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Please read the below case and check out at the questions to start a discussion. The article for this week’s journal club is also posted for you to read.
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1.Based on the subjective findings, what are your immediate differentials? Do you ask any more probing questions?
– Impingement syndrome, RC tendinosis, ACJ arthrosis
– Patient goals
– Any change in lifting or activity (frequency, intensity, type, especially around the time he started to have pain)
– What is his typical exercise routine (i.e chest day every day?)
– Gun posture
– Pain at work?
– Imaging2. Based on the objective findings, are there any other tests that you would have performed?
– Seems like you hit everything, pretty awesome you had him bench 275 #
– Dumbbell press to compare to bench press, also look at other exercises performed at gym
– How does he lift objects to the side (impingement positions?)
– AC joint mobility
– Pec flexibility
– Neuro? If radic was on your differential3.What is your primary hypothesis?
– Same as yours4.Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– Yeah, I agree with your order. If they patient had low irritability/severity, and his main goal was to return to bench pressing pain free, I definitely would have tested that. I think doing the objective tests first like you did, helps to eliminate any large structural deficits so that you feel confident having the patient perform a bench press without injuring the patient.
5.What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– Gym and exercise modifications (decrease intensity, frequency, active rest)
– Continue nsaids – if irritability is high
– Foam roll thoracic ext and pec minor/major stretch
– Scapular retraction exercises – show things that he can do at the gym
– I typically run out of time on my evals, so I don’t always perform manual interventions on the first day. The manual exercises you did seemed to help address his specific limitations. Maybe thoracic spine manipulation? -
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1. Based on the subjective findings, what are you immediate differentials? Do you ask any more probing questions?
– SA impingement, RTC pathology, partial tear, ACJ arthrosis, Labral pathology
– Any change in programing or activities at the gym
– Pt goals
– Imaging?
2. Based on the objective findings, are there any other tests that you would have performed?
– I agree with Cam that you definitely worked systematically to rule out cervical involvement
– Potentially looking at other aggravating factors during eval even through you hit his main c/o
– Interesting he had pain w/ pushups but no p! w/ bench press under 275… I wonder how his bench form looked?
3. What is your primary hypothesis?
– I agree with you
4. Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– I agree with your order of testing especially if you felt that his symptoms were highly irritable and may have affected some of your other objective examination findings. I personally do not have access to a barbell bench at my clinic so I may have performed a push up prior to initiating my objective examination especially if his c/o were benching at higher weights knowing that I would not be able to replicate his exact aggs.5. What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– I would provide education on resting posture at work to promote improved thoracic extension as well as promote improved resting GH position
– Education on activity modification at gym, dec weight, intensity, repetitions to avoid aggravating factors; I definitely like how you educated him on improving his push pull ratio.
– I agree with your exercise prescription; I definitely would have included some form of scapular retractions and Tspine extension over FR
– I too find that I do not have too much time during my evaluations to perform manual techniques on everyone. Typically if indicated I will try a quick manip to improve pt buy in and have them leave the clinic feeling better. Or during assessment if a restriction is identified go right into a quick round of treatment for said restriction. -
1.Based on the subjective findings, what are your immediate differentials? Do you ask any more probing questions?
– Supraspinatus impingement, partial RTC tear, supraclavicular origin (1st rib and scalenes have familiar referral patterns)
– If scalene or 1st rib were on my DD list, I’d be interested in some questions oriented to that including a report on his breathing even if he doesn’t outright mention it.
– I’d be interested if he felt there was a particular day or event when he began noticing his pain. Insidious onset is helpful to get a sense that it probably didn’t happen after a fall from a crossfit bar, but maybe it became noticeable after his 200th rep of shoulder abductions during a training session (or actually training for the police force).
– I’d also be interested in his typical exercise routine.2. Based on the objective findings, are there any other tests that you would have performed?
– AC jt mobility, 1st rib mobility, length/ flexibility of pec minor and scalenes ipsilaterally.
– Special test to determine long head of biceps involvement for pain origin.
– OP into CS mobility to truly clear?
– He has difficulty with OHP and lifting objects out to the side – how’s his Inf glide of the GHJ?
– How’d his scapular motion look during shoulder AROM?3.What is your primary hypothesis?
– sounds like a case of arnold schwarzenegger subacromial impingement4.Do you agree with the order to have the “functional testing” after the rest of the exam? Would you have done this day 1?
– I love that you included it, and I think performing this at the end is smart. As stated prior, irritability depending this can be a great way to really observe the problem in action without confounding a specific, sterile objective exam piece later on since you’ve already gathered them. I also think this is an important piece to day-1 with this gent, since he’s a 27yo police officer, cross fitter, gun shooter, and heavy lifter. It sounds like he has high expectations of himself physically, and you examined what he really values. This shows that you’re not going to just tell him to stop lifting – rather you’re actually interested in seeing how you can get him back to where he feels like he should be.
5.What interventions would you have performed on the first day? More/less/different MT? Different exercises? Let me know your thoughts.
– Sounds like a great opportunity for a TSpine manip
– This wouldn’t be my first go-to, but KT tape could be a good tool to include as an educational piece and add proprioception to this 27o he-man demonstrating your postural points.
– I’ve found that a gentle inferior traction in neutral to the GHJ provides significant relief to folk who have a hot supraspinatus tendon.
– Simply providing a few designed sets of AAROM to the affected arm’s scapula during AROM GH movement in the affected planes has served me well in 1) providing pt understanding of what kinds of muscle groups I’m asking them to use and 2) provide a NMR benefit to actually using them.
– I like that you gave him a few home-run hitters that attack the low hanging fruit in your exam. You immediately showed him your value as a clinician and can later work on the bigger piece – lifting heavy weights again without pathologic limitation. -
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1. In order of likelihood:
– SAI
– RTC partial-tear/tendinopathy
– AC joint pathology
– Labral pathology
– Cervical facet/disc (C4-5, 5-6, 6-7)2. I would have looked more closely at AC joint, especially done a couple of special tests for it. Even if SAI is the most probable pathology, I would want to rule out AC joint involvement. I’ve seen several heavy lifters have an AC joint component to their pain, and working on it has helped me with several patients. Just curious, you said there was a painful arc of motion, but was there pain at end-range shoulder flexion or ABD too?
Also, if you had more time, I would’ve looked at his scapula more and really tested his arc of motion pain with scap assist with ER, post tilt, and UR, and tried to determine which, if any, decreased his pain.
3. SAI due to supraspinatus tendinopathy (and likely scap dyskinesia as well)
4. Yes, I agree with doing functional activities afterwards. I’d want to have an idea of what was going on prior to having him do heavy bench, that way I can provide him with better education on how to lift with decreased pain. Also, if doing heavy bench at the beginning flared him up, you would likely have some false positives with your additional testing. But I think its great you did it day 1, because it shows you are in-tune with his goals, and if you can make a change in his pain with his bench, you’ve got your buy-in.
5. I think your first day interventions were great. My only question is did you have him doing T extension just because he had bad posture, or because you had test/treat/re-tested this with something and saw a decrease in pain?
I would’ve looked more closely at AC joint like I mentioned before and tried joint glides here, but that is just my bias with this patient population.
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1. Nothing really new to add here.
2. I probably would have probed more into looking at his aggravating factors and the onset a little more like Erik was alluding to. Based on how much this guy is pushing he obviously wasn’t able to do this overnight so was there a new training regimen whether it be in the gym or at work? Possibly asking more about his hobbies and if there was a recent change whether it be intensity/frequency of an activity, gun type/posturing, seeing if there is something setting him up for failure to pump iron like he normally does? Just a thought.
3. Nothing new to say here. Agree.
4. Order seems logical and sound. I definitely agree with your choice to do it day 1, its his c/c so buy in points right there. Like Jeff said I think knowing where his deficits lie by performing the objective test and measures first would be helpful to understand where the weak link might lie and to facilitate cueing with his bench form. Because I have little new information to add, I am going to be devils advocate here. I just wonder how much of our typical PT objective data and assessment would directly translate into benching 275 pounds or his “push days”? Would it make us more specific with our education or cueing for this activity? If you screened for red flags, cleared cervical spine, and narrowed down the aggravating MOI to weightlifting could you have started with functional testing to drive your assessment? Most of those shoulder tests are sensitive anyway and he likely might have concomitant pathology so how much does it matter knowing this day 1 versus FU visits? I don’t think I would have done it any differently then you did Jon but I do wonder. Regardless, doing it day one…. I applaud.
Jon your earlier post said: “He wasn’t training the posterior chain or back muscles appropriately and was suffering from it. As a result, his scapular mechanics were wonky and his lack of motor control of the middle/lower trap showed.” How much of that would you have gotten if you went through his workout routine “functional testing” versus the rest of your exam?
5. I think as far as day 1 I think activity modification and education would be my go to!
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