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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. Subjective Information 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).  Objective Information Observation: -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 ROM: -Hip Flexion: 120 degrees bilat -Ankle DF: 15 degrees bilat Strength Testing: -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 Muscle Length: -Gastroc: decreased bilat -ITB: decreased bilat Palpation: -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 -Special Tests: -(+) 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 Treatment: IASTM to bilateral calves and grade V distraction manipulation to R SIJ
Day 2: 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. Day 3: 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. Day 4: 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. Day 5: 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. Day 6: 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. Day 7: 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. Day 8: 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.  Day 9: 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. Day 10: 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. Day 11: 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. Day 12: 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. Day 13: 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. Day 14: 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. Day 15: 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.  Discussion:
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. Conclusion 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. -Chris
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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. Subjective 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. Objective (I will only post the relevant findings) Observation: -patient overweight -excessive lumbar lordosis Mobility Testing: 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 Flexibility Testing: Hamstrings: Abnormal bilat Hip Flexors (Thomas Test): Abnormal bilat ITB (Ober Test): Abnormal bilat Strength Testing: Glut Med: 4+/5 bilat Glut Max: 4/5 bilat Special Tests (+) 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. Day 2 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. Day 3 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.
Discussion
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. -Chris |
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