The Evaluation Doesn’t End on Day 1

“This doesn’t fit with anything I learned in school.”

We often encounter this uncomfortable situation in the physical therapy clinic. In school, we are trained to fit each patient into a neat diagnostic category; grade II ankle sprain, subacromial shoulder impingement, radicular low back pain. These diagnostic categories often work in acute situations with a clear mechanism of injury. However, we also see atypical presentations, that is, a mix of signs and symptoms that don’t match any single diagnosis.

We can think of this like a spectrum. On the one end are “textbook” injuries that neatly fit a diagnosis. On the other end are atypical presentations that make one say “Hmmm”, those ones that don’t match a single diagnosis.

For those atypical, “Hmmm” presentations each subsequent visit is a mini evaluation. We learn more about how the person responds to therapy. We learn about their pain triggers. We learn about their adherence to home exercise. For example, we assign a patient with chronic low back pain the “bird dog” exercise. On the next visit, they have more pain. So we adjust the exercise (such as the range of motion, volume, etc). Or we select a new exercise. Every visit gives us more information and we better adapt the program to that patient.

On the flip side, the evaluation for “textbook” injuries doesn’t end on day 1. Every patient responds differently to therapy. Every patient has different goals. Every patient has unique factors that impact their rehab (psycho-social, economic, etc). For example, consider two people post total hip replacement. One has a telework job with flexibility and a gym in their apartment building. The second works long shifts in a factory and has to drive an hour to get to therapy. Do these people neatly fit into a diagnostic category? Yes. But will they respond the same way to therapy? Probably not.

The process of evaluating is iterative-it is not something we “complete” on the first visit. The evaluation starts in that first hour with a patient, but continues at every following visit.

The Clinic is a Trojan Horse for Exercise

“In the 21st century, health care is increasingly about long-term condition management and thus about health behavior change” [1]

Inactivity is a major worldwide problem. The World Health Organization (WHO) lists “physical inactivity” as the fourth leading risk factor for mortality [2]. Unfortunately, the rates of exercise participation are shockingly low. In the U.S. it is estimated that less than 30% of adults meet current exercise recommendations [3].

We, as physical therapists, are uniquely suited to combat this problem. The PT clinic is the perfect Trojan Horse to get clients exercising regularly.

Why PT’s Should Promote Exercise

Promoting exercise doesn’t just improve general health-there are musculoskeletal benefits that may prevent the need for PT in the first place.* Exercise, specifically resistance training, has preventative musculoskeletal health benefits including: preserving cartilage, preserving/increasing bone mineral density, improving tendon stiffness (a good thing for tendon function), and reducing frailty (which relates closely to fall risk) [4].

However, beyond the preventative benefits of exercise, many of the conditions we treat require long term management. Physical therapists no longer just treat acute injuries. For the chronic conditions we are increasingly working with, patients need tools like exercise, to manage pain and improve function.

The Unique Advantages of PT’s to Promote Exercise

PT is one of the few healthcare professions that spends massive amounts of time with patients. A PT might see a patient for several weeks for 30-60 minutes per session. On the other hand, a physician might only see a patient for an annual checkup for 10-20 minutes.

With so much time spent with patients we are able to:

-Understand and change beliefs about exercise like “lifting weights is dangerous” or “just swim because it’s low impact”. We not only have the time to discuss these beliefs, but the context of the clinic can help patients feel “safe” while exercising. Patients can gradually build up confidence exercising in the clinic in order to exercise independently upon discharge from PT.

Design exercise programs that fit a patient’s life. We get to know our patients well. We deeply understand their exercise preferences and the constraints of their life. So we can create exercise programs that a patient will actually stick to.

For example, I would love all patients to have gym access. However, this is not always possible. For some patients a bodyweight exercise program would have to suffice. Sometimes, the “optimal program” is the program that patient will stick to long term.  

-Help patients build support to exercise. Having support from loved ones and social groups helps many patients stick with exercise. As PT’s we often meet patients’ loved ones and can talk directly with them about how to exercise long term. For example, we often need the buy-in of loved ones to help a patient get exercise equipment, make time to exercise, and to motivate them.

However, even if we don’t meet a patient’s loved ones, we can still help them build support for exercise. We can help them involve their loved ones in exercise. Or we can even help them connect to groups to make exercise social.

But won’t this take away from “treatment” time?

We shouldn’t see exercises for fitness as distinct from exercises for “treatment”.  Many rehab exercises are quite similar to general strength and conditioning exercises. For example, with rotator cuff tendinopathy, we often use isolated strengthening exercises and then progress towards compound movements like pushups and rows. With the right dosage of load and volume, the same exercises that were once rehab exercises become general strengthening exercises.

The clinic need not be only a place for PT “treatment”. The clinic can be the Trojan Horse to empower patients to transform their health through exercise.  

*We cannot truly “prevent” injury or pain, but we can reduce the risk of injury. I use the word “prevent” since “reduce risk of injury” is too verbose.


1. Rollnick S, Miller WR, Butler CC (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press.

2. GLOBAL HEALTH RISKS GLOBAL HEALTH RISKS WHO Mortality and burden of disease attributable to selected major risks. (2009). Retrieved November 19, 2020, from

3. Piercy, K. L., Troiano, R. P., Ballard, R. M., Carlson, S. A., Fulton, J. E., Galuska, D. A., George, S. M., & Olson, R. D. (2018). The Physical Activity Guidelines for Americans. JAMA320(19), 2020–2028.

4. Maestroni, L., Read, P., Bishop, C., Papadopoulos, K., Suchomel, T. J., Comfort, P., & Turner, A. (2020). The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care. Sports medicine (Auckland, N.Z.)50(8), 1431–1450.

Cues Gone Wrong-“Shoulders Down and Back”

Cues Gone Wrong-“Shoulders Down and Back”

“Shoulders down and back”. This cue is practically gospel in the world of physical therapy. And it has seeped into the world of fitness as the “safest position” for the shoulders.

Unfortunately, this cue is overused and creates confusion when misapplied.

While shadowing as a PT student, I recall watching a PT cue a patient doing dumbbell overhead presses. They kept telling the patient to keep their shoulders “down and back”. The patient struggled and struggled. Over the next few weeks the patient would lament, “I just can’t seem to get it”. At the time I thought the patient just needed more practice. I’ve since learned that the patient couldn’t keep their shoulders down and back while overhead pressing, because that’s not what the shoulders do in an overhead press.  

In this article I’ll discuss the use (and misuse) of this cue in pressing exercises.

What is this cue intended to do?

This cue is intended to create scapular retraction (squeezing the shoulder blades towards the spine) and depression (bringing the shoulder blades towards the pockets, away from the ears).

When does this cue apply?

The bench press and its variants.

In the bench press creating a back arch allows the user to lift more weight. This back arch creates various mechanical efficiencies: a smaller range of motion (ROM) for the bar, improved leverage in the lift1, and “tightness” or stability that allows the user to generate more force.

Shoulders down and back can help the user to create that arch, thereby allowing them to lift more weight.

When does this cue NOT apply?

The overhead press.

Trying to keep the shoulders down and back when lifting overhead is contradictory to the motion of the scapula.

When the arm lifts overhead, the scapula rotates upwards. It is estimated that 1/3 of the range of motion lifting overhead comes from this scapular upward rotation2.

Further, this scapular upward rotation is created by the synergistic actions of the trapezius muscles and the serratus anterior2 . So using the upper trapezius is actually necessary to lift overhead with full ROM.

Figure 2: Scapular Upward Rotation

As a self-experiment, lift your arm overhead. Then pin your shoulders “down and back” and try lifting again. There will be significantly less ROM because pinning the shoulders down and back limits scapular movement, which limits full shoulder ROM.

The pushup is another exercise where the shoulders should not be held down and back. During the upward, concentric phase of the pushup, the scapula protract (move away from the spine, see figure 1 above). That protraction is accomplished mostly with the serratus anterior. Trying to cue shoulders down and back is contradictory to that “natural motion” of the pushup.

Why do the pushup and bench press have different cues?

First, the bench press is derived from the sport of powerlifting where the goal is to lift the maximum amount of weight. As discussed above, arching allows the user to lift more weight.

Second, in a bench press the support from the bench gives the scapulae a surface to brace against. In the pushup, there is no external stability, so the serratus anterior has to create the platform for pushing.

Cues have a time and place. The right cue applied to the wrong lift creates confusion and frustration. “Shoulders down and back” has its place in the bench press, but generally should not be encouraged in the overhead press or pushup.


  1. Rippetoe, M., & Kilgore, L. (2011). Starting strength: basic barbell training. 3rd ed. Wichita Falls, TX: Aasgaard Co.

2. Levangie, P. K., & Norkin, C. C. (2005). Joint structure and function: A comprehensive analysis. Philadelphia, PA: F.A. Davis Co.

Which Measurements Matter to Patients?

“When faced with a difficult question, we often answer an easier one instead, usually without noticing the substitution.” -Daniel Kahneman

As physical therapists we have many tools to track patient progress; outcome surveys, range of motion measurements, etc. However, which of these measurements meaningfully reflect patient outcomes?

This might seem obvious. But we often forget to ask these big picture questions in the clinic. We also forget such questions when reading research or choosing con-ed courses.

To pick the right measurements, we need to understand “clinical endpoints“. This term comes from clinical medicine trials. A clinical endpoint is “an event or outcome that can be measured objectively to determine whether the intervention being studied is beneficial”.1

There are three types of clinical endpoints2:

1. Direct clinical endpoints
These directly relate to patient outcomes. For example, consider a soccer player with knee pain. A direct clinical end point would be their ability to play soccer with an acceptable level of pain. We could measure that with the Victorian Institute of Sport Assessment–Patella (VISA-P). An improvement in the VISA-P likely means an improved ability to play soccer with an acceptable level of pain.

Of course, direct clinical endpoints are not the only meaningful measurements. But they most directly relate to patient outcomes.

2. Surrogate endpoints
These predict patient outcomes. We use these if we can’t directly measure an outcome. For example, we don’t know whether an elderly patient will fall – until they fall. But a measure like the modified 30-second Sit to Stand (m30STS) predicts fall risk.3 If we improve the patient’s m30STS score, they should be at a lower risk of falling.

A surrogate endpoint should be validated. Meaning that data supports its ability to predict an outcome.2

However, some surrogate endpoints are not validated. Such endpoints theoretically relate to an outcome. But data doesn’t show that connection. For example, consider the elderly patient at risk of falling. Low calf muscle strength might correlate with falls. However, there are many other factors related to fall risk, so we can’t predict fall risk with calf muscle strength alone.

3. Biomarkers
These correlate with biological activity in a patient. They are least relevant to patient outcomes. For example, a PT might use a tool shown to “increase blood flow” in a patient with low back pain. “Increased blood flow” is a biomarker. This biomarker might correlate with tissue healing. And tissue healing might decrease low back pain. But this is a weak connection. The increased blood flow is an interesting effect, but may not be relevant to improving low back pain.

As we see, clinical endpoints are not all equally relevant. Understanding them is crucial to interpreting research findings, picking con-ed courses, and tracking patient progress. The goal is to not forget the goal: getting patients back to activities they love.


  1. NCI Dictionary of Cancer Terms. (n.d.). Retrieved November 13, 2020, from
  2. Sullivan, E. (n.d.). Clinical Trial Endpoints [Powerpoint slides]. Retrieved November 13, 2020 from
  3. Applebaum, E. V., Breton, D., Feng, Z. W., Ta, A. T., Walsh, K., Chassé, K., & Robbins, S. M. (2017). Modified 30-second Sit to Stand test predicts falls in a cohort of institutionalized older veterans. PloS one12(5), e0176946.

Is pain during rehab exercise “OK”?

*Medical Disclaimer: Please be advised, the information provided in this article is educational in nature and not meant to diagnose or treat any disease, illness, or condition. For individualized recommendations it is best to follow up with a licensed provider, like myself or another physical therapist.

A common concern among clinicians is when a patient experiences pain during exercise. Some clinicians rush to modify the exercise so that the patient has no pain whatsoever. Others ask the patient to describe the pain, trying to differentiate between muscle fatigue and nociceptive pain. And some say it’s just part of the rehab process.

Thankfully in the past couple of decades research has been building on this question. In 2017 Smith et al. did a systematic review trying to answer this question. Their review included studies that:

-Were randomized control trials that compared exercise where pain was allowed/tolerated vs exercise that was pain-free
-Had adults with chronic musculoskeletal pain (defined as >3 months)
-Measured pain, disability, or function

*Note that adults with “non-musculoskeletal pain” were excluded (this list ranged from cancer to headaches to fibromyalgia).

From their search, 7 studies made the cut: 1 trial on low back pain, 3 trials on shoulder pain, and 3 trials on foot/ankle pain. Patients in the studies were instructed that pain during exercise was acceptable (in some studies up to even 5/10 on the VAS), but that the pain should subside afterwards.

They then analyzed the effectiveness in the short (<3 months), medium (3-6 months), and long term (>12 months).

The results?

– Short term, patients who had pain during exercise had statistically significantly LOWER pain scores compared to pain-free exercise
-Reductions in pain levels were similar in the medium and long term between groups
-Improvements in disability and function were similar in the short, medium, and long term between groups

In short, for patients with chronic pain, pain-free exercises and exercises where pain was allowed resulted in similar outcomes (though short term, exercises where pain was allowed led to significantly decreased pain levels). However, we still don’t know about acute injury and post-surgical patients. We likely have to rely on clinical judgement for this. Also, the research doesn’t address other regions of the body (knee, elbow, neck, etc), but I think that we can reasonably generalize the results to other regions of the body-it is likely that chronic pain responds similarly to treatment, regardless of the region of the body. Lastly, a major limitation is that patients with conditions like fibromyalgia and migraine were excluded-this is a major group of patients who suffer from chronic pain! It would be helpful to examine the effects of painful exercise in these populations.

A few questions remain for me:
-Is there a ceiling on the “allowable pain” during exercise? Is there a point of “too much” pain?
-Related, is pain post-exercise “OK”? Would patients have better or worse outcomes if the pain from exercise lingered for a couple days?
-After discharge from therapy if a patient experiences pain with general exercise (a general training program), does this predict future pain?

Here is the original paper for review: