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Erik – “pain is a concept built on perspective and experience”, got me thinking a little off topic… I feel that our treatment/management of this younger patient and other adolescents presenting with MSK injuries could have a serious impact on their future perspective (for better/worse) of pain and other injuries. I feel that education is key with this age group, making sure that both they and their parents received a positive message on how to manage and recover from whatever issues they may be presenting with.
To the case I like everyone initial idea to use our CPR (pittsburgh and ottawa) to determine if further imaging would be necessary prior to initiating treatment. Key questions I’d be curious about would be any recollection of knee/hip/LE position during MOI, immediate WB status s/p backhand, knee A/PROM, and palpation. Do her symptoms appear to be “fx quality pain?”. Also I would want to know her experience with gymnastics.. Is that her only sport? How long has she been participating in? What does her training schedule look like? And how many backhand springs has she performed in her lifetime?
As for gaining information, communication could definitely present as a challenge as children are very poor at describing symptoms. I typically attempt to give some examples of activities when I collect subjective information from adolescents and try to piece together some information from the parent if they were present during the injury or to help fill in the blanks from initial onset to initial evaluation. Jeff I like your point of “show me” as we might learn more from them in action after collecting whatever subjective information we can as that may look significantly different from what they portrayed to us. With that being said every adolescent is different some of them are wise beyond their years and are ready to answer all our questions and needs to be approached case-by-case in my experience.
Interesting scenario here especially with the patient only being seen for 3 visits and already being recommended for advanced imaging despite the initial findings and noted functional improvements and tolerance at work since beginning PT. I think Jon and Cam hit it on the head here where our role is to provide as much education we can to this patient so that they can make an informed decision on their next steps for care. For me I might be a little more aggressive on advising against pursuing an MRI especially due to her financial situation as it seems unnecessary at this time. I like your suggestion Cam of not completely shooting down the idea of an MRI but providing the alternative of giving PT a few more weeks/session to see how symptoms progress. I would also be sure to ask her more about her follow up with her NP-C to see what type of message was being passed along to her during her visit.
I agree with everyone’s earlier remarks regarding wanting to know more information about the patients running history, running schedule etc. prior to jumping to immediately refer out for imaging.
One thing I was considering which Cam touched upon was if I was suspecting potential tibial stress fx, being a low risk region, how much would an imaging confirmation change our initial POC with this patient? The articles discussion states …“When there is strong clinical suspicion of a low-risk stress fracture and initial radiographs are normal (eg,assumed false negative), imaging confirmation of a stress fracture is unlikely to alter patient management.”
With this patient being DA it appears that his symptoms are getting worse and I would lean towards recommendations to modify activity including more cross training w/ dec running for the short term to see if that resulted in any improvements. If symptoms did not seem to improve I would push for an MRI depending on feasibility due to its high sensitivity and specificity to help confirm potential stress fx.I had a HS female runner come in a couple months back with c/o of anterior lower leg pain worse with her first few steps in running which improved as she ran more. Her sx ended up being more myofascial in nature as she overstrided and was a heavy heel striker. With this I feel it would be appropriate to have this patient run for us if he could tolerate to determine if there were any other running mechanics we can alter to decrease his symptoms irritability.
I also had a HS basketball athlete present with lateral foot pain and a Dx of peroneal brevis tendonitis. Upon evaluation he was severely tender to palpation over his 5th met and 5th metatarsal stress fx was high on my list. However, prior to arrival MRI was performed and was negative. He was treated with walking boot prescribed by his orthopaedic and his symptoms improved with activity modifications and we progressed him accordingly.
Interesting articles here especially being performed in two very different regions of the world. I am not sure what the PT curriculum was in these regions of the world when these articles were published, but I had a separate pharmacology course which I am not going to lie was like a different language for me. My understanding is that they take different pathways for their effects hence the different side effects listed, but beyond that I feel that my knowledge is not comprehensive as the ontario article had mentioned.
WIth that being said during my first year of practice I have found myself to be on the more conservative side when it comes to recommendations for NSAIDs and acetaminophen. I would typically ensure that patients are not abusing their use and staying within the recommended amounts and doses and attempt to wean them off of their use as treatment progresses. At the same time I make sure they are aware that these are not completely scope of practice as we cannot prescribe meds and if they had more questions to address it with their doctor or pharmacist.
I loved that the New Zealand article (2011) brought up the discussion of NSAID use within the first 24-48 hours of sprain/strain as there is conflicting views. Thus far I have yet to see patients day of or the day after injury so I have not had to make these recommendations. I believe that NSAIDs should be withheld during the first 24-48 hours due to impairing the inflammatory response necessary for tissue healing. While these medications do have their benefits when used appropriately I believe the more we can sway individuals away from a pill to solve their problems it may deter them from seeking more medications for their problems in the future.How does this information change you differential list? Any concerns?
– After this objective information I think my differential list would remain the same with lumbar referral and hip OA being my two primary and glute tendinopathy cracking the top three due to reproduction of SLS, and hip ABD. With that being said as jeff mentioned he demonstrates signs and symptoms that makes me believe he might have two separate issues going on here that are resulting in his irritable state.
– The swelling noted on his R ilium raises a few concerns for me especially with no direct MOI. With that and his high irritability I would want to keep a close eye on how he may progress.
What would you have done differently?
– I would have performed a neuro screen especially w/ positing neural testing and further assessed l/s joint mobility to see if there may have been any reproduction of hip sx.
Day one
– Number one for me would be attempting to address his sleeping issues. If he is not able to get comfortable and sleep comfortably that is a big concern for me. If he is not sleeping well he is not giving his body time to shut down and recover. Talking through strategies w/ potential use of pillows and seeing if we can find a position of comfort could help calm down his system.
– Treatment wise I would probably attempt to address some of his L/S restrictions due to the irritably of his R hip examination and see if that changed any of his symptoms.
– HEP would have been on the conservative side as well due to his increased irritably during initial evaluation. I would likely lean towards gluteal isometrics and recommend the use of a recumbent bike to incorporate some cardiovascular component back into his regime if he could tolerate the hip flexion moment.Hey Casey, I just have a few clarifying questions that I may have asked during my subjective questioning to hopefully better guide my objective examination. Did you happen to clarify which position he prefers to sleep in/ what position give him his pain? Getting into and out of his car did his symptoms change if he was getting into the drivers side or passengers side? Additionally did he have hip symptoms initially when he had this most recent episode of LBP, does his LBP and hip symptoms have similar aggs and eases? Has he had treatment for his low back in the past? When he says stepping wrong over-striding/under-striding, side stepping? What did he do for work in the past/did that lead to his initial onset of LBP?
With this being said my diff Dx is as follows:
– Lumbar stenosis w/ dural irritation
– R hip OA
– Lumbar discogenic referral L3-4With this information I would probably start by assessing his L/S and a through neuro screen. Based on what information I am able to gather there I would move towards his hip and see exactly what sleeping positions seem to be provoking his symptoms.
Yellow/Red flags?
– Completely stopped daily routing and working out due to fear
– Unable to tolerate sleeping in bed
– “pulling his back out” with no MOII am definitely curious to see what everyone else thinks and how you approached the rest of your evaluation.
I agree that questions regarding sensitivity and irritability would help guide how much we might do on initial evaluation and that red flag questions should definitely addressed here.
I am a little more curious about the MVA, how was she hit, LOC, air bags, imaging? She notes HA and neck spasms but did she have jaw symptoms prior to the accident? If so did the MVA change her sx in any way? If not did the HA and neck spasms correlate with any jaw symptoms?Secondly I would like to know a little more about the dental procedure, what was done? how long was the operation was her mouth held in an open position for an extended amount of time? Other than experiencing more constant symptoms has the intermittent clicking been changed since the procedure/ where in the chewing/eating process does the clicking occur (opening vs closing) and is it one click or two?
List your differential diagnosis after the subjective exam.How does this re-rank after the objective exam? Primary hypothesis to conclude?
Post subjective:
– Lumbar clinical instability
– Lumbar discogenic dysfunction
– Lumbar facet mobility dysfunction
– SIJ dysfunction
– Myofascial hypertonicity
Post Objective:
– Lumbar clinical instability
– Lumbar facet mobility dysfunction
– Lumbar discogenic dysfunction
– SIJ dysfunction
Primary hypothesis
– Lumbar clinical instability (+resting posture, movement screen, TrA control, prone instability test, PA shear testing, aggs – sitting prolonged periods of time)Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
– I might have asked a little more about her responsibilities in relation to taking care of her mother-in-law. Does she require any assistance with transfers? ADL’s? etc. and how do these activities if she participates in them affect her symptoms?
– Is her only goal of PT to make sure that her back pain does not get worse?
– Also I’d like to know a little more about what finally brought her into PT if she has been dealing with these symptoms for over the past 1-2 years?List any Yellow or Red flags you’d consider for this case.
Red flags – none
Yellow flags
– “I know my back is a mess. I’m just hoping you can help me, so it doesn’t get worse”
– Occupation: caretaker for mother-in-law with depression -curious what her daily interaction is like and how that affects her
– Avoiding leisure activities, i.e fishing, hiking – due to fear of pain
– PMH of depressionErik great breakdown of the patient presenting in front of us. She definitely has many factors working in her favor here as you mentioned, however her symptoms seem to be worsening leading her into our clinic.
I also do not have much personal experience with treating patients with CMC OA. There was one patient who Kristin and I worked with the other day complaining of radial sided wrist pain and my initial primary Dx was CMC OA and of course after testing it was not.
I too believe that this article has clinical value for promoting a patient centered approach that can be applied to our 39 y/o mother. Despite the study only recording changes over a 6-week period of time while attempting to address a chronic issue, their results did reflect short term positive change in pain and function. With continued adherence over a longer period of time as demonstrated by other studies cited in the article, I believe there is room for even more improvement depending on the patient.
For this individual I believe educational interventions would be the biggest part of my treatment plan. It has already been recommended by a surgeon that she have a CMC arthroplasty. From my experience when patients are told they most likely need surgery from their surgeon, their first question is, “so what’s the point of doing therapy if this (insert joint/muscle) is damaged?” Setting realistic expectations and educating her on the benefits of conservative treatment centered around HEP + split use to manage her symptoms would be essential for patient buy-in day 1.
For this patient I would begin with recommendations for activity modification or compensatory strategies to perform said activities to offload her affected thumb and decrease stresses that she is exposing her joint to on a day to day. As the article mentioned using necessary assistive devices when meal prepping or carrying her kids items over her shoulder and not gripping them with her hands would be a great place to start, as well as addressing other activities she is having difficulty with.
In regards to a splint for this patient I would lean to a more rigid brace short thumb spica for increased protection of her CMC joint. I would prescribe the brace to be worn prn, recommending usage during provocative activities.
I would have this patient performing exercises 1x/day centered around CMC distraction with mobilizations as well as incorporating some neural mobilizations presented during our course series.
Prognosis: I too would expect a longer prognosis for the patient in order to see significant improvements in her symptoms. It does not sound like her life will be slowing down anytime soon, which appears to be a direct cause of her increased symptoms. Thus, my POC would encompass a multi-modal patient centered approach centered around education, compensatory strategies, splinting, and HEP.
Erik I think the quote you highlighted was one that stuck out to me the most when I was reading Karen’s passage. She notes that she was once a strong confident women who is now withdrawn, timid, and questioning her future. I feel that these worse exemplify how many individuals who suffer from persistent symptoms describe their journey. Our job is to address their current fears cautiously and identify areas of strength for these patients that can hopefully restore some confidence.
By the time these patients present to us typically they are only a shell of themselves; as Karen mentioned, “..pain took over her life, her thoughts, decisions and even her personality..” Educating these patients that we are not going “fix” their problems in a few visits and setting realistic expectations is essential for these patients. Much like Karen’s story, patients who suffer from persistent chronic symptoms there was not direct mechanism that caused their symptoms or if there was tissue healing time has passed. Thus, we need to identify their functional deficits and implement strategies for them to complete these tasks to create positive change.
To your question Erik, if a patient present to me with chronic symptoms, being a “musculoskeletal expert” I would assess them as a whole and treat the person in front of me as we normally would, addressing any biopsychosocial factors that may be identified in the process. To me, not much changes. We need to treat the person in front of us as a whole as we would with anyone.
I agree that this article has clinical value and can be applied to our practice. My greatest takeaway mimics Cam’s in the fact that we might not be able to detect true instability unless both passive and dynamic stabilizers are compromised. Knowing this if patients are presenting with DRUJ symptoms it increases the importance of our ability to differentiate these different structures to determine the best POC for our patients. As Erik mentioned if we determine loss of passive joint stability we can educate patients about how we can help them improve the dynamic stability of the joint so that normal kinematics can be maintained.
Erik to your question, I agree with Jeff that a good thorough subjective examination is more important than objective information during the initial visit. As our understanding of pain and how psychosocial factors can affect its presentation, I feel that it is imperative to listen to the patient and their beliefs on what may be causing their symptoms. Listening to what the patient is saying (ammo) may affect some of the verbiage we use to discuss our findings and how we formulate our treatment plan.
In my short time of practice I have found myself opening conversations along the lines of, “why don’t you tell me a little of what is going on?” I have found this to be effective for some but others go on to tell me their entire life story and I feel the need to interject. Erik I have been trying to utilize the opening line you suggested as it is still open ended but provides more direction to the patient in regards to information we would like to hear in return.
Jeff I too was surprised at the average time a PT allows the patient to speak before interrupting. I’d like to think that I wait longer than 23 seconds before interrupting the patient but I have never timed myself. I have made a more conscious effort to shut up and listen over the past week allowing them to get their entire thought across even if it does not seem relevant to our conversation. I think this has been beneficial as the patients typically feel more respected not being interrupted and are more active listeners in return.
Hey all,
Erik interesting take on the information presented. To your point about picking up his golf bag with the proposed theory your mentioned, I think we need to consider hand position and how forces distributed about the wrist may change when attempting to carry a cumbersome golf bag. If surrounding soft tissues are compromised then to perform the activity we may load structures differently than normal. From my experience these bags are often large and unbalanced and we are typically carrying them with slight ulnar deviation (inc compression of TFCC).
Everyone thus far has provided sound reasoning to help differentiate structures and diagnoses. For me I would start with palpation as well to help identify potential areas of isolated or localized tenderness. Fracture would also be lower on my list at this point due to chronicity of symptoms and description of symptoms. I believe all the tests mentioned prior are appropriate for ruling in or out fracture for this patient.
TFCC: being the “meniscus” of the wrist we would expect increased symptoms with compressive/axial loads with torsional and shearing forces. We have a battery of special tests to assess this structure but as mentioned the press test should be utilized based on its metrics to rule out potential involvement.
ECU: I agree that in order to rule in/out potential ECU involvement we need to perform an APR exam for the wrist to see if these active and restive tests reproduce the patients symptoms.
Ligamentous laxity: A passive wrist exam coupled with compression, distraction, and joint mobility would provide useful information for determining potential ligamentous involvement. Casey I love the information you presented in regards to the study performed. Speaking from personal experience, I had a torn ligament in my wrist and we were unable to identify its involvement in my wrist pain without advanced imaging as all surrounding structures were intact. If instability was present during examination I would definitely consider a potential multifactorial cause to the patients symptoms.
Hey Laura, thanks for posting the case and articles. These articles provided me with great guidance on how to approach an evaluation of the wrist systematically. I have treated one patient with complaints of localized ulnar sided wrist pain worse with weight bearing and carrying activities at the gym. In this particular case local wrist structures did not reproduce his symptoms. With help from Kristin we looked up the chain and were able to help him resolve his symptoms by addressing 1st rib mobility on his affected side.
For this case I’d like to know if there was a direct MOI a year ago when his symptoms presented? Are there any easing factors? Which hand is involved, is it his dominant hand? Is he a righty or lefty when if comes to golfing (top hand vs. bottom hand when gripping the club)? How long does the deep ache last after activity? Is there any clicking associated with his pain or clicking with rotational motion? Has he had any PMH of any injuries to the neck, affected shoulder, elbow, or wrist? Does he have any decreased sensation or strength in the hand, n/t? Does position of hand (neutral/pronated/supinated) affect his ability to pick up/carry moderate to heavy weights? Has he had any treatment in the past year (injections, splinting, PT)? Why does he believe his wrist hurts?
As of right now without more information my DDx would be centered on localized structures including TFCC partial tear, DRUJ instability, ligamentous tear (UT lig), ulnar impaction, then potentially looking up the chain.
Objectively I would watch him as he walked through the door, does he favor the wrist/hand with simple tasks such as opening a door, WB while sitting down, writing etc. I would proceed to perform an assessment of his quality and quantity of wrist motion in all planes comparing the unaffected to the affected side. Direct palpation of local structures of the wrist may help identify potential sources of his symptoms. I would also look at his grip strength and his golf swing (not that I am a golf pro). Additionally I would take a look up the chain at resting posture, ROM quality and quantity as well as strength to determine if other structures may be involved.
In regards to key clinical examination tools I would use with this patients or patients in the future, I would work systematically attempting cluster findings to help me to rule in/out suspected diagnoses. After reading these articles I believe assessing resting position of the DRUJ and quality/quantity of pronation and supination could provide useful information in the assessment of static and dynamic stabilizers of the wrist and forearm. I would also make sure not to focus in on the wrist itself and be sure to examine joints up the chain for potential involvement.
Being a young clinician in the outpatient setting it is easy to overcomplicate patients who may present to us with wrist pain since it is not the most common area we treat on a day to day. I received great advice this past week while shadowing Stacy (CHT) over at UVA HS. She told me that the hand/wrist is just like any other joint in the body and it needs to be treated as such. As I have not treated many patients with wrist pathologies to this point I am definitely interested to see how everyone else would go about the evaluation.