Physical Therapy school prepares therapists to be general practitioners. Upon graduation, PTs are not experts in Orthopaedics, Cardiopulmonary, Geriatrics, or any specific subject area. There is simply not enough time! Due to a lack of classroom time, education focuses on the best current evidence, much of which is guided by pathoanatomy. To become an expert, we need to apply ourselves on a much further level. Below I have listed 2 clinical concepts that are not given adequate attention in Orthopedic Physical Therapy practice.
Muscles can be dominant, but still weak
Most people are trained to view muscles as either short and strong OR long and weak. Clinically, this is not always how muscles function. The upper trapezius is a classic example of muscle dominance with poor performance. The upper trap functions to upwardly rotate and elevate the scapula. The function of this muscle is especially important above 90 degrees of shoulder flexion. Due to scapular positioning, prolonged postures, and body composition, many people overactive the upper trapezius in lower levels of shoulder flexion (0-90 degrees). Consequently, the muscle becomes 'dominant' early in the range of motion. In these individuals the upper trapezius is actually weak in the functional range (above 90 degrees). When this muscle prematurely activates, it can lead to shoulder impingement syndrome or rotator cuff dysfunction. For this reason, it is important to retrain the upper trapezius in the functional range of motion.
The upper trapezius is a single example of muscle dominance. Similar dysfunction can also be found in the hip flexors and hamstrings.
Treat the joint first and the 'tight muscle' will resolve itself
The joints are the gate-keepers to our other tissues. We cannot clear up muscle dysfunction or movement impairments if the joint is not moving properly. An example of this clinical reasoning is treating the thoracic spine with shoulder dysfunction. If a patient lacks upper thoracic extension or side bending, they will not be able to fully reach overhead. The hypomobility in the thoracic spine will limit rib cage expansion as well. If the practitioner only focuses on glenohumeral joint mechanics and scapular strength, they are not treating a major cause of the dysfunction. While the patient may make improvements, the long term solution to this problem is addressing the spine in conjunction with retraining the shoulder complex.
-Jim Heafner PT, DPT, OCS
OPTIM COMT Instructor
Jim is author of The Guide to Efficient Physical Therapy Examination & the Anatomy of Human Movement (an online movement resource).
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