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I really look forward to seeing where JOSPT goes with this new series. I enjoyed reading this first entry and found aspects of this that unfortunately reflect some bias in my practice.
Though I cannot recall just one specific instance of confirmation bias, I think this is something that I have had to consciously work to limit in my practice. Especially being this new in my career, I have been guilty of conveniently skimming over information in an eval that does not fit my picture of what the patient SHOULD present with. Especially earlier in the residency, I tended to latch on to specific pieces of information, form a diagnosis in my head, and then only ask questions and perform tests that would confirm the diagnosis that I had made. Over the second half of the residency year, I have been more aware of this bias and tried to maintain a larger differential list and focused more of my time and attention on ruling out other potential pathologies first before shifting my attention towards ruling in a diagnosis.
I think recall bias is something that has led to a great deal of frustration for me personally in certain instances. Early in the residency, I had a string of patients with subacromial impingement who did really well in a short period of time. As I have begun to see more individuals with this pathology, I often find myself second guessing my choice of interventions or diagnosis if they are not completely better in the first few visits, which is likely an unrealistic expectation. With more experience in the profession, I hope that my expectations will regress to the mean with regards to prognosis with patients with certain pathologies.
I agree with Jen that this article evokes memories of Tim Uhl’s presentation on rotator cuff exercise progression. I was interested in the data presented on stress through the Achilles tendon with squatting and lunging. I currently have two patients who are ~3 months s/p Achilles rupture and repair who are stuck in the phase between being able to do bilateral heel raises easily but being mostly unable to perform single leg heel raises. I would like to use some of the information presented in this article to load their Achilles tendons a little more without having to try unilateral heel raises over and over.
Hey Sarah,
1) Before looking at objective findings, my differential diagnosis list would include some form of bone stress injury, compartment syndrome, and tibialis posterior tendinopathy. I’d want to get a pretty good idea on when symptoms come on during activity and how long symptoms remain following activity to help grade severity of bone stress injury. Symptoms such as numbness/tingling, pressure, and burning could take you more towards compartment syndrome.
2) The two main things that stood out to me regarding her PMH were her history of prior “shin splints” and history of bilateral ankle sprains. A history of bone stress injury could indicate some underlying biomechanical factor or training error that may predispose her to these types of problems. History of ankle sprains could lead to deficits in ankle mobility, stability, and strength that could also play a role in the way she loads her tibia.
3) I’m sure we will discuss it during journal club, but I would like to get an idea on when during activity her symptoms are present. You could also do some hop testing to get an idea of tissue irritability in the area.
4) Based on the article that you attached and the objective findings, I would probably go with some single leg activities (squats, lunges) to try to address hip strength and motor coordination. You could also incorporate foot intrinsic work (toe yoga, short foot) in these single limb positions to incorporate more distal factors as well.
5) Activity modification is what I have found to be most successful in my patients with overuse injuries of the lower extremity. Based on her symptom severity, it may be appropriate to shut her down for a few weeks and have her cross train until you find it appropriate to gradually increase her running back to pre-injury levels. If it seems to be less severe, it may be appropriate to decrease distance and attempt to regulate her running surface to reduce loads. Unfortunately, what I have found most difficult with these patients is deciding what level of activity modification is most appropriate for which patients.
Hey Jen,
I had a similar case a few months ago who had a return of her LE symptoms about a month after a lumbar fusion. In her case, she was doing a lot of extra exercises at home in addition to her HEP and I think she was probably just getting some inflammation in the area. When we worked through her exercises and educated her on not doing too much, her LE symptoms resolved. That may be something worth looking at with your patient.
I’d also recommend using the first article that Katie posted to help with patient education, I have used some of those techniques in the past and found them reasonably successful. As far as a referral to the surgeon goes, I would probably get in contact with the surgeon yourself to let them know what is going on. Depending on how long you have treated this patient, a referral back may not be necessary, but it could not hurt to open the line of communication.Echoing both Katie and Justin, I think that I will begin to use RPE more to judge the intensity of sessions as a whole rather than just asking how difficult individual exercises are. One of the more clinically relevant lectures for me at this juncture was Tim Uhl’s talk on exercise progressions for patients with rotator cuff pathology. In some of my patients s/p cuff repair, I probably initiate pulleys with them too early in the rehab process after seeing how much muscle activation actually occurs with pulleys. I will likely spend more time on supine exercises before progressing to exercises against gravity.
I also found it particularly interesting that the painful arc of shoulder motion that we use as a part of a diagnostic cluster for sub acromial impingement is not actually due to the tendon being compressed under the acromion, because the tendon does not get compressed above 60-70 degrees of abduction. When I treat patients with a painful arc, it will definitely change the way I use that information, leading me more towards tendon overload in that position rather than a mechanical compression.
Hey Justin,
What did her L hamstring strength and bilateral quad strength look like? The article showed better rates of returning to previous level of sports participation in those with higher leg symmetry index values, so I think it is important to compare the two sides before making a decision. I would want to see how she responds to single leg dynamic balance tasks with some speed component like she may encounter when running on uneven terrain (maybe small hops onto airex, etc). It would be hard to make a guess about her SL hop test performance without quad or hip extensor strength numbers. Based on the results of her functional screen, I’d imagine that she may experience some dynamic valgus and trendelenberg upon landing. I’d say a single leg exercise that emphasizes the hamstrings, but also requires hip abductor strengthening, such as an RDL, could be beneficial for the patient. However, that would be dissimilar and out of context with her primary functional goal, so you would have to decide whether she lacks the strength for the activity and may require something out of task before progressing into something more functional.
I would echo the points that Justin and Sarah found helpful above. I think that some of the points from the article, including the point about radial tears of the lateral meniscus not increasing contact pressure, are excellent things to keep in mind when educating these patients about possible surgery. When working with these patients in the future, I will certainly look more closely at gait and attempt to address if they appear to be compensating to ensure that they do not develop abnormal gait mechanics in the long term. I found the section about the increased strain on the ACL following medial meniscectomy particularly interesting. I have had a couple of patients undergo medial meniscectomy that expressed a desire to return to sports. With this knowledge, I will probably be more thorough and look more closely at functional tests (landing, cutting, etc) before giving a patient the okay to return to sports.
Hey Sarah,
Sorry for the late response. My PICO was, “In patients who undergo PAO, which gait characteristics are most affected between pre-operative and post-operative analyses?” I’ve attached the article I found below.
Karam MD, Gao Y, Mckinley T. Assessment of walking pattern pre and post peri-acetabular osteotomy. Iowa Orthop J. 2011;31:83-9.
The researchers used a GaitRite gait analysis system pre and post-operatively to measure changes in gait as well as pedometers to measure activity level. Data from an average of 11.5 months post-op showed a 5% increase in gait velocity, a small improvement in cadence, and a 4.5% increase in stride length compared to pre-operative data. At 9.5 months post-op, there was an 8.75% decrease in overall physical activity level (measured by pedometer), though there was a significant increase on the physical component score on the SF-36.
The mean age of patients in this study was 28.5, so definitely younger than your patient. However, if you choose to use this data with your patient, you can use this data to encourage her that she may be able to walk better than before.
Hey Sarah,
I do not have any experience with pt’s s/p PAO either, so I cannot offer any personal anecdotes. When deciding whether or not I is appropriate to d/c a cane, I generally look at how well the patient is able to control the pelvis in the frontal plane when walking with and without the cane. If they are able to ambulate with minimal-to-no trendelenberg, then I am generally fine with letting them d/c the cane. However, I would be sure that she is sure to bring the cane with her when she is going to be walking longer distances so that she can use it when she becomes fatigued. It is all about graded exposure to walking without the cane.
I have had a few patients with anterior hip discomfort following arthroscopy that appear to have components of psoas pathology as well as intra-articular hip pathology, so I’m curious to hear other people’s strategies for managing your patient’s anterior hip pain as well. This is always something that I have had some trouble with.
My biggest takeaway from the conference was a more systematic approach to running analysis in the clinic. Before the conference, I felt that I was filming my patients while running and having difficulty determining which problems could be causing certain symptoms. Now I feel that I have a better understanding of the mechanics and I have tools to change the forces that may be contributing to a patient’s symptoms. I found the videos of patient’s returning to run post ACLR particularly eye opening. It left me with some questions about when the appropriate time to clear an athlete to return to run would be. If elite athletes are still having these deficits years after their surgery, how can we expect your typical college student who is coming to PT 2x per week to be able to run well 12-16 weeks post-op? Additionally, do those decreases in knee flexion during stance phase predispose our patients to further injury? Is running something we should push down the line further in order to allow more time for increased LE strengthening and eccentric control? I also enjoyed Jay’s lab session, particularly some of the interventions to improve foot intrinsic recruitment. This is probably an area that I do not address as much during the rehab process as I can.
Hey y’all,
I think this is a really good resource that puts a lot of pertinent information in a form that is easy to digest. In clinical practice, I think the second rule, Don’t prescribe incorrect exercise, can be tougher to follow than it may seem. I occasionally find it difficult to determine whether or not an exercise is more than the tendon can handle until I’ve actually tried it.
For example, I have been treating a gentleman for 2-3 months who presented with a reactive on degenerative Achilles tendon that has been bugging him for the past few years who is looking to return to running. We have been progressing slowly, starting with isometrics and eventually progressing to plyometrics and running in the Alter G. Along the way, we have hit periods where the pt is tolerating a certain load and he appears to be ready to progress, but when we progress, he has a big increase in tendon pain for the next 2-3 days. When we tempered expectations and started incorporating those new loads (plyos, for example) more slowly, he was able to tolerate the intervention without issue. I think this graded exposure to loading is something that I tend to rush in these patients due to my own impatience.
Hey Katie,
In this situation, I probably would not prescribe orthotics at the initial evaluation. Similar to what we discussed regarding the case that I presented last weekend, I would be interested to see how your patient did with some cueing for more equal weight bearing throughout the foot and I would consider orthotics if it became apparent that she would not be able to control it after a few sessions. It does not seem to be a structural issue, so I would not jump right to orthotic prescription. As far as special questions to rule in PFPS, I do not think that I know of any. Taking care to ask the special questions that would help you rule out other diagnoses at the knee would be the special questions that you need to come to the conclusion that this would have to be PFPS.
Primarily, I would want to rule out any UMN disorders or vascular causes, as Sarah noted. The lateral thigh numbness sounds like it could be related to meralgia paresthetica/LFC entrapment, especially since it began soon after hip surgery. I think that spinal stenosis could explain his leg pain, especially since he has had a history of central LBP and since his leg pain is aggravated by extension-based activities and relieved by sitting and unloaded positions. I’d definitely want to get a good picture of his hip mobility, particularly into extension. If he is no longer getting any hip extension, then it would make sense that he is extending his lumbar spine more irritating some neural tissue. I’m curious if you asked what approach they took for his hip replacements and whether or not he is still observing his post-op precautions. I’d also be interested to see results of his slump and SLR testing.