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For this visit I would first inquire about possible red flag differentials including cancer, infection/UTI, cauda equina and upper motor neuron pathology. Key questions would include; frequency/timeline/nature of symptoms, difficulty and/or pain urinating, recent signs of infection (fatigue, night sweats, fever), unrelenting night pain, saddle paresthesia’s, flank pain, unexpected weight loss, unilateral or bilateral LE pain/weakness/sensation loss, and individual/family history of cancer. If I suspected cauda equina or UMN pathology I would proceed with a neurological screen (dermatome, myotome, reflexes, UMN testing and cranial nerve testing). Based on the information currently provided in the prompt my differential would include cancer (kidney, bone), infection (spinal, kidney/UTI), and cauda equina. With these differentials I would likely refer this patient to the ER for advanced imaging to rule out serious pathology before proceeding with treatment.
At 3 months into treatment, I would hope that my relationship with this patient is at a level where they feel comfortable speaking with me about these concerns. I would start with bringing up my observations in a nonchalant manner infrequently throughout the treatment session without being too invasive. I think that it is important that the patient does not feel forced to share their feelings/experiences and willingly shares information at a pace that they feel comfortable with. At this point I would hope that I had gathered some information that can be correlated with my observations. With this information I would establish communication with the patient’s parents to inform them of my findings and see if they have noticed similar behaviors. Establishing this relationship with the patients’ parents would hopefully allow for more observers to collaborate as the behavioral changes may not be seen by the parents at this point. It may be beneficial to establish communication between myself, the parents, and even coaches to gather more information.
This can be a difficult situation to deal with depending on a variety of factors. There could be something going on in the patient’s home life that is leading to distress that involves the parents and/or family members. It is also important to think about the social stressors at this age and pressures that are associated with being on a sports team. This could also be more personal to the patient, possibly associated with fear and/or anxiety around confidence and return to sport. Because there are so many different routes this situation can take, it is important that we determine the underlying cause. Depending on the underlying cause of the behavioral change we must also understand where our role stops and where other individuals/professionals begins.
I would first re-evaluate this individual’s neuro screen looking for any significant changes in myotomal strength, sensation, and reflexes of the lower quarter. Significant changes in any of these areas may correlate with a progression of the patient’s stenosis. I would also assess the patients gait pattern looking for any abnormalities. I would also want to see if his symptoms are recreated with lumbar ROM and/or PPIVM/PAIVM testing. If I can recreate his symptoms by narrowing the neural foramina bilaterally then it drives my diagnoses towards stenosis with claudication. The article also discusses the idea that muscle loss may occur in areas that are not being exercised and may be beneficial to assess some of the major muscle groups of the upper extremity for strength deficits.
I would also want to differentiate neurogenic versus vascular claudication. This may be assessed with a treadmill walk test. A treadmill walk test may be more beneficial as I can utilize the incline and have the patient assume a more flexed position as this should not provoke symptoms if it is neurogenic claudication. The patient would be asked to perform either of these tests until onset of symptoms. After symptom onset I would be assessing distal pulses, sensory changes, reflex changes, and relieving factors. For neurogenic claudication I would expect a normal pulse, dermatomal pattern of sensory loss, diminished reflex testing, and pain only relieved with sitting. For vascular claudication I would expect an absent/diminished pulse, variable/non-dermatomal sensory changes, normal reflex testing, and pain relieved with cessation of activity.
Other tests that could be utilized would be functional tests such as the 5 timed sit to stand, 6 minute walk test, or any other functional strength/endurance testing. I would be considerate of the positions the patient would have to be in for these tests as extension biased positions may provoke stenotic pathologies. I could also assess the variables discussed above for the treadmill test with these tests as well to differentiate between neurogenic and vascular origin.
Initial Differential List:
Disk displacement with reduction with a myogenic component:
o Subjective findings: Chronic (4 years) intermittent joint noises and pain that resolve spontaneously, unilateral symptoms, age, gender PMHx of anxiety and depression
o Any locking of the jaw?
o Do the jaw symptoms tend to worsen when stress/anxiety levels increase?
o Any significant dental history?
o Jaw pain with taking lager bites, chewing food on one side versus the other?Myogenic TMD:
o Subjective findings: chronic headaches and jaw symptoms, age/gender, PMHx of anxiety and depression, high stress lifestyle
o Provocation of symptoms with mastication, especially tougher foods?
o Significant dental history?
o Relationship between stress/anxiety and jaw pain?
o Any history of grinding and/or clenching teeth?Cervicogenic Headache:
o Subjective findings: chronic headaches, high stress lifestyle
o Provocation of headache with neck movements or prolonged postures?
o Does your pain start around the head and neck and then radiate to the jaw?Cervical Arterial Dissection:
o Subjective findings: chronic headaches, symptoms in the jaw, chronic stress/anxiety
5D’s and 3N’s ?
Description and location of headache?
Do you feel like the headaches are worsening? Are the more recent headaches unlike any others before?
Any history of trauma?
PMHx – HTN, DM, HLD
History of smoking?Screening tools:
A screening tool that I feel would appropriate for this case is the OSPRO-YF screening tool. This tool covers a variety of domains and will help identify the domains that are of greatest impact for this patient. Depending on the factors that are identified as most limiting, we may alter our treatment approach or even provide referral to other medical professionals. If the anxiety and stress are chronic and not well managed it may be beneficial for this individual to consult with a therapist who specializes in these domains.
Key Clinical Examination Findings for Differential:
Triangular fibrocartilage complex articular disc pathology: (+) TFCC grind test, (+) fovea sign, snapping/clicking with A/PROM supination/pronation, (+) test – pain with compression to the TFCC, pain free/decreased grip strength
Chronic distal radioulnar joint instability: hypermobility with the distal radioulnar shift test, pain with pronation and supination, (+) piano key sign
Extensor carpi ulnaris subluxation and/or tendinopathy: pain and possible tendon subluxation/snapping with resisted wrist extension and ulnar deviation, pain with passive wrist flexion and radial deviation
Distal ulnar fracture: swelling/bruising at the distal ulna, global loss of ROM at the wrist, deformity at the wrist depending on the extent of the fracture, pain with all active and resisted movements at the wrist, painful/weak grip strength
Important points to conside when deciding whether or not to refer for imaging would include observable edema/discoloration/bruising, a decreased willingness to move at the wrist, palpable deformity, presence of ROM loss in a capsular pattern, painful/weak grip strength testing, empty or hard end feel with ROM testing. I would also consider subjective findings including MOI, timeline/stability of symptoms (worsening/persistent symptoms raising suspicion), and response to any conservative management performed.
Triangular fibrocartilage complex articular disc pathology:
Subjective: location of symptoms, aggravated by weight bearing positions or impact in wrist extension, traumatic compression injury, reposts of mechanical clicking at the wrist
Chronic Distal radioulnar joint instability:
Subjective: pain at distal radioulnar joint, aggravated with holding or manipulating objects (possibly for sport), noticeable loss of grip strength, difficulty supinating/pronating wrist, feeling of instability at wrist
Extensor Carpi ulnaris subluxation and/or tendinopathy:
Subjective: recurrent swelling, pain with activities that require active wrist extension, pain with compressive forces in wrist extension, painful snap at the wrist with supination
Distal ulnar fracture:
Subjective: timeline of symptoms, swelling, traumatic MOI, pain with any impact or loading of the wrist, bruising at original injury, painful with most movements of the wrist
I think articles like this are great for bringing awareness of an issue that I believe relates to many post op protocols. The major take away from this article is that there are inconsistencies in protocols and we need to utilize factors such as tissue healing time frames, exercise loading principles, and biomechanical principles to provide care that is individualized to the patient. This becomes more apparent when patients have multiple procedures preformed and we have to consider multiple structures that may have completely different functions. Overall I think that protocols are a great place to start, but we do need to consider many other factors that affect tissue healing and loading that are not typically discussed in the protocols.
A specific pathology that I have found a common mechanical fault associated with it is gluteal tendinopathy/trochanteric bursitis. The research behind this pathology suggests that increased tensile forces are applied to the hip abductors and IT band when here is a lack of lateral pelvic stability and an increased adduction/internal rotation moment at the hip. In my experience, it is common for me to altered motor control patterns with these patients and I find success in improving their ability to maintain a neutral pelvis and strengthen the appropriate hip musculature to reduce the valgus moment of the femur with closed chain loading activities. I am typically able to explain this fault to patients by discussing the findings and showing them how the activities that are aggravating to them are affected by the mechanical fault. Another way I find success in explaining the fault is by demonstrating modifications to the patients positioning of the hip and allowing them to feel the difference between resting in an adduced position versus a neutral position. I think the fact that I can show them immediately how this impacts their symptoms makes a large impact on their perceptions and understanding of the implications regarding the movement fault.
These two articles both do a great job of identifying the challenges we face with patients suffering from all forms of low back pain and provide us with great ways to change the way we go about improving patient perspectives. I am hoping that this is something that all healthcare professions are seeing as more research is developed because we need consistency across all professions. I have seen numerous patients who have been hopping between healthcare providers and have received numerous diagnoses and treatments that have failed them. I can see how this becomes very frustrating as it leaves the patient hopeless and misunderstood. These are the patients that I find the most difficulty with because they have this misconception from hearing all these different problems that are poorly understood by the patient and the healthcare provider. I hope that this information is making its way into other areas of the health care system because we are typically seeing these patients after they have seen a physician. If this first interaction is a negative experience for the patient, then it sets them back immediately. I find it interesting how much the patient’s perspective on the problem can affect their prognosis. We discussed a study in a previous course that looked at patients’ perceptions of pain before and after an initial evaluation. It was interesting to see how much of a difference we could make by using positive language, allowing the patient to have their concerns heard, and giving them a sense of understanding. Another study that we discussed that has helped me provide objective information to the patient is a study that looked into imaging findings in patients without back pain. This specific study provides a great chart showing common findings on radiographs at different age ranges. It is a great resource to help patients understand age related changes and how pain does not necessarily correlate to findings on imaging.
– What are the pros associated with shoulder surgery? We tend to focus on the risks (e.g. infection, post-operative stiffness, subsequent procedures, etc) but there are a number of reasons why someone would have surgery of their shoulder – what are some of them?
Shoulder surgery offers a range of benefits that can significantly improve a patient’s quality of life. It is primarily sought for pain relief, addressing chronic or severe shoulder pain caused by conditions like rotator cuff tears, labral tears, or arthritis. Surgery can also enhance shoulder functionality, improve range of motion, and prevent further joint damage. Correcting structural abnormalities and ensuring a faster recovery are additional advantages. Many shoulder surgeries provide long-term relief and contribute to an improved quality of life by allowing patients to engage in daily activities and return to sports or work with less discomfort. Importantly, shoulder surgery is tailored to the specific condition and patient, offering a personalized approach to treatment. However, the decision to undergo surgery should be made in consultation with a healthcare professional, considering both the potential benefits and risks.
– We spoke to the lack of efficacy of a variety of surgeries for shoulder impingement. What shoulder conditions have evidence to support the use of surgical intervention? Please come up with 1-2 conditions, and offer a couple citations to support your answer.
Rotator cuff tears, especially full-thickness tears, are a common condition that may require surgical intervention. The evidence for the effectiveness of surgery in treating rotator cuff tears is well-documented. A systematic review and meta-analysis by Moosmayer et al. published in the Journal of Bone and Joint Surgery in 2017 found that surgical repair of symptomatic full-thickness rotator cuff tears was associated with significantly better outcomes in terms of pain relief and functional improvement compared to non-surgical treatment.
Reference: Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Brox, J. I. (2017). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. JBJS, 99(2), 83-92.
Glenohumeral instability, which includes conditions like recurrent shoulder dislocations or subluxations, can often benefit from surgical intervention, particularly for cases with frequent episodes of instability that significantly impact a patient’s quality of life. A study by Hovelius et al. published in the Journal of Bone and Joint Surgery in 2008 demonstrated that surgical stabilization of the shoulder joint was effective in reducing the recurrence of dislocations in young, active individuals.
Reference: Hovelius, L., Sandström, B., Olofsson, A., Svensson, O., Rahme, H., & Akermark, C. (2008). Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five-year follow-up. JBJS, 90(5), 945-952.
– What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?
The role of diagnostic imaging in the surgical management of shoulder pathology is essential but should be considered in the context of a comprehensive clinical evaluation. Imaging is a valuable tool for identifying structural abnormalities, confirming a diagnosis, assessing the extent of the pathology, and guiding treatment decisions. However, it should not be the sole determinant for surgery.
As for the concern about asymptomatic individuals showing abnormalities on imaging, this is indeed a common occurrence. Many people, especially as they age, may have shoulder abnormalities that do not cause symptoms or limit their function. This phenomenon is referred to as “incidental findings.” The relevance of imaging in such cases comes down to whether the imaging findings correlate with the patient’s clinical symptoms.
Imaging becomes relevant when the clinical presentation and physical examination findings align with the imaging findings. In other words, when a patient has symptoms that are consistent with the abnormalities seen on imaging, surgery may be considered. However, if an asymptomatic individual has abnormal findings on imaging, surgery is typically not indicated. The clinical evaluation and patient’s symptoms should guide the decision for surgical intervention, and imaging serves as a supporting tool to confirm and assess the condition.