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I thought the video was a really helpful explanation of the concept. I downloaded the article “Neural representations and the cortical body matrix: Implications for sports medicine and future directions” by Wallwork et al that they discussed at the end of the video. I’ve attached it below. It was an interesting read, even if a bit of it did go over my head.
Hey Katie,
Definitely an interesting case. Have other medical providers ruled out a hernia as a cause of his symptoms? Considering many of his aggs include increased intra-abdominal pressure, that would be my first thought. If that has been ruled out and we are looking at a strictly MSK cause of the pain, I would have to lean towards SIJ dysfunction due to the 4 positive findings from the test cluster, though it seems curious with no mechanism. Did this pain begin insidiously or was there a mechanism to it? Have you asked him if he is worried that his pain may be coming from cancer? I would say that his answer to that question could determine whether that may be a factor in his treatment. Has he seen a urologist? I would be most concerned about the testicular pain when emptying a full bladder in the morning.
Hey AJ,
Interesting study. With some reflection on my treatment of patient’s with RC tendinopathy, it seems that I may have been overworking them slightly. This study emphasizes that sometimes less is more with this population, especially in the early stages of rehabilitation. In the future, I will likely limit the prescription of RC exercises to once per day and be sure to alter set and rep schemes to not overwork the patient. However, this does bring up some questions in my mind about how we can load the tendon enough for it to adapt without causing harm. How much is too much? Are there any objective changes we should be looking for to determine whether we are consistently overworking the tendon, or if we are loading it appropriately?
Interesting read and definitely something I need to be more consistent with screening out in my patients with hip and thigh pain. I found the correlation between chronic proximal hamstring strains and sciatic nerve entrapment interesting. This is something to keep an eye out for in patients with persistent hamstring strains. Though I’ve only seen posterior nerve entrapments clinically, this article provided some helpful tools to keep other nerve entrapments on my radar. I thought the chart at the end with the various sites of entrapment for each nerve was very beneficial.
Hey Kristin,
I’d probably say the reason he did not feel the pain initially has to do with a combination of all of the factors listed above. If I had to choose just one, however, I would go with “no visual input of the injury.” He stated in the article that he thought that his chinstrap had slipped up and was resting on his lip, which is something that he has probably trained himself to ignore at this point. Without visual input to tell his brain that something more sinister has occurred, his brain is treating the situation like business as usual and not sending pain signals. I find it amazing the things that our bodies can ignore if we do not consciously perceive them as threatening.
Hey Sarah,
Initially, I find that gentle oscillations in distraction work well for pain relief with these patients. For home, I would try what Justin suggested and tape the scapula into a posteriorly tilted and depressed position to see if that changes anything for her. I would also want to see what her mechanics are like when having to lift her mother’s AD and see if there is anything you can work on there. I’m curious to know if you were able to get a sense of how much having to care for her mother seems to affect her pain levels and her overall psychosocial status. Other than assessing her ER/IR ROM at different levels of abduction, I like to get an idea of what level they can reach to behind their back bilaterally so that you have a baseline. I’ve had moderate success with mobilization with movement into that position in similar patients.
Hey Jen,
After reading your case, my primary hypothesis would be L5-S1 disc pathology. I’m a little unclear on your neuro screen. By “MMT: Heel raises” did you mean that she had weakness with heel raises? Was it bilateral or only on the involved side. I would also have screened dermatomes and DTRs at some point even if you missed it at the initial evaluation so that you have a baseline. One of the criteria I would use for determining if a referral is necessary at any time for this patient would be worsening neurological symptoms. If you test reflexes at visit 8 and find out they are absent, you will not know if that was the same as the eval or if they are worsening. If you eventually decide to refer, it is imperative that you have those data points to provide to the physician. I’m also interested to hear your reasoning for performing overpressure with lumbar flexion during your active ROM assessment due to the fact that you rated your patient’s irritability as mod-severe and that you had already elicited her primary complaint with active movement. What did you hope to gain by overpressing?
As far as manual techniques I would try, I usually try some nerve flossing in the SLR position and UPAs to see if I can make a change in their SLR. I’ve found that that is a really powerful tool for increasing patient buy in. I’m curious to hear if you attempted any repeated extension to see if her symptoms changed at all because it seems that extension positions (standing, lying prone, etc) helped relieve her symptoms. If she responds to repeated extension, that gives you a pretty clear path to follow with the initial HEP.
Looking forward to seeing everyone this weekend!
After reading this article, I will likely have stress fracture on my initial differential list for most runners I see who have lower extremity pain. During my subjective exam, I would like to get a good idea of recent changes in mileage, when during the running process pain occurs (both at what point during the gait cycle and whether it occurs during or after the run), and what the patient’s typical diet consists of.
During my objective exam, I would plan on palpating the area and performing some bone loading tests if stress fx was on my differential. If the athlete had a history of stress reaction/fx, I would perform a functional assessment including SLS and single limb squats as well as a running gait analysis if the athlete was cleared to run again. In our clinic, we use the Hudl Technique app to analyze gait frame by frame to better pick up abnormalities. As far as providing education for an athlete returning to run following stress fx, I would want them to be aware of their weekly mileage and I would advise them to increase their weekly mileage by no more than 10% from week to week.
I’m curious to know what kind of advice regarding return to run that you all like to give to your pts.
Hey Justin,
Interesting case. Did you happen to assess thoracic mobility, particularly into rotation? If his thoracic rotation is limited, that would certainly stress the L shoulder of a L handed golfer more at the top of his backswing and would likely lead to decreased distance on his drives. Additionally, we discussed some research studies during the second weekend of the course series regarding thoracic mobilization and manipulation as an intervention for patients with impingement.
As far as addressing his MRI findings, I would try to explain to him that studies have shown that a high percentage of people have evidence of labral tears on MRI that never experience shoulder pain. I’ve attached one of the more recent articles discussing that.
There is no specific diagnosis that I associate with shoulder pain with simple arm swing. May sound weird with a patient with shoulder pain, but did you asses his gait? If he has differences in arm swing bilaterally or abnormalities with trunk motion, it could potentially stress the shoulder differently (just grasping at straws here).
Hey Justin,
I’m treating a couple of patients currently with similar issues. My favorite analogy has been to tell the patient that the brain becomes a helicopter parent when the body is chronically in pain. Helicopter parents, much like the brain, will give you no freedom because they are trying to keep you safe when, in fact, they are doing more harm then good. Maybe that will be helpful for your patient. Good luck!
I would say that the biggest thing that I took from the course is that we should utilize imaging like we would utilize a special test. It should not be used in isolation, but rather taken in the context of our larger clinical examination. Imaging may reveal pathology that is unrelated to the symptoms that our patients are experiencing, which is a concept that is well supported by our literature. We could all benefit from practicing our explanation to patients that the results of imaging can be misleading. Ultimately, we can use an image to guide the rigor of our intervention and to determine whether or not a patient’s pain may be coming from a more insidious source.