Mechanics of the Subjective Exam: 3 Steps to Delivering Quality Care

Being a sports rehabilitation specialist is like being a private investigator: each new patient is a multifaceted challenge. Why are they limited? Where do they hurt? How can we prevent them from hurting?

To solve the puzzle and provide an effective treatment plan, we need to constantly seek out the relevant information and formulate a game plan that fits the patient’s needs, often times within the limits of an insurance company. When I talk to students and other therapists, I’m constantly emphasizing the importance of a good subjective exam. Below is an example of how this process helps in the treatment of overhead throwing athletes.

Build Rapport

In a short amount of time, the subjective exam can make or break the relationship between yourself and your new patient. Our questions need to be succinct enough to guide us down the correct road.

Once established, this rapport can help determine a treatment program, gaining you the trust needed to investigate the issue and build an appropriate plan of attack.

Assess Biomechanics and Key Movements

Once you grasp what’s potentially going on with the client, you will need to understand how it fits with known anatomy and biomechanics research.

For example, if a baseball pitcher complains of pain or clicking (or both) that affects their velocity or pitch location, you must be prepared to assess the relevant anatomy and biomechanics of the throwing shoulder.

Piecing together the clues can be daunting, but asking the right questions and assessing the key movements facilitates the process. I am certainly not going to think the patient has a full blown rotator cuff tear if they are 19 years old and can still throw the ball with decent velocity.

However, I should know that the stresses on the shoulder joint, especially during the late cocking phase, through the acceleration phase, and ending with the follow-through phase, place a tremendous amount of stress on the static and dynamic structures of the glenohumeral joint. These stresses can lead to a painful labral pathology causing the pitcher to lose 10 miles/hour off his fastball or the ability to locate his pitches. He can still throw hard, but not for his own liking and for his abilities. The clinician needs to put these clues together in order to diagnose and treat with an effective plan.

Understand Typical Presentation

The rehabilitation specialist needs to understand the typical presentation of the overhead athlete as well. Concepts like humeral retroversion, glenohumeral internal rotation deficit, and total rotational range of motion are crucial. Knowing these baseline measurements can guide the treatment plan and aid in returning the athlete to the field of play.

The overhead athlete, no matter their level of play, will present with a distinct and unique profile. It’s essential to understand anatomy, biomechanics and evidence-based treatment for many of the common injuries that you may come across in an outpatient setting.