Outpatient Case Study-Shoulder Pain

Outpatient Case Study from a student’s perspective…

Clinical Scenario:

Patient is a 63-year-old female who presents to physical therapy with left shoulder pain that started 3 months ago. Patient said that she was lifting an object from overhead when she felt sudden pain in her left shoulder. Patient also said that sleeping is okay, but can be uncomfortable if she tries to sleep on her left side. Additionally, brushing her hair and doing anything above shoulder height is very difficult and causes her pain. Patient is very active and says that her shoulder pain is limiting her from bending her arm, lifting, and working out. Patient went to the MD where she had an x-ray done; x-ray was negative for bone spurs. MD told the patient that she may have bursitis and was sent to physical therapy to treat. Patient has had two cortisone injections into her left shoulder, both which have helped to some degree.

During the examination, it was noted that the patient presented with rounded shoulders and a forward head position during stance. Patient was able to perform all cervical AROM within normal limits (WNL), as well as elbow AROM. Patient’s shoulder AROM was assessed and noted that left shoulder flexion was limited to 135-degrees and abduction to 87-degrees. The right side was compared; shoulder flexion reached 171-degrees and abduction 175-degrees. Patient’s external rotation and internal rotation was WNL on the right side, however left external rotation measured 45-degrees and internal rotation was 10-degrees. Gross muscle testing was examined with both cervical flexion and extension a 4+/5. Patient’s right shoulder flexion, abduction, elbow flexion and extension were all 4+/5. Left shoulder flexion, abduction, elbow flexion and extension all measured 4-/5. Patient’s myotomes and dermatomes all tested normal. Power grip was assessed, with right handedness noted. Patient’s grip on the right was 17 kg and left grip was 14 kg. Special tests were not assessed during the time of the examination due to patient apprehension to move her left shoulder. When palpating around the left glenohumeral joint, patient had moderate tenderness along her left levator scapulae, upper trapezius, supraspinatus, and infraspinatus. After further evaluation, patient was given a physical therapy diagnosis of “adhesive capsulitis.”  

After a complete and thorough examination, I was interested to see if dry needling to the patient’s peri-scapular area would increase her ROM faster than manual therapy alone. Patient’s first two treatment session consisted of manual therapy and PROM alone to assess how much ROM the patient could achieve. After one week, dry needling was performed to the same area that manual therapy was administered to see if further ROM could be achieved. Further treatment is detailed below.   

Focused Question:

In a patient with adhesive capsulitis, what will produce the greatest ROM- dry needling plus manual therapy or manual therapy alone? And which intervention will have the greatest improvements within a 12-week period?

Articles Selected for Appraisal and Summary of Their Study Design:

Articles Selected for Appraisal and Summary of Their Study Designs

Level of Evidence References *

References for all articles selected for and used in the appraisal.  Please list in hierarchical order (1-5) of evidence; min total of 4. (AMA)

Study Design
  1. Clewley D, Flynn T, Koppenhaver S. Trigger Point Dry Needling as an Adjunct Treatment for a Patient with Adhesive Capsulitis of the Shoulder. Journal of Orthopaedic & Sports Physical Therapy. 2013;44(2):92-101. https://www.jospt.org/doi/abs/10.2519/jospt.2014.4915. Accessed July 24, 2018.
Case Report
  1. Bron C, Wensing M, Franssen JL, Oostendorp RA. Treatment of myofascial trigger points in common shoulder disorders by physical therapy: A randomized controlled trial [ISRCTN75722066]. BMC Musculoskeletal Disorders. 2007;8:107. doi:10.1186/1471-2474-8-107. Accessed July 24, 2018.
Randomized Control Trial
  1. Palomares S, Blazquez B, Palomares A, Calvo E, Benito M, Lapena E, Beldarrain M, Botaya R. Contributions of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A randomized clinical trial. Journal of Orthopaedic & Sports Phyiscal Therapy. 2016; 47(1):11-20. https://www.jospt.org/doi/abs/10.2519/jospt.2017.6698. Accessed July 24, 2018.
Randomized Control Trial
  1. Liu L, Huang Qm, Liu QG, Ye G, Bo CZ, Chen MJ, Li P, et al. Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck and Shoulder Pain: A systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944-55. https://www.ncbi.nlm.nih.gov/pubmed/25576642. Accessed July 24, 2018.
Systematic Review
  1. Bron C, et al. Prevalence of MTrPs in Patients with Shoulder Pain. Dry Needling for Craniofacial, Cervicothoracic & Upper Extremity Conditions: An Evidence-Based Approach. 2011;9(6):117-118.
Systematic Review  
  1. Langevin HM, Schnyer R, MacPherson H, et al. Manual and Electrical Needle Stimulation in Acupuncture Research: Pitfalls and Challenges of Heterogeneity. Journal of Alternative and Complementary Medicine. 2015;21(3):113-128. doi:10.1089/acm.2014.0186. Accessed July 24, 2018.
Systematic Review
Total Number of Articles 6

Summary of Key Findings:

In a case report by Clewley et al, 1 they looked at a 52-year-old female with primary symptoms of shoulder pain and decreased motion, secondary to adhesive capsulitis. The authors initially treated the patient with joint mobilizations to the shoulder region and trust manipulations to the cervicothoracic region. However, the patient continued to have pain and limited motion in her shoulder. On the third visit, the patient was treated with dry needling targeting the upper trapezius, levator scapulae, deltoid, and infraspinatus muscles. The patient was treated with dry needling for 10 visits, with improvements in pain-free ROM and an increase in functional outcome measures, like the DASH and Shoulder Pain and Disability Index. In conclusion, the authors found that when incorporating dry needling into the treatment sessions, the patient seen rapid improvements in ROM. Additionally, the authors suggested that the above musculature is a great source of pain in regard to adhesive capsulitis.

Bron et al,2 conducted a randomized control trial to investigate whether physical therapy modalities could inactivate trigger points in order to reduce symptoms and improve shoulder function in a chronic, non-traumatic shoulder population. They compared the modalities to a wait-and-see approach that many people often use when dealing with shoulder injuries. One hundred subjects between 18 and 65 years old were included, all with unilateral shoulder pain, and sent to physical therapy to treat the neck, shoulder, or, arm. Patients completed the DASH for baseline testing measures and myofascial trigger points were identified before beginning. The control group took the wait-and-see approach and the intervention group received physical therapy. At the 12-week mark they all received the same physical therapy program and were re-evaluated using the DASH. The physical therapists used stretching, compression, and cryotherapy in order to decrease pain and symptoms, whereas the control group just used over-the-counter painkillers. Researchers found that stretching and compression to trigger points increased patients’ ROM and decreased pain sensitivity when comparing to just taking medication alone.  

Palomares et al, 3 conducted a randomized clinical trial intended to treat MTrPs with dry needling. One hundred twenty patients were looked at, all of which had nonspecific shoulder pain. Subjects were randomly placed into either a physical therapy treatment group or a trigger point dry needling plus physical therapy group. Patients were measured in regard to pain and function and the number of active MTrPs were calculated. Investigators found that there was no significant difference between evidence-based physical therapy treatment compared to dry needling, both showed significant improvements over time.

Liu et al,4 evaluated dry needling used as the main treatment in patients diagnosed with MTrPs associated with neck and shoulder pain. Two independent reviewers looked at twenty randomized controlled trials involving 839 patients and found that dry needling for MTrPs was effective in short term (3 days) and medium term, however wet needling was more effective to treat trigger points for medium term cases.

Bron et al,5 looked at the prevalence of MTrPs and the correlation between MTrPs and pain intensity in patients with chronic, non-traumatic unilateral shoulder pain. Researchers found that all 72 subjects that were studied had active MTrPs and 67/72 had latent MTrPs. Active MTrPs were found in the infraspinatus, upper trapezius, middle trapezius, anterior deltoid, middle deltoid, posterior deltoid, and teres minor. Latent MTrPs were found in the infraspinatus, upper trapezius, teres major, and anterior deltoid. Examiners found that the infraspinatus and upper trapezius muscles were the most common muscles to have active MTrPs. By treating the active trigger points, patients were able to have a more normal activation pattern and had spontaneous recovery of shoulder pain.

Langevin et al, 6 evaluated the benefits and modes between electrical acupuncture versus manual acupuncture. The authors found that MA encompasses a much shorter duration than EA and provides a brief, intermittent stimulation to the muscle. On the other hand, EA provides a constant stimulation that causes depolarization of the muscles for several minutes (15-30 minutes). Depending on the duration of stimulation and mechanism of acupuncture that is being elicited to the muscle, there are different physiology responses that can occur. The authors looked at 89 systematic reviews and found that EA is superior to MA when treating knee OA. Lastly, the authors suggest that many factors play a role in comparing the two modes, including: mechanism of action, clinical recommendations, and patterns of use; which the authors state is widely different across practitioners. The authors suggest that both EA and MA are beneficial, however it just depends on clinician preference, treatment area, and patient symptoms.   

Limitations that would apply to Clewley et al would be that they only looked at one individual patient’s outcomes, rather than examining a larger subject field. By doing this, readers cannot conclude whether DN would work for their patients because it was administered to a female, of a specific age, with a specific diagnosis. Contrarily, Bron et al looked at a large range of ages within their study. Although this is better for data collection purposes, age can play a role in shoulder function and pain perception/sensitization. I think future studies should look to see how dry needling varies across multitudes of ages and compare outcome measures based on improvements in ROM and pain perception via the DASH.

Application to Patient Care:

For this particular patient case, I wanted to apply a similar study design like that of Clewley et al,1 but apply dry needling to the same musculature as Bron et al.5 In my patient case, we decided to treat the patient with just manual therapy for the first two visits. Manual therapy consisted of massaging the patient’s active MTrPs within the left trapezius, levator scapulae, rhomboid major and minor, serratus posterior superior, latissimus dorsi, serratus anterior, deltoid, supraspinatus, infraspinatus, teres major and minor, subscapularis, pectoralis major and minor, and coracobrachialis. Additionally, PROM was performed into shoulder abduction and flexion to stretch the left latissimus dorsi and RTC musculature.  On the initial evaluation, patient was able to reach 87-degrees of left shoulder abduction and 135-degrees of left shoulder flexion. After the second visit with just manual therapy and PROM alone, patient gained 3-degrees of shoulder abduction. Patient was unable to improve in shoulder flexion. During the third visit, patient was administered manual therapy to the same muscles and then dry needling was applied. DN was performed x 15 mins at 2Hz for 250usec to the patient’s left shoulder. 25-40 mm single use needles were administered and individually wrapped with guide tube (Sierin) were utilized. Needles were inserted targeting: trapezius, levator scapulae, rhomboid major and minor, serratus posterior superior, latissimus dorsi, serratus anterior, deltoid, supraspinatus, infraspinatus, teres major and minor, subscapularis, pectoralis major and minor, and coracobrachialis. Unilateral spins were applied to all needles, as well as slight tenting. Patient was sidelying with ipsilateral UE resting on a pillow. Patient responded as expected, with mild deqi response noted. Patient did not have significant pain and was able to tolerate treatment. Patient was also educated on the effects of DN and what to expect over the next few days. Needles were counted upon insertion and all needles were accounted for upon removal.

After two visits of administering manual therapy plus dry needling, patient has had an additional 5-degree improvement in shoulder abduction and 4-degree improvement in shoulder flexion. Patient has also stated that her pain has decreased significantly with shoulder all motions. Patient will continue to be evaluated for the next 10 visits to see how effectiveness dry needling is on the patients shoulder mobility.

Clinical Instructor Feedback:

My CI is on board with implementing the plan above and thinks that dry needling is a good recommendation for this patient, especially when treating adhesive capsulitis. CI said that dry needling will facilitate breakdown the adhesions within the glenohumeral joint since manual therapy alone cannot. My CI discussed that there is a neurophysiological response that occurs once the skin is punctured that releases opioid  and non-opioid factors that are found present in the tissue for 7-10 days post treatment, Thus performing this treatment allows for the patient’s healing of the injury to continue upon leaving. This response can be exaggerated by piggybacking the days that the patient gets the needling performed. We are also using 25 mm to 40 mm needles, thus we are able to access areas of the joint that we are not able to normally access. One in particular is the area of the supraspinatus that is deep to the AC joint and rarely able to be stimulated. She has seen great improvements in shoulder injuries when this area is addressed with the DN. CI also says that dry needling will be beneficial to administer for the next couple visits to see if further improvements are able to be made. After proper lengthening of above musculature is addressed and relieved, then the patient will progress into a strengthening program.

Data Bases and Sites Searched:

  1. Journal of Orthopaedic & Sports Physical Therapy (JOSPT)
  2. PubMed
  3. PEDro
  4. Physiopedia
  5. PTNow
  6. Journal of Alternative and Complementary Medicine
  7. Osteopractor WordPress
  9. Dry Needling Institute: American Academy of Manipulative Therapy

Pain can be a REAL GRINCH! Let TOPS help you STEAL back your Holiday Spirit!

Is the “Grinch” trying to hold you back this year and steal your HOLIDAY SPIRIT?!

Tis the season of giving…. But, pain is not what you want to be given! And, at this time of year, pain can be the REAL Grinch…

How can you overcome the PAIN-Grinch?

Well, we have some GREAT NEWS FOR YOU! Your deductible is most likely met! Arizona is direct access, meaning you don’t even have to see a doctor before coming… You can come straight in and we will check you out, and get you started, on your FIRST appointment. We are a one stop shop at T.O.P.S. (rare thing to find during the Holiday time)!!! In the clinic, we have an Osteopractor, which means you can get all your dry needling, joint manipulations, or physical therapy done in ONE LOCATION!

We want you to enjoy eating TOO much Turkey, Christmas shopping, home decorating… Annnnddddd, great weather in Phoenix! This is the time of year when we start to get back out running, hiking, biking, etc. At T.O.P.S., we believe that getting out and moving is essential to your physical and mental health. We also understand that you may have aches and pains that arise after hibernating all summer! Not only does this affect you physically, but it’ll take a toll on your mental well-being as well. Don’t let that happen! Aches and pains should not be on the forefront of your mind, or limiting your desire to do any of these activities!

Not to mention, once your physical pain is minimized, your mental clarity will improve, providing for shopping stamina, great gift ideas for those hard to shop for, and delicious meals!

As Saint Augustine said, “The greatest evil is physical pain.”

So, we invite you in, to come check out what we can do for you during these hectic holiday times, and get you running, hiking, or biking your way into 2019!!!

Young Female Athletes Sidelined From Injury- Week 3

How much is too much?   

Below is the max pitch count for each age group. It is important that your young female athlete does not pitch the same pitch over and over to decrease overuse injury. In order to prevent injury and harm, you should have your female athlete following these guidelines as closely as possible.

Every athlete should have two days of rest after a day of pitching to prevent injury. A day of pitching would include two or three games with the maximum pitch count listed below. Girls < 12 years-old should not pitch more than 2 consecutive days and girls > 13 years-old should not pitch more than 3 consecutive days.

Recommended rest time means no live pitching, which includes no pitching during batting practice. It is important that your young female athlete takes this time to fully rest to allow proper healing components to the area.  

Young female athletes that are in their resting phase can still participate in hitting and fielding drills, but should eliminate as much overhead throwing in the field as they can. During rest periods, it is essential that your athlete performs a 2-5 minute jogging routine to stretch muscles before starting to stretch specific areas. They then should follow-up with a 20-30-minute stretching program that targets cross-body movements, shoulder rotation, flexion, and abduction, and wrist motions.   

Maximum Pitch Count

Age Pitches/Game Pitches/Day
Days 1 & 2
Day 3
8-10 50 80 0
10-12 65 95 0
13-14 80 115 80
15-over 100 140 100

Reference for chart:

Ireland L. Mary, MD, Snyder-Macker Lynn, PT, ScD, Ferguson Bonnie-Jill, Coach. Stop sports injuries- Keeping Kids in the Game for Life. American Orthopaedic Society for Sports Medicine. 2010. https://www.sportsmed.org//aossmimis/stop/downloads/Softball.pdf. Accessed July 31, 2018.

How can physical therapy prevent your young female athlete from injury?

Surprisingly, surgery is not always required! Whether preventing injury or stopping further injury, physical therapy can help in various ways. Physical therapy will give your female athlete insight on proper body mechanics both on and off the field in order to prevent injury.

Referring back to the electromyogram (EMG) study I talked about in my first blog on young female athletes who perform windmill pitches; it has been found that there is a greater increase in the biceps and brachialis musculature contractions than all other muscles within the arm.

Physical therapy can provide your athlete with specific exercises to these muscles to promote proper contraction throughout the arm. This can be done through specialized training like dry needling, myofascial decompression, or individualized manual therapy techniques. Your female athlete can also be provided with knowledgeable experts who have background on functional training and proper upper body mechanics in order to prevent unnecessary strains and sprains.  

Additionally, your athlete must have good stability of their lumbo-pelvic junction. This include their low back and pelvis. If your athlete does not have a strong base of support then they will have poor body mechanics, will eventually fatigue, and cause injury to areas that cannot handle torque and compression. Physical therapy can address this deficit by engaging your athlete in glute exercises, lower body functional strength and endurance, as well as stretching routines to perform pre and post gamedays.

Lastly, it is pertinent that your athlete knows how to properly transfer ground-reaction forces throughout their body. This means transferring forces from their legs, through their abdominal cavity, and up to their pitching arm. If this is not done properly, then momentum will be lost, and power and speed will be decreased. At therapy your athlete can be taught proper rotational forces to apply along the spine, can receive evidence-based osteopractic techniques, and be provided with a sports-specific program.  

At TOPS Physical Therapy your athlete is guaranteed an individualized program to get stronger and faster both on and off the field! Come see us today before it’s too late!!    


Young Female Athletes Sidelined From Injury-Week 2

Why do we see so many young female athletes sidelined from injury?

Did you miss the first blog? Go back and check it out! This is an awesome series!!! Our student Ashley is sharing her personal story and some insight on why so many young female athletes end up injured. If you are wanting to get a better understanding, then this blog series is for you! The purpose of this blog series is to go through some of the most common injuries, early identifications, and prevention of injuries for young female athletes.

Do you know what the most common injuries are that a young female athlete can endure?

Most of you can probably come up the obviously injuries like: rotator cuff tears/ strains, low back pain, and nerve impingement, but what how many of you actually know why these occur? Well, below I have listed common injuries that young female athletes undergo, as well as some explanation as to how these injuries occur.

  • Shoulder-Impingement (most common)

    • Compared to an overhead thrower who has a range of motion (ROM) of 108 degrees, a female windmill pitcher requires 360 degrees of motion. This ROM then places torque on the biceps brachii (talked about in last week’s blog). The biceps tendon can either become impinged underneath the acromion of the shoulder, cause inflammation of the biceps tendon, or at worst, can rupture the tendon. In turn, your young female athlete may start to complain of pain on the front side of their shoulder, state relief of pain when the shoulder is down by their side, or the biceps muscle may look like a “pop-eye.”
    • “Pop-eye” muscle:
  • Ulnar Nerve Impingement 
    • This injury is due to abnormal forces through the elbow. While pitching, you may notice that your young female athlete may have her forearm too far outside her pitching zone while her elbow is tucked near her body. This causes a valgus force and can end up causing impingement on the inside portion of the elbow (Cubital Tunnel) or at the wrist (Guyon’s Tunnel). If your athlete has a nerve impingement they will complain of numbness and tingling down the inside of their forearm and/or in their fourth and fifth (pinky) fingers.
    • Cubital Tunnel Entrapment
    • Guyon’s Tunnel Entrapment
    • Pain Location


Check out the blog next week to learn more about when these young women are over doing it! 

Saved By The KettleBELL

Saved By The KettleBELL!!! The rundown on kettlebells and how to add them into your gym routine.

Kettlebells are a common workout tool in almost any gym. They come in a variety of different sizes and the specific shape of the kettlebell adds an element of versatility that you just can’t get from a dumbbell. As healthcare professionals and people who are constantly looking to improve our physical capability, using kettlebells simply makes sense. The distribution of weight with the modification of a larger grip allows for more powerful and dynamic movements that challenge your entire body, including your core to a much greater extent. As with any exercise, learning proper form is absolutely essential to maximize the intensity of your workout as well as prevent injury. Below you will find a few of the TOPS Teams favorite kettlebell exercises as well as some instruction on form. Give these exercises a try next time you’re at the gym to revamp your normal routine.

Kettlebell Swing


  • This exercise will not only challenge full body strength and power, but also your cardiovascular system. It’s crucial to implement proper hip hinging technique when the kettlebell is lowered and then exploding into a standing position. Do not raise the kettlebell above shoulder height

Goblet Squat

  • As opposed to a traditional squat, the goblet squat with a kettlebell will allow you to squat through a larger range of motion. Controlling this larger range of motion is essential before you hit the squat rack with heavy weight. It also adds some arm and shoulder strengthening. Grip the kettlebell on either side of the handle and keep the weight close to your body.

Reverse Lunge in Rack Position

  • This is a traditional reverse lunge with the kettlebell in the rack position. This means that the weighted portion of the kettlebell is supported by the forearm and upper arm, just below your shoulder, while gripping the handle (as pictured).  Maintain an upright posture throughout the movement, not letting the kettlebell deviate your trunk.

Single Arm Press

  • TOPS has found that the use of a kettlebell when pressing overhead allows for a more fluid motion than with a dumbbell. The weight of the kettlebell will rest against the back of your forearm here. Performing this with a single arm (rather than both arms at once) with challenge your core to a greater capacity.  

Single Arm Row

  • Start in a lunge position with the same leg extended backward as the arm you are rowing with. Rotate the back leg out and place your opposite arm on your thigh for added stability with the exercise.  The rowing motion should be performed through full range of motion, with the kettlebell returning to ground height with each rep. Again, this single arm exercise is great for core strength as well.

Kettlebell Cleans

  • This exercise is a true total body, explosive exercise. Start with the kettlebell at ground level and your body in a squatted position. Similar to the kettlebell swing, explode into a standing position bringing the kettlebell to shoulder height, and ultimately into the rack position. This movement takes practice, as it is a more advanced exercise, so start with lower weight, perform in front of a mirror, or have someone with experience critique your form.

Know Your Insurance

Know Your Insurance

What do you know about your medical insurance? What services does your insurance cover? What does “patient’s responsibility” actually mean? How can you better understand your policy? Will medical offices check your benefits for you? T.O.P.S. is here to answer all these insurance questions and more!

We know that no one plans to get sick or hurt, but there comes a time that everyone needs medical care at some point. Health insurance and coverage seems to be a sensitive topic today, so we wanted to provide you all with a quick read that is important for all consumers to understand when getting medical services from ANY OFFICE! Consider this as a simple lesson on health insurance and medicine…

Do you know your plan?

Did you know… you can easily check online or make a phone call to the number on the back of your insurance card to learn more information about your specific plan??  Take the time to check what type of plan you have during open enrollment aka prior to committing to the insurance! Find out what type of policy you have, check to see if you have: premiums, deductibles, copays and in/out of network benefit details, and etc. (Here a quick breakdown of what that means:  Premium- the amount paid monthly for health insurance, Deductible- the money that is paid out of pocket before coverage starts, Coinsurance- the percentage you will need to pay after the deductible is met, Co-pay- a flat payment for medical services, In-Network- doctors and medical office that are covered in the insurance plan, Out- of-Network- Doctors/ medical office that are NOT covered)

Do medical offices verify your coverage?

At T.O.P.S. Physical Therapy, as a courtesy, we verify insurance benefits for physical therapy for all new and past patients. (NOT ALL MEDICAL OFFICES WILL DO THIS FOR YOU).

Regardless of whether offices check your insurance benefits for you or not, you should really know all parts of your plan to make sure that it can be used to it fullest. Knowing your plan allows you to see what you like/don’t like. If you don’t currently like something about your plan, keep that in mind when you go to back to open enrollment to choose your plan for 2019. You should pick a plan that best fits the needs of family/yourself.  If your someone with a pre-existing condition, you might want to consider a plan with a high premium and low-deductible. If you’re a healthy family/individual, then a low premium with a high-deductible. One thing to always keep in mind is that insurance is an investment and if you don’t know what your signing up for, how do you know if it can really help with your needs?

If you know your insurance plan start here!

For those of you who know your plan, you already know and dread this time of year because you know your plan has to RESET! Which means that when you visit TOPS Physical Therapy, or other medical offices, you are most likely going to have some out-of-pocket costs.

With that said, we saw an interesting post by, Dr. Ron Pavkovich. He gave a great summary of the fiasco that patients and offices go through when this reset happens. He wanted to share and give the point of view of a PT front office… It is a great read, for consumers, PT offices, and ANY medical office!

For those who don’t know, you, the patient, is ultimately responsible for knowing and understanding your benefits for medical care. The patient has the responsibility of knowing their plan, what is, and is not covered. As a courtesy, physical therapy and medical offices verify your benefits and explain them to you in a “language” that you can better understand. This courtesy of checking benefits is a relatively COST CONSUMING gesture on their part. It is also ALWAYS an estimate. With that said, it is your choice and responsibility to either check your own benefits or know your plan. If your insurance does not pay for the services or care you received, it is still your responsibility at the end of the day. This is why you sign your initial paperwork advising that you understand and agree to pay for the services provided, in the scenario that your insurance does not pay.

If you have had a service performed, it is not the PT or MD office’s fault that your insurance did not pay. Therefore, you cannot, and should not, expect that office to not collect for services rendered and treat you for free.

This is a simple education lesson on health insurance and medicine. Please do not blame your provider for you not knowing what your plan does and does not cover. Your provider’s office is simply the messenger and doing you a courtesy by trying to help you understand the type of coverage you have. At the end of the day, your provider does not make these insurance policies nor do they have a say in what is paid for. Also, please keep in mind that your provider is likely only getting reimbursed about 40% of what they bill your insurance carrier. Insurance carriers are killing medicine!

Another point made is that often the PT or MD offices are responsible for pre-certifications. If the office is “in-network”, the office is obligated to write off some procedures, which are oftentimes beneficial.
Furthermore, if you provide insurance information that has lapsed after the first of the month, that carrier isn’t liable for payment! Good luck collecting or getting backdated approval from whatever carrier, if any, succeeds the lapsed carrier. And TPA’s will not backdate authorizations until you can prove they were wrong with processing it the first time. So in other words, they can allow for their mistakes, but never yours.

This becomes particularly frustrating for small private practices. They bill everyone the same, yet they generally are not able to negotiate with insurance companies, as they have no leverage. Thus, they have to either take what they pay (usually around $0.40 of every $1 billed) or not participate as in-network. They then approve the full rate, but pass it to the patient as an out-of-network cost. Most small private practices will offer anyone who pays day of service, a discount (and if insurance paid day of service, they would get it too). So, anyone is welcome to see the prices, but insurances can change what they pay on a whim, so that is more difficult to keep up with.

This is an issue in our healthcare system that tends to be heated and followed with a lot controversy. Some responses we have had about this topic are:

  • Insurance anymore is only catastrophic Insurance at best. The deductibles are crazy and you’re 100% right about it killing medicine.
  • The mouse print on our patient delivery confirmation is extensive and has expanded to include all these points. Most folks have no clue how their insurance works. I have to explain regularly that office visits to their doctor and prescriptions don’t generally apply to deductibles.
  • I agree and fully understand your point. When will I be able to pay my doctors the same price for a service that they accept from insurance companies?
  • I agree the patient is ultimately responsible to know their benefits but we all live in the real world and that usually never happens. Protect yourselves and document, document and document some more!

If you do not like your coverage… Make a change for 2019!

Now is the time of year to start talking with your employer and see what other health insurance options exist for you. Do some research on your end and think about what medical services you will need for the upcoming year. Call around and see if your doctors offices take the various insurances your employer offers and which one gives you the most coverage at the offices you visit the most. Do your homework!

Young Female Athletes Sidelined From Injury- Week 1

Why do we see so many young female athletes sidelined from injury?

Why do so many of these female athletes suffer the same injury? What are the most common injuries? Can we prevent these injuries? Why are we not doing more?

If you are seeking answers to any of the question above, then this blog series is for you! The purpose of this blog series is to go through some of the most common injuries, early identifications, and prevention of injuries for young female athletes.

My Background as a Young Female Athlete and How it Shaped Me Into The Physical Therapist I am Today:

First, I would like to share my background and why this topic is so important to me! My name is Ashley Burkhardt and I am a Student Physical Therapist at TOPS Physical Therapy. Since I was 6 years old, I grew up watching my aunt play catcher in collegiate softball at Northwood University, and was inspired by the athleticism and finesse of big time college players, as well as professionals like Jennie Finch and Jessica Mendoza. They all inspired me to start my own softball career as a catcher. In my career as a catcher I was fortunate enough to stay injury free but unfortunately, that was not the case for most of my teammates. I watched countless injuries happen both on and off the field and through poor training habits. Coaches and parents never seemed to know the root cause of why young female athletes were getting injured or even how to properly teach injury prevention.

Now fast forward eight years later, I have ended my softball career and entered my professional career as a physical therapist. I have recently started doing clinical rotations and am shocked at the amount of young female athletes who are getting injured due to poor mechanics, fatigue, strength deficits, and overall lack of knowledge of how to properly train in the weight room. I can see that these injuries are not only common in young female softball athletes, but within the female athlete population.

It is a shame knowing that high school female athletes are losing collegiate scholarship opportunities due to rotator cuff tears, shoulder impingements, low back pain…the list goes on. These injuries are serious and can be prevented if these young female athletes start a training program early on that is individualized to their needs and given by someone who is knowledgeable about windmill pitching mechanics and functional muscle training.

I hope this blog can serve as an informative piece, yet personable to what I have experienced. Enjoy!

Research Behind the Windmill Delivery:

It is important for not only the young female athlete to understand the mechanics behind the pitch, but it is pertinent for coaches and parents to know in order to help prevent injury. There have been many research studies conducted regarding windmill pitching, but the below study really stood out to me because it compared female athletes to male athletes and how the pitching mechanism involves different muscle forces.

The American Journal of Sports Medicine did a motion analysis and EMG study on seven female pitchers and the activation of the biceps brachii muscle during a windmill pitch and an overhead baseball pitch. Researchers found that the peak activation of the biceps brachii was significantly greater with a windmill pitch than an overhead throw. The highest activation of the biceps brachii being at the 9 o’clock phase of the pitch in which the pitcher is eccentrically contracting their arm and during the follow-through phase. With the repetitive contraction of the biceps, female athletes are more prone to anterior shoulder pain and shoulder impingements. Not only can physical therapy help prevent shoulder pain and impingement through osteopractic techniques, but it can provide evidence-based strengthening and flexibility programs to your athlete in order to prevent injury and ensure proper pitching mechanics.

Check out my blog next week to see a breakdown of the most common injuries and early identifications in young female pitchers!


Hays, Graham. “EspnW — Florida Southern College Softball Players Carry Injured Eckerd College Opponent around the Bases after Game-Winning Homer.” ESPN, ESPN Internet Ventures, 28 Apr. 2014, www.espn.com/espnw/news-commentary/article/10848732/espnw-florida-southern-college-softball-players-carry-injured-eckerd-college-opponent-bases-game-winning-homer.

Idubijes L. Rojas, Matthew T. Provencher, MD, MC, USN, Sanjeev Bhatia, Kharma C. Foucher, PhD, Bernard R. Bach, Jr, MD, Anthony A. Romeo, MD, Markus A. Wimmer, PhD, and Nikhil N. Verma, MD. Biceps Activity during Windmill Softball Pitching: Injury Implications and Comparison with Overhand Throwing. The American Journal of Sports Medicine. 2009; Vol 37, Issue 3, pp. 558 – 565. https://doi.org/10.1177/0363546508328105. Accessed July 17, 2018.

Lower Body Workout Variations

Lower Body Workout Variations

Last week we asked if you were a frequent gym-goer or someone who is newer to the gym to see if you could benefit from upper body variations. This week we would like to share with you all some simple lower body strengthening exercises. We picked a few that we see people perform consistently at the gym. Especially for a beginner, we think it is essential to know some of the big muscle groups that are targeted before performing an exercise and the difference in modifications of each exercise. Use this as a general guideline when tweaking your exercise routine and regardless of your experience working out, always emphasize proper form.

Squat Variations

The squat is everyone’s favorite low extremity strengthening exercise. By adjusting the placement of the bar you can easily target different muscle groups. Keep in mind there will be overlap in muscles you strengthen with each variation and the muscles listed below are not the only muscles being used.

  • Back squat
    • High glute involvement
    • Ideally you want your trunk and tibia in line with each other. Try to not let your knees progress over your toes throughout the movement.

  • Front squat
    • More quad involvement
    • Placing the bar on the front of your shoulders, rather than behind your head, moves the center of gravity of the weight you are lifting forward. This is why your quads now become the chief mover rather than your glutes.

Lunge Variation

The lunge is one of the most versatile lower extremity strengthening exercises that we use consistently in physical therapy.  It is an extremely useful exercise to build frontal plane strength, which may of us lack. In addition, the exercise will strengthen some of the large muscle groups people focus on at the gym, including quads and glutes.

  • Forward lunge
    • More quad involvement
    • It’s ok to progress your front knee over your foot slightly with this exercise, but slowly control the motion and do not let you knee dive inwards

  • Backward lunge
    • More glute maximus involvement
    • Try to keep the front knee behind your toes and actively drive the motion through your hips

  • Lateral lunge
    • More glute medius involvement
    • This is a muscle that stabilizes your hips in the frontal plane and often times a muscle that is weak in the general population
    • When initially performing this exercise, do not use weight and keep your hands in front of you to counterbalance your hips going backwards

Deadlift Variation

The deadlift can be an extremely beneficial lower extremity strengthening exercise. It is easy, however, to perform the exercise with incorrect form and place high levels of stress on the low back. With all variations, think about keeping the shoulders and back engaged and core activated. The bar should always be as close to your body as possible.

  • Traditional deadlift
    • More glute activation here
    • Knees start bent and finished extended

  • Romanian deadlift
    • More hamstring activation here
    • Knees stay relatively extended throughout the movement
    • This is typically a more difficulty variation to perform, thus start with lighter weight and focus on proper form

Upper Body Workout Variations

Are you a frequent gym-goer? Are you new to the gym? If you answered yes to either question, then you could benefit from exercise variations. Why is that? The simple reason is, we all can benefit from variation in our training. (Variation in terms of training can mean intensity, volume, frequency, lifting tempo, exercise selection and so on).

Today we would like to share some simple upper body strengthening exercises. We picked a few that we see people perform consistently at the gym. Especially for a beginner, we think it is essential to know some of the big muscle groups that are targeted before performing an exercise and the difference in modifications of each exercise. Use this as a general guideline when tweaking your exercise routine and regardless of your experience working out, always emphasize proper form.

Push Up Variations
The push-up is an extremely functional and simple exercise that can easily be altered to train different parts of your body. Whether you’re a beginner or advanced gym-goer, knowing the different variations of the exercise can be useful when tailoring your workout and building full body strength. Regardless of alteration keep a neutral spine with chin slightly tucked.

  • Shoulder width
    • Targets deltoids>pecs>triceps
    • Focus on neutral spine throughout the movement
    • Hands slightly outside shoulder level

  • Wide placement
    • Targets pecs>deltoids>triceps
    • Hands should be further outside of shoulder level slightly above mid pec level

  • Close placement
    • Targets triceps>deltoids>pecs
    • Keep hands at or slightly inside of shoulders at level just below the pecs

Pull Up Variations

The pull up is another very functional upper body strengthening exercise.  The pull-up can be adjusted with arm positioning and grip variations to target different muscles in your body. Keep in mind however, the main muscle groups will include your lats, rhomboids, biceps, and forearm musculature regardless.

  • Wide and close grip
    • Back muscles (lats, rhomboids)>biceps>forearm

  • Open grip
    • More biceps activation here with less back and forearm activation

  • Closed grip
    • More forearm/bicep activation here with less back activation

Curl Variations

You’ve likely tried or seen people doing different variations of curls at the gym. All curls should not be considered the same however. With whatever variation you choose to perform, keep the shoulders back and down, keep a neutral spine and work through full elbow ROM.

  • Supinated (open) grip
    • Palm up
    • Targets biceps>medial forearm>lateral forearm
    • Be careful not to lose the palm up grip when lowering the weight.

  • Pronated (closed) grip
    • Palm down
    • Targets lateral forearm>biceps>medial forearm
    • This is typically a more difficult curl, so go down in

  •  Neutral grip
    • In-between an open and closed grip
    • Equal activation of biceps and lateral forearm (roughly), not much medial forearm activation here
    • weight and focus on form

National Athletic Training Month

Here at TOPS Physical Therapy we celebrate athletic trainers everyday, but each March it’s highlighted on a national level during National Athletic Training Month. To celebrate this month we would like to highlight the BEST athletic trainer, Chad Bohls! Chad, like all athletic trainers across America, deserves to be recognized for his commitment to helping people prevent injuries and stay healthy and active. These men and women go above and beyond to provide the highest level of care! We thank you all for your hard work and dedication. You guys have “our back”! It is our time to have yours, so with that said we are behind this initiative fully, as it helps spread awareness about the important work of athletic trainers.

In many ways, an athletic trainer can be synonymous with a PA in a traditional medical model. And Chad certainly fulfills his role as the “PA” for TOPS Physical Therapy. Chad has worked along side world renown physical therapists for the past 11 years and he has the knowledge of an honorary physical therapist. TOPS Physical Therapy wouldn’t be the same without him! Chad is an expert in manual work and excels at getting patients back to the life they want to live, whether it is a small tweak to their system or a full blown return-to-professional sport. And let’s not forget, Chad has endless movie quotes, South Dakota knowledge, sports trivia, and personality for days!

Athletic trainers are health care professionals. They are highly educated and dedicated to the job at hand and can be found in high schools and colleges, corporations, professional sports, military, performing arts and clinics, hospitals and physician offices. The BEST ATHLETIC TRAINER WE KNOW CAN BE FOUND AT TOPS PHYSICAL THERAPY! For all who don’t know, National Athletic Training Month is held every March in order to spread awareness about the important work of athletic trainers. This years slogan is “Compassionate care for all.”

And Chad certainly provides COMPASSIONATE CARE FOR ALL!

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25 Questions To Get To Know Chad