March 08th, 2016
I recently had a patient come in with reports of R-side lower thoracic pain that radiated down the flank. The patient denied any mechanism of injury but the pain began sometime within the last 3 days. The lower thoracic pain was increased with bending forward and with oblique cervical flexion to the opposite side. When the patient was asked to touch his toes, his preferential movement was to go into a sumo squat. When asked to perform normal lumbar flexion, he tried and immediately stopped due to pain. The primary thing that should stand out about this is potentially a neural component. Flexion of the spine lengthens the vertebral canal, tensioning the spinal cord. Both of the pain provoking motions increase tension in the spinal cord. The patient denied any real pain relieving positions or motions but it was eased with avoiding the provoking positions. Another thing to consider with the R-side flank pain is potentially kidney involvement, however, the patient denied any bowel or bladder problems.
Cervical Flexion: DN
Cervical Extension: DN
Cervical Rotation: DP bilat L<R
Shoulder Pattern 1 (ext/add/IR): DN bilat R>L
Shoulder Pattern 2 (flex/abd/ER): FN bilat
Thoracic Rotation: DN to R
Multisegmental Flexion: DP
Multisegmental Extension: DN
Multisegmental Rotation: DN bilat
Side Glides in Standing: Dysfunctional loading R side
R iliac crest/PSIS/ischial tuberosity all depressed compared to L
12 rib anterior on R
PA of 12th rib on R recreates patient's pain
Due to my suspicion of rib involvement, I had the patient perform repeated thoracic whips for 20 repetitions to the R side. I then had the patient perform the oblique cervical flexion, which was no longer painful. If we are to put a pathoanatomical name to the patient's pain, I would say there was a combination of 12th rib dysfunction and downslip of inominate on the R side that was straining the Quadratus Lumborum (flank pain). As far as manual treatment goes, I did some IASTM along the thoracolumbar paraspinals and a superior mobilization to the R inominate. The patient's HEP was only thoracic whips to the R side.
I thought this was an interesting case due to the involvement of the entire spine for a very small pain location (relatively speaking). While the patient's pain may respond to repeated thoracic whips, it is essential to address any remaining mobility restrictions in the objective findings as well as abnormal movement patterns and postures the patient regularly displays that contributes to the dysfunction.
I recently presented an interesting case to my fellowship class. On 4/3/15 the patient presented to my PT clinic with L medial scapular border and L cervical pain with N&T along radial border of L forearm. The patient was a 45 year old female. The symptoms were intermittent symptoms and began 4 months prior with insidious onset. Symptoms were increased by sleeping, prolonged sitting, and having her L arm unsupported. Symptoms were improved with arm support and being active. Pain intensity was described as dull and was 2/10 at the time of the evaluation on NPRS and 6/10 at its worst. Patient denied any N&V, fever, significant changes in weight in last 6 months, B&B problems, and S&S of cauda equina syndrome. Patient’s job requires prolonged sitting at a computer, with turning her head to the L frequently. Patient also has to fly across the country every week for work. Patient denied any significant PMHx, past surgical history, and taking any medications.
Postural Assessment: Forward head posture. Rounded shoulders with bilat scapula depressed and downwardly rotated L>R. Excessive kyphosis at CT junction.
Active Range of Motion:
-Cervical spine: Cervical Flexion/Extension/bilat Rotation DP (Dysfunctional Painful)
-Cervical Retraction with SB DP to L
-Thoracic spine: Rotation DN (Dysfunctional Non-Painful) to L
-Right UE: Flex/Abd/ER FN (Functional Non-Painful), Ext/Add/IR DP
-Left UE: Flex/Abd/ER DN, Ext/Add/IR DP
-Elbow and Hand: WNL
Passive Range of Motion:
-Cervical Spine: Cervical Flex/Ext/L Rotation DP
-Cervical Rotation R FN
-Thoracic Spine: Rotation DN to L.
Joint Mobility: Hypomobility with left sideglides throughout cervical spine; Hypomobility with PA assessment of T1-T3; Hypomobility with PA assessment from T6-T8.
-Shoulder Flex/Ext/Abd/ER/IR: 5/5 bilat
-SA 3-/5 on L and 4-/5 on R
-MT ⅘ bilat
-LT ⅗ on L and 3+/5 on R
-Rhomboids 4-/5 on L and ⅘ on R
Neurovascular screening: Vascular deferred (not applicable). Neuromuscular: Decreased sensation along L radial forearm and lateral 3 fingers.
(+) Neck Flexor Muscle Endurance Test
(+) ULNT (Median)
(+) ULNT (Ulnar)
(+) Spurling’s Compression Test
(-) ULNT (Radial)
(+) Cervical Distraction Test
Cervical Radiculopathy Cluster:
(+) ULNT (Median on L)
(+) Spurling's Compression Test on L
(+) Cervical Distraction Test
(+) <60 deg Rotation to L
4/4 = +LR 30.3
Treatment Day 1
My primary focus for the treatment was to educate the patient on proper posture and regular performance of repeated motions. Her symptoms centralized with repeated cervical retraction with SB to the L, so this was prescribed 10reps/hour. Manual treatment included: Supine Thoracic Manipulation: Grade V to T2 and T6, IASTM to L volar forearm and L UT/scalenes/SO and manual median/ulnar nerve glides 20x3 on L. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat and Quad Rock Back: 2x10.
Treatment Day 2 (1 week later)
The patient reported she performed her exercises, but was not compliant with the prescribed frequency. She stated that she was sleeping better than she had in months. Pain was rated 1/10 at the time of this session and 3/10 at its worst in the last week. The patient continued to have a directional preference of cervical retraction with L SB, so she was instructed to continue with this for her HEP. Manual treatment included: Prone grade III PA mobs to T2-8, Seated CT Junction Distraction Manipulation Grade V, Grade III OscillatoryUpglides to C6-C7 on R followed by MET for flexion 6sec x3, Grade III Flexion mob to OA joint bilat, IASTM to L volar forearm and L UT/scalenes/SO. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, and Supine Chin Tuck with Rotation: 2x10.
Treatment Day 3 (2 weeks later)
The patient reported she rarely did her exercises over the last 2 weeks, so her symptoms have increased, but a bad day includes pain at its worst 3/10 on NPRS. The patient was educated again on the importance of compliance with HEP in order to decrease her symptoms. The patient continued to have a directional preference of cervical retraction with L SB, so she was instructed to continue with her HEP. Additiionally, upon reviewing the technique of cervical retraction with SB, the patient was not getting to end-range, so this was corrected. Manual treatment included: IASTM to L median nerve distribution, Grade III oscillatory upglides to R C6-7 followed by MET for flexion on R C6-7, Grade III distraction mob to R OA, Inf grade III mob to L C6-7 followed by MET 6sec x3, Seated grade V distraction manipulation to CT. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, Supine Chin Tuck with Rotation: 2x10, Lumbar Locked Low Trap Isometric: 10” x10, Quadruped Cervical Rotation with Chin Tuck: 10x bilat, and Quad Rock Back with Thoracic Kyphosis: 10x.
Treatment Day 4 (1 weeks later)
The patient reported that she no longer had any pain and only developed some mild N&T in her forearm when she would sit with poor posture for prolonged periods. Manual treatment included: IASTM to L volar forearm, Grade III upglides to L C6-7 with L UE in median nerve tensioned position (no symptoms after) followed by MET and grade III upglides for flexion on R C6-7, manual median nerve glides on L 20x3. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, Supine Chin Tuck with Rotation: 2x10, Lumbar Locked Low Trap Isometric: 10” x10, Quadruped Cervical Rotation with Chin Tuck: 10x bilat, and Quad Rock Back with Thoracic Kyphosis: 10x. the patient's HEP was progressed to include some of these exercises including continuing with her repeated motions HEP when symptomatic and how to progress to retractions. With the patient's work involving prolonged sitting, she is at risk for developing these symptoms again, so she will likely have to continue with her HEP. The patient was discharged to indept management.
Overall, this case was not too complicated. With the patient's intermittent symptoms, there was a high likelihood of her responding to repeated motions. The toughest part, as usual, was patient compliance. Both frequency in exercises and proper technique are often where the deficits occurs. The patient had to be re-educated on proper form and truly getting to end-range. When communication is intact, repeated motions can make treatment significantly easier for certain populations.
At my clinic, we offer a rapid referral system where we provide free screens for patients in order to determine either a need for skilled physical therapy or possible referral to another practitioner. Recently, I had a 12 year old boy come for a screening due to knee pain. The patient reported that he had been practicing kicking footballs when on one kick, he felt a "pop" and developed severe knee pain in the planted leg. The patient denied any hx of knee pain prior to the incident. Pain was located over the tibial tuberosity and painful with palpation. Pain could also be increased with squatting or jumping and decreased with rest.
Due to the location of pain being only over the tibial tuberosity, I immediately had minimal suspicion of a ligament or meniscal tear. Objective testing confirmed my hypothesis: (-) Lachmann's, (-) Anterior Drawer, (-) Posterior Drawer, (-) Valgus/Varus Stress, (-) Extension Overpressure, (-) Joint Locking/Catching, (-) Joint Line Tenderness, (-) McMurray's, (+/-) Flexion Overpressure (pain located at tibial tuberosity). There was pain with resisted quadriceps contraction and with a stretch of the quadriceps. Based on the location of the patient's symptoms and tenderness at the tibial tuberosity, a potential diagnosis is Osgood-Schlatter's. The patient is in his adolescent years, there was increased prominence of bilat tibial tuberosities, and the location of the pain matches. However, there were several factors that made Osgood-Schlatter's less likely. It typically has an insidious onset and is often found bilaterally. This patient had a sudden development of pain with a "pop" and only had unilateral pain. With the negative ligament and meniscal testing and decreased likelihood of Osgood Schlatter's, my initial hypothesis of avulsion fx of the tibial tuberosity had moved up the list.
While there is no orthopedic test to specifically test for avulsion fractures of the tibial tuberosity, we can still use our clinical reasoning to come to this diagnosis by effectively ruling out other pathologies. One factor that stood out in this case was the patient's age. In the adolescent stage, this patient's growth plates had not closed yet. Patients this age are more susceptible to avulsion fractures in general. In school, we are taught to test for stress fractures using tuning forks or possibly ultrasound (ouch!), but the diagnostic accuracy is lacking. Needless to say, I referred the patient to an orthopedic surgeon who later confirmed an avulsion fracture. The patient will trial rest for 2-4 weeks before potentially initiating therapy.
A few weeks ago I had to do a progress note on another PT's patient (something I do not enjoy since it disrupts continuity of care). Typically I re-take the key measurements and continue with the current treatment. If a significant lack of progress has been noticed, I may adjust the plan of care. It is not an easy task or decision to make, changing a treatment plan, but we must look out for the patient, especially if we notice key interventions are missing. There are various ways you can accomplish this. You can speak with the regular PT about your findings with recommendations, include your findings and recommendations in the note (if you are unable to speak to the PT before the next treatment session), or sometimes adjust the plan right there.
The patient I saw was an approximately 40 year old male who regularly competes in events like the Tough Mudder, Spartan Dash, etc. Last April 2014, he competed in one of these events and developed a "calf strain." He took a couple months off the symptoms improved, but he never reached 100%. Approximately 6 weeks ago, he began physical therapy with one of my colleagues. With exercise, soft tissue work to the calf, and ankle joint mobs, the patient's pain improved some. However, upon return to activity, he noticed pain within the first few miles of running which progressed to an almost constant "ache" in the past two weeks.
Something should immediately stand out to you about the timeline: the time since the original injury. If the injury were truly just a muscular strain, the patient should have had recovery with his pain far earlier than 7 months. Due to the persisting pain, I suspected neural involvement that lead me to question the patient about his history a little more thoroughly. The patient works in IT (desk work) and sits with his legs crossed often. This further increased my suspicion of a neural component as the prolonged unloading of the spine can make symptoms persist. At this point I did several tests to confirm my hypothesis:
1) (+) Straight Leg Raise with Sural Nerve Bias: symptoms altered with neck positioning
2) Multi-Segmental Flexion: Functional and Painful (recreated symptoms in calf)
3) Mutli-Segmental Extension: Dysfunctional and Non-Painful
4) Standing Sideglides: Possibly Dysfunctional to Involved Side
Following the recreation of the patient's symptoms in flexion, the next step is to do repeated extension/loading of the lumbar spine. Typically with unilateral complaints we should expect unilateral losses in loading, thus requiring a unilateral loading treatment. The loss seemed minimal with my testing, so I decided to trial repeated extension (bilateral loading) first. After 15 repetitions of standing extension, the patient had no pain with flexion of the spine. Patient was instructed to perform 10 standing extension repetitions every hour and use a lumbar support when sitting. (Note: While I moved to the bilateral loading strategy with this patient, that small unilateral loading loss to the symptomatic side is often indicative of the directional preference. This may be where your treatment should be addressed. As always, test-treat-retest).
I followed up with the patient a few weeks later. The patient had a significant reduction in pain levels but some pain remained and he reported recreation of pain with twisting in bed. Upon further investigation, the patient revealed how he was only doing the repeated extensions 3-4 times a day and indicated some uncertainty with lumbar spine as a source of calf pain. I explained to him how muscle tissue in the calf would have healed within a faster time frame and would not have been painful with twisting in bed. This too indicates a neural involvement. As is often the case, the patient's lack of full recovery is due to the lack of compliance or proper technique with the exercise. It is imperative to review how the patient is performing their exercises when they return each session and report no recovery.
I recently began treating a patient who was seeing another physical therapist for "lateral epicondylitis." The original physical therapist treated the patient with wrist and elbow ROM, eccentric extensor strengthening, and the appropriate stretching. The patient was not getting better. He saw this physical therapist for two visits and stopped attending therapy for two months because the patient felt that the treatment was not addressing the cause of his pain.
Following two months of increased pain, the patient returned to therapy. During my initial re-evaluation, the patient had complaints of lateral elbow pain as well as pain along the dorsolateral forearm. Pain increased with wrist extension, elbow flexion, and shoulder D2 flexion. The patient had a positive Cozen's Test, positive Mill's Test, tenderness to palpation at the common extensor tendon mass, and pain with resisted elbow extension. Of note, the patient also had a positive radial nerve tension test. Remember, positive neural tension testing reproduces the patient's primary complaint of pain. Assessing proximally, the patient had hypomobility in the CT junction, thoracic spine, and lower cervical spine.
During the re-eval, I was able to decrease the patient's pain from 8/10 to 4/10 by performing a thoracic manipulation, CT junction manipulation in prone, lower cervical sideglides with active radial nerve glides, and IASTM along the radial nerve (EDGE Tool). Additionally, I focused on strengthening the scapulothoracic muscles per his impairments. At his second follow-up the patient returned with 5/10 pain. Following a similar treatment progression, the patient left physical therapy pain free. The patient's third visit was last Friday. He presented to the clinic with pain only during overhead movements and end-range radial nerve stress testing. After addressing postural deficits (see his resting shoulder position in the picture above) and GH joint rotational deficits, he again left treatment pain free.
I have only seen this patient for 3 visits thus far, but he has made significant improvements. These improvements were made because of proper differential diagnosis. As for prognosis, I am expecting 2-3 more visits to maximize strength, normalize GH joint and thoracic ROM, improve posture, and education.
Always assess the radial nerve in patients with lateral elbow pain.
Management of Acute Ankle Sprain
In previous posts, I have discussed the importance of checking the intermediate dorsal cutaneous nerve with inversion ankle sprains. In this post, I will discuss a real patient case that verifies the importance of this assessment. Additionally, I will show you my treatment strategy which decreased her pain.
For the past three weeks I have been treating a USPS mail carrier who injured herself while working on the job. The initial evaluation was consistent with an acute lateral ankle sprain. During the first few visits, I focused on restoring normal joint mechanics, ROM, gait pattern, and strength of the foot and ankle. During her fifth visit, she had made significant progress except persistent pain that ran along the dorsal aspect of her foot. The patient traced a line of pain from her ATFL to the 2nd metatarsal. Immediately, this cued me to assess neural tension. (Anytime a patient traces a line of pain or describes the pain as running, shooting, traveling, I suspect neural involvement.)
The patient had symptom reproduction with peroneal nerve biasing allowing me to rule in neural tension as the source of her pain. Upon further subjective questioning, she reported having a previous history of back pain. I assessed the low back and found hypomobility throughout the thoracic and low lumbar spine. Initially, I chose to perform a gapping manipulation of L4-L5 to mobilize the segments of the superficial peroneal nerve (the proximal branch of the intermediate dorsal cutaneous nerve). This manipulation decreased her symptoms by roughly 70%. Next, I manipulated the thoracic spine and talocrural joints which eliminated her symptoms completely.
Neural tension is a real component of common musculoskeletal injuries. Be sure to check for it in your patients.
For the past two weeks, I have been treating a middle-aged man who sustained a compression injury to his right shoulder/ neck region (unofficially coined the schneck). When I first began treating him, his primary complaint was paresthesias in his right radial three digits with referral up the dorsum of the forearm and posterior arm. He reported a nearly constant dull or "blunted sensation" in those fingers at all times and noticed symptoms increased when looking down while at work (a combined cervical flexion and retraction movement). I was not the therapist who performed his initial evaluation, so I performed a mini-reassessment at my first visit to clear each region. Here are the pertinent positive clinical finding:
Posture: depressed, down sloping shoulders
Range of Motion: shoulder and cervical WNL except decreased R cervical sidebending.
Strength: WNL except minimal Serratus Anterior weakness
Muscle Length: short Latissimus Dorsi bilaterally
Joint Mobility: hypomobility noted in the thoracic spine, CT junction, and R first and second ribs. (Normal mobility noted in the cervical spine)
Neural Tension Tests: negative median, ulnar, radial
Repeated Movements: Symptoms increased with cervical retraction, No change with other cervical movements.
Prior to performing the mini-reassessment, I hypothesized that the patient would have cervical joint dysfunction with underlying neural tension. However, the cervical spine, elbow, neural tension, and glenohumeral joint all cleared. Everything was clearing! How was this guy still having pain!?!?
The answer lies in his posture. His primary complaint of pain occurred while looking down at work and nearly constant decreased sensation. When delving deeper into my subjective history, his symptoms generally increased after several hours of working, not immediately. Clinically, I find that when someone has pain after several hours of performing a task, it is generally a muscle endurance or stability and motor control issue. Muscles can support the body for a period of time without pain, but when stressed past a certain limit, symptoms increase. It is one of the body's protective mechanism responses. In this case, his depressed shoulders were causing problems. The upper trapezius, scalenes, and other cervical stabilizers were putting extra tension on the brachial plexus..
Not Every Patient Needs Scapular Depression and Retraction
My treatment: Thoracic spine, CT junction, and first rib manipulations. Manual therapy restored normal mobility, but had minimal effect on his symptoms. I had him perform wall slides with a chin tuck + Shrug overhead, and he noticed his symptoms gradually decreased. Since this decreased his symptoms, his HEP was Wall Slides + Shrugs 10x/hour while maintaining a neutral cervical spine. I chose this treatment approach because it is imperative to restore a neutral scapular position prior to strengthening. I want to make this distinction because previous therapists had attempted to strengthening his lower trapezius and middle trapezius. They were cueing him into further depression and retraction of the shoulder girdle. Strengthening the scapular stabilizers is generally great, but having this particular patient depress his shoulders further was only creating more tension with each repetition. It is important to get each joint in a neutral posture prior to initiating strengthening. Thus far, within one visit (3 days), the patient noticed that the blunted sensation in his fingers was not longer constant. He continues to have an increase in symptoms with cervical retraction over pressure, but it too is of less severity.
My words of advice
You may not always be able to find a dysfunctional tissue during the evaluation, but first make sure the patient is appropriate for physical therapy and then begin addressing primary impairments. I thought for certain my patient would have underlying neural tension and/or cervical joint dysfunction. These did not play out. I was temporarily stumped so I took a step back, looked at the entire patient, and focused on big impairment: his postural deficits.
Ever since my residency, I have become more aware of the advantages of using multiple resources and clinical backgrounds to treat various issues. One of the most useful resources I was exposed to was pelvic floor physical therapists. We have had guest posts and written ourselves about the various pathologies that can present as "orthopaedic" and truly be secondary to pelvic floor dysfunction. Recently, I evaluated a patient who in the initial exam reported her gynecologist instructed her to pursue pelvic floor physical therapy, yet she never did. I had already developed the opinion that this was the source of the patient's dysfunction before even treating her, but this was one of those cases where multiple issues were involved.
Patient is a 28 year old female with a referring diagnosis of bilateral foot pain. Patient reports in March 2014 she ran a half marathon and developed foot pain a few days later. She then stopped running for a couple months, which decreased her pain; however, when she started running again, the pain returned and became constant. Foot pain is located in bilateral plantar arches. Patient denies any increases or decreases in foot pain. Since then, patient has been treating her feet with night splints, tennis ball rolling, and stretches, but has noted little improvement. Additionally, the patient reports she has had R buttock and R lower abdominal pain for years with no mechanism of injury. Both the buttock and abdominal pain are constant except for brief relief with manipulation. The patient was instructed to pursue pelvic floor physical therapy by a gynecologist years ago, but she refused to go. Patient denies any N&T, B&B problems, N&V, and fever. The patient does have night pain and did lose 30 lb. unintentionally but did gained a lot of it back. MRI on her feet was found to be negative. Patient reports limitations in walking, running, and sleeping without pain. She can also not wear heels secondary to pain. Patient's job requires lots of desk work and her normal recreational activity is yoga and biking. Patient denies any history of lumbar surgery, however, she does have a history of exploratory surgery in her abdomen after she developed the abdominal pain (results were inconclusive).
-Patient stand and walks with minimal arch collapse bilaterally
-Patient stands in excessive lumbar lordosis
Selective Functional Movement Assessment (SFMA):
-Multi-Segmental Flexion: FN (hand flat on floor)
-Multi-Segmental Extension: DN (decreased thoracic motion)
-Multi-Segmental Rotation: DN bilat (negligible hip motion bilat)
-Seated Active Hip ER: DN bilat
-Seated Passive Hip ER: FN bilat
-Seated Active Hip IR: FN on L and FP on R
-Seated Passive Hip IR: FN on L and FP on R
-Prone Passive Hip ER: FN on L and FP on R
-Prone Passive Hip IR: FN on L and FP on R
-SLS: FN bilat eyes open, DN bilat eyes closed
-Overhead Deep Squat: FN
-Hip Flexion: 120 degrees bilat
-Ankle DF: 15 degrees bilat
-Hip Abduction: 4/5 on L and 3+/5 on R
-Hip Flexion: 4/5 on L and 4-/5 on R
-Hip Extension: 4-/5 on L and 3+/5 on R
-Ankle DF: 5/5 bilat
-Ankle PF: 25/25 bilat
-Great Toe Extension: 3+/5 bilat
-Gastroc: decreased bilat
-ITB: decreased bilat
-R iliac crest, R PSIS, R medial malleolus superior compared to L
-R lower quadrant of abdomen tender to touch
-Joint Mobility and Neurological Testing:
-L4-5 PA: painful
-L3 PA: hypomobile
-Talocrural AP: hypomobile bilat
-Subtalar: hypermobile bilat
- (-) Slump Test bilat
-(+) SIJ Compression Test
-(+) SIJ Distraction Test
-(+) POSH Test on R
-(+) FABER Test on R
-(+) Sacral Thrust Test
-(+) Fortin's SIgn
-(+) Supine to Longsit Test - R medial malleolus short in both positions
IASTM to bilateral calves and grade V distraction manipulation to R SIJ
Patient reported her foot pain improved and no longer felt constant. Her back pain felt better as well, but abdominal pain felt worse after palpation during the evaluation. Treatment consisted of IASTM to bilateral calves and plantar surfaces of feet, supine grade V manipulation to T6 and T-L Junction (thoraco-lumbar). Initiated core stabilization, hip strengthening, and foot intrinsic strengthening exercises. Core stabilization exercises included: supine TA isometric, supine BKFO, and quad rock back. Hip strengthening included sidelying clamshells and bent-over fire hydrants. Foot intrinsic strengthening included marble pickup, toe flexion with ankle PF, ankle PF with toes flexed, ankle DF with toes flexed. Patient was instructed to follow a HEP (home exercise program) of toe flexion with foot PF, ankle PF with toes flexed, and marble pickup.
Patient reported that her foot pain slightly improved, but both her back and abdomen are hurting today. IASTM was again performed to the calves and plantar surfaces of feet. A distraction manipulation was applied to the R SIJ and a supine grade V manipulation to T6. Patient's pain improved with inferior grade III mobs to R iliac crest. Patient reported pain with clamshell and fire hydrant exercise.
Patient reported that her foot pain definitely was doing better. Patient stated that her back and abdomen were sore for 3 days after last treatment session but is doing better today. IASTM was again performed to bilat calves and plantar surfaces of feet. SIJ distraction manipulation performed to R side which resulted in pain relief. I initiated some hip motor control exercises and held on clamshells and fire hydrants.
Patient reported that her hip and feet were feeling much better, but her back has not changed. Patient stated that it felt like her back "needs to be cracked" (hasn't done it since last session). IASTM was performed to bilat calves and plantar surfaces of feet. Distraction manipulation performed to R SIJ and supine grade V manipulation to T6, which resulted in decreased pain. Patient instructed to avoid manipulating her back, as she does so regularly throughout the day.
Patient reported that today all her pain was doing better, but she feels like it is inconsistent. Patient states she did not manipulate her back since last treatment session again. Continued with IASTM to bilateral calves and plantar surfaces of feet, but was becoming frustrated by recurrent need for manipulation. Assessed repeated lumbar extension and found it to centralize her pain. This was administered for her HEP 10x/hour.
Patient reported her back and feet are feeling much better. Patient stated that her hip was a little sore after last session but good today. Patient requested to wear heels for a wedding this weekend. Performed IASTM to bilateral calves and plantar surfaces of feet.
Patient reported that she had no foot pain with wearing heels for 4 hours at a wedding, although she does still have some minor occasional foot pain. Patient reported that her back pain was doing much better, but she had not been as compliant with repeated lumbar extension HEP. Performed IASTM again to bilateral calves and plantar surfaces of feet. Patient was instructed to be more compliant with repeated lumbar extension HEP and to trial running.
Patient reported that her back feels better than it has in years. Patient reported that she has no pain in her feet with walking but developed pain after only 20 seconds of running. IASTM was performed to bilateral calves and plantar surfaces of feet. Mobility band was used to provide overpressure with active hip IR and ER to improve active motion. Patient was instructed to trial elliptical.
Patient reported that she had no back or abdominal pain since last treatment session and no foot pain when wearing heels for 3 hours. Patient reported that she had been more compliant with her repeated lumbar extensions. Patient stated that she did the elliptical for 20 minutes then developed some numbness in toes, but it dissipated with active toe flexion. Patient reported that she did have some foot cramping after spin class and with her normal toe exercises in the clinic and at home. IASTM was again performed to bilateral calves and plantar surfaces of feet. Patient was instructed to try repeated lumbar extensions before spin class to see if it altered the foot cramping. Patient also instructed to bring her running shoes to the clinic.
Patient reported that she did repeated lumbar extensions before and after spin class, which resulted in no foot cramping. Noted patient's running shoes had excessive wear on lateral heel and shoes were very flexible. Patient was instructed to purchase more stable running shoes. Performed IASTM to bilateral calves and plantar surfaces of feet.
Patient reported she hiked over the weekend on some mountains and her feet are a little sore as a result. Patient's new running shoes are more stable. Patient instructed to try walking extended distances in new shoes. IASTM was again performed to bilat calves and plantar surfaces of feet.
Patient reported that she was able to run 10 minutes pain-free in her new shoes. Patient reported that she still fatigues with her foot intrinsic strengthening exercises. Performed IASTM to bilat posterior calves and plantar surfaces of feet in addition to AP mobs to bilat talocrural joints.
Patient reported that she is wearing heels a lot at work with no problems and that her back and hip feel good with the repeated lumbar extensions. IASTM was performed on bilat calves and plantar surfaces of feet. Analyzed running form on treadmill and noted excessive hip ext on R, decreased arm swing on L, excessive hip rotation on R, and increased vertical displacement. Patient was instructed to soften steps in order to decrease vertical displacement and stabilize hips.
Patient reported that her feet feel great as she can run 20 minutes pain-free. Patient stated that she had no problems returning to her normal workout. HEP was administered with progression of hip motor control exercises and foot intrinsic strengthening. Patient also instructed to continue with standing lumbar extensions prophylactically.
There are several things I want to discuss in this case. Let's start with the pelvic floor dysfunction. While I initially figured the patient's buttock/abdominal pain were related to potential pelvic floor dysfunction, I proceeded to treat what I saw as an orthopaedic physical therapist, which included the lumbar spine, SIJ, and hip, as it easily could be contributing to foot pain. While the patient's pain responded extremely well to my treatment, the presence of pelvic floor dysfunction may still be present, and the patient may be hesitant to report any symptoms. Since this patient was instructed by a gynecologist to seek a pelvic floor therapist, I encouraged the patient to do so at discharge, even though she was pain-free.
With reference to the lumbar spine, this case was a perfect example of why we cannot exclude the proximal chain. Occasionally, you'll run across therapists that refuse to assess a "distal" joint if it is not on the script. For example, if a patient has a script that says "foot pain," but the patient also reports back pain, they may avoid assessing the lumbar spine. It is obvious the lumbar spine can refer as far as into the feet, but this patient had negative neurological testing that is typically what leads a therapist to addressing the spine. With the effect repeated lumbar extensions had on the patient's foot cramping, it would seem the potential exists that the lumbar spine was at least contributing to the pain or dysfunction in the feet.
What was it that lead me to trial repeated extensions? I had recently been implementing the assessment/treatment technique frequently due to the development of my understanding of repeated motions thanks to The Manual Therapist. In my evaluation, there weren't many mobility deficits, as the patient was typically hypermobile in most joints. However, she was limited in lumbar extension and her job requirements of desk work (and recreational activity of spin class) require prolonged lumbar flexion. This is a pretty common sign of those that would benefit from repeated lumbar extension. I honestly did not think the abdominal pain would respond to the repeated motions, due to my hypothesis of pelvic floor dysfunction, but I was clearly wrong.
Finally, I want to address my usage of IASTM. It would seem that much of the physical therapy population is aware of more common IASTM techniques, like Graston and ASTYM, and their indications. Typically this involves "soft tissue restrictions and decreased muscle length." With the training I received from the IASTM Technique course and some research regarding manual therapy, I have learned to use IASTM for other indications as well. In this case, the patient presented with dominant extrinsic foot musculature activity and chronic pain. The goal of IASTM for me was to alter muscle function, helping to restore intrinsic activity and to address any potential cortical smudging. I explain to each patient how there is a representation of the human body in the brain, known as the homonculus, that has its representational size based off of number of receptors in the body part. With pain, the corresponding cortical area becomes enlarged and the borders develop "smudges." The tissue becomes extra sensitive and things that shouldn't hurt, do hurt. With IASTM, mechanoreceptors can be activated to help redefine those smudges.
I know this was a long case presentation, but there was a step-by-step process I wanted to display. Initially, I figured the buttock pain would be a quick fix with a manipulation and was not entirely related to the patient's foot pain. However, with eventual examination using repeated motions, the patient's results significantly improved. We are not always right with our initial hypothesis and diagnosis. We must continuously be critically assessing the progress, or lack thereof, of our patients. Be prepared to change your plan of care. If you have any other questions about the case, don't hesitate to ask. I'd be happy to discuss the progression of my thought processes in this case and the reasoning behind any of my decisions.
A little more than a month ago, I was treating a young child for groin pain that responded fairly well to manual therapy within a few sessions. One day his mom came into clinic and started telling me about some buttock pain she had had for over a decade. There were some other odd subjective complaints, so I advised her to schedule an appointment with me to thoroughly address it.
The patient reported 11 years go she developed buttock pain near her piriformis after giving birth via C-section. Patient reported sometimes her pain goes all the way down her R leg as well. Patient believed that her pain was increased by prolonged sitting on firm surfaces but was not certain. Patient could not identify any alleviating factors. Patient also reported an occasional "cold" sensation down her leg, but is uncertain of what causes it (upon retrospect, the patient's perception of "cold" may have been actually numbness). Patient states she has seen multiple doctors for years about it but no one could treat it. The patient denied any N&T, B&B problems, significant changes in weight in last 6 months, N&V, fever, or night pain.
(I will only post the relevant findings)
-excessive lumbar lordosis
Multi-Segmental Flexion: DN
Multi-Segmental Extension: DP
Multi-Segmental Rotation: DN bilat
Lumbar Sideglides: Decreased and Painful to the R (repeated motion had patient report improved mobility)
Deep Squat: DN
Seated Passive Hip ER: DN on R and FN on L
Hamstrings: Abnormal bilat
Hip Flexors (Thomas Test): Abnormal bilat
ITB (Ober Test): Abnormal bilat
Glut Med: 4+/5 bilat
Glut Max: 4/5 bilat
(+) Slump Test
(+) Fortin's Sign
(-) Sacral Compression/Distraction, Sacral Thrust, POSH Tests
Clinical Reasoning and Day 1 Treatment
It seemed pretty clear to me she had a loading problem on her R side, suggesting repeated lumbar sideglides would be an effective treatment. Due to the positive Fortin's sign, I thought she would respond well to a SIJ manipulation as well. I performed a SIJ distraction manipulation which eliminated her pain and changed her Multi-Segmental Extension to Functional and Non-Painful. I followed that up with some general core stabilization exercises and a HEP of repeated R lumbar sideglides 10x/hour. I should note that I don't often just rely on a positive Fortin's sign to direct my decision on whether or not to use a SIJ distraction manipulation, but with the patient being overweight, palpation of anatomical landmarks was difficult.
A week later the patient returned and reported she had no pain for a few days, but then it returned. The patient stated she was not consistent with the HEP and was uncertain if it was helping. The patient again presented with Multi-Segmental Extension Dysfunctional Painful and a (+) Fortin's Sign. I repeated the SIJ distraction manipulation and did some IASTM to her lumbar paraspinals. Again, her Multi-Segmental Extension became Functional and Non-Painful. I followed that up with some core exercises, again, and changed her HEP to Quad Rock Back, Supine BKFO, and repeated lumbar sideglides, emphasizing the importance of compliance on the frequency of the sideglides.
The patient returned a week later again and denied any of the pain near her PSIS, but reported severe buttock pain after sitting for 2 hours. The patient also reports she had one night with significant swelling in her R leg but both the pain and swelling had improved since. At this point, I realized that the manipulation was inappropriate for the patient as she had difficulty complying with her HEP when she wasn't in pain. It appeared the repeated sideglides were not as effective as I had hoped either. I reassessed lumbar extension and noted that it recreated the patient's buttock pain. I also noticed during extension, that her L shoulder would go further posterior than her R shoulder. I had the patient do 20 repetitions of lumbar extension in standing but cued her to push her R shoulder further back. While the motion initially recreated her pain, after 20 repetitions, she had full lumbar extension and no pain. The patient's new HEP was standing lumbar extension (to end range!) 10x/hour.
Days 4 and 5
A week later the patient returned and stated that her back pain was better than it had in years and she noticed significantly less "cold sensations." I instructed the patient to continue with repeated standing lumbar extension in standing, emphasizing end-range and hourly performance. At the final visit a week later, the patient reported no pain or cold sensations her her leg, buttock, or back. The patient was discharged with a progressed HEP emphasizing core stabilization and movement retraining exercises.
I wanted to present this case for several reasons. One is to never rule out a person with a long history of pain as a potential fast responder. Often when we assess a patient that has had pain for several years, we assume that degenerative processes or central sensitization will make them a slow responder requiring significant education and lengthy treatment. That is not always the case, as most patients are fast responders. We should be looking for significant changes in pain in the first several visits. Secondly, I want to address the comparison of treating this type of patient with a Sahrmann approach versus repeated loading. With the Sahrmann approach, we are taught to stay away from the painful motion and educate the patient on proper movement patterns using core stabilization. This is contradictory to the repeated loading approach, as often we must repeatedly perform the painful motion (not always the case). It often also takes much more education and time for the Sahrmann method to succeed. Previously, when a patient would present with extensive lumbar lordosis, I would disregard extension as a useful treatment method, but think about all the time we spend in sitting! The final aspect I want to discuss revolves around the importance of end-range for repeated motions. I have treated multiple patients recently where I first assessed repeated motions and the patient reported no change in pain, ROM, or any other symptoms, thus making me hesitant to proceed. I have learned that I have to consistently tell the patient they need to get to end-range, as that is what is required to make a difference. We can't be scared away from pain so easily as that can contribute to central sensitization.
Saphenous Nerve Pain
I recently began treating a patient who presented to clinic with a referring diagnosis of bilateral patellofemoral pain syndrome (PFPS) with intermittent low back pain. She had many common movement impairments associated with PFPS- pain with ascending and descending stairs, adduction and internal rotation of the lower extremities with squatting activities, weak posterior glut med and hip extensors. Her low back pain was consistent with Sahrmann's lumbar extension syndrome with several positive functional instability tests.
Second Visit Assessment
During her second visit, the patient also had new complaints of pain around the medial tibial plateau. Specifically she had tenderness to palpation along the infrapatellar branch of the saphenous nerve. Palpating proximally the patient had tenderness to palpation along the femoral nerve as well. Further objective testing revealed a positive sidelying femoral nerve tension test and tenderness to palpation with L3 and L4 PA assessment.
Second Visit Treatment
Following the brief daily assessment, I performed a lumbar gapping manipulation at L3-L4, long axis hip distraction, and a tibiofemoral distraction manipulation. To maximize gains, I performed neural mobilization along the femoral nerve tract as well. Pain was completely relieved and neural tension testing was negative following treatment. More impressively, the patient was able to perform a single leg step down pain free and with improved lower extremity mechanics (an activity that previously provoked pain).
Just as the sciatic nerve can develop tension, adverse neural tension can develop in the femoral nerve. Since the patient has low back pain and poor lower extremity movement patterns, there are several regions where the femoral nerve and it's distal branches can become compressed or tensioned. The femoral nerve exits from the L2-L4 nerve roots and travels along the anterior and medial thigh across the medial knee where it gives off the infrapatellar branch of the saphenous nerve and medial crural cutaneous branches. I chose to manipulate L3-L4 because I wanted to mobilize the segments that correlate with the femoral nerve. Additionally this was the region she had pain as well. As we know, there are several benefits of manipulation, one of which is the neurological reset or jump-starting the nervous system.
In addition to a lumbar gapping manipulation, I chose to manipulate the hip and knee to restore normal joints mechanics and allow for improved muscle activation surrounding the hip. In hindsight, I do not believe the neural mobilization was necessary because the patient's symptoms were already relieved by manipulation and the psychometric properties of this technique are unknown.
I want to conclude by reminding the audience that the patient's movement pattern changed following manual therapy. I had expected to see a decrease in pain and negative neural tension testing, but I was amazed to see an improved single leg step down. By relieving pressure along the nervous system, there was an immediate improvement in function.
Do not underestimate the power of manual therapy in the presence of neural tension!