Category Archives: Case Studies

Patient Case – Chest Pain

22 Sunday Jun 2014

Posted by in Case Studies, Trunk

≈ 4 Comments

This was an interesting patient case study.  I was wondering if I missed any special questions and what the origin of this patient’s symptoms.

Subjective: The patient is a 61 year old female with a chief complaint of right chest pain of insidious onset a couple years ago.  Patient states that her pain encompasses her right ribcage; from her clavicle to 12th rib and sternum to the spinal cord.  The patient mentions that the pain is 6/10 and feels as though there is a lot of pressure on her chest and similar to the feeling of someone having punched her.  Pt states that at its worst her pain reaches 10/10 and has gone to the emergency room due to the pain.  She mentions that the pain has been worsening and fears a flare up of 10/10 which occurred a couple years ago.  The patient states that the pain worsens with physical activity such as walking, stair climbing, etc.  She states that she feels her breathing increase dramatically, increased perspiration, and a rapid heart rate.  She mentions that the symptoms may linger for a couple hours after the onset.  She reports right sided cervical pain and a history of migraines, a history of right sided lower back pain and sciatica that started in 1999, and a left sided meniscal repair.  She states that there may be a correlation between the chest pain and her cervical pain but does not see a correlation between the chest pain and the LBP/sciatica.  The patient had MRI’s completed on the chest, x-rays, and blood work.  All tests were negative on abnormal findings.  She was referred with the diagnosis of right chest wall pain by a physician and was told by another physician that she has myofascial syndrome by another physician.  She mentions that she is on several prescribed medications (about 5-6 types) for pain management, cholesterol, blood pressure, etc.  She mentions that she would like to be weaned off of her pain medication and was prescribed another less strong medication and reduced the dosage of the stronger medication.  She went through physical therapy in the past and stated that she recalls receiving ultrasound to her chest which reduced her symptoms to manageable levels.  She mentions that she had a recent flare up of discomfort around the time of her meniscal repair surgery.  The patient lives at home and her three grandchildren are always present (males ages 19, 20, and 21) to help care for her.  She works as an accountant and will not be working for the next month due to symptoms.

Objective: 

  • Observation: Posture – forward head, protracted shoulders, hyperkyphotic upper thoracic spine, and limited lumbar lordosis; Breathing – paradoxical breathing (chest breathing only)
  • Palpation: Tenderness at right chest wall (unable to reach R1 upon palpation), cervical paraspinals, right upper trap, thoracic paraspinals, psoas, quadratus lumborum, and diaphragm.
  • Joint mobility: Not assessed due to hypersensitivity
  • Manual Muscle Test: Not assessed due to hypersensitivity
  • Neuro Exam: Not assessed due to hypersensitivity
  • Special Tests: BP = 131/82; no audible sounds of pulse in the abdomen, no rebound tenderness

Treatment:

  • Soft Tissue Massage: Left side-lying – thoracic paraspinals and right ribcage to R1; Supine – abdomen; all of which caused increases in discomfort
  • Deep Breathing: reeducation on breathing with one hand on chest and one on stomach which also became her HEP.

It seems to me that the patient is expressing signs of chronic pain.  Her sympathetic is in overdrive and causing her to be hypersensitive.  The side-lying soft tissue massage caused tearing of the eyes which is not so much due to pain but more due to her sympathetic system.  I plan to calm down her sympathetic system with more breathing reeducation, visualization, abdominal STM, foot rolling on lacrosse ball, and slight stretching.  I am concerned that there may be more going on with the patient such as a systemic issue even though she has been to 3-4 physicians for the problem and all medical tests were negative.  Are there other areas I should assess or special questions to ask?  Or am I on the right path and she is suffering from chronic pain?

Bilateral Plantar Fasciitis

18 Sunday May 2014

Posted by in Case Studies, Plantar Fasciitis

≈ Leave a comment

I am having difficulty figuring what to do with this patient.  Let me know if you have some thoughts.  Sorry it’s long but there is a lot.

Patient Case Study:

Subjective: Patient, Pt, is a 17 year old female diagnosed with bilateral plantar fasciitis for the past couple of years. Pt states that her discomfort ranges from 5/10 to 7/10 predominately at the plantar aspects of both of her feet and describes her pain as sharp to dull aching.  Pt mentions that when her symptoms worsen her feet swell and the symptoms will be present from the bottom of the feet to the posterior lower legs and thighs and occasionally to the sacrum. She states that the pain can increase quickly and take a bit to subside depending on how severe the symptoms become.  Pt reports a history of posterior sacral and tailbone pain that started from a fall during a novelty race (such as a tough mudder or wipe out type race) when she was eleven.  Pt states that she was running up a ramp and fell back onto her butt hard. She mentions that her pain occurred later that day.  She states that her symptoms have worsened at her coccyx and sacrum since then.  Pt states that when her pelvic pain increases so do the symptoms at the bottoms of her feet and back of her legs.  She is on the track team and runs the 100-m and 200-m races.  Her symptoms prevent her ability to fully participate in practice.  She mentions that she has to take breaks during practice due to increases in pain and swelling at her feet.  During the breaks, she completes calf stretches that return her pain to more manageable levels but the swelling does not subside for a day or two. She was referred by her podiatrist.  Pt mentions that she was treated by the podiatrist for the last couple of years with massage creams, injections at the feet, and three different types of orthotics; none of which changed her symptoms. Pt denies changes in her bowel and bladder function or numbness at her saddle region.  She has not had imaging completed of her lower back as of yet but will be getting imaging next week (May 20).

Objectives:

AROM:

  • Ankle
  • DF: R = 15 degrees with knee bent and 5 degrees with knee straight; L = 15 degrees with knee bent and 10 degrees with knee straight
  • PF: R = 55 degrees; L = 60 degrees
  • Inversion: R = 15 degrees; L = 15 degrees
  • Eversion: R = 28 degrees; L = 15 degrees
  • Hip
  • Extension: R = -5 degrees; L = 0 degrees
  • External rotation: R = 22 degrees; L = 14 degrees
  • Internal rotation: R = 35 degrees; L = 25 degrees

Reflexes

  • 3+ at patellar tendons and Achilles tendons; bilaterally

Palpation

  • Tenderness at bilateral tibial nerves and sciatic nerves and lumbar paraspinals.

Joint Mobility

  • Slight hypomobility of L2-5 with central PA’s with increases of pain in lumbar region to 5/10 (PA’s at L5 and sacrum reproduced symptoms to posterior thigh and popliteal fossa)

Neurodynamics:

  • (+) SLR with reproduction on pain in the back and posterior thigh at 25 degrees hip flexion bilaterally

Special Tests:

  • (+) Sacral thrust test bilaterally
  • (+) Thigh thrust with symptoms into posterior thighs bilaterally
  • (-) Heel Drop test bilaterally

Gait:

  • Pt ambulates with a stiff-legged gait (limited hip flexion and extension)

Treatment:

  • Completed at IE and given as HEP
  • Focus on improving neurodynamics and core/pelvic stability
  • Supine hamstring stretch with a belt
  • Supine hamstring stretch with a belt and completing ankle pumps
  • Supine TA contractions while marching
  • Pelvic Tilts
  • Completed at second visit
  • Grade 2 joint mobilizations at L2-5 with central PA’s
  • Single leg stance on a Bosu ball
  • Balancing on knees on a Swiss ball
  • Balancing while sitting on a Swiss ball
  • Neutral planks and lateral planks

Other Plan of Action: Pt was recommended to see an orthopedic physician with a specialty in sports related injuries while she is being seen at physical therapy.  Pt is awaiting x-rays and potential MRI next week.

Penny for your thoughts: Was the referral to see an orthopedic physician necessary or should I have completed a trial period of PT first?  Should I still be seeing the patient or wait for results from the imaging and the physician?  What other tests and measures would you do?  What treatments would you recommend to do and what would you recommend not to do? What else do you want to know?

Achilles Tendinopathy

10 Saturday May 2014

Posted by in Achilles Tendonitis, Case Studies

≈ 5 Comments

Patient Case Study:

Subjective:  Patient, Pt, is a 53-year-old female who was referred for a 3-year history of right sided Achilles tendinopathy.  Pt arrived to physical therapy in a boot prescribed by her physician.  Pt reports 7/10 pain at baseline that can increase to 10/10 at its worst when not wearing the boot.  Pt mentions that she always uses the boot when weight bearing.  Pt describes her pain as stabbing and achy.  Pt states that she has a large growth on the posterior aspect of her Achilles.  Pt mentions that she has swelling at the lateral malleolus.  Pt mentions that using the boot and non-WB help to return her symptoms back to baseline.  Pt states that she has been to multiple trials of physical therapy in the past without improvement in symptoms and function.  Pt’s goals for physical therapy are to ambulate without the boot and reduce symptoms.

Objective measures on the right: 

AROM:

  • Dorsiflexion with knee straight = 10 degrees
  • Plantarflexion = 65 degrees
  • Inversion = 22 degrees
  • Eversion = 35 degrees

PROM:

  • DF with knee straight = 15 degrees
  • Talocrural Eversion = -5 degrees

MMT:

  • Dorsiflexion = 5/5
  • Plantarflexion = 3/5 (limited due to pain)
  • Inversion = 5/5
  • Eversion = 5/5

Sensation:

  • Unremarkable

Palpation:

  • Tenderness along the Achilles tendon.
  • Thickened nodule at Achilles tendon about 5cm proximal from the calcareous.

Joint Mobility:

  • Grade 1 hypomobility of the talocrural joint into eversion with a hard end-feel

Neurodynamics:

  • (+) Straight leg raise

Gait:

  • Pt ambulates with a short step length on the right, right knee in excessive flexion during initial contact and mid stance, and a contralateral hip drop on the right.

Treatment:

  • Home Exercise Program – Day 1
  • Gastrocnemious Stretch – hold for 30 seconds x 3
  • Soleus Stretch – hold for 30 seconds x 3
  • Eccentric Heel Raises – 20-25 pounds of weight in backpack that she wears during exercise; complete full heel raise with both lower extremities and eccentrically lower on right lower extremity at a 3 second count; 15 repetitions or to tolerance (increase in discomfort during activity with a reduction in symptoms to baseline with rest and discontinuation of exercise for a day if symptoms remain elevated for greater than 24 hours) 2-3 times a day
  • Self Joint Mobilizations – mobilization of talocrural joint into eversion for 1 minute a day
  • Home Exercise Program – Week 3
  • Soleus and Gastrocnemius Stretches
  • Eccentric Heel Raises – increase weight in backpack by 10 pounds with the rest of the parameters the same.
  • Single Leg Heel Raises – holding two 10 pound weights in hands; complete concentric contraction of plantarflexors and eccentric lowering of heel to ground at a 6 second count; 10 repetitions or to tolerance (increase in discomfort no greater than 5/10 on a pain scale during activity with a reduction in symptoms to baseline with rest and discontinuation of exercise for a day if symptoms remain elevated for greater than 24 hours) one time a day.

Results:

  • Pt has a reduction of symptoms to 3-4/10 at baseline, a reduction in size of Achilles nodule upon visual assessment and palpation, ability to complete 25 single leg heel raises on the right without increases in symptoms >5/10 on the VAS, no use of boot during ambulation or throughout the day, but continued increases in discomfort at the end of the day greater than baseline when in bed going to sleep.

Research Studies Used:

Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, Kjer M. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports. 2007; 17: 61-66.

(Click on the link for access to the article)

  • The purpose of the study was to investigate the effect of a 12-week eccentric rehabilitation program on local collagen turnover in the area surrounding the Achilles tendon in 12 high-level soccer players with chronic Achilles tendon disorders.
  • Protocol: Two training sessions daily for 12 weeks that consisted of 15 eccentric repetitions of heel raises on a straight leg (full weight on the injured leg, forefoot on a step, going from maximum heel lift to maximal dorsiflexion, and using the healthy leg to lift back up to maximal heel rise) and 15 repetitions of the same exercise with the knee bent.  The subjects were instructed to complete exercises while wearing a backpack containing 20% of their body weight.  The subjects were instructed that their symptoms may increase for the first 3-4 weeks.  The load was increased when the patient was able to complete the protocol without increased pain immediately after completion.
  • Results: There was a significant increase in collagen synthesis after training at the injured tendon.  There was no significant increase in collagen degradation when compared to the health tendon.  The experimenters found a significant decrease in VAS after the 12-week protocol but did not fully eliminate the pain.  All subjects were able to return to sports.

Silbernagel KG, Thomee, R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy. Am J Sports Med. 2007; 35(6): 897-905.

(Click on the link for access to the article)

  • Purpose: To evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome.
  • Protocol: The exercise training group (n=19) continued without their Achilles tendon loading activities, such as running and jumping, following a pain-monitoring model.  The pain-monitoring model consisted of using the VAS.  Individuals were allowed to reach 5/10 during activities with 10 being the worst pain imaginable.  The pain was allowed to reach 5/10 but should have subsided by the next morning and pain/stiffness at the Achilles was not allowed to increase week to week or the activities were discontinued.
  • Results: There was no significant improvements between the experimental group compared with the control/rest group.  Both groups showed improvements in outcome measures.  There were no negative effects for individuals with Achilles tendinopathy continuing to participate in their recreational activities during their rehabilitation process when using the pain-monitoring scale.

Thoughts:  Any thoughts on how to improve the patient’s discomfort that she is feeling at night when in bed or now that she is ambulating, has a reduction in nodule size, and a reduction in symptoms overall, it is a waiting game to let it continue to heal?