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Obviously I can not speak for Matt, but I would assume maybe he wants to explore both of these aspects. I know I would.
That being said I think its important to take into account how many times is she loading her LE. Are we talking about one bad landing out or are we talking about 100’s of repetitions of the same activity over and over. Is there a history of pain with this activity or soreness with or after practice? Is the athlete and her parents attributing this new symptom to an acute injury inaccurately? Maybe with more inquiry, maybe mechanism is more a multitude of microtraumas to her leg with this being the landing that took it over the edge? If the mechanism seems less mechanical maybe we do need to look into more psychosocial aspect of her activity level and her training.
I think getting an overall idea of the health of this patient with respect to her training history, schedule (and its relation to LE symptoms), and its relationship with her physical/emotional/social well being would be a huge part of my subjective history taking.
I think I would want to make sure we aren’t missing anything more serious here. I’d inquire about onset of symptoms and if the features fit to warrant knee pain as the structure at fault. Location of pain (both locally or proximally), severity (swelling details, WB details-immediate delayed), progression from time of onset to now, mechanical sx, prior history of LE injury/pain (different? Same but worse?). I’d take a thorough history to inquire about hip or anterior thigh pain. Based on her age I think we have to remember the importance of not missing a stress fracture, or OCD. I think asking about nutritional status, menstruation (started/abnormal?!), history of fractures (idea of bone fragility), recreational demands, and other metabolic or systemic conditions would be important.
After investigating some I think I may refer ultrasound right away. This is a young man with a classic presentation of stress fracture. Why wait? If it looks like a duck and quacks like a duck, its probably duck. This area is a high risk area and this is a young healthy man I saw we skip the 85% negative x-ray and push for something better. I know its not easily that accessible but to me its the risk versus reward here and ultrasound is superior to x-ray for sure with less cost then MRI. I found this case report that I thought was interesting detecting a tibial stress fracture via ultrasound after negative x-ray. Whether this is right or not to me, it seems easy to go the protocol route. Try x-ray and conservative treatment but to me based on the presentation, patient, and location I would say the reward would be bigger her to go ultrasound referral if available.
I’ve attached the article I mentioned above if anyone wants to see what the hallmark findings are for tibial stress fracture on an ultrasound are!
Differential: hip and lumbar pathology
To answer your questions Erik
His occasional lower leg pain was brought to my attention as I asked if it every went past his knee. Lucky me, he said yes and it was a relatively new symptom of his. He states its very minor to his hip, and unable to put an aggravating factor and was minimal to not present during examination or during treatment session. I always had that symptom lingering in the back of my head however I agree I do not know how much of it was mechanical.
BMI: I would say he was somewhere in between your two descriptions.
Red Flags: his subjective did not scream red flags… his objective on the other hand
That being said good segway to objective information.
Anwsering the questions!
Did you happen to clarify which position he prefers to sleep in/ what position give him his pain? -states just getting in bed was painful, states not being able to get comfortable….
Getting into and out of his car did his symptoms change if he was getting into the drivers side or passengers side? both but more getting out as the driver
Additionally did he have hip symptoms initially when he had this most recent episode of LBP, does his LBP and hip symptoms have similar aggs and eases? My understanding was some hip pain with his back pain but both usually went away together and now his hip was more intense with no back pain
Has he had treatment for his low back in the past? YES! Had PT for his back about a year ago, was given stretches which he does almost everyday. Help tremendously, not this time.
Stairs? “not bad” standing? didn’t seem to be too much of an issue as a aggravating factor, just less tolerance to walking his usually 10,000-15,000 steps.
Bringing on Leg pain? lateral hip into anterior thigh most prevelant, (feeling it at rest during evaluation), he states it was more painful with the aggs listed (SLEEP being the biggest), standing/stairs or lumbar flexion/extension questions did not seem to be huge contributor to his symptoms
Normal Routine? Gym 5x/week: back stretches, bike, weights, general UE and LE strengthening exercises; states since his normal stretches were not helping he stopped not so much because pain but because he didnt know if what he was doing was bothering his hip
I’ve also attached his p! drawing below. Does this change anything?
I wonder what everyone else’s thoughts are on how much centrally mediated myalgia/central sensitization is occurring with this patient? I mean she’s had multiple insults to her cervical spine and her jaw and wonder if the repetitive nociceptive input has her central system playing a role in her pain and dysfunction. I liked this article’s insight on common characteristics of central myalgia involvement (as I am not familiar with the common asterisks to look for): prolonged and uninterruptable pain, duration of greater than 1 month, pain in multiple mastication muscles, p! at rest, and p! worse with function. I think I would be definitely cautious of only treating local tissue and pushing hard to find the pain generator and assessing for the involvement of yellow flags. I also would have relaxation and pain relief interventions (like let’s get this girl a mouth guard or something) high on my list of things to address and educate on the first day. I agree though we don’t have all the information to really accurately diagnosis in my opinion.
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI- with active synovitis or hemarthrosis
– anterolateral impingement
– peroneal tendinopathy
– ATFL/CFL injury
2. List any yellow or red flags you’d consider this case
I agree with Jeff- on the new onset occurring at PT and self-report of passive interventions as easing factors. I would dive deeper into this topic to gauge her beliefs on previous treatment.
3. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
–What part of walking, jogging, jumping are bothersome (PF or DF motions)
-CKC DF symptoms
-PF activities (swimming and driving, different location, or description of pain)
description of antalgic gait
– description of the most recent sprain and comparison to hx of sprains (agree with this one)
-Forefoot and rearfoot position (NWB and WB)
-kinematics of ankle and associated joints, midfoot,STJ with functional/WB movements and activites
-Palpation in sinus tarsi
– Looking into yellow flags; gauging patients beliefs of passive versus active
– DF limited on the uninvolved side, or excessive?
To be short and sweet here are my 1-2 subjective questions I’d like to ask:
1. Pain location/locations (musculature, joint line, etc.), different from previous episodes/symptoms? -help with cervical spine involvement and its involvement potentially
2. Description of pain (tightness, sharp, clicking, locking (mechanical sx/symptoms)) and their association with aggravating activities? Change from previously? -Disc pathology (conversion from reduction to non-reduction?)versus myogenic.
(Shaffer et al. paper helpful with pt history section and table 1 info)
1. List your differential diagnosis after the subjective exam. How does this re-rank after the objective exam? Primary hypothesis to conclude?
a. Lumbar clinical instability (chronic pain)
b. Myofascial pain
c. Lumbar discogenic
d. Facet arthropathy
I agree that the biopsychosocial component may be a big player with this patient. I think inquiring more about her pain beliefs would be important. I wonder if you inquired any more on this during subjective? If this was my patient retrospectively, I would have wanted her to elaborate on the terminology she used to describe her back pain and her goals. I would have loved to know what “my back is a mess” means to her? What would reflect not “getting worse”, is she referencing pain levels, functional mobility, activity tolerance? Is she stopping activity due to an assumption of pain like hiking and fishing? So many questions.
a. Lumbar Instability with lumbar facet arthropathy
b. Myofascial pain
2. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
Subjective: I alluded to some of the questions I would have asked above to gauge her pain beliefs. I also agree with everyone that finding out what her role in care-taking involves and what toll does that take on her mentally, physically and emotionally? Has this role changed in any way or are there any new stressors in her life? What were prior episodes of low back pain like and are there common triggers for onset? How did she manage before (get a sense of coping)?
Sx related questions: when she is sitting can she alleviate her symptoms with movement? Inquiring about morning symptoms or with general getting out of bed motion?
Objective: Quadrant, OP in standing (change with cues for anterior abdominal recruitment or neutral spine- interested if this changes sx with lumbar rotation as well), sitting and supine lumbar spine posture compared to standing, hip quality/quantity of motion (you said no p! reproduction, but wondering overall profile… hyper or hypo?, potentially look at lumbopelvic dissociation in quadruped
5.List any Yellow or Red flags you’d consider for this case.
Agree with what everyone else has said regarding this. I think knowing how she responds to pain belief questions would give me a better sense of if she is going to be a responder or not. Is she responsive to cueing and patient education to perform her chief complaints with less pain like sit to stand, squatting, postural cues, etc. How much of this is lack of knowledge of how to move or is it more deeply ingrained in her beliefs.
Erik- I had extreme difficulty finding the exact article I pulled my excerpt from but this is the one I found that most related. I will continue to look and get back to you
Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study
Gofton, Wade T et al.
Journal of Hand Surgery, Volume 29, Issue 3, 423 – 431
TFCC is a structure to withstand load transmission. I think is a big part of where I can use both my subjective and objective questions to tease out. There was a sudden rotary injury that occurred here. The subject mentioned in this case would definitely fit this case, with a precipitating MOI and aggravating factors of hitting a golf ball and WB through that arm. The press test would be helpful to rule out TFCC if negative 100% sensitivity for a TFCC tear, however when performing this myself you definitely need to compare sides! There is also some good metrics to use ultrasound to assess ulnar displacement compared to the uninvolved side with reports of 88% sensitivity and 81% specificity (Hess et al., 2012)
Fracture: Likelihood small in my opinion. I think ruling out fracture would be relatively easy with palpation thinking the quality of pain and the other tests Jon mentioned. I did find however interesting metrics of concern for TFCC or instability complications relative to the location of a radial fracture. ” 22 patients in whom the fracture was within 7.5 cm of the distal radius’ articular surface, 12 were associated with intraoperative DRUJ instability. While 18 patients whose fracture was greater than 7.5 cm from the radius’ articular surface, 1 patient had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture.”
Ligamentous: I agree with what Jon has presented, using passive and resistive testing might be helpful as it is a noncontractile tissue. Using the table or supportive base under wrist during testing should allow for less contractile tissues to be contributing and may be helpful. I think using distraction versus compression, in this case, could potentially be helpful to assess ligamentous integrity/pain generator. There was a study done that showed when all soft tissue constraints were intact, despite sectioning to the radioulnar ligament and TFCC DRUJ kinematics were normal.”the investigators concluded that the radioulnar ligaments and TFCC are not essential for maintaining normal DRUJ kinematics as long as the remaining soft tissues are intact. Therefore, when true instability is recognized, there is likely a concomitant injury to multiple structures.” Therefore with the patients’ complaint of pain with fatigue and lifting heavy items requiring increased stabilization with heavy lifting makes me think the stability of that joint is compromised via ligamentous or TFCC complaints.
In my search, I found that ulnar displacement in full pronation was common in patients with instability. “Instability is dorsal displacement of the ulna with respect to the radius, and the loss of congruity will be most pronounced in pronation” Therefore when considering static stability of the wrist noticing differences between nonaffected hand and involved hand in pronation/supination would be helpful.
ECU: tension on the subsheath is greatest during activities involving supination and holding the wrist in a flexed and/or ulnarly deviated position. Active testing in this position is consistent with our patients MOI wrist position and should be tested in this manner. Looking for tendon subluxation would be sound as the ECU tendon does change its angle of pull or dynamic support in different positions. ECU synergy test is a described maneuver proposed to help differentiate ECU pathology from other intraarticular diagnoses. “The test is performed with the patient’s arm resting on the table and elbow flexed to 90° with the wrist in supination. The patient is asked to radially abduct the thumb against resistance. Reproduction of pain in the ECU is a positive test. The test is based on the theory that there is isometric activation of the ECU during resisted thumb abduction” Ruland et al, 2008. There is also another test I found to help identify ECU involvement called the “ice cream scoop” test. “This test is performed with the patient’s wrist in pronation, ulnar deviation, and extension. The examiner palpates the ECU tendon and has the patient proceed with a scooping motion. Any subluxation of the tendon is noted as a positive exam finding” (Ng C et al, 2013)
I really enjoyed Dr. Boissannault education course. I think he did an amazing job of taking patient examples and showing how efficient screening for red flags in a subjective patient interview can be. Especially if you know what you are looking for. Dr. Boissannault continues to be another example of how I truly believe our profession is both an art and a science. Knowing the red flags questions is not skillful, ascertaining information from the patient that captures the overall risk of this patient having a rare pathology with skillful questioning is. Asking blanket questions of red flags is not all that helpful? Is it relevant or not, will the answer change your clinical decision to evaluate, treat, or refer? This course did a good job of navigating those questions for me. For example, if a patient that meets a lot of the risk factors for cancer, but they just followed up with their oncologist and had imaging 2 months ago you should feel better that serious pathology might not be the cause of their pain (obviously being confirmed by other subjective and objective measures). I took away that being skeptical but being thorough with appropriate /relevant questions (specific for what you are trying to rule out) are where we as health care providers have the unique opportunity and time advantage to screen for red flags. After reading this article is confirms just that, with primary care providers only screening 5% of the time. I think we should consider ourselves the first line of defensive for screening for these pathologies until proven otherwise, or at minimum understand how well this patient has been evaluated by the system.
I also really enjoyed his emphasis on educating the patient on how they should relay concerning findings to their health care providers. He gave examples of how he would tell the patients how he wanted them to explain their symptoms to their health care provider, not something I think ever really considered. He wanted them to avoid the broad pain complaint “shoulder pain” or “toe pain” but get them to relay the signs and symptoms that may indicate pathology not musculoskeletal in nature he was wanting to rule out. Seems intuitive however don’t know that I have been that skillful when I have asked patients to follow up with their healthcare provider, I just assumed these physicians would understand. Wrong assumption. I can hear his voice “Now Joe, I want you to call your doctor, don’t tell them you have back pain, but you have flank pain that has progressively gotten worse over the past 2 weeks and is constant and unlike any back pain you’ve had before and that you are have noticed an increase in urination frequency” The man was great, I could go on and on!
Reading through your patient case examples got me thinking of where my current frustrations lie with where I think I miss with some of my patients. I get stuck in this realm of patient A walks in and it’s time to use my PT knowledge and fill in the blanks: subjective, objective, PT diagnosis and give them 3 exercises. Bam, I’m done. I just vomited my knowledge onto this person, they now know all the tissues, movements and structures that are at fault and are educated on how we are going to address and rehabilitate them. However, what I fail to recognize is maybe I just did more harm them good. Maybe I just added more yellow to their system. For a patient who has seen multiple different health care providers, who’s life has been defined by pain for X amount of time, did I just medicalize a pyschosocial persisting pain problem? I probably just created more fear by informing them of the structure that is at fault, the muscle that isn’t working appropriately, and their awful posture. Probably things they’ve heard a million times and I am another provider amplifying their pain beliefs. I think forgetting to ask these open-ended cognitive and emotional questions is where I am doing a disservice to my patients and where I miss my opportunity to truly assess and evaluate their yellow flags and ultimately knowing where the focus of my treatment should be. So thanks Cam for that article, table 2 will be extremely useful to me!
I took this quote from a book I am reading “Remember, pretty much every assumed dysfunction, (posture, tightness, weakness, structure, degeneration) can exist in people without pain” And I think sometimes as health care providers we can drive this train, blaming the impairments which we are trained to find, to believe these factors are the causation of their pain which may be faulty thinking and hindering their recovery. I want to be better at screening for these yellow flags, identifying patients (using the appropriate tools and skillful patient interviewing) who need more pain science education and step away from the biomedical explanations and treatment I tend to lean towards.
I wanted to ask people what are your go-to pain education strategies. I’ve found that examples or analogs are the best way for me to understand and educate my patients when the majority of what they need is pain education. My go to lately is pain is an alarm (stole this by the way) analog. I’ve found it to be helpful to get some of my points across and drive my agenda, especially with patients with high fear of movement. Below is one I’ve found to be successful for me.
My patient education tends to be something along the lines of this: Pain is an alarm (house alarm, smoke alarm, alarm clock, whatever)… its purpose is to alert you of potential danger, or motivate you to take action. However, the magnitude or number of alarms going off doesn’t always equate to the level of action or protection need, it’s not a direct correlation. When there is an insult to our system our bodies often go into overamplification of protection mode. For example, when we break a bone our body makes extra bone or when we burn our skin we produce extra skin scar tissue and sometimes that process goes overboard, like some people getting keloid scars. Pain can do the same thing; our bodies and our brain can have an overreaction and almost becomes better at producing it. So, what started off as a “oh s*** meter” which was helpful and potentially necessary at the time, now is continuing to alert you however is no longer helpful and has become its own problem.
Sorry for the rant, I love this stuff!
- This reply was modified 1 year ago by Caseylburruss.