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Technically the Pittsburgh Knee Rule says < 12 y/o post-fall or blunt trauma. She’s close enough in age that I would go ahead and send her out for an XR.
I would want to know if she could walk/WB immediately after the fall, any isolated patella/fibular head p!, and see if she is able to bend her knee past 90. If not, I’d recommend an XR ASAP.
Talking to young patients about pain can be challenging, due to their lack of experiences and knowledge. I would love to hear how others communicate with children regarding pain because this is something I struggle with.
We also have to take into account that this kid’s body is constantly changing, growing, and adapting. I would not want to miss a potential fx of a growth plate.
I think our role in this situation is to provide the patient with the most information that we can, and let the patient make the decision. Just because there is an order for an MRI, does not mean that she is required to have the MRI. I would first talk to the patient to see what the NP’s thoughts were with ordering an MRI. Then ask the patient about their thoughts regarding an MRI. I would then explain the objective and subjective success that she has made in physical therapy. Explain the negative findings of red flag and cervical testing (neuro/spurling’s). Explain the purpose of an MRI.
– pro’s: more information, rule out red flags
– con’s: irrelevant information, costsThen propose the idea to the patient of potentially getting the MRI in a couple of months if her pain is not getting better, but after completing 6-8 weeks of consistent physical therapy. See what the patient’s thoughts are with that plan. Maybe explain tissue healing timelines and how her job might continue to aggravate her pain so it might take longer to heal.
So, my first post was primarily looking at modifiable risk factors that I could alter to change the load due to my conservative PT bias. Yet after Laura’s point I started to do some more research to find out when is the best time to refer out for imaging. Based on the articles I read, this is the flow of potential stress fracture management that I came up with:
1. Is this a high-risk stress fracture area? (femoral neck (tension-side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal 5th metatarsal, and great toe sesamoid)
– “These locations all have a region of maximal tensile load in a zone of diminished blood flow that is vulnerable to stress injury, with suboptimal healing potential. Although HRSFs are relatively rare, they have important clinical relevance, because they can keep athletes from participating in sports for long periods of time and can cause significant morbidity if not properly treated. Athletes with HRSFs may require surgical intervention to return to play in a timely fashion. A high index of suspicion and early identification are critical to proper treatment and successful outcomes.” (McInnis 2016)
2. Does the individual have a lot of risk factors for stress fractures?
– Previous history of stress fracture and female sex are risk factors that are strongly supported by the data (Wright 2015)
– Non-modifiable: Bone strength, genetic/nutritional factors, biomechanics, structure, physical fitness, sex, menstrual status
– Modifiable: Training load, footwear, running surface, etc
3. If suspicion is high for stress fracture, then refer out early for MRI. If there is a stress fracture present on MRI, determining the grade of stress fracture will determine the appropriate management.
– MRI stress fracture grades (Nattiv 2015)Going back to the patient in this case. This has only been going on for 2 weeks. He has a high risk fracture location of anterior tibia. Yet, I would want to know more risk factors before referring to imaging.
(McInnis 2016): High Risk Stress Fractures: Diagnosis and Management, PM R 2016, https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2015.09.019
(Wright 2015): Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis, BJSM 2015, https://bjsm.bmj.com/content/49/23/1517.long
(Nattiv 2015) CORRELATION OF MRI GRADING OF BONE STRESS INJURIES WITH CLINICAL RISK FACTORS AND RETURN TO PLAY: A 5-YEAR PROSPECTIVE STUDY IN COLLEGIATE TRACK AND FIELD ATHLETES, AJSM 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367232/
First, I would like to know a better history – specifically with running
– Too fast, too soon?
– Novice runner?
– Training program – safe mileage progression?
– Where does he run (treadmill, outside, trails, hills)?
– Shoes (any change, old?)
– Hx of stress fx or shins splintsNext, I would want to see if there is anything objectively that I could modify in regard to his tibial stress
– Running form
o Cadence – slow?
o Heel strike – high angle of inclination?
o Stiff lower extremity
o Too much frontal plane motion
– Foot posture
o Cavus or planus foot
o Dynamic foot posture
o Potentially post or use an orthotic
– Functional exam – weakness, dynamic control
– Soft tissue restrictions – gastroc/deep extrinsic extensors/flexorsSo, there are plenty of things I would try first before referring out for imaging. It’s likely that he is having a stress reaction to his tibia. Why would we need costly imaging if we already know what is going on? However, what would change my imaging recommendation would be the severity and irritability. If he only had pain with running, I probably would not. If he was having significant pain with ADL’s then I would probably refer out for imaging. And, if he is going to continue to train for his race, then we need to make sure this stress reaction is not going to get worse (into grade III-IV).
Would love to hear other’s thoughts on this.
If imaging referral is needed, then I would express my concerns to the referring physician and let them make the decision. If I had to choose, I would recommend an MRI because it is the gold standard for stress fractures. MRI has high sensitivity and typically does not require additional further imaging because of its inclusiveness. I would still continue to see the patient in physical therapy to address his impairments while waiting on imaging.
Pretty interesting findings from these articles. I found this quote from the second article a little concerning, “Almost half of the respondents who recommend NSAIDs are doing so despite being uncertain of the sufficiency of their knowledge or reporting that their knowledge is insufficient.” Basically saying the PT’s who are recommending NSAIDs are doing so without an appropriate knowledge of why they are using it.
I will make OTC NSAID recommendations if I feel like there is a high presence of an inflammatory process or chemically driven pain producer. With that being said, I try to make it clear that as PT I cannot officially recommend medications. I try to also go over some main side effects briefly. And for those patients with an extensive medical/medication history, I recommended communicating with their MD before taking anything new. Does anyone do this differently or any concerns with this?
With that being said, there are other things that I recommend that might be outside my scope of practice such as counseling. I may make general stress/emotional/depression/sleep recommendations yet I am not a therapist/counselor. I think referring out to a therapist when appropriate could be just as important as referring to a PCP for medication management. I think the big thing is knowing what is in your scope of practice and refer out when appropriate.
Great example Jeff. I am sure that you also demonstrated correct Irish Riverdancing form to correct her knee pain.
I feel like younger patients and acute patients are more likely to listen to you regarding this subject. Do any of you use the ‘Why do I hurt’ book regarding medications?
Based on the objective, I am having a hard time differentiating my post-subjective hypothesis of: lumbar referral, hip OA, and glute med tendinopathy. Seems like the patient is too irritable for a true differential. I am curious to hear why gluteal tendinopathy was your primary diagnosis for this patient. I would actually lean more towards a synovitis in an arthritic hip as my diagnosis.
I think I would have tried to unload his spine and tried a quadruped position with quadruped rocking, to see if his lumbar motion increased. Quick neuro screen as well.
I might recommend a referral to ortho for a stronger anti-inflammatory due to his inability to sleep, high pain levels with minimal active and passive motion, and significant decrease in activity level. I would recommend isometrics (hip ER in supine) and potentially a bike for some active NWB exercise.
I think I would start to first express what you can offer as a physical therapist in regard to the patient’s low back pain. Explain what your plan is to improve his pain and function based on your exam. I would then bring up the point that his doctor made, regarding decreasing his dose, then ask him what his thoughts were about that. I feel like most people will say, I don’t want to take pain medications for the rest of my life, but I am scared to stop because of the pain. I think then you can follow that up with stating that I (as the PT) can offer some techniques to help reduce your pain, but most importantly give you the tools and education so that you can manage your pain on your own without the need for taking medications for the rest of your life. I might then explain that ibuprofen is great for pain and inflammation in the early stages of acute back pain to calm the inflammatory process for a week or two, but it doesn’t have that great of long-term effects and can even cause stomach problems or other health related problems down the road. I might encourage the patient that he is already getting better due to the fact that he has returned to his normal activity. But now we need give him some safer techniques to help decrease his pain and learn self-management strategies for long term. I would not ask him to stop taking ibuprofen on day one. Yet, I would try to present the information to the patient in a way that encourages him to decrease his dose on his own. I think if you can acknowledge his fear of pain, acknowledge that his current self-management strategy is not the best, and give him an alternative solution – that should help with patient buy-in to decrease his NSAID use. I would also make sure that the patient knows his prognosis and that PT is not an overnight fix. Bring up the point that this has been going on for 6 months, so it might take a couple of weeks to months based on the chronicity.
1. Jon – I like the ankle sprain analogy and finding something on the eval that makes his pain better
2. Erik, I do like the recommendation to switch to Tylenol, especially based off this article. However, if we are trying to decrease medication use, do you think that just switching medications would help or harm the solution?
3. Jon – I feel like unless I can offer the patient an alternative solution to help with their pain, then they will not buy in to decrease their meds, but that’s just my opinion. Laura’s patient seems reasonable to decrease his pain medication use. However, folks who have been in chronic pain, fibromyalgia, or chronic pain med users then I feel like the focus can switch. I might then ask if they are being managed by pain management or their MD. Then educate the patient about pain meds within our scope and continue to work towards their goals. I haven’t had much success with these individuals. Jon, has anything worked for you?List your top 3 differential diagnosis after the subjective?
– Lumbar referral (degenerative disc/lateral stenosis)
– Hip OA
– Glute min/med tendinopathyHow is would this information drive your objective exam?
– Try to differentiate whether this is primarily hip or lumbar driven, knowing that it could have a component of both (If hip, is this intraarticular (joint) or extraarticular (glute tendon)
– Clear SIJ
– Also want to make sure this is a mechanical MSK pain producerYellow or red flags?
– Red:
o Non-MSK referral: prostate, GI/GU, cancer – low on my list
– Yellow:
o Sleep
o Stopping gym routine
o Stress about upcoming trip?Other subjective questions I have:
– What sleeping position
– Which direction when turning (hip IR/ER or lumbar rotation?)
– Standing, stairs – hip related questions
– Non-MSK special questions (CA,GI,GU)
– Prior trauma or injuries?
– What is his exercise routine?
– Stenosis questions – walking in flexed positions vs extended positions (shopping cart/up hill),
– When does he get the leg pain?Jeff and Erik,
My thought with communicating with the dentist would be:
– location of procedure (soft tissues, teeth, etc)
– what was performed (hardware?)
– how long the mouth was in an opened position or immobilized closed position
– any post-op precautions or limitations
– the referral was from the dentist, so he/she must feel like this is out of his/her scope of practice, so seeing their thought process of what was going on in regards to the patient’s pain would be helpful– The Tendinopathy continuum is so broad. Because of this, we have make sure we identify where the individual falls within the continuum. For example, is this a 1) young individual with a reactive tendinopathy, 2) an older individual with a degenerative tendinopathy, or 3) someone with a degenerative tendon that is currently in the reactive phase? Based on where the individual falls within the continuum, the treatment plan will be very different.
– One of their questions was, it is beneficial to achieve acute pain relief in individuals with long standing tendinopathy? Typically with someone with chronic tendinopathy, typically I try to stimulate an inflammatory type response to promote with healing, and working through some pain (i.e. eccentrics). This is what the authors where eluding to in their article. However, I would be more inclined to perform isometrics if this is an acute-subacute tendinopathy (tendonitis). I personally have seen good results with pain in the short term with a reactive Achilles tendinopathy/tendonitis and gluteal tendinopathy. It doesn’t make sense to use isometrics for chronic tendinopathy if the goal is to stimulate an inflammatory response.
– My take on isometrics would be that they are great for cuing certain muscles (i.e. post-op or an inhibited muscle) and they are great for decreasing pain during an acute inflammatory phase. It also doesn’t make sense to make specific treatment recommendations (isometrics) for a broad pathology (tendinopathy).
I would say something along the lines of, “You have been through a lot of over the past couple of years in regards to the MVA, surgery and chronic pain – not to mention completing your PhD. I’m sure that is frustrating and challenging. Do you feel like stress affects your pain? If yes, how do you typically manage your stress?”
1. List your differential diagnosis after the subjective exam. Does this change after the
objective exam?After subjective: acute synovitis in anterior ankle / impingement, CAI, peroneal tendon tenosynovitis, peroneal tendon tear, OCD talar dome
After objective: CAI with anterior ankle synovitis and impingement
2. List any yellow or red flags you’d consider this case.
Red: peroneal tendon tear or frature
Yellow: avoidance of ADL’s3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?Subjective: imaging, detail regarding ankle sprain history (when was the first, what was the worst sprain, are they all in the same direction, any immobilization, how many times has she had rehab, weight bearing), walking up vs downhill, bruising, swelling, popping, give-way, bilateral?
Objective: double/single hop test, y-balance, single leg lateral and forward hop tests; edema in anterior ankle/sinus tarsi, tuning fork on lateral malleolus, distal tib/fib mobility, cuboid motion, foot joint/ROM assessment
4. What would be your manual, exercise, and educational interventions are for IE? Does her
past treatment influence interventions during day 1?education: Anti-inflammatories and ice for 1 week (2x/day), potentially ASO brace for 1 week to limit TC dorsiflexion with weight bearing and provide some stability laterally,
Manual: TC posterior mobz and distraction (grade II-III),
Exercise: Unloaded pain-free AROM (stationary bike, half foam roll) and potentially single leg balance on half foam with different directions based on irritability
1. Need to know more information regarding the MVA. So, starting with an open-ended question about the MVA. Specifically looking for 1) red flag signs and symptoms that could be related to cervical instability (Canadian C-spine, cranial nerve, and VBI) and 2) yellow flag symptoms of emotional and psychological stress. Also need to know when the MVA occurred and the details during and after the accident. Because upper cervical spine can have pain referrals into the TMJ region, it is important to try and differentiate between upper cervical and TMJ, yet it sounds like this patient could have pain generating from both areas based on the brief history.
2. I would want to know about the history of her jaw pain from the patient’s perspective, but also, I would love to hear what her dentist thought was going on in regard to her jaw pain. Specifically, I would want to know more about how her jaw pain initially started (i.e. trauma or stress), details of procedure (immobilized?), ROM loss, unilateral vs bilateral, still have clicking in jaw, and pain with compression vs opening.
My thoughts initially would be 1) disc displacement without reduction due to history of clicking but now no clicking versus a capsular hypomobility of the joint, 2) in combination with peripheral sensitization of soft tissue structures (upper cervical and local jaw musculature).
This article was helpful to highlight the limitations of RCT’s. My biggest takeaway was that RCT’s demonstrate the efficacy and effectiveness between interventions, but do not tell you why there was a difference. This article also highlights how difficult it is to make a good RCT. There are so many biases that go into any study, but it is important to understand these biases and take them into consideration when reading the conclusions of a study.