By Drayton T. Perkins, PT, DPT, ECS | EMG Solutions
Most physical therapy students begin their training focused on the world of orthopedic movement and musculoskeletal mechanics. They learn how muscles, joints, and connective tissues interact and what happens when those systems break down. But sometimes, what looks like an orthopedic problem actually starts somewhere entirely different: within the peripheral nervous system.
That idea was at the center of a recent lecture I gave to the second-year Doctor of Physical Therapy students at the William Carey University College of Health Sciences. The session, titled Introduction to Electrodiagnostic Testing: Nerve Conduction Studies (NCS) and Electromyography (EMG), was given as a part of their Physical Agents and Modalities course and aimed to introduce them to electrodiagnostic (EDX) testing as both a clinical tool and as a growing area of specialty practice within physical therapy.
My goal was to help these students see how NCV/EMG testing connects to the types of patients they will soon encounter in the clinic. Many orthopedic cases that seem straightforward on the surface can actually have a neurogenic origin. Recognizing when that might be the case is one of the most important aspects of clinical reasoning.
When “Orthopedic” Isn’t Orthopedic
As physical therapists, we have all seen it. The patient with persistent shoulder pain that does not respond as expected with standard interventions. Or the one with lingering dorsiflexion weakness after what seemed like a routine ankle sprain. Maybe the strength and range of motion improve, but function does not. Maybe the pain persists in a pattern that doesn’t match the anatomy of a specific muscle or joint.
When that happens, we have to start asking different questions. Is this really a tendon or joint problem? What am I missing? Should I expand my differential diagnosis to include a nerve root problem? Plexus involvement? Or could the findings be related to an injured peripheral nerve?
Electrodiagnostic testing helps answer those questions.
By combining nerve conduction studies (NCS) and electromyography (EMG), clinicians can evaluate how well nerves are conducting electrical signals and how muscles respond to those signals. EDX testing allows clinicians to assess the functional integrity of the peripheral nervous system, from the level of the spinal nerve roots all the way to the smallest peripheral branches of the motor and sensory nerves.
Nerve studies and EMG testing give clinicians information that imaging alone cannot provide. For example, a shoulder MRI might show a perfectly intact rotator cuff, yet the patient is unable to lift their arm because the axillary nerve is compromised, affecting the ability of the deltoid muscle to activate properly. A lumbar MRI might show several vertebral levels with disc bulges, but only one of those may be causing the radiculopathy symptoms. EDX can identify exactly which nerve root is affected and to what extent. This precision can change the entire course of care.
Case Example: Shoulder Pain, Scapular Winging, and a Hidden Nerve Root
During the lecture, we discussed a case that perfectly illustrates this point.
A patient presented with a gradual onset of shoulder pain with scapular winging. At first glance, the findings suggested a local musculoskeletal problem such as serratus anterior weakness or a long thoracic nerve palsy. However, EMG testing revealed denervation in multiple muscles innervated by the C5 and C6 nerve roots. The real source of the problem was a cervical radiculopathy.
That finding changed everything – the diagnosis, the prognosis, and the plan of care.
Now, rather than focusing solely on shoulder strengthening or scapular stabilization, the emphasis shifted to protecting the affected nerve root(s), avoiding mechanical aggravation, and coordinating with the referring physician to monitor neurological recovery. It also guided the referring physician toward appropriate imaging studies, medications options, and potential surgical interventions.
This case reminded students that a patient’s symptoms may not always match their pathology or their referral diagnosis. And we, as physical therapists, are uniquely positioned to recognize when those do not align and when EDX testing may be utilized to help to provide the missing link between the clinical presentation and the underlying pathology.
Bridging Anatomy and Physiology
Students often view electrodiagnostic testing as something separate from traditional physical therapy practice; something “only neurologists do.” But, in reality, it is a natural extension of what PTs already do every day. Our musculoskeletal and neuromuscular examination provides us with mechanical information: range of motion, strength, reflexes, special tests, and movement quality. Electrodiagnostic testing adds a physiological perspective, revealing what is happening at the cellular level. It helps localize the area of damage and determine if it’s demyelinating, axonal, or both, as well as whether it is acute, subacute, or chronic?
That information becomes especially valuable when establishing prognosis and when providing patient education.
A demyelinating injury, such as a mild carpal tunnel syndrome, typically responds quickly to conservative treatment once the cause of compression is removed. In contrast, an axonal injury, such as a severe fibular neuropathy, may require months of neural regeneration before strength can return. Once signs of reinnervation appear, therapists can confidently progress exercise intensity knowing that recovery is already underway.
These distinctions allow therapists to give patients clear, evidence-based expectations. Instead of vague encouragement like “let’s see how this goes,” we can say, “here’s what your nerve is doing, here’s what recovery usually looks like, and here’s how your rehabilitation plan supports that process.” This combination of objective testing and individualized education builds trust and confidence for both the therapist and the patient.
PTs as Diagnostic Collaborators
Electrodiagnostic testing also expands the PT’s role within the interdisciplinary care team. When a physical therapist who holds the Electrophysiologic Clinical Specialist (ECS) credential performs an EDX study, the results contribute directly to the work of physicians, surgeons, and other providers.
- Physicians gain precise localization of the pathology, which helps determine whether imaging findings are clinically significant.
- Physiatrists and neurologists use the information to confirm or rule out suspected neuropathies or myopathies.
- Surgeons rely on EDX data to determine whether a decompression or nerve repair procedure is warranted, and to track recovery afterwards.
- Physical therapists integrate those same results into treatment planning and patient education; helping us to set functional expectations and appropriate progression of recovery for goal-setting.
In this way, EDX-trained PTs act as diagnostic collaborators, a link between diagnostic medicine and rehabilitation.They help clarify what type of pathology exists, estimate prognosis, and influence the overall plan of care. This diagnostic partnership strengthens communication across the healthcare team and ensures that patients receive the most targeted, efficient, and effective interventions possible.
A Niche Specialty with Growing Demand
Clinical electrophysiology remains one of the most niche and specialized areas of physical therapy practice, but it is one that is growing rapidly. The American Board of Physical Therapy Specialties (ABPTS) recognizes it as an advanced practice area and awards the ECS credential to PTs who meet rigorous educational and clinical requirements and pass a comprehensive board exam.
The most direct path to board eligibility is through an ABPTRFE-accredited residency program. At EMG Solutions, our Clinical Electrophysiology Residency provides structured mentorship, hands-on patient experience, and focused study in nerve conduction and EMG testing. Our residency graduates are fully prepared to sit for the ECS exam and to practice independently in collaboration with referring physicians.
For PT students who enjoy clinical reasoning and puzzle-solving, neuromuscular anatomy and physiology, and interdisciplinary work, this specialty can be an incredibly rewarding career path. It offers intellectual challenge, direct impact on patient care, and the opportunity to operate at the intersection of diagnosis and rehabilitation.
Why Every PT Should Understand EDX
Even therapists who never perform NCV/EMG testing themselves benefit from understanding the fundamentals of electrodiagnostic testing. Even a basic understanding of NCV/EMG report helps clinicians make better decisions about treatment progression, referral timing, and prognosis. It also helps therapists recognize when symptoms do not fit a purely orthopedic pattern and when further diagnostic evaluation is appropriate.
EDX awareness strengthens collaboration between PTs and physicians and enhances the overall quality of patient care. It is another reminder that physical therapists are not simply movement experts but integral members of the diagnostic team who bring a unique perspective on how structure, function, and physiology interact.
Looking Forward
One of the ongoing goals of EMG Solutions is to build partnerships with physical therapy programs across the country. By offering guest lectures, lab demonstrations, and clinical rotations, we hope to introduce more students to the clinical and professional opportunities within electrodiagnostic practice.
Our mission is to empower physical therapists to take a leadership role in diagnostic science, bridging the gap between medical evaluation and functional rehabilitation.
When PTs understand and apply electrodiagnostic principles, they enhance not only their own practice but also the effectiveness of the entire healthcare team. They become clinicians who can explain not just how movement is limited, but why it is limited and what can be done about it.
Conclusion
Whether in an academic setting or a busy outpatient clinic, the value of electrodiagnostic testing lies in its ability to reveal the unseen. It allows us to move beyond symptom management and truly understand pathology at its source.
As I told the students at William Carey University, when you encounter weakness, paresthesia, or pain that doesn’t follow a typical orthopedic pattern, pause and consider whether the problem might be neurogenic. The insight gained from that perspective can completely change the trajectory of care.
EDX testing reinforces what makes physical therapists so essential within modern healthcare. We don’t just restore motion; we interpret the systems that make movement possible. We identify the source of dysfunction, help define the diagnosis, and build the pathway toward recovery.
To learn more about EMG Solutions’ Clinical Electrophysiology Residency or to explore student clinical rotation opportunities, visit www.emgsolutions.com.
