Posts tagged Physical Therapy examination
Physical Therapy Treatments for Knee Pain

The internet is excellent at providing information on a multitude of subjects, but the application of this information is limited because of the existence of individual situations and people.  An example of this would be the failure of a one size fits all approach to Physical Therapy.  In this example, every patient with a certain diagnosis would be given the same treatment regardless of their presentation.  This approach has led to higher costs and poor outcomes in the Physical Therapy research.  Conversely, examining each patient and providing specific treatments to match their presentation has been shown to improve outcomes for many conditions including low back pain.  

Pain on the front of the knee, anterior knee pain or patellofemoral pain, is a common source of knee pain in the active population.   Patients with this diagnosis often present with impairments in flexibility and/or strength at the adjacent joints in the hip and ankle.  These impairments above and below the knee joint can affect both the mechanics and loading of the leg during activity.  The multifactorial nature behind knee pain limits our ability to find a one size fits all treatment option.  Instead new research is identifying sub groups of patients with knee pain to improve our ability to study and treat these patients.  

In a recent issue of the British Journal of Sports Medicine authors studied 130 patients with anterior knee pain and placed them through a Physical Therapy examination (Selfe et al. 2016).  The authors broke these patients with knee pain into 3 sub groups based on the examination findings.  The groups included strong (29 patients), weak and tight (49), and weak and pronated feet (49).  Each group consisted of individual exam items which either precipitated or perpetuated their knee symptoms.  For example, in the weak and pronated foot group authors found weakness throughout the lower body likely contributing to the poor mechanics during activity seen in this group of patients.  Future research is needed to determine if these subgroups lead to more specific and impactful treatments as seen in the low back pain research.

Patients with knee pain are encouraged to avoid a one size fits all exercise approache and instead use a local Physical Therapist to identify impairments like flexibility and/or strength leading to reduced costs and improved outcomes.   

Impact of Communication on Patient Outcomes
communication-listening-healthcare-physical therapy

William Osler, M.D., considered by many to be the father of modern medicine once said "listen to the patient he is telling you the diagnosis".  Others in the medical field have similar quotes including "listen to the patient long enough and they will tell you the diagnosis, listen longer and they will tell you the treatment".  Hampton et al. confirmed Osler's thoughts by reporting up to 83% of medical diagnoses are made through the subjective history alone (BMJ, 1975).  Indeed, our prior blog post reports on the power of the subjective history to rule out non musculoskeletal sources of pain.  This interview with the patient is a crucial component of any medical encounter and allows the clinician to begin their initial hypothesis generation on what brings the patient into their office.  Unfortunately, on average patients are interrupted 18 seconds into their opening statement, but given the chance to talk they finish their statement in under 3 minutes (Beckman, H. Ann Int Med. 1984).

One of the main reasons we started Mend was to create a one on one environment where our clinicians have 60 minutes of uninterrupted time with each patient at each visit.  This gives the clinician ample time to conduct a thorough history focused on a patient's individual complaints and symptoms.  Starting the initial evaluation with this line of questioning focuses our Physical Therapy examination and treatment.  We find the simple art of listening has helped accelerate our patient's outcomes in fewer visits by providing optimal treatments at each Physical Therapy session.  To experience the difference, contact the experts at Mend. 

Running Foot Strike Patterns and Injury Risk

Our previous blog post detailed the differences in biomechanics between foot strike patterns in runners.  There are clear bio mechanical differences between utilizing a forefoot and rear foot strike pattern and these are important for gait retraining and injury risk.  Obviously, the foot is the first part of the body to strike the ground in running and this impact transmits forces through the lower quarter.  For example, a fore foot versus rear foot striker would have more knee flexion or extension at impact, respectively.  This would require greater or lessor work from the quadriceps to control this impact.  When we consider the number of strides taken in a runner's mile, up to 2000 strides per mile depending on speed, we can gain an appreciation of the repetitive loading which may predispose a runner to different injuries based on their stride frequency and foot strike pattern.  

running, heel strike pattern, physical therapy gait analysis
running, forefoot strike pattern, physical therapy running analysis

A recent article in the American Journal of Sports Medicine examined the impact of stride frequency and strike patterns on injury predictors in running (Boyer et al. 2015).  The authors examined 42 runners (50% rear foot, 50% mid foot) as they ran between 7 and 8 miles per hour at their self selected stride length then at both 5 and 10% shorter lengths.  The authors noted changes in biomechanics within runners when they shortened their strides consistent with a greater stride frequency to maintain the 7-8 mph speed.  Iliotibial (IT) band strain did not differ between forefoot and rear foot strikers but did increase when runners reduced their stride length (greater knee flexion).  A reduction in both pelvic drop and knee adduction, which we commonly see in overuse injuries of the lower quarter in runners, was reduced when runners increased their stride frequency and decreased their stride length.  The authors concluded that one foot strike pattern was not better than another, but rather the step rate and stride length has a greater impact on these biomechanics variables.  

Consistent with our understanding on running injuries and biomechanics, there is not one preferred strike pattern for the foot but rather the amount of time an athlete spends in contact with the ground as well as stride variables (step length and rate) may have a greater impact on injury.  To learn more about your running gait and its' impact on performance and injury risk contact the experts at Mend.  

Can We Predict Dynamic Foot Function from Static Physical Therapy Tests

After hearing a patient's history, Physical Therapists decide on known tests and measures to assess for impairments such as a loss of joint range of motion or muscle weakness which either precipitated or perpetuated a patient's symptoms or injury.  The foot and ankle are commonly assessed as a contributing factor to lower quarter injuries and pain because of their ability to influence the mechanics of proximal joints.  One method of static assessment is the Foot Posture Index (FPI), a 6 item tool which allows the clinician to visually examine the foot structure.  This assessment tool has demonstrated some effectiveness at predicting lower quarter overuse injuries (Burns et al. 2005, Yates et al. 2004). 

foot posture index, lower extremity physical therapy examination

A recent study by Paterson et al. examined the predictive ability of the FPI, motion analysis, and a depth camera on dynamic foot function.  The authors found the majority of static foot measurements (85%) did not correlate with the dynamic foot and ankle motion they found during walking.  The authors concluded that static measures of foot posture have limited diagnostic utility to predict mechanics noted during a gait analysis.  Similar to other postural assessments, a static foot assessment does little to help us determine how an individual moves or if this posture is related to their current symptoms.  Whenever possible a dynamic assessment including functional testing and walking or running gait should be used to provide a better assessment of a patient's injury or pain.