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Thanks for the feedback. I’ll be sure to take a look at the article. He does have testicular pain with ejaculation (or, he did before he started taking nerve pain medications). I didn’t want to post the full case because I think it would end up hashing out in a million different directions on the message board.
There were a couple points from the course that I can do a better job of incorporating into my clinical practice. Occasionally, I will ask a patient during an eval if they feel that it is reasonable for them to be able to complete their HEP. I need to do a better job of doing this more consistently as it could improve compliance with HEP and also help build a therapeutic alliance with the patient. Additionally, I enjoyed our discussion and activities about acute:chronic workload ratios. I think this could be particularly helpful with our patients who we are helping return to run in order to ensure that they are not doing too much too soon and further injuring themselves. I may tinker around on Excel a bit and see if I can make a patient-friendly spreadsheet for them to track their mileage so they can progress appropriately.
I agree with Steph on a couple of points. It seems like your examination was pretty thorough and that you got a lot of good information. I would try him with a lateral wedge and see if that changes his symptoms at all. That seems like the low-hanging fruit to me. Your hypothesis sounds pretty reasonable from a symptom standpoint, though I would expect some ROM loss or joint mobility issues if you think there is joint degeneration. Any reports of stiffness after prolonged positioning or is it just running and stairs? One thing Eric has drilled home during residency is trying to utilize exercises that can address both proximal and distal factors at the same time when treating knee pain in order to get more bang for your buck.
I agree with Justin’s point that red flag screening should be used as a piece of the larger picture and not the end-all be-all of determining whether or not a patient needs further imaging. One point I found interesting from the article was the suggestion that red flags are likely more indicative of poor prognosis than they are of actual serious pathology. However, this leads me to a gray spot in my practice. At what point do I refer a patient with LBP for further imaging? Do I refer if they have certain red flag symptoms and do not improve with a reasonable course of PT? Do I refer for further imaging anyway if they have a certain number of red flags? Is it a “gut feel” type of thing? I’m curious to see if anyone has any other thoughts about when we should actually refer these patients out.
I’ll be sure to keep you in the loop, Dragon.
Good points about possibly having glute involvement on my differential list. I felt stronger about my diagnosis with TTP over proximal HS tendons and more distally into the proximal muscle bellies and the fact that there was little palpable glute max activation with hip extension. She experienced hamstring cramping pretty quickly with active hip extension in prone. Additionally, we were unable to provoke any symptoms with resisted testing of the hip abductors and she did not report pain with palpation of the glute muscle bellies or tendons.
- This reply was modified 1 year, 7 months ago by Tyler France.
Initially, her LBP was much more of the typical “hurt my back bending forward and it’s sore for a few days” type of presentation. This time, her LBP is aggravated by running and walking. Definitely seems more like a facet type issue. She was prescribed meloxicam and flexeril last week which got rid of a lot of her symptoms. When we watched her run, her anterior pelvic tilt and lumbar hyperextension became much more apparent. With some cueing there, she has been able to run pain free for the past week.
Jen, I ended up starting with isotonic loading in positions of minimal hip flexion. During her first follow-up, we ended up doing a running analysis and having to address her lumbar pain some, so we have not had too much time with the hips for me to progress into the stages as much.
I love the chart in that article. I have seen it floating all over PT social media in the past week, which I think is awesome. I will definitely be sharing that table with my future students. One of the big takeaways that I have gotten from residency is the importance of challenging patient beliefs from the start and using your exam to de-threaten. For example, if I have a patient who comes in with a script for hip OA and spends the whole subjective talking about how their hip is degenerated, I may use their negative scour test or something from their functional screen to emphasize that their hip is functioning better than they give it credit for. I have also tried to adopt a habit of Eric’s in my patient care. At the beginning of first follow-up visits, I often ask “What did you learn from me at the evaluation?” That way, I am able to assess a patient’s understanding of what we discussed and I am able to address any shortcomings early on in the rehab process.
Interesting article. Serves as a good reminder that tendinopathies can take longer to heal due to the poorly vascularized nature of the tissue. I found it interesting that neural and vascular tissues can infiltrate injured areas of tendons. The article stated that this ingrowth of neurovascular tissue can be halted with exercise due to a degree of neuronal plasticity. To me, that reinforces the need for tendon loading of varying degrees in patients with tendon pathology. It was striking that collagen synthesis begins immediately following exercise.
Additionally, it was interesting to see the emphasis on the proprioceptive and nociceptive nerve endings in knee ligaments. This further pushes the need for proprioceptive interventions in our patients s/p ACL reconstruction in addition to traditional strengthening exercises.
Interesting case. As far as the neurodynamic testing on the L UE reproducing his familiar R sided pain, I would take that as an indication that there is either something occurring centrally or that his system is a little irritated. Not sure what to make of worsening symptoms with traction in R extension and L flexion quadrants. That doesn’t really compute in my brain. As far as starting treatment, I would probably address joint mobility in the cervical region and see if symptoms change at all with improvements there. How did first rib mobility compare from side to side?
After reading up a little more on the meniscoid, I would likely opt for cervical mobilization with this patient when you take into account the acuity of the condition and the fact that he is having pain with facet opening and closing. You can always consider thoracic manipulation to decrease some pain in the cervical spine if your patient ends up expressing the desire to be manipulated. That may be enough to satisfy patient while minimizing the amount of energy that you put through the cervical spine.
Justin, I had the same takeaway from Katie’s article, that it seems like a pragmatic approach is better than a prescriptive approach when it comes to outcomes (duh).
I agree with Justin that I think the best way to address his focus on manipulation is to educate him that it will be a part of a larger treatment plan, but certainly not the only intervention. If you feel that he is appropriate for manipulation, I think that you should perform it as he seems to believe it will help. I feel that we should almost always attempt interventions that the patient thinks will help if there is no contraindication to the technique. I have some trouble addressing concerns that symptoms will return with cessation of medications in my patients. If the medication is an anti-inflammatory, I usually tell them that there are other ways to control inflammation aside from steroids if his pain does return. With this type of patient, I have progressively incorporated more SNAGs as part of the HEP to continue to address these hypomobilities.
Structues to Assess:
Ant and Mid Scalene: Palpation for hypertrophy or increased turgor/trigger points that may cause reproduction of distal symptoms. Can also perform Adson’s test if suspecting vascular TOS.
First Rib: Can perform cervical rotation-lateral flexion test or palpate for hypomobility with breathing. We probably should have checked CRLF in our patient, but we were scrambling a bit when she kept asking to change positions.
Pec Minor: Observation of scapular positioning at rest and palpation of pec minor for turgor.
GH Mobility: Palpating for position of the humeral head and assessing GHJ mobility, particularly posteriorly.
Has anyone used the prominent TOS special tests (Adson’s, Roo’s, Costoclavicular, etc) in their practice and do you feel that you can comfortably diagnose TOS without performing these tests?
Thanks for the input. TOS is the diagnosis we have settled on based on the findings that you mentioned. We have not yet done any specific TOS special tests, and I am not sure what I would hope to gain by performing them. I had not thought of playing with different neurodynamic positioning techniques, but that is definitely something I will try to see if she can tolerate supine positioning better in order to perform other interventions. She had slightly decreased pain with cervical lateral flexion with the shoulder girdle passively elevated, though it was not significant. Incorporating MWM to the CTJ is definitely something that could be beneficial in this particular patient. Education is something that we likely need to do a better job of with her. I do not get the impression that she has a good understanding of our role in the recovery process. We likely need to do a better job of selling her on what physical therapy can do for her condition, and I think achieving some symptom relief with certain interventions could go a long way. Unfortunately, we have not made significant strides in this area yet.
Thanks for the input! Definitely some helpful ideas about different things that I can try with her.