Physiotherapy- 50 shades of grey
Never read the book, but I always thought that the title described our profession well, here's why...
As allied health professionals we are generally dealing with fewer black and white clinical presentations than our medical colleagues. That is, we are evaluating presentations like Myofascial Pain Syndrome, T4 Syndrome, Non-specific low back pain, Rotator Cuff Related Shoulder Pain, and Fibromyalgia Syndrome. Because of this, we are often balancing client quality of life decisions with the degree of intervention we provide. Tied up in this are difficult to tackle topics like lifestyle factors (e.g., sleep quality, smoking, healthy weight), health literacy, physical conditioning, psychosocial factors, underlying medical conditions, attitudes and beliefs, and a society becoming reliant on fast fixes.
Syndromes don't have a specific diagnostic test to confirm a yes or no, rather they are a collection of symptoms that most people will have and guide us toward a probable diagnosis. Hence the 50 shades of grey concept. As clinicians, we evaluate the many, many aspects of a client's presentation and prioritise them based on our training and experience. A decision then needs to be made in consultation with our client about what to tackle and how. Some decide to take the easy, fast fix (but often repeated) road while others the slower, more complex, client educated road. With the latter option, as practitioners we aim to address each contributing factor to arrive at a point where our clients are better informed, making their own health decisions, and addressing their health as a bigger focus than just their initial presentation.
Following my subjective examination, I aim to streamline my physical examination, by using quick scans of key anatomical areas above and below the area of symptoms, to piece together my priority list. This identification process keeps me on track and limits the chance of me becoming overwhelmed and clinically lost.
Neck. Up to the age of 40ish, there will only be minor OA changes, so the limitations of movement are usually myofascial. As clients age, they lose side flexion first, so I am on the lookout for ROM reductions that don't match this profile and will direct treatment appropriately. For this reason, a 25-year-old presenting with limited neck movement is highly unlikely to be due to joint stiffness.
Shoulder. Designed to reach for apples, the shoulder allows great dexterity. External rotation is required as a conjoint rotation to clear the humeral head from the acromion as the shoulder flexes > 90 degrees. Clinically, I find this translates to needing around 40 degrees external rotation in the arm by the side position, to then allow near-full shoulder flexion. If not available, I check subscapularis, latissimus dorsi, pectoralis major, and teres major for trigger points. Neural sensitivity is also a possible culprit (thanks to Bob Elvey) limiting external rotation, as the brachial plexus passes anterior to the shoulder joint pivot point, but I find this is less common. Check using upper limb neural sensitivity tests.
Lumbar/Pelvis. Designed as a base of support, it is probably one of the hardest areas to clinically determine the relative merit of contribution to presenting symptoms of each area. But hey, we are up for the clinical challenge. I use frontal plane (side flexion) and sagittal plane (flexion/extension) movements to scan symmetry, ease of movement, proportional loss of movement, noting if limitations are predominantly pain or stiffness with pain. I aim to match these movements with aggravating factors learned from the subjective. I use a slump test for neural sensitivity and lower limb neurological tests to rule in/out hard neurological finding involvement.
Hip. The hip joint is designed to absorb large ground reaction forces, step by step, and has a deep socket providing great stability, and less mobility cf the shoulder. Cyriax's close-packed position (also known in Maitland language as the Quadrant Test) is a great scanning tool to identify joint problems like early-onset OA. Trigger points in the adductors (especially adductor longus will limit external rotation). Most of the posterior trigger points (gluteus medius and minimus) are found along a line from the greater trochanter to the posterior superior gluteal line and can cause referred lower limb pain +/- paresthesias like a radiculopathy, but usually do not limit spinal movements relative to the amount of pain presenting.
Ankle. At the ankle joint proper (i.e., talocrural joint) 10 degrees of dorsiflexion is the key (knee to wall of about 10-12cm), and this needs to be checked for all lower limb chronic conditions. Why? During the midstance phase of the gait cycle, as the contralateral limb advances, a lack of dorsiflexion means the body will try to accommodate and will seek assistance by gaining movement from joints above or below. That is the subtalar or knee joint. In the case of the subtalar, the axis is nearly 45 degrees to the frontal and sagittal planes. The result is for every degree of dorsiflexion (i.e., sagittal plane movement) we also give up a degree in the frontal plane (i.e., that is inversion). Not so good biomechanically, as this leads to excessive +/- prolonged pronation and associated internal tibial/lower limb rotation. Prolonged or excessive pronation is a starting point for so many lower limb overuse presentations. You can use the knee to wall test and capture both TCJ and soleus flexibility.
Great Toe. In the last phase of the gait cycle, toe-off, we need to allow our body to advance over a rigid hind/midfoot and a flexed great toe to propel ourselves forward. If we don't have around 50 degrees of dorsiflexion at the 1st MTPJ of the great toe with the midfoot in neutral, pronation compensation can again ensure all of the negative side effects as noted prior.
Would love to hear what anatomical quick scans you use in clinical practice, to identify areas requiring more detailed investigation. Please add your comments on the Blog.
Like we routinely check for red and yellow flags, I always question sleep quality & sleep routine, to gain an understanding of my client's recovery capacity. We will talk about the why and how next time.