[ABengtsson]

For the article I decided to look at shin splints/ medial tibial stress syndrome for one of my pts (14y/o female runner).

I kept the PICO very general – In patients with MTSS, what are risk factors/causes/etiology and what what are supported treatment approaches/methods?

Narrow search strategy using
“shin splints” = 4 articles
“medial tibial stress syndrome” = 2

Expanded search strategy using
“shin splints” = 65
“medial tibial stress syndrome” = 50

The article I looked at was included in the expanded results using both terms.

I read a lot of the abstracts and quite a few of the articles and just based on what I found with these searches there doesn’t seem to be a whole lot of research for causes/treatment etc of shin splints and certainly not a lot of consensus. That probably explains why I had to use the expanded search strategy to find more relevant articles.

A lot of the literature I found was looking at military recruits/service members and/or medical/radiologic dx tests. This article stood out bc it was more relevant to my pt.

Measurements
– BMI
– hip IR/ER ROM at 90 deg
– DF ROM at knee EXT and 90 deg FLX
– SLR
– Intercondylar interval (knee valgus/varus)
– Intermalleolar interval (ankle inversion/eversion)
– Q-angle
– Navicular drop test (NDT)
– hip ABD strength

Results – sign increased rist
MTSS in females
– >BMI
– >hip IR ROM
Stress fx in males
– <SLR ROM

All other measurements did not yield significant results.

I thought it was interesting to see how the different strategies work depending on the topic. I’ve used these with a couple of other topics and the narrow search strategy has definitely been a great help!

[ABengtsson]

Nick – the Graichen articles utilized MRI, sorry I forgot to mention that initially. I haven’t found any US articles looking at larger angles. Desmeules et al. state in the 2004 article that measurements >60 were not possible.

Laura – the 45 deg was just were they found the most significant narrowing as compared to 0 deg. They did not find a statistically significant narrowing from 45 to 60 deg (see attached article). Unless I missed it in that article, I don’t think they related the narrowing at 45, or 60 deg to reproduction of symptoms. If that is the case the question is whether or not that narrowing is significant functionally, or pathophysiologically. I’ll have to read through the article again to double check if there was a difference in that narrowing between symptomatic and asymptomatic subjects and whether that could be significant.
I think that’s where the Graichen articles make for and interesting addition, because of the ranges they measure and how those findings are related to what we consider more painful ranges.

Hope this helps!

[ABengtsson]

Thanks for your response Nick!

1. The only reason that the authors cited for using these angles and not going above 60 was “constraint of the imaging technique”, which is a valid point, but I don’t think that means that they should disregard syx above 60, especially considering that their 1st incl criterion was Neer’s and H-K. Definitely on the same page as you with pt experience in regards to onset of syx at higher ranges. I think another aspect that the authors could’ve considered more closely is the literature that is available on AHD, especially since they already quoted 2 studies by Graichen et al. talking about AHD and motion patterns at larger angles (both of those studies are definitely worth reading, especially because the authors make some interesting points about function and relation to symptoms; I emailed Heiko Graichen with a few follow-up questions and if he gets back to me I’ll write a separate post)

2. and 3. great points!

4. thanks for sharing that video. I like the way he breaks down the cueing. I haven’t tried anything like that specific technique, but I’ve gotten some good results with the AAROM exercises Eric went over (prone with arm on the stool/ball).

[ABengtsson]

It’s a really interesting article and I like the very objective reflection on our limitations, as well as strengths when it comes to evaluation.
The main thing I take away from this is, similar to what we talked about during our shoulder weekend (and in general), is that we really need a good cluster/combination of tests to determine how to treat a pt.
I think it would be interesting to know what Mark Jones (or Chad Cook) would have to say about how and if these results significantly change the way they evaluate and treat patients.
One of the hardest evals for me is still the shoulder, especially when it comes to figuring out structure at fault/interpreting clusters, even more so when it’s a very irritable pt and the majority of tests are (+).

Thanks for posting this!

[ABengtsson]

Another follow-up regarding aforementioned pt:

She has cont to improve significantly since I saw her with Aaron, both in her functional limitations and perception (self-efficacy, fearfulness).

She is still very focused on the fact that she never had anything like this before, but with the understanding that she won’t have pain forever, which is probably the most significant improvement as compared to a few weeks ago. She still has minor limitations in C/S AROM and PAMs (C4-5 only).

The other day I talked to her about how she improved her movement patterns, motor control and habits and how, at this point, that is a lot more important than any manual intervention. I also talked to her about D/C planning and she was still a little nervous about stopping right away, so we decided to decrease frequency just to follow up for 3-4 weeks (I believe we have 3 visits over the next 4 weeks). She said she was 96% better, but when we talked about D/C, she was still very fearful about possible re-exacerbations, although not nearly as fearful as she used to be.

Seeing how that was a nice example of how it can work, I figured I’ll share a story about another pt (I mentioned in my first post here).

Quick overview, this guys has had 4 L/S including laminectomies, discectomies and fusion of 2 levels. He’s been in PT on/off for 3 years and has seen the majority of PTs at our clinic.
As I mentioned above, I had the same conversations with him as I did with the pt I saw with Aaron. His L/S AROM was pretty much normal in sitting and he could move without increase in “baseline pain”, in every direction. As soon as he stands though, his AROM is maybe 10% in all directions, if that. As soon as he started moving, his entire trunk started shaking and he had a hard time moving back to neutral; also reported sig increase in pain.
The second to last visit, I spent close to an hour talking to him about pain science and everything that Aaron talked to that other pt about (relaxing trunk/core etc). It was kind of a perfect situation, because I saw that first pt with Aaron just the day before. I got him to figure out why he has more pain with AROM in standing, as compared to sitting and got him to come to his own conclusions. He even figured out how to adjust himself and move differently in standing and he increased his pain-free L/S AROM significantly (hands below knees in FLX).
I was really excited to see him again to see how/if he improved and I was hoping for the same, or a similar outcome as with that other pt.
He cx/NS the next 2 visits so I didn’t see him for another 2-3 weeks. When I saw hime again, he was still in a lot of pain and seemed to move even worse.
The interesting part was that he was able to repeat everything we had talked about verbatim, even how he was able to move better during the last visit, taking control of his pain/importance of improving his own movement etc. etc. etc. etc., but followed up immediately with “I need to find somebody to fix me”. It was another 50 min visit with a lot more conversation/education, but at that point it was pretty clear that regardless of what I told him (or all the other PTs for that matter) and what he learned, it wasn’t going to change his outlook.
He told me how he already tried pain management and psych therapy (depression, anxiety, PTSD – deployment, several near death experiences) and that it did not help him at all. He was even able to recite the neurophys of pain modulation and connection to depression etc., but apparently did not make that connection.

Hope it helps to have an example of where all that stuff does not end up helping.

In conclusion, I fully agree with Nick… can’t wait to learn more about this during the next courses. It also showed me again how little preparation I got for these situations in my curriculum.

[ABengtsson]

Great discussion! Sorry for not contributing sooner!

One thing I noticed in the Puentedura T-Spine vs C-spine thrust study was the following combination of symptoms:

“Finally, patients had to satisfy at least 4 out of the following 6 criteria: symptom duration less than 30 days, no symptoms distal to the shoulder, no aggravation of symptoms by looking up, Fear-Avoidance Beliefs Questionnaire Physical Activity (FABQPA) subscale score of less than 12, decreased upper thoracic spine kyphosis (T3-T5), and cervical extension range of motion (ROM) less than 30°.”

In my rather limited experience, I must say I haven’t seen a single patient who’d satisfy 4/6 here. Most of my patients with mechanical neck pain (or in general) have an increase in upper T-spine kyphosis. Also, from what I’ve seen so far (again, not that much) is that pts who have <30 deg cervical extension, usually have aggravation of symptoms looking up.
Also, just two sentences above the author states that pts with unliateral UE symptoms would be included, but one of the 6 factors is no symptoms below shoulder level. If there’s UE involvement, say coming from stenosis, wouldn’t there be a good chance that ext would aggravate that?

Have you guys seen pts that would satisfy 4 out of those 6 and if so, what kind of presentation did they have and how did you treat them? If not, how would you take the findings in that study into consideration with other patients?

Didn’t mean to pick on this article, but reading through that I just felt like I was really missing something. If anybody has had experiences that fit here, please do share!

Nick – any new developments with your cervical case since your last post? Also, I think considering his legal action status is a great clinical decision regarding thrust techniques.

Reg. Osteopenia: I had one CI who’d use the supine t-sp thrust set up with an open hand as a mobilization technique, just not perform the thrust and just based on how I saw the pts progress, he appeared to have pretty good outcomes overall. Also, the pts tolerated this technique really well, which kind of surprised me at the time.

[ABengtsson]

I agree with Sean… great post!
I like the point you made about the non-neck pain subjects being treated for something else (non-upper quarter) at the time of the study. It would be interesting to know what kind of pathologies those subjects were treated for, or at least include anything that could affect the cervical spine (postural deficits etc.) in the exclusion criteria.
The authors specifically mention that they did not address postural deficits (i.e. thoracic kyphosis) prior to the movement testing, which I’d say is very important as the neck pain may only be the result from the weak link breaking down.

I think it would have been beneficial if they were more precise about what the source of neck pain was (perhaps by grouping subjects similar to the Fritz article) to distinguish between symptomatic vs. non-symptomatic cMCD.

Regarding your last question: I’d say especially aggravating/easing factors like being in specific positions and also duration of position vs. onset and severity of symptoms. Depending on what the pt says, considering those could be a good pointer as to what the underlying cause is (muscular endurance/strength/activation etc.).

Sean, have you checked her general thorax mobility? I worked with a swimmer who had similar issues to your case (shoulder pain resulting from poor scapulo-thoracic movement) and I ended up working on his rib cage mobility a lot as his sp facet joints didn’t show a lot of hypomobility. I read a book by Diane Lee on the subject and one of the things she talks about is thorax mobility vs thoracic spine mobility. Could be interesting to look into especially with altered breathing patterns in swimmers. Thorax mobility might also be interesting when looking at cervical pain, considering regional interdependence models.

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