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1. Overall thoughts on the study? Anything stick out to you that I didn’t mention?
– Like you mentioned Scott, I thought this article reviewed the relevant gait mechanics in a straightforward way, which is always pleasant. I thought it was interesting that there was a 1:1 ration of the percentage time spent in eversion during stance and the increased risk of injury. I think these sorts of statements help me to remember the important findings more easily. I liked that they called attention to the static morphology of the tibial varum angle and why that might be a factor in the increase eversion time.2. What are your thoughts on associations between MTSS and AT? Why are they so similar biomechanically? I didn’t group these conditions together previously, but I sure do now!
– I think the most simple way to group these two diagnoses together is by looking at them as diagnoses associated with training error ie improper recovery, improper footwear, large increase in volume etc.3. We have beaten AT to death with our tendinopathy write-ups, but what are your common exam findings and treatments that you use with MTSS patients?
– I have not seen very many patients with this dx, but I would expect pain with palpation of the posteromedial tibia. I would expect a more cavus foot that has mid and forefoot hypermobilities compared to a hypomobile talocrural joint. I would expect over-pronation with increased loading of the LE kinectic chain: SL balance > SLS > double leg hop. As the motion was more approximated to running (SL hop) I would expect pain provocation. For treatment I would focus on education (inc rest days, dec mileage, improved sleep/nutrition, cross training) first, orthotics to control the pronation in the latter part of stance, intrinsic strengthening, proximal weakness/hypomobilities. Just like with AT the idea is about modifying what you can and then slowly began re-introducing stresses to those tendons.4. For running analysis, what tools do you use in the clinic?
– We use Hudl. I’m sure others could speak to the positives or negatives of each, but I’ve liked Hudl for the basics.5. What cues can we give these patients that won’t just screw them up? (Looking for some input from Eric Magrum on this one).
– Cadence, as Eric mentioned, would be my first thought. Besides cadence, you could modify their striking patterns to more of a midfoot strike by cueing them to land softly/quietly. I think this is an external cue that most people can make sense of fairly easily and promotes landing through the mid foot more. As for exercises you could do several variations of things to promote increase supination at toe off. This could be done with a box step up with heel raise focusing on supination, or using the sport cord while doing a heel raise and contralateral high knee into the resistance.6. What orthotic or taping interventions have you used with patients with AT and MTSS? I’m starting to try more of these in clinic, and I’m eager to see what you guys have up your sleeves.
– As the article mentions, if a runner has a hypermobile midfoot and forefoot and are over-pronating then they wont have a stable base to push off from during terminal stance. I think a motion control orthotic (we use vasyli), possibly with additional medial rearfoot and midfoot posting would be helpful. As we’ve talked about before for AT, a heel lift or medial rearfoot posting would likely decrease the stress through the tendon.I don’t have any dazzling examples like you all, but I do have one that highlights the importance of this concept. For several months I have been seeing an 18 yr old male high school pitcher who has had IM 1 yr h/o L anterior shoulder pain and decreasing velocity with throwing. I saw him after he had taken 3 weeks off and his shoulder was minimally irritable, with only an uppercut motion and palpation of the biceps tendon reproducing even minimal soreness. He had ~20 degree loss of total shoulder rotation and had rotator cuff weakness in IR and ER. At the IE I looked at him do L SL balance and a SLS and unsurprisingly he had deficits: compensated trendelenburg, dynamic knee varus into valgus. It wasn’t until I watched a video of him pitching the next session though that I realized I needed to look further into his hip motion. He was 10 degrees shy of neutral hip extension and had only 15 degrees hip ER on his L. With sprinkling in some hip mobilization, self mobilization, and stretching he now has hip extension to neutral and his hip ER is symmetrical. While he isn’t pitching at game speeds he has been doing well with his interval throwing program and has been able to increase his distance and then velocity without symptoms much more successfully than when he had tried in the past. I think I would have missed out on a lot of important secondary factors if I had only focused on the upper quarter.
Erik, I think your case and second comment really highlight the importance of thinking through what the reassessment or continued assessment will be in the first follow up or two. It’s hard when you’re behind on notes and would rather be doing something else, but I try to take the time when I’m writing up an eval to really wrack my brain about what else I can look at in the next sessions. Obviously you can’t do a CRF on every patient, but I find running through a few of those items each eval helps me catch things I might miss until weeks later. I feel like this is especially true for those frequently secondary sites of importance: elbow, wrist/hand, and SIJ (essentially doing more than just ruling out with the cluster).
Between this and the Bialosky piece, seems like cheeky extended metaphors are the way to get published these days! But really though, I love this perspective, especially since it’s coming from some of the biggest researchers in our field for this area. I think the quote, “Clinicians should quit looking for overly simplistic answers”, is perhaps the over-arching point of the article, and one that is important to keep in mind throughout our practice.
Since the start of the residency a few things about my use of special tests have changed. After the stats presentation by Dr. Cross I think I pay more attention to the inclusion criteria and gold standard in studies looking at special tests. I certainly am more interested in +/- LR than I was before the Fall. The biggest thing is not feeling wed to one particular test or particular result, except for some rare exceptions. It’s all about looking at the big picture and clustering findings, something that I think I struggled more with earlier on in the year. I think knowing that the metrics on a lot of tests are pretty dismal also lets me feel more comfortable modifying the tests slightly, looking as a measure of tissue irritability versus a straight yes or no sort of result.
AJ, thanks for posting. It certainly wasn’t on my radar but definitely makes sense. I think for my patient in particular, he had a MOI (albeit a rather innocuous one) and overall was not very irritable. The heel drop is not something I was really using before this fall so in my limited experience I’ve seen both irritable and non-irritable patients with positive tests, with the magnitude of their response correlating with their overall subj/obj irritability.
I’ll keep an eye on this gentlemen going forward and certainly will consider something like discitis in the future.
Interesting read. My small brain had to re-read it multiple times to appreciate some of the points he was making. After reading this my mind immediately goes to the “guru” practitioner that gets everyone better. Maybe their confidence, patient rapport, showmanship, etc. all contribute to the results they claim for a particular technique. I think this certainly adds another wrinkle to what might separate expert versus novice clinicians.
This article also highlights things we’ve already been aware of and have talked about before, with the importance of language and of patient expectation of improvement. Coupled with what we had briefly talked about with nocebo effects this weekend, I think it just continues to drive home the importance of effective patient-provider communication.
At the end of the day, analgesia is only one of the proposed benefits of MT, so while I think this article is good as a reality check for practice and research I don’t think it vastly changes my MT world view.
Eric thanks for posting. Since I have yet to see someone with this diagnosis my thoughts really just boil down to some questions I had for you/others:
– What special tests do you like to incorporate? I like the idea of using the malleolar compression as a quick test during functional mobility, but I’m not sure how much utility that has during an eval or during assisting a provocative movement during treatment.
– What have you found successful for bracing/taping? Eric I know when you had that eval it seemed like you spent a significant amount of time discussing the patient’s current orthotics.
Good to see everyone this weekend!
I’m less hip on PT podcasts, blogs, etc. so I don’t know very much about using blood flow restrictive training. I’m typically a believer in a “believe none of what you hear and half of what you see,” sort of mantra. I do know that the cuff that is sold through the store on Modern Manual Therapy is 130 (save $10!) and that could be put towards other things in a clinic instead. I think for this population my mind goes more quickly to NMES or any number of different patellar taping techniques, both of which are things that could also be done at home if it seemed appropriate for that particular patient. My assumption would be that those interventions are also slightly more user friendly than the restrictive training for at home use, but that could be incorrect.
As for the article, the main results are definitely interesting. Less pain with ADLs and improved quad strength are two pretty relevant outcomes, and maybe this would be a useful adjunct to care early on for more irritable PFPS. I’d be interested to hear everyone’s thoughts on the exclusion criteria…
Katie, how are you tracking the area of symptoms currently? Mapping it out like in the LANSS or taking pictures?
How often are you seeing this patient?
What does this patient do to cope with her symptoms? Were there emotional triggers early on that contributed to these symptoms?
1. None at this point. I do have a patient s/p plical excision with some impressive color changes (deep purple) around her patella but seemingly none of the other signs of CRPS besides a high level of pain. For this patient using TENS has helped her be able to do more strengthening in the clinic without a greater flare up in her symptoms. I’m not sure if your patient could tolerate this sort of intervention at the moment, but maybe further down the line when strengthening might be indicated.
2. I have not had this situation nor would I pretend to know how to best navigate this situation. I think I would fall back on what helps me with any emotional patient: body language. I try to make sure I lean forward, make eye contact, not cross my arms etc. I think just listening without trying too hard to redirect back to the matter at hand typically works the best.
3. Again I’m not sure if I have a great answer for this. I think keeping contact open with her PCP might be a good step, but it would be helpful if there were some kind of management tree/algorithm for CRPS. What sort of specialist in your area would you want to send this patient to?
Scott, did these other pain areas correlate with life events like his current symptoms?
And do you know any of the doctors that he has consulted with so far, whether that be his PCP or the surgeons? Maybe reaching out to them to ask what their thoughts are on psychological counseling and whether they had any recommendations on who or where that might be most appropriate. Couldn’t hurt to have someone else potentially on your side.
Question for Katie/everyone: is this an area of pain science research that should be emphasized in physical therapy research? In a JOSPT from mid last year the intro opinion article made a point of talking about how our pain science research should focus on decreased costs of care and translating current research into actual clinical practice. Which is more important to advance our work as clinicians?
Justin, I’d love to hear your experience if you do use this as a visual aid with a patient, as I feel like I would struggle to be concise with breaking down what is happening in those visuals and why it matters to that patient. You are a much more charismatic man than I though…
I do like your approach with directly asking about the FM from the intake form. Sometimes I wait to see if a patient makes a point of bringing it up on their own, especially if it is something like you mentioned where it is self diagnosed, but it might be better for everyone if it was addressed early.