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Hey Kyle!
Some other differentials on my list are athletic pubalgia, or moderate-severe FAI, however, femoral neck stress fracture is highest on my list. Based on the lack of improvement, weight bearing sensitivity, low BMI, recent training changes, history of anorexia, and positive PPPT, I would not treat this patient until after an additional follow up is completed with the orthopedist, despite negative radiographs. We also know that not all radiographs pick up on stress fractures, and the positive PPPT with other factors would spark enough concern for to not feel comfortable continuing to treat her at this time until further imaging such as an MRI was performed to rule out the presence of a fracture more accurately. If she were my patient, I would educate on symptom monitoring and activity modifications in the meantime while she is waiting for further testing/direction from the orthopedist.
Hello!
Since this patient is referred to PT with the diagnosis of spinal stenosis with bilateral leg pain, I would want to see if symptoms are arising from the spine through lumbar AROM and OP/quadrant testing if necessary. A thorough neurological exam is also warranted due to complaints of bilateral leg pain with testing consisting of dermatome, myotome, and reflex testing. To be extra thorough, UMN testing would also be helpful with consideration of bilateral vs unilateral presentation to rule out more severe pathology. Providing those don’t give the information we need to address the full picture, with lingering complaints of BLE pain, I would also consider doing the bike/treadmill test to determine if this could potentially be vascular vs neurogenic claudication. Frequent strength testing as well as endurance testing like 6MWT would be helpful in tracking any potential decline since medication was changed. Blood pressure measurements would also be beneficial to record over time as well. Some follow up questioning I would have for this patient would consist of: 1. How much did your PCP increase your statin medication? 2. Are you experiencing soreness or fatigue in areas in which those muscles were not exercised? Based on the answers to these questions and results of clinical testing, I may refer him back to his PCP for bloodwork and discussion on statin dosage adjustments if necessary. I would present my findings on what I have ruled in, ruled out, and share my thoughts on what could possibly be driving symptoms in addition to stenosis diagnosis. I would ask the PCP for their opinion on the case as well to determine the best team approach for treating this patient.
Hi Kyle!
As someone who has frequent headaches of varying types, I would want to dive deeper into her headache frequency, location, duration, and any correlation with her jaw pain during headache onset. I would also want to ask how she is managing headaches where it be through medication, massage, ice/heat, etc. as this could also help tease out myofascial involvement in neighboring musculature that could be referral or if more of a cervicogenic involvement could be present, which could also be related to her jaw pain based on innervation involved.
Questions: How often are you having headaches? Can you tell me where they are located and how long you have them for? What are you doing to help with headache pain? Do you notice you have jaw pain the same time you have headaches? Also, have you had headaches for as long as you have had your jaw pain?
Sorry it wasn’t just 2 questions either, but all are related!
Hey Kyle!
Some further questioning I would like to ask is when does his swelling onset? You had mentioned it is recurring, so I would like to know if it is primarily after activity or if there is a 24hour pattern associated with it. I would also like to ask if he has any resting pain as well, or is it just a sharp and lingering pain when provoked by activity and use? Key clinical examination tools or methods I would use would be swelling measurements, grip strength testing, observation of any abnormalities, palpation, as well as the usual AROM/PROM/OP measurements and end-feels comparing bilaterally. The top hypothesis and differentials on my list are TFCC injury, UCL injury, and fracture. Another follow up question that I didn’t see mentioned was if symptoms were getting better, worse or staying the same at 4 month into recovery? If symptoms are staying the same and/or getting worse, I think Ortho should be brought on the team to get adjunct treatment. The recurrent swelling and longer duration of symptoms up to 4 months now, paired with pain with weightbearing and limited ability to lift over 10#, would prompt me to refer out to see Ortho for imaging and a more team based approach to make sure there aren’t any missing pieces or additional treatments that can expedite his recovery to return to play while he is in season for his sport.
These are my thoughts!
Sarah
Hey Kyle! That article demonstrates the inconsistency between protocols as well as the subjective liberty with designing them that can take place based off of surgeon experience, opinion, and surgical method done. While this may not be a bad thing, as we utilize similar methods with our own practice, this does mean that there isn’t a very specific guideline to follow for post-op procedures. I am limited in my experience with multiple clinics, I have noticed different protocols for same/similar procedures. The biggest factors for progressing patients during rehab for me personally are based off of patient’s symptom irritability/severity, prior level of function, and compliance with PT recommendations and HEP.
“The ability to act in spite of uncertainty requires appropriate vocabulary and a deliberate manner of speaking without anxiety.20 Geller et al. argue that tolerance for ambiguity is a prerequisite characteristic for effective healthcare provision.21 Physiotherapist ‘disposition’ for accepting and working with uncertainty may have impact on care-seekers and students/ novice physiotherapists and has not been adequately researched22,23” (Slade et al, 2012). This paragraph in particular from the article written by Slade et al resonated with me the most and is something I have been actively working on improving. As a new physical therapist, displaying confidence in the face of uncertainty and limited experience can be a challenge for me. Having a background in evidence-based practice from a PT school who taught on the topics of BSP model, non-specific LBP, and pain science, I am aware of the complexity of pain in these populations. “Experience is the real teacher” (Slade et al, 2012). Even with this background knowledge of all that goes into treating these patients, experience is where I feel like I will learn the most and have the least. Actively working on identifying and developing clinical patterns is one way to help improve this weakness.
Another method to improve this is by observing and modeling the actions of my mentor and experienced colleagues around me who demonstrate this ability to address concerns in the face of uncertainty with the confidence and demeanor needed. “Theme 5: Physiotherapists seek ‘certainty’ from experienced colleagues.” I am very blessed to be surrounded by such knowledgeable and experienced physical therapists that I can learn from in the clinic each day. Some of the most valuable parts from residency so far have been in the moments talking with my mentor about difficult patient cases, reflections, and discussion on ideas/topics; specifically, the moments of past experience, expertise, and advice given.
Many patient experiences come to mind when thinking about patients who had elements of the biopsychosocial model involved in their presentation. I believe building rapport and a therapeutic relationship is essential before diving deep into these topics. Some parts may be able to be addressed during initial evaluation, however, I have found the most benefit in addressing BSPM aspects during the subsequent follow up visits once the patient has developed trust and a bond with their therapist. The aspects that I have personally struggled with is finding the right amount to discuss with the patient before overloading them with information, as well as finding the right time to discuss the contributing factors to their pain that may not be related to an anatomical diagnosis; I know this will also come with experience and practice. I have made it a personal challenge to not shy away from addressing these parts of patient care, to address them to my best ability, and to always seek advice and literature when I don’t have an immediate answer.
Reference:
Slade, S. C., Molloy, E., & Keating, J. L. (2012). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558–569. https://doi.org/10.1177/0269215511420179Hey Dave!
Good thoughts here! I would like to mention though that not all patients might understand the concept of velocity and load when explaining the benefits of eccentrics, and that reframing this in simpler terms might be helpful as well, or being able to explain those concepts as an educational opportunity would be great! I would also caution using the phrase “sick region” if using that quote during patient education, as this could potentially be a harmful phrase to patients. The intention of this quote is wonderful, but may be misconstrued to a patient that might already be fearful or avoidant. Just food for thought! I do appreciate how you have redirected the thought back to their functional goals, where this is stuff patients appreciate when they see us being specific in our treatment for the purpose of getting them back to the activities they want to do.
Eccentrics are a great exercise technique if used properly for the appropriate patient. Typically, I will use eccentrics for the chronic tendinopathy (no longer in the acute/inflammatory phase) as a method of restarting a mild inflammatory process to reproduce optimal blood flow and nutrition to that degenerative area. This patient would likely present with pain at Achilles tendon (mid portion or insertional) describing tenderness or sharpness. They would likely have pain/discomfort with ambulating or activities that put that area/tissues on stretch. Potential hypertrophy or thickening of the tendon may be noted compared to the opposite side as well. If pain is at insertional site, I would recommend eccentrics to neutral versus into dorsiflexion to not encourage increased compression. If actively monitoring symptoms and tracking latent symptom response post-session, eccentrics can be a great addition when treating chronic/degenerative tendinopathies.
In addition to avoiding end range dorsiflexion, I would educate on avoiding stretching in that area if provocative to symptoms since this adds extra compression to the insertional site. Interestingly though, the study done by Gatz et al determined that isometrics do not provide additional benefit when added to an eccentric program (Gatz et al, 2020). However, I do feel isometrics would be appropriate if the patient was of high irritability and would be a good starting point. If eccentrics were not providing the intended outcome, one study showed that heavy slow resistance training also provides just as much benefit for Achilles tendinopathies as eccentrics (Beyer et al, 2015). Addressing any physical impairments at the foot and ankle with appropriate manual therapy techniques (STM, joint mobilization/manipulation, etc.) should also be incorporated when indicated as well.
When explaining eccentric exercises, I like to use the analogy of a bicep curl first since this a fairly understood/common exercise to most patients regardless of educational background. I first explain concentric shortening with the curl up, and the eccentric lengthening phase on the down portion of the curl. I find that patients can understand this concept better this way and then transition the concept to a heel raise or similar exercise regarding the Achilles tendon. I also mention, when dealing with the degenerative/chronic tendinopathy, that the eccentric exercise is a good method of “restarting” or “jump starting” a slight inflammatory process to the tendon we are treating so that their tendon gets the nutrients it needs to heal more optimally and to become stronger. I try to not get overly anatomical with patients but explain the purpose of it followed by symptom monitoring education.
Work Cited:
1. Gatz, M. et al. Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography. Sports Health. Jul/Aug 2020;12(4):373-381. doi: 10.1177/1941738119893996. Epub 2020 Jan 31. PMID: 320036472. Beyer, R. et al. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27. PMID: 26018970
David,
I enjoyed reading your post and can relate to several of the topics you addressed. I too have made the mistake of incorporating stretching and mobility work to that region that was only adding to the compression issue of the tendon. This is an area I have improved on since then and will change my practice pattern moving forward! I also can related to your statement of broadening the utility of certain tests and looking at them in different ways, such as SLS, to gain more comprehensive information and data in the patient presentation. I also have broadened my knowledge on postural assessments as well, and incorporated this into my patients treatment plan after this past weekend and Dr. Grimaldi’s article. I found this to be an area that could make a significant impact on symptoms if educated properly since these are positions the patient could be sustaining frequently throughout the day. Thank you for your thoughts and commentary!
This past weekend was very helpful for me as I have a patient currently with a likely gluteal tendinopathy. Initially, lumbar referral was on my radar and something we were working on however she didn’t seem to make much progress. I then transitioned to targeting the hip and that didn’t seem to make much of an impact either. I felt like I was chasing her symptoms and couldn’t figure out the root of the cause. I sought out some advice on the presentation and gluteal tendinopathy was mentioned. After attending this weekend’s course and reading the associated articles, it is a fairly clear presentation of gluteal tendinopathy. She is an 84 y/o female with the symptom presentation of glute and lateral thigh pain, glute weakness, and described pain with activities of side-lying sleeping, stairs, SL stance, and sometimes sitting. She has recently started responding well to glute medius targeted exercises. Initially, her symptoms would be aggravated with exercise, and we had to be mindful of dosage and intensity of exercises prescribed, but now she is able to tolerate more exercise with increased resistance within the clinic. Though we are doing more in the clinic, the dosing of the exercise varies based on her ability and the level of difficulty of the exercise. Most exercises are with a moderate resistance (resistance bands, kettle bells, and bodyweight) and work to a level of fatigue. I also explained potential sleeping position modifications to provide decompression with pillows since pain at night/waking up seems to be the one variable unchanged (she sleeps side-lying with significant adduction of affected limb); I am hopeful to see some impact in this by the end of the week. After having this patient and the weekend course, I will be more cognizant of the presentation and be able to identify it much quicker in the future. Also, I will be able to perform more specific exercises for this type of patient presentation. Prior, I feel I wasn’t as specific because I did not fully understand the presentation or recognize that was the potential diagnosis. Moving forward, I think I will be able to address this presentation much more efficiently. Should conservative management fail to mee the patient’s goals, some options may consist of further patient education on expectations and functional abilities, as well as a potential referral to another provider. The two that come to mind are orthopedic surgeon and functional medicine. Most people are familiar with ortho and this could be an opportunity to see what methods are available and potential avenues for the patient. I also like the potential of what functional medicine offers. I have had good experience with functional medicine doctors that also treat with the “whole person” mindset and might dive deeper into more holistic and less invasive methods to see if there are other variables that can be addressed in the patient’s lifestyle. These referrals would also be paired with patient education on what the current research shows regarding potentially invasive procedures so that my patients can make an educated and informed decision regarding their healthcare.
References:
1. Distafeno, L. et al, “Gluteal Muscle Activation During Common Therapeutic Exercises,” JOSPT 2009 July 1; Volume 39, Issue 7: pg 532-540
2. Grimaldi, A. et al, “Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management,” JOSPT 2015 October 31; Volume 45 Issue 11: pg 910-922Non-specific and persistent low back pain, as well as pain science, have always been topics that have caught my attention and interest early on in my PT career. Thankfully, the curriculum of my doctoral program included an entire course on pain science and went into great detail in our musculoskeletal courses on persistent non-specific low back pain. I feel very fortunate to have this incorporated into the foundation of my practice patterns due to the prevalence of this population of patients. Even with this foundation, I have so much to learn with understanding and treating this group. Areas I can continue to improve on to help with patient’s confidence is by continuing to improve my own confidence, as I recognize that my patients need to see me as confident and capable in being able to treat their condition. Some ways I try to build self-efficacy and autonomy with my patients is through patient education and decision making with HEP, treatment, and visits frequency. With most of my initial evaluations, I try to ask the Patient Specific Functional Scale to get an idea of what activities the patient desires to return to. I put a lot of weight into this, and it subsequently guides my selection of many exercises to teach the patient; therefore, they see a meaningful and functional connection to their treatment. With this comes the patient education on the importance of the ‘why’ behind why I choose specific manual therapy techniques or exercises during their visit. This will also elicit the patient to have confidence in me by demonstrating I have heard their goals and desires and am educating them on how to do these exercises at home to build confidence in themselves. Though patient dependent, I will also sometimes incorporate having the patient select exercises for that day based on ones we have already done to have them be part of the visit process, showing they have autonomy and active participation in their care. To build on ways I incorporate autonomy, I try to advise my patients on scheduling appointments ahead of time for days/times they prefer so they are seen at the most convenient time in their schedule. This, I believe, promotes therapeutic alliance, especially in a time where making medical appointments is particularly tough due to Covid; recently, I have had numerous patients endorse they are waiting upwards of 3+ months to be seen by other providers. Just like in the article by O’Keefe on what influences patient-therapist interactions, the mix of interpersonal, clinical, and organization factors all play a role in patient encounters and experiences, subsequently influencing results1 (O’Keefe, M., What Influences Patient-Therapist Interactions). Confidence, self-efficacy, and autonomy are all areas we can leverage with our patients to promote independence in an area of their lives they have felt such lack of control, many of which have felt for decades.
In the hustle and bustle of a busy outpatient clinic, there have been occasions where I would say there have been non-encounters with patients when I haven’t been as present mentally or physically. As a newer PT, I am still learning the best ways to manage my time and the flow of patient care to optimize the time I have with my patients without feeling overwhelmed or feeling like I am “going through the motions” of the day. As I learn how to do this better and grow in my knowledge as a clinician, this is not as frequent, and keeping the intention of being present in the forefront of my mind is a gentle reminder. There have also been times where I have had encouraging encounters with patients. Just yesterday, I had a patient come in for a follow up visit where he shared he almost went to the ER earlier due to 8/10 low back pain that was fairly debilitating throughout the day at work. He is a patient that has been pulled in different directions regarding his care for LBP (with a prior fusion) and has been handed off by several providers. In that visit, I was able to listen to him, provide some gentle manual therapy to calm symptoms, and educate him on ways to manage his symptoms at home. Because of the rapport I have with this patient, the perfect opportunity presented itself yesterday to sprinkle in some pain science education with him. By the end of the visit, his pain was down to a 2/10 and he left with strategies to manage his symptoms further independently. I believe this was incredibly important to him since he has been going to many providers without improvement and feeling hopeless as a result. With Physical Therapy, we are in the awesome position of being able to guide patients in their recovery with the end goal of equipping them with the tools and knowledge to manage their symptoms confidently on their own.References:
1. O’Keefe, M. et al, “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis,” Phys. Ther. 2016 May; 96(5): 609-22. Doi: 10.2522/ptj.20150240Hi David!
I enjoyed reading your perspective on this topic. As I found, many patients have come in to the clinic, like you have mentioned, already with their diagnosis and imaging to follow it up. However, many of my patients also come in with all of information they have been given and the associated look of lost hope and fear because they feel like surgery is the only option, and many tell me they don’t want it. This is where our utilization of the literature we are discussing here can educate the patient on their situation (whether it be partial-tear or full-thickness) to help reassure them on the best course of action while keeping in mind their goals. I also appreciate the statement you made in your entry saying, “or if the patient has made up their mind about it.” I agree with you that patient perspective is incredibly important, as well as respecting their decision even if we may not agree with it. Thank you for your thoughts and references on this subject!
-Sarah
Hi Dhinu!
Thank you for your response. To answer some of your questions, surprisingly there was no severe weakness and strength was overall fairly good before surgery. Some planes of motion were limited and his initial injury, from what I recall, was more of an overuse injury from the sailing position/role he was doing. Both the patient and I were shocked at how abruptly physical therapy ended after receiving imaging results, and I think a few more visits were warranted to see further progress or for at least “prehab” going into surgery. He had not plateaued, but progress was simply slower for him.
I believe there is a hesitancy to use imaging to guide management, especially surgical, because of the known variability with imaging (Brady, Insights of Imaging 2017; Herzog, Variability in diagnostic error rates, 2017). With potential for error and variability in interpretation of results, the risk of having imaging and potential subsequent surgery, does not always seem like the best, especially when Physical Therapists are diagnostically accurate and appropriate with diagnosis and screening (Deyle, The role of MRI, JMMT, 2011).
I have also had personal negative experiences regarding imaging results and the follow up recommendation for surgery when it was not the appropriate next step. These experiences have made me more cautious with the use of imaging recommendations, especially when both instances surgical management was the recommended next step.
We could spend hours discussing this, but these are just a few of my thoughts to answer some of your questions!
-Sarah
References:
1. Brady AP. Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging. 2017;8(1):171-182. doi:10.1007/s13244-016-0534-1
2. Deyle, GD. The role of MRI in musculoskeletal practice: a clinical perspective, J Man Manip Therapy, 2011 Aug;19(3):152-61. doi: 10.1179/2042618611Y.0000000009.
3. Herzog, R. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period; Spine J. 2017 Apr;17(4):554-561. doi: 10.1016/j.spinee.2016.11.009.
The two questions I was drawn to and want to address most were, “What are the pros associated with shoulder surgery?” and “What role should diagnostic imaging have in surgical management of shoulder pathology?”. I feel these two questions are related to each other. In my experience so far, I have seen where imaging has done more damage by instilling worry, and where more of my time is spent educating on possible normal imaging findings and calming fears regarding imaging results; but for the appropriate patient, imaging can provide possible answers and open opportunities for further indicated treatment that can help the patient return to optimal functional ability. While I am biased towards conservative management being trialed first before seeking surgery, I have had one patient case where surgery was indicated AND he was comparatively better for having it. This patient was in Physical Therapy for a couple weeks with only slight improvement noted when he was then sent by his doctor to receive further imaging. He proceeded to have an MRI performed where he was told to stop Physical Therapy until after he had surgery where he would have his rotator cuff and biceps tendon repaired. This patient is an older gentleman in his late 60’s and is very active outdoors. He is a frequent competitive sailor as well, which he desperately wants to return to. After having his surgical procedure, and post-op Physical Therapy, his shoulder is remarkably better in both pain levels and functional ability. His range of motion and strength are nearly full, and he is looking at returning to sailing at the beginning of this upcoming year. This is the case where I believe the abnormality in his imaging was relevant to his symptoms and impairments, and where surgery was absolutely indicated. In my reflections, I have often wondered to myself, if it hadn’t been for the doctor requesting further imaging, how long would I have kept him in Physical Therapy before I would have sent him back to his PCP to have imaging performed? Would my biases have prevented or delayed him from getting the care he needed? This specific patient case has challenged my biases and has helped me be more open to the option of possible surgery for the patient that truly is appropriate for it. I still believe that good, mindful, and evidence-based conservative management should be trialed first before being deemed “failed therapy”, and all possible avenues of potential pain drivers need to be addressed to the best ability before recommending surgery. However, when this truly is not enough, the patient’s goals are not being met, and symptoms are not improving, I do believe imaging and surgery have their place in patient care; a team based, multi-disciplinary and collaborative approach to provide the best care to make people feel and move better.
Hey David!
Thanks for your question! Personally, I like to sprinkle in pain science early on and only if appropriate/after assessing if the patient is willing to hear it, as it can sometimes not be accepted well if the patient isn’t ready. However, I did just find an article with an interesting result. The article was titled, “The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: a randomized clinical trial” by Ludvigsson et al. The article shared that between the neck-specific exercise group and neck-specific exercise group with a behavioral approach, that there was no significant difference between groups. They did note that there was a potential trend toward better improvements with the behavior approach, but not enough to be significant. In my opinion, I think adding a behavioral approach is still worth implementing if appropriate for the specific patient. Try to identify any possible factors in the patients life that might be able to be modified that could aid in improving progress early on in the course of care, and address them as you see appropriate!
Hope this helps!