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Hey Katie!
This is for sure a challenging case and I am happy you brought it up for discussion. I know your primary dx reflects something dural in nature and I have just seen Kyles post about it potentially having a lumbar component to it. What are your thoughts on bringing him into lumbar flexion and comparing his sx with this to his sx with lumbar flexion with his left leg on a stool (to allow hip and knee flexion) to put some slack back into his neural tissue? This is something I have used to determine how much of the pie is dural vs lumbar and may help you adjust treatment time delegation to each component. I think this may be one of the times you can utilize traction as a means of taking some of those loading stressors off for that tissue to have a change to heal without constant irritation. I’ll attach an article that I used for my case series presentation last year for our lumbar unit. I think he hits the inclusion criteria (pending his ODI score). I hope this helps!Hey Tyler!
All of those questions Katie listed are great for determining if this is a pelvic floor case. To take it a step further, if it is pelvic floor I think on of the main objectives is to determine if their pelvic floor is hyper or hypo active. This is particularly important in determine treatment and exercises to give. Some special questions may be asking if he has the feeling of his pelvic floor dropping or if it feels like it is taught. Does anyone remember other ways to determine the difference? Do you have a hypothesis for what end of the spectrum your patient is? If so, what are some manual treatments/ HEP you gave him day 1?I think one of the main issues I have as a clinician is ther ex. I think this course helped push me in being more creative in designing ther ex for a patient and the specific activities they need to return to. Like wise, it helped break down how each players position on a team can also impact exercise prescription and type of activity (power vs endurance vs strength). I think the biggest point I got from this weekend was that as a profession we are guilty of under loading patients and sending them back to sports they may not be ready for. This is going to impact my practice in making sure we are doing sport specific tasks to further make sure they are returning with their tissues fully prepared. This ties in with another point I started using in my evaluations. Screening the likeliness of a patient to perform their HEP and how often they can perform them is a new step in my evaluations after this course. I feel like making HEP a joint decision will help with pt buy in as well and help them decide what they would get the most out of.
I think one of the main issues I have as a clinician is ther ex. I think this course helped push me in being more creative in designing ther ex for a patient and the specific activities they need to return to. Like wise, it helped break down how each players position on a team can also impact exercise prescription and type of activity (power vs endurance vs strength). I think the biggest point I got from this weekend was that as a profession we are guilty of under loading patients and sending them back to sports they may not be ready for. This is going to impact my practice in making sure we are doing sport specific tasks to further make sure they are returning with their tissues fully prepared. This ties in with another point I started using in my evaluations. Screening the likeliness of a patient to perform their HEP and how often they can perform them is a new step in my evaluations after this course. I feel like making HEP a joint decision will help with pt buy in as well and help them decide what they would get the most out of.
Hey Justin! Thanks for posting! I agree with Tyler and Steph’s points about low hanging fruit and utilizing the lateral wedge. Hopefully with this you are able to unload the medial compartment enough for his sx to calm down to help perform more pain free exercises. In regards to exercises, I would base HEP and ther ex on his impairments to work toward his goals. Like Mike said this weekend you ask what was reasonable for him to do at home and potentially incorporate that return to run algorithm we were utilizing in the course.
Building on Tyler’s questions as to when we should actually refer these patients out would be based on the “closely monitor for changes in symptoms over time”. I feel like red flag questions are still relevant and it gives us a great baseline at initial eval to be able to monitor any changes in the time we spend with these patients. One of the main reasons I became a therapist was because we are the medical provider that spends the most one-on-one time with our patients. With this being said we will be the first to recognize a status change on these patients in regards to the red flags and this is then the time to possibly refer out. I feel like this article has a great point about diagnostic imagine showing “abnormal” findings on 94% of MRI findings with only 3% being a serious pathology. Just like imaging, our red flag questions may show abnormal findings but in many of these cases it will be a horse rather then a zebra. This is when monitoring is the key and a referral is indicated with + clusters/ status changes.
Hey Tyler! I am really excited about this case and article. I feel like a a residency class we have been focusing on tendinopathy dx and treatments. I feel like what you did in applying other tendinopathic scenario’s that are more common (such as the Achilles or RTC) is what I would have done as well. Although it is not the same area I feel like the properties are similar enough to apply those interventions to other areas and modify per tendon you are working with. As for the stretching, I would explain to the patient that although this was something that made her feel better to maybe give the interventions you were showing her a chance and hold off on the stretching until she is in a stage that it is more appropriate. In addition, I feel like even though the protocol offers 4 stages you should assess what stage she is in and apply the specific interventions from the article that matches her presentation then move forward. Where did you end up starting with her?
This article was a great A and P review on ligaments and tendons. I thought it was great to give the normal values of tendon loading vs the amount of load it takes for total tendon failure. Although we went over it in classes, it was nice to see it spelt out the physiologic mechanism of the changes that occur to the tissues when a tendon is injured and attempting to heal. Above all, I think this is a great patient education source to help explain realistic healing time lines to patients. This past week I was asked by a patient with gluteal tendinopathy how long it takes for her condition to get better. I definitely stumbled and was not able to give her a confident answer. After reading this article I feel like I will better be prepared to explain expected time frame and lay out realistic tendon healing expectations early in treatment.
Hey Katie! It seems from day 1 until his second visit he had some great improvements. I was wondering what you attributed these changes to (being the techniques you utilized day one or medication). Also, how long ago did he start/ end his dose pack. I ask because I had a patient like this a few months ago that had a very similar response to early treatment and steroid pack. As the dose pack wore off his sx returned almost to baseline. I was wondering what your plan was if this occurred and suggestions for what I could have done with my patient way back when I struggled with a similar presentation.
Hey Eric! I love this post- especially the 1st, 2nd and 5th tip. One of the number one things that has resonated with me throughout my PT schooling and career has been the saying “we are the biggest advocates for our patients”. I feel as a new health care provider I have all of the opportunities to try and better the community I work in by further understanding their needs and advocating for these needs. I think these principals apply across the board, weather it is furthering my education to better help them, reaching out to “my tribe” for more ideas or going above and beyond to get them the care they need is part of my job to shape our societies health care system to be better.
Hey Katie! Thanks for posting. I feel that in response to your question about his fear of coming off medication you will have to have conversations on how PT and exercise can be its own natural “medicine”. With this I would dip further into pain theory and how finding some sort of physical outlet and exercise prescription in junction with PT techniques can help him manage his sx without the need to depend on drugs.
I was also wondering what you meant by saying this “type” of patient.
In response to the prior discussion to manipulate or not- I would probably be hesitant to do this day one and I would use mobilization techniques. As stated above by tyler I would be nervous to lose some bye in but I feel like the evidence Eric posted would be a great conversation to utilize with the patient describing the same effects can be reached with a less aggressive technique.
This is a very eye opening to me and I have definitely found myself conforming to confirmation and recall bias situations. I think my personal bias comes from familiarity of techniques in research and the more familiar I am the more bias I tend to be. I also find myself recognizing certain patterns and utilizing techniques that have worked previously even though ALL of the features do not fit. I feel that at times I have tunnel vision and I need to start taking a step back and remembering that all patients are not the same and the same sequence of techniques are not applicable to every patient despite my past experiences.
I agree with Justin to look into 1st rib cervical rotation and lateral flexion is one way to further assess this potential structure at fault. That or looking at the ability of that first ribs mobility with palpation to B 1st ribs with inhalation and exhalation to assess potential movement restrictions. If these are positive and tolerance of supine is poor I sit the patient up and put the effected arm over my leg to put slack into the UT and then perform my 1st rib mobilizations with them SB toward that side.
Have you thought about a seated CTJ manipulation? I know this is more aggressive but I was unsure how she was progressing or if you think she would tolerate this. Maybe it would be enough of a kick start to allow you into the system and treat other impairments.
This article reminds me of the presentation during the art and science conference on RTC loading that was very helpful. I feel that this article helps break down the appropriate exercise progression/ regression based on what stage of healing a patient is in. In the course series we always spoke about progressive tendon loading and we talked about some ideas we could utilize in the clinic, however, I have had a hard time identifying what exercises were most appropriate to a specific phase of healing. This article helps break this idea of tendon loading down even more with explanations of how varying the speed of motion or magnitude could help provide the stimulus needed for adaptation. Right now I have a young boy with severs and I believe most of these concepts and ideas would carry over well to his treatment plan but I am unsure. Does anyone have any ideas of applying this article to this population?
Hey Sarah! Thanks for posting.
Along with what Tyler said I would look at activity modification first. Maybe reducing the amount she is running or the surface she is running on and unloading the effected areas for a short period of time would be beneficial in the long term, although I typically do not like to take an athletes sport away. Do you think she would be receptive to this?
I would also love to see her running mechanics and think that a gait analysis would be huge to see any other deficits occurring up the chain. If you can possibly tease out any potential compensatory strategies she has been using it may make exercise prescription more meaningful to her.
Looking forward to discussion!