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We are nearing the end of our residency and have had the chance to treat a variety of patients and pathologies. I thought it may be a good time to highlight some interesting cases we have had regarding regional interdependence. There is certainly literature to support treating t-spine for cervical or shoulder, treating lumbar for hip or knee, treating c-spine for shoulder or elbow, etc. I thought we could highlight interesting cases we have had that we maybe had to think a little outside the box and treat further away (than the established regional interdependence in the literature) to get positive results.
I’ll start by talking about a case report I read awhile back about a pt who was suffering from L posterior shoulder pain only after running for greater than 4 miles. Anything less than 4 miles and she was fine. The therapist assessed the pt’s ability to perform a single limb bridge and her ability to independently contract glute max in prone. Limitations were observed with R glute activation and single limb bridge. The pt was treated with glute activation exercises, with emphasis on R glute max. After 3 weeks of tx, the patient reported no pain with any of her runs including 8-10 miles.
I will mention two cases that I have had to get this thread started.
The first was a 48 y/o male that was coming to PT for R LBP consistent with L5/S1 facet dysfunction. His pain was only with playing tennis and usually would not come on until 2nd-3rd set. He was a L handed tennis player. I had treated him by improving restrictions in his R hip rotation that I thought was likely affecting his swing. Additionally treating his lumbar spine to improve mobility and motor control. I had also treated thoracic spine based on rotation needed for sport. This was all performed with little efficacy. Upon reviewing his case due to lack of progress I had failed to find it important that he had previously had a L RTC repair. Upon assessment, he was still lacking significant L shoulder ER (needed for tennis serve and forehand). Manual therapy to improve ER and education of self posterior cuff STM, stretching, and mobilizations prior to playing tennis was used. Within a couple weeks, the patient was able to play full tennis matches without R LBP.
Another case was for a 68 y/o male with R LBP. In addition, he reported fatigue in his calf after walking >10 minutes. This pain and fatigue was reported to be present for >5 years without any change in symptom during that time. His symptoms were consisted with chronic L5/S1 radiculopathy. I had treated him for his lumbar, hip, and neurodynamic restrictions on that side. The patient has reported 75% improvement based on this treatment but was still having R LE “fatigue” after 30 minutes of walking. While treating during mentoring time, Aaron pointed out to me that I had overlooked a previous meniscal debridement of his R knee. Upon secondary examination of his knee, there was a restriction in knee extension with a much firmer end feel compared to L. I had missed this initially. By adding knee extension mobilizations and self reverse TKEs in a neurodynamic position, he reported being able to perform his 45 minute treadmill walk (normal exercise routine >5 years ago) without LBP or R LE fatigue.
This is an example of two cases I have had where I had to treat distally to achieve full symptom resolution. In both of my cases, they were previous surgical regions I had overlooked as I originally found them unrelated to the patient’s current condition.
Share your thoughts on these cases or give an example of an interesting case you may have had where you had to treat further away than expected to get the best result.
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One patient I recently saw presented with cervical radiculitis. She had a long Hx of cervical pain and distal numbness/tingling in 4th and 5th digit of RUE. Her sxs had been exacerbated by an UE traction injury at work when attempting to catch a heavy object that fell from her work bench. Her sxs at IE included BL neck pain from mid Csp into her shoulder. She described a pulling sensation at R elbow and increased numbness and tingling in her 4th and 5th digit. These sxs were worst when sleeping. My diff Dx included cervical radic, disc dsyfnc, facet dysfnc TOS, rotator cuff pathology, and trigger point of lev scap/rhomboids.
Objective findings included neck pain with R rotation and extension, R back quadrant increased shoulder and elbow sxs. Distraction eases UE sxs. Rotator cuff was not fully assessed at IE, but ER lag and belly press were negative. Patient was unable to raise RUE from side. Shoulder PROM was WNL, she limited end range flexion and ABD BL. Neuroscreen showed increased C5 and C6 reflexes on R compared to L. Sensation screen WNL and myotomes unable to assess due to pain. At follow up visit pnt had positive findings during ULTT for median and ulnar nerve. Median reproduced elbow pain and ulnar reproduced numbness and tingling in hand.
At this point I was confident that cervical radiculitis was the primary pathology with a probable peripheral traction injury present. I was also keeping an eye on shoulder sxs to monitor for rotator cuff injury. After 3 weeks her neck pain had subsided an her shoulder pain was minimal. She could modulate her sxs at home with head positioning in supine and sidelying positing. I continued to treat postural and cervical impairments, however mild shoulder and elbow sxs remained. Upon reassessment I found supination limitation and radial head restrictions with reproduction of elbow sxs. With functional lifting it was apparent she was compensating for the lack of supination with shoulder protraction and ADD. We treated the radial head restriction for 2 visits and she was back to work without issue. I should have reassessed earlier in the rehab process. I do not think I would have been able to discern any local elbow dysfunction at IE, but radial head dysfnc with a described traction is not uncommon. This was a case of me having my blinders on early on.-
Erik, I think your case and second comment really highlight the importance of thinking through what the reassessment or continued assessment will be in the first follow up or two. It’s hard when you’re behind on notes and would rather be doing something else, but I try to take the time when I’m writing up an eval to really wrack my brain about what else I can look at in the next sessions. Obviously you can’t do a CRF on every patient, but I find running through a few of those items each eval helps me catch things I might miss until weeks later. I feel like this is especially true for those frequently secondary sites of importance: elbow, wrist/hand, and SIJ (essentially doing more than just ruling out with the cluster).
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Erik, i think justin is absolutely right about peeling away the onion layers, but I also don’t think you necessarily had blinders on. From the looks of it I think your eval was pretty thorough and you may not have even gotten (+) findings from radial head limitations had you assessed that day 1. I have had a couple mentoring patients that had things show up after a few visits that even Aaron can attest weren’t there on day 1. I think sometimes we have to treat one area in order to expose another. As Aaron would say in my feedback write ups, thats why we assess, treat and reassess, so we can have a constantly progressing list of aggs/impairments.
I had one lady that was involved in an MVA in which she was struck in by a vehicle while walking in a crosswalk. Primary injury was RC with cervical component and some distal UE symptoms. Long story short her aggs were reaching OH and HBB to strap bra, take care of hair, don/doff clothes, etc. Those gradually got better and we discovered that she was having difficulty with carrying groceries up the stairs. As strength improved her difficulty with carrying did not. As it turned out, she had some old/cold knee symptoms that were making it difficult to nav stairs. We added some strength training and knee mobility treatment and 3-4 weeks later she was able to carry multiple grocery bags up the stairs.
Like your case, I don’t think we had blinders on but we had to improve her shoulder to expose the knee.
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One thing that jumps out to me when reading your cases and reflecting on my own below is the importance of reassessment/reflection and getting a second pair of eyes on the case when needed. I know with my case especially it was something that I should have picked up on earlier and would have if I did a reflection of the case. This is the true benefit of a residency program. It forces us to use tools like the clinical reasoning form for reflection and provides mentorship for complex cases. Keeping this in mind as this rez year comes to a close, it will be important to continue to use the tools/skills learned over the last year and to keep in touch with you guys when a tough patient comes along. I think back to what Eric Kopp said about his time “treating on an island” and can see the difficulty in that when compared to my clinical experience over the course of this program.
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Great reflection Justin and Erik
I think you both hit on great ideas about bouncing ideas off other therapists. Putting your ego aside and knowing that you do not have all the answers is key. Being able to listen to the patient and hear that they are actually till having issues is the first step.
You both did a great job figuring this out and going to another mind to get other ideas.Keep strong clinical reasoning and reflecting in-action and on-action as you move on in your careers.
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I don’t have any dazzling examples like you all, but I do have one that highlights the importance of this concept. For several months I have been seeing an 18 yr old male high school pitcher who has had IM 1 yr h/o L anterior shoulder pain and decreasing velocity with throwing. I saw him after he had taken 3 weeks off and his shoulder was minimally irritable, with only an uppercut motion and palpation of the biceps tendon reproducing even minimal soreness. He had ~20 degree loss of total shoulder rotation and had rotator cuff weakness in IR and ER. At the IE I looked at him do L SL balance and a SLS and unsurprisingly he had deficits: compensated trendelenburg, dynamic knee varus into valgus. It wasn’t until I watched a video of him pitching the next session though that I realized I needed to look further into his hip motion. He was 10 degrees shy of neutral hip extension and had only 15 degrees hip ER on his L. With sprinkling in some hip mobilization, self mobilization, and stretching he now has hip extension to neutral and his hip ER is symmetrical. While he isn’t pitching at game speeds he has been doing well with his interval throwing program and has been able to increase his distance and then velocity without symptoms much more successfully than when he had tried in the past. I think I would have missed out on a lot of important secondary factors if I had only focused on the upper quarter.
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August,
I had a similar pt, HS pitcher with throwing shoulder pain. I had inherited him from another PT. Classic signs of impingement: painful arc, pain w/ resisted ER, (+)HK, active impingement test, full can. When I first saw him and looked at his total arc ROM limitations, I was concerned about GIRD and he had some (+) tests for labrum pathology as well. I got him on teaching time and Aaron and I immediately screened lower quarter and trunk. He had some serious weakness in his glutes and could only hold a bird dog on one side opposite his throwing arm. We gave him some isolated glute strength and added some posterior chain and oblique sling motor control and his total arc ROM improved. We were also able to look at his pitching mechanics with the same guy Justin mentioned who treats a lot of pitchers. As it turns out, his lead leg (L leg) was stepping across his body to the R instead of straight down the mound. This created increased torque on his shoulder and strain on his RC to do the majority of the work. After looking at that on film and slowing it down for him, we gave him a window for stepping with therabands and had him practice high volume reps of just stepping. He was able to pitch the entire season without any more shoulder issues. In hindsight, it would have been really cool to get a speed reading pre and post on his throws.
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