I act as an athletic trainer/s&c coach for a local public service agency. A service support individual was brought to me today c/o of lack of progress in her shoulder strength, specifically in overhead pressing movements. Hx of RC and labral repair. Mentions crepitus w/ shoulder flexion, but it does not cause pain. I approached the entire situation from a stimulus/load management/fear avoidance standpoint without physical eval of the shoulder given she didn’t c/o pain associated with the movement, but more so apprehension due to fear of tissue failure and a short time to fatigue. She has heard a pretty nocebic narrative from her previous PT which I’ve begun to try to undo. My question is this: from a professional standpoint, if a patient/client doesn’t complain of pain or isn’t looking for an eval, but brings up a Hx similar to that above, should a physical eval be offered/completed?
In an effort to increase confidence overhead, I coached her to be, hopefully, more efficient with her technique, replaced push press with 303 tempo press, and suggested a pivot in an effort to let fatigue dissipate prior to moving into a new rep/set scheme.
andersonoo7 - great question. These sorts of topics are areas we will likely cover with our coaching certification. Based on the info you’ve provided here, I’d say you handled the situation appropriately. Without presentation of symptoms and/or trauma in these scenarios, it is difficult for me to see the need for a referral for a consultation. It also sounds like you did aspects of a phys exam by checking her range of motion (“efficient with her technique,”) specific to the task she wanted to complete. However, my baseline assumption here is the prior surgical intervention was quite some time ago (years).
Thanks for the reply, Mike. You are correct in the assumption that her surgery was years ago (3). In regard to the eval, I was pointing more toward the fact that I did not complete the eval based on her concerns and lack of symptomology (outside of the crepitus) vs. referring her to a physician. My struggle here is with where she might be at in her own experience and how initiating a physical eval might play into that. If she has no complaints of pain, only a sense of apprehension and fragility would the fact that I feel an eval is necessary contribute to those feelings. Or better to frame a quick eval as a way to reinforce positive aspects of her recovery and gaining buy-in. As for the ROM assessment, she was simply 5-10 degrees from “vertical” (for lack of a better term) on a BB OHP. Which is likely a big contributor to her fatigue. Interested in your take on how evals (especially those that are not requested or necessarily warranted might affect psycho-social factors in rehab and training.
Good follow-up questions. I think ultimately we will need to define what an evaluation means in this context. I can say clinically, I do many consultations (involving an evaluation e.g. subjective history, review of systems, and physical exam) from the standpoint of addressing patient concerns, ruling out a finding that would potentially alter the likely trajectory of the case or desired outcomes and/or necessitates co-management. There is great power via the consultation alone and has been described as a therapy in its own right.
I like your phrase ‘physical exam’ better than evaluation. I believe it is more specific to what I am talking about. While I do understand the general lack of validity and reliability of MMT, assessment of PROM and AROM, and special testing, those are generally the patient’s expectations. However, due to the nature of the conversation, she didn’t seem as though those were of concern at this time, therefore, I did not perform them. Because her chief complaints were a quick stall on OHP and short time to fatigue, I focused my assessments on her efficiency of the movement.
MMT - has some validity for some scenarios. We’ve talked about this previously. Our larger issue with MMT via clinician’s hand(s) is the lack of objectivity, which is why we advocate for using a dynamometer setup if possible or some other proxy for “strength” and function test specific to the desired movement (e.g. knee extension on selectorized machine as a tracker for strength and function for a knee related case). PROM and AROM is case dependent. In the scenario you are describing, often I check AROM as a means of appeasement to expectations of insurance companies but also a confidence boost to the patient they have the necessary range to accomplish the task they are looking to do. In this context, that could have just been reaching overhead unloaded. I think overall you did what you thought was appropriate at the time and sounds like addressed the individual’s concerns.