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Some initial thoughts…
Possible differential diagnosis:
TFCC injury
DRUJ instability
ECU tendinopathy
Ulnocarpal impaction syndromeSubjective:
– 24 hour symptom pattern – morning vs evening
– when does it swell? does ice help? has he tried a brace of any sort?
– numbness/tingling
– does it seem to be getting worse, better, or staying the same over the past 4 months
– snapping/clicking/popping?
– does hand/wrist position change pain while picking up an object? (supinated vs neutral wrist position)Objective:
– elbow/wrist AROM, PROM, resisted testing
– carpal palpation, intercarpal mobility testing
– TFCC grind testImaging – I’d want to refer for imaging if I suspected a fracture or another condition that would require surgery… I haven’t seen many hand patients so I’m not exactly sure what subjective/objective findings would lead me that direction.
Nice points, Brandon. I especially agree with your idea about using the tests to progressively overload the system.
I like to view these tests as part of a bigger cluster. Yes, on their own, they are not great but this is why we cluster! Use info from the subjective, the description of their symptoms, mechanism, etc to then have a series of data points that lend support to rule in/out diagnoses. As the authors pointed out, it doesn’t add much time to do these tests so they may be worthwhile, however, at the end of the day “do no harm” is the major player in my book. We have enough ways to treat patients that don’t involve cervical mobilization/manipulation and end range techniques, that if there is even a small part of me that is concerned about VBI, I’m probably not going to go that route. Why do a risky technique when other techniques might yield the same result?
At the very basics of the test, I think it is interesting to note the effect of the Circle of Willis. We think we are restricting blood flow and looking for symptoms, however, it’s really more about the rest of the circulatory system and how well it is able to compensate.
Great points Anna and Taylor. Love the creative thinking!
I like Barrett’s impingement cluster and totally agree about the labral involvement points he made. I have a hard time thinking she wound up with a labral tear from a “bump” a year ago. Does she seem to be hyper-mobile in general? And what did the apprehension test look like on her non-involved side? I’m on board with the biceps involvement based on your thought process, Taylor.
Also – it’s interesting to me that you had adhesive capsulitis as first on your differentials (or maybe your list wasn’t in order). That one is usually further down on my list just because I feel it isn’t quite as common as impingement or other RTC issues. What were your thoughts with that?
Whoops – a bit late to the game here.
My other issue with protocols (that hasn’t already been discussed) is that we need better medical team communication. If a surgeon gives me a protocol, I think it depends a lot of the specific surgeon as to whether or not they are okay with me discussing tweeks to it. I think the old school surgeons tend to think we are just glorified personal trainers and should just follow their directions, while more forward thinking surgeons recognize our clinical reasoning and are open to discussion. I tend to be like Taylor and shy away from confrontation with the docs if they start to tell me I’m wrong, though I should probably be more like Eric and hit them with a bunch of research… I think I worry that if something goes wrong with their recovery/surgery, if I’m the one that went away from the protocol, it’s way more likely to be me that’s blamed for the outcomes than the surgeon.
A few questions – what do we think about the elbow findings? Seems like there might be two things going on. Same question as Anna – did you palpate around the elbow and the deltoid tuberosity? Wondering about referral vs local muscular involvement.
What led you to doing the anterior slide test? And was the “positive” findings the true positive -clicking and reproduction of symptoms? For apprehension/relocation was it familiar pain?
Per Eric’s post: I would have done the radic cluster probably first (Spurling, distraction, ULTT, cervical rotation) and looked at ruling at the neck/neural involvement before I did shoulder special tests. The research on shoulder special tests is so bad that I would have wanted to use the stuff that IS well researched to rule out my differentials first.
Can we also talk about an elbow “screen”? I tend to do AROM with OP and resistance, palpation, and grip strength… what do y’all do? I also think you might need to take a closer look at her elbow given the findings.
Differentials
– impingement
– cervical radic C4/5
– infraspinatus referralQuestions (post Taylor’s clarification already)
– head position affecting symptoms?
– how long did the gripping issue last? was the “difficulty” due to weakness or pain or both?
– had she been treated for this over the past year? when did she start this new workout routine?
– does she remember more about the “started at the elbow then radiated to the shoulder” situation? how long was it like that before it switched to this new pain location?
– any other variables to note? maybe something happened earlier in the day and she doesn’t realize it and instead blames the “bump” into her arm – this just seems like too insignificant of an event to cause her symptoms and pain for this long
– yellow flags? super anxious? stress levels at home/work?Objective tests
– neuro – reflexes, dermatomes, myotomes
– cervical radic cluster – if ruled out, proceed with neck exam
– elbow clearing exam including grip strength
– shoulder exam – AROM, OP, joint mobility
– shoulder special tests for instability, labral involvement, impingementI wish we could have been in person for this and had the lab but it was still awesome with so many good take aways, most notably being:
As everyone mentioned the review of nerves and nerve entrapments in the lower extremity was incredibly helpful. I tend to focus on the major ones so having a comprehensive review will certainly impact my foot/ankle assessment moving forward.
I loved the talk on pediatric sports, especially the importance of rest.
Like Lauren said, the S’s of treadmill running analysis will come in handy in the clinic to give me a framework to base my assessment on as well as the functional tests to determine running readiness.
In general, the diverse group of presenters was awesome. It was really cool to hear from both PTs and non-PTs. I think the surgical perspective gave me a lot of good insight into the non-PT based treatment of some of these conditions.
1)Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
Primary: L cervical facet
Differentials: muscle strain (L paraspinals), mid cervical disc2)Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?
Whiplash associated muscular dysfunction. Sounds like he’d fit into the motor control bucket possibly since all head movement is a bit painful. Could still be facet but less likely given subjective report.3)After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
I think it still seems muscular… Weakness noted with rotational resistive testing (was it painful?) and not a strong directional preference. What was the quality of movement like (aberrant movements?)?
4)What else would you have asked in the subjective and/or what other testing would you have performed?
– Headaches?
– when in relation to the MVA did his symptoms start
– MVA – rear end, T bone, etc? How fast? Did he see it coming? Did he go to the hospital afterwards? Whose fault?
– vision changes? nausea?
– how have his symptoms changed since June
– 24 hour period: morning pain vs evening pain
– Craniocervical flexion rotation test
– deep neck flexor endurance test
– UPAs
– with palpation – was that muscular at C2-4? wondering about SCM, UT, levator, suboccipitals1. Based on the body chart and subjective, what is your primary hypothesis and top 2-3 differentials?
Primary: PFPS
Differentials: meniscus injury, MCL injury, patellar tendonopathy, stress fx2. With the subjective and objective information, does this patient fit a clinical pattern?
Not a very clear pattern – now between PFPS and patellar tendonopathy based on functional assessment. Doesn’t seem to be a ligamentous injury.3. Do you feel like you need more subjective/objective information for this case, and if so, what?
– Palpation of quads/adductors – wondering about a pes anserine irritation vs restrictions in her quad that may lead to more of a patellar tendonopathy diagnosis.
– As Taylor and Brandon mentioned, more info on running history: is this new for her, treadmill vs outside, how old are her shoes, what’s her normal mileage, any cross training?
– Observation/assessment: foot/ankle – arch strength/positioning while walking/standing/running; pronation/supination
– resisted testing of adductor; quad testing in a variety of ranges4. What is your treatment for day 1 and what are you reassessing next visit?
– education on preventing dynamic knee valgus
– lateral steps with band at midfoot with cuing for proper form
– reassess squat at next visitI’ve been thinking about this article so much this week! I tend to do a lot of assess/re-assess to determine effectiveness of my technique and really look for within session changes to guide my treatment.
For example – anterior hip pain – positive FADIR, FABER, and psoas and pain with active hip flexion (just to be brief). I had him run then did soft tissue to psoas and then had him run again. No change. Then I tried mobilizing his hip joint and had him run again. No change. Then I had him do lateral band steps and side planks to better activate glute med and had him run again. It was better. So then I concluded that getting his glutes on would make the most difference, so that’s what I gave him for home. Maybe not a super fantastic approach, and you could argue it might have been the compound effect or that I did too much within the one treatment session and if he came back worse we wouldn’t know why… but I think it helps guide my treatment and gives me good information. I’ve seen this strategy work well and my mentor really emphasizes it as well. Thoughts??
I think we need to believe in our own techniques in order to teach and educate our patients well. A big point is that if we don’t feel good about it, but then we repeat it over and over to patients, then it becomes our norm and then we don’t know how we got there.
It’s tough to not just practice in a well rounded, educated manner. Taking into account clinical experience, research, the individual patient, and what we’ve been learning can be a lot to figure out how to fit into one patient session. I think we continue to strive to make ourselves better, and not just settle into an easy routine, then that’s about all we can ask for.
Such a good article that really calls out why we are still doing things that for one aren’t supposed by evidence and two that almost contradict each other (mobilize the SIJ but give stability exercises for home).
Thoughts:
– the movement that happens at the SIJ is SO minute, how can we think so highly of ourselves that we are able to detect it?
– if the movement is minimal, why treat it like it has a major impact (i.e. mobilizing to get back 1 degree of motion is likely not relevant to the patient)
– I think Anna picked two of the best quotes from the article – why are we even teaching PT students the Gillet test if we aren’t even good at finding the PSIS?!
– I love the idea of talking about tissue sensitivity and neurophysiologic mechanisms as a rationale for why exercise is the best bet in most of these patients.
– We as a profession are movement experts – not ANTI-movement experts. We’ve got to stop (intentionally or unintentionally) making people fearful of movement.Great article with lots of good take aways to apply to our daily practice. Sending this to my coworkers!
Interesting case, Lauren! I don’t have any experience with NOF in patients. I think it’s good her sport is low impact, and I would maybe limit the amount of impact exercises I gave her just since there is an increased risk of fracture.
Other questions – how big is the NOF? Any idea how long it’s been there? (wondering if it’s new and therefore more related to her current symptoms, or it’s been there for years so it’s possible for her to be asymptomatic) Do you know the stage of lesion?
I’d want to know more about the aggravating factors – I feel like there’s no way her symptoms are the exact same degree/location of aggravation with both biking and running. If so, it’s not a weight bearing/load sensitivity issue I suppose. Specific to rowing – which part of the motion is bothersome? On the erg, is the forward position with increased dorsiflexion or pushing back or another part? I think getting more details on what part of the activities are aggravating and in what way would be helpful. And how much rest is needed for symptoms to subside?
Did you test resisted inversion? And what about neural tension in the medial ankle like a SLR with a tibial nerve bias?
Hope some of that is helpful! Good luck!