One of the components I love about this residency at Scottsdale Healthcare is the amount of information to which we are exposed. One of the core sets of readings we have includes the APTA Orthopaedic Section's Current Concepts for each joint, both standard and post-op. These readings give us some of the most up-to-date findings regarding ROM measurements, anatomy, special tests, examination and treatment techniques. What is really nice is that the authors of each section are typically the ones responsible for writing the questions on the OCS exam.
While the information from the Current Concepts readings is useful for treating each pathology, it unfortunately can stray away from a more important part of our plan of care. The Current Concepts readings (and much of what we were taught in PT school) function in that they identify the source of the pain and how to treat that specific structure and the pathologies associated with it. What they don't do is help us identify the cause of the of pain development in that structure. Another large chunk of our readings come from Sahrmann's Movement Impairment Syndromes books. She emphasizes the importance of assessing subtle joint movements. These are often the key to determining why a patient developed pain. Take a patient with groin pain with hip flexion. Our special testing may tell us that there is some femoral acetabular impingement, but WHY is that occurring? Reading the evidence alone will tell you it's because of bony deformities such as pincer and CAM lesions, but remember how bone deformities develop. Bone grows in response to stress. That means that often the CAM and pincer lesions only developed as a result of repeated contact as a result of abnormal joint mechanics (yes there are likely genetic bone deformities as well). By assessing the actual joint mechanics we can determine why that impingement ever started. Sahrmann teaches using palpation of the greater trochanter during hip flexion (or the affected motion) to determine the mechanics. If the greater trochanter glides anteriorly with hip flexion, it's no wonder the patient is experiencing impingement! Often this is a result of decreased strength of gluteus maximus and iliopsoas, along with the patient having a preference for recruitment of hamstrings for hip extension and a tight posterior capsule.
Another example I have seen quite frequently since starting my residency has involved shoulder impingement. In school and in the literature, subacromial impingement is the primary type of impingement addressed. We are taught to utilize special tests and clusters to determine the diagnosis. Following accurate diagnosis, research gives us exercises that are commonly used for treating that diagnosis. What is the problem with this? Again we are ignoring why the patient developed impingement in the first place. Without understanding the cause, we may be incorrect with the type of impingement. Since covering this material in the residency, I have found far more cases of anterior glide/impingement compared to "subacromial impingement." Often your patients with the many types of impingement may test positive for your subacromial impingement clusters. This can be problematic if you are treating your patients based on diagnosis as opposed to an impairment-based approach. The types of impingement often require very different methods of intervention. If you are doing a thorough examination, you will find the accurate impairments and treat accordingly anyway!
A lot of what Sahrmann teaches is common sense to the physical therapist upon retrospect. If we are thorough with our evaluation and treat the impairments (strengthen, mobilize, motor control training!), we would end up with the same result. Yet, Sahrmann's readings do an excellent job of bringing everything together and forcing us to actually live up to our name - movement specialists. It is easy to get lazy and not do a thorough movement analysis at the joint level. While special tests have their place (especially in the acute/traumatic cases), I am finding the use of them less and less important the more I work with an impairment and movement-driven approach. By going back to anatomy and fully assessing movement, we can determine why the structure ever developed pain in the first place and restore proper movement patterns.