Physical therapists see many patients who have sustained orthopedic or athletic injuries and, with a good clinician, the results from rehabilitation are usually excellent.At Pivotal Physical Therapy, the physical therapists are experts in both how to treat the immediate trauma and preventing future injury.Initially, we evaluate the injury and determine the most efficient method of recovery.
Case Study 1
44-year-old male runner (15 miles per week) with a 3-month history of right heel pain. Originally the heel was only painful when running. Currently, it is very painful with his first steps in the morning and, the end of the day (after wearing leather soled shoes). He has had to stop running because of the pain.
During the initial evaluation the physical therapist noted:
1. Extreme tenderness of the right medial heel 2. Tightness of right calf muscles 3. Over-pronation of right foot 4. Significant weakness of R hip muscles. 5. Patient’s walking pattern indicated a poor heel strike (especially on right) and excessive medial rotation of the right hip. 6. Running style assessment was deferred due to pain. The patient reported he ran primarily on his toes. 7. A soft gel heel insert was suggested to help decrease the pain with daily walking, and reduce stress upon heel strike. 8. The patient was educated regarding footwear for daily use and running.
The first 4 sessions were dedicated to pain relief
1. Ultrasound, ice was applied to the tender spot on his heel. 2. Massage, stretching to his R calf muscles 3. Hip strengthening exercises were taught to begin addressing the hip weakness.
Treatment 5 progress and results.
1. The right heel pain had decreased by 50%. 2. Right calf muscles were longer and more supple 3. The hip exercises had begun to feel easier. 4. Deep massage to the heel was performed which helped to alleviate another 20% of his pain.
Sessions 6-8 emphasized lower extremity alignment when standing and walking.
1. The patient would practice balancing on his right leg on various surfaces (e.g., wobble boards, trampoline, soft foam pads) with the exercises becoming progressively more challenging.
By the 8th session, he had to squat on his right leg while standing on the foam pad and maintaining ideal lower extremity alignment.
Sessions 9-12 were dedicated to fine-tuning his running style.
1. No R heel pain 2. The running style was assessed on the Treadmill and his heel strike had normalized on the R side while he had some residual excessive medial rotation of the right hip. 3. His balance exercises continued to become more difficult (because running, if you think about it, is really a single leg sport, you are never on both legs at the same time). 5. Continue to increase right hip strength.
At the time of discharge, the patient had returned to running 10 miles per week at an increased pace (formerly 8 now 7 minutes per mile)and without pain.
The above case history represents our “typical” patient. Obviously, results and duration of treatment can vary for each patient depending upon their age, severity of the condition, diagnosis, and compliance with their Home Exercise Program.
Case Study 2
A 57-year-old female who presents into the clinic with lower back pain and stiffness. She states symptoms occurred for no specific reason and have been present for 3 months. Her symptoms gradually were getting worse and now feels she can’t sit or stand for long periods of time. Anecdotally she said her worst activities were placing her dog’s food on the floor, turning over in bed, pain especially at the end of the day or end of the workweek. About 15-20 years ago she had an episode of intense lower back pain, but has not had any pain since. She works full time in the financial sector and takes 2-3 exercise classes on the weekends.
Patient’s Goals: Her goals are to be able to make it through her workweek pain-free so she can enjoy her weekends with her grandkids and dogs.
Upon evaluation, the biggest findings were limited movement and pain in all directions: forward bending, backward bending, side bending, and rotation. The pain was located only in her back and did not travel into her legs.
We discovered along the course of her treatment that stress management and inactivity during the week escalated pain levels. We quickly knew that if we did not address these factors, that her back pain would not decrease. Primarily education about how beneficial movement is for back pain reduction and prevention. One of my phrases is “a healthy spine is a flexible spine”. A lot of times when patients experience pain in their back they develop a fear of moving. Typically introducing movement quicker from the time of pain onset will improve a patient’s outcomes.
This patient was treated in the office for 9 visits. We tiered her return to movements based on what she was comfortable with so that her pain would not be triggered or flared. Her home exercise program mirrored the exercises we performed in the clinic. Allowing freedom of movement in one plane until the body is comfortable builds confidence (achieved by repetition of safe movements) within the neuromuscular system. More confidence will help the body decrease its threat response. When the body feels safe doing an activity it will decrease the inflammation in the tissues, thereby decreasing a person’s pain.
After the first 3 visits, this patient reported an improvement of overall pain intensity. She started to report improvements in sitting and standing and pain did not wake her while she was turning over in bed. After 5-6 visits she reported she regained the ability to get out of bed in the morning without pain and played with her grandkids all weekend. She stated that the Monday after she played with her grandkids she had some pain and stiffness, but she didn’t feel discouraged with her progress. At visit 9, this patient was able to engage in most of her normal activities and was experiencing pain at most 2-3 days per week which were relieved by her home exercise program.