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Very interesting case, Kyle!
Considering that this is his 6th session, I would imagine that his neurological sx have been tracked and monitored. I would initially reassess these neuro signs to see if there is any change in his status to try and better differentiate if this is a medication issue vs a worsening neurological status vs a localized calf issue such as a strain. If it was a med issue, then I would expect his neurological assessment to demonstrate no change in his sx compared to last session. I would also do a quick strength and muscle length assessment of the calves in addition to a subjective exam pertaining to the calves to see if there is a possible somatic MSK explanation to his sx. If all of this is negative, I would treat and refer the patient back to the prescribing physician to potentially alter the dosage of the medication, reconcile all of the patient’s medications to see if there are any drug-drug interactions that were not realized, or a electrolyte panel to see if there is a disturbance contributing to his sx.
Laura,
Thanks so much for organizing our thoughts into 3 different differentials. When it comes to ruling in arthrogenic pain, I think inquiring about mechanical symptoms such as locking, catching, clunking, etc of the involved side of the jaw would help me gauge to what extent the joint might be involved. Also, with arthrogenic pain, oftentimes there will be ipsilateral lateral excursion of the jaw to the involved side with opening due to difficulty with movement of the involved side’s TMJ. When it comes to myogenic pain, I would expect less mechanical symptoms and more pain in the region of the master of the temporalis muscles with opening and closing of the jaw.
Kyle,
Q1) If she feels as though a glass of wine at night (as long as it is not in excess) can sufficiently mitigate her stress I wouldn’t necessarily discourage that. However, I would explain how stress can perpetuate her TMJ sx and discuss how counseling can potentially help her stress and this her TMJ pain. I would also advocate the positive effects non-specific exercise can have such as walking or running on mental wellness and discuss strategies on how to implement that into her busy life.
Q2) I would encourage her to think about what side she naturally chews on and if she ever varies the side of her mouth in which she chews on. If she finds it is constant left sided chewing maybe try the right side and see what affects that has on her sx.
Kyle,
I think this is a great case as I rarely see this in the clinic so having a good refresher will help immensely.
Q1. “How are you going about managing your stress with everything that you are responsible for in your everyday life? Are working with any health care professionals to manage stress? Are you exercising and getting good sleep? How does your jaw respond to stress alleviators?” I know this is more than one question, but they are all pertaining to the underlying understanding that stress can perpetuate pain in the TMJ region to getting a good understanding of daily stressors, especially in this patient’s situation, is of upmost importance.
Q2. “What side of your mouth do you find yourself chewing your food on?” Given the reports of clicking in her jaw, this sounds to me like more of an Arthralgia than a Myalgia, but I would still like to begin my differential with confirming what side she favors, if any at all, while eating. I would expect with an Arthralgia there would be an increase in the R sided symptoms with chewing food on the L side of the mouth and relief if chewing food on the R side.
Kyle,
That’s great, sounds like the injection helped him. What did you ultimately think was implicated and driving his pain? I am curious now!
Kyle,
Is the pain worse in the evening even days of lower activity/no golfing? With the tuning fork being inconclusive and in the absence of MRI imaging I am curious what types of treatment worked (relieved sx) and did work as this can sometimes be diagnostic in itself. Sometimes when I am unsure I heavily rely on test-treat-retest. At this point I am starting to think there is something ligamentous such as the scapholunate ligament as I would not think that radial deviation even with load would produce TFCC mediated pain. Very interesting case thus far!
Hey all,
Very interesting case for sure! Thank you Sarah for raising many of the same questions that I would have. I think I would like to know a little more about the pain cycle such as how pain levels/levels of stiffness in the wrist (if any) occurs more in the morning or the evening hours. I am concerned for a traumatic injury that is not healing due the persistent nature of the pain and the initial MOI. I would also like to know what hand positions specifically bring on symptoms besides gripping >10#. If positions of greater ulnar variance such as forearm pronation produce pain, that would immediately lead me more in the direction of TFCC injury. Like Sarah, I would like to take measurements or photos of the swelling to track progression/regression. I would also like to perform a typical APR exam with the goal of trying to differentiate between a tendinopathy, ligamentous injury (scapholunate ligament), and/or fracture of the distal RUJ or carpels, or an injury to the TFCC. I think a tuning fork test and scaphoid shift test will be helpful with my differential. I also think imaging would be very important at this point as the patient would not want to discontinue their sport but given how long this injury has persisted, imaging would be an important tool with trying to establish prognosis. I would advise a MRI to be able to pick up on any soft tissue insults that could be easily overlooked with standard plain film radiography.
Sarah and Laura both bring up great points about how it is arguably more important that we know what to avoid in the protocols rather than following the suggestions of what to do. I agree with Sarah that ultimately the patient’s pain and irritability will ultimately dictate everything that we do. I think protocols definitely have a place as a framework or a guide with surgeries, especially when it comes to procedures that we’re not familiar with. I think as long as we have a good understanding of the surgical procedure, the anatomy involved, and the current state of the patient, we should be able to navigate the rehab without relying on the protocol. If we truly know what was involved with the surgery, then we will automatically have a good idea as to what to avoid when rehabbing the patient. This coupled with our understanding of tissue healing timelines will help us guide our patients back to their PLOF. I think a very interesting part of the article was how, although the exact exercises and timelines for incorporating these interventions varied between physicians, the phases and progressions for the protocols were more or less the same. I think thanking the timeline into account, coupled with the response to the patient with increased loads, should help navigate these types of surgeries.
As always, I thought your take on this subject was very well put! I agree with you a great deal when it comes to knowing how to dose this information and creating a solid rapport with the patient before diving too deep into BPS talks. I like to “plant the seed” so to speak at the eval with maybe a few min of these kinds of talks depending on the personality and receptiveness of the patient and then chip away at it little by little as time goes on. I find it is difficult to have these conversations and knowing the best way to navigate them when you do not know the person that well and there is a bit of uncertainty as to how the patient will interpret what you are trying to convey. I think this topic is one of the more difficult ones to discuss with patients and colleagues alike. Great thoughts!
Sarah,
Great thoughts of trying to improve the strength of a chronically pathological achilles tendon! One thing I would be wary of however is when you are trying to facilitate an inflammatory response there will be a secondary nociceptive response of the body which can drive moderate to severe pain. It is important to listen and monitor your patient’s response to these exercises as we do not want to evoke too much discomfort for a patient who has already been undergoing persistent pain in this region. I strongly encourage you to read Tompra et al’s article on central pain processing and central sensitization in the region of the achilles tendon and let this guide your dosage and parameters surrounding this exercise. I enjoy your insights to modifications and education surrounding how to present these exercises in a meaningful and impactful manner for the patient. Great work!
In terms of incorporating an eccentric calf raise protocol, I would initially begin to gravitate towards this exercise if the patient’s pain is more mild to moderate in nature as I typically would want to avoid overstraining the muscles and tendon if it elicits a significant pain response. After last weekend’s course series and learning that the achilles tendon is potentially a site of central sensitization (Tompra, et al, 2016), I would want to avoid putting the patient through an excessive amount of pain which is what the protocol calls for. This would be especially true if the patient had been dealing with significant pain for multiple years. Moreover, when it comes to this protocol, I would utilize it with a patient that had long term dysrepair/degeneration to the tendon that has been driving pain for multiple years. I would avoid this kind of stress in a patient that is more in the reactive acute phase as I know this style of exercise can be counterproductive for that patient and further aggravate the tendon.
I would encourage the patient with insertional tendinopathy to spend a short time wearing a heel lift in their shoe if they are presenting with high levels of pain and must stand or walk for their job. The idea of this would be mainly for pain modulation and to control symptoms early on. My goal is to avoid excess strain through the stretch-shortening cycle that the tendon undergoes during gait and reduce the patient’s pain and disability while trying to maintain as much function as possible. If the patient is not responding well to an eccentric protocol due to increases in pain and disability as a result, I might resort to long duration isometrics as we can still intervene from a strength perspective but in a way that is more tolerable to the patient. I would explain the importance of stimulating the muscles in a pain-free manner to better encourage healthy adaption of the muscles and promote healthy retention of the tendon fibers. Also, I would encourage the patient to engage in a self soft tissue mobilization protocol as there is evidence presented by McCormack et. al supporting self STM to the tendon and supporting myofascial tissues in conjunction with strength exercises provided greater benefit than strengthening alone. I would encourage this approach of self STM as a way to keep the tendon and muscles mobile while not over stretching the ankle into dorsiflexion which would lead to further compression to the distal aspect of the tendon.
For education and explanations of why I would be taking on a strengthening approach in the form of eccentrics, I would explain the importance of strengthening and loading of tendons as an imperative strategy to allow the tendon to heal and come back stronger. I would explain that with complete rest, the tendon does not know how to organize itself in terms of which direction to orient fibers and loading the tissue safely is the best way to go about this. I would also reiterate the importance of making our strength program functionally specific in terms of the amount of resistance we ultimately want to build ourselves up to and the importance of the types of contractions we subject the tendon to. I think the research done by Kjaer and Heinemeier helps people understand why eccentric exercises can be beneficial. This is especially true when they say: “When a tendinopathic tendon region is subjected to explosive loading, the load development in the sick region is potentially markedly lower than in the surrounding healthy region, while the slow eccentric (or concentric) contractions may lead to a beneficial stimulation of the entire tendon” (Kjaer, 2014). I would explain to the patient that with time, the contractions can change in velocity and load as they apply to their functional goals, but we must stress the tendon to encourage it to heal back stronger and more functional.
Work Cited:
Tompra N, van Dieën JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med. 2016 Aug;50(16):1004-7. doi: 10.1136/bjsports-2015-095476. Epub 2015 Dec 23. PMID: 26701922.
McCormack JR, Underwood FB, Slaven EJ, Cappaert TA. Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy. Sports Health. 2016 May/Jun;8(3):230-237. doi: 10.1177/1941738116631498. PMID: 26893309; PMCID: PMC4981065.
Kjaer, M., & Heinemeier, K. M. (2014). Eccentric exercise: acute and chronic effects on healthy and diseased tendons. Journal of applied physiology, 116(11), 1435-1438.
Sarah,
I think this is a very interesting reflection on your experience with this condition, because like you, I have had trouble diagnosing it and recognizing it with some patients as well. I feel like I am very quick to assume it’s related to tightness in the TFL and glute max causing compression of the GT via the IT band when in reality that is just one of many causes that could be contributing to pain in this region. Like you, I have treated patients with lateral hip pain with limited relief in their symptoms that would leave me scratching my head. I am curious, once you picked up on the fact that your patient was presenting with gluteal tendinopathy, how did you go about dosing your patients and from there, how did you plan your progressions? Did you prescribe exercise purely based on goals and functional limitations or did you start your patient on one of the progressions outlined in the literature provided?
In the few patients that I have worked with that have gluteal tendinopathy the common theme is moderate to severe and disabling pain that can impede the patient from being able to engage in recreational activities or worse, their ADLs. In terms of how I gauge how much to load/unload a patient, I typically base it off the patient’s severity/irritability of symptoms. If a patient begins to experience pain 2 miles into a run versus not being able to even walk because of pain will directly inform me of how aggressive to begin the patient. In addition, I typically will have the patient perform a LQ functional exam and assess for any faulty movement patterns such as excessive adduction moments created at the hip with SL loading. Grimaldi and Fearon demonstrated that there are multiple sound clinical tests to reliably and confidently diagnose gluteal tendinopathy that I plan to use in the future when I suspect this pathology. SLS is something I have always used with these patients but more the purpose of balance and not pain provocation and I never put very much emphasis on how the test feels to the patient compared how their balance was and how much pelvic drop was present. Moving forward, I plan to incorporate many of the tests outlined in this commentary to better improve my own confidence that my diagnosis is correct.
Following the course series last weekend as well as the research provided for this discussion, I have discovered that I have more or less overlooked potential postural contributions that the patient has engaged in at home and put all of my postural related focus on my functional exam. Grimaldi and Fearon did a fantastic job of outlining many postural faults that the patient could be inadvertently engaging in in their daily life that can explain a vast majority of their symptoms. This is something I plan to incorporate in future patients with this condition. Dr. Grimaldi also highlighted these points and went on to stress the importance of educating the patient on avoiding sustained positions with the legs adducted to avoid the strain that is ultimately induced at GT and over the tendons of the glute med/min.
I also enjoyed the loading progressions outlined in Dr. Grimaldi’s article as many of these exercises that were included I have prescribed to my patients for the same purpose. I would say one thing I have overlooked is the progression of these exercises by starting with a more basic form of a squat before going to a SL squat or a step up. I often will start a patient with both a bilateral squat and a step up which are on opposite sides of the spectrum in terms of intensity. Moreover, I have also made the mistake of putting a decent amount of focus on mobility exercises for the glute max and TFL with the purpose of trying to relieve the pressure and compression being imposed on the GT via the IT band, something that both the LEAP and GLoBE protocols in Dr. Grimaldi’s article advised against.
I also enjoyed Beneck et al’s research that was cited over the weekend’s course series pertaining to minimizing TFL activation when performing glute strengthening exercises. After learning more about the importance of minimizing the amount of stretching to perform for the TFL and glutes, it makes sense that with patients trying to recover from this pathology to perform glute strengthening exercises that midgate the amount of TFL activation and thus further compression over the GT. These exercises are something that I plan to incorporate more readily into my patient’s POCs going forward, especially in the early states of rehab when the patient is in pain.
Lastly, if conservatie management fails and the patient has not responded or improved over the course of 6-8 weeks, I have no problem explaining the advantages and disadvantages of steroid injections to calm down the bursa and any other inflammation that could be driving the patient’s pain. Following the injection, this could open a temporary window where we can continue to strengthen the patient with lesser degrees of associated pain in the hopes that when the injection wears off, the patient is in a better place strength wise and hopefully the pain won’t return to the same level.Grimaldi, A. et al, “Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management,” JOSPT 2015 October 31; Volume 45 Issue 11: pg 910-922
Grimaldi, A., (2021, September 20). How physiotherapists treat gluteal tendinopathy. Dr Alison Grimaldi. Retrieved December 15, 2021, from https://dralisongrimaldi.com/blog/how-physiotherapists-treat-gluteal-tendinopathy/
Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy, 43(2), 54-64.I think this is an interesting topic that speaks to the core of not just our profession but all health professions involved in the care team for a patient with low back pain. Because persistent low back pain can linger for years following tissue damage, it can be very difficult to identify a source of the pain that then can be treated. Despite being trained in pain management and neuroscience, myself (and I’m sure many other clinicians) and the patient desperately want to identify something tangible, like tight muscles or nerves or a hypomobile spinal segment, that when improved, will help resolve their symptoms. I think this is a significant factor fueling these “non-encounter” situations that Holopainen et al spoke about in their research. When a patient has been dealing with these symptoms for many years, and are given different information regarding different diagnoses from different providers, this can easily lead to confusion, anger, loss of the therapeutic relationship, and ultimately a sense that the patient is in the middle of a tug of war between all the information they are being given and advice that they should follow.
For me, a prime example of a patient that I believe was a “non-encounter” was a patient I worked with during PT school when I was volunteering at a pro-bono clinic. The 62 year old patient had been experiencing low back pain with radicular sx for several decades and had numerous comorbidities including high blood pressure, diabetes, and obesity. She had been bounced around to numerous providers to little avail. She had seen a physician, two different PTs, and had been through pain management before her insurance ran out of visits for the year. Despite being told different information about what was driving her symptoms, she still believed wholeheartedly that she could be “fixed” by physical therapy without any input on her part. This thinking was partially entrenched because of a MRI printout of her back showing multiple disc bulges that she brings with her everywhere she goes in her purse. As a student, this was immediately intimidating to me, and with guidance from one of my faculty professors, we decided to try to educate the patient on pain neuroscience and try to convey that there was no longer anything healing in her low back and that instead the brain’s homunculus had been smudged. The patient immediately shut down to this and would not entertain the idea that there was nothing to “fix” in her low back. The patient became defensive and reacted saying that we thought her pain was purely in her head and that she was making everything up. This was an almost impossible conviction to break through and the patient was essentially ignoring our educational pieces. I showed her the video “Understanding Pain in Less Than 5 Minutes, and What to Do About It!” as well as tested her for left right discrimination (she was postive for this), but no matter what I said, she would just say we were wrong. Needless to say, the patient never came back, and I felt terrible and felt as though I had failed her.
I think this case speaks to a bigger problem in the healthcare system and our ability to properly deal with patients with persistent pain. The article does a good job of showing how many health care professionals lean on their scientific background and try to come up with a biomedical explanation instead of just listening to the patient’s story. I think if my patient had been better listened to and pain education was begun sooner, she maybe wouldn’t have had MRI imaging, and she would never have had the idea that there was still a tissue disruption in her low back. Instead, she was given multiple different nerve and pain medications from pain management, and recommended surgery from a physician but was also told she was too overweight to undergo surgery. Had all the health care providers involved in her case been on the same page with each other and collaboratively educated the patient managing expectations highlighting function rather than focusing on her low back pain only maybe her outcome would have been different. I think if PTs and all other healthcare professionals prescribe and encourage non-specific exercises for patients with persistent low back pain and begin this line of rhetoric and education at the very beginning, health care costs, back surgeries, and most importantly, patient outcomes and quality of life will ultimately improve.Sarah,
Thanks for your post, I think this is a very interesting case. With only a “couple weeks” of conservative management under the belt (I’m assuming circa 2 weeks?), I feel like it is important to manage expectations in that outcomes from treatment aren’t typically very apparent that soon especially when our goal is strength gains. Did the patient have a sufficient understanding of healing timelines? Also, I understand your position with imaging, unfortunately, if a patient sees an orthopedic surgeon and they are recommended for imaging, we have right then and there lost control of the case and with imaging almost always will come the recommendation for surgery. I am curious if he made the appointment to see this physician after not being satisfied with a couple weeks of PT or if this was the plan all along for him to get imaging this soon after the start of PT. If it is the former, again education of managing expectations of basic tissue healing timelines become very important. Luckily, it sounds like this patient did well post-op and hopefully will continue to do well at follow ups in the future. I think the unfortunate dilemma with imaging is the radiologist knows nothing of the patient in front of them, they only know to read an image, and find anything and everything that is out of the norm. Without the clinical side of the patient, there is no saying the relevance or the impact of what is found will ultimately have on the patient. I think this is another very important piece we need to convey to the patient if there is a sense that they might be leaning towards returning to the referring physician or making an appointment with a surgeon.