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This change in status would raise concern for CES, spinal fracture, or obstruction d/t tumor. With the new symptoms and confirmed urinary retention, I would recommend emergency referral for MRI and medical management.
I like that Zack included the notes about a nonchalant initial questioning and making an effort to draw on the positive rapport already built and avoid being perceived as overly invasive. Sometimes a more indirect approach might be helpful, such as asking how things are going at school, if they are excited about the upcoming return to sport testing, or what they are most excited about with regard to getting back to play without directly pointing out the change in engagement.
I think involving the parent is necessary, and ensuring that the parent is also demonstrating as much engagement and drive as they had been in the past could help build the picture further. The parent might let you know about a loss in the family, trouble at school, or something else that the patient has not been comfortable bringing up to help put things into perspective, and ensure that it is being addressed. At the very least, if the parent had not noticed anything, it would give them the insight needed to recognize there may be an underlying issue to keep an eye on. If necessary a discussion with the parents and coaches together could be beneficial to get to the bottom of the issue and create a game plan.
As for the gender difference, It seems the patient started off doing well and did not seem to have any issues there, but she is entering a challenging age for all of us and may be experiencing different emotional, social, or hormonal stressors that she was at the beginning of the plan of care.
Either way, letting the patient know that you are there for support and that you can assist in finding other resources or connect them with a female therapist if they feel that would be helpful. Just giving options and expressing your caring support is often a big impact.Nice!
Given the background, history of anorexia, and presentation, a stress fracture of the femoral neck or head would remain at the top of my list, and I would continue conservative care.
Other causes of this imaging finding and hip pain may include avascular necrosis, which would be more likely if the patient is a heavy drinker, using corticosteroids, biphosphonates or certain antiviral drugs or if the patient is suffering from lupus, HIV, pancreatitis, or certain types of cancer.
Pubic ramus stress fracture would also be a consideration. This would also initially be noticed during or after provocative activities and worsen over a period of weeks following, with pain over the fracture site.
Labrum injury or FAI could lead to similar pain location and behavior, though this would typically be more with the sporting activities and positions of increased flexion or adduction, and there is often an associated clicking or popping sensation.
Inquiry into any past episodes of similar pain, any trauma or even minor injury, clicking pr popping, substance abuse, steroid use, medications undisclosed medical conditions, or other potential diseases that may sway the differential list would be helpful. Repeat imaging (MRI) should be recommended if symptoms persist, given the history of anorexia increasing potential for reduced bone density and high risk site for stress fracture.
In addition to the testing and assessment mentioned by Zack above, discussion of other medications and specific foods that may increase risk for statin related myopathy or cell damage. Inquiring into whether the patient has been using antifungals, fibrates, calcium channel blockers, or if they are aware that grapefruit juice can increase risk of statin toxicity. Patients should also be encouraged to be adequately hydrated at all times, especially before, during, and after exercise sessions.
Being aware that statin use can increase risk of exercise related muscle injury is key in determining need for adjustment to exercise plan, and potentially referral back to the physician to determine if adjustments to dosage or dose frequency (though studies may not support dose dependency), or a change in choice of statin used, is indicated. The patient may require reduced intensity, load, or exercise time to prevent worsening tissue damage. If eccentric exercise has been the focus, other approaches may need to be considered.
Monitoring the patient for multi segmental strength decreases in targeted and non targeted exercises would be helpful to determine if referral is indicated due to potential for higher risk situations. Also, new onset weakness or fatigue with ADLs and things like stair climbing in healthy individuals would be a flag for serious side effects of statins. Id DOMS seems to be lasting too long, or non targeted muscles are sore, this would be another red flag.
Thank you. That is useful. It makes sense, and could directly translate into patient education on which side to chew, etc.
The joint compression test would potentially be helpful to determine intraarticular involvement. Joint palpation at the joint line, over the muscles of mastication, and over the temporomandibular joint with jaw motion to assess for popping associated with reduction would also be helpful to determine whether more myogenic, current displacement with reduction, or a combination of the two.
Thanks for your feedback in my initial first thoughts.
In reference to the Central sensitization article, there is evidence to support the presence of central and peripheral sensitization (pain pressure threshold) in many TMJ patients. The article also references the association of increased stress and anxiety being a factor in the development of these hypersensitivities. Therefore assessment of the level of stress/anxiety the patient is under, as well as her pain beliefs would be beneficial to inform treatment and prognosis.
One tool found on the orthopt.org website is the OSPRO-YF outcome measure, which is described as a concise yellow-flag assessment that allows for accurate estimate of individual, full length psychological questionnaires for depression, anxiety, anger, fear-avoidance, kinesiophobia, catastrophizing, self-efficacy, and pain belief with decreased burden on the patient. This could be a valuable tool for this case. There are three versions of this test, with the 17 question version achieving a minimum accuracy of 85% according to the Academy of Orthopedic Physical Therapy website.
I have never utilized this tool, and plan to look into it further.
Have any of you used it? Do you have thoughts on this? What tools do you prefer to assess yellow flags in cases such as this?
As for my initial comment and mention of cervicogenic headaches, I did not do a good job of differentiating it from tension type headaches, which would be more in line with the description of the patients symptoms. Differentiation of various headaches requires attention to detail and noting triggers and symptom behavior.
Both migraine and cervicogenic headaches are often more one sided.
Migraines typically more moderate to severe and are associated with aura, nausea, dizziness, hypersensitivity to light and sound, speech and language difficulty, they are often unilateral and may side shift, and they are not often associated with neck movement. The pain is often throbbing, pulsating, and intense. They often have known triggers, which may be certain foods or chemicals, stress, dehydration, and changes in sleep.
Cervicogenic headaches are often chronic or episodic and associated with upper cervical spine dysfunction, are associated with neck movements, are typically one sided and perceived to be in the head or face. They are commonly confused with migraines, though pain is typically non throbbing/pulsating, starts in the neck, and also moderate to severe. Can last for hours to weeks.
Tension type headaches are more diffuse and bilateral, not typically caused by neck movements, more mild to moderate, and associated with tension in the muscles in the shoulders, neck, and suboccipital area. They are often associated with increased emotional stress and anxiety, postural deviations, and sleep disturbance.Very thorough response Zack!
You hit the nail on the head with your primary Dx.Thanks!
My initial thoughts on the patient diagnosis would be centered around TMJ with accompanying cervicogenic headaches. The patient’s history of chronic jaw pain with clicking and popping would lead me to strongly consider TMJ. With her high stress levels and intermittent symptoms, this could be associated with grinding or clenching the jaw at times during the day and overnight. It would not be out of the question to expect tension in the neck and shoulders with trigger points and associated headache referral symptoms. Question and discussion of correlation of symptoms with periods of higher stress, pain/clicking with jaw opening, chewing, and speaking, and any successful interventions self learned or prescribed by the dentist would be helpful. Questioning into any history of migraines, association of neck tension with headaches, and if symptoms are more common on one side than the other or if always in the halo distribution would also give further insight.
A few hey components would be APR testing and noting any pain with passive or active extension, clicking or popping with rotation/circumduction. Grip testing and associated weakness or pain, observation for cyst or other lump or any other obvious deformity, as well as specific location of swelling or redness. Palpation and accessory motion testing to identify specific structures.
TFCC would typically be more ulnar sided pain, many of the symptoms do align there. The prompt isn’t very clear exactly where the pain distribution is, though I didn’t interpret it as ulnar sided initially.Given the chronicity of symptoms, repetitive swelling, pain with passive extension (pushing up from a surface), pain with golf swing (especially impact), and pain picking up heavy objects, and without the description of a lump (bony or resembling a ganglion cyst), paresthesia or nerve related pain descriptors, or radial pain at the base of the thumb, I would initially begin thinking dorsal wrist impingement. Differentials include ganglion cyst (which may accompany this condition), scaphoid impaction syndrome, and carpal boss, as well as wrist extensor tendinopathy, though the pain seems to be more likked with compression than stretch. I would want to see ROM, tolerance of restisted motion and passive stretch to gain more insight to build my case for or against a diagnosis.
Subjective questioning may include a more specific location of pain, and inquiry into the presence of paresthesia, presence of a lump or bump (and location), and severity and distribution of swelling when it occurs.Further, while I feel many of us intuitively recognize and attempt to address/buffer the negativity leading to a disability spiral, it can be a challenge. Helping the patient to recognize these negative beliefs and utilizing the structure proposed in the PRISM model may be useful to begin introducing those positive belief and processes that lead to the upward trend depicted in the sustainability spiral and building a sense of empowerment and decreasing tendency for rumination, fear, and further anxiety.
I think as physical therapists we often naturally begin to pull from many skill sets, and psychology is one that is very useful in managing certain patient populations. The PRISM framework suggested here offers some useful structure, and breaks down the different aspects of the patient background and experience that may be useful for those struggling with pain management. However, the fact that PTs are not recognized as professionals that can effectively bill for the time these techniques are utilized and the fact that more studies are warranted prior to adopting this approach makes it less likely to be fully utilized.
With that said, I have had several patients that seem to lack resilience, and feel more of a victim when they may be in better physical and functional shape than others who have a better outlook and have positive outlook.
Having this theoretical framework in my back pocket will allow me to have a quick reference to identify specific areas that I light be able to highlight and help the patient begin to feel more empowered and build a more resilient thought process.
Starting with identification of where the patient stands in each process in a specific domain will be helpful and creating a sense of empowerment and shifting the patients beliefs and behaviors, while continuing to be productive and avoiding significant interruptions in billable time.