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.