Friday 5! 5 Things I Learned This Week in the Clinic

Here are 5 things I learned this week the the clinic. It's a bunch of mini-COTW in one post!

Uncommon things can happen

I often teach about pattern recognition and how it can cut down on clinical decision making. Well, seeing TMD patients there is a pattern of difficulty opening, facial/neck/head/ear pain, cervical pain, forward head, retracted mandible
after 2 visits, a patient with difficulty closing due to lack of molar occlusion bilaterally, only mild pain with eating, good posture, and no other complaints had no changes with the normal Tx and education that helps 90% of the TMD cases I see
after really listening to her, the following things stood out
- difficulty CLOSING with only incisor contact
- pain only at end range closing
- mandible retraction improved occlusion

provisionally, she is now classified as a posterior disc subluxation, which is rare because it normally subluxes anteriorly
her mandible is actually protracted, causing her to bite and chip her incisors, and the difficulty in closing is very much like a springy end feel
passive distraction, posterior glide, and superior glide with light opening/closing was given and instructed to try and remodel the inferior disc as it has now most likely lost it's bi-concave shape

You don't always have to look globally

after resolving a left lumbar, right cervical pain patient with MDT, education and little manual, she tells me she cannot squat due to right knee pain
the right knee LE in WB had a DN in SL stance, and also medial knee tracking/DP with single and double leg squat
knee flexion was FP, knee extension was DP, mod loss
I was ready to treat lateral upper and lower LE patterns, try tibial IR MWM, etc... my normal “go to” patterns, but I was also teaching a new intern about MDT
so what is the contrary end range loading strategy for a knee that has trouble with flexion?
If you said “extension” give yourself a gold star!
- End range passive overpressure into extension was PDM, no worse as a result
- after 5 reps, extension improved from -10 (flexion) to 0, minimal PDM, 10 more reps, she had the normal 10 degrees hyperextension that her other knee had
- her knee was now pain free in AROM/PROM flexion
- retesting SL stance, single and double leg squat was now FN with no tracking issues
- she was instructed on PROM knee extension to end range in sitting (heel on floor, pushing femur posteriorly – 10 times hourly)
- since then she was able to work out completely pain free with her trainer
- btw, I did look at her hip/ankle – both were FN prior to the repeated end range loading strategy

RockTape tweak taping works very well!

I am currently treating a few runners training for a half marathon, here are similarities in two of them
both are
- female
- running minimalist
- first time training over 5 miles
- both have DN SL stance on right
- both had sudden onset of severe medial arch pain at 8+ miles, unable to resolve with rest from running > 3-4 days
- the first patient had cleared lumbar pain, hip mobility after 3 treatments and only had remaining onset of arch pain, since she transitioned to zero drop and dramatically increased her mileage, had severe tenderness in her arch, I told her she may be at risk for a stress fracture according to running research
- I decided to tweak tape using RockTape (small piece of tape not along an entire LE line) from the midfoot plantarsurface medial arch to just the anterior talus)
- to the patient's, mine, and the MDT Diplmat's surprise, her severe arch pain immediately and completely abolished in WB, walking, and SL stance was now easily FN with eyes open and closed
- I explained to her the tape on skin rationale and she was satisfied but confused as she used to work in an ATC room and was used to A LOT more tape
- instructions, leave the tape on for 4-5 days, if she was pain free for 3 days (4^th day was supposed to be a 10 miler) she could run
- she emailed me over that weekend and was still 100% pain free, I gave her the ok to run and she ran 11 miles completely pain free
- 2^nd patient – wife's personal trainer, also training for half marathon
  - also sudden onset medial arch pain
  - same tweak tape made her SLS FN with eyes open and closed, DS went from DN with right medial knee tracking and foot ER to FN
  - that day and since then (5 days) she was able to run at least 11 miles with absolutely no medial arch pain

Great toe rapid responder

another runner, training for half marathon – we have the Buffalo half marathon coming up, can you tell?
Cleared right hip of extension limitation which was causing overstride caught on slow motion treadmill analysis
this improved ITB and hamstring discomfort
last complaint was great toe pain with extension on the right side with push off
great toe extension was DP, mild loss
previously instructed on slight toe adduction with end range overpressure into extension, which had no lasting effect
after light IASTM to the dorsum and plantar surface of the first ray, she had nearly pain free great toe extension
repeated great toe flexion further increased great toe extension and made it pain free, instructed on this for HEP

The patient's belief in your explanation is entirely dependent on how they are responding to treatment

previous hip/lumbar, knee, ankle patient
always responded to education, manual therapy, HEP at least 9 times over the past several years
recently has been instructed on updated modern mechanisms of manual therapy over the past year, and had no issues with me going lighter and giving less exercises for HEP when she responded to therapy
she fell 8 weeks ago skiing, landed on her left side with L UE abducted, hitting her left mid ribcage
she is now left with cervical SB loss to the left and painful catching in lateral upper arm at rest and with elevation movements
she is not responding to cervical, thoracic, GH, treatment, taping, neurodynamics, IASTM, sustained positions, MDT, or anything that she has responded to in the lower quarter in the past
she keeps asking “What's going on?” “What is wrong?”
- she is very frustrated and confused with my lack of pathoanatomical explanation
- I even said, when you responded in the past to these treatments/education, you did not question the lack of anatomical structure behind the pain
- I also asked her if she would be less frustrated if I told her it was a disc/rotator cuff tear, and she said not really

it was entirely context dependent and difficult to convey. I ended up trying repeated shoulder extension end range loading, which improved her ROM, but not discomfort
a trial was given to be performed hourly for HEP, she is going out of town for three weeks, and will update by email, keep your fingers crossed!