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1. Based on the subjective information presented above what are your top three differential diagnoses? (Ranking order)
– CRPS
– Central sensitization
– MCL/PCL injury2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
– CRPS: swelling, changes in skin temp and color, hypersensitivity, decreased sensation that is not at one specific dermatomal level.3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?
– Skin texture changes?, hair growth?, sensitivity to light touch?
– I would ask yellow-flag questions to get an idea of she has any S&S of these. This also might be a good way to begin any education that you believe the patient needs.4. Rank by % her origin of Pain: central, nociceptive, neuropathic.
– Central: 40%
– Nociceptive: 20%
– Neuropathic: 40%5. Rank which of these you would want to provide during IE: Education, Manual, Exercise. Why?
– #1: Education – I would explain to her that there is something more going on beyond anatomically-driven knee pain. I’d say that it seems as though her whole body is in a sensitized state, and that it is interpreting thinks that aren’t normally painful as pain.
– #2: Low intensity exercise – She has probably been very guarded since the MVA and since she has been in so much pain, and I think low-intensity activities would help facilitate decreased fear of movement.
– #3: Manual therapy – I would not make this a priority during treatment, at least until her widespread and vague pain symptoms begin to normalize to something that makes more sense anatomically.6. How would you educate the patient regarding our findings and her upcoming surgery? If this means a suggestion of no surgery, how would you address the doc?
– I would briefly explain to the patient that there doesn’t seem to be one pathological structure at fault for her pain symptoms, and therefore don’t think surgery should be considered at this time.
– This would be a time when I would try to get in touch with the physician, especially if surgery is already scheduled or in the closing stages of being finalized. I would tell the physician that you found that the patient is displaying pain complaints that are much more widespread than just her knee, as well as S&S of non-MSK issues.Questions:
1. Based on the subjective information presented above what are your top three differential diagnoses? (Ranking order)
– Gluteal tendinopathy
– FAI
– Lumbar discogenic pain with referral2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
– Gluteal tendinopathy: Pain location in hip with lateral LE referral. Aggs are holding baby (likely hip-ABD position to support child’s weight), SLS, crossing legs, laying on R side. Wide hips. Pain with SL squat. Pain with hip ER PROM and pain with initiating hip ER in lengthened position, pain with resisted hip ER and ABD. TTP glute med insertion.3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?
– Generally more info on groin pain, and if this pain increases with either the LBP or hip pain.
– May have thrown in a prone instability test for palpation/mobility testing.
– Mobility of the segments above L4-5
– Which pain did FABER reproduce?4. What would have been your exercise prescription and educational interventions for day one?
– Supine hip ABD/ER isometrics (hooklying TB around knees)
– Education on sleeping and standing positioning for decreased compression of gluteal tendonI like the idea of the tendon continuum model. It helps guide treatment as well as set expectations for how much achievement can be made. What I found very helpful was that the continuum states that you can only improve so much if you are only treating an individual’s pain. I think so many people (non-PTs) have the thought that rest is the best treatment for tendinopathy, but this article really explains why that is not the case. I think this also explains why so much individuals suffer from recurrent bouts of tendinopathy – they are not address the function and load capacity of the tendon itself.
What I did not like about this article is that it didn’t seem to assist the reader in knowing where to place their patient on the continuum. I wish it would’ve given examples or common S/S of individuals in different stages of the continuum. Obviously some of this is common sense, but more emphasis on this would’ve been helpful.
My patient was a 14 yo male who played basketball. He had recently undergone a growth spurt, and had b/l achilles pain that was worst after he played basketball. I would place him on the reactive tendinopathy continuum (btn yellow and red). This was his first bout of pain, but it had been going on for several months before starting PT, and he was not taking breaks or doing anything to address his pain before beginning PT. He had fairly high pain levels.
I began him with isometrics of about 5-10 seconds at a time (going back in time I would’ve had him hold these for 20-30 sec). I had him do these about 2x/day for the first couple of weeks. I also videotaped his running, jumping, and landing mechanics – so while he was performing mild-intensity activities, I was also working on proprioception, gait mechanics, and hip strengthening – as I felt these were all impacting his pain. Some examples of these exercises were holding heels off stairs, SLS and balance exercises, double leg squatting with TB around knees.
As his pain became less limiting, I progressed him to concentric and the eccentric exercises, going from double limb to single limb exercises. At this stage he was more-so in the reactive tendinopathy (yellow stage). Eventually I had him jumping and landing and working on his biomechanics with these. I don’t remember the specific dosage for these exercises, but generally began low resistance/high volume –> higher resistance/low volume. Examples of these exercises included PF on leg press machine, jumping/landing on SL, bounding side-to-side, running and landing in SLS on foam pad.In the future, this article will change my patient education about this pathology. Not all of the science jargon, but educating the patient on the importance of more than just their pain-rating in dictating their treatment. I will make more of an effort to discuss and treat their function, looking at how they do their sport/activity that caused the tendinopathy in the first place, and treating the impairments appropriately.
I am not DN certified either, however would like to become certified within the next couple years. I asked the PT at the clinic who is DN certified if she has used DN for PHP, she stated she rarely used it.
In practice, I think I would consider DN if a patient had PNP with a trigger point distal to the knee, especially if referred pain with compression. The article stated the NNT was only 4, so I would ensure to use other treatments in addition to the DN. I agree with Cameron, DN would be a good tool to use if a patient stated decreased pain following manual compression of a trigger point, or if a patient was immobilized for a long time.
Overall I thought that the article’s methods were well done and appropriate. I don’t think that the limitations of the study significantly altered the findings of the study.
Cameron, I agree with your last comment. It seems that PHP generally takes a very long time to heal, and therefore these patients are more likely to be seen less frequently but for longer overall treatment lengths. With this in mind, I would emphasize the importance of HEP adherence and provide education about the length of time PHP takes to improve. However if a patient has acute-sub-acute pain, I wonder if the prognosis for these patients is any better?
I liked the articles as well. I appreciated that the treatment was similar to how we would all treat a patient, which is with consistent reassessment of their symptoms and appropriately progressing or regressing from there. Most articles are very specific and rigid in their treatment protocols, so I liked the flexibility and it was more applicable to the clinic. I think it is a good reminder to be as specific as possible in addressing the impairments in front of you. Each patient had specific impairments and therefore the PT used different MT and exercises techniques to treat. They did not treat every frozen shoulder patient the exact same.
I found it interesting that they kind-of categorized the patients in different stages of frozen shoulder, but their stage didn’t dictate their treatment. In addition, the case series showed that improvements can be made in any of the different stages, so it should not be necessarily expected for outcomes to regress depending on their stage. However, there were some patients who had declines throughout their treatment in different outcomes.
Lastly, I really like how they included so many different MT techniques used in their treatment. I found the MWM especially useful, and definitely want to take time and see how I can possibly incorporate these into my treatment.
My takeaway from the second article is how much time it takes for pain to decrease in this population, no matter what treatment the individual received. This will help me set patients’ expectations. It may also result in me tapering off their frequency so that when their pain is manageable, I’d only see them once a week or every other week to check-in and make adjustments as needed.
I also really liked the exercise the exercise group received. It combined strengthening as well as included a stretch of the plantar fascia via the windlass mechanism. I also was intrigued that it may have combined an ankle DF stretch with it. Was anyone surprised that the stretching group only focused on DF the toes and not working on ankle DF ROM?
My biggest takeaway from the article is the importance of acutely off-loading the plantar fascia in order to decrease symptoms. I think my PT-brain would want to immediately turn to stretching or exercise to help decrease symptoms, but its important to give the fascia time to heal. I don’t see my clinic implementing their TCFO technique, however the basic principle is still helpful. I could try taping techniques, or patient-education about foot postures to decrease stress until the fascia has time to heal.
I don’t use orthotics at my clinic but that is mostly because I have had minimal exposure to them. We have them available to give to our patients. Also, in my September lit review, my systematic review was about orthotics in the treatment of posterior heel pain. Overall, there were only short-term positive effects with some of the orthotics (vs. conservative management, which was loosely defined) and these effects weren’t found usually after two weeks. My personal bias would be to promote education, and if the patient wants to buy an orthotic (thinks it will help), to recommend a general prefab, because in the systematic review, there were no differences between custom-made and prefab. The only exception to this would be if the patient demonstrated a very noticeable and likely pain-provoking foot posture, then I may recommend a specific orthotic to help their specific foot type. I’ve attached the article at the bottom.
Going off my last point, yes I think that the patient’s foot type should dictate if, and what type of orthotic I would use, if I truly think an orthotic would help. In Dhinu’s presentation, he mentioned that a pes cavus foot usually results in a shortening of the plantar fasicia, and a pes planus foot is an overstretch of the plantar fascia (someone correct me if I heard this incorrectly). To me, this would make my treatment for these two things very different, and this is one of my difficulties with the article. The article protocol was two weeks of the TCFO, then a bunch of weeks of stretching. However if the patient’s plantar fascia is already overstretched due to their foot type (pronated foot resulting in pes planus), continuing to stretch it may add to the problem. I would be interested in what others think about this.
1. In order of likelihood:
– SAI
– RTC partial-tear/tendinopathy
– AC joint pathology
– Labral pathology
– Cervical facet/disc (C4-5, 5-6, 6-7)2. I would have looked more closely at AC joint, especially done a couple of special tests for it. Even if SAI is the most probable pathology, I would want to rule out AC joint involvement. I’ve seen several heavy lifters have an AC joint component to their pain, and working on it has helped me with several patients. Just curious, you said there was a painful arc of motion, but was there pain at end-range shoulder flexion or ABD too?
Also, if you had more time, I would’ve looked at his scapula more and really tested his arc of motion pain with scap assist with ER, post tilt, and UR, and tried to determine which, if any, decreased his pain.
3. SAI due to supraspinatus tendinopathy (and likely scap dyskinesia as well)
4. Yes, I agree with doing functional activities afterwards. I’d want to have an idea of what was going on prior to having him do heavy bench, that way I can provide him with better education on how to lift with decreased pain. Also, if doing heavy bench at the beginning flared him up, you would likely have some false positives with your additional testing. But I think its great you did it day 1, because it shows you are in-tune with his goals, and if you can make a change in his pain with his bench, you’ve got your buy-in.
5. I think your first day interventions were great. My only question is did you have him doing T extension just because he had bad posture, or because you had test/treat/re-tested this with something and saw a decrease in pain?
I would’ve looked more closely at AC joint like I mentioned before and tried joint glides here, but that is just my bias with this patient population.
Casey – I agree that making the patient’s treatment more specific to function and less about changing their ROM (which didn’t work anyways) may have been helpful and more individualized for the patient. This makes the patient feel more like an individual and less than just a diagnosis. Like the article stated, the placebo group likely had more patient-PT interaction and therefore felt like they were listened to.
Another thought I have is that I think its so important to give the patient SOMETHING to go home with. I have had evals where at the end, I don’t know exactly what is going. Even if I don’t have time to test/treat/re-test, or don’t know exactly the best exercise to give the patient, I should give the patient something to do that I can be 99% certain at least won’t increase their symptoms. That way they feel like they are working on improving their problem and have some sort of control. I think that is why the US group got better too – because they were at least doing something at home to control their pain.
Cameron – I agree with you, I was sad by the results of this article, and definitely tried to think of reasons why they were wrong as I was reading it. I agree with you that their methodology for assessment of HEP adherence is iffy. However, the article reports that both groups had similar adherence, so I don’t think we can say that this favors either group more than the other.
What I was surprised mostly about was that there were so little improvements in strength and ROM of the PT group. I could see how the PT group doesn’t have significant differences when it comes to pain and physical function. But if the PTs are working at exercises and manual techniques to gain ROM, how did this not show in the results? In some categories, patients had less strength or ROM than when they began. My thought is that with hip OA, it is a joint issue, and it is tough to work on joint mobs in an HEP. Does anyone know if the patients were at least using bands and MWM techniques for their HEP? If the patients are only being seen once a week to once every two weeks for the last 10 weeks of the study, maybe this wasn’t enough frequency to make these changes (especially when it comes to improving accessory motion). I wonder if 2x/week for the entire duration of the study would have been enough frequency to notice a change.
My last attempt of reasoning through why this study is maybe wrong, is that the exclusion criteria consisted of participants who did NOT participate in more than 1x/week of structured physical activity. Maybe the participants are used to being sedentary, and so laying down and rubbing gel on their leg suits their bias better? Maybe the adverse effects, likely mild increases in pain, were just soreness, and these patients did not know the difference between pain and soreness? Maybe the patients in the PT group were performing their HEPs, but doing a shitty job with their form because they have poor motor control/body awareness, or just not challenging themselves enough – because they are not used to exercise? Again, these are just possibilities and me trying to rationalize the findings of this article.
Erik – My clinic has a hip ABD/ADD machine, that I think it used too often, however I think this would be a good way to test the strength ratio of ADD:ABD. I have no research-supported rationale, but I tend to have patients do an 8RM when trying to quantify their strength. I think with many injured patients, placing the increased load of a max contraction, or 1RM, puts the muscle under a lot of stress. Especially if I am dealing with something like a strain, I wouldn’t want to re-injure or flare up the patient. I also think that a 1RM is not as helpful, as it doesn’t capture any possible fatiguing issue in the muscle. Does anyone else have any thoughts on this?
Casey – That seems pretty crazy. Especially since he has an extensive surgical history, I would definitely err on the side of caution.
As I have never treated an athlete with AP, this article gives me a good framework for DD and intervention when I eventually come across this diagnosis. I think the red flag pathologies is an important reminder of what to keep in the back of my mind, and gives me a better idea of what questions to ask about in my subjective exam, that I never really ask patients (burning with urination, any pain in testes area, etc). The “typical” subjective findings are helpful as well, and it was a good reminder that this does not only affect men.
One question I had was why the authors emphasized doing a neuro screen for these patients (dermatomes, myotomes, reflexes, UMN testing – table 2). Does anyone have a good explanation for this? Is this part of the author’s lower quarter exam for every patient they see?
I like the advice to rule out red-flags, then the the LS region and the hip, before continuing with the exam. As AP is a diagnosis of exclusion, it makes sense to ensure these are all negative before assigning them a diagnosis of AP. I also like that instead of suggesting to treat all patients with AP similarly, it is most helpful to categorize them and treat their primary impairments first. Especially since most of these patients are highly competitive athletes, it is imperative to treat the local impairment, and then treat regionally/globally, so that the athletes can move properly and dynamically for their sport, without adding unnecessary loads/stress.
My takeaway from the second article is how small changes in exercises greatly affects the GMax and GMed activity. In general, I try to be particular about my patient’s form when prescribing exercises, but this article showed me the importance of really being a stickler, as small changes in trunk position and depth of squat can make big differences in strength gains.
I think this article will help increase my exercise bank for glute exercises, but also make my exercise prescription for specific to where my patient is in the rehab process. If a patient has never activated their GMed in her life (every older patient I see), I may want to start with exercises under that 40% MVIC mark, because I need to teach the muscles how to fire neuromuscularly, before they can tolerate exercises for muscle hypertrophy. In general, both GMax and GMed had higher activity in standing positions, so I may want to include these later on the rehab process when they are less irritable and demonstrate improved stabilization and strength. Similar to some of the above posts, if a patient still demonstrates weakness or irritability, having patients in WB positions may be too quick of a progression.
I really enjoyed this article, and am now kicking myself for discharging my patient with glut tendinopathy just last week (who only got mod pain relief from PT).
My biggest takeaway from this article is the importance of keeping the hips in neutral of a hip ABD position throughout their exercises. Simply adding a pillow inbtn knees for clamshells or sidelying hip ABD is very important yet simple change to be made to these basic exercises. Ensuring patients don’t go into hip ADD during lateral side-steps with TB is another good tip. I may start to give monster walks instead of side-steps for these patients, as I think this exercise promotes a more hip ABD posiiton throughout the movement.
The educational advice in this article is really key, and if patients are able to make modifications, I would imagine this would lead to much less compression of the glut tendons throughout their every day lives.
One last takeaway from this article is when prescribing exercises that are supposed to promote muscle hypertrophy, they should only be performed 3x/week to allow for increased soft tissue healing and adaptation. I have almost never advised someone to do exercises at this low of a frequency, however this makes perfect sense. When I go to the gym, I don’t do chest day every single day (although my PT school classmates may argue this), so why would I prescribe this to my patients? This is another example of how I believe our profession tends to treat patients very different from a healthy population, sometimes for the worse.
Jon,
In the past, I generally have people perform as strong of a contraction as they can without causing any pain (or increase in pain). I usually say 5 sec holds. However after reading this article, I think I am definitely going to start with much lighter contractions (25-50%) and longer holds. This was something I found very valuable from this article.
In regards to sleeping positions, I have been using this advice in clinic, with moderate success at best. Many of my patient say that either they can’t lay in supine, or that the pillows move when in sidelying with pillows inbtn knees and shins, or that they toss and turn too often. Some patients say that sleeping on the couch helps, because it forces them into a supine position. I never thought about sitting/standing position before – that will be another useful piece of advice I can offer my patients who tend to stay in hip ADD positions.