Weekend 5 Case Presentation

[helenrshep]

Please view the attached document and answer the questions below.

1) Looking ONLY at the body chart, what is your primary hypothesis?

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?

4) Does the objective information/patient presentation make you think of a particular diagnosis?

5) What would be your first thought on treatment for this patient?

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[awilson12]

1) Upper lumbar radiculopathy

2) Primary = hip OA; differentials = myofascial referral (iliopsoas or quad), upper lumbar facet referral

3) Other questions:
– Same aggravating factors for both areas? If separate then would lead to further questioning and suspicion about multiple things going on
– To help rule in OA would want to ask more about 24 hour pattern and pain reproduction- How long have AM stiffness and what helps? Immediate onset of pain with WB or how long to come on? Better or worse when do more? –> would expect that AM stiffness improve with movement but then worsen with too much activity, with aggravating factors potentially immediate onset of pain that improves over time but again worsens with large amounts of activity
– Questions to help with myofascial- For aggravating factors any specific points that are worse? Ex: with iliopsoas maybe with lifting leg to go up the stairs or during terminal stance when on full stretch; or if quad then maybe it’s the concentric portion of the squat or eccentric lowering down steps
– Would want to ask about history of any low back pain or any current low back pain to help differentiate lumbar vs hip pathology

4) With negative lumbar screen, neuro exam, and neurodynamic testing, and positive hip intra-articular testing, range of motion losses in all planes, and noted gait deviations it seems to be in line with my primary hypothesis if hip OA; to further rule this in hip accessory motion testing would be useful to perform

5) Depending on severity and stage of OA, irritability, and patient goals I feel like my first line of defense would be lateral distraction with a belt more so for pain alleviation

[Steven Lagasse]

1) Looking ONLY at the body chart, what is your primary hypothesis?

Primary hypothesis: Femoral nerve entrapment.

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?

Primary hypothesis: Hip OA

Differentials:
1. Capsule
2. Myofascial – TFL/ITB, Hip flexors
3. Femoral nerve entrapment

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?

– Does your hip pain come on with back-related movements? (bending, twisting, etc.)

– Does it feel like your hip has less motion compared to the other?

– Does your hip pain mostly subside 30 – 60 minutes after waking up and moving?

– Does snapping, popping, and/or locking occur?

– Does movement after sustained sedentary positions increase your symptoms?

4) Does the objective information/patient presentation make you think of a particular diagnosis?

I believe the objective information and patient presentation helps to rule-in hip OA

5) What would be your first thought on treatment for this patient?

I would likely attempt a low-grade distraction technique. If the patient tolerated this well, move into higher grades.

[lacarroll]

1) Looking ONLY at the body chart, what is your primary hypothesis?
L3/4 Lumbar Radic

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?
Primary: Hip OA
Diff dx: labral tear, lumbar radic

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?
– Difficulty with putting on/taking off shoes?
– Painful clicking/popping in her hip since incident?
– Pain with bending, twisting?
– Did she receive any medical treatment after the misstep 2 years ago?
– Did she quit her previous exercise regimen? If so, why?

4) Does the objective information/patient presentation make you think of a particular diagnosis?
This presentation makes me think hip OA with the pattern of pain that’s worse in the morning, less pain with activity, limited ROM (esp. IR), increased pain with weight bearing, pain with squatting, age >50.

5) What would be your first thought on treatment for this patient?
Educating patient on prognosis and importance of activity; inferior/lateral hip mobs to improve joint mobility

[pbarrettcoleman]

1) Looking ONLY at the body chart, what is your primary hypothesis?

L3/L4 Lumbar Radiculopathy

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?

Hip OA
Labral/Impingement
Lumbar Referral

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?

– Popping/Clicking/Catching.
– Clarity on 24 hour pattern.
– Problems with certain sleeping positions.

4) Does the objective information/patient presentation make you think of a particular diagnosis?

Seems very OA — global ROM loss; Aggs/Eases; 24 hour pattern; pt demographic; (+) intraarticular testing.

5) What would be your first thought on treatment for this patient?

Obviously I first think of manual therapy to improve range of motion, but let’s get her more active (motion is lotion). She already reported that she felt better when she worked out so it should be an easy educational moment. Let’s see what activity she could do (recumbent bike?) and then go from there pending irritability and pain.

[helenrshep]

Great thoughts guys! I especially like the ideas about questions to help differentiate lumbar and hip pathology. Definitely an area I struggle with. Looking forward to talking more about this tomorrow.

[Taylor Blattenberger]

1) Looking ONLY at the body chart, what is your primary hypothesis?
-Hip OA

2) Looking at the body chart AND subjective exam, now what is your primary hypothesis? Next 2-3 differentials?
-Hip OA

-Greater Trochanteric Pain syndrome
-Labral Tear
-Upper Lumbar radic

3) What are some other questions you could have asked to help rule in/rule out your hypotheses?
-Has this been getting better/worse?
-What part of going up stairs hurts? Lifting the leg, pushing on the step, having the hip in ext while stepping up on the other side?
-How does the pain behave? – Start lateral and move distal? Mostly anterior thigh and rarely lateral?
-At what point is squatting painful? – full depth, entire movement, sustained squat?

4) Does the objective information/patient presentation make you think of a particular diagnosis?
-Seems like OA due to ROM loss, special testing results, and WB intolerance.

5) What would be your first thought on treatment for this patient?
– For this patient I would employ light AROM and AAROM exercises into limited ROMs to improve ROM impairment, encourage active participation in treatment, and ensure she was getting ROM work frequently at home. Specifically I like a supine knee rock into ER/IR (due to IR limitation) and SKTC.

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