Treating Movement vs. Treating Anatomy

Patient's often present to the clinic with pathoanatomical diagnosis'. For example, they may have a referring diagnosis of a rotator cuff tear, hip bursitis, or sciatic nerve pain. While this information can often guide us to the region involved, it rarely sheds light on the underlying cause of the problem. As a profession, it should be our goal to be experts in treating the movement dysfunction. 

Do you find yourself treating local anatomy or searching for underlying movement problem?

At the last OPTIM course, I posed the question, "what regions and systems should a PT assess if someone presents with a rotator cuff tear?" If you answered only the shoulder joint and rotator cuff, you are missing quite a bit.

From a movement perspective, there needs to be adequate mobility in the thoracic spine, normal upper rib mobility, stability in the cervical spine, coordination among the many muscles that control shoulder movement, the proper sensory awareness to complete the movement, and more. A lack of mobility, motor control, or strength in any of these regions can contribute to patient's rotator cuff problem. 

Clear hinge point or breakdown in the thoracolumbar junction during a Lat Pull Down noted in a patient with right low back and neck pain.

In my recently published clinical booklet, 'The Guide to Efficient Physical Therapy Examination,' I stress the importance of having a movement based examination process. For example, during a shoulder evaluation, the majority of special tests taught in physical therapy school assess specific tissue dysfunction (biceps tendinopathy, labral tear, etc...) Additionally, many of these tests have poor statistics. Remember, we need to assess movement dysfunction - not anatomical tissue dysfunction!

Below I have included my step-by-step shoulder examination. In my standard exam, you will not see glenohumeral joint mobility testing or strength testing of the rhomboids. These tests are typically not indicated. The glenohumeral joint is built for mobility, unless the individual has clear mobility deficits (i.e. adhesive capsulitis), joint mobility is usually not an issue. Additionally, many people rest in scapular downward rotation and demonstrate strong and dominant rhomboids muscles.  While your personal examination may include or exclude certain steps, always remember that we are movement specialists and your testing should be guided by movement impairments. 

Want a full look at my examination process with added clinical pearls?

Guide to Efficient PT Exam Booklet

-Jim Heafner PT, DPT, OCS