[Jon Lester]

Here’s how I would attempt to differentiate from those possible differentials.

TFCC:
– isolated tenderness to TFCC
– joint assessment of the DRUJ could be painful/lax/restricted because of stabilization relationship
– compression in UD will be painful
– press up from chair likely painful but might be for other injuries also
– supination lift test

Fracture:
– isolated tenderness to a specific carpal bone or ulna
– maybe tuning fork
– guarded movements disproportionate to other structures

Ligamentous Injury:
– differentiating between laxity vs pain with ROM
– resisted testing might not be painful if it’s an isolated ligament injury (non-contractile)
– isolated tenderness to a specific ligament
– excessive motion?
– end feel

ECU Involvement:
– TTP to mm belly or tendon
– Possible subluxation could be palpable or reproducible with AROM
– strength testing and testing in lengthened position
– atrophy might be noted

[Jon Lester]

Subjective Questions:
– MOI or insidious?
– Swing right or left handed?
– numbness/tingling/weakness
– any other location of pain/symptoms?
– symptom trend? Worsening, improving, stable
– eases?
– clicking/popping?
– Isolated TTP?

Objective Tests: All would be based off of the subjective responses
– Observation
– neck/shoulder/elbow clearing if appropriate
– neuro screen and tinel’s if appropriate
– APRs w/ quadrants if appropriate (wrist and possibly fingers/elbow)
– Joint mobility testing if appropriate
– Distraction/compression
– Palpation of TFCC, carpal bones, distal ulna
– grip strength
– golf swing, picking up 5+ lb weight, and “WB through joint”

What are some key clinical examination tools that you would use or have used with similar patients?
– I have only worked with one patient with a wrist pathology, which was a diagnosed fracture, so I really don’t have many clinical pearls or habits with this pt population to be honest. However, I agree with your comment Matt regarding the wrist just being another joint. Evaluation of the wrist/hand is the same as the other joints that we deal with every day. APRs and subjectives will drive the rest of the objective exam and isolate areas to treat. Have any of the other residents seen wrist/hand pathologies more frequently?

[Jon Lester]

1. Based on the subjective findings, what are your immediate differentials?
– Stenosis (L uni or central)
– facet referral on L
– lumbar myofascial referaal
– L inta/extra articular hip referral
– possibly disc/SIJ referral but less likely

2. Based on the objective findings, are there any other tests that you would have performed?
– SIJ cluster to rule out differential
– paraspinal palpation
– dermatomes
– FABQ?
– varying heights willing to pick up object (if she’s willing to do lumbar flexion during APR)
– any improvement in pain with intra-abdominal contraction?
– hip strength?

3. What is your primary hypothesis?
– facet referral of L lumbar spine without radiculopathy

4. What interventions would you have performed on the first day?
– education regarding fear avoidance, continued movement, length of time to expect “tissue damage” if MOI was so long ago, analogies if appropriate (i.e. car alarm leaf vs burglar)
– possible gapping mobilization based on response – general L lumbar if she seems comfortable with this
– Exercises to work on gapping the L side, possibly some light activation drills based on strength levels found

5. Would this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which technique would you choose?
– I would consider doing a gapping mobilization if I felt it was appropriate based on how our conversation was going. If she’s bought in, the info in the sheet indicates that it could give her relief. If she appears too fear avoidant/cautious/anxious, then it would not be appropriate and you could give her variations of exercises to work on gapping on her own.

I think the majority of my eval day would be education although. Exercise and manual would come second to this on the first day because likely this person has not been moving due to fear for several years. Some education/pain neuroscience would be most beneficial for her most likely, especially if we only had 15-30 mins after the eval with her. I’ll be interested to see where you took this and if we all would have treated her similarly/differently.

[Jon Lester]

Jeff – I like your points about the ACJ and looking into this closer. I agree that with heavy benching the ACJ needs to be able to move and avoid excessive stress at the bottom of the bench specifically. This would be a good place to look at moving forward. To answer your question, I did the Tsp extension because of his postural faults and hypomobile Tspine. I was running out of time, but a quick manip would have been appropriate here for pt buy-in and to tell me that working on Tsp extension would have actually done some good. In future sessions, I did this and I’ll talk more on this tomorrow during journal club. Tsp manips and mobs ended up improving this guys function quite a bit.

[Jon Lester]

Matt – I like doing my manual in a similar manner during IE. Find an impairment and treat it. For this guy, I didn’t do this because I knew I needed some time to really bring on his symptoms (benching), then try manual and re-test. I like your idea of checking the bench form. I’ll talk on it a little in the journal club but he definitely lost thoracic extension in the bottom of the bench –> anterior tipping of the scap –> elongation of the moment arm of the shoulder flexors –> impingement…at leas that was my thought process.

Erik – Good thoughts on finding out more about his exercise routine. He was a upper body dominant lifter..really likes “push days and arm days”. He wasn’t training the posterior chain or back muscles appropriately and was suffering from it. As a result, his scapular mechanics were wonky and his lack of motor control of the middle/lower trap showed. I like your idea of adding KT tape to aid in correcting his postural faults. Especially for someone like this who is going to continue to be active and lift daily. This might be enough in terms of NMR to get his scap/shoulder/Tsp in a better position for long term success.

[Jon Lester]

Cam – I’m glad you said that last part about adding in some Tsp manips. That’s what the article discussion is about this week so this ties in well. I agree that I probably could have done a Tsp manip day 1 and gotten some good buy-in. I’ll give away a little of my talks for the journal club and say that I manipulated this guy quite a bit in future sessions.

Also, I agree with your additional questioning/objective stuff. His biggest goal was to get back to benching. He had just started a new training program that had more of a strength phase than he was used to, so we decided this was the likely cause because of his lack of ability to control his shoulder positioning north of 3 plates.

I probably should have looked into my radic DD closer, in addition to the AC joint. I guess once I cleared the C-spine and from his subjective I saw red and went for the GHJ pretty hard. In hindsight, I could have been more thorough for sure.

[Jon Lester]

1. Cervical radic (lower cerv levels), Cervical facet/multifidus referral, R SAI/RTC irritation
2. Radiculopathy cluster, ULTTs, dermatomes, myotomes, DTRs
3. C5 radiculopathy with associated myotomal weakness
– myotomes, RUPA for distal symptoms, pain with closing down on nerve root or lengthening nervous system structures
4. Age, more specifics on quality/frequency of each symptom, Tsp mobility, grip strength, DTR
5. C5 myotome, DTR, symptoms with L SB/R rot, CPA/RUPA C4-6
6. Self Tsp mobs if appropriate, SNAG to L or supine L rot over towel, rows or similar to work on positioning of Csp/Tsp

[Jon Lester]

Casey – I’m actually working with a gentleman with a B rectus femoris, B adductor, B pectineus release, pelvic floor repair, and R THR (all performed on the same day). He was also seen at Vincera in Phili…makes me wonder if that’s a common sx that they perform there. He had a different protocol than the one you described. He is not cleared to return to sport-like activity (running, agility drills, advanced plyometrics, etc) until 14 weeks post-op. He’s a recreational weight lifter and works as an X-ray tech so has to push patients on stretchers up to 400# on his own. It’s interesting how different the post-op protocol was despite similar sx. Of course, the additions of the pelvic floor repair and R THR likely play a factor, but running at 8 days post op is drastically different than 14 weeks. I’m curious how their presentations would differ at IE and d/c.

[Jon Lester]

I like the second article quite a bit. It was one that I read in school after we discussed it during class. I think it puts a lot of the “strengthening” exercises that we prescribe into perspective. The side plank has the highest activation, but this is not necessarily appropriate for someone with irritable glute med tendonopathy. Similar to what Cam was saying, single leg activities have a lot of activation (via EMG), but this might not be where to start for those with higher levels of pain/irritability. I like how the article goes into some detail regarding the lowest EMG level that has been shown to “strengthen” muscles (40%). Knowing this and what we took from the 1st article, we could start somebody with isometrics for pain relief, then progress them to an exercise within the 41-60% MVIC category to begin tendon loading. Of course, each pt would be more appropriate for different exercises (e.g. lateral step up vs pelvic drop), but this is how I would interpret the findings of this study. Additionally, certain patient’s would not be appropriate to jump right into “high-level activation” exercises after isometrics, but this would be up to clinical judgement of course. My goal would be to progressively load their glute med tendon, similar to what Eric was saying, by moving them into either higher volume or greater activation levels. I think I’ll try to take this approach more directly for the next patient I have with glute tendonopathy.

[Jon Lester]

This was a great review article for all things gluteal tendinopathy. I appreciate that they included the stats (sens/spec) on the diagnostic tests for confirmation of pathology. I’ve been thinking more about streamlining my clinical exam after our discussions about exam efficiency last weekend. While I still want to be thorough in my exam, it seems that the subjective and objective findings consistent with this condition would allow us to rule in/out fairly easily (knowing it’s the most common condition associated with lateral hip pain).

The discussion on isometrics for their analgesic effect is interesting. I’ve utilized isometrics for patella tendon, RTC tendons, and achilles tendon pain fairly regularly. I haven’t thought of using it for gluteal tendon pain, but it makes complete sense. For someone that is very painful and cannot tolerate isotonic exercise, this is a great option that I’m definitely going to start trying. I’m curious if anyone has tried this before and what volume/intensity they choose? AKA 25% vs 70% contraction // 30 vs 45 vs 60 second holds. I would assume start light and assess response but if someone has some clinical in regards to this that would be great!

Also, I like the suggestions for sleeping positions to avoid irritation during the evening. I’m going to start suggesting the supine position with pillows under knees for those who have a lot of night pain. Again, this is intuitive, but I haven’t consistently made this suggestion to all of my patient’s in the past.

[Jon Lester]

1. What are your top three diagnoses based on the subjective information? (ranking order)
– discogenic referral
– extensor muscle strain/pain referral
– facet referral (gapping)
2. What is your top clinical diagnosis based on the objective information and why? (asterisk signs/symptoms)
– possible disk referral, neurodynamic limitations (dural resictions), and associated ES muscular guarding
3. What subjective and objective information do you feel is missing and would have been helpful to assess with this
patient?
– quadrants for cervical spine
– quadrants and H&I testing lumbar if applicable
– prone lumbar rotation to identify level
– DTRs for UE for comparison
– deep breath for Tsp
– upper cervical ligamentous testing
– I would probably take myotomes/dermatomes because of pain extending throughout entire spine even though it does not extend past AC joint or gluteal fold.
– maybe repeated motions based on pt age and presentation
4. How would you have explained your findings and PT diagnosis to this patient? Do you have any concerns with this patient regarding prognosis?
– Indicate positive findings to support hypothesis and ensure that pt understands that you were able to reproduce her symptoms with clinical tests. Also ensure that she understands that this follows a clinical pattern and is treatable. For further reassurance in regards to prognosis, I would make her aware of any (-) signs that were found in the exam that would improve her prognosis ((-) myotomes/dermatomes, (-) ligamentous testing, (-) crossed leg SLR sign, etc).
5. How do you expect to progress your treatment program over subsequent visits? Where would your focus lie regarding patient education, manual therapy techniques, therapeutic exercises, etc.
– Target Tsp hypomobility to work on neurodynamic limitations – manual techniques and HEP to match if possible. Repeated motions if applicable and helpful based on pt age and presentation. Could add in upper lumbar mobilization if tolerable early on. Attempt some form of mild nerve gliding with little volume early on and add to HEP based on response over a week or so. I would progress her into some form of encouragement of lumbar mobility as pain lessened to avoid fear avoidance and re-integration of full movements in all planes of motion to be able to play with daughter. That would be where I would start at least.

[Jon Lester]

Hey all,

This discussion resonates with right now in particular. I’ve been treating a guy with what appeared at first to be a partical RTC tear from a traumatic traction injury (caught himself from falling from a roof). At IE, he was actually the one advocating for conservative tx before I got the chance to bring up the conversation. He wanted to avoid further imaging, sx, and any other medical management, which I thought lined us up for a pretty successful bout of conservative care.

I’ve seen him 5 times up until yesterday and he was making decent progress at first. He was able to reach his forehead with his R hand after not being able to lift it beyond 60 deg elevation at IE. He was having a somewhat easier time doing ADLs – was able to eat with his R hand, get dressed slightly easier, and wash his left arm with his R hand. However, over the past three visits, he has developed significant mm guarding, N/T in his fingers, shooting pains throughout UE, and other signs of possible nerve originated symptoms. At this time, we had made no progress over the past 2 weeks and the pt appeared to be getting more painful as these shooting pains worsened. I suspected that he might have a brachial plexus traction injury or something similar at his IE, but it wasn’t until more recently that it became more apparent.

Because of the new onset of symptoms, he began to worsen within session too. Anything I tried made him more painful and he was noticing more difficulty with the ADLs described above. I had the discussion with the pt about how it did not appear that conservative management was appropriate for him at this time due to his onset of neurological symptoms and worsening of UE ROM/strength. We decided yesterday to refer him back to his referring physician for further consult. It was a joint decision and he was definitely on-board because he knew that his recent deterioration was a good reason for some form of continued medical management outside of PT (e.g. imaging, pharmacological intervention, etc). He is still on my schedule moving forward but we plan on changing his appts as appropriate based on his consult.

This was my first time having to refer someone who “failed” conservative management. I’m curious if anyone else would have kept treating him, referred him earlier, or done similar to what I did (ride it out for a few visits and then refer). Let me know your thoughts.

[Jon Lester]

I agree with Kurt – thestudentphysicaltherapist.com was a great resource early on for quick reference of spec/sens of various tests. They also have videos of tests and techniques that I find useful for reference.

I am a little biased, but I like to follow Eric Cressey’s content. He provides a considerable amount of references and recommendations for corrective exercises, movement eval techniques, and return to sport guidelines. He specializes in pitchers/shoulders mostly (works with a lot of MLB guys) but talks about other body regions in detail as well. He is not a PT, but graduated from my undergrad before going on to get his master’s with UCONN’s Kines program. Although he is not a PT, I can still take things from his blog/social media and apply it to my daily practice.

I also follow a bunch of instagram pages that provide interesting eval and exercise ideas. A lot of the content is more creative exercise ideas in general, but they will occasionally discuss the research and current evidence, which is nice to see on social media. Here’s a few off the top of my head.
– thestrengththerapist
– prehabguys
– barbellrehab
– physicaltherapyresearch
– VOMPTI (shameless plug)

[Jon Lester]

Jeff – In response to your post – I agree that education would be key to her understanding her symptoms and prognosis. I would educate her on the findings that I found that were reproductive of her symptoms (hypo/painful joint mobs, +distraction/compression, dec DCF activation, etc) and how they are all treatable from a rehab standpoint. I would educate her on the length of time I would expect her mobility to improve (gradual over several weeks of directed treatment) and with her motor control/endurance (can take 6-8 weeks to have true muscular changes). My hopes would be to both have her understand that her symptoms are reproducible and treatable, but also that she needs to be an active participant in her therapy. If she was still worried about something being “structurally wrong” with her neck because of the injury, I would educate her on the negative findings that I had that would implicate this to be true (i.e. sharp purser, alar lig test, (-) CN screen). I typically only do this if they press for the information because I feel that some might be concerned that we were concerned enough to look for those things. I’m curious on other’s thoughts on this?

[Jon Lester]

1) Based on the examination, is there any missing data or information that you feel is required to proceed with decision making/treatment?
a. Fosamax – dosage, how long, compliance, recent inc? – Common side effect is joint/muscular pain
b.I’d like to know more about previous PT. Why did she have to return 2x/year for 4 years? Did she have resolution of symptoms and then they came back? Or was it a financial/insurance reasons? Could give us an idea of expectations. Also what part of PT that she believed helped the most would be nice to know when planning POC.
c.How did they rule out fracture? MOI alone would warrant an x-ray at that time (Canadian C-spine rules) but doesn’t mean we can assume one was performed. Hx of osteoporosis is concerning as well. Also, does she notice any “clunking” with cervical movements, feeling of “lump in throat” or any other subjective c/o that might indicate ligamentous disruption? MRI might be better choice in this case.
d.Recent increase in symptoms – was there another mechanism that caused this? Or is this how her normal pain fluctuates (PT 2x/yr for 4 yrs)? Additional, seemingly minute, trauma to a previous injury could be more deleterious in someone with osteoporosis as compared to those with good bone density.
e.How often does she receive imaging for bone density (i.e. DEXA scans)? Any changes since the initial injury? How has it trended since starting vit D and Fosamax?

2)Would you consider this person to fit the Whiplash Associated Disorder diagnosis? If so, why? If not, what would be a better diagnosis classification?
a.Yes I would consider this a WAD presentation with associated mobility and motor control deficits. The underlying condition is likely WAD because of MOI with motor control impairments present (stretching of DCF causing inhibition with cervical movements), which is common with similar trauma. This improper motor control could possibly have led to compensation of the facet joint capsules to “tighten up” and limit motion via non-contractile contribution. This could possibly be why this case could fall into either the neck pain with mobility deficits or neck pain with movement coordination deficits based on how you interpret it. The objective findings show that both classifications are likely present to some degree (hypomobility + pain at Csp facets and inability to activate DCF). It’s a bit of a chicken-or-the-egg conversation and I could see both sides.

3) Do you see any red or yellow flags associated with this condition?
a.Fear avoidance with driving
b.Worsening of symptoms – especially without mechanism at point of worsening
c.MOI with hx of osteoporosis
d.LOC at initial injury
e.Cervical “manipulation” in previous PT
f.Somewhat failed PT because she was unable to maintain improvements on her own (PT 2x/yr for 4 years)

4)What concerns do you have about the patient’s current presentation and previous treatment?
a.Current Presentation
i.Worsening of symptoms – inc in fear avoidance
1. Also worsening without obvious MOI – possibly more sinister implications (e.g. tumor)
ii.Inability to activate DCF
iii.“Worst pain 8/10” and NDI 44%
iv. Hypomobility for B UPAs throughout all mid-cervical (not that concerning but more difficult than one sided or less levels)
b.Previous PT
i.Cervical manipulation in patient’s age group, with hx of osteoporosis, with fear avoidance, and MOI
ii.Dec duration of relief (had to keep coming back to PT) – doesn’t sound like she ever got back to her PLOF
iii.Hard to tell what helped give her some relief (heat vs TENS vs exercise etc) – also sounds like a lot of variations of passive therapy

5)What would you prioritize for the first treatment option? Second? How would you progress or regress the interventions?
a.Manual Therapy – manual distraction because it was (+) for pain relief, but I could also promote improved joint mobility bilaterally without aggravating either side
i.HEP – Pain-free AROM in all directions – start with NWB if WB is not tolerable
ii.Progression – begin to mobilize both B facet joints with distraction combined with opening joint mobilizations (SB/rot) → then opening without distraction → then eventual closing to improve tolerance to closing movements (as pain permits)
b.Exercise – tactile/verbal cueing to promote improved DCF activation via light chin tucks in supine
i.HEP – light chin tucks over towel for tactile cueing in supine
ii.Progression – chin tucks in upright position → upright position with arm movements → upright position with cervical movements (i.e. rotation to improve confidence/endurance with driving) → eventually add resistance that is pulling out of upper cervical flexion
c.Pt education on how movement won’t cause pain and how it’s important to reduce her symptoms. Also could include some pain neuroscience analogies if she presents in a way that I feel like this would be helpful on her first day.

6)Are there any interventions that you would consider to be inappropriate for this patient at this time? Why?
a.Cervical manipulation
b.Cervical mobilization to promote opening/closing on one side (will cause opposite effect on other side, might be painful)

Additional Discussion
1)Would anyone have tested deep cervical extension endurance? I feel like this would be nice to do in someone who has pain onset after sitting >30 mins (losing battle to gravity). Maybe scapular endurance also?
2)Who would do some form of trigger point release early on in rehab for this person? It looks like she might respond to other more mild forms of treatment but her active trigger points might respond to more aggressive forms of MT also (TDN, ischemic pressure, pinning down with active movement). Just curious to see how aggressive others are during early rehab in those with fear avoidance.
3)Would you implement the FABQ with this patient?

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