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Great idea on dynamic movements. I had him standing with a PNF D1 pattern while keeping his knee stable. I know rotation movements will aggravate his symptoms due to a potential meniscal pathology. Something that I don’t understand is no matter what we do a torn meniscus will still be a torn meniscus. I know we treatment impairments and function but the structural component throws me off? I wonder how the nociceptors are adapting to motions with the given pathology?

I’ve distracted his knee before and it helped. I thought it would help more. Something that I failed to mention was how much dorsiflexion he lacked on his left ankle. We need at least 10 deg for gait and he had maybe 5 degrees. In order to complete his gait cycle, he had to externally rotate his L foot more to clear swing phase. That motion I could only imagine how much more torque that places on his knees with every step.

I noted the lack of terminal knee extension and therefore gave him standing terminal knee extensions (I also forgot to type that earlier). That is amazing that your patient got better so quickly! I tend to assess his extension motion but I have yet to incorporate that into a treatment protocol. That is such a great idea! I’ll have to turn that into a treatment. His right LE is 0 deg and no pain to over pressure. Thanks for all your input!

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Thanks Nick!

Primary hypothesis: Medial meniscal tear
Differential list: ACL, PCL, LCL, MCL, pes Anerine/ Hamstring strain
Exercises: SLR in ABD, ext, ADD, flexion. Squats with a theraband. Gait: cue walking softly. Progressed to standing LE ABD with a theraband. SL balance VC on hip and knee alignment.

With increased height I would say that there would be more hip, knee and ankle excursion. I tried jumping off a surface higher than 1 foot and found that to be true for myself. I completely agree with form when it comes to landing. We move in multi planes, how we move through them is vital. Knowing proper cues and educating patients on why we are looking for a particular form is our profession. Something that helps me is showing patients how they look through a movement and why that might be harmful and then I try to show them what I’m looking for.

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During one of my rotations at a SNF, one of my patients re-dislocated her posterior approach hip. She was about 85 years old and osteoporotic. The patients that I have seen in the past most MDs prescribe precautions for the posterior and no precautions for anterior hip replacement. Both types of patients had difficulty moving and were cautious with gross movement. Patients are worried about their surgery in fear of dislocation, we need to instill motivation (within proper limits) not fear. Those who get hip replacements are motivated to walk, or else they wouldn’t have had the surgery. I’m thankful those surgeons changed their practice, I wonder what our surgeons will have to say about this?

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I’ve thought a lot about this article. Yes- we know that MRI findings do not correlate to symptoms. I educate patients about MRI correlations and symptoms, that barely gets through. Some patients come back with MRI’s and it’s as if they’re healed (several hundred dollars later). Has anyone had patients like that? It doesn’t always happen to me, but patients will want to do what they want to do.

I know reaching out to MDs can be difficult because most of them do not want to change their habitual practice. I do appreciate that this article was written by an MD and I think it’s great to share this with different medical practices. We did a spinal/posture educational class at a medical office and it was great. We also participated in an x-team fitness class and people asked us PT questions after. I’m learning that one of the best ways to promote change is to educate, finding the time is rough! As for social media, I have seen some PT commercials via youtube. I’ve used FB to educate on what’s out there for PT and I’ve had several people email me questions.

Sean- I agree with you we need a voice and so far we have social media. It’s a little intimidating teaching at a fitness facility when others have 10+ years of experience and I just graduated. Building confidence is one thing, the second thing is getting out there.

Laura- That’s a great article! People constantly want to know what’s going on. Diagnosis is important, but also impairments help guide our treatment. I try to connect some of the dots for my patients and show how that relates to their low back pain. IE: “when you walk your hip doesn’t extend well and therefore you can see how that increased stress on your low back when walking.” Having a skeletal model is helpful.

Thanks for all your thoughts, they’re very helpful!

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This is really funny, thank you for sharing! I read this case report earlier this week. I have a patient currently with morton’s neuroma and I found this article as well. I wonder how this article taught the self navicular glide? For my patient, something that I found helpful was reviewing his footwear. He said he felt better walking barefoot as compared to sneakers. Overall, walking was more difficult. I reviewed another article that mentioned “chronic trauma occurs to the forefoot and plantar intermetatarsal structures, including the communicating branch in the third webspace. This may be aggravated during ambulation in which dorsiflexion of the toes and contraction of the flexor digitorum brevis stretches the common digital nerve, causing a traction injury”. Maybe that’s why mobilizing the mid foot is vital. As well, I showed him shoes with a wider toe box could help decreased the tension on his mid-foot. We’ll see how that goes this week.

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Sean, I have the same struggle. There is obviously something there that caused pain receptors to activate. The main thing we can do is treat what we see. I found an article looking at forward head posture corrective exercises in the management of lumbosacral radiclopathy RCT. You mentioned earlier he had forward head. This is something you can present to him and it might be helpful? You’re more than welcome to check it out.

I used the narrow search strategy- golden. “low back pain radiculopathy”

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[omikutin]

Thanks for sharing Sean. His symptoms sounds like a discal presentation but MOI doesn’t correlate. Nick brings up a good point on educating him on the negative presentation of the neural exams. As well, you said he doesn’t experience pain while performing surgery. Is he standing during the whole procedure? Did he get an MRI or is he still contemplating?

I like this article’s quote: “CFT combines a functional behavioral approach of normalizing provocative postures and movements while discouraging pain behaviors, with cognitive reconceptualization of the NSCLBP problem.” O’Sullivan also mentions how flexion based movements activated higher levels of muscle activation. Have you tried to have him “relax” into lumbar flexion? (I’m thinking of the video we saw during Mark Jone’s lecture). If you get better results with lumbar flexion after “relaxing into it” then I’m thinking more along the lines of maladaptive CNS.

Open ended questions are difficult sometimes. Sometimes I have to politely interrupt. Something that is helping me is to repeat what they said to make sure I’m understanding exactly what they’re saying. Then I would ask further questions if I misunderstand and help facilitate the conversation towards pertinent information. It’s a game I’m learning. If you found something that works for you, I’d love to hear it.

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I recently evaluated a patient with a diagnosis RTC tendonopathy secondary to subacromial impingement. I remember in school we talked about prescribing “eccentrics” for tendonopathies and I’m curious to see if there are any articles that compare eccentrics. However, I kept my PICO question broad in hopes of looking at optimal innerventions.

My PICO question was: What is the optimal innervation for patients with rotator cuff tendonopathy?

I copied and pasted “rotator cuff tendinopathy” under name-of-disease.

Narrow: 24
Expanded: 237

I copied and pasted “rotator cuff tendinopathy eccentrics” under name-of disease

Narrow: 0
Expanded: 12

Narrow search: first 8 articles were published within the past 5 years and included articles such as Manual Therapy, Physiotherapy, JOPST, American journal of Physical Medicine and Rehabilitation. The first article was a systematic review showing the efficacy of manual therapy for RTC tendinopathy which found that manual therapy was found to decreased pain but more studies are needed to see if there is a functional improvement. None of these studies had eccentrics.

Expanded search: first 20 articles were all published within 2015, including RTC surgical procedures, multiple RTC diagnoses, modalities, taping, diagnostic images, ther ex, medications and other diagnosis. I noticed many of the articles that I used for my narrowed search appeared in the expanded search. I found myself getting lost in reading most of the articles that come up during the search.

Expanded search:
There was one 2015 RTC “COMPARISON OF ECCENTRIC AND CONCENTRIC EXERCISE INTERVENTIONS IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME.” It was found that there was no difference between concentric and eccentric program, both had improvements in function, AROM and strength.

There was another 2014 article” Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives. That mentioned how eccentric training shoulder be used to improve tendon degeneration and more research is needed to help find optimal dose and long-term follow-up effect. I didn’t find this very useful, but under “similar articles” I found a 2015 article: “Eccentric strength training for the rotator cuff tendinopathies with subacromial impingement. Current evidence”. Only one study was a RCT that compared eccentric exercises to conservative treatment for impingement. It was found that the experiment group had an improvement in strength but no difference in functional gain.

Both narrow and expanded searches were very helpful. Narrow: I was able to find articles that were more centered around rotator cuff tendonopathies. Expanded: I was able to see multiple RTC diagnosis and it gave me more opportunities to search for eccentric exercise programs.

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Hey Laura- I thought of you when I read this case study. Check it out.

“The patient also has a presentation of bilateral paraesthesia “The GP had performed blood tests including B12, ferritin and folate, which had returned normal. Vitamin B12 deficiency can result in paresthesia, peripheral neuropathy, and demyelination of the corticospinal tract and dorsal columns (Robert and Brown, 2003). The possibility of alcoholic sensory neuropathy was considered as chronic ethanol exposure can cause polyneuropathy characterized by axonal degeneration (Mellion et al., 2011). Recent studies have shown that ethanol exposure has direct neurotoxic effects on peripheral nerves.”

I thought this was interesting.

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Great article Alex!
The inclusion criteria are for participants 18-65. In my 60 yo patients have a decreased ADH which may contribute to a painful arch at earlier ranges. That’s an interesting finding where 45 degrees was the most significant narrowing as compared to 0 and there is no significant narrowing from 45 to 60 deg, I would think greater elevation would increase narrowing.

I still find it difficult to classify impingement versus SPS. Either way treatment would be similar and that’s to decrease the irritation causing the increased narrowing. Now if there’s a hard end feel and a potential osteophyte then treatment will be different.

I found this interesting from reading Roy et al (article quoted by Savoie) “increased activity of the upper trapezius and decreased activity of the lower trapezius during arm elevation in the frontal plane for young athletes performing overhead sports and decreased activity of the serratus anterior. Increased activity of the lower trapezius during arm elevation in the scapular plane for construction workers routinely exposed to overhead work.” It’s interesting how motor strategies are dependent on what activity you do. I find that a majority of my SPS patient have a downwardly tilted/ anteriorly tilted scapula (which makes sense why they have SPS). I’m still trying to find the best protocols without progressing to far and further increasing inflammation.

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She had pain with hip flexion and extension. However, I don’t know how much of her pain catastrophizing characteristics played into her pain level and lack of mobility? Gait: decreased B hip extension, anteriorly tilted pelvis, decreased stride length, B LE was externally rotated (L>R).

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Nick- Thanks for pointing this out, I looked over my data again and hip flexion was limited to pain and objectively R/L 95/100.

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Thanks Sean!

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I’ve only seen this patient once and she hasn’t come in since her evaluation. It’s been very difficult trying to get in touch with her.

Sean- Great idea on manually compressing the lateral cutaneous femoral nerve and glut min! I put some stress on her ASIS/ inguinal ligament and did not get a numbness response. However, she was tender. The numbness comes and goes, she does not recall a certain activity that brings on the numbness and tingling. I asked about sitting/ standing/ laying down/ putting on shoes and we still could replicate the cause of her numbness. She was hypermobile on L4/L5 with tenderness that did not reproduce numbness. I also applied pressure to her glut min/med and it was tender but also did not reproduce her lateral thigh numbness. I also did not hold it for 15 seconds. I applied gradual pressure for about 10 seconds. Do you think holding for 15 seconds I would have a different response? Given the opportunity, I would love to try it again.

Laura- I checked upper lumbar and she was not as tender as PA L4/L5. However, upper lumbar facets could potentially refer to lower back so I can’t rule out upper lumbar. I would definitely put her in the pain catastrophizing category due to her fear of movement/pain. Her hip mobility was decreased and an empty end feel due to pain in flexion.

Nick- Thanks for brining up those test, that would have been ideal! I completed a neuro exam and she appeared to have sensations intact B. I believe she uses the term numbness to describe a form of peristhesia. I didn’t even think about that! Earlier when I was questioning her numbness feeling she wasn’t able to distinguish a certain position that would increase her symptoms. I could have done a better job of digging further. I also asked her to pay attention to when she gets those lateral thigh numbness sensations and what position she is in. We also did not do a prone instability test, H or I test. I would like to perform them but she highly irritable and decided not to. I think it hurt me due to not being specific with my hypothesis of “lumbar hypermobility” but I was thinking to try those test next time. Sadly, there has not been a follow up. Her SLR passive was R/L 60/65 with pain in her low back, SLR active was worse and she had pain with initiating movement. No lateral thigh peristhesia from active or passive SLR. End feel for hip flexion was empty (pain) and limited due to pain and ext there was a muscular end feel (pain).

I was also thinking of a potential facet referral due to the pattern distribution. My hypothesis for the lateral thigh peristhesia might be referred from a facet due to lumbar hypermobility and constant stress and lack of stability. I chose this patient because her lateral thigh pain was interesting for me. I wanted to further explore more during her next visit if she calls back. Due to her apprehensiveness would you guys continue to gather more objective data during her initial visit?

Thanks so much for everyone’s input! Intervention: I classified her in Chronic Low Back pain with movement coordination impairments per Dellito. I decided a lumbar stability program would be the best way to go. I found an article comparing motor control to a graded activity approach (attachment). The graded activity approach uses a cognitive behavior approach. This approach “involves encouragement of skill acquisition by modeling, the use of pacing, setting progressive goals, self-monitoring of progress, and positive reinforcement of progress.” It was found that motor control exercises and graded activity exercises have improved outcomes however there is no difference between both interventions. Moral of the story treat patients with the skills you have.

RCT with 173 participants. Inclusion criteria: chronic nonspecific low back pain > 3 months with or without leg pain, currently seeking care for low back pain, between 18-80 yo, clinical assessment indicated the patient suitable for active exercises, score of moderate or greater on question 7 (“How much bodily pain have you had during the past week?”) or question 8 (“During the past week, how much did pain interfere with your normal work, including both work outside the home and housework?”) of the 36-Item Short-Form Health Survey questionnaire (SF-36). Exclusion criteria: known or suspected serious pathology, previous spinal surgery, health condition that would prevent exercises programs. Treatment provided by 10 PTs with 2 years of clinical experience who received training in motor control and graded exercise training (2-day workshops and a series of interactive seminars).

Do you prefer motor control or graded activity exercises for chronic nonspecific back pain? Have you used graded activity exercises in your practice? Any other ideas of the hypotheses of lumbar hypermobility potentially causing a lateral thigh peristhesia? Would you like to test anything else? Which treatment protocol do you think my patient would benefit more from motor control or graded activity?

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Thanks for sharing! It’s interesting that we have a lower sensitivity. I sure hope we are able to rule out any serious underlying pathology, VBI, systemic, UMN, LMN. I believe ruling out the red flags are most important. Like you said as a PT our goal is to look at movement and function and correct the impairments. I still get stuck trying to figure out how do I treat a patient with low back pain if I don’t know the specific pathology? Specifically patients with low back pain, I have found it helpful putting them in classifications per Dellito and treating them accordingly. Alex- I also find the shoulder tricky. I try to rule out first anything systemic and then from the subjective I see which test clusters I shoulder use (impingement? instability?etc.) It’s a lot to think about.

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