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Along with everyone else I thought it was very helpful to see the EMG presentation with the stage by stage break down of appropriate exercises as to not stress the repairing tissue too much. I also thought it was very interesting to see the break down of impingement and how the tendon is actually cleared by the time out special tests would pick this up. It suggested it was tendon overload at these significant overhead motions which will absolutely change the way I think about the mechanics of the shoulder. Another great point that all of the presenters seemed to agree with was the lack of evidence supporting surgical repair of a slap tear and their prognosis. I am a firm believer in trying conservative methods first and some patients want the quick fix. This information is a great way to present the evidence in a way that may help patient buy in. In lab it was nice to see the three instructors different opinions on shoulder screening and special tests however, I was slowed down a bit and we were given more time to practice because the information given was valuable. Over all great weekend!
Without being repetitive I’d like to agree with a lot of the discussion going on. After the running med course I had major changes in the way I looked at return to run protocols for post op ACLs in how much time and effort goes into getting them back. I feel that for cases like this it is very important to give her all of the tools that she needs to be able to have a successful RTS, however, her compliance may be a hurdle – especially when getting her to commit to her rehab outside of the clinic. In this case I think having a discussion on more specific short term goals that lead up to her ultimate goal is worth while. If she feels like she is progressing and hitting smaller more achievable goals this may increase pt buy-in and increase her motivation. I also agree with the group with starting her hs strengthening out of context (RDL, Bridge walk out or Nordic hs curl) and progressing to something more meaningful once her strength increases. Maybe even go over the warm up and cool down activities we were shown at running med during the lab portion once she has met the appropriate goals.
As for her hop tests I’d anticipate decrease in hop distance as well as specific mechanical deficits such as what Tyler suggested.Hey Sarah!
I am in the same situation as Justin and Tyler in the sense of I have not worked with this population before. I loved Justin’s idea of taking a video and giving he a goal to work toward. I find sometimes breaking down the gait cycle and going step by step can help her see what compensatory strategies she has developed and give her the opportunity to correct these. Sorry I don’t have more to offer!In general, I am not very experienced working with the running population and I believe that this conference was able to my eyes to many things that I was unaware of that I wish to start implementing into my practice. I thought that the discussions about fitting the shoe to the foot and not the other way around was very helpful. I receive questions all of the time about types of running shoes and I was never sure how to tackle this question. Now I feel like I have a better understanding on foot type and appropriate shoe option. I also thought the talk about PRP and stem cell therapy was very interesting. Patients are always looking for other options and asking if injections work. Even though this presentation was geared toward Orthopedic doctors, I feel that it gave me the tools to explain these options and the evidence behind them. Additionally, I think lab gave great ther ex tools for the foot as well as warm up/ cool down sets we are able to teach as return to run activities.
Hey Tyler thanks for this case! I was wondering if you looked at her patella position/ mobility? I’ve seen great results with patellar taping techniques in the past with similar presentations. For this assessing the position that her patella sits in is very helpful for your directional force you use to with the tape and if you need to put a tilt or rotational direction on the patella. Of course this is a short-term fix but as Katie said it can be used as a starting point.
Hey Tyler! This is a great case and extremely helpful being that I have been seeing a lot of patients recently with a variation of this presentation.
1) I agree that choosing our words is extremely important and what we tell patients can change their outlook on what is causing their pain. Using words like “unstable” tends to do more hard than good. I personally try to explain this by relating it to another joint that is less intimidating and giving them a personal example from myself. I would explain that as swimmer growing up I had a good amount of shoulder motion for my sport and all the muscle to back this up and now that I stopped swimming I still have that motion but no muscle to work and control for this motion. Then relate this back to him being a college runner and his back pain. I also like to emphasize that movement is not a bad thing and this will not harm him or make his back worse.
2) My discharge criteria for a patient like this would revolve around me being confident in their abilities to self manage this. A good HEP with proper progressions and regressions that they could manage their sx would help me rest easy letting this patient manage this after PT ended.
4) I agree with Katie in that manipulation is not something I would use on this patient. I would also use mobilizations and potentially some gapping/ lumbar rotation techniques working out of those painful quadrants and progress to working into those problematic quadrants.
Hey Katie! Thanks for your case for this weekend. It is definitely a presentation I have not seen either. Did you use any special questions to further r/o the other more serious things other than cancer? I think that his family history can have an impact in his psychosocial presentation but this is a great place for you to step in and show him how mechanical some of his symptoms are presenting. Hopefully showing him that movements can provoke his pains can help put his mind at ease and at the same time help use pt education to build his confidence in you to treat him. Its great that he is feeling better knowing that CA has been ruled out and will also help with pt buy-in. You mentioned him seeing a urologist, has this presented with any new findings that may help understand why he is having pain emptying his bladder?
Hey Eric,
I found this article to be very helpful being that I am currently treating a patient who may fit into the anterior nerve entrapment category. Specifically, I believe her
femoral nerve is possibly being entrapped post anterior THA. She relieved this surgery over 4 months ago but is still having severe pain on the anterior aspect of her hip, groin and quadricep weakness. I have tried STM, nerve glides and dry needling to the ant thigh and this has all helped a small amount but she is still in a ton of pain. I think this article is going to help me offer additional patient education points because right now she is very confused as to why she is still in pain. In addition I am able to offer her education on possible surgical interventions (such as neurolysis and neuroectomy)so she is aware of all of her options moving forward.Hey Guys!
These are all great points and I do have some answers for you. I honestly was so focused on posting the positive Objective * I neglected to post the things that helped me rule out my differential diagnosis. Here are some other things I looked at during the IE. I hope this helps clarify!
ROM: Repeated Ext centralized sx (Sessions 1-3)
Gait: Antalgic in nature
LE dermatomes: Intact and equal B to light touch (Increased sensitivity to palpation along the S1 neurodynamic pathway)
LE Myotomes: Fatigable weakness with L PF (heel raise) All others strong and pain free
SIJ: (-) Thigh thrust, Sacral thrust, compression and distraction
Hip: (+) FABER (Pain in L low back), (-) FADDIR but painful in LB getting into this positionHey guys, what are your thoughts on some of these questions? Lets see if we can get some good pre-presentation discussion going!
1) By reading this patient summery what would your primary hypothesis be? What are some differential diagnoses that cross your mind? Is there anything that I did not look at during the IE that I should have to have made this a more comprehensive evaluation?
2) What are some manual techniques/ HEP that you would apply to this patient day 1?
3) What are some early indications seen in this case that would lead you to think the use of mechanical traction would be effective or ineffective?This article has opened my eyes to some of the risk factors that may lead to BSI and how to better screen and treat this in the clinic. Subjectively, I would like to clarify where the pain is coming from, diet and nutrition, endocrine/ hormonal influences, current medications, and bone quality. I would also like to ask about extrinsic factors such as running surface, shoe type and recent increase in activity levels such as speed or distance.
Objectively, I would like to watch them run, if they are cleared to do so. Their form and recognition of malaligned lower limbs/ abnormal movement patterns can have an impact on tis type of injury. Additional, functional testing such as SL activities and palpation are both important to look at especially to use as pre and post testing assessment tools over time.
I agree with what Sarah said in respect to education being a huge factor in this population. Typically, these athletes will want to return to running before their body is ready. This article lays out a great timeline to return to sport to be able to relay to the patient so they know when the guidelines to increase pace and time for running. Education on when this is appropriate and why they should allow for the proper time is huge in decreasing a reoccurring injury.
Hey Justin! Thanks for the patient case and article. I think your first question would be nicely addressed with utilizing some of the conversation points Gail Deyle expressed to us during our imaging course. It may be beneficial to communicate to this patient that imaging is not the gold standard of determining where pain is originating from. Maybe by using the article Tyler posted and relaying that even though an abnormality (fraying) is seen on an image it is not necessarily the cause of the specific pain that patient is experiencing can help ease the patients concerns.
With the recent injection to the GH joint I would anticipate a potential increase in tolerance to activity. With this I would take note of objective finding taken with the injection in comparison to without the injection but this would not impact the management in my care. I would still progress this patient as per subjective and objective asterisk findings for each follow up session.
I also agree with Tyler in assessing Thoracic spine mobility and possibly implementing some of the side lying techniques that Jake Magel showed us this weekend to help increase overhead motion during the shoulder sweep on the floor.
One of the main clinical pearls that I was able to take from this weekend was how to communicate to patients that imaging is not the gold standard of determining where pain is originating from. I think this course made a great point in emphasizing that even though an abnormality is seen on an image it is not necessarily the cause of the specific pain that patient is experiencing and how to express this to the patient. Additionally, I think it re-opened my eyes to the fact that imaging is exposing a person to harmful radiation and it should only be used if it is necessary. Sending a person for imaging is expensive and harmful and can be avoided if a full comprehensive physical exam is performed. This is especially important when conservative approaches will be the main means of treatment regardless of the findings shown on the image.
Hey Sarah, I think this is a great article that looks into all of the available conservative treatments available to patients with SIS. This article helps confirm that the conservative interventions we are responsible for as Physical Therapists have been proven to be more effective than the control. Although most of the treatments being looked at are categorized as a low level of evidence to back this up, it is still a means of reference for potential interventions. I particularly think this article is a good pairing with the weekend radiology course we have this weekend. During day one of this course Dr. Gail Deyle expressed that RTC repairs typically have the same outcome as conservative treatment methods. This study enables us to use a mix of these interventions in hopes of getting the same recovery results and eliminating surgical intervention.