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Oksana – just for some more concrete evidence on what Eric was saying: see the attached article, read the conclusion and check the charts at the bottom. If nothing else, read the conclusion.
I can show you the reverse McMurray technique this weekend.
Oksana – thanks so much for the response!
Love the movement correction in single leg stance – would try and progressively load it over time as appropriate further with dynamic movement with similar cues for the proper movement pattern
Any manual work on him? I have tried lots of tibifemoral distraction techniques with patients with meniscal pathology in the past and feel I have had some success
His lack of full knee extension is also certainly something to look at – Eric and I saw a patient together at the beginning of the residency who had combined ACL + meniscus tear who lacked a good 10 degrees of extension. We played with his tibiofemoral IR/ER ROM and coaxed it down into full extension within a minute or two. It was really amazing and a learning experience I will never forget. I would try the same and see if you can get his extension to full. I have been assuming (as I often but should never do) that his opposite LE has full extension if not a normal amount of hyper?
Oksana – thanks so much for posting the case and the article!
I was curious as to what you thought the primary tissue at fault was in the case – it looked to me like there was potential meniscal pathology, however I was curious as to what your differential list included and what you think is most likely.
What has your treatment consisted of thus far?
I love the article – it is always helpful to know that the clinical measures we use (i.e., landing sound) correlate with variables we are attempting to correct but are harder to measure (i.e., vertical ground reaction force). The breakdown of the joint excursion was also helpful and provides another way of cuing – this is one answer to your second question.
One thing I found particularly interesting was the change in hip excursions. I would have expected a much more direct and linear change in vGRF with hip excursion – that is, I would have expected quiet landing to have shown much greater hip excursion, loud landing much less hip excursion. However, after reflecting on this, it seems that the drop height (30 cm = 12 inches = 1 foot) was probably not enough to elicit this. I bet that a double leg drop from 4 feet would have shown reduced sound and decreased vGRF with increased hip excursion.
With regards to your first question – I think this study itself (including the literature review they perform) points us in the direction that increased joint excursion has the potential for decreasing, not increasing joint injury. However, we must of course ensure that patients are moving through joint excursions in the proper plane and with proper motor patterns, or else the risk of injury may indeed increase. For example, I bet I could decrease my vGRF upon landing with increased hip adduction/ankle pronation excursion and knee valgus, however that is certainly not reducing my risk for injury.
I heartily agree with the above, especially point four. I would not doubt that you can alleviate a substantial portion of this patients suffering just by positive feedback, healthy prognosis, long term goal setting where she can see how she can gradually return to activity even post labor. I really think that will help.
Halley,
Thanks so much for posting. I certainly appreciate the difficulty with regards to the differentials for this patient. Just a few thoughts:
– When you palpated her superior-medial patella (the area that was tender), did she identify this as HER pain, or distinct from her usual pain? Any sense of a taught band (e.g., thickened synovium)?
– Did you/could you perform the medio-patellar plica test? Certainly not one I am very familiar with, believe it only has limited research, however if positive would certainly point you in a certain direction.
– Hard to say if the fat pad itself is a pain generator for her (thanks for the updated article from McConnel also), however I certainly think that her landing/standing in full knee extension/hyperextension is not helping the cause. Eric has helped me to appreciate excessive knee hyperextension on a number of patients and the deleterious effects this has on the fat pad/other structures. I am sure that education and slight gait alteration will be nothing but helpful there.
– Pregnant patients have been difficult for me to manage at times; definitely not sure I have the answer, however (as in all patients really), I think that education and an encouraging outlook/positive prognosis is always helpful. “Pregnancy certainly has its challenges and there are real changes occurring in your body right now, however there is absolutely no reason to fear that this will be a linger condition. You certainly should be able to get back to your pre-activity levels.” Something like that perhaps.
Laura – thanks for taking the time to pull and post that clinical guideline. I read the section you mentioned and thought it was very beneficial and continues to highlight several of the issues at hand. I highly recommend even just that section to the rest.
Sean – I think educating the public is certainly a good option and one that we should be aiming at, however I am uncertain that it alone will be enough to make the appropriate changes. The patient-held belief that imaging is necessary to truly determine the source of pathology in their back is a deeply rooted, strongly held faith, and I am not sure that we as PT’s alone have the kind of public respect and authoritative voice, as of yet, to change that. This is especially difficult if what we are saying goes AGAINST the grain of what the patients MD is telling them.
I think this a ridiculous issue that is causing a lot of people harm and a lot of health care dollars lost, but I don’t think the solution is necessarily an easy one.
Although it should be completely unnecessary for the physician, I am not sure why an epidemiologic statement would not be placed on every single MRI report for routine LBP.
The most immediate thing that comes to mind in light of this study is: do is it really require a printed epidemiologic statement on the MRI report to help the MD understand the findings in their proper context? I mean, does anyone else think that the mere idea of having to perform this study draws attention to the apparently large deficit in primary care’s understanding of common, non-concerning findings on MRI reports? And the fact that there was a change in narcotic prescription based on the printed statement further confirms that they were impacted by the statement, further giving evidence of their prior ignorance.
This is such a basic, well known, easy to understand issue, that the necessity of a printed statement on the MRI report seems utterly absurd. The burden of persistent LBP is so large and expansive, that to be unaware of the basic issues surrounding it, proper education and management, seems inexcusable.
I certainly had more of an emotional response to this article than to most. Anyone else feel the same? Different?
Sean,
Glad your computer finally decided to let you post.
I resonate with you in regards to the difficulty of managing patients who you think truly have a an active, nociceptive injury, and yet whose pain is also driven by all kinds of maladaptive behaviors and beliefs, central sensitization.
The more I consider the situation and what I might say, the more aware I become of my uncertainty. I still think it would be very smart to help him understand the true biology behind pain and the truth of central sensitization; I would want him to understand that at the end of the day pain is the response of the BRAIN to several factors, and that tissue damage does not correlate 1:1 pain. “Explain pain” has some great examples to illustrate this that you could review or have him read. I would not flat out deny to him the possibility of structural damage, however I would educate him on the natural strength and resiliency of the spine, his negative findings, and the high likelihood of central changes that have occurred.
In summary, I don’t think you can or should try to convince him that there is no structural damage/nociception, however I would educate him on the multifaceted nature of pain and likely central maladaptations, as well as his own maladaptive beliefs and behaviors.
Sean,
Thanks for the thorough and detailed post.
I definitely think that the combination of the patients comments, surgical history, and profession give you substantial amounts of information that alter your treatment of him. In my experience, physicians, and especially surgeons (as in this case), can sometimes (though not always) be difficult to treat as they view their bodies through a more exclusive pathoanatomical model, a model they are very familiar and versed with, and with which pathoanatomical correction (i.e., surgery) is the answer.
I would definitely be educated this patient regarding the NEGATIVE findings (negative slump, SLR, myotomes, dermatomes, reflexes) that point away from a serious neurological injury that would require surgery. I am not 100% sure how I would classify this patient; certainly flexion movements are painful, however at his age I think it is less likely that it is a true disc injury; my suspicion is that it is myofascially related, driven and support by unhealthy beliefs and maladaptive central changes.
Although aspects of his profession may indeed make aspects of treatment more difficult, there are certainly advantages to treating a patient with the knowledge and intellect that he has. I would leverage his background understanding in going deep with him regarding pain mechanisms and the disconnect between MRI findings and pain/functional loss.
To me, it just doesn’t seem to have as many features that fit with MP vs. lumbar pathology. No sensation loss, I think, would weigh heavily against MP. However, if you wanted to test further the article we posted earlier this year mentioned 3 tests – pelvic compression, a sidelying neural tension test, and tinels.
If you go back and look at the referral patterns for L spine, it sure looks to me that in patients with symptomatic LBP, facet stimulation caused lateral thigh symptoms. Does the patient use the word numbness to describe actual loss of sensation/tactile touch, or just a form of peristhesia?
Several features may fit with L spine instability. Did you do a prone instability test? What was her SLR ROM? Also, the hip flexion ROM you gave was extremely limited – was this due to pain or what was your end feel/take on that?
Thanks for the help on point #1 Alex – I missed over that on your first post
With regards to those other studies that examined AHD at larger angles, did they utilize US or MRI?
Halley – I completely agree with the notion of affecting multiple structures, not just the structure at fault. There could be one or multiple subacromial structures serving as the pain generating, and yet in my PT intervention I am focusing on a whole host of factors and tissues to improve mechanics and function.
I would want to add that, although at one level identifying and treating a highly specific tissue (supraspinatus tendonitis vs. subacromial bursitis) may not make our treatments different in LARGE proportion, it may make a small difference, and those small differences may in some ways be significant. That is, although our accuracy may not be all too good, I don’t think we should completely abandon the attempt itself to try and be as specific as possible, recognizing full well our limitations. My guess is that expert clinicians have learned to better (though not perfectly) detect subtle differences in pattern recognition and because of this they are slightly more pointed and focused in their treatment.
Sean – I completely resonate with your example. I simply think we need to be so confident and convincing in our explanation of the impairments we find, how such impairments are contributing to the patients pain and specific functional limitations, and how we can adequately address them that the patient has trust and confidence in us even if we haven’t given them a specific pathology. Easier said than done for me.
Thanks for posting Alex! I enjoyed the article the AHD measurement was one I had not yet encountered.
1. “Subgroups were divided according to initial AHD at 45 degrees, since a previous study showed that the most important narrowing is observed at this position (Desmeueles et al, 2004).” At the least, that is the reason why they observed at 45 degrees. I have certainly seen people who have onset of arc type symptoms this low, though it is certainly more common in my experience (and in my reading of the literature) for this to occur higher than 60. In Eric’s shoulder presentation, 70-110 is the range given for the painful arc sign. I have not read the study they reference, however I too am a little puzzled that they did not at least comment further on why they only measured at what seem to be relatively lower elevation angles. 45 and 90 or 60 and 105 would have seemed more appropriate to me.
2. For me, the painful arc itself is a great objective asterisk sign that can be immediately re-assessed following any number of interventions. With the large emphasis on movement training in this study, I sure would expect this outcome measure to be markedly improved. Cuff irritability and strength (resisted ER, scaption) is also a measure that can be quickly re-assessed and compared contralaterally.
3.I hope the answer to the third question is “growing,” although I still am nowhere near where I want to be with regards to at least a more concentrated effort at being specific with my diagnosis, though of course the recent Cook article suggests that we are not all too good at achieving a tissue specific diagnosis in shoulder pain. I need to continue to review the Ann Cools algorithm presented at the 2nd course series weekend. Although I wish that more objective exam info was reported on/reexamined at DC, I think that for a study like this the inclusion criteria is appropriate. This is the same cluster presented at the course series for impingement and is reported to have a (+) LR of 10.56 and (-) of 0.17, which is pretty good.
4. Not too many secrets here beyond what is commonly employed, however here is one recent variation of a typical serratus wall slide that I came across recently. It is shown by Eric Cressey (who has some good material) with good coaching of the movement. Certainly improving serratus activation/upward rotation is a goal in a number (though not all) of patients with SPS.
http://www.ericcressey.com/serratus-anterior-activation-reach-round-and-rotate