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Tales from the Table



In the office, here at Accelerate Sport and Spine in New Braunfels, TX, we see patients from all different walks of life. In this blog, I wanted to show you some of the cases we see and how I approach fixing patients. The good the bad and the lessons I have learned. Here are some tales from the table.

 

Megan


Megan was a 15-year-old cheerleader who came in with achilles pain. She had been seen by trainers and an orthopedist who had diagnosed her with Sever’s Disease. Sever’s is a painful inflammation of the growth plate at the heel. It is common in younger athletes and seemed like an easy answer. Unfortunately, after weeks of physical therapy, she was no better. Luckily, she had a teammate who had used me recently to overcome a stress fracture in her foot and whose mother recommended they try me.

         During the first exam, I tested movements and palpated the achilles insertion. Although the description seemed accurate things didn’t add up. The location was similar to Sever’s she had zero palpatory pain and we could not recreate the pain with load testing. When asked to put “one finger” on where it hurts, she couldn’t. She described a general area around the heel foot and calf. The only thing that recreated the pain was when I lifted her leg and pulled on the toes to stretch the calf. Stretching the calf in a standing or seated position recreated the pain. Suspicious I asked her to humor me by laying on her stomach and arching her back up towards the ceiling. After 10 repetitions I re-tested her. Her pain was almost nonexistent. Megan had a disc herniation putting pressure on the S1 nerve root.

             This was a perfect case of incorrect diagnosis.  No matter how good the therapy is if we have the wrong diagnosis we won’t improve. We switched her treatment and began to have her focus on radiculopathy or “nerve irritation”. The next week she came back in and had zero heel pain but her back was sore. This is a common side effect of the healing process in disc issues called centralization. When distal pain reduces towards the spine. I modified her activities and by the next week, she was pain-free.



Because the disc has poor blood supply I discussed with Megan and her parents the need to allow the disc to heal completely. This can take months sometimes, even if the pain is gone. Since she was in a sport that required a lot of spine integrity, she was not in season at the time, and improper healing could lead to recurrence, I convinced them to take the rest of the semester to let things heal. Her bigger goals were still ahead of her and this was the best option to not have future issues.

                


She went on to have a great high school cheer career and never had issues again. This shows the value in not just healing fast but healing well.

 






Nancy

                 

Nancy was a very active 66-year-old triathlete coach. She was extremely active and until recently relatively pain-free. She had begun to have episodes of debilitating lower back pain that would cause her to “lock up” and be unable to get off the ground or get out of a chair. Not being one to give into a sedentary life she began doing yoga. This made things worse. Sometimes in yoga, it felt great, but other times she couldn’t get off the mat.

                  She saw an orthopedist who did x-rays and recommended physical therapy. After 6 weeks she had made no changes and now the pain was also interfering with her swimming and biking. One of her friends suggested she see me.

On our first visit, I asked for her history and what she had done in physical therapy. I must know what was tried first. This can give me a great indication of what the problem is NOT. Nothing the previous physical therapist had done was out of line or inappropriate. It was very basic early-stage spine rehab and although a little scattered it generally seemed safe enough. When we got to my exam Nancy had marked pain with standing back extension.

Curious about this I investigated further. First, I had her try to extend on one leg at a time. This made things worse. We then had her lay down and extended her on the table from the elbows and hands. Both created significant pain. Finally, I pulled on her legs and lifted her lower body into extension. She had pain but not as bad as in other positions. Nancy had something called a Spondylolisthesis. This is where one bone in the spine shifts forward or backward in relationship to the bone above or below it. It is painful but rarely dangerous. It also typically hates extension, like an upward dog of yoga or the cat position in cat camel exercises used in rehab.

I asked if anyone had ever used the term spondylolisthesis. She said no. I asked for a copy of the X-ray she did. She had the report but not the films. The report noted a grade 1 spondylolisthesis at L5. Why the ortho had not mentioned I am not sure. This would have helped the physical therapist tailor treatment. At the same time, the therapist should have performed their own exam.

We changed her exercises, and I told her to avoid all forced extensions. I gave her routines that incorporated flexion and hamstring loading. The first week she made it without one episode of the back seizing up. The second week she was able to bike again with no pain. By week 4 she swam pain-free, the most difficult thing to return to since the back is in extension in the water, without issues. I upped her rehab and started her on deadlifts. Despite fear mongering deadlift when coached properly is one of my favorite exercises for spondylolisthesis.

Six months have passed and although she may have stiffness in the back occasionally, she has had no more painful episodes and is still crushing it…by land, by sea, and by bike.

 

 

Victor

                 



Victor was a high school athlete currently a starter on both the varsity baseball, football teams and track in long jump. He played receiver and outfield respectively. Shortly after starting baseball, he developed pain in the front of his hip.  He came to my office on the recommendation of a family friend who was an orthopedist and had seen me fix his son earlier in the year.

This is a common occurrence in my dual sport athletes. The transition from one sport to the next can often bring up injury. First, if a team has gone into playoffs the body has been taxed for months and is at the end of a grueling demand schedule. Second, although many sports involve running or explosiveness the postures and demands of each sport vary. This leads to overdevelopment in some tissues and underdevelopment in others.

Hip pain can be annoying and loves to linger. The first thing we do in office is rule out red flags. Things to be imaged to ensure we aren’t doing further damage. All the testing was straightforward. I did not see anything that concerned me. Victor had a mild insertional hip flexor strain. I asked what he had done for it. He said the trainers were having him do ice. He was stretching as well as foam rolling and using a massage gun.

I never mind passive modalities like ice, electrical stim, massage (including self-massage), chiropractic or acupuncture. They can be great ways to desensitize an area and make it less painful. This is the “decrease pain and increase confidence” we talk about in my model for recovery.  The issue I take is they do not fix the most important issue which is; building capacity. Bodies need load to adapt. This is true in all cases but especially in cases of tendon pain. Tendons become painful when they exceed the capacity for the current tendon fibers to transmit force efficiently. This causes swelling in the tendon and disorganization of the individual fibers. That leads to pain as the body tries to warn us of the threat of further use. Victor was doing nothing to build capacity. It also didn’t help that he was a pinch runner, which meant staying warm between sprints was difficult. He never knee when he would be called to run.

The passive modalities of ice, massage and stim made it FEEL better. When he used it again everything would flair back up because nothing had been fixed. The other thing we had to address was the stretching. I am not opposed to stretching but insertional tendons often do NOT like stretch. This goes for all tendons. Achilles, knee, elbow, hip, hamstring…the list goes on. Mid tendon injuries are usually fine but insertional tendons get worse when stretched.

We stopped the stretching and substituted it with strength exercises for the hip, glute, and hamstrings. I also asked him to stop icing and instead went with heat. I like blood flow for tendon issues. I did not take him out of baseball. If we changed strategies I could keep him playing while also healing. The first week Victor played 6 games of baseball (2 separate tournaments) and had a track meet. He had some soreness in the hip but no pain. On the second visit, I broadened my rehab to include strengthening the calf and lower leg. Often sprinters will develop issues in the lower leg that lead to knee and hip pain due to a reliance on knee extension at push-off. By week 2 Victor was 100%. We followed up one more time to make sure to progress his rehab, which looked more like training than rehab. Both he and his parents were ecstatic about the results and grateful his season had been saved.



Patricia

Patricia was a sweet 78-year-old woman who came to see me because I fixed her husband months before. She had intense lower back pain that began when she was doing laundry 2 weeks prior. The pain was mechanical in nature. Meaning it could be recreated with certain movements. In her case extension as well as lateral flexion made it worse. She also had severe catching pain when going from sitting to standing.

After an exam, we tried some relief positions as well as very light stretch and control exercises. She felt relief for the first time in a week. We sent her home with a home plan and set a follow-up 3 days later.

On follow up she was doing 70% better. She had no catching pain since the last visit. We did some light stim as well as sit-to-stand work to encourage confidence. She left moving well and grateful to be out of pain.

On Saturday I got an email asking if I could give her any advice because she had taken a turn for the worse. All of her pain was back and she was considering going to the ER it was so bad. I called her and told her that if things were that bad she needed to go to urgent care and at least do some imaging to rule out anything serious. It turns out Patricia had a vertebral body compression fracture. This can be common in older adults but confused I asked if she had fallen. There was no history for this. She said no. But she said when she first hurt her back she was trying to pull a very wet heavy comforter out of the top load washer.

This was a lesson for me to ask better questions in the future. I assumed laundry meant a basket of clothes. Nothing we had given her would have made things worse. It had provided relief. But she needed further consultation and a brace for full resolution. This would have saved us a little time and led to better case management for Patricia. We got her over to a surgeon who was able to give Patricia her options for recovery.

I tell this story to show that even the best of us can miss sometimes. The goal is to miss small. I follow up with Patricia occasionally to make sure she is doing well. She has a great spirit and bounced back strong.


 The Truth about Injury Rehab

The recovery process can be a difficult time. We cannot predict everything. We should be able to forecast the probabilities. If things are not going as expected we should be prepared. I often tell patients “If things get better great!  I have a plan. If things do not get better great!  I have a plan.”  This emphasizes the uncertainty of rehab, the team nature of the solution, and the expectations for everyone on the team.

 

I hope these examples helped you understand how we attack injury. It is not a one-size-fits-all model. We cannot take the injury out of the patient. I love the challenge of figuring out the needs of the individual. Helping them understand what their body is saying. Creating a plan for success. Seeing them accelerate. If this sounds like you make an appointment today and let us be your last stop for injury.

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