This past weekend, I attended a great seminar here in Boston with Dr. William Brady.  In fact, it was among the best I’ve seen.  I was the only non-chiropractor/manual therapist in attendance, but walked away from the seminar with some tremendously valuable insights that’ll help me with each and every one of my clients moving forward.

The first lesson of the day is that those of you who have an opportunity to see Dr. Brady speak should absolutely, positively check him out: Integrated Diagnosis.  Diagnostically, he’s among the best I’ve ever seen – and that includes his ability to teach others.

The second lesson of the day revolves around an important concept Dr. Brady extended – and my take on how you can modify this message to accommodate your role as a coach, trainer, or fitness enthusiast/athlete.  There is a reason that almost any doctor or physical therapist gets results – and it resolves around understanding where symptom threshold occurs.  To illustrate this, let’s examine a shoulder problem purely from a soft tissue perspective.

Dr. Brady talked about how you have building blocks to threshold.  Let’s say that after an accurate physical examination, this particular shoulder problem (supraspinatus tendinosis, for example) presents with soft tissue restrictions at the infraspinatus, teres minor, subscapularis, inferior capsule, and pec minor.  So, symptom threshold (the dotted line) might look like this relative to baseline (straight line):

Pec Minor
– – – – – – – – – – –
Inferior Capsule
Subscapularis
Teres Minor
Infraspinatus
BASELINE – NO SYMPTOMS

So, imagine a therapist who just addresses pec minor.  He gets that patient below threshold, but doesn’t necessarily “fix” him; he might be back in with the same problem weeks later.  This is confounded by the fact that “overuse” is actually one of the building blocks, too.  So, even if you leave all the soft tissue restrictions alone, simply resting will get someone below threshold – even if the therapist has done ZERO to address the underlying problems.

This is one reason why a MRI might not tell you much at all about someone’s problem.  With this problem, the MRI would probably just say “supraspinatus tendinopathy” and recommend physical therapy and rest from painful activities.  So, in the “full picture” – where soft tissue work is one of several components (assume they are equal contributors, for the sake of our argument) – the building blocks to threshold might look something like this:

Overuse
Rotator Cuff Weakness
Scapular Stability
Poor Glenohumeral (Ball-and-Socket) Range of Motion
– – – – – – – – – – – – – – – –
Soft Tissue Restrictions
Poor Thoracic Spine Mobility
Type 3 Acromion (non-modifiable, without surgery)
Poor Exercise Technique
Poor Cervical Spine Function
Opposite Hip/Ankle Restrictions (baseball pitchers are great examples)
Inappropriate Structural Balance in Programming (e.g., pressing more than pulling)
Faulty Breathing Patterns
BASELINE – NO SYMPTOMS

So, we’ve got 12 factors, and it’s been my experience that conventional physical therapy only treats the first four – which would, in fact, bring a patient below symptom threshold.  Put that patient back in the real-world with the other eight factors still present (seven of which are modifiable), and as soon as he gets back to bench pressing with terrible technique Monday, Wednesday, and Friday, he’s going to be back in for more physical therapy sooner than later.

So, what do we do in an ideal scenario (not always possible with today’s insurance plans)?

1. More time with patient education (exercise technique, programming strategies – or just outsource it to a qualified professional or good book/article or DVD).
2. Address Thoracic Mobility (Assess and Correct is a great resource for this)

3. When present, address Hip and Ankle Mobility
4. Retrain some breathing patterns with initial instructions home exercises
5. Provide some take-home neck drills and get people out of chronic forward head posture

All told, I think this could be as simple as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each patient on exercise program modifications; it really is that simple.  Unfortunately, it rarely happens – and that’s when things become chronic.

So, fitness professionals and coaches need to step up as advocates for their clients and athletes, respectively, and fitness enthusiasts need to be relatively informed “consumers” to look out for themselves.

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