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SUBJECTIVE:
Pt is a 40-year old female who reports 2-8/10 bilateral glute and proximal posterior thigh pain that she describes as an ache with occasional sharp pains. Pt reports onset of R sided glute and proximal thigh pain in 2012 while running and training for a 10K and has progressively worsened since that time. Her L sided pain began while training for a race and has remained the same. She had an MRI on the L hip in 2016 which showed moderate tearing and tendinosis of the proximal hamstring tendon. She had physical therapy in 2016 which helped decrease symptoms. She has tried chiropractic care, steroid injections, acupuncture, and dry needling without relief. She has also experienced recurrent episodic LBP for the past few years, which she is currently experiencing.Aggs: walking uphill, sitting (worse on hard surfaces), open chain hip extension, running, and heavy squats.
Eases: yoga, pain gets better after running for 4-5 minutes
Goals: decrease pain, improve LE strength, train safely for ten miler
OBJECTIVE:
Posture: Increased anterior pelvic tilt and excessive lumbar lordosisFunctional Screen: moderate Trendelenberg bilaterally with single limb squat. Decreased hip extension and excessive pelvic rotation with swing test.
-Hypomobile and painful posterior glide of bilateral hips
-WNL hip ROM bilaterally except -5 deg of ext and 30 deg of IR
-Strength (equal bilaterally): Hip Abd- 4/5, Hip Ext- 4/5 (painful), Hip ER- 4/5, Knee Extension- 4+/5, Knee Flexion- 4+/5
-TTP bilateral proximal hamstring attachments to ischial tuberosity and L sacrotuberous ligament.
-Slump (-)
-Reproduction of familiar pain with Askling’s H TestPICO: In a patient with proximal hamstring tendinopathy, is heavy, slow resistance training more effective than eccentric training at decreasing pain and improving function?
**Due to the lack of RCTs on treatment of PHT, I used research for Achilles tendinopathy in conjunction with clinical commentary discussing treatment of PHT for this presentation.
1) When you are treating a patient with pathology that is not heavily researched, what strategies do you utilize to ensure that you are attempting to be evidence-based in your treatment?
2) How do you address the fact that one of the only strategies that the patient has found to decrease her pain (stretching) can likely be detrimental given her condition?
3) The clinical commentary by Goom that I attached below suggests a 4-stage rehabilitation program progressing from Isometric Hamstring Load->Isotonic Hamstring Load with Minimal Hip Flexion->Isotonic Exercises in Positions of Greater Hip Flexion->Energy Storage Loading in patients with acute PHT. Considering that my patient has more chronic tendinopathy and is not limited in her activity, would you still begin with isometrics? -
Hey Tyler! I am really excited about this case and article. I feel like a a residency class we have been focusing on tendinopathy dx and treatments. I feel like what you did in applying other tendinopathic scenario’s that are more common (such as the Achilles or RTC) is what I would have done as well. Although it is not the same area I feel like the properties are similar enough to apply those interventions to other areas and modify per tendon you are working with. As for the stretching, I would explain to the patient that although this was something that made her feel better to maybe give the interventions you were showing her a chance and hold off on the stretching until she is in a stage that it is more appropriate. In addition, I feel like even though the protocol offers 4 stages you should assess what stage she is in and apply the specific interventions from the article that matches her presentation then move forward. Where did you end up starting with her?
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Hey Tyler,
Thanks for posting-
1. I probably handle the lack of available evidence the same way you did – expand my search to tendon injury in different areas of the body, eg. Achilles and try to discern what’s applicable to my particular patient’s injury.
2. Regarding the hamstring stretching. My first step would be to have her demonstrate how she performs the relieving stretch. It’s possible she may be getting relief from some other aspect of the position besides actual hamstring stretching, possibly posterior pelvic tilting?. After checking that out, I would have the conversation about tendon injuries not typically preferring stretching. I would likely encourage her to keep it low intensity if she must stretch.
3. I think I may start this patient on isometrics in the first session, knowing that we may quickly move on to the next phase. It may help with reducing the pain that comes with sitting. -
Hey Tyler,
I think teaching isometrics if they are pain-relieving could still be beneficial. As you progress her program, they could be used on the off days to manage her symptoms. I would also be curious to see how she is stretching her hamstrings and what she feels about yoga is beneficial (again thinking along the lines of Justin – could it be core/pelvis positioning having an impact). Potentially an indication to add exercises focused on lumbopelvic stability, etc.
“She had physical therapy in 2016 which helped decrease symptoms. She has tried chiropractic care, steroid injections, acupuncture, and dry needling without relief.” She seems to have tried a lot of passive interventions without success – but PT has helped in the past…do you know anything about her previous program?
I was also curious about the nature of her LBP symptoms? Does she feel LBP when running or with similar aggs to her posterior thigh/glutes?
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Tyler,
As mentioned above, I would likely still work on isometrics to start. Especially if they are pain relieving like Sarah said. You could even use them as a “substitute” for the stretching. Maybe presenting it like “I recognize that you are stretching to look for relief from your symptoms, but lets give this alternative a try for a little bit and see if it makes any more of a difference in your symptoms”.
I agree with your rationale of utilizing concepts from achilles tendinopathy literature to aid in your treatment selection and interventions for this patient. I would (and do) the same thing, specifically for tendinopathies. I agree with Jen in that I have gotten a lot out of residency in regards to tendinopathy and feel that I am improving in my ability to treat tendinopathies in a variety of locations by utilizing concepts gained from literature such as achilles research, since it is so much more prominent.I had a question or two about your case as well. I am wondering what lead you to a proximal HS tendinopathy more so than gluteal involvement? Hip extension seems to be a strong asterisk for her (OKC hip extension, limited/painful posterior hip glide, MMT hip extension, etc.) and I am just wondering what lead you to PHT>glute for my own future reference? Was it the TTP of HS attachments and the pain with sitting that swayed you?
Also, what is the Askling’s H test? I am unfamiliar…Looking forward to Thursday!
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ahh, thanks for the clarification, its hard to visualize without the patient in front of you. I also evaluated a lady with PHT today, so this was super relevant! excited for tomorrow!
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Hey Tyler,
Erik Kreil here, I graduated from LCDPT 2017 and am excited to begin the program at the Progress PT location in Glenn Allen.
I have to say, that was such an interesting presentation of a convoluted case yesterday that lead to some really interesting discussion of the importance of specifically describing a patient’s irritability when determining stage of classification in a protocol for treatment.
I think the group discussion hit on some important points — will you keep me posted how she progressed through rehabilitation?
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