Physical Therapy or Surgery for a Meniscus Tear?

Today’s article is a guest post from Lenny Macrina, my co-owner of Champion and co-author of my online knee course.  Meniscal tears are common, and some interesting new studies are coming out showing that surgery may not be the best option, at least for some people.  Social media is quick to shun meniscus tear surgery, however there are likely still some people that will benefit from this more than physical therapy alone.  Lenny discusses more in the article below. But I also wanted to make sure you knew that Lenny and I’s online course on the Evaluation and Treatment of the Knee is on sale this week for 50% off.  More info below!

 

Meniscus tears are very commonly diagnosed by physical therapists and doctors. The question remains, what is the best treatment for someone with a meniscus tear…surgery or physical therapy?

I may be a bit biased because I am a physical therapist. Let me get that out there right now. I’d almost always advocate for physical therapy over surgery for most of the cases that I deal with. But I do believe we are trying to be too black and white at times and need to keep an open mind.

There are many factors that need to be considered when deciding between physical therapy or surgery for a meniscus tear.  Some people may do better with physical therapy, while others may do better with meniscal tear surgery.

It depends.

With that, I decided to do a literature to see what the latest research is telling us. There’s lots out there and it seems as if the recent studies push for physical therapy as the first line of defense for someone with a mensical tear.

Intuitively, that makes sense but I wanted to dig deeper and see if this was true for everyone, or are there certain people that may benefit more from surgery.

 

Do You Need Surgery After a Meniscus Tear?

Of course, I went to PubMed because that’s my go to website for the latest in research topics. My search for knee meniscus physical therapy pulled up hundreds of papers, so of course I read them all…ok, maybe not.

I did my best so here goes…

In summary, it seems like there’s pretty good evidence to support that physical therapy should be used early after a meniscus tear in most of the common cases that we see.

There’s a growing body of evidence to try physical therapy first, especially for chronic degenerative meniscus tears. When I say a degenerative meniscus tear, I mean a tear that is probably a bit older and has been chewed up, well beyond repair.

Mensicus Tear Surgery or Physical Therapy

 

These degenerative meniscus tears are also often associated with knee arthritis, to some extent. Because of this, surgery to help with the associated pain is often limited due to the arthritis, and may not help the patient as much.

A period of active rest to calm the knee down and determine the course of treatment (surgery or more physical therapy) is often employed.

Very rarely is there a case where we should rush in to a surgery unless there’s a gross loss of motion, as in a bucket-handle meniscus tear that is obvious and leading to a disability.

I also think there’s a population of people who will benefit from surgery because they MAY be expecting to have surgery. I know, it’s complicated but that’s why we practice this stuff daily.

It’s not always cut and dry. People are human, and have emotions and opinions.

We can do all of the educating that we want but if they expect to have surgery and WANT surgery then just maybe they may benefit from having surgery. And that group of people may just do well.

Part of my treatment plan early on would be to educate them regarding the surgery, potential complications, some of the research and the post-op course.

All too often people are told that they’ll be back in 4-6 weeks after meniscus tear surgery and we all know that is NOT true. I usually tell people that it will take 4-6 months and even then, they still may not feel right until a year later. Sure, they may be doing some of their activities in 4-6 weeks, but that doesn’t mean they are completely back to normal.

The key is to recognize and find that person during your examination. I previously wrote a blog post on meniscus examination that goes over this in more detail.

Once diagnosed, can you separate out the meniscus tears that truly could benefit surgery from the ones that would do just as good without surgery?

Unfortunately, that’s the complicated part!

In a recent study from 2016, this group found that shorter symptom duration and greater baseline pain may be a predictor of who would qualify for earlier surgical intervention rather than physical therapy. They also suggested that an initial course of rigorous treatment prior to a knee scope may not compromise surgical outcome.

When in doubt, take it to Twitter.

In a recent Twitter discussion with some doctor colleagues of mine, we talked about this same and it was refreshing to hear that many are recognizing the fact that physical therapy may be the better option for most meniscal injuries.

Mensicus Tear Surgery or Physical Therapy

What is the Best Treatment Option for a Meniscus Tear?

Like I said earlier, there’s a bunch of research, so I tried to pick out some that I thought were the best and from highly reputable journals.

This study from the Journal of the American Medical Association showed that among patients with non-obstructive meniscal tears, physical therapy was equal to arthroscopy for improving patient-reported knee function over a 24-month follow-up period. ⠀⠀

They went on to say that “Based on these results, physical therapy may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”

So, basically if there is not a bucket handle meniscus tear present that may be blocking joint range of motion, then it is highly encouraged that the treatment and exercise, and not undergo surgery.

Without going out on a limb, I’d say this is a much cheaper treatment option as well and would greatly reduce health care costs associated with the surgery and lost time from work.

This study from the British Medical Journal looked at the cost-effectiveness of meniscus tear surgery versus nonoperative treatment and showed that surgery was not economically effective and should be reconsidered.

I did note a couple limitations: the surgical group did not get treatment after surgery if they did ‘as expected’ but they could get treatment to help improve their symptoms.

The physical therapy group did pretty basic exercises although leg press, lunges and balance type exercises were included. I would’ve liked to have seen a more robust attempt at treatment that involved more strength training and true progressions for the quads, hip and complete lower body.

Another study that I wanted to discuss was a systematic review that looked at the best treatment options for someone greater than 40 years of age diagnosed with a degenerative meniscus tear.

They showed that ‘the results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy for a meniscus tear.’

There was an issue with the quality of the studies involved in the study, including a high risk of bias, weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics.

Furthermore, they said that no conclusion could be drawn as to which treatment was the best option for this patient population. Which I tend to agree, right?

Intuitively, one would say that physical therapy, as the cheaper option, would be the best but I think it goes to my above statements that “it depends” on the person, type of mensicus tear, chronicity of the tear, their symptoms, AND their beliefs.

I think this study from The New England Journal of Medicine basically says the same thing. A course of physical therapy may be good for some but often times surgery may be needed for a select group of people.

This study from the British Medical Journal looked at exercise versus surgery for degenerative meniscal tears in Norway. The mean age was 49.5 years, which is pretty typical, right?

This study also controlled for degenerative tears only and most everyone had no signs of radiographic knee osteoarthritis (96% of the cohort had no definitive radiographic evidence of osteoarthritis).

They showed that middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis should consider supervised meniscus tear physical therapy as a treatment option over surgery.

 

What to Recommend to Your Patient, Physical Therapy or Surgery for a Meniscus Tear?

Remember, about 1/3 of the meniscus has blood supply that can help it to potentially heal on its own. We got that information from a paper way back in 1982 and it still seems to apply today.

I don’t think there’s any doubt that physical therapy (swelling control, range of motion, strengthening, education) should be one of the first treatment options in someone that has been recently diagnosed with a meniscus tear.

This seems to definitely be true in the groups of people with a degenerative meniscus tear. They seem to do just as well with early treatment than a more expensive surgical option.

For someone with an acute meniscus tear that is blocking range of motion, such as with a bucket handle tear, then surgery may be indicated right away.

For the younger athlete with an acute meniscus tear, I would potentially consider a surgery a bit earlier but still gives them a course of treatment for 4-6 weeks to see if the symptoms subside and the person can resume their normal function.

So, try meniscus tear physical therapy and hope to see significant changes in the patient’s symptoms and function in the first 4-6 weeks. If no true changes or if they are getting worse (and frustrated), then consider surgery.

After meniscus tear surgery, pick up the therapy where you left off and hopefully get them back to their ultimate goals.

 

Learn How We Evaluate and Treat the Knee

For those interested in learning more about how Lenny and I evaluate and treat the knee, we have an amazingly comprehensive course that covers everything you need to know to master the knee.  Our detailed examination process, all our treatment progressions, and detailed information on nonoperative and postoperative treatment of ACL, patellofemoral, meniscus, articular cartilage, osteoarthritis injuries, and so much more.

 

 

 

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:

 

 

Strength Training for Runners

There are still a lot of misconceptions about running and how to best train runners to minimize injuries and enhance performance.

Part of the problem is that there is a low barrier to entry to running.  All you need to do is start running, right? No gym membership, no equipment, heck most people don’t even do anything to prepare themselves for running.  They just decide to start running.

For recreational runners, running also tends to be a fitness choice.  Many people pick a way to get in shape and start exercising, and feel like they need to choose.  Do I want to do strength training or do I want to do cardio work?

Competitive runners also have some misconceptions when it comes to training to enhance their performance.  In the past, many have believed that strength training will bulk you up too much, make you less flexible, and may even slow you down.

There is no doubt that running requires cardiovascular conditioning.  But we can’t ignore how the rest of the body is biomechanically involved.  

Let’s simplify running a little more.

Running is a series of little jumps.  The rear leg has to propel the body forward.  The stride leg has to absorb force.

To minimize your chance of running related injuries and enhance your running performance, you need to understand both of these concepts.  

The key to both of these is strength training.  We can build tissue capacity to handle these forces much more efficiently, especially if we build a specific strength training program for runners with these two concepts in mind.

 

Strength Training for Runners

When it comes to runners, my go-to resource for injury rehab and performance enhancement is Chris Johnson.  Chris has an excellent website and clinic that specializes in runners.  He’s helped me a ton over the years.

Chris has an amazingly comprehensive book right now, Running on Resistance: A Guide to Strength Training for Runners.

We had been talking online recently, and I thought that my readers needed to benefit from Chris’ amazing knowledge on runners.  So we sat down and talked about the book, as well as a bunch of other topics related to strength training in runners:

 

Running on Resistance: A Guide to Strength Training for Runners

If you’re interested in learning more, Chris’s book is an amazing resource for both runners, as well as rehab and fitness professionals that want to work with runners.  It is a detailed guide and program to building capacity, becoming more resilient to injuries, and enhancing running performance.

Chris was nice enough to extend a special 15% off discount just for my readers.  Check out the book below:

 

 

Why You Should Be Using Biofeedback in Rehabilitation

This week’s article is an excellent guest post from my friend Russ Paine, PT, discussing why and how we should be using biofeedback in our rehabilitation patients.  Russ and I are both big fans of biofeedback but unfortunately it’s fallen out of favor because insurance companies don’t reimburse it. But that doesn’t mean it’s not effective.  And now, there’s a new biofeedback device, the mTrigger, that uses an app on your phone that is amazingly easy to use and affordable. I think this is going to be a real game changer.  And mTrigger was nice enough to offer my readers 10% off! More details below, but check out the article and our video first!


Why You Should Be Using Biofeedback in Rehabilitation

I have been involved in the evaluation and treatment of sports medicine injuries for 33 years.  I have been very fortunate to have a “true” sports medicine practice that predominantly includes professional, college, high school, amateur, and aging athletes.  Having this type of clientele has forced me to explore and pursue restoring full function in the timeliest manner, being very careful to not cause harm using an aggressive approach.  

I believe that one of the secrets to having successful return to sports with minimal adverse effects is fully restoring muscle function.  

Although many aspects of our field have seen excellent advancements and growth, we continue to combat one of the most difficult challenges following injury and surgery, muscle atrophy and weakness.  

Restoration of muscle function should not only be measured by muscle force output and scores obtained on functional tests, but neurological function. In my practice, establishing normal neurological function following knee surgery is goal number one for our patients’ initial step on the path toward successful return to function.  

 

The Use of Biofeedback in Rehabilitation

So how do I do this?  The use of biofeedback is my preferential method of attacking the neurological deficit following surgery or injury.  

New advances in biofeedback devices have recently allowed the ability to provide a general assessment of the patients’ EMG neurological status. The subjects’ ability to fire the inhibited muscle may now be conveniently measured by recording EMG activity of the involved extremity and comparing this to the opposite normally functioning muscle group.

The primary rationale for use of biofeedback is the belief that the patient should begin use their own “electrical system” as soon as possible through volitional contraction.  

The concept known as order of recruitment lends support to the use of biofeedback to enhance volitional contraction.  This order is based on the size principle. Heinemann’s size principle states that under load, motor units are recruited from smallest to largest. In practice, this means that slow-twitch, low-force, fatigue-resistant muscle fibers are activated before fast-twitch, high-force, less fatigue-resistant muscle fibers.  

When using a biofeedback device, the clinician sets the goal for the inhibited muscle so that a strong voluntary effort is required by the patent for each contraction.  This is visible to the patient and forces a strong contraction to reach the pre-set goal. I believe that voluntary contraction using biofeedback produces the greatest results in restoring muscle function early.

 

Biofeedback or Neuromuscular Stimulation?

Neuromuscular electrical muscle stimulation (NMES) is often used to stimulate muscle contraction.  There is a vast amount of literature supporting NMES for use during rehabilitation. Until recently, NMES has been a reimbursable modality, thus there was much financial support to research its’ effectiveness.  

Biofeedback has not been reimbursable and that may have had an effect on the comparative lack of literature.  One article from Draper and Ballard supports the use of biofeedback over NMES.  This article compared the two modalities during ACL rehabilitation.  After 6 weeks, the biofeedback group was shown to provide greater quadriceps isometric muscle strength than NMES treated group.

I believe in the use of NMES if a patient is unable to make any voluntary contraction, which sometimes happens following ACL reconstruction surgery.  But, once a patient is able to produce a voluntary contraction, detected by the biofeedback, we immediately switch the patient to biofeedback.

When using NMES, all nerve fibers are stimulated simultaneously.  This, in my opinion, is not as effective as biofeedback because the order of recruitment from small to large diameter nerve fibers is not sequential as is the case with voluntary contraction.  NMES actually recruits the large diameter nerve fibers first because they are more excitable, as large diameter axons have less resistance to firing. Atrophy of muscles has predominate effects on the slow twitch smaller diameter Type I  fibers, so recruiting these muscle fibers is critical to reverse the effects of muscle inhibition and atrophy.

 

How to Use Biofeedback in Rehabilitation

I use biofeedback on virtually every knee patient that has decreased neurological EMG output.  As previously mentioned, we are able to use a new device to provide a side to side assessment of EMG activity.  

This information as also very educational and motivational to the patient as they can see the actual deficit via visual EMG numbers between normal and involved.  

Cycles of 10 seconds on and 10 seconds off are utilized during the 10 minute biofeedback session.  My instructions to the patient for quadriceps re-education are to “tighten your muscle and force your knee straight”.  Progress is continued to be monitored on a weekly basis to measure the change in EMG activity, as shown using the biofeedback application.  

The mTrigger Biofeedback device that we use utilize has an amplifier that sends the measured EMG activity via a Bluetooth signal to an android or IOS device with the appropriately downloaded software application.  

This mTrigger is available for home use as well as clinical use.  Patient reported motivation using this type of biofeedback product is very high as they can actually visualize their intensity of muscle contraction when performing home exercise programs.  There seems to be an interesting psychological connection between the use of one’s personal smartphone or computer pad and their muscle activity.

Lack of extension of the knee has been shown to have an adverse effect of knee function.  Loss of extension alters the gait pattern and can produce abnormal stresses to the patellofemoral joint.  Due to a lack of quadriceps control many quad inhibited patients will ambulate with a flexed knee gait pattern.  

The use of biofeedback can be used to combat this common malady often associated with post-op care of the knee.  Lacking quad control, patients’ are unable to eccentrically control the knee flexion moment that occurs during single limb balance.  A quad inhibited patient will assume this flexed knee position because they “know” the position of the knee during single limb balance.

This sets up the knee for a co-contracted state and presents as muscle splinting until normal muscle tone and function are restored.  This muscle splinting will continue to exacerbate the lack of extension in the knee. Biofeedback can be very effective at addressing this issue.  

With muscle splinting, we want to teach the patient to relax the hamstring muscle during knee extension stretching, thus negating the effect of a contracting hamstring muscle.  The patient is placed in a prone position, with both patella over the edge of the table. Electrodes are placed over the hamstring muscle. Unlike the inhibited quadriceps muscle where we are trying to elicit a more perfect contraction, the biofeedback unit is now used for relaxation purposes.  As the patient uses the relaxation mode of the unit, and learns to control the overly active hamstring contraction immediate increase in passive knee extension is observed.

This position is maintained for a 10 minute period.  Once the patient has “learned” to control the hamstring over activity, a light weight may be applied for the 10-minute period to produce a low-load long-duration stretch.  Change in knee extension can be measured using heel height difference measurement technique. Dale Daniel described this measurement and showed that 1cm of HHD = 1 degree of flexion contracture.

Note from Mike: That’s a great example of how you would use biofeedback to work reducing muscle activity.  It’s not always used to increase activity. Another way we use it is to use both channels together on 2 different muscle groups.  Imagine doing a bird dog or glute bridge with the pads on the glutes and low back. You would focus on performing the drill with high glute activity and low back activity.  It’s pretty neat.

 

Return to Play

Return to play is a hot topic in rehab right now.  It’s difficult to determine if the athlete is ready to return to sport.  There are many obstacles when assisting your athlete to the ultimate goal of returning to sport with pre-injury level of performance.  

Too often, a shift is made during the rehabilitation process to more functional activities and reduced emphasis on strengthening.  If your patient continues to possess a decreased EMG signal compared to normal side, it will be highly unlikely that they will be able to resume the pre-injury level of function.  

With biofeedback, we have a tool that makes certain that we have completed one of the early critical steps in the process of rehabilitation – restoring and measuring normal neurological function of the inhibited muscle group.  Don’t allow decreased EMG function be one of the obstacles to continue to linger.

 

The mTrigger Biofeedback Device

I thought that was a great article from Russ.  Many don’t even realize how impactful biofeedback can be as it has fallen out of favor.  Here’s a great video from Russ and I demonstrating the mTrigger device and talking about how and why we use biofeedback:

 

As you can see, the new mTrigger device is so simple to use and completely affordable.  That has always been a limitation in biofeedback devices, they were just to clunky and expensive.

If you want to get started using biofeedback, mTrigger was nice enough to offer my readers 10% off their purchase, making this even more affordable.  Click the link below and be sure to use coupon code REINOLD to get your 10% off

 

About the Author

Russ Paine, PT, is known for his experience in sports medicine with special interests in injuries to the knee and shoulder, as well as golfing injuries and conditioning. His client list includes many professional athletes who have sought his expertise to help them recover to their prior level of function. Russ has a long career in sports medicine, having served as rehabilitation consultant to the Houston Astros, Houston Rockets, and NASA. Currently the Director of Sports Medicine Rehabilitation at UT Physicians in Houston, TX, Russ continues to devote his time to research and education while maintaining a busy sports medicine clinical practice.  Russ was inducted into the Sports Physical Therapy Hall of Fame in 2018. As a well-established author and lecturer on topics related to sports medicine, he has lectured at over 500 meetings in the US and abroad. He has published 25 chapters in textbooks and over thirty research articles in peer review journals.

 

 

 

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: