scientific journals as well as the popular literature on expertise and skill learning. (1,2,5) In order to improve a skill to the level of “mastery” or “expertise”, you must practice that skill in very specific ways. The way you practice must include focused attention as well as a means for receiving reasonably timely feedback. As students, some of this feedback can come from our professors, some can come from peers, but much of our feedback is self-delivered feedback.

​Setting up conditions for practicing evaluations is not so different from how you might approach (or teach) someone who is learning a new movement skill. The complex skill, either movement skill or orthopedic evaluation, must be broken down into its component parts and each part practiced to the extent that it is performed correctly.

1. Break Down The Evaluation into “Sets and Reps”
     1st “Parts” Practice > 2nd “Whole” Skill Practice

• Practice 10 “subjective” patient interviews in a row, then practice 10 “objective” patient exams in a row (if they are not all close to the “perfect” way you want them- do it again. Use the checklist to assess your accuracy/completeness).  
• Only once your “Parts” are consistently very good should you go on to doing a full practice evaluation: practicing the “Whole”
• If you need to break this down into smaller “Parts” to improve your consistency and quality, do it! For example: practice assessing shoulder AROM 5x in a row, until it is automatic.  

2. Increase the Quality of Your Practice Reps
     “Practice” the way you want to “Play”

• Well documented in the learning science literature is the idea that “practice does not make perfect. Perfect practice makes perfect”
• Checklists can increase the “quality” of your practice reps
• If you practice an evaluation completely “by memory” and are forgetting pieces, I hate to say it, but this is how you will most likely perform

3. Your Evaluation Should Be 75% Identical EVERY TIME
​     The Fundamentals Must Be Automatic Before You Get Fancy

• You need to become a robot: With the exception of special tests/add ons your flow in evaluating a certain body part should be predictable and scripted (e.g., AROM > PROM > MMT)- once this is automatic, then and only then will your higher level clinical reasoning and differential diagnosis skills improve
• You must minimize errors of omission (leaving out key items) (Use The Checklist to make sure you have performed every piece and in the correct order)
• You must minimize errors of commission (doing unnecessary tests), If 75% of your evaluation is the same every time- you have more cognitive resources to decide what is MOST important for that other 25%, make it count!
• Speed/efficiency is developed second (I believe that “fast and sloppy” is never a good place to start. I tend to believe that it is best to start off with a slow but “technically” correct skill and the speed will come).
• If you are always thinking about what comes next, you cannot effectively listen to the patient and evaluate their response (again your exam flow must be automatic). 

As clinicians, I think there is a natural desire to want to feel the state of “Flow” early on- that everything is clicking and you are utilizing a unique combination of scientific “truths” and intuitive judgments in your evaluations. But, flow and mastery take time to develop. So, I would argue that as you are starting out, the number one priority should be to make your evaluations as consistent as possible- almost to the extent of feeling “boring” or rote. This idea, I think is well expressed by famous psychologist, Mihaly Csikszentmihalyi, who coined the term “Flow” (4) and is author of the book: “Creativity: Flow and the Psychology of Discovery and Invention” (3). In this book, he writes,“You must first learn your craft and then set it aside.”

​I’m off to practice my evaluations…
 -Leda McDaniel, SPT 

Leda is a current Doctorate of Physical Therapy (DPT) candidate at Ohio University and upon graduating in May 2019 is interested in working with orthopedic patients with chronic pain. Leda recently published a book about her experience of personal recovery from chronic pain, which you can find on Amazon:
https://www.amazon.com/dp/069212120Xref_=pe_870760_150889320
You can also find her blogging at: https://sapiensmoves.wordpress.com/

One of the foundations in our residency and fellowship training and a component of our courses is Sahrmann's Movement Impairment Syndromes (MIS). While it has its faults, the system can be incredibly effective in identifying and categorizing abnormal movement patterns. When reading the text, it becomes apparent that the concept isn't all that unique; however, the system connects clinical reasoning pathways in a very easy to understand way. 

Recently, I had two patients come in with presentations of thigh and knee pain that I initially diagnosed with meniscus tear with sciatic nerve adverse neural tissue tension (ANTT). While this diagnosis may be correct in some circles, our current understanding on the lack of correlation between tissue injury and pain means there can be many different methods of diagnosis and treatment. Under Sahrmann's MIS, I would classify the patients' presentations as Hip Extension with Knee Extension Syndrome. While the diagnosis is targeted towards the hip, the presentation can include posterior thigh pain (similar to sciatic nerve ANTT). I thought it would be an interesting presentation to review.

With Hip Extension with Knee Extension Syndrome, pain may present at either the ischial tuberosity or along the hamstring muscle belly. Pain may be present with moving from sitting to standing, walking, sitting, and negotiating stairs. The primary issue that develops with this condition is overuse of the hamstring muscle. Due to weakness in the quads and/or glutes, the hamstring muscle becomes the primary hip and knee extender. The hamstrings very obviously can extend the hip, but they can also extend the knee if the foot is fixed. 

Movement Impairments and Examination:
When the patient gets up from a chair or goes up the stairs, it appears as if the knee moves backwards to pull the body up as opposed to the body leaning forward and using the glutes/quads to extend the hip and knee. You may also see the hip extend during a long arc quad and the glute won't displays any contour changes during prone hip extension until the end of the motion. Additionally, the knee is typically held in hyperextension (and possibly hip internal rotation) in standing, which typically is a swayback posture.

In testing, the hamstring is tender, tight, and painful with contraction. Typically the glutes and lateral rotators are weak (the quads may or may not test weak with MMT). Hip flexion may be stiff due to hypertonicity in the hamstrings. Slump test may be negative, but may be positive with presence of >1 condition.

Treatment:
Overall, the goal is to strengthen the glutes, hip lateral rotators, and quads, while simultaneously decreasing overactivity in the hamstrings. This includes avoiding hyperextension of the hip and knee and encouraging glute contraction during gait, stairs, and transfers. Exercises that are encouraged include (for more detail on each one, check out the Sahrmann textbook on MIS or check out the Management of the Hip Course):
-Quad Rock Back                                            -Heel Slide without Rotation                  -Straight Leg Raise
-Prone Hip Extension with Glutes       -Prone Bilat Hip LR Isometric                 -S/L Hip Abd with LR
-Seated LAQ without Rotation              -Sit to Stand with Glutes/Quads           -SLS/Step-Ups with Glutes

For more information on evaluation and treating hip conditions like these, be sure to check out the brand new course by TSPT, Management of the Hip, an in-depth lecture series on Anatomy & Biomechanics, Differential Diagnosis, Examination, Treatment, and more! Below is a trailer of what's offered in the course.
-Dr. Chris Fox, PT, DPT, OCS

When you hear overhead athlete what do you think about? Do you think baseball or tennis player? Do you think about the weightlifter? Crossfitter? What about basketball? 
 
You see, there is many different types of overhead athletes.  Yet, preparing these athletes can be both entirely different and also very similar.  Many don’t consider basketball an overhead sport but next time you watch a basketball game take a closer look at the players blocking, dunking, and rising up for a shot.  It is indeed an overhead sport.  Furthermore, one of the greatest players to ever play the game, Kobe Bryant, underwent rotator cuff surgery late in his career.  Again, just more evidence that the game of basketball is an overhead sport. 
 
So, what is it about the overhead athlete that is unique?  Well, other than the lack of return to sport tests for the upper extremity, gaining end range stability is absolutely crucial for preparing them for their sport.  Later in this article I am going to show you some of my favorite end range shoulder stability drills that I’ve had success with.  These are drills that can be used across all of the athletes mentioned above (within your clinical reasoning framework of course).  
 
First, let’s talk about screening the overhead athlete.  This step cannot be overlooked as this is the cornerstone to determine what our overhead athlete needs.  For those of your who are also strength coaches, this is part of our “Needs Analysis” phase.  There are a few must have screens for this part.  The standing shoulder flexion screen gives us an overall first look at movement quality.  Does the athlete have full range of motion? Is it smooth?  Does the athlete substitute with the lumbar spine or forward neck? Is their rib flare? Pain? From here we can break down the motion in supine with a lat screen if the movement is limited.     See the video below for an explanation on this. We can also look at subscapularis and pec minor tone and mobility here.

Once we’ve established a baseline of movement quality and possible restrictions there are a few key muscles to look at testing.  While I hate MMT’s, they serve a purpose at times.  Looking at serratus anterior strength is one I often look at with this population. I will also look at middle trap, low trap, and RTC strength.  Again, without some type of assessment it does not matter how “good” of an exercise it is or how “cool” it looks.  There’s a lot of great exercises out there but they might not be appropriate for YOUR athlete. Assess, don’t guess.

Now for the fun part. Once you’ve worked on ROM and basic strengthening you will want to start working on end range stability.  I often see this phase botched and it’s a disservice to our overhead athletes because ultimately, we do have to load them to prepare the tissues and shoulder for more intense activity and their sport/positional demands. See below for a short list of exercises I use.  For the complete list and progressions/regressions check out my full videos on our Insider Access page. 

My favorite OH exercises

• KB Walk
  
• Banded OH Flexion Wobbles
  
• Banded OH Flexion
  
• Wall Slides with band
  
• Quadruped Swiss Ball against wall
  
• Landmine Press
  
• T-Bar Single Arm Snatch
  
• Quadruped Reach Turn Lift (Low Trap)
  
• ER 90/90 Keiser Walkouts

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