Self-delivered home-based mirror therapy for lower limb phantom pain.

Darnall BD.  Self-delivered home-based mirror therapy for lower limb phantom pain. Am J Phys Med Rehabil. 2009 Jan;88(1):78-81.
This is a case study of a 35 year old man with an above-knee amputation of his left leg.  He noted phantom limb pain almost immediately after the injury, and continued to have symptoms despite completing rehabilitation and multidisciplinary pain management, and was consistently using pain medicine.  Prior to initiating mirror therapy, the patient reported a pain level of 4/10.  He was introduced to the concept of mirror therapy, as well as diaphragmatic breathing and progressive muscle relaxation.  He purchased a full-length mirror, which he placed on the floor opposite his intact limb.  He performed a self-designed program for 3 times a week for 30 minutes, which included multiple movements of the ankle, knee and hip.  He maintained a focus on viewing these movements in the mirror, and visualizing movement of his phantom limb.

He reported a consistent improvement in symptoms, and after increasing his frequency to daily performance, reported that his pain level decreased to 0/10, with no further need for pain medication.  He noted that he would have a return of symptoms if he did not perform his exercises for 1-2 days, but he was able to control this if he returned to regular performance.

Mirror therapy has been shown to be effective in hand and upper extremity treatment, but the same effects haven’t been shown in the lower extremity.  Some of the people I’ve spoken to hypothesize that this may be due to the significantly higher cortical representation of the hand, as one of the main effects of mirror therapy is thought to be changes in the cerebral cortex.  This case study demonstrates that in certain patients who have not had a satisfactory outcome with other appropriate pain-control measures, mirror therapy can have a significant effect on lower extremity phantom limb symptoms.  I especially liked the simplicity of this program, in that the subject bought his own inexpensive mirror, and was able to create his own program to control his symptoms.

The Moving Patellar Apprehension Test for Lateral Patellar Instability.

Ahmad CS, McCarthy M, Gomez JA, Shubin Stein BE.  The Moving Patellar Apprehension Test for Lateral Patellar Instability. Am J Sports Med. 2009 Feb 3. [Epub ahead of print]

This is a diagnostic study looking at a new variation of patellar provocative testing to determine patellar instability.  The test has two phases.  In phase one, the patella is pushed laterally, and the knee is passively moved from full extension to 90° flexion – a positive test involves apprehension by the patient, or contraction of the quadriceps in an attempt to stabilize the patella and prevent lateral dislocation.  In phase two, the patella is pushed medially, and the same movement is performed – with a positive finding, the patient will not report any pain or apprehension.

This test was performed on 51 patients with various knee symptoms, and compared to whether their patella dislocated with a lateral glide under anesthesia.  The test was found to have a sensitivity of 100%, a specificity of 88.4%, a positive predictive value of 89.2%, a negative predictive value of 100%, and an accuracy of 94.1%.  All of these findings are significantly more robust than previous versions of patellar apprehension tests, which usually involve pushing the patella laterally in full extension, at 30° flexion, or some motion between them.  The test picked up every patient whose patella dislocated under anesthesia, and only 3 false positives out of the 26 who did not dislocate.

This study is made more powerful in that they compared patients with dislocation to patients without, making this much better than one in which normal control subjects are used.  Of course, considering the patients were put under anesthesia for this examination, it would have been hard to convince people without knee symptoms to agree, although I suppose they could have used the contralateral knee.  The authors noted that each of the 25 subjects with positive findings who were positive on the gold standard test also felt better with the patella glided medially.  This calls into question the need for phase two, but I agree with the authors that it can be helpful to use this to confirm the diagnosis, especially since it is performed quickly, and there is no reason to expect harm from performing the second phase.  We should remember that the gold standard used in this exam (dislocation under anesthesia) may not be correlated to any specific functional findings, but with this in mind, the moving patellar apprehension test seems to be a significant improvement over the standard tests we learn.

Slump stretching for low back and leg pain

Cleland JA, Childs JD, Palmer JA, Sarah Eberhart S. Slump stretching in the management of non-radicular low back pain: A pilot clinical trial. Manual Therapy 11 (2006) 279-286

This study was performed to assess the additive effect of slump stretching on patients with low back and leg pain, with the idea that patients who received slump stretching in addition to a standard physical therapy plan would have greater improvements in disability, pain, and centralization of symptoms than patients who received standard care only. Subject were 30 people between 18 and 60 years of age with a chief complaint of LBP referred to physical therapy. Patients were required to have symptoms that referred distal to the buttocks, reproduction of the patient’s symptoms with slump testing, no change in symptoms with lumbar flexion or extension, and a baseline Oswestry score greater than 10%. Exclusion criteria included positive neurologic signs or symptoms suggestive of nerve root involvement (diminished upper or lower extremity reflexes, sensation to sharp and dull, or strength), osteoporosis, or a straight leg raise (SLR) test of less than 45 degrees. Eighty-one patients (69%) did not satisfy the inclusion and exclusion criteria for the study.

All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the modified Oswestry Disability Index (ODI). Fourteen patients were randomized to receive lumbar spine mobilization and exercise, and 16 received lumbar spine mobilization, exercise, and slump stretching. All patients were treated in physical therapy twice weekly for 3 weeks for a total of 6 visits.

Slump stretching was performed with the patient in the long sitting position with the patient’s feet against the wall to assure the ankle remained in 0 degrees of dorsiflexion. The therapist applied over pressure into cervical spine flexion to the point where the patient’s symptoms were reproduced (Fig. 2). The position was held for 30 s. A total of 5 repetitions were completed.

At discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI), pain (.93 points on the NPRS), and centralization of symptoms than patients who did not. The results suggest that slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms.

I absolutely love this study. It represents a lot of what I like about some of Josh Cleland’s work – it asks a straightforward clinical question that has been generally accepted but not formally tested in the physical therapy world, and then sets up a trial that involves treatments with strong external validity. Many studies answer such specific questions that it is hard to take the information straight to the clinic. This study is different, because if you have a patient who fits the criteria outlined above – leg pain, not changing with lumbar flexion and extension, no neurologic symptoms and, generally, fairly well-controlled symptoms – you may be missing something if you are not adding slump stretching to that patient’s treatment. I found it especially interesting that the authors found increased centralization over time, as I had not read of or seen that previously in relation to slump stretching.

The one problem that I have with this study comes from my background in McKenzie training, and is an issue that often comes up with the type of repeated motion testing performed in this study and those carried out by Cleland, Childs and others. The patient group that was treated here would be analogous in diagnosis and treatment to McKenzie’s adherent nerve root – intermittent leg pain, produced with tension on the nerve, but otherwise painfree in the leg. This diagnosis is only arrived at after exhaustive repeated motion testing, and is probably found in 2-5% of patients, versus the 31% of patients in the current study. Given that the repeated motion testing was not specifically described in this paper, it would be interesting to see if more subjects would have been excluded with different repeated motion testing. Perhaps the results would have been even stronger.

Does muscle stretching stretch muscles, or do we just get used to it?

Folpp H, Deall S, Harvey LA and Gwinn T  Can apparent changes in muscle extensibility with regular stretch be explained by changes in tolerance to stretch? Australian Journal of Physiotherapy 2006: 52. 45-50

I’m always interested in studies that address stretching, because it seems that nearly every patient with an orthopedic ailment expresses guilt that they don’t stretch enough, or they do the wrong stretches, and that they know that (insert individual ailment) would be better off if they would just stretch more. Hamstrings seem to be especially culpable – everyone has been told by their friend, doctor, or personal trainer that if their hamstrings were looser, they wouldn’t have their back pain. It’s remarkable, because it comes even from people with excellent flexibility. While there is very good evidence that applies to many people regarding the negative effects of sustained postures, especially on the spine, and the benefit of frequent position change, there is very little evidence for the benefit of standard stretching in preventing injury or increasing performance (although yoga is gaining evidence as a treatment for chronic low back pain). If anything, static stretching has been shown to decrease performance in activities requiring power, such as vertical leap.

Given that caveat, there are people for whom there are benefits to stretching, such as gymnasts and ballerinas, or hurdlers, who require muscular flexibility to perform their sports with good form and efficiency. This study went beyond looking at ways to increase hamstring flexibility, which is what is performed in most flexibility studies, and focused on the mechanism of change. They did this by differentiating between muscle extensibility, which was the motion achieved with application of a standard external torque, and stretch tolerance, which was motion achieved with the subject’s maximum tolerated torque. They used 20 subjects, average age 24, with “tight” hamstrings (unable to put their palms on the floor in standing) but otherwise free of back, hip or knee pathology. Hamstring flexibility was measured in supine, with the knee locked in an full extension with a brace, and rotated through use of a wheel with weights to produce rotation, which was centered at the hip joint. To test muscle extensibility, a standard load was applied to the leg, and the degrees at the end of three minutes was used. In assessing stretch tolerance, weights were gradually added in a standardized manner until the subject reported that they could not tolerate any further stretch. All subjects were randomized to have one experimental limb and one control limb; the intervention on the experimental limb involved performing a 20-minute seated hamstring stretch five times a week for four weeks. Four of the five weekly stretch sessions were supervised, and the subjects generally had excellent compliance.

After the intervention, the intervention and control limbs were retested. There were almost no changes in motion in any aspects of testing in the control limb. In the experimental limb, the increase in motion with the standardized torque was –1 degree (95% CI –4 to 3 degrees), while the change in motion with the maximum-tolerated torque was 8 degrees (95% CI 5 to 12 degrees). It’s interesting that a P value wasn’t reported, but the difference in 95% confidence intervals indicate the significance of the difference. This increase in tolerated stretch was matched by the increase in the torque tolerated by subjects of 12 Nm (95% CI 7 to 18 Nm).

The authors describe these results as supporting the idea that muscle stretching does not increase the extensibility of the muscles nearly as much as it increases the subject’s tolerance to stretch, and if 4 weeks of 20-minute stretches isn’t going to increase it, I don’t know what will. While this is interesting, the authors contend that clinically, it’s probably not as important to know the mechanism of motion improvement as it is to know how stretching should be performed, and what results can be expected. To that end, one of the most important findings of this study is that the motion gains they found (8 degrees) matched nearly perfectly those of other studies, some of which used much less time- and effort-intensive stretching routines. Given this information, we should expect something on the order of a 5-10 degree increase in straight leg raise motion with the regular performance of a 4-week stretching program.

Can we identify who benefits from lumbar traction?

Fritz J et al. Is There a Subgroup of Patients With Low Back Pain Likely to Benefit From Mechanical Traction? Results of a Randomized Clinical Trial and Subgrouping Analysis Spine 2007;32:E793–E800

When I was in college, sometime back in the last century, one of our group projects in my research class involved choosing a topic, and presenting the research behind it. My choice for our group was lumbar traction – I had seen it performed fairly often on my clinical rotations to that point, and was interested to see what evidence there was behind it. Unfortunately, our presentation ended the same way as everyone else’s – “more research is needed.” What amazed me was not that no specific benefit was found, it was that the different authors couldn’t seem to agree on anything – some studies included only those with radiographic evidence of HNP, while others excluded all patients with any evidence of neural signs, and everything in between.

This study is an attempt to determine whether there is a specific subgroup of patients that will benefit from lumbar traction. This was one of the categories in original treatment-based classification systems, but seems to have been left out in the more recent research due to lack of evidence. The symptoms historically associated with lumbar traction include signs of nerve root compression, a positive SLR, and lack of centralization. This study randomized 64 subjects to two treatment groups: up to 12 visits of an extension-oriented treatment program, or that same program plus up to two weeks of prone traction at the start of treatment. Subjects were between 18 and 60, with pain below the buttock and signs of nerve root compression. The extension-oriented treatment program has been described elsewhere, and involves active and sustained extension exercises, as well as P-A joint mobilization. It has shown benefit over strengthening in patients who centralized with extension on examination. The traction was applied in prone, with a 10-minute sustained force, and was adjusted in flexion, sidebending, or rotation as needed to promote centralization, attempting to move the patient into a flat prone position as treatment progressed.

Follow-up assessment was performed at 2 and 6 weeks. Those in the traction group had greater changes in Oswestry and FABQ scores at 2 weeks, but there was no significant difference by 6 weeks. Those in the traction group were seen for a median of 8 visits, versus 4 for the extension group. In looking at all of the physical examination variables initially assessed, two demonstrated a positive benefit of traction plus extension versus extension alone: those who peripheralized with extension had a 15.5 greater change in Oswestry at 6 weeks, and those with a positive crossed SLR test had 18.9 points more change. Overall, this serves to support the general opinion that traction may be beneficial in patients with signs of a large nerve compression (such as a crossed SLR), or who don’t centralize at evaluation.

One of the challenges to any examination and treatment study like this is that you can almost always say “they didn’t test it the way I would have”, and for me that applies here. From a McKenzie background, the appearance of only peripheralization and no centralization during an evaluation is a fairly strong indicator that repeated movements won’t work, at least in the short term, and may be indicative of disc derangement. However, peripheralizing with extension is not the sole criteria, as this same patient may demonstrate a directional preference, and possibly centralization, with flexion or lateral forces, and likely would not have the same additional benefit of traction. Changing the criteria from “peripheralized with extension” to “only peripheralized and never centralized with repeated movements” would likely have yielded somewhat different results, as overall those who centralized with extension at evaluation improved 8.8 points more than those without centralization. I know that these issues have been a point of some debate between Julie Fritz and some of the people in the McKenzie institute, and I imagine it will continue for some time.

It also seems strange, and clinically unlikely, that one would treat patients who peripheralize with extension with more extension, and I actually wonder how they progressed treatment for the patients that were peripheralizing with extension. It is especially strange that they were so consistent with this, given how they readily adapted the traction set-up in different planes to promote centralization. The extension classification has been shown to beneficial in those who centralize with extension, so I assume are using it as a general treatment for those with peripheral and nerve root signs.

The authors recognize that this paper is the first step in trying to decipher who may fall into this subgroup. The general information I take from this is that if patients are centralizing with extension (and likely any other movement), there is no significant additional benefit to traction. There may be some benefit in those with harder neurologic signs, and I expect this will be better understood with further research. I admit that there will have to be exceedingly strong evidence in favor of lumbar traction for me to start utilizing it on almost any patients, but if this research continues to come out with some stronger evidence, I can definitely think of several patients I’ve had who might benefit. Of course, then the clinic would have to buy a traction unit.

Effect of taping and bracing on step-down control

Selfe J.,Richards J., Thewlis D., Kilmurray S. The biomechanics of step descent under different treatment modalities used in patellofemoral pain Gait and Posture 2008;27 258-263

Patellar taping was made popular and common as a treatment for patellofemoral pain after Jenny McConnell published her work in the mid 1980’s. Since then multiple effects have been attributed to patellar tape: medial shifting of the patella, stronger firing of vastus medialis obliquus (VMO), earlier firing of VMO, and improved proprioception of the knee. McConnell described applying the tape with medial glide (adding tilt or rotation as indicated on the evaluation), but effects have also been found with applying the tape in a neutral position and force.

This study assessed the effect of patellar bracing and neutral patellar tape (applied directly onto the patella, with no bias toward medial or lateral glide or tilt) on knee moment and angles in the frontal and transverse planes. Subjects performed a step-down off of a 20 cm step, with a multi-camera setup tracking reflective markers.

Compared to no intervention, the patellofemoral brace and taping led to a significant reduction in the maximum coronal and range of torsional knee angles, and the range of coronal and transverse plane knee moments was also significantly reduced. The brace was most effective in controlling frontal and transverse planes, with the tape providing small but statistically significant effects. The authors recognize that they are unable to discover the cause of the changes seen in the study, and caution that the subjects in the study were asymptomatic, and young (average 28 years) – they are working on a follow-up with subjects with knee pain.

Christopher Powers came to Duke last fall to present on lower extremity mechanics, diagnosis and treatment, and he put on a fantastic course, full of his leading research and basic and advanced biomechanical concepts. As one would expect, a part of his course involved his research on weightbearing squatting in dynamic MRI machines. The primary finding in these machines is that the patella doesn’t really shift between the femoral condyles during the squat, as it’s pretty well anchored to the tibia by the patellar tendon. There is rotation at the patellofemoral joint, but it comes primarily from the femur rotating under a fixed patella. This is the reverse of what most of us were taught, especially in relation to the mechanics that we were supposedly addressing with patellar tape. Dr. Powers used these images as support for his argument that patellar taping should be forgotten for control of the patella in patellofemoral rehabilitation. I wanted to argue with him, but felt the way some of my friends and colleagues (and patients) must sometimes feel when they argue with me: they know they’ve seen something clinically, but they don’t have the research to back it up. I wanted to argue that the tape had to have some effect, because I’ve seen it work immediate wonders for some patients (including myself when I had knee pain), while doing nothing for others. The tape has some sort of effect, even if it can’t be explained mechanically through an MRI.

Dr. Powers describes weakness of the hip leading to increased frontal and transverse plane motion with knee flexion loading to justify his treatment paradigm, and there can be little argument that this is an important aspect of diagnosis and treatment when these movement patterns are present. Given the results of this study, however, there appears to be a role for bracing in controlling some of this aberrant motion, and also for taping, albeit with a lesser impact. Hopefully studies like this and those that follow it will continue to address the proprioceptive versus mechanical aspects of patellar tape application, and help us to better understand if we can determine which subgroup of patients will best benefit from it, and for what precise purpose.

Reliability of weightbearing dorsiflexion measurement

Bennell K.L., Talbot R.C., Wajswelner H, Techovanich W, Kelly D.H and Hall A.J. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother. 1998;44(3):175-180.

Regaining dorsiflexion after an ankle injury is one of the most difficult and important aspects of rehabilitation. This paper was designed to assess the reliability of a weightbearing dorsiflexion measure with the knee bent. Given the high levels of force and motion required of the ankle during daily activities such as squatting and descending stairs, and the difficulty of replicating this with manually applied forces, the authors discuss the importance of having a reliable weightbearing measure that can accurately capture the maximum available functional ankle motion.

The subjects were 13 healthy physiotherapy students, with an average age of 19 years. The test involves standing facing the wall, and then lunging forward to reach the knee toward the wall, without lifting the heel. Subjects attempted to move their feet as far backwards as possible, while still being able to both touch their knee to the wall and keep their heel flat. Heel contact with the floor was manually maintained by the assessing therapist. The result was recorded two ways: distance of the toes to the wall, and ankle dorsiflexion angle as measured by inclinometer on the tibia. To assess the inter-tester reliability, 4 assessors – 3 experienced physiotherapists and one student – performed sequential evaluations, and 2 of the therapists performed re-tests one week later to assess intra-tester reliability. The test was carried out three times by each assessor, and the average of the results was recorded.

The inter-rater ICCs were .97 for the angle measurement and .99 for the distance measurement, indicating nearly perfect reliability. The intra-rater reliability was also within that range, and the results measured by the student were found to be consistent with the other testers. Given a standard error of 3 approximately 3 percent for both methods, the authors indicate that a change of greater then 1 centimeter or 3° would be required to be confident in a change in motion, at least among subjects without injury.

Despite these excellent outcomes, there are several things to keep in mind. As the subjects in this study were young and free of any ankle pathology, they were likely reaching their true endrange, a fact supported by the wide variation in the measurement between subjects (30-68°). Pain, swelling, balance, or difficulty with weightbearing may influence the ability to reach endrange, influencing the reliability of the findings. There was also no mention of subject or tester blinding that I could find, a finding that could certainly affect the intra-rater reliability, but would likely have little effect on the inter-rater reliability, unless the subjects with repetition were able to learn where to place their feet for the most efficient outcome. It is difficult to accept the results of a reliability study that does not include blinding, and this certainly could have an effect on the standard error measurement. Given these drawbacks, this study shows the test to be reliable in a healthy sample, and it certainly appears to be a more functional and reliable test than dorsiflexion in lying.

I was at a continuing education course once where the instructor had me come up to the front to demonstrate how to perform a screen. I indicated that for at least the past several years, my right ankle has been tighter than my left into dorsiflexion (there is a several centimeter difference when I perform the test above). In testing this prone, he reported that it was not a significant difference, and had me then perform step-downs. This was easy on the left, but nearly impossible on the right, due to my inability to dorsiflex and the resultant increased stress on the knee and hip. I did not want to debate with the course instructor, but ever since he demonstrated the inability of the prone dorsiflexion test to pick up functionally important differences in dorsiflexion motion, I have placed greater importance on including this test in my lower extremity screen. I have always measured the distance to the wall, but given the excellent correlation shown in this study, I may have to pull out our inclinometer and save myself a few steps.

Diagnosis of Radicular Quadriceps Weakness

Rainville J, Jouve C, Finno M, Limke J. Comparison of four tests of quadriceps strength in L3 or L4 radiculopathies Spine 2003;28:2466–2471

This study was designed to address the lack of a standard test for quadriceps weakness in patients with L3 or L4 radiculopathy. The authors describe, given the high levels of strength usually seen from a large muscle group like the quadriceps, the low sensitivity of standard manual muscle testing. If quadriceps strength is used to assess for L3 or L4 radiculopathy, a test with low sensitivity is likely to result in substantial false negatives, and missed diagnoses. The goal of the authors was to determine if a clinical test exists with sufficiently high sensitivity to detect this lesion.

Two sets of patients were assessed: the study group included 33 patients with symptomatic, unilateral lumbar radiculopathy, and an MRI or CT that demonstrated displaced or compressed the L3 or L4 nerve roots on the symptomatic side. The control group was made up of 19 patients with MRI or CT confirmation of displacement or compression of L5 or S1 nerve roots. Symptoms of radiculopathy included unilateral leg pain of the groin, thigh, or lower leg, paresthesias involving the thigh, knee, or lower leg, and/or symptoms suggestive of weakness in the affected extremity.

The following tests were chosen to assess quadriceps weakness: single leg sit-to-stand, step-up, knee-flexed MMT and knee-extended MMT. The single leg sit-to-stand test was the most accurate (61%), versus the step-up (27%), and the bent-knee MMT (42%). In those with L3 or L4 radiculopathies, the single leg sit-to-stand revealed all but one subject with decreased quadriceps strength found by the remaining three tests. The sit-to-stand test was normal in all patients with L5 and S1 radiculopathies.

The subjects were also given a modified Lysholm questionnaire, and both groups described a statistically similar level of difficulty with lower extremity strength activities, including sit to stand, knee buckling, and difficulty with sit to stand. This came despite the fact that those with an L5 or S1 lesion had no demonstrable quadriceps weakness. The only subjective question that could be correlated with quadriceps weakness was the use of a step-to gait in ascending and descending stairs. Description of this gait pattern should be a warning to clinicians that quadriceps weakness may be present and should be assessed.

The authors performed intertester studies on 39 of the patients. The Kappa reliability scores for the single-leg sit-to-stand and step-up test were very good, at .85 and .83, respectively. The Kappa for the knee-extended MMT was .08, which is really no better than flipping a coin. Given the low reliability, and the fact that it detected weakness in only 9% of patients with radiculopathy, it appears that the quadriceps may simply be too strong in this position, and there is no reason to include this test as a screen for quadriceps strength. The bent-knee MMT, however, has moderate reliability (K = .66) and found weakness in half of the expected subjects, and as such may be useful for patients with weightbearing restrictions or restrictions at other extremity joints, who cannot perform the other, multijoint tests.

The other day I was in a meeting where we were reviewing the dermatome tests in our lumbar spine template. Remembering this article, we had a discussion about how best to test the quadriceps (and gastroc/soleus, for that matter), as standard manual muscle testing is fairly ineffective, as shown by this study. I didn’t convince them to include the single-leg sit-to-stand test, but I continue to use as my primary screen for quadriceps weakness in this population.

Snapping Popliteus Tendon

Krause D.A., Stuart M.J. Snapping Popliteus Tendon in a 21-Year-Old Female J Orthop Sports Phys Ther 2008:38(4):191-195

This case study describes a woman who presented with a 7-year history of pain and audible clicking at her lateral left knee when moving the knee through 20 to 30 degrees knee flexion. This occurred both actively and passively, and was present whether moving into knee flexion or extension. The patient reported that she had been very active previously, but now had to limit her activites due to pain. She had undergone several rounds of previous physical therapy, when she was diagnosed with snapping iliotibial band and treated with passive modalities, stretching, strengthening, and NSAIDs. She denied any improvement with those treatments.

On evaluation, all clinical and radiographic findings were normal with the exception of pain with palpation of the lateral epicondyle of her femur, as well as pain and an audible click with the knee at 20 to 30 degrees of flexion. Initial treatment consisted of posterior mobilization of the distal fibula, which eliminated the pain and clicking with knee movement. A trial of taping was performed, but the patient couldn’t tolerate it, which led to use of an exension brace for two weeks, with the goal of avoiding knee flexion and decreasing irritation to the painful site. This was effective while the brace was on, but had no lasting benefit after returning to activities without the brace. The patient was then referred to the surgeon, and open surgical exploration revealed that the popliteal tendon was snapping over the tubercle of the popliteal sulcus. There is a terrific video of the snapping tendon at the JOSPT website. At 6 weeks after surgery she was performing all activities without complaint.

I thought this was a great case study, and a few things jumped out at me:

Before reading this article, if this patient had come to me, I might very well have diagnosed it similarly to her previous therapists (snapping iliotibial band), and while the treatment might have been a bit different, it’s unlikely that it would have been any more effective.

It’s interesting that they tried a posterior distal fibula mobilization as the initial treatment, versus just going right to an anterior proximal mobilization, if that was the goal. I wonder if this mobilization technique was the first thing the author tried, or just the one that had such a dramatic effect. Either way, it’s a great idea and a good way to isolate the lower leg and help to further rule out the iliotibial band.

The author references a few case series that highlight clinical tests to provoke the snapping popliteus, neither of which I had ever heard of. One description is of increased snapping when a varus force is applied to the knee, and the other describes the Cabot sign, in which the knee is extended against resistance with the leg in a figure four position. I doubt that these have been studied extensively for reliability and validity, but they may be helpful to keep in mind the next time someone comes in with snapping at the lateral knee.

The authors note that although this patient required surgery, there are some reports of treating this conservatively; all of those reports were of patients with relatively acute symptoms, who may very well have improved without treatment. If someone comes in with a chronic case, and the above signs are noted, it’s probably a good idea to start thinking about more aggressive measures fairly early, rather than go through multiple visits of ineffective treatment.

Thoracic spine fracture

Ross M.D., Elliot R.L. Thoracic Spine Compression Fracture in a Patient With Back Pain J Orthop Sports Phys Ther 2008;38(4)218.

This case study describes a 55 year old man who presented with immediate onset of thoracic spine pain while running. He had no specific findings on examination with the exception of a general decrease in mobility, as well as severe point tenderness at T9. His past medical history included discovery of T8 compression fracture several years earlier during an employment physical, as well as a family history of osteoporosis.

Imaging studies were performed, and indicated compression deformities at 4 levels of the thoracic spine, including T9. He underwent vertebroplasty with immediate abolition of his pain. On further testing it was found that he had osteoporosis, and medical treatment was initiated.

I can remember working with a similar patient, with nearly the exact same diagnosis – she was referred by a chiropractor with a diagnosis of thoracic disc derangement. She was in her 70’s, and had recently begun working out at a gym, when she noticed a “pop” in her back while using the deadlift machine. She had not had any radiographs, and on examination her motion was essentially normal, and repeated movements had no real effect on her symptoms. The only thing that reproduced her pain was direct palpation, as in this case study. She had denied any specific health complaints, but on further questioning revealed that she was osteopenic. She was referred back to the chiropractor for radiographs, and they confirmed the fracture. After laying off the gym for a few weeks, she was pain-free.
I frequently think of that patient and the importance of taking a thorough history and probing further when things don’t add up clinically. Unfortunately, with therapists often limited to 30 minute evaluations, taking a thorough health history is often not the first priority. In this case a thorough evaluation, including repeated movements, helped to rule out most mechanical causes, and further questioning helped to make the appropriate diagnosis.

On a side note, she sent a note to the chiropractor, thanking him for helping her to make the diagnosis – I never heard from her again.