[Katie Long]

Hi Jen,

Thanks for the reply and the article! I appreciate it. Yes, I forgot to include that he does have more lumbar flexion ROM with his L LE in knee and hip flexion. I have had him working on some declined plinth flexion with his LLE slacked and he reports no provocation of his posterior thigh sx, only mild “pulling” in his low back.

After reading yours and Kyle’s posts, I definitely think I am going to try some lumbar traction with him. See if I cant get some decreased stress to the disc and maybe even some synovial fluid movement to aid in any lingering inflammatory process still occurring. Pending success with that, I will try to teach him some self-distraction for his long work shifts where he is on his feet for prolonged periods of time.

Ill keep you posted on how it goes!

[Katie Long]

Hi Casey,

I have looked into his hip a decent amount. He denies sx with palpation of his gluteals. He has limited hip extension ROM and hip PA is limited (symptom-free). His hip flexion is WNL** with reports of thigh tightness (not his pain, unless his sx are overall increased/irritated). **As long as his knee is bent, when his knee is straight, it is symptomatic, i.e. SLR testing. Hip ER/IR is limited bilaterally (symptom-free).

Functionally, he has decreased pain during SL squat with manual cueing for increased hip ABD activation. I think the antalgic gait is directly correlated to his disliking of a terminal knee extension position during IC of gait, therefore he is decreasing his stride length.

Does this help?

Thanks so much for your reply!!

[Katie Long]

Hey Kyle,

Thanks for the reply. He stopped seeing the chiro several months ago. The chiro only ever helped him with his severe, constant back pain. He continues to report minimal to no back pain, his complaints now are all posterior thigh pain, which he did not have with the chiro.

He is currently taking anti-inflammatories when his sx are very bad, which help when his sx are at their worst, which could speak to the potential inflammatory process. I wonder about getting him back to his doc for a potential dose pack to address this?

Thats a good point about his loading pattern in standing. If anything, I would say that he sits in more anterior pelvic tilt than posterior. We have worked on some supine PPT activities such as bridging, squatting with PPT supine PPT. But I could definitely work on more of that, specifically in standing since that is much more functional for him and relates to his sx.

I honestly have not done any basketball specifics because I have been trying to calm things down before we build into functional (work) activities or recreational (basketball) activities. He likely would still be unable to do layups even without jumping because of the extensive stride length it requires, which is significantly symptomatic for him.

Thanks again for your input! It has given me some new things to look at when I see him next week!

[Katie Long]

Hey AJ,

It sounds like this is the patient that you and I had discussed a while ago when I was still in Woodstock? Sounds like she is seeing improvements! Great!

This actually reminds me a lot of a patient of yours that I was treating at WRF a while back. He came in for low back pain and while I was seeing objective improvements throughout his POC, he kept reporting to me subjectively that he did not feel like he was making improvements. He kept telling me about how you had “cured” him and how amazing his PT was with you. I remember how frustrated I was because you and I had spoken about his case and I knew I was on the right track with his treatment. However, I decided to put him on mentorship with you just so he could see you and get the “placebo” of seeing you. Sure enough, I only saw him 3 visits after that because he made “leaps and bounds” of improvements according to his subjective reports. We really did nothing different, but because he had the placebo of seeing you and getting your confidence, he did so much better with therapy.

This was so incredibly frustrating for me, because I was trying to assert my competence as his treating therapist, but also be sensitive to what he believed would help, which was seeing you. So to answer your second question: no, I don’t think it is “wrong” perse to “allow” patients to dictate parts of their plan of care as long as it is used in attempts to continue their progress towards active, evidence based, meaningful treatment. I think we find it very frustrating because we are trying to help our patients in the best way we know how. But in the end, I think we must consider that this patient is taking time out of their day, paying a co-pay (or insurance, or out of pocket), taking time off work, etc. to come to us in attempts to help them feel better. So to bring up a point in your question: “…if we believe the requested passive treatment will not be valuable?” valuable to whom? Them or us? in the end, it is their [shoulder, knee, ankle, etc.], not ours. There are three tiers of evidence-based practice: current literature, clinician experience and patient values/expectations. And I think that I need to remind myself of the third component in these situations. It is just as important and should be considered just as critically and with as much merit.

Thanks for the post, it is always a good reminder to reflect on these types of scenarios.

[Katie Long]

Jen, I agree on differentiating between hypo- and hyper-active. It is essential to determine the difference because exercises for hypoactivity (kegels/TA activation) are going to make hyperactivity worse. Good exercises for hyperactivity are diaphragmatic breathing and correcting any regional myofascial tightness. The article I attached does a good job of laying out the patient demographics for men with hypo vs hyperactivity. Other special questions with b/b sx are differentiating between leaking urine vs straining to urinate and if there is sx with referral during straining/bearing down.

[Katie Long]

Heres that article Tyler.

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[Katie Long]

Yeah that’s understandable. Let me know if the article is helpful or if you have any other questions. I wrote up my guy with pelvic floor pain for an abstract submission for CSM, so I have a few other resources available if you need them.

[Katie Long]

Hey Tyler,

I’m going to post the article I used in my case discussion again, because I found it very helpful for male pelvic floor special questions and differential diagnosis. Some questions I would ask: Any bowel issues? Specifically in the AM? Pain with ejaculation or after? Any NT? (thinking about the article Eric posted on peripheral nerve entrapment at the hip and keeping that on your differential list). Also, any testicular referral? (thinking about myofascial imbalances and their pull on the pubic symphysis and the inguinal ligament).

Keep us posted!!

EDIT: I’ll post the article when I get home because Valley Health’s system wont let me upload the attachment. But its the first article I posted on my OMPTS case discussion for Weekend 5.

[Katie Long]

Hey Justin,
It sounds like you have a ton of things to work on with this guy! I think a lateral wedge, yes, is a “low-hanging fruit”, but I wonder about the utility in such a significantly cushioned shoe such as a Hoka? I just remember from the running med course about how Jay was talking about “accommodating” a foot type rather than “correcting” a foot type. He is likely going to blow through that wedge in the cushion of those Hokas. But, like you said, its a low-hanging fruit and easy to implement, so its worth a shot! In thinking about the running med course, I think that Jay’s presentation on foot strengthening is going to be great for this guy. A lot of people already touched on 1st ray stability, and I think that is definitely a place to hit hard so that he is better able to stabilize during his running mechanics.
Interesting case, keep us updated!!

[Katie Long]

Thanks for this Eric, I’m always looking for good podcasts!

[Katie Long]

Hey Justin, I took home a couple of key points that I have already started to incorporate. I have a younger athlete with ACLR who I utilized a few things with last night. I really liked Mike’s emphasis on “active rest” periods. This athlete plays rugby and he rarely ever stops moving during a match, let alone sit all the way down. So I began to incorporate active rest periods with him. I also made sure to monitor RPE with him. One of the exercises I thought was the hardest for him, he only reported a 4/10 with, so I felt confident in progressing some increasingly difficult quad strengthening exercises. At the end of the session, he reported an overall workout of 8/10. I think this goes back to Mike’s point that we are chronically under-loading these patients. I never would have known this if I hadn’t have asked him about RPE! Im definitely going to try to incorporate this more.

Another point I thought was interesting was the amortization phase concept. I have a volleyball athlete who plays on the back row and she needs to be able to explode from a prolonged loaded “ready” position. We started her working on some explosive movements laterally from a loaded position to make sure she is preparing for her sport-specific needs.

[Katie Long]

Thanks for this Aaron. I don’t know how I feel about this article. They bring up a lot of good points in this article, and it makes sense, but I feel like I have spent so much time learning red flags and screening and feel conflicted. The article that comes to mind is one published in 2007, which Chad Cook was also on (attached). This most recent article has definitely given me a lot to think about but I did like that they proposed recommendations along with their points regarding issues with utility of red flags. I liked the quote of “Watchful waiting may also improve patient–provider relationship, improve clinician clinical reasoning/decision-making, improve patient satisfaction and anxiety” and addressing the potential benefit to excessive healthcare costs. After all, these are many of our goals as therapists.

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[Katie Long]

ahh, thanks for the clarification, its hard to visualize without the patient in front of you. I also evaluated a lady with PHT today, so this was super relevant! excited for tomorrow!

[Katie Long]

Tyler,

As mentioned above, I would likely still work on isometrics to start. Especially if they are pain relieving like Sarah said. You could even use them as a “substitute” for the stretching. Maybe presenting it like “I recognize that you are stretching to look for relief from your symptoms, but lets give this alternative a try for a little bit and see if it makes any more of a difference in your symptoms”.
I agree with your rationale of utilizing concepts from achilles tendinopathy literature to aid in your treatment selection and interventions for this patient. I would (and do) the same thing, specifically for tendinopathies. I agree with Jen in that I have gotten a lot out of residency in regards to tendinopathy and feel that I am improving in my ability to treat tendinopathies in a variety of locations by utilizing concepts gained from literature such as achilles research, since it is so much more prominent.

I had a question or two about your case as well. I am wondering what lead you to a proximal HS tendinopathy more so than gluteal involvement? Hip extension seems to be a strong asterisk for her (OKC hip extension, limited/painful posterior hip glide, MMT hip extension, etc.) and I am just wondering what lead you to PHT>glute for my own future reference? Was it the TTP of HS attachments and the pain with sitting that swayed you?
Also, what is the Askling’s H test? I am unfamiliar…

Looking forward to Thursday!

[Katie Long]

I agree with Tyler, I think the information regarding neural ingrowth into injured tendons was very interesting and reinforces the concept of prescribing isometrics in painful tendinopathies. I often utilize isometrics with these patients, but it was nice to get a little more of the pathophys behind why this concept works. I also thought the mechanism for ligaments accepting load was interesting in regards to elongation prior to failure. This article is also a good reminder of a great educational tidbit for patients regarding tendon healing, that although the remodeling phase begins within 6-8 weeks, tendons can take 1-2 years to complete their remodeling.

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