[Aaron Hartstein]

Great case! You all make an excellent case on focusing on impairments first, then addressing gait. I could justify in my head also starting gait training earlier than later if her irritability allowed. It sounds like anything more than 5 mins is aggravating (and I wouldn’t want to flare her symptoms if she truly can’t make any form adjustments due to lack of flexibility/strength initially) but maybe just a few mins per session early on to work motor control in the task that she struggles with would be beneficial. I’d have to see her be able to make some modifications to feel it was accomplishing anything (mirror might come in handy here) and if she truly could not adapt form due to other impairments, I’d work there before doing motor control training on the treadmill. My brain tends to go back to the article where they looked at retraining gait mechanics in running vs training step downs and found only training running led to improvements in running (and improvements in step downs) while training step downs did not improve neuromuscular control with running. Just a thought :)

[Aaron Hartstein]

Hey great case and I appreciate the video. Just curious as to what lumbar/neurodynamic screen you went through? When I see this asymmetry I think spine (whether it is lumbar spine versus thoracic spine) especially with N//T involved. Were her peripheral nerve bias tests also negative or a slump with thoracic SB or rotation? Seems like she may be increasing tension on that side or wanting to avoid compression? I would think that prior to gait re-training working on NM control and strength and breaking movement patterns down for her may seem more beneficial since this has been going on for ~ 3 years. What was her single leg calf raise MMT like?

[Aaron Hartstein]

Great suggestions Kyle! I definitely agree with you that taking a more global approach to address her impairments and not focusing solely on the hip is the way to go. Since I have only seen her for two session we have not begun gait retraining on the treadmill, however, I like the idea of using the mirror for visual feedback. Question for the group: when would you start gait retraining with this patient? Would you begin immediately or would you take the initial visits to focus on treating impairments with manual therapy and TherEx/NM Re-ed in preparation for running? If she doesn’t have the strength and NM control, would it be counterproductive to start gait retraining right away?

[Aaron Hartstein]

Hey guys,

I am treating a pt. right now that is a runner and has quite a few gait abnormalities. I would love to get everyone’s input on treatment planning and where to start with her. The video of her running gait analysis is included (gracias Miguel).

Some background on the patient…primary c/o R anterior hip/groin pain and posterior gluteal pain, with occasional R calf pain, that began insidiously with running 3 years ago.
-occasional numbness in R calf and foot
-Aggs: running > 5 min., hiking, wide straddle pose in yoga, low lunges (with L foot leading), ascending stairs, sitting > 30 min.
-Eases: temporary relief from chiropractic manipulation of R SIJ every 6-8 weeks, dry needling to piriformis

Objective Findings:
-Functional Biomechanical Screen:
-Bilateral Squat: anteromedial hip pain at end range
-SLS: decreased stability on R with R ipsilateral trunk lean
-Swing Test: pain in R glute during R terminal swing
-SL Squat: bilateral valgus; pain with R
-MMT: pain and weakness with R hip flexion (4/5), R ER (4/5); weakness with B hip ABD (R: 4/5, L: 4+/5)
-TTP at R rectus femoris, TFL, piriformis, glutes
-moderate flexibility restrictions in B iliopsoas
-hypertonic L QL
+McCarthy/Fitzgerald, FAI special tests
-Lumbar & neuro screen (-)
-SIJ provocation tests (-)

The results of the article, “The relationship between hip strength and trunk motion in college cross-country runners” were that decreased hip extension and abduction torque was correlated with increased trunk axial rotation and pelvic obliquity in the frontal plane. These results can be applied to my patient’s gait. As you can see in the video, her trunk is upright throughout the gait cycle and she gets almost no hip extension at terminal swing. Unlike most runners that we see in the clinic, she has what I would consider decreased stride length and an appropriate cadence. She’s not necessarily a pt. that would benefit from cadence cues. She presents with significant trunk compensations, displaying increased L thoracic rotation at R toe-off. The increased trunk rotation may be due to decreased hip extension/glute activation which is leading decreased propulsion (thus she is trying to generate propulsive forces from increased trunk rotation and arm swing). She also has hip abductor and extensor weakness (contralateral hip drop, valgus and pronation at midstance), which the article alluded to is correlated with increased trunk rotation. In addition, she has excessive L lateral trunk lean during L stance phase, which is also present in static standing (not as excessive). I thought that this could be due to LLD, however, upon examination, she did not present with an apparent LLD. She does have mild scoliosis, but I would not expect such an excessive lateral trunk lean with the degree of scoliosis that she has. Other gait abnormalities that are present are increased vertical excursion, excessive knee flexion and decreased rotation during R swing and decreased knee flexion and increased ER during L swing, crosses midline on L.

There are definitely quite a few impairments to address with her and I’m sure I missed things during my initial examination. Eric suggested that I take a closer look at her pelvis and and reassess the mobility there since it appears that she may have a hypomobile pelvis; in addition I need to further assess the mobility of the thoracic spine. Anyone else have any other suggestions on objective measurements that I should assess/reassess that I may have missed?

I have only seen her for two treatment sessions. Manually, I’ve been doing STM to iliopsoas and QL. For TherEx: thoracic SB mobility to open up L side, clamshells, side stepping with T-band around arches, quadruped alt LE, kickers, posterior step downs, trunk lean with alternating hip flexion/extension for glute activation.

Any suggestions for further evaluation and treatment ideas would be very helpful! Thanks!

[Aaron Hartstein]

Thanks Myra, that explanation was really helpful!

Anisha- I like to tell patients what the goal is (for MET, for example, 30 reps pain free x 3). Then when I set them up, the instruction to remain pain free naturally makes them choose their ROM. I tend to start with a really light weight and monitor them with the instructions of “the goal is 30 reps, but rest before that if you experience excessive fatigue or form change”. Based on how effortful the first set was, I may modify the weight and allow them to choose reps again. If they know the goal of dosage (3 x 30) and of the exercise (with MET- to modulate pain, improve tissue healing… not hypertrophy of muscle, etc.), I think patients can often effectively pick dosage/ROM with your guidance. I think their involvement is critical becuase it encourages self-efficacy and better carryover both for an HEP and after DC, plus we need their input to see how they are tolerating an exercise.

[Aaron Hartstein]

Comments from Anisha (my current student)

“I found this article very interesting and think that MET would be a great approach for patients with chronic pain, especially chronic low back pain. I think that sequencing a treatment by breaking up more local exercises with global ones is a good idea to give the patient’s painful area a break, but also to give the patient the confidence to see that they can exercise for an hour while still being pain-free or close to it. I found it interesting that the patient helps determine the dosage and range of motion of the exercise. It makes sense that control over their treatment would help them, but I was unsure of how to approach this in the clinic. For giving a HEP in the past I have suggested dosage with a number of sets and reps but to use fatigue and their symptoms as a guide. How involved have your patients been in determining their dosage for MET or otherwise for you guys? Have you found it helpful to have more of their involvement?”

[Aaron Hartstein]

Michelle, I’m glad you mentioned your case. I have had two similar patients recently- one who had a TKA this year and was recently DC by another PT and now is back in PT with me due to continued pain/loss of motion. The other had a TKA and manipulation in 2012 and still has extremely limited motion. For both, I have been doing a ton of manual to normalize range but then am using exercise following MET as Eric Kopp mentioned to both actively and passively use the new range. I struggled with the MET approach with them because if I keep the exercises pain free, I feel like they are not gaining motion, but then if I have them push into resistance, they are often achey after. Anyone else have any insight in using MET on chronically stiff capsules, particularly at the knee?

[Aaron Hartstein]

I agree with everyone else—definitely a great follow-up article following Eric Kopp’s course. I’ve also been trying to incorporate MET more frequently as part of treatment with appropriate patients. I have one patient that recently had his knee manipulated under anesthesia due to significant ROM restrictions s/p MFPL reconstruction from non-compliance. Even after the manipulation, his knee is still very stiff and presents with both capsular and soft tissue restrictions. I’ve been very aggressive with manual therapy to target knee flexion ROM (utilizing some of the new mobilization techniques with the belt from the Kopp course). As expected, the pt. has been sore so I’ve been alternating manual therapy with MET global and semi-global exercises throughout the treatment session and this seems to help with his pain level and mobility.

I think the biggest obstacle with using MET more frequently in the clinic is time limitations, as I’m sure most clinicians would agree. It’s not always feasible to keep patients in the clinic for an hour, especially if you are treating another patient simultaneously that requires primarily manual therapy. For those of you that use MET on a regular basis, any suggestions for managing the treatment session or sequencing the MET exercises to make the most efficient use of treatment time?

[Aaron Hartstein]

I thought this was a great follow up as well after the MET course and I appreciated the language spoken in the article to assist me with day to day explanations of MET. Previously before the course, I did not prescribe high repetitions of the exercises, but did prescribe the type of exercise for functional impairments. After the Kopp course and reading the article, I believe MET is again another tool in the tool bag to use with patient’s who meet a certain criteria such as fear and avoidance of movement, and especially in large part psychosocial component to care. Overall, MET is to decrease the patient’ subjective pain experience, which entails performing exercises within in a pain free ROM and movement, and to instill self-efficacy, which is my overall goal for any patient. I have noticed my willingness to prescribe 3×30 since the course and to be able to justify my clinical reasoning in doing so. I also appreciate articles to refer to show patients the research behind this method and reasoning.

[Aaron Hartstein]

I agree Kyle- definitely a great follow-up to Eric Kopp’s course and addition to Michael’s VOMPTI presentation.
I was first introduced to MET through the VOMPTI course series which I’m really thankful for and have found many of the exercise principles to be extremely helpful. I will say I have not done as good of a job utilizing the dosage aspect. For me, I think it’s been most challenging having a patient perform an exercise for 3×30. Usually the MET patient population I’m thinking of are not as highly motivated as I would like. However, I think much of this has to do with my inability to appropriately explain to them the importance of having a high dosage exercise which luckily this paper helps a lot with. The article did a great job of explaining how the patient can initially be involved at determining their own dosage to decrease fear while working up to the goal of 3x/30. Eric Kopp also provided a great way to explain to patients the importance of global exercise and to follow-up with his talk, probably my favorite part of the paper was the ‘Biological aspects of the medical exercise therapy approach’. Like Kyle, I really liked the use of the term endogenous analgesia. I think communicating this section of the paper in a patient friendly way will make a huge impact on how patients may view exercise and how it can have a positive effect on their pain.

[Aaron Hartstein]

great discussion so far team– I thought the article was insightful regarding return to running protocol (powered by some big names in our field as well). In regard to discussing diet and restrictions, it is definitely hard to do, especially with an individual who may already be “diet sensitive” in nature. I have had this discussion with one of my female athletes before. Her male physical therapist at the time had tried to discuss this with her but was not breaking through with her, therefore he asked me to treat her a few sessions and then talk nutrition, diet, female athlete triad. Also, I recommend to an extent an overall healthy lifestyle, and I think being a health care provider allows us to professionally recommend and suggest this, as well as patient’s may abide by a professional recommendation.

[Aaron Hartstein]

Great article, Steph. I thought this was an awesome overview with some great resources that I will definitely reference when treating patients with suspected BSIs. Unfortunately I have not had the opportunity to treat any as of yet. I am remembering any injury my sister had while training for a marathon however- she had B anterior shin pain (and a past history of tibial stress fracture prior) while running that eases with rest. She swore by compression socks and kinesiotaping which apparently eliminated her pain with running. Anyone have any experience in an actual clinical setting with success with this?

Anisha- great comments! Regarding switching terrains, the article mentions leg stiffness can increase on softer terrains but not enough to make the GRF more than on less compliant surfaces. I think you are definitely right to proceed with caution when switching terrains for injured runners, however I think we could trial switching terrains from non-compliant to semi compliant (such as from asphalt to a rubber track) with some success where as a more extreme switch (asphalt to sand or even grass where ankle instability, etc. may lead to altered biomechanics) may be more detrimental. So picking the right kind of switch and using are clinical judgement there might be successful versus encouraging them to choose any “soft” surface.

Regarding discussing dietary supplements, I was definitely hesitant to do this as a new grad as we are conditioned that medications are out of our scope. After working with Myra, however, I realized this was a huge area of knowledge we have that can help supplement our treatment (more wholesome care is best!). We have discussed the benefits of concentrated tart cherry juice, omega 7, magnesium, etc with patients. When initially concerned about practicing out of my scope, it was a nice reminder that these supplements are over the counter and a patient can go and get them without any medical guidance. Our guidance will allow them to make more informed decisions than if they went picking through on their own. I would never order that a patient take this (just recommend they look into it) and always encourage a patient to read the label and to be sure nothing is contraindicated on the label based on meds they are on, etc. and if they have further concerns, to talk with the pharmacist or their MD.

[Aaron Hartstein]

Good points, Anisha. If I suspect that a patient has a BSI and that dietary factors may be a major contributing factor, I think it’s certainly necessary to address these issues with the patient and also communicate suspicions and findings with the referring physician. It may not always be an easy conversation to have (especially with a teenage athlete), but I think linking appropriate nutrition with performance and the patient’s ultimate goal of returning to running at the highest level will motivate the patient to address nutritional needs and ultimately he/she will be more receptive to your suggestions. We’re fortunate here at UVA to have a nutritionist, so certainly utilizing all of your resources is important in getting the patient back to optimal health and performance.

Like Kyle, I also like the fact that the article provided a gradual return to running protocol. This is a great resource to provide patients with exact dosage when a patient asks you where to start with a walk-run interval program.

[Aaron Hartstein]

I certainly think it’s within our scope to discuss dietary needs with patients as it relates to their energy requirements for their respected activity level and healing; especially when bone stress injuries are on the table.

I’ve had one patient over the last 6 months where this conversation definitely needed to take place; 16 y/o high school female running cross country and track that presented with all the positive signs of the female athlete triad. I typically don’t recommend supplements but rather approach it with a discussion with the patient on how much/what their eating throughout their day and potentially make recommendations more related to caloric intake and examples of nutrient dense foods. For this particular patient, I clued the mom in on the findings of my exam since she wasn’t with us during the evaluation and reiterated the importance of caloric intake to meet the energy demands of patient’s activity level and how the adverse effects present clinically. I also spoke with the referring physician to communicate my concerns and discussed a plan for further follow-up with a sports nutritionists for a more in-depth consultation if the patient’s condition and complaints weren’t improving.

[Aaron Hartstein]

Comments from Anisha (my current student from VCU)

The article addresses how physical activity history can be protective against BSI. This reminded me of a class discussion we had where we talked about how there are a lot more stress fractures in basic training now than there used to be. This has been attributed to children not being as physically active as they used to be, so they did not engage in proper bone loading when they were young, making them more susceptible to stress fractures. I think that if we are able to address it, an important factor to prevent stress fractures as well as many other health issues would be for children to be more physically active in general.

I found it interesting that switching to a softer terrain for training does not necessarily decrease BSI risk, but rather the change could be problematic. I think that is a good education point for runners who maybe are starting to get injured and decide to switch terrains, to a treadmill or softer surfaces to try, to be cautious.

Another aspect of this article I found interesting was how protective calcium and Vitamin D supplements can be in preventing BSIs. However, as a physical therapy student, I wasn’t sure how in our scope it was to recommend dietary supplements. Is this something you guys address or recommend to patients you feel could benefit from the addition of these?

[Author]

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