The Student​ Physical Therapist
  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test

Mini Case: The Questionable Calf Strain

12/22/2014

4 Comments

 
Picture
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.

-Chris

4 Comments
Adam Kelly, MS, ATC link
12/23/2014 02:59:37 am

Good Post! Reminds me of a similar pt that I had this summer. Breaking out and addressing her DN MSE helped resolve her lingering Sx. I think of this because an inability to extend the hip can result in an over-use of the lower leg tissues.

Reply
Chris link
12/23/2014 06:04:30 am

Hi Adam,

Thanks for your comment! I completely agree. Cases like these are a perfect example of why we need to be thorough with our exams.

Reply
Megan
12/23/2014 12:02:28 pm

Hi Chris, Great post. Could you point me in the direction of more information on the unilateral vs bilateral loading? I'm not sure I'm clear on what you mean with that phrasing.

Thanks very much. Megan

Reply
Chris link
12/23/2014 12:53:18 pm

Hi Megan,

I have linked to a post I had several months ago all about repeated motions that should cover any background information you have questions about. In general, when we are talking about loading the spine, we are referring to the posterior elements that become compressed with extension (facets). If the patient has unilateral symptoms, they often have difficulty "extending" on the involved side. If bilateral complaints, bilateral extension is limited. This is a real rough overview of it. If the link and this explanation are not sufficient, let me know as I'd be happy to provide a more thorough explanation.

http://www.thestudentphysicaltherapist.com/home/repeated-motions-exam-and-treatment-why-you-should-be-using-it

Chris

Reply



Leave a Reply.

    Archives

    March 2016
    June 2015
    February 2015
    December 2014
    November 2014
    October 2014
    September 2014
    July 2014
    May 2014
    February 2014
    December 2013
    September 2013

    Categories

    All
    Cervical
    Nerve

    RSS Feed

Home

Contact Us

Copyright © The Student Physical Therapist LLC 2022
Photos used under Creative Commons from Misha Sokolnikov, Alan Light, jpalinsad360, Hanna Alicé, molybdena, amsfrank, Idhren
  • Home
  • About Us
  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
    • Physical Therapist Consultant Course
    • Orthopedic Management of the Cervical Spine
    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test