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Shoulder Impingement – 3 Keys to Assessment and Treatment

Shoulder impingement is a really broad term that is used too often. It has become such a commonly used junk term, such as “patellofemoral pain,” especially with physicians.

Other common variations include subacromial impingement or rotator cuff impingement, but it seems as if any pain originated from around the shoulder is often labeled as “shoulder impingement.”

Unfortunately, the use of such a broad term as a diagnosis is not helpful to determine the treatment process. There is no magical “shoulder impingement protocol” that you can pull out of your pocket and apply to a specific person.

I wish it were that simple.

This is also why conclusions are difficult to be drawn from meta-analysis and systematic reviews. A paper looking at hundreds of people age 25-65+ with “shoulder pain” isn’t going to provide much clarity, it’s too diluted.

Luckily, a thorough examination can be used to determine the best treatment plan. Each person will likely present differently, which will require variations on how you approach their shoulder rehabilitation.

Most of the clinical examination for shoulder impingement involves provocative tests. Those are great, but the real challenge when working with someone with shoulder impingement isn’t figuring out that they have shoulder pain, that’s fairly obvious. That’s why they are there.

It’s figuring out WHY they have shoulder pain, and what to do about it.

Shoulder Impingement: 3 Keys to Assessment and Treatment

To make the treatment process for shoulder impingement a little more simple, there are 3 things that I typically consider to classify and differentiate shoulder impingement.

  1. The location of shoulder impingement
  2. The structures involved
  3. The underlying cause of shoulder impingement

Each of these can significantly vary the treatment approach and how successful you are treating each person.

If you approach each patient with these 3 things in mind, you are going to do a much better job developing an effective treatment plan, versus just trying things and hoping they work.

I’ve called this the corrective exercise bell curve in the past. If you just throw the same treatments at every person with shoulder pain, you’ll probably get lucky 20% of the time, make them worse 20% of the time, and simply waste your time the rest.

Let’s dig in…

Location of Shoulder Impingement

The first thing to consider when evaluating someone with shoulder impingement is the location of impingement. This is generally in reference to the side of the rotator cuff that the impingement is located, either the outside of the rotator cuff or the undersurface of the rotator cuff.

These are broken down into either:

  1. Bursal sided shoulder impingement – this is your traditional subacromial impingement
  2. Articular sided shoulder impingement – this is called internal impingement
shoulder impingement - bursal articular side

Bursal Sided Shoulder Impingement

See the photo of a shoulder MRI above (photo credit). The bursal side is the outside of the rotator cuff, shown with the red arrow. This is probably your “standard” subacromial impingement that most people refer to when simply stating “shoulder impingement.”

This is often called subacromial impingement because of the location of impingement occurs between the rotator cuff and the undersurface of the acromion, hence the term “subacromial.” This is also called the bursal side of the rotator cuff because there is a bursa located between the rotator cuff and the acromion, which acts as a shock absorber.

Articular Sided Shoulder Impingement

The green arrow shows the undersurface, or articular surface, of the rotator cuff. This Impingement on this side is often termed “internal impingement” because the impingement occurs on the inside, or joint side, of the rotator cuff. If you look closely in the image above, the yellow arrow shows an articular sided partial thickness rotator cuff tear. Note the irregularity of white at the bottom of the dark line of the rotator cuff.

This often involves the supraspinatus and infraspinatus rotator cuff muscles as the undersurface impinges against the glenoid joint rim. I’ll go over this in more detail below.

The two types of impingement are completely different and occur for different reasons, so this first distinction is important.

Because the cause of shoulder impingement is so different, the evaluation and treatment of subacromial and internal impingement will also be completely different. More about these later when we get into the evaluation and treatment.

Impinging Structures Involved

The next factor to discuss is which structures are involved in the shoulder impingement. This is more for the bursal sided, or subacromial impingement, and refers to what structure the rotator cuff is impinging against.

Take a look at the shoulder from the side view, with the front of the shoulder to the right and the back of the shoulder to the left. You can see the acromion is superior and the coracoid is a little more anterior. The coracoacromial ligament runs between these two areas.

shoulder impingement - subacromial space acromion coracoid coracoacromial arch subcoracoid

As you can see in the image, your subacromial space is pretty small (the red areas). It’s pretty easy to impinge on the acromion, coracoid, or coracoacromial arch. There isn’t a lot of room for error. In fact, this really isn’t a blank “space”, there are actually many structures running in this area including your rotator cuff and subacromial bursa.

Get ready… I’m about to blow your mind…

You actually “impinge” every time you move your arm. We all do.

That’s right, impingement of these structures itself is normal and happens in all of us every time we use our arms. It’s when this becomes abnormal, excessive, or too frequent that shoulder pain and pathology occurs.

This is why it is very shortsighted to say “impingement” is normal and that people should work through their discomfort. Yes, some impingement is normal, but excessive impingement is what may cause pain and pathology down the road.

So when it comes to the structures involved in impingement, I try to differentiate between subacromial and coracoacromial arch impingement. These can happen in combination or isolation and typically involve the supraspinatus rotator cuff muscle.

Another area that has received more attention lately is the subcoracoid space or the area below the coracoid. You can also have subcoracoid impingement. Because this is located more anteriorly, the subscapularis rotator cuff muscle can be involved with subcoracoid impingement.

The three types of bursal sided impingement are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial and subcoracoid impingement, which we will discuss below.

So if we were to get very specific, you can break shoulder impingement down into four different types based on the location and structures involved:

Bursal sided impingement:

  • Subacromial impingement – Involves the supraspinatus and acromion
  • Coracoacromial impingement – Involves the supraspinatus and coracoacromial arch
  • Subcoracoid impingement – Involves the subscapularis and coracoid

Articular Sided:

  • Internal impingement – Involves the supraspinatus and infraspinatus and glenoid rim

See what I mean? How can all of these be “shoulder impingement?” They all involved different muscles, different impinging structures, different locations, and different mechanisms!

OK, great, we now have differentiated and know “what” is impinging, we still don’t know “why” the person has impingement.

Cause of Shoulder Impingement

The next thing to look at is the actual reason why the person is experiencing shoulder impingement.

There are two main classifications of causes that I refer to as “primary” or “secondary” shoulder impingement.

Primary Shoulder Impingement

Primary impingement means that the impingement is the main problem with the person.

A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below. Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):

acromion tip hook osteophyte

This also happens with the coracoid and subcoracoid impingement. An anatomical variation of the coracoid or bone spur can be present.

As our knowledge of shoulder impingement improves, it appears that the larger a bone spur, the more problematic it may become.

This is referred to as primary impingement because improving things like mobility, strength, and dynamic stability may be ineffective as there is a primary cause of impingement causing the symptoms.

Sure we may improve the symptoms and often times are successful with rehabilitation, but sometimes we aren’t. It’s not because a certain treatment “isn’t effective for shoulder impingement.” It’s because there is a primary reason why impingement is occurring that we can’t change.

Without addressing the primary issue, like a large bone spur, working on secondary issues may not be effective.

Secondary Shoulder Impingement

Secondary impingement means that something else is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in its center of rotation and cause impingement.

The most simple example of this is weakness of the rotator cuff.

The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.

The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid. The deltoid and larger muscles power the ship and move the arm.

Both muscles groups need to work together.

If rotator cuff weakness is present, the cuff may lose its ability to keep the humeral head centered. In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:

rotator cuff biomechanics - supraspinatus deltoid line of pull

This is just a simple example, but as you can see is very impactful for shoulder function. It’s not just weakness of the rotator cuff, it’s also imbalanced strength ratios and improper timing of dynamic stabilization.

Other common reasons for secondary impingement include mobility restrictions and poor dynamic stability of the shoulder, scapula, and even thoracic spine.

All of these areas need to work together to produce optimal shoulder function.

I see this a lot in my patients.

In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.

shoulder impingement overhead mobility

If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited. He’ll return to the gym and start the process all over if we don’t restore this mobility restriction.

The funny thing about this is that people are rarely aware that they even have this limitation until you show them.

Also, keep in mind that this is not “chronic pain.” Sure this person has had shoulder pain for 8 months, but it’s because they keep irritating the area. This is more like recurring acute pain.

Differentiating Between the Types of Shoulder Impingement

In my online shoulder program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training. There are specific tests to assess each type of impingement we discussed above.

The two most popular special tests for shoulder impingement are the Neer test and the Hawkins test.

In the Neer test, the examiner stabilizes the scapula while passively elevating the shoulder, in effect impinging the humeral head into the acromion.

In the Hawkins test, the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, impinging the cuff under the subacromial arch.

As I mentioned earlier, these special tests for shoulder impingement are provocative in nature, meaning that we are looking for reproduction of pain.

Both of them will cause the structures to impinge in all of us, but they shouldn’t produce pain. But if the area is sensitive and irritable, they will cause pain.

You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch or subcoracoid types of subacromial impingement.

Because these structures are more anterior, we can alter the tests to better assess this area.

The Neer test can be performed in the sagittal plane, and the Hawkins test can be modified and performed in a more horizontally adducted position. Both of these positions will impinge more anteriorly.

shoulder impingement special test - hawkins kenedy test neer test.jpg

There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.

Now, before we go any further, let’s talk briefly about the reported accuracy of these tests in the literature.

Just like we’ve talked about with the studies looking at the treatment effectiveness in people with shoulder impingement, most studies published vaguely look at how accurate a test may be at detecting “impingement.” Hopefully, if you’ve gotten this far in the article, you see how flawed this approach is, as this is simply too broad.

How can we evaluate how “specific” a special test is for such a “non-specific” diagnosis?

Internal impingement is a different beast.

This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity of the shoulder in the anterior direction.

As the athlete comes into full external rotation, such as the position of a baseball pitch, tennis serve, volleyball serve, and others, the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.

shoulder internal impingement

This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of the time. They aren’t the same partial thickness tears your grandmother has.

The best special test for internal impingement is simple and is exactly the same as an anterior apprehension test.

The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms. Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms. Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left). When the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).

3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?

Using the three main keys from the above information, you can alter your treatment and training programs based on the specific of impingement exhibited:

  1. The location of shoulder impingement – bursal or articular sided impingement
  2. The structures involved – Subacromial, coracoacromial arch, subcoracoid, or internal impingement
  3. The underlying cause of shoulder impingement – primary or secondary.

I promise you are going to have much more success in designing a physical therapy or training program if you factor in these keys.

Treating Different Types of Impingement

As I hope you can now see, to properly treat shoulder impingement you should differentiate between subacromial, coracoacromial, subcoracoid, and internal impingement.

Treatment is similar between these types of impingement. There is a bunch of overlap.

However, there are some differences:

  • With subacromial impingement, you should be cautious with overhead activities that produce discomfort
  • With the more anterior-based coracoacromial arch and subcoracoid impingement, you need to be cautious with elevation in more of a sagittal plane and horizontal adduction movements that produce discomfort
  • With internal impingement, you should be cautious with excessive external rotation at 90 degrees abduction (like the throwing position) that produce discomfort

Notice that I said “that produce discomfort” for all three? The key here for me is that you should not work through discomfort or a “pinch” with impingement.

A “pinch” is impingement of a sensitive structure!

I’m not a fan of working through pain with shoulder impingement. That to me shows me that you either have a primary or secondary cause of impingement that hasn’t been addressed. Trying to work through this could actually just irritate it more.

Treating Primary Versus Secondary Shoulder Impingement

This is an important one and often a source of frustration in young clinicians.

If you are dealing with secondary impingement, you can treat the person’s symptoms all you want, but they will come back if you do not address the underlying reason why they have symptoms.

But please remember, I do treat their symptoms, that is why they have come to see me.

I want to reduce discomfort and inflammation. This is going to allow me to do more in the long term. However, this should not be the primary focus if you want long term success.

This is where a more global look at the patient, their posture, muscle imbalances, and movement patterns all come into play. Breakthrough and see patients in this light and you will see much better outcomes.

You should have a systemized way of assessing movement and building programs to optimize and enhance their function. If you don’t you really should check out my system in my free online Introduction to Performance Therapy and Training course.

Introduction to performance therapy and training - laptop mockup

A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.

Again, using the example above, if you don’t have full mobility and try to force the shoulder through this motion restriction you are going to likely cause some irritation.

This is especially true if you add speed, loading, and repetition, such as during many exercises in the gym.

I spend a great deal of time discussing what “zones” of motion the person should be working in. Essentially, I try to develop a “green zone” and a “red zone” depending on when they have symptoms.

Shoulder overhead elevation mobility

It’s important to continue working within their green zone and not simply say “take a few weeks off.” And slowly over time, our goal is to expand their green zone and reduce their red zone.

Treating Internal Impingement

Internal impingement involves a little more discussion. The main thing to realize with internal impingement is that this is pretty much a secondary issue. It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.

The overhead athlete will show some hyperlaxity in the “lay back” shoulder position of external rotation. Most overhead athletes have underlying laxity, what tends to happen is they lose strength or have an excessive workload that causes fatigue and then the structures impingement more and become irritable.

Treat the cuff weakness and its ability to dynamically stabilize to relieve the impingement. This often includes an initial period of rest and then building back their strength and dynamic stability.

How to treat internal impingement is a huge topic that I cover in a webinar for my Inner Circle members.

Learn Exactly How I Evaluate and Treat the Shoulder

If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder.

mike reinold shoulder seminar

The online program takes you through everything you need to become a shoulder expert. You can learn at your own pace in the comfort of your own home. In addition to shoulder impingement, you’ll learn about:

  • The evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers CEU hours for physical therapists and athletic trainers. Click below to learn more:

Assessing Overhead Arm Elevation – Video Case Study

Assessing overhead arm elevation is one of the many things I look for during my integrated movement assessment.  This is a big part of the Champion Performance Specialist program.  The information you gather on the person’s ability to perform such a basic task is often invaluable when designing someone’s rehab or training program.

I have a video below of an assessment I performed that I wanted to share.  It’s an interesting case with a bunch of movement compensations.  I thought it would be nice to outline my thought process

But first, let me give you a little history…

The patient is a competitor high school swimmer with insidious onset of bilateral generalized shoulder discomfort and fatigue in the pool after prolonged swimming.  He had been seeing another clinician for soft tissue treatments in the past (hence the cupping marks.  His laxity was mostly posterior in nature, but certainly multidirectional.  The exam obviously reveals generalized laxity you would expect with a swimmer, however no significant structural pathology detected.

Here’s what I saw:

Pretty interesting, right?  Scroll down to the comments section and let me know what you think!

Let’s dig into some of my thoughts.

 Assessing Overhead Arm Elevation

  • I would first comment and state that this is one quick video in a long series of assessments.  I chose overhead elevation because it was simple and reproducible  and showed a bunch of interesting things!  I start my assessment off by simple asking them to raise their arms over head.  That is it.  No other instructions.  I feel that it is important to assess how “they” want to move, not how “I” want them to move. assessing overhead arm elevation
  • A test like overhead elevation in the sagittal plane, such as in this video, assumes two thing: symmetry and neutrality.  I don’t think either of these exist.  So it is inherently flawed.  Think about it, if his scapulae are off, then doesn’t that mean his glenoid is off?  Then technically the “sagittal” plane is just in relation to the ground, not to his body.
  • There is also a “chicken and the egg” concept here.  Did his pain create the dysfunctional movement or vice versa?  Unfortunately in retrospect we’ll never know.  Taking this into consideration I don’t think it is fair to assume that anything we are seeing is the “cause” of his pain.  Essentially it is all just the summation of where we are today.
  • Many people often want to jump right in and label specific muscles, such as being “tight,” “long,” “short,” or “weak.”  Remember all we know here is that he has a movement dysfunction.  I think it is appropriate to suggest these may be true, but you will need to take the next step and assess these assumptions.  I wouldn’t just jump in and treat based on assumptions.
  • I should also comment on the marks on his back.  One relevant, the other not so relevant.  The circles are cupping marks.  He is seeing another provider that performs this as part of his maintenance program while swimming in addition to massage etc, not for treatment of his symptoms.   However, the horizontal marks on his low back are relevant.  Those are stretch marks.  More on this later…

Static Scapula Position

  • I have commented on this before in my article on Myths of Scapula Exercises, but I don’t put a lot of emphasis on resting static scapular position.  Realistically, the scapula sits on the ribs, so it’s resting static posture is likely more a reflexion of rib and thorax position that scapular position.  I prefer to look at scapular dynamic movement quality.
  • Interestingly, you can see his dynamic concentric control of his scapulae doesn’t seem as bad as you would think based on his static resting position, especially as he gets high into elevation:

static and dynamic scapula position - assessing overhead arm elevation

The Head Wiggle and Scapula Wing

  • The first thing that really stuck out to me was his head wiggle.  I bet you missed it the first time!  A very interesting movement pattern.  In retrospect, you can find him shift his neck in this fashion quite a bit while observing him moving around and performing activities, even just talking to you sometimes.  It is not limited to just overhead elevation in the sagittal plane.  
  • We can’t really separate this from his winging scapula, they go together.  It sure looks like the head wiggles when the scapula wiggles.
  • To me, this looks like the levator scapula pulling the head with a complete lack of opposition from the lower trapezius and serratus anterior.  His head goes into side bend to the left and extension.  This is the cervical responsibility of the levator.  However, his scapula also shoots up into elevation and downward rotation.  This is my biggest indicator that levator is the one acting.  There could be more involved, like SCM, but I’m focusing on levator.
  • There is obviously some winging and lack of opposition of the levator by the traps and serratus.  This is really obvious on eccentric lower.  He also does not have a painful arc during this movement.  He is not shifting away from pain.

scapula winging - - assessing overhead arm elevation

  • So while the levator may be causing the head wiggle, it sure looks like the serratus and lower trap are not doing their job and creating the scapula wiggle.
  • See how everything plays together?

 

The Elbow Wiggle

  • Did you notice the elbow wiggle?  I don’t think this is really an elbow issue.  If you watch closely he keeps his hand in the same position.  He essentially fixes his hand on an imaginary sagittal plane track.  To me his shoulder and scapula want to move into adduction and internal rotation with the beginning of his scapula winging about to occur.  I feel like his glenoid may be the one the is not stabilized.  Since we have forced him to perform a strict overhead assessment in the sagittal plane, he is keeping his hand fixed and his elbow has to hyperextend to not allow his hand to horizontal adduct.  Again, just shows some of the flaws of assessments like this.

elbow compensation - assessing overhead arm elevation

  • So while this may be glenohumeral instability, I think it is still just the scapula as it occurs during the eccentric lowering and he has almost no ability to control winging.  And again, he does not have a painful arc.
  • This really illustrates a general point that I tend to make about humans in general, but even more so on high level athletes.  We are excellent at getting from point A to point B.  It’s all about how we get there.  Unfortunately the overhead elevation assessment uses an internal cue to “raise your hand up in front of you.”  Perhaps it would be better to give an external cue like “reach up and touch the ceiling.”

 

Thoracolumbar Flexion

  • So taking away all the interesting things happening from the scaps up, I also notice some interesting thoracolumbar compensations.  Remember, this client is a swimmer, and a high level swimmer.  Is it me or does his left latissimus look too small for a swimmer?
  • I mentioned earlier the stretch marks on his lower back.  When he tries to pull down with his arms with any resistance, his movement compensation was to go into a large amount of thoracolumbar flexion, which is a compensatory movement for the inability to extend his arms against resistance.  His lumbar paraspinals show hypertrophy.  So while this could be poor core control, I feel that may be too simplistic.  He goes into thoracolumbar flexion with minimal resistance.  Seems more compensatory rather than poor patterning.  In the photos below, that is not just paraspinal hypertrophy, that is also flexion:

latissimus - assessing overhead arm elevation

  • In looking at the photos above, see how he moves into thoracolumbar flexion?  These are fairly recent photos.  Here are a couple of photos from two months prior.  You can really see the thoracolumbar flexion compensation.  But also notice the dramatic increase in body composition in 2 months.  He put on 15 pounds of muscle mass in a 2-month program designed specifically for him:

thoracolumbar compensation - assessing overhead arm elevation

  • One thing I mentioned was that he feels symptoms with prolonged swimming.  He actually fatigues out well before his fellow swimmers.  Feels strong and swims well, then hits a wall quickly from 10-20 minutes in the pool, while everyone else is in there for 60-120 minutes without complaints.  While he looks a lot better.  There are still some muscles that are not coming back as expected, and he is still fatiguing out in the pool and feeling generalized symptoms.
  • This really makes me question a nerve issue that is just not allowing proper muscle function, and/or the fact that he is essentially swimming with his accessory muscles like his teres major and deltoids.  This is something we need to explore further.

 

Conclusion

Assessing overhead arm elevation is an important part of my overall movement assessment process.  There are many compensations that I typically see, but most don’t present as complex as this video case study.  I hope you enjoyed reading through my breakdown of how I assess overhead arm elevation and some of the things running through my mind!

Comment below if you think I missed anything!

Interested in learning my whole movement assessment system?  It’s a part of my Champion Performance Specialist program, where you’ll learn our exact system of assessing movement, then optimizing and enhancing performance.  It’s exactly what all the physical therapists and strength coaches follow at Champion when building our performance therapy and training programs.

 

Champion Performance Specialist - laptop mockup

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 4

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 4 is now available.

 

 How to Perform a Thorough and Systematic Clinical Examination – Part 4

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 4.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 4 of 4 and will focus on how to sequence your objective portion of your examination, as well as plenty of clinical pearls from experience. Part 4 is the 2nd half of the objective exam, focusing on motor control and special tests.  There’s a ton of info here so I wanted to break it down in detail.

 

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

 

To access this webinar:

 

Do You Want to Learn More About Optimizing Movement and Enhancing Performance? 

I’m really excited to be launching my brand new course for rehabilitation and fitness professionals looking to help people restore, optimize, and enhance performance.   It’s my Introduction to Performance Therapy Training course.

And you know what the best part is???

It’s absolutely FREE!

Check out the information and video below, and click the link below to enroll today!

 

Introduction to Performance Therapy and Training

If you’re anything like me, I’m sure you’d love to work with more highly motivated people, and even athletes, that want to focus on improving their performance.

But I remember not really feeling prepared for this or knowing how to get started, I really felt overwhelmed. We all learned the basics, but no one really teaches you how to optimize movement and enhance performance.

Over these years, I’ve learned a ton. Good and bad! But everything I have learned has shaped what I do, and it took some time and experience to realize this.

There so much info out there, but people tell me all the time they’re still confused and that they feel like they just start treatments and training programs and aren’t even confident that they choosing the right ones!

Check out this video for more of what I mean:

 

Enroll in My Course for FREE

I want to help.  When we started our facility at Champion PT and Performance, one of our biggest goals was to develop a simple system for our physical therapists and strength coaches to help people move and perform better.

My Introduction to Performance Therapy and Training program will teach you our 4-step system at Champion to assure you have everything you need to start helping people move and perform better.

Introduction to Performance Therapy and Training

Best of all, it’s absolutely free to anyone that signs up for my Newsletter. You’ll get all my best articles straight to your email, and immediate free access to the course.

Thank so much, hope you enjoy!

 

 

 

 

 

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 3

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 3 is now available.

 

How to Perform a Thorough and Systematic Clinical Examination – Part 3

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 3.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 3 of 4 and will focus on how to sequence your objective portion of your examination, as well as plenty of clinical pearls from experience. Part 3 is the first half of the exam, focusing on observation and mobility.  There’s a ton of info here so I wanted to break it down in detail.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

Measuring the Position and Mobility of the Patella

Measuring the position and mobility of the patella is still a very important component of my clinical examination of the knee.  It gives me a great sense of soft tissue restrictions that may be present when patellar hypomobility is noted.  This is especially common after knee surgery.  But measuring patella mobility is also important to assess generalized laxity when patellar hypermobility is observed.

The first time you feel either of these during your clinical exam, you’ll know what I mean.

But if you read through the literature, you may find conflicting results regarding the validity and reliability of assessing patella position and mobility.

The Reliability of Measuring Patella Mobility

One study that I reference often is a systematic review by Smith, who looked at the reliability of assessing patella position, specifically in the medial-lateral position.  Like any examination technique that is commonly performed, it is necessary to establish that the test has adequate intra-rater and inter-rater reliability. The test needs to be easily replicated and produce accurate results both between two different clinicians but also when repeated during re-evaluation with the same clinician.

Otherwise, the test may have limited use and not be able to provide helpful information.

The authors conclude the intra-tester reliability is good to assess medial-lateral patellar position, but inter-tester reliability was variable.  The variability is interesting to me and makes me wonder if we just aren’t standardizing how we look at patella mobility.

Another study by Herrington demonstrated that a group of 20 experienced therapists could reliably measure patellar position.  This tells me that a group of similar trained or skilled clinicians will show greater inter-tester reliability than a randomized selection of clinicians.  When I see that a test has good intra-tester and worse inter-tester reliability, I think one of two things:
The test is difficult to perform and/or is more accurate with more experience.

Reliability can be enhanced if we all use the same examination techniques. There may be subtle differences in techniques that may produce poor inter-tester reliability. This is what came to my mind when the Herrington study showed good inter-tester reliability with a group of experienced clinicians.

The Validity of Measuring Patella Mobility

In regard to validity of the measurements, the authors conclude that the criterion validity of this test is at worse moderate, based on limited evidence.  However, a couple of interesting studies were referenced.  A study by McEwan demonstrated that a lateral tilt of the patella greater than 5 degrees can be detected.  This was confirmed with MRI measurements.  The previously reported study by Herrington also reported that medial-lateral patellar position could accurately be measured as confirmed by MRI measurements.

A Simple Way to Measure Patella Mobility

It appears that clinical measurements of patellar positions can be both reliable and valid.  While intra-tester reliability, or your own ability to accurately repeat a test, appears to be more accurate, inter-tester reliability may be enhanced with a standardized examination technique.

Taking all this into consideration, I honestly do not try to “measure” patellar position.

I will assess the position but I do not try to place a label, such as millimeters or degrees, on the exact position.  If I want or need this information, I would much rather obtain this from a MRI.  I focus more on assessing the amount of hypomobility or hypermobility.

And there is a really simple way that we can do this that I think will great enhance our reliability.

To simplify this measurement, I try to just use a percentage of the patella that I feel can displace.  Here is how I do it:

  1. I break the patella down into 4 equal segments representing 25% of the width of the patella each.
  2. I visually try to establish where I believe the midline of the trochlea is located when I am measuring position.  If I am measuring displacement, I will visualize the edge of the lateral trochlea.
  3. I then measure the percentage of the patella that is positioned beyond the midline of the trochlea and then displace the patella and attempt to determine if 25%, 50%, 75%, or 100% of the patella can displace beyond the lateral edge of the trochlea, as in the image below:

Measuring the Position and Mobility of the Patella

I’ve learned over the years that knee experts, such as Dr. Frank Noyes, consider 50% displacement to be “normal.”  I use that as a frame of reference, but comparing side-to-side is probably even more important.

I feel that this provides me with plenty of information to compare to the other extremity and simplifies the process, which I hope would enhance intra- and inter-tester reliability.  If we all do it this way, I think we’ll be far more accurate.

What do you think? Is this too simple? How do you measure patellar mobility?

 

How to Perform a Thorough and Systematic Clinical Examination – Part 2

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 2 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 2

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 2.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect an structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 2 of 2 and will focus on the objective, assessment, and planning portions of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 1

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 1 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 1

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 1.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 1 of 2 and will focus on the general concepts and subjective component of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar: