Clinical Sough

Let’s introduce to you our second guest blog by follower Björn Westerin from Sweden!


My name is Björn Westerin and I’m a physiotherapist in primary care in Sweden. I have a bachelors degree in sports science and a few courses short of a bachelors in sports medicine.

In December 2016, I passed my basic exam in orthopedic medicine. Besides the job as a physiotherapist in primary care I’m a physio- and fitnesscoach for a soccerteam in 4th tier in Sweden.

I’m planning on writing at Physiotutors about the everyday clinic and my view on some of the challenges a physiotherapist can encounter, both in sports medicine (mostly soccer) and in primary care. My perspective is influenced by Cyriax’ view on orthopedic medicine and you will see that in physiotherapy (and manual therapy) there are as many theories about problems and solutions as there are therapists. Which makes it hard for a student to know what to rely on. Hopefully this blog can shed some light (from one perspective at least).

For example the SI-joint; some therapists find this rotated (although it moves only <2°), see here, while other therapist’s don’t seem to find the SI-joint responsible for pain. A very good post about this problem , which sums up my feelings during my bachelors pretty well.

First of all, let’s get this straight; as a physiotherapist you will meet a variety of symptoms, problems and persons that will mix up and partly confuse you. So the sooner you find your own way of taking the story and making the examination to sort out irrelevant symptoms and signs, the sooner you will be able to come to the right diagnosis, and thereby the right treatment.

For me, symptoms is the problems the patients present to you, and the signs are the positive tests you find in clinic; these do not always come together, and that’s why it’s important for you to sort out what I like to call the “clinical sough” and be able to rely on your findings of signs. For a student or even a fresh physiotherapist it’s hard to know which tests you should use for a joint, for example, the shoulder joint has about 140 tests; a few are listed here, but how to know which test you should use?

My advice is that you make sure to test every structure as isolated as possible, for example the rotator cuff, use the isometric tests to sort out if there’s any problem with each and every cuff muscle, (repeat for yourself which muscles adducts and which external rotates the shoulder)*. My experience is that an impingement test is not so specific, you will press many of the structures in shoulder against the acromion and it will be hard to sort out exactly which structure that elicits pain and then you need to do another special test to keep sorting out. It all comes down to narrow the suspects, is it a passive structure (e.g. bursa, joint) or active (muscle-tendon)?

In clinic you will soon see that most symptoms and problems have a pattern, Cyriax refers this to inherent likelihoods. This is a strong weapon for us to sort out “clinical sough” and test what is important. Take for routine to test the joint proximal and the joint distal to the tender area to make sure that you find any referred pain from a proximal joint.

*Teres minor adducts and external rotates while pectoralis major, latisiumus dorsi and teres major adduct and internal rotates, this is a great example on how you can sort out a muscle by isometric tests.

Instagram: bjornwesterin
PM me if you wish to read about something specific.

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