Thursday Thoughts: Where Will This Take Me? | Modern Manual Therapy Blog

Thursday Thoughts: Where Will This Take Me?

This post is based on a reader comment from our latest Therapy Insiders Podcast, An Eclectic Approach to Cervical Dysfunction. I thought it was right on the money and the podcast along with the comment can be found here.

All my regular readers know how I feel about special tests, or for you DC good guys (mixers) out there, ortho testing. For those of you who are not MDT, Sahrmann, PRI or other classification based training, my question to you is: Where will this take me?


  • shoulder patient
    • you may think, RC cuff tendinitis, impingement syndrome, labral tear, cervical radiculopathy, rule out referral patterns from certain TrPs... 
    • Neer's, Hawkin's/Kennedy, The battery of some of the worst special tests ever for TOS, cervical quadrant or compression testing.... does any of this lead you to intervention?
    • or would you have still just treated any mobility and stability based impairment and asymmetry you found?
I am not just for cutting out most special tests (unless there is an actual traumatic injury), but any movement testing you do. You should always be asking yourself, why am I testing this movement, and where will it lead me to a particular treatment?

Dr. Gene Shirokobrod and I just finished another podcast for Therapy Insiders last night on Differential Diagnosis, special tests, and pathology. It's interesting hearing from the other side. I certainly do not expect a few blogs posts here and there to change anyone's mind in regard to moving away from pathoanatomy and special testing, and am only trying to get you to think and stimulate some discussion.

If you are strongly into special testing, biomechanics, pathoanatomy, and differential diagnosis as part of your evaluation, please chime in below or on my facebook page and let me know a few things. 1) How long you've been practicing 2) The background/training you have 3) How special tests or differential Dx, and pathanatomical practice helps your treatment and outcomes.

Keeping it Eclectic...


  1. Hey thanks for the blog post and another good pod cast. I thought I should say something since I can see the tumble weeds blowing through this comment section. I left the original comment on the insiders web site due to having interacted lately with students and new grad employees. I find myself thinking they need the academics shaken out of them! Since students and new grads are great for doing 1-hr evals and using 100% of that time to fire-up the pt so much your lucky if they come back ever again. When I teach people the simplistic approach in my clinic they look at me like I'm joking and/or trying to get them to do something they shouldn't be doing. I haven't been practicing very long, 25 months to be exact, but I do run/manage/own a clinic and see a fair volume of pts and have a strong referral source. So i'll tell the student/new grad this is how easy it is to make people better and be successful (cue blank stare from them). So I have started telling Pt's and students to read your blog and listen to therapy insiders and hope the more people they here the good news from the more they will forget that life-time of school that they were enslaved in. For now this blog and the insiders pod-casts are my happy echo chamber :)

    Elliott Davis, DPT

  2. Thanks for dispelling some of the tumbleweeds. Yeah, a few thousand reads and one comment. Guess everyone agrees! My favorite part of taking students is educating the typical PT school education out of them. They're typically more of the sponge variety than some of the fellow mentees I have had in the past who were practicing longer. In the end, i think we're taught everything has to be complex (including pain, which I think is not), when in reality, most cases can be evaluated and managed simply. Wish i realized this when I was only a few years out!

  3. ··
    Well I should probably let the Dr.E reply first.... but it is 12pm and my wife and daughter are out of town so I am up loitering on the internet while Dr.E is likely exhausted from wrangling his 47 children. I personally prefer to explain it as a victim vs perpetrator / dysfunction vs irritated tissue. But in the end I will give whatever answer fits the patients’ needs so they can buy in to fixing themselves. I will give a few examples.

    Direct access patients who haven’t seen a Dr. for their pain, I find generally would like a diagnosis. If it is a simple problem and they are happy with “your knee hurts because your pelvis is moving poorly and your hip abduction is poorly controlled” then great If not then here come the PFPS and ligament strains ect….

    Pt is referred from physician with anterior/lateral shoulder pain above 90° with no causation. X-rays were negative (of course since there was no causation there was no broken bones). Most of the time it comes down to your shoulder is irritated/inflamed because your cervical/thoracic spine/ribs have not moved/extended for likely years and it is causing your shoulder to be abused. If they say “yeah but what hurts?” I’ll say good chance it is RTC tendons and maybe biceps tendon but that doesn't matter since we know why it’s happening.

    Low back pain patients I find to be more of a mix bag…. Plus there is LOTS of family/co-worker/Dr google input into most these prior to arrival at my door. Some are very excited to hear there back is just angry and once it gets moving better they should have a good outcome. Others seem to be looking for a bad outcome with statements like “The Dr. says I have to come here prior to having
    a MRI but once I have done 4wks I can get the MRI. Then they will see I need a surgery” This is when I give them the imaging doesn’t mean much and surgery only means they will fix a problem they see not that your pain will stop. Some buy in and some run to the first person with a scalpel.

    In the end you need to meet the patient were they are at and give them the answer you’re the most confident about. I am not that great at picking out the exact structure since I’d just naming stuff in the general area and in the end it doesn't matter what the exact tissue is. So I try to steer away from pathoanatomy and give them a solution at the same time.
    The best route for me is, if you have the right patient with the right (pain level, dysfunction, pt comfort ect) is to do a eval and treat all at once. Once I get the history and have an idea of their issue I will look at movement and treat it at the same time. It goes like this: oh your shoulder moves fairly well but your back does not…. Lay down and let’s see if moving it helps out, (insert mob/manip
    here)…. Ok sit up and lift your arm again. Oh wow look your shoulder is 75% higher than it was. You see your cervical/thoracic spine is keeping your shoulder form moving correctly… the patient says “yeah! That is way better, how do I keep it like that?” you say let me show you with these functional movements/resets/HEP/repeated loading ect. In these nice cases they have already seen and felt the reset and their pain doesn't matter as much anymore to them since you showed them their
    shoulder was just another victim of the thoracic spine. So the patient doesn't really give a hoot about the anatomy if you already showed them it doesn't matter.
    this was of some use, and Dr. E sorry if I hijacked the blog I am not sure about the proper interweb/blog etiquette :) Elliott

  4. Great Read and comments! I have been practicing for a little over 3 years and it is great to hear philosophies of evaluation and treatment that are falling in line with where i have gravitated to in my clinical practice.