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Eric,
Thanks for this article. I think this was very helpful for me in considering differential diagnoses prior to the subjective history and can help me formulate more specific differential-based questions. I just saw a patient with medial groin and medial thigh pain last week, and after reading this article, I think I should have had a peripheral nerve entrapment on my differential list going into the subjective.
I also think the way they broke up the possible areas of entrapment for each peripheral nerve was helpful. I don’t think I had considered the correlation between previous hamstring injuries in those with sciatic nerve complications, and that is likely a question I will ask in the future when I am suspicious of sciatic nerve compression in that region.
The special tests that they listed with their metrics were exceptionally helpful as well. I also agree with Jen in that this article was helpful for patient education on conservative vs. surgical management of peripheral nerve entrapments so that patients are aware of the treatment options.
Hi Sarah, thanks for posting!
It sounds like this patient would have fit the inclusion criteria in this study, although I am wondering if the author’s note about the high percentage of the participants who had more chronic pain than your patient does caused you any concern about the applicability of their results to your patient? As we know, chronic pain can present very differently than acute pain, such as with your patient, and I am wondering if this caused you to interpret the article’s results any differently for your specific patient?
In your objective exam, did you look at ER/IR ROM? I see that you said she had trouble putting her hand behind her back as an aggravating factor, but was there any kind of ROM limitations there or capsular pattern?
As for your third question considering thoracic manipulation with these patients, I think I go to mobilization before manipulation, although admittedly, I do not have a much experience treating this patient population. In my limited experience, I have gone to mobilization before manipulation as well as giving thoracic mobility exercises for HEP. I think if I were having success here and her irritability at the GH joint prevented aggressive intervention to the shoulder, I would consider manipulation at that point.
Looking forward to hearing more tomorrow!
Hi Jen, thanks for sharing!
I would think that with this case as presented, the steroid dose pack would have helped. It is unfortunate that it does not seem that it has made much of an improvement, and additionally seems to be worsening from what your assessment says. I think my primary hypothesis according to what you have presented would be an injury to the disc with subsequent nerve root involvement, potentially a neuritis. I am wondering, did she get the LE sx immediately with the LBP? Or did they take longer to become apparent?
With patients who are highly irritable, my goal day one is usually sx relief. It sounds like your patient is somewhat familiar with comfortable and uncomfortable positions for her, but I am wondering if you were able to educate her on potential positions/movement strategies for relief of her sx? I think that leads into your question about traction. Did you try any manual traction day one? I would want to assess that before initiating mechanical traction.
Looking forward to hearing more this weekend!
Hey Scott,
I dont know if you’ve seen this one yet or not. This is the article I am doing my December article review on. Its in the most current BJSM issue and explores biceps tenodesis vs. labral repair vs. sham surgery in patients with type II SLAP tears. They found significant improvements in all outcomes assessed in all three groups with no difference between groups.
Like the article you posted, I think this one provides an excellent educational opportunity for us with patients presenting with these impairments and pathologies that are considering surgical intervention for their pain.
Hi Scott,
Thanks so much for posting! This is a great article and I definitely plan on using it for an educational tool for patients. I also like your strategy for patient buy in by loading the tendon in a position of decreased subacromial narrowing. My caseload is very light on shoulders right now, but I utilize a similar strategy with my patients with meniscal pathology. I use the article Kyle referred to to educate them on surgical outcomes vs. therapy to try to get them to commit to a month of PT to see if we can make any kind of changes without surgery, and re-evalaute at that time. I tell them if they aren’t seeing any changes in their symptoms by then, maybe we can consider contacting their MD regarding their symptoms. In these patients, I usually try to “feel out” their opinions on surgery, if they seem hesitant, I usually try to use this hesitation to try to convince them to give therapy a try before surgery.
Hey Tyler, Thanks for sharing. I think its interesting that they upgraded the neuro re-ed and NMES from B to A. It makes so much sense in my mind to utilize these tools with these patients, its great that there is such high evidence coming out to support the utilization of these tools. Its something unique that our profession has to offer these patients and we need to own it!
I think this article provides an excellent example of asking specific differential-driven subjective questioning. Questions regarding running surface, changes to training, running shoes, pain descriptions, when in their running cycle/time pain comes on, and types of running (long-distance vs. sprinters). While I am not currently seeing patients of this population, I think being aware of these types of questions when stress fracture is on a differential is extremely important.
I really like the charts in this article as well as the factors listed that can modify the load applied to bone. I like the way the article breaks up the biomechanical factors, training factors, muscle factors, running surfaces, shoes, and the bone’s ability to resist load without damage. This breakdown of factors helps me formulate a list of potential influencing factors and prioritize what I can address. While I cannot change all of these factors, I think it is important to examine the factors that I can change in my objective exam and in subsequent treatment sessions. After reading this article, I think making a point to utilize a more “running specific” objective exam is critical with these patients. Watching them run and perform SL tasks is a must.
Tyler, I usually use the Brigham and Women’s Hospital return to running protocol. It provides strategies for advancement and regression as well as what pain is “okay” and what is “not okay” in regards to return to training. (Like I said, I don’t see a lot of these patients, but this is one I have used in the past).
Hey Justin,
I recently evaled a patient with central sensitization following an infection in his hand, he presents with shoulder and neck dysfunction/pain. AJ sent me several good articles on central sensitization (which I have attached) involving what it is, how to explain it to patients and some treatment strategies. I don’t know if these will be super applicable to you and your patient, but I found them very helpful with my patient!
Best of luck, these patients are tough!
I think one thing I took away from this course the second time is the apparent lack of utility for an oblique view of the lumbar spine. I have a patient right know, whom I suspect may have a spondylolisthesis, and I was under the impression an oblique view would be the best image for this type of patient. However as mentioned above, Dr. Deyle’s emphasis of “do no harm” and performing only images in the best interest of the patient has caused me to second guess the necessity of that particular view, as opposed to perhaps a flexion and extension set of lateral views.
I think I definitely got more out of this course by going through it a second time, I always learn better when I have examples of patients to apply new knowledge to as I am learning the material. Last year I was just trying to keep my head above water ;)Hi Tyler, I have a somewhat similar case I am working with in the sense of struggling to manage two body regions. My patient had a fall a year ago and then experienced CRPS leading to disuse of the entire right UE. He has severe mobility and strength impairments of both the hand and shoulder now that the CRPS has cleared up some. He is most concerned about his hand, stating that “the shoulder will get better once I get it replaced”. However in the evaluation, we discussed working on both regions and came to the agreement to treat one body part each session and alternate between the two. While this is only one case I have personally been responsible for managing, I think discussing the plan of care to address both body regions independently with each visit was successful for me. That way when he comes in on Monday, he knows its a hand day and when he comes in on Wednesday, its a shoulder day. Maybe try something like that with your patients? Good luck!
Hi Justin, I just had a few questions regarding the provocation of his distal symptoms. It sounds like his left rotation and sideband are the strongest objective ROM asterisks you have as well as the ULTT for reproduction of local and upper trap symptoms respectively, but I am wondering if you were able to bring on his upper arm, elbow or forearm symptoms? Or if maybe his irritability prevented you from further provocation testing?
Looking forward to hearing more this weekend!
Hey Jen, thanks for posting! This case and article was very helpful for me, as I just saw a patient with cervicogenic headaches and myofascial pain in the cervical region this past week.
I think that your first question is a good one, and I think I consider the use of the C1/2 manipulation even though your patient has OA hypomobility similar to our discussion at the last course about utilizing thoracic manipulation for cervical pain as a way to “gain access into the system”. I also think it is realistic to have some effects occurring at adjacent segments when we are manipulating, so a C1/2 manipulation could potentially benefit one with a OA dysfunction. Getting into your second question, I used manipulation with my patient to affect the cervical myofascial tissue in the surrounding area, so that could be part of the apparent benefits of the bilateral manipulation as well.
My only issue with this article is that I wish that the manipulation group also got exercise (or that the mobilization group didn’t get exercise), I feel that it is a little bit of an unbalanced comparison. I am also wondering what your opinion on patient education and dependence/independence based on their results. From this study’s results, it appears that we could manipulate our patients and then send them out the door and they would still get better than those who were mobilized and got exercises. I am wondering if the results of this study could foster dependence from our patients and less self-efficacy in their symptom management. I am curious about the nature of the conversation that you had with your patient regarding manipulation, its effectiveness, and the role of exercise (if any)?