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I thought this article was interesting and thought-provoking. I racked my brain for specific patient examples that illustrate my biases, but cannot come up with anything specific. I’m certain I have biases in my clinical decision making.
I can think of a bias that has affected my selection of strengthening and balance training recently. Jay Dicharry made an offhand comment during Running Medicine that stuck – he said something to the effect of “why would you put an athlete on an airex pad when their foot needs to get better at controlling motion on a flat surface; I use the balance board, not an airex”. I’m pretty sure I haven’t used the airex since as a way to add challenge to an exercise. What type of bias would you call that? I’m sure I should be weighing evidence on the subject instead of Jay’s opinion, but it made good sense to me, so it stuck.
Similarly, I stopped giving people the sleeper stretch after seeing many videos of Mike Reinold explaining why he rarely utilizes it. This example is different in that he conducted the research that found horizontal adduction stretching was more effective in improving internal rotation ROM than the sleeper stretch. However, it was likely his status as a credible expert that most impacted(biased) my thinking.
Hi Sarah, Thanks for posting.
What’s the medial gutter? Is that posterior to medial malleolus?
Agree with above- diff. dx BSI or posterior tibialis injury.
As for additional information – Have you already had the conversation about female triad components?
Were the SL Heel raises painful or just easily fatigueable? 8 reps seems odd if she has been doing some calf strengthening with her athletic trainer.Hi Jen,
Thanks for posting – Most of my initial thoughts are probably strategies you have already tried.
In terms of addressing his fear of movement – I think I’d stick to simple, non-threatening language, over and over again. I suppose I’d hammer home the point that the surgery fixated those segments but that can easily cause irritation, increased demand on all the tissue around that area. Describing the nervous system as irritated/angry, hurt not equal to harm.
I’m out of time but will think on this and address your other questions.Thanks for the clarification – that makes sense.
Glad to hear he’s responding so well.Hi Katie,
How did you make the decision to dry needle his adductors? I don’t know much about appropriate needling scenarios.One take away from the lab portion – the importance of taking objective measures/assessing from the same position every time to improve accuracy. I remember Jake Magel stressing this as well. For example, if you assess ER PROM supine with the patient’s elbow supported on your leg – then that’s how you want to re-assess it post manual, or next visit, etc.
Thigpen made a couple of really good points that stuck with me. He emphasized that he tries to stick with a consistent progression for athletes rehabbing their shoulder, for example. With a healthy athlete we may have a tendency to skip some of the more basic exercises. He tries to start them in the same place, but move through simpler exercises(eg in supine) more quickly for those who can – his point being that you can be more consistent and make sure that athletes are not missing the key components of a movement pattern.
I also like his idea of using a type of RPE(rate of perceived exertion) scale to help determine appropriate progression of strengthening exercises. For example – if an athlete finishes your whole session and rates his RPE at 3-4, they probably need to be pushed a little more.
I really enjoyed Tim Uhl’s review of shoulder exercises with EMG findings as well. One great point he made when considering progression of a patient post Rotator cuff repair – Don’t underestimate the weight of the arm as a contribution to torque as it can make a very big difference in the difficulty of elevating the arm. As Katie said, short lever arm with elbows bent can be considered for many variations of elevation.
Tim also cited a 2017 JOSPT study by Edwards that lays out a nice chart of typical Shoulder rehab exercises and progressions based on EMG activity.