Residency Blog

Lumbar Spine Evaluation

This weekend we had one of our monthly guest lectures on Saturday and Sunday, Kris Porter, PT, DPT, OCS. We covered the assessment of the lumbar spine. The course reviewed many of the concepts introduced to me during the residency, along with some variations from another expert clinician, Kris Porter.


Collective learning of skills from other residency programs and clinical experts helps to solidify concepts and introduce clinical pearls from other experts.

Some topics covered and hopefully summarized in the near future:
-Relative flexibility of muscles in relation to the spine
-Clinical prediction rules for the lumbar spine
-Manual therapy assessment/ treatments
-Mulligan techniques
-Tri-planar assessment of joints
– Neuro tension mobilizations
– Core endurance assessment

Looking forward to the next lecture with Kris Porter’s mentor Richard Jackson and more specific assessment and treatment options for the pelvic girdle.


Rotator Cuff Tears

Shoulder impingement and pain are very common and can be improved with physical therapy. Partial rotator cuff tears can also benefit from rehab and would be determined on an individual basis with clinical symptoms and imaging guiding the decision process.


Full rotator cuff tears, which are most commonly the supraspinatus and/or infraspinatus should be addressed in a timely manner with surgery. Delayed surgery could cause further retraction of the torn tissue and scarring, which research shows can cause decreased functional performance after surgery.

This picture shows a complete rotator cuff tear that is repaired with a suture bridge technique.

Conservative rehab after surgery is essential to protect the repaired tissue and aggressive therapy that is short sighted in improving ROM and function has demonstrated an increased rate of repair failure with no increased long term functional outcomes.

Therapy may be uncomfortable, but increased pain is usually not required to attain ROM or improved function.

High Foot Arches & Peroneus Longus

Working with an athlete that had years of plantar fascitis and a recent tear in their plantar fascia has led to a lot of studying about the biomechanics of the feet.


Peroneus longus is one of the muscles that stood out in it’s role to support the arch or in this case to cause a high arch. A high arch secondary to a plantar flexed 1st ray leads to a shortened plantar fascia, which would be susceptible to tearing when the foot goes from an open chain high arch position to a closed chain pronated position.

A: Peroneus longus functions as an ankle pronator

B: Peroneus longus can now work properly

C. Peroneus longus functions as a 1st ray plantar flexor.

Jeffery Zimmerman Does a tight/short peroneus longus cause high arches or an overpronated foot? Do you see people with high or low arches with tight/short peroneus longus?

Shoulder Impingement

I got to spend the morning observing surgery with Dr. Dillingham and Dr. Donahue from SOAR Medical. Definitely a great experience to watch 2 of the best surgeons at work.

Subacromial decompression and a release of the coraco-acromial ligament are common procedures used to relieve shoulder impingement after conservative treatment has not resolved the problem.


“the site of contact between the humeral head and coraco-acromial arch may deserve to be viewed as a neo-articulation that developed during evolution to compensate for the relative weakness of the supraspinatus muscle in humans. This neo-articulation is poorly suited to the current long lifespan of humans, which is the result of cultural developments, as opposed to evolution. Its existence may contribute to explain the high prevalence of rotator cuff tendon disorders in humans.”

Summary: We have a coraco-acromial ligament due to our deltoid being much stronger than our rotator cuff muscles (primarily suprapinatus). Strengthening the rotator cuff and lessening the discrepancy in strength compared to the deltoid is essential to decrease increased articulation of the shoulder with the coraco-acromial ligament and would decrease shoulder impingement.

Evolutionary bio article explaining the shoulder’s evolution:


Breast Cancer Awareness

The boys at Willow Glen High School were proud to switch their spar tape to pink, in honor of breast cancer awareness month.


I have had multiple friends lose their moms to breast cancer and I feel very fortunate to have had my mom survive her fight this year.

It was all thanks to her general practice doctor being aware and catching it sooner than later. Awareness and prompt treatment are essential.

SI Joint Tensegrity

I am looking forward to participating next month in the orthopedic residency program at The Jackson Clinics in Virginia, in order to gain more knowledge and experience in order to further understand the SI joint and treatment techniques

1. Research performed in 1990 dissected the SI joint and showed large amount of texture and ridges, which was presumed to cause a lot of friction and not allow the SI joint to move.

2. Contrary research by Vukicevic (1991) reports that the pelvic joints maintain joint space even when they are under load and counters the idea that the SI joint has too much friction to move.

Tensegrity is in short and extremely simplified as a model that looks at the reactions that occur at a cellular level. It also supports the idea in #2, that the SI joint has minimal movement, as research in tensegrity has shown that with compression the cells react with increased tension.

Overall the research is outdated and current research is focused on pregnant women who are most likely to have SI dysfunction due to an increase in relaxin and pelvic hypermobility, which is kind of important for having a baby.

Lesson: The SI joint would thus be “floating” and stable (through ligamentous support) simultaneously in order to allow for the transfer of loading forces from the upper torso to the legs, which supports the estimates of 1-2 degrees of rotation and <1mm of translation.

Treatment lesson: Manual techniques are valuable to decrease acute symptoms in patients with SI dysfunction, but ultimately the muscles around the pelvis should be emphasized to increase stability of the pelvis and assist with load transfer between the legs and upper torso. Isometric and eccentric exercises are both necessary to attain these goals.

Hamstring and/or Groin Strain

The hamstrings and the Adductor Magnus all attach to the ischial tuberosity, so determining which muscle has the strain can be difficult to discern in acute injuries.

These injuries are two of the most common athletic muscle injuries seen in recreational and competitive sports. The causes of these injuries are continually misunderstood and many attempt to stretch the respective muscles and hope for the best.


Unfortunately, often at the expense of the athlete, this approach doesn’t work very often. The key is to determine the cause of the injury and not to treat the symptoms. Sometimes it can be faulty biomechanics or a lack of flexibility, but many times it can be poor nutrition/hydration and an overload to the tissue that causes injury.
Clinical Pearls For Treatment:
1. Make sure the athlete can activate their glutes and is not relying on their hamstrings to produce hip extension. This is a recipe for disaster with the hamstring always being overworked.2. Don’t stretch the muscle during phases 1-3 of rehab. These stages are designed to protect the injured tissue and stretching is too much tension. If you don’t know what stage of recovery the athlete is in find someone that can properly assess the patitne
*Gentle movement to produce small amount of tension on the muscle should be allowed.

3. Advise the patient to stay active. Stairs, core work, flute activation, hip ABD (decrease hip ADD tone), and upper body exercises can still be performed to allow the athlete to keep their conditioning and have a smooth transition back to their sport once their tissues have healed.