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I agree with everyone’s comments to this point. Taking into account her emotional response to her sx is something that could prove to be both meaningful to her at this time and perhaps shape her perspective of pain in the future. This is something that other healthcare providers, her parents, her friends, and her teachers might or might not be taking into consideration.
It would be interesting to see if her fear of flexion and/or her antalgic gait is purely pain related or related to fear of re-injury. I had the opportunity to work with a 11 year old girl with a hx of lateral patellar dislocation x3 and she would not bend her knee past 20 deg when I first saw her. She truly had no reason of not bending her knee other than fear at the time of IE. She had the ability to reach 130 deg by the end of that session but it took 45 mins to get her there (only with verbal encouragement and various exercises that required knee flexion). Anytime I see a kid that will not move their knee or weight bear I think of this. However, without seeing this pt it is obviously impossible to know if this would be related to her case. The discussion to this point just made me think of this case.
I too believe that an XR is warranted in this case based on the above information (without seeing the pt in person). Getting a detailed subjective of training hx, competition level, skill level, hx of trauma/similar pain, mechanism during the backhand spring, swelling/pain trend, and other questions that were mentioned above would be crucial to determining need of XR and appropriateness of PT.
I think that’s a good point, Aaron. I definitely just assumed from AJ’s post that it was the NP that drove the bus, but I agree that this is not necessarily the case for all people that would be meeting with a health care provider. I guess that would be the first area to pursue if the patient was in front of you, by asking their opinion on the matter before shoving a bunch of education her way. I would have a hard time tying the religion/spirituality into the conversation, so it would be interesting to see how their perception of the situation appears from our perspective and allowing the amount and/or way of educating the patient to be dictated in part by that.
I agree completely with you Cam. I think education is the most important aspect of care for this patient at their next PT session. Educating them on the rationale for MRI and making sure they are aware of them would be appropriate. Letting them know of the costs and that their presentation does not warrant the MRI is important for their ability of making an informed decision. The fear would be “finding something” on the MRI that is not related to their symptoms and having them “label themselves” as whatever the MRI says (e.g. “I have a disc bulge. That’s why my neck hurts”). The irrelevant information, as Cam suggested, could potentially lead to worsening of symptoms/presentation due to catastrophizing of pain due to something potentially unrelated and asymptomatic found on the MRI. Ultimately, it is the patient’s decision to make, but making them as informed as possible is the minimum of what should be done by us as one of their healthcare providers. Informing them of the objective improvement, subjectively improved tolerance to work, and the rationale for getting an MRI might sway their decision appropriately.
Due to the history provided above, I would suspect possibility of a stress fracture of (likely) the tibia due to the probable increase in training volume and locality of pain in this younger athlete. The worsening nature and pain onset with running/prolonged WB is concerning, especially knowing that he is DA (yay DA!). With a thorough objective exam, we could rule out lumbar spine or other orthopedic cause (i.e. MTSS, hip/knee referral) of his anterior shank symptoms. Likely he will have direct TTP over the tibia and the surrounding tissues if this region has a stress fracture. If so, or if the other objective findings warrant reasonable concern for a stress fracture, then my first thought would be to refer and treat this patient. Referral would be necessary immediately to confirm/rule out the fracture and determine the location (high or low vascularity) to decide on appropriate intervention. Radiography would likely be the first imaging of choice, however could lead to a false negative according to the research presented. If negative, a MRI would be the imaging of choice to rule in/out a stress fracture in this patient due to the high sensitivity and specificity of detection (94% and 97% respectively in a subject pool similar to current pt according to the study). If treatment is warranted, then addressing volume management would be high on my priority list. We could also address running mechanics, cadence, striking patterns, LQ strength/ROM, and other objective findings that could reduce the stress within the region of symptoms upon return to running. I have not seen any patients with this type of presentation, however this is how I would manage it based on the above description.
From the Subjective:
List your top 3 differential diagnosis after the subjective?
– hip OA
– glute med/min tendinopathy
– lumbar referral (lateral stenosis/facet arthropathy?)
How is would this information drive your objective exam?
– Need to screen both the hip and lumbar spine and determine relation of posterolateral hip pain, anterior thigh, and lateral shank pain
– Determine relation of intra vs extra articular hip contribution with clustering of findings
– Neuro screen needed and should be multileveled due to varied location of symptoms
Yellow or red flags?
– I don’t see any red flags, but fear of activity, stopping exercise routine, and no MOI are worthwhile to write down and revisit later in the session as yellow flags.From the Objective:
How does this information change your differential list? Any Concerns?
– The swelling is concerning and I would probe about this a little bit. History of this? TTP to the area and surrounding structures? How long has it been like this? History of trauma even prior to current onset of sx? History of cancer? This is just an odd place to have swelling that I haven’t seen before so maybe I’m overthinking.
– My DD list would be similar but I would add in dural tension. Hip OA might be a little bit less on my radar due to 130 deg of flexion prior to pain – still a possibility though with his limitations in other planes. Depending on the probing about the swelling I might add other DDs like fx, cancer, etc.
What would you have done differentially?
– Maybe try to influence the hip and lumbar spine positioning during lumbar screening (put foot on stool if he had pain with flexion and see if it changes symptoms for example)
– Neuro screen
– Lumbar spine joint mobility testing for hypomobility and referral down the leg/hip
– pubic percussion?? The swelling is concerning and I might be overthinking it just from reading the sheet but this might be beneficial in ruling out more sinister possibilities.
What would do day one?
– possibly mobilize hip (extension/IR) and/or lumbar spine (gapping) for pain relief due to his high irritability within session
– education regarding movement and relation of symptoms to dec in activity level
– exercises to improve lumbar mobility and tolerance to mobility based on response to MT (if gapping helped give gapping exercise, if hip extension mobilization helped give hip extension exercise, etc)
– all of these could change based on the other questions/answers I get and other objective findings that I listed as possibilities to look at (insert girl shrugging emoji)I like those suggestions. I think switching to Tylenol is warranted and appropriate for the patient’s presentation. The justification of getting a better view of progress is also a good point and I think most people would buy in to that. I think the tapering off of the dosage would resonate more so with someone who is fearful of cutting the dosage dramatically so I agree that this is also a good suggestion.
How do you guys go about the discussion with a patient that is very pressing about medication usage despite this education and recommendations? I work with a lot of people with chronic pain and reliance on pain medicine is incredibly common. This is a challenging talk with certain individuals who have such a high psychological attachment to their current pain management strategies and I’d be curious of other discussions that everyone might create to mediate.
As far as use and reliance on NSAIDs, I would address the length of time that he has had symptoms. If he’s been taking the NSAIDs for 6 months and only noticed a reduction in pain within the past week, then the likelihood that the NSAIDs are helping is small. You might have to encourage them to come to this realization although. We could educate on the relation of chronic symptoms (lack of inflammatory response) with the current NSAID use and likely lack of benefit. Also, we could educate on the relation of side-effects and potential risks of chronic usage of NSAIDs, like delayed healing, GI irritation, renal function, and hemorrhagic events to name a few. Additionally, we could drop in some analogies regarding acute and chronic pain with something the pt could relate to (i.e. sprained ankle). Hopeful the education on the risk/reward would be sufficient (in addition to his MD’s recommendation) to decrease his usage/reliance.
Based on the examination, we will likely find a couple movements, stretches, or exercises that reduce the patient’s symptoms to some degree. I like to encourage self-reliance for those who rely on pain medication by finding an activity that decreases their symptoms and utilizing it to replace pain medication or at least decrease the volume they’re taking. This could hopefully help this patient realize that his pain is multifactorial and not related to an inflammatory response specifically, harvesting self-efficacy and hopefully a realization that he can become the driver of his management (not the medications he takes).
I think those would be great questions to ask. Mainly because I don’t have much experience with TMJ specifically (only 2 this year) and this makes me not very confident with the various procedures that could be performed. I wouldn’t think that a dentist would refer to a PT expecting for us to “know what to do”, so I think it would be appropriate for us to ask clarifying questions to get a better idea of what to avoid/what to focus on based on what they saw during the procedure. Great list of questions Cam, especially the last one about a more specific reason for referral out of their office.
Jeff, I like your point of using isometrics to provide a window of opportunity to improve ROM and tolerance to more functional exercises/movements. I think this is where isometrics in even a chronic tendinopathic scenario can be useful. I don’t think this will help in the healing process necessarily (unless you’re trying to encourage activation like Cam said), but I believe that using the pain modulation qualities of isometrics can allow for more specific treatment in those with higher pain levels. Even chronic tendinopathies can have higher levels of pain and any method that can encourage pain reduction and increased tolerance to loading/movement can be beneficial for the right patient. I realize I’m playing a little bit of devil’s advocate with this viewpoint – I agree with everything that everyone has said.
Subjective Questions:
1. Pain intensity/location and comparison of symptoms to before exacerbation. Is anything new or just worsening of old symptoms? How have the clicking symptoms changed or have they? More irritabile also?
2. Relation of neck pain to her jaw symptoms? Can she correlate the pains?
3. How is her schooling affecting her symptoms? Reading, classwork, etc. Are there certain things on a day to day basis that can make her symptoms worse (either jaw or neck) other than chewing?In regards to questioning her psychosocial impacts on her symptoms, I would start by asking if she feels like her symptoms are interfering with her school life. Either from a productivity standpoint or a interpersonal standpoint due to high pain levels and difficulty eating (going out with friends). Based of this, we might get to interfering factors and better be able to understand her stress management strategies. As far as building a therapeutic alliance that encourages self-efficacy and self-management, I think it’s important to ask what she has tried other than pharmacological management. I think asking those questions and getting a sense of how active someone has been in management is a good way to get a sense of potential self-efficacy. Someone who has “tried everything under the sun” might not need as much encouragement for compliance to a home program or activity modification as someone who has been historically a passive participant in their symptom management. Obviously this isn’t the only important subjective piece, but I think asking this and then seeing how that conversation goes gives you and idea of how the PT prognosis will shape out to be.
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI
– anterolateral impingement
– peroneal tendon pain
– DJD of TCJ or distal tibfib
– isolated ATFL/CFL high grade sprain
– stress fx
– After the objective: I agree with your primary hypothesis. Would have ruled out stress fx, isolated high grade lig sprain, and peroneal tendon pain based on your findings.2. List any yellow or red flags you’d consider this case.
– yellow: history of sprains, fear avoidance with walking on uneven ground/recreational activities3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?
– description of antalgic gait
– SLS on stable and unstable surface
– description of the most recent sprain and comparison to hx of sprains
– what kind of MT did she get before? Was it appropriate?
– pop/bruising/swelling both from her perspective and yours
– CKC DF since this was the most limited ROM in OKC
– is she still doing any of her PT exercises from the other clinic?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– Manually, I would try a TCJ posterior glide graded to tolerance – possibly MWM in CKC based on your findings there. If successful, you could show her how to perform at home with band at talus off step. Could also give strengthening exercises for her DF/Evertors, but she is likely already doing some of these if she was just in PT. You could ask what she is still doing any of those exercises and base your decisions off of this. Based on this you could fill the hole that might have been there (i.e. add proprioception drills if she was just doing isolation stuff). Depending on her irritability at your IE, you might have to tailor this accordingly since she just recently had an exacerbation in sx. Could educate her with some hurt vs harm talk, how to manage her current inc in sx (RICE/NSAIDS if appropriate), and your anticipated POC.I find that quite a few people don’t take these “reasons” as to why a RCT is not gospel into consideration for their clinical decision making. Most readers will look into the conclusions of the study (maybe the methods if they feel ambitious) and extrapolate the findings to use on their next patient. Like the authors were stating, this is not always the best way of thinking and further investigation into the rationale behind said conclusions is needed. It’s challenging to look into new research this way because we all want the newest, most interesting way of treating our patients. However, I agree that not every RCT should be so heavily relied upon without delving deeper into the clinical reasoning side of our brain and questioning the results and their application to the patient in front of us.
Erik,
I think this is a great case. Can’t wait to hear more about how treatment went.
When you say you used no manual, do you mean joint mobs/STM/TPR/etc? Or do you mean no hands on whatsoever including manual cueing during activities/exercises? Just curious because I could see either side of hands on being either beneficial or not for someone who presents similarly. With certain patients, I avoid excessive hands on in any form to promote active participation in their rehab and hopefully teach them that they are 100% in control of their symptoms and management. I find this helpful in those with fear avoidance and similar perceptions as it appears your pt had. I’m curious of your perspective on that.
1. List your differential diagnosis after the subjective exam. How does this re-rank after the objective exam? Primary hypothesis to conclude?
I would agree with your general order and ranking due to the location, age, and subjective aggs/eases. It definitely appears to be lumbar in nature based on the subjective. The only things I might add are myofascial referral from the hip or possible SIJ referral based on the location, but I would rank these low prior to other subjective questioning.
Post-subjective
– lumbar clinical instability causing facet arthropathy
– extension sensitivity secondary to facet arthropathy
– Lumbar discogenic referral
– SIJ dysfunction
– lumbar paraspinal referral
– glute max referralPost-objective:
– lumbar clinical instability causing facet arthropathy
– Lumbar discogenic referral
– SIJ dysfunction
– lumbar paraspinal referralPrimary Hypothesis:
– 100% agree with you2. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?
– asking specific hip aggs/eases (e.g. cross legs, glute tenderness, etc)
– even though this episode is insidious, any previous pain? MVA? fall? etc
– relation of stress with her pain?
– relation of lack of exercise to her pain? Was she a frequent exerciser prior to? Yes that’s a word I looked it up.
– Beighton scale?Objective:
– H&I, quadrants
– does abdominal bracing reduce her pain with rotation/SB?
– I don’t often use the BP cuff for abdominal control (I think it’s a good idea I just don’t use it) – maybe her ability to maintain the flexion endurance position? That’s just what I use more often so curious if you do as well or if it wasn’t appropriate for her case.
– hip strength/extension ROM
– SIJ cluster if you deemed it appropriate giving her presentation
– Have her pick up a weight similar to her fat cat to see strategies3. List any Yellow or Red flags you’d consider for this case.
– Definitely yellow flags for her fear avoidance and the comments that you listed. She seems both aware of her pain and perhaps hypervigilant to it. With all we know on this topic, we can relate the chronicity of her symptoms with this mindset. I’ll be interested to hear of any PNE that was provided for her and if it was effective. She seems like the perfect candidate for it given her presentation in paper format. I think the fact that she is a caregiver is also a yellow flag due to her reports of stress and likely needing to do activities that she perceives as painful during that process.I agree with both of you guys. I think that treating this person as a “MSK specialist” only would not only be inappropriate, but could also make her symptoms worse. I’m picturing this person as not only having constant fear and pain, but perhaps hyper-analyzing everything in her life that could contribute to her symptoms. If we step in and tell her 10 objective findings that were “positive”, is that going to reassure her of possible ways to help (how we might think) or affirm to her that she is “broken” and structurally faulty (how she might interpret them).
She herself states that she is fearful of movement, activities, and other parts of her everyday life due to the thought of making the pain worse. If we don’t address this and educate her on the resiliency of the human body, we might be missing a huge aspect that could benefit her. Just because she is a physical therapist does not mean that she has delved deep into the non-mechanical contributions of her pain and this is a way that someone could help her.
This shows that anybody can experience chronic pain and be stuck in the vicious cycle that it causes. I’ve had people tell me that it feels like a vortex and every time they start to feel like they’re getting out of this vortex it feels like they immediately get sucked back in. This is definitely a challenging patient population to work with, but giving them 5 different pain medications and sending them on their way is missing a big piece of the puzzle.
I’m curious, how do you guys treat people with chronic pain? Especially those with a history/background in the medical field? I find this challenging and often more difficult due to their base knowledge of the possible mechanical/biochemical problems that might be present. Curious to hear everyone’s thoughts.