Y

Professional PT
Clinical Corner
Issue 11

Inside this issue:

Welcome 2016

Making your Patients

Experience a Magical
One!

Ruptured Spleen

Compliance Corner

SFMA-Course Review

Core Resisted FABER

Ask the Expert

Case Study

Clinical Gems

10

Announcements:
4 th Annual Student Symposium : February 20,
2016
USA-W Sports Performance
Coaching and Certification:
January, 16-17 2016
Garden City, New York.

January 2016

To all at Professional PT we, at the Clinical

Education Department, would like to wish
everyone a Happy and Healthy 2016.
We are very excited with the opportunities that will be available to our clinical
staff in the upcoming year. In addition to
our established education programs, the
Clinical Education Department will be instituting a Professional Education
Training Center in New York City. This
new facility is located at the former Premier Corporate Center located at 1536 3rd
Avenue (at 87th Street) on the 5th floor.
Clinical Educational presentations in association with hands-on laboratory experiences will be provided in small groups to
continue to further enhance our critical
thinking and manual skills in the clinical
setting. Additional information about this
training center will be provided in the
near future.
Included in our 2016 seminar schedule,
this years annual Professional Seminar
Guest Lecturer will be world renown
physical therapist Dr. Kevin Wilk. Dr. Wilk
will be presenting the topic of Recent
Advances in the Rehabilitation of the
Shoulder Complex to our professional
clinical staff the weekend of April 2nd.
Please mark this date in your calendars.
2016 will be an exciting year for the continued educational growth of our company. We look forward to working with our
clinical staff and appreciate all clinical
staff interest and participation in our education programs.
Best,
Robert Panariello MS, PT, ATC, CSCS

Education Training Center in NYC Opening

soon!
Dr Kevin Wilk : Recent
Advances in the Rehabilitation of the Shoulder
Complex, April 2,3 2016

Chief Clinical Officer

Editors note:
We hope you are enjoying the Monday morning educational updates!, Please feel
free to reach out to us with any questions, comments or recommendations that you
may have. The company continues to grow and we now over 400 clinicians strong.
There is some incredible talent in this company and we encourage each of you to
contribute articles, case studies, technique peeks , article reviews etc. We can be
reached at education@professionalpt.com.
Enjoy
Robert Shapiro MA ,PT, COMT, NKT, SFMA

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Professional PT Clinical Corner

Page 2

Making Your Patients Experience a Magical One

David Skudin, Director of Customer Service

-What if coming to Professional for physical therapy felt a little bit

#3 Know your Patients and Listen to Them.

Even in a business setting as large as Disney World they find ways to

customize your experience and listen to what their guests are saying.
I once took my daughter to Disney World for her birthday. When I
made the reservation, they made note that it was her birthday. They
gave her a special name tag, and that whole day every worker at Dis#1 Remember that coming to Professional is an
ney World wished her a happy birthday using her name! We can ask
patients about their family, work and hobbies and continue to engage
experience.
them at future visits about these things. Also, calling patients by
In Healthcare, many clinicians feel that they need to be real and
their name is a powerful reminder of how important they are to you
be themselves all the time. Being part of The Professional Experiand Professional. A recent Wall Street Journal article reported that
ence is like being in a play or drama performance. You may be in a
more and more healthcare providers are forming patient advisory
bad mood outside your clinic or in the break room, but once you walk councils and patient focus groups to learn how to deliver better care.
through the door you are on stage!
We should ask patients about their experience and welcome their
Disney World has a yellow line at the edge of each break or employee feedback.
area. No matter his/her job, every employee is reminded that once
I hope these short tips will help you make your patients Professional
the line is crossed he or she is performing on stage for the guests.
Experience more magical next year!
more like
coming to Disney World for
your patients? These are three practices that you
can implement to bring a bit more happiness and magic to your patients experience.

#2 Go Above and Beyond.

If you want to have more than just good customer service, you are
going to have to differentiate yourselves from others. The way you
interact with your patients should involve something special that
they will immediately associate with you and Professional. For instance, you could give them a quick call to see how they are
feeling, give a small gift to new patients (tee-shirt), or anything you
may think can et you apart from others and show your patients
appreciation for doing service with you. These are the types of
gestures that patients will remember and appreciate you and Professional for. They may seem small to you, but thats the point.
Something small can really go a long way in maintaining relationships.

If you have any questions, comments or want to share an exceptional

patient experience, please feel free to reach out to David at
dskudin@professionalpt.com

Random Questions:
1. What is the capsular pattern for the mid carpal joint?
2. What is the action of the tensor fascia latae?
3. The L4 disc will compress what nerve root(s)?
4. If a patient presents with ankle eversion weakness due to a
HNP what level would you expect to find the herniation?
5. What is the difference between CRPS type 1 (RSD) and CRPD
type 2?

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Professional PT Clinical Corner

Page 3

Dealing with a Ruptured Spleen and How to Protect Your Athletes:

With the recent news of the New
Jersey high school football player, Evan Murray, who died this
past September from a ruptured
spleen, it becomes more apparent for ATCs to take all preventable measures to try to avoid a
horrific incident like this from
occurring again. After his autopsy, the medical examiner reported that Murray had an abnormally large spleen that ruptured
due to a direct hit in his backside. The cause of death was
attributed to massive internal
bleeding from the ruptured
spleen.

from infectious mononucleosis

are predisposed to having an
enlarged spleen as well. When
your spleen becomes enlarged
either from disease or direct
contact, blood cells accumulate
in the spleen causing it to become susceptible to rupture.

Christina Kavanagh MS ATC, USAW

portant to recognize the signs

and symptoms of a ruptured
spleen to ensure the best outcome. Those suffering certain
diseases such as mononucleosis
should avoid any contact sports
and minimize activities that may
increase the risk for abdominal
trauma. Those suffering from a
direct blow to the lower left side
should be examined for any
changes in vitals and tenderness
to the abdomen. By taking these
steps we can help prevent this
life-threatening occurrence.

Knowing the signs and symptoms of a ruptured spleen may

help you get the immediate
treatment it needs to help increase the chance of survival.
A ruptured spleen will usually
cause severe abdominal pain. It
will be felt along the left side of
Works Cited:
the abdomen under the rib cage,
The spleen is a delicate fist-sized sometimes traveling to the left
Derrer, D. (2014, 3). Ruptured
Spleen. Retrieved 10 1,
organ that serves two primary
shoulder due to irritation to the
2015, from WedMD: http://
functions: it contains special
nerves. The internal bleeding will
www.webmd.com/digestivewhite blood cells that destroy
cause lowered blood pressure
disorders/ruptured-spleen#2
bacteria to help your body fight with a rapid pulse. This can
off infections and makes red
make the victim have blurred
Press, A. (2015, 9 29). New jersey
high school football player
blood cell while also helping to
vision, confusion, lightdied of lacerated spleen,
filter old ones from the bodys
headedness, fainting, and possimedical examiner says. Recirculation. The splenic capsule, bly go into shock.
trieved 10 1, 2015, from
a thin layer of tissue covering
If any athlete has a suspected
FOXNEWS.com: http://
the spleen, helps to protect the
www.foxnews.com/
ruptured spleen, especially after
spleen from direct injury. An enus/2015/09/29/new-jerseysustaining a direct blow it is critlarged spleen stretches the
high-school-football-playerical to get them to the hospital
splenic capsule, causing it to bedied-lacerated-spleenright away. A physical exam
come fragile and more susceptimedical-examiner/
showing sudden low blood presble to rupture. When this splenic
Silvis, M., Plakke, M., Tice, J., &
sure, rapid heart rate, and discapsule breaks open, typically
Black, K. (2012). Splenic
tended hard abdominal area will
due to blunt trauma or a direct
Lacerations and Return to
indicate emergency surgery. If
blow, blood pours into your abPlay . Sports Health , 232there is uncertainly and time al235.
dominal area. This is known as a
lows, a computed tomography
ruptured spleen.
(CT) scan of the abdomen is the Contact Christine at:
A ruptured spleen can occur in
next course of action. Based on
people of all ages. The common the severity of the splenic injury, ckavanagh@professionalpt.com
causes of a ruptured spleen inathletes can generally return to
clude injury to the left side of
play within 3-6 months.
the body or an enlarged spleen
Whether you are an athletic
due to disease. Direct injury to
trainer working with a team or a
the spleen can occur during contherapist in the clinic, it is imtact sports. Those suffering

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

YPage 4

Professional PT Clinical Corner

Compliance Corner:

Daniel Hirsch PT, DPT | Director of Internal Audit

Staying Compliant with Discharge Documentation

This article is intended to emphasize the importance of properly
discharging each and every patient. Discharge planning begins
at each patients first visit. As
licensed physical therapists, performing the initial evaluation is
the beginning of the creation of a
discharge plan. The Plan of Care
is also an integral component of
a discharge plan. A complete
Plan of care includes creating
measurable and obtainable appropriate goals related to listed
functional deficits that are agreed
upon by the patient. In ensuring
that each patient has an appropriate discharge plan, the basis
of discharge will dictate the discharge process. A planned discharge visit is often the exception, but simple documented
facts can be easily recorded to
summarize the episode of care
with all the necessary details.
These include:

Maximum benefit from PT

services

Change in medical status

MD hold for therapy request

30 days has passed since the

last treatment session

Patient request to selfdischarge

In addition to a planned discharge visit, a patient may selfdischarge for a variety of reasons, including financial, scheduling or personality issues. . In
such circumstances the physical
therapist may base any conclusions necessary to complete the
note based on the prior treatments documentation such as:

Last visit status for each goal

Coverage date
Total number of visits
Coverage date (from last pro- Summary of episode of care
Any prior HEP instructions
gress note)
Total number of visits
Circumstances for discontinu Summary of episode of care
Current patient functional sta- ing skilled physical therapy
services may include, but are
tus
not limited to the following:
Analysis of patient goals and
expected outcomes
Three consecutive scheduled
Rationale for discharge
appointment cancellations
Referral for additional services or equipment provided
Patient communication re PT signature with date and
quest to end physical therapy
time
Circumstances for discontinu- No indications to return to
therapy
ing skilled physical therapy
services may include, but are
not limited to the following:

Patient has attained their

functional goals

Coverage date

Total number of visits

All communication related to

the patients future expectations with continuing of care
elsewhere including the referring physicians

All patient safety education

Any resources provided

A complete history of noncompliance behavior/actions

limiting the success of skilled
PT services

Summary of the episode of

care with updated goals.

Circumstances for discontinuing skilled physical therapy

services may include, but are
not limited to the following:

Failure to maintain precautions

Failure to adhere to guideline

instructions for the HEP

Every physical therapy has the

legal responsibility to properly
document a discharged patient
regardless of the reason for discharge. Proper discharge documentation reduces the risk of patient abandonment, as well as
dissatisfied customers or referral
sources. As a result, we must ensure that proper notification is
clear, comprehensive, discussed
and documented.. As always,
please feel free to contact me
directly with any questions, comments or concerns. Thank you
very much.

One further basis of discharge

may be that of discharge due to
non-compliance. In such circumstances, documentation must Daniel Hirsch, DPT
include:
dhirsch@professionalpt.com

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

YPage 5

SFMACourse Review:

Professional PT Clinical Corner

Vito Pinto DPT, SFMA

What is the SFMA?

SFMA stands for the Selective
Functional Movement Assessment and is a standardized way
of looking at the human body to
see how each and every segment
interacts with another segment
The SFMA is based on the theory
of regional interdependence.
Regional interdependence is the
theory that seemingly unrelated
impairments in a remote anatomical region may contribute to,
or be associated with the patient's primary complaint.(Wainner et. al.) The
SFMA postulates that by assessing the human bodys whole
movement as opposed to each
isolated joint, one can discover
the actual driver of a patients
dysfunction, pain, gait deviation
etc. The SFMA provides 10 fullbody movements. The idea is
that the 10 movements encompass most if not all of the possible ROM a human should be able
to obtain. The SFMA starts with a
screen that goes through these
ten movements and then has a
quick report of whether the
movement is dysfunctional, functional and whether the pain is
present or not. These are abbreviated DN (dysfunctional nonpainful), DP (dysfunctional painful), FN (functional non-painful),
FP (functional painful). When you
encounter any movement pattern that is DN, DP, FP, there is a
breakout or break down of that
movement into its isolated components to find out what is driving the patient's primary complaint and determining if the dysfunction is a mobility or a stability issue. . For example, let's say
cervical flexion was limited and
the patient was not able to touch
their chin to their sternum. The

control, by giving you a standardized way of evaluating the

patient.
next step is to determine if the
movement was painful or not. If
the movement were DN, you
would move on to "breaking
down the movement" to determine if the movement dysfunction was due to a mobility problem (soft tissue or joint restriction) or due to a motor control (stability issue). The cervical
flexion breakout involves having
the patient perform supine active

How I use the SFMA in clinical practice:

I had the opportunity to take the

SFMA course recently and found
it to be beneficial. With practice,
performing the SFMA has become easier and much, much
quicker to perform. In my facility, we tend to see a lot of older
individuals but I tend only to use
the SFMA on younger, active patients. I will continue to expand
my use of the system as I become more comfortable with it .I
will have the patient perform the
10 movements at IE because
they take 2-3 mins to perform.
Then as we go about the plan of
care, I will break out some of the
DN, DP, FP movements to see
what I can find. SFMA consists
of two continuing education classes, the second class consisting
cervical flexion that takes away
the bodies need to stabilize, and of how to work through a motor
if active flexion is normal we
control issue. I have not taken
know we are dealing with a sta- the second class (yet), however
bility issue. If the movement is
in my daily practice, I have used
not full we can confirm it is a
the SFMA to improve a patients
mobility issue by performing pasoverhead deep squat, a regular
sive neck flexion and if range is
deep squat, and improve their
still limited we confirm that we
are dealing with a mobility prob- balance and thoracic mobility
lem. Treatment involves evaluat- when those issues have been
related to joint or tissue dysfuncing your findings of all the test
movements and treating the
tion. I have tried also to intemost dysfunctional/ non-painful
grate some motor control re(DN) movements first and syslearning, with variable results.
tematically clear each region.
The beauty of the SFMA is that
you, as a PT, essentially already
(continued on the next page)
know the breakouts; however
the SFMA guides you into working through whether an issue is
related to joint/tissue, or motor

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

YPage 6

Core Resisted FABER Test:

Professional PT Clinical Corner

Robert Shapiro MA PT COMT

The FABER test, also known as

the Patrick test has been used to
assist in the differentiation of
hip, groin sacroiliac joint or lower
back as the cause of patients
symptoms. Voight et al suggest
adding a core assisted (aka stability assisted) FABER test to
determine if a patient has a mobility issue (lack of ROM) or a
stability issue (lack of core stability).
The basic test is performed with
the patient supine and the hip to
be tested is placed in a flexed,
externally rotated and abducted
position with the ankle resting
just above the opposite knee.
The clinician stabilizes the opposite ASIS and the patients knee
is lowered toward the table until
end range is attained. A test is
considered positive when the patients reports pain in any location and/or the patients fibula
head is more than approximately
6 inches from the table. Location of the patients symptoms

assists in differentiating the

structure at fault. If the pain is
felt in the front of the hip suspect hip joint pathology. If pain
is felt posteriorly over the lumbar
spine and/or SIJ suspect that
limited hip mobility is creating
lumbo-pelvic instability.

pist resists trunk flexion thus activating the core. If after activating the core the tested leg is
now able to touch the table we
are dealing with a stability issue
not a mobility issue. If the leg
position does not change the
presence of a stability issue is
confirmed. Activating the abdominal muscles (core activation) causes the pelvis to rotate
posteriorly of the femur and allows the ilium to be in a more
neutral starting position. This
neutral position allows the head
of the femur to become centrated within the acetabulum.

Clinically this means if we have

a stability using continued
stretching of the hip will not be
an effective treatment choice.
This test gives us, as clinicians,
the ability to utilize clinical reasoning in our treatment approach
The core assisted test is perand helps us know the appropriformed the same as outlined
above except this time the thera- ate tissue to address.

SFMA: Course review: Vito Pinto DPT, SFMA

(continued from previous page)
The pros of the SFMA are the
standardized assessment tool
that helps guide clinicians
(novice or otherwise) and the
breakouts that help to uncover
movement patterns that may be
subtle and overlooked especially
when the patient is in a lot of
pain. The cons are that it can
take time to learn (I still do not
have all of the breakouts memorized) and that they split the
SFMA into two classes, both of
which are quite costly. Regardless, I enjoyed the class, and will

be taking the second part soon.

Lastly, my original desire to take
the class stemmed from a frustration that some of my runnerpatients were not improving to
100%, which is what made me
want to improve my clinical
skills. In that sense, the class
helped.

spt.2007.0110. Accessed 2015

Pictures taken from:
www.functionalmovement.com

Wainner, RS, Whitman, JM, Cleland, JA,

Flynn, TW. Regional Interdependence: A
Musculoskeletal Examination Model
Whose Time Has Come. J Orthop Sports
Phys Ther
Journal of Orthopaedic &
Sports Physical Therapy. 2007:658660.
Available at
http://www.jospt.org/doi/pdf/10.2519/jo

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Professional PT Clinical Corner

Page 7

Ask the Expert: Tim Stump MS PT, CSCS, USA-W

A clinician emailed this great question
to the education department

article A Multicenter Study of the Test

Retest Reliability of the Lower Extremity

Functional Test http://
I have a patient whos a boxer whos
portal.professionalpt.com/
in for triceps tendonitis and has shoulclinicaleducation/Clinical%20Library/
der weakness. Does anyone have any
Shoulder/Davies%20CKC%20UE%
suggestions on exercises or tests that
20Test.pdf
I can do in the clinic to see if hes
ready to return back to activity?
Response by Tim Stump :
My first question is how symptomatic
is the triceps tendonitis? If the patient is still in the acute phase all the
return to activity suggestions I have
are not appropriate at this point. The
2 things I always consider when determining treatment plan is: 1) What
phase of the healing continuum is the
patient & 2) what physical qualities
still need to be improved. (mobility,
strength, power etc)

If the triceps is still symptomatic then

I would treat it as any tendonitis: educated the pt on the importance of activity modification, modalities, cross friction massage, normalize tissue length (long head of triceps or tight biceps may be suspect)
and when ready emphasis on eccentric strengthening. But I would do
this for any pt with tendonitis regardless of activity level.
When appropriate a good functional
test in the clinic that I like to use on
my shoulder and elbow pts is Davies

Heavy bag due to the force and

level of impact

Double end striking bag due to

the speed and if a miss occurs

Hope this helps. Let me know if you

have any further questions.

This will give you a good idea on the

readiness of higher demand activities.
As far as a gradual return to boxing I
can give you a progression & guidelines based on my boxing experience:

Rope & Road work he can be doing now

Pre-requisite strength to perform

traditional upper body strengthening calisthenics

Primarily- push ups and dips.

Light shadow boxing & foot work

Speed bag- for timing and rhythm

Intense Shadow boxing if not tender- snapping out or doubling up

on a jab and be extremely stressful on the elbow.

Hitting Mitts lightly & progress

intensity based on symptoms.

Heavy bag & double end striking

bag are the last stop before sparring.

Location of Shoulder Pain and Possible causes:

Top of the Shoulder
Over the front and outer aspect of the joint
Pain when the arm is in the window cleaning position
Pain comes on suddenly when the arm is
held high overhead

AC joint
Referred pain from the neck
The GH joint and RC
RC impingement
Instability

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Page 8

Issue 10

Lever Sign for ACL Tears:

Dr. Alessandro Lelli of Bologna Italy
described a test for detecting the
presence/absence of ACL tears which
he named the Lever Sign test. The
Lever Sign test is performed with the
patient in supine position, with the
knee in full extension and heel touching the edge of the bed. The clinician
places their clenched fist beneath the
proximal calf just distal to tibial tuberosity then applies gentle posterior
directed thrust over quadriceps tendon (not the ligament) at which time
they look to see if the heel raises off
the table. If the patient's heel raises
completely off of the examination
table the ACL is reported as intact. If
the heel does not raise off the table
with this maneuver the test is considered positive for ACLS deficiency.

The lever sign test differs from

other tests in that the basic area
of application of forces is not the
tibia but the femur. The application of the test is very easy and
practical. There is no difficult
learning curve for the test.

Robert Shapiro MA PT COMT

included 80 patients between the ages of 20-45 years of age who presented to an orthopedic department
with knee symptoms that included
giving away/locking/pain following
sports or non-sports injury. Examination for these patients included the
anterior drawer test, Lachman test
and the Lelli test (aka Lever sign
test). A positive ACL tear was diagnosed using these tests and arthroscopy was used to confirm or refute
the diagnosis. Comparisons were
made of the arthroscopic findings and
the clinical tests. This study showed
the Lever Sign test to have comparable sensitivity and specificity to the
anterior drawer test and Lachman
tests. The authors concluded that the
Lever sign test is a good test to use
for the patient with acute and chronic
injuries due to its simplicity, reproducibility and comparable findings to
the gold standard tests being used
today.

Lelli, Alessandro, Rita Paola Di Turi, David B.

Spenciner, and Marcello Dmini. "The Lever
Sign: A New Clinical Test for the Diagnosis of
Anterior Cruciate Ligament Rupture." Knee
A recent study performed by Thapa et Surgery, Sports Traumatology, Arthroscopy
al attempted to determine the accuKnee Surg Sports Traumatol Arthrosc(2014)
racy of the Lever sign. The study

Hand position, positive test for ACL tear

Negative test, foot comes off table

YouTube link:
https://www.youtube.com/watch?v=eEhpwTU3KXg

MedBridge Facts:
Professional Physical Therapy clinicians earned 2543 C.E.U's and completed 1021 courses last year
through MedBridge.
Top 5 clinics in completed courses are :
1. Queens (106)
2. Columbus Circle (76)
3. West Side (63)
4. Garden City (61)
5. Rosyln (48)

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Page 9

Issue 10

Case Study: Gluteal Pain:

Patient History: Pt is a 32 year-old
female teacher who experienced onset of right buttock and posterior
thigh pain 1 year ago. Pt is not sure
of the exact mechanism of injury but
states that she got a new job last
year and has to drive 45 minutes to
work each way. The pain started as
an annoyance and has progressed to
the point that she decided to see her
physician. Pt did receive an MRI
that showed a bulging disc at L4/5.

Robert Shapiro MA PT COMT

to the gluteal fold). We should keep

in mind that the patient is taking
cholesterol lowering drugs that may
have an adverse side effect and may
cause muscular symptoms, this is
unlikely in this case. Next we need
to r/o lumbar pathology as a cause
of symptoms even though the patient does not have LBP, and lastly
we must examine the hip and associated structures.

Body Chart: pain right lower glut

and proximal hamstring, no lower
back pain
Imaging results: MRI: posterolateral disc protrusion L4/5, agerelated degenerative changes
throughout the lumbar spine
Medications: Hydrocodone as
needed, Simvastatin

Squatting : right hip demonstrated

excessive hip IR/Adduction.
Single leg stance right: unable to
maintain w/o excessive compensation in the transverse plane (loss of
height)
Palpation/Findings: pain with palpation to right piriformis posterior to
the right greater trochanter
Special tests:
Negative SLR/Well Leg Raise, Negative SIJ tests (compression, distraction, sacral thrust, Gaenslen Test
and Thigh thrust). Positive piriformis
test (pt is sidelying, with the tested
hip on top. Passively move the patient's lower extremity into flexion
(90 degrees), adduction, and internal rotation. A positive test occurs
when pain is produced in the sciatic/
gluteal area.)
Likely Diagnosis: Piriformis Syndrome, compression/adverse neural
tension of the sciatic nerve.

Chief Complaint: right buttock

and posterior thigh pain.

Treatment Options:
Focus on balancing of the forces
Rule
out
Exam/Sinister
Findings:
about the hip. First attain normal
VAS: 5/10 (moderate requiring the
nothing
was
suggesting
sinister
pahip mobility and look for restrictions
use of pain medication, activity limthology.
above (thoracic) and below (eg. a
ited but functional)
loss of ankle DF). Next retraining
Patient Specific Functional Scale Active Physiological Findings:
exercises for the hip ER, extensors
Single and repeated movement of
(0-10 scale) 0=unable 10=fully able
and hip abductors. Exercises should
Lumbar spine were unremarkable
start NWB, attaining appropriate
1. driving: 4/10
although lumbar flexion caused the
muscle recruitment and progressed
patient to experience right lower
2. jogging: 6/10
gluteal and upper hamstring pulling to controlled WB and lastly to dynamic plyometric training.
3. lifting weights: 6/10
the patients symptoms were no
worse or better due to these moveOutcome Measure: LEF score:
Discussion:
ments even when repeated 20 x.
60/80 (25% moderate disability),
Piriformis muscle tightness in this
Active hip abduction and ER caused
case may be due to 1) over activaComparable Sign: Driving or sitTHE pain.
tion of the piriformis for an inhibited
ting for more than 30 minutes
gluteus maximus as evidenced by
Passive Physiological Findings:
Behavior of Symptoms: pain
hip add/IR with squat. The piriformLumbar Spine and SIJ unremarkaworsens during sitting, eases with
ble. Right hip flexion, adduction and is can is a synergist for the gluteus
meds or when she lies down flat on
IR are restricted and when combined maximus and may be attempting to
her back.
control motion causing compression
caused THE pain.
on the sciatic nerve. 2) possible
Planning the exam: although it is
double crush injury due to the presunlikely that the patients symptoms Passive Accessory Testing Findence of nerve root irritation to the
are caused by a sinister disorder
ings:
L4 nerve root without compression.
(red flag) we should perform a quick unremarkable, none of movements
3) irritation of the sciatic nerve due
neurological exam (recommended
caused THE pain.
to loss of control during single-leg
when patients symptoms are distal
Functional Tests:
stance and while running.
PMH: high cholesterol, bulging disc

Objective Exam:

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016

Professional PT Clinical Corner

Page 10

Clinical Gems of the Month

Look for trigger points in Sartorius with patients who c/o pain
consistent with meralgia
parasthetica

If your patient has pain with

turning in bed look for trigger
points/dysfunction in the QL and
gluteus minimus

McGill et al recommend waiting

approximately one hour after
waking up to perform spine exercises especially those that require
full spine flexion or bending

The Dial test is used to assess

anterior laxity and possible instability of the hipperform the with
the patient supine with leg
straight, forcefully ER the extended hip (o degrees) - look for pain
as a positive sign

Robert Shapiro MA PT COMT

Crossover Impingement Test:

performed by the examiner stabilizing the trunk and then passively and maximally horizontally
adducts the shoulder, a positive
test is defined as pain the shoul-
der.

In order for your patient to put

the foot on their opposite thigh
the hip joint must flex 120 degrees, abduct 20 degrees and
laterally rotate 20 degrees.

Location of pain with the above

test indicates possible pathology
as follows: superiorly (AC joint
pathology), Anteriorly
(supraspinatus, subscapularis,
and/or long head of the bicep),

A pectineus trigger point will refer to the groin to the upper medial thigh.

Normal anteversion of the hip is

b/w 8-15 degrees

Dont be shy.
Please feel free to contact Rob Shapiro
with any gems you want to share with
your colleagues:

How to grade tenderness:

Grade 1: mild tenderness on palpation

Grade 2: mild tenderness with

grimace and flinch to moderate
palpation.

Grade 3: severe tenderness with

posteriorly (infraspinatus, teres

minor, and/or posterior capsule)

withdrawal.

Grade 4: severe tenderness with

withdrawal from noxious stimuli.

If you observe wasting of the

supraspinatus and infraspinatus
muscles think suprascapular
nerve lesion or a full-thickness
RC tear.

When a cervical patient tells you

they feel the most relief when
they lift their arm above their
head and rest their hand on the
head think cervical radiculopathy
since this puts the cervical nerve
roots on slack (Jolly sign).

rshapiro@professionalpt.com

Quiz answers:

1. Equal restriction in all directions.

2. Hip flexion, abduction, medial rotation.
3. L4 and/or L5
4. S1 along with weakness in ankle PF and hip extension
5. CPRS Type 1 does not involve actual nerve damage where Type 2
does.

For internal use only. Not intended for external sharing or distribution.

Professional Physical Therapy 2016