Keeping it Eclectic…
Accidental Physical Activity: A holiday in Naples, Italy
5 days in Naples doesn’t sound like it’s going to involve a lot of physical
activity/exercise, but without even trying the reality is different…
Of course, any city holiday can easily involve a good deal of “pounding the streets”; wandering around, guidebook and map in hand, seeing all the sites without even noticing just how far you’re walking. And Naples was perfect for that, as the weather was warm but not too hot, and there are so many things to see: 3 impressive castles, a host of magnificent churches, beautiful palazzos & a gorgeous coast line.
So I wasn’t surprised that my husband’s iPhone reported several miles of walking each day.
One day we left the city to visit the Roman remains at Herculaneum, and then went on to climb Vesuvius. It’s a pretty steep climb for the last 800 metres or so, & can only be done on foot – & of course a steep climb is excellent aerobic exercise. To be able to peer over into the crater of a volcano was brilliant – it felt rather surreal, although there was no
bubbling of lava so we never felt in any danger. My husband’s iPhone report for the volcano climb shows that it is equivalent to climbing 67 flights of stairs.
A holiday doesn’t have to be a “walking holiday” to involve exercise: grab your guide & your map, & explore…
Treating runners can be a difficult task. There are many types of injuries and they originate from a number of different areas. Is it a running form error? Is it weakness? Maybe something is too stiff? The number of possibilities is partially why so many runners struggle to return to activity. I discussed this breakdown in a previous post and how we use the ACE Running Movement Screen to identify the “weak link(s)”.
Here, I wanted to talk about the Unilateral Hip Bridge Endurance Test¹ and its amazing utility in runners with knee pain, back pain, and many other issues. If you’re not familiar with the test, you can watch me explain it below. On the surface, the test appears to be a simple test of the glute max, but as you look deeper, the knowledge you can gain from this is extraordinary.
The first step of the test is to perform a bilateral bridge. At this point you gain a few points of knowledge:
- Is the runner not able to lock out the hips? It could be strength. It could be a range of motion limitation.
- Does the runner hyperextend at the lumbar spine? This could be a clue into a motor control deficit that may contribute to back pain.
During the next step, the runner lifts one leg in a marching action. Again, you gain the next insight:
- Does the entire body drop in the sagittal plane? This points you towards the glute max in the sagittal plane.
- Does the pelvis rotate in the transverse plane? This points you towards an inability to control the pelvis in the transverse plane and it may show up in a runner who demonstrates a high level of excessive rotation during running.
A passing test would be the ability to perform the bridge with a leg lift, while maintaining a locked out hip and no deviation in the transverse and sagittal planes. Then you must hold this position for 10 seconds. Can you complete this seemingly simple task? If not, it could be a flag to work on with you or your runners.
If you aren’t using the Unilateral Hip Bridge Endurance Test as part of your screen with your runners and athletes, you can start now. You will find the best outcomes when it is used as part of a larger overall screening process, such as the ACE Running Movement Screen.
If you find the test difficult, try the corrective activities to the right. Once you get comfortable with performing the test, work on determining where the deficit is during the test. Was it motion? Was it strength? Was it something else? This will allow you to treat that athlete’s specific deficit and fix them more quickly!.
Want to learn more about running gait analysis and the ACE Running Movement Screen? Stay up-to-date on course offerings and receive tips on treating runners here.
- Butowicz CM, Ebaugh DD, Noehren B, Silfies SP. Validation of two clinical measures of core stability. IJSPT. 2016;11(1):15-23.
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The only way to grow is by continuing to learn.
How do you decide which is the best option for continued learning?
Continuing education (con-ed) for physical therapy is a necessity. You need to do it to maintain your license. You need to do it to maintain your skillset. You need to do it to simply keep up. How do you choose which con-ed courses to attend? They are often expensive, require travel and integration.
Listen in for the answers.
What do you do when a patient presents with cervicogenic dizziness? How do you go about addressing the problem? How do you keep the patient comfortable? Answers in the podcast.
Is cash physical therapy better than traditional physical therapy? Is spending MORE time with someone equal to spending BETTER time with them? Is there any data to show that more time is better time? Discussion in the podcast.
Keeping it Eclectic…
With the rising costs of health care—and the increase in high-deductible health plans (HDHPs)—patients are assuming a greater portion of their healthcare bills than ever before. So, it’s no surprise that they’re beginning to exhibit many more consumer-like behaviors, including performing online research to assess the value of potential healthcare providers and treatments rather than blindly accepting referrals from their primary care physicians. And it’s not just these patient-consumers who are redefining value in the healthcare space; referrers and payers are evaluating providers against new standards as well. While price is certainly still a factor, it’s far from the only one. So, providers in all disciplines—especially specialists such as rehab therapists—must adapt their value propositions to match their audience’s needs. And that starts with discovering the role value plays across all five of these important categories:
- Convenience; and
While it’s gotten better in recent years, physical therapy still has a branding problem. Most people in the general public—and even some of our peers in other disciplines—don’t really understand what we do. And no one is going to be able to change that but us. While creating a stellar brand at the individual clinic level has its own benefits—like attracting more of the right customers and building a better reputation in the community—we can also use our individual brand power as a launching pad to develop a unified brand for the profession as a whole.
So, what separates a good brand from a not-so-good one? Good brands connect people, elicit feelings, address pain points, and create impressions of culture. If your clinic’s brand doesn’t do that—if it doesn’t provide your patients, peers, and referrers with a sense of who you are from the get-go, or if the brand that you’ve created doesn’t align with what those parties perceive as valuable—then it’s time reconsider your clinic’s persona internally and online. The latter channel is especially important today, as more and more patients are interacting with your clinic for the first time via your website or social media pages. That means every aspect of your online presence should be optimized to tell the story of your value.
Most healthcare providers—especially rehab therapists—understand the importance of the patient-provider relationship. We all know that the quality of our relationships with our patients directly correlates with their ability to achieve the desired clinical outcomes, fully engage in their course of care, and experience the full value of the care we provide. While many small practices are able to achieve success by prioritizing the patient relationship and patient experience, it can become increasingly difficult to deliver that level of one-on-one attention as a practice grows—especially when the time devoted to fostering patient relationships gets replaced with things that feel more urgent (like discussing symptoms).
However, there is a way to scale relationship-building efforts to ensure patients feel cared for as individuals—without burning yourself or your staff out: namely, leveraging patient relationship management software. I urge all practice owners—and especially those whose clinics are growing—to adopt a PRM platform that:
- enables providers to effectively connect with patients between sessions and after discharge by providing relevant value-add content at optimal intervals;
- collects valuable patient feedback providers can use to address patient concerns in (near) real-time and identify trends that may be impacting the patient experience on the whole; and
- leaves you—and your staff—with enough extra time and energy on your hands to get to know your patients as people.
In today’s patient-centric, value-based healthcare paradigm, more and more focus is being placed on the quality of care we provide—and rightfully so. Patients, payers, and referrers are coming to expect the very best as a baseline. Thus, it’s imperative that we all step it up a notch and ensure that we truly are practicing at the top of our licenses—which means not only choosing the continuing education classes that best enable us to support our patients and our practices (no shoddy, free CEUs), but also diligently tracking outcomes in order to foster quality care delivery. After all, tracking outcomes via patient satisfaction surveys and outcome measurement tools is the best—and only—way to truly know if the plans of care you’re prescribing are the best ones available. Just be sure that the data you choose to collect is risk-adjusted and that all members of the greater healthcare community can readily share and understand it. Collecting data in silos isn’t going to help our individual practices—or our profession.
Quality doesn’t apply only to in-clinic practices, either. Your home exercise program is another way to demonstrate the quality of your services—or the lack thereof. If you’re still relying on difficult-to-follow paper exercise sheets, you’re missing out on a wonderful opportunity to serve your patients, demonstrate your value, and—as an added bonus—differentiate yourself from other providers. Just think: if your patients can piece together a higher-quality exercise program from YouTube videos than the one their expert-level provider is giving them, they may very well ditch your services—and perhaps physical therapy altogether. Instead, adopt a brandable, interactive, multimedia HEP that makes it easy for patients to complete their home exercises safely and provide you with feedback along the way. That way, you can make changes to the program in real time—instead of waiting until the patient returns for another session. The best HEPs also come complete with a secure patient-provider messaging platform you can use to answer questions, provide additional instructions for exercise completion, and cheer on your patients for jobs well done.
Want to learn how to discover value in the last two categories—convenience and price—as well as learn strategies for communicating your value to patients, referrers, and payers? Check out this free webinar in which Tannus Quatre, PT, MBA, and I discuss the art of discovering and selling your value. It’s high-time that every physical therapist learned how to tap into his or her potential—and articulate that potential in a way that aligns with his or her audience’s perception of value. It’s the only way we’re going to thrive in this new era of healthcare—as individuals and as a profession.
About the Author
Heidi Jannenga is co-founder and president of WebPT, the leading physical therapy software platform for enhancing patient care and fueling business growth. She has more than 15 years of experience as a physical therapist and clinic director, and she’s an active member of the sports and private practice sections of the APTA as well as the PT-PAC Board of Trustees.
- The TFCC originates from the distal radius (sigmoid notch on the ulnar border of the articular surface of the distal radius) and ulnar head (ulnar styloid and fovea of the ulnar head) binding the distal radioulnar joint together.
- It travels distally to the proximal row of carpal bones (lunate, triquetrum, hamate, and base of fifth metacarpal) (Ko & Wiedrich., 2012, p.308).
THE ARTICULAR DISC
- The function of the TFCC is to stabilize the ulnarcarpal and distal radioulnar joints (DRUJ).
- The TFCC is a load-bearing structure between the ulnar head, and lunate and triquetrum bones, which makes it susceptible to acute traumatic and degenerative overload injuries (Ko & Wiedrich., 2012, p.308).
- It is believed to take about 18-20% of the load of the wrist (Ko & Wiedrich., 2012, p.309).
- The part of the TFCC which inserts into the ulnar carpal bones is hammock-like in shape and structure, and allows smooth motion of the bones during flexion, extension, radial deviation and ulnar deviation by accomodating twisting movements. (Nakamura, Yabe & Horiuchi., 1996)
- There is little deformity seen in the disc proper during pronation and supine” (Nakamura, Yabe & Horiuchi., 1996, p.585).
- During supination & pronation the deep dorsal and superficial volar radio-ulnar ligaments tighten to prevent further dorsal displacement of the ulna. These extrinsic ligaments (ulnotriquetral and ulnolunate) act as stabilizers between the distal ulna and volar carpus.” (Sachar., 2008, p. 1669).
- Don’t forget that pronator quadratus and the extensor carpi ulnaris are also dynamic stabilizers of the distal part of the ulna.
1. LOCATION OF PAIN
tenderness, possibly associated with an audible or palpable click on forearm rotation.” (Ko & Wiedrich., 2012, p.307).
2. MECHANISM OF INJURY
- ** Wrist extension injuries will impact the lunotriquetral ligament
- ** Dislocation of the DRUJ may be associated with a pop or noise and immediate visible deformity (Sachar, 2008, p1670).
- “The lunotriquetral interval (lime green) is palpated dorsally between the fourth and fifth compartments one finger breadth distal to the DRUJ and with the wrist in 30 degrees of flexion” (Sachar, 2008, p. 1671).
- The TFCC (light blue) is best palpated in the soft spot between the ulnar styloid, FCU and volar surface of the ulnar head. This is known as the ulna fovea sign (Ko et al., 2012; Sachar, 2008; Tay et al., 2007).
- The fovea sign test has a 95.2% sensitivity and 86.5% specificity (Sachar, 2008, p.1671; Tay et al., 2007, P483). That is, it is sensitive and specific in detecting foveal disruption of the distal radioulnar ligament and ulnotriquetral ligament injuries (Tay et al., 2007).
- UT ligament injuries are typically associated with a stable DRUJ and foveal disruptions are associated with an unstable DRUJ (Tay et al., 2007, p. 438).
PAIN PROVOCATION TESTS
- The scapholunate ligament is tested by applying pressure through the examiner’s thumb to the scaphoid tubercle.
- The lunotriquetral joint/ligaments can be evaluated with 3 tests (Sachar., 2008, p. 1671; Sachar., 2012, p.1491-1492)
- The Regan shuck – a sheering test between the lunate and triquetrum. Move the lunate in a volar and dorsal direction while moving the remaining wrist in the opposite direction.
- The Kleimman Shear test – a similar sheering test for the LT ligament but with more fine hand placement than the Regan shuck test. One thumb and index finger is placed over the pisiform and triquetrum while the other hands stabilises the lunate and radial column of the wrist.
- LT ligament ballottement /compression. Stabilise the hand while the thumb applies a radial force driving the triquetrum into the lunate.
- The arcuate ligament is tested with the midcarpal stress test and considered positive if there was a catch up clunk in the midcarpal joint in the addition to pain reproduction.
- The distal radioulnar joint (DRUJ) – piano key test
- “This test is performed with the patient’s palp flat on the table. The test is performed by applying a dorsal to volar load across the ulna 4cm proximal to the DRUJ. Pain should be reproduced at the DRUJ joint level.” (Sachar, 2012., p. 1492).
- If the deep dorsal fibers have been severely sprained or detached from the fovea, performing this maneuver may cause subtle subluxation or gross instability of the DRUJ (and pain).
- Laxity in both supination and pronation potentially represents a multiplanar tear of both deep dorsal and palmar fibers of the ligamentum subcruentum. (Ko et al., 2012, 310)
- The TFCC is tested with a stress test (wrist is in ulnar deviation while applying a shear force across the ulnar complex of the wrist) and compression test (as per stress test but with compression).
- The GRIT test is used to evaluate the integrity of the lunate cartilage (ulnar impaction syndrome) using a grip measurement in neutral, pronation and supination.
- ECU (extensor carpi ulnaris) is examined by resisted movement into ulnar deviation (MMT). This is performed with the forearm in supination and elbow flexed to 90 degrees.
- Weight bearing on the wrist in extension – the press test.
- Combined pronation, ulnar deviation and compression – reproduce clicking sounds.
CLASSIFICATION FOR DIAGNOSIS
PALMER CLASSIFICATION SYSTEM
DIRECTIONS FOR SURGICAL TREATMENT
- “Arthroscopic debridement is the treatment of choice for IA lesions, with biomechanical studies showing that up to 80% of the articular disc can be removed without creating instability.” (Ko & Wiedrich., 2012, p.312).
- Splinted for 1 week
- Most athletes return to sport at 4-5 weeks.
- Success is 66-87%
- “Lesions of the ulnar, vascular side of the TFCC (IB lesions) are most amenable to arthroscopic or open repair, and early arthroscopic intervention should be encouraged in the elite athlete.” (Ko & Wiedrich., 2012, p.312-313).
- Splint for 6 weeks
- ROM for 6 weeks
- Return to sport around 3 months post surgery
- “Although IC tears are diagnosed arthroscopically, they are generally repaired using an open technique.” (Ko & Wiedrich., 2012, p.313). The postoperative regime is similar to IB repairs.
- “Radial avulsions of the TFCC at the sigmoid notch are often associated with distal radius fractures and can lead to DRUJ instability (ID lesions).” (Ko & Wiedrich., 2012, p.315)
- ‘A critical step necessary for healing of the repaired ID lesion involves introducing a burr into the sigmoid notch and a 16-mm (0.062-inch) K-wire is advanced through the distal aspect of the sigmoid notch and out through the radial wrist incision.’
- The postoperative regime is similar to IB repairs.
- “The athlete with a IIA or IIB lesion presents with an insidious onset of ulnar-sided wrist pain that is worse with activity and relieved with rest. Plain radiographs should be obtained to evaluate for DRUJ arthritis and assess ulnar variance, including the pronated grip view. High-performance athletes will most likely not agree to a conservative treatment regimen, so ulnar-shortening osteotomy should be offered to the athlete with ulnar-neutral or ulnar-positive variance.” (Ko & Wiedrich., 2012, p.316-18).
- IIC lesions “should be treated by either arthroscopic debridement and wafer resection or formal ulnar shortening in athletes with ulnar- positive variance.” (Ko & Wiedrich., 2012, p.318).
- IID & IIE lesions are treated similarly to IIC lesions, however there is a focus on determining in lunotriquetral instability exists or not. If there is instability, “then a wafer procedure is not recommended because it does nothing to address the lunotriquetral instability. Instead, the ulna should be shortened, which tightens the ulnocarpal ligaments and thereby helps to stabilize the lunate and triquetrum. If the lunate and triquetrum are still unstable, then a lunotriquetral arthrodesis may be necessary at a later date if the patient does not respond to ulnar shortening.” (Ko & Wiedrich., 2012, p.318).
- Generally, a ‘good to excellent’ outcome is achieved in 63% (Reiter et al., 2008).
- 1A debridement specifically achieved a 66% to 87% successful outcome (Ko & Wiedrich, 2012).
- 1B repairs specifically achieved a better result with 94% of patients reporting they were satisfied or very satisfied with their surgery (deAraujo et al., 1996).
- Ulnar shortening osteotomy resulted in 92% complete pain relief or occasional mild pain (Minima & Kato, 1998).
- Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary.
ROLE OF PHYSIOTHERAPY
- Passive mobilisation can help with pain – treat the dysfunction you find!
- Help to restore pain free ROM.
- Need rotational control- pronator quadratus and ECU (attachments into the complex) are important- isometric and dynamic.
- The pronator quadratus actively stabilizes the joint by coapting the ulnar head in the sigmoid notch, particularly in pronation, and it passively stabilizes the joint by viscoelastic forces in supination. An intact extensor carpi ulnaris and fibro-osseous tunnel partially stabilize the distal radioulnar joint even after the triangular fibrocartilage and other ligaments are sectioned (Szabo, 2006).
Keeping it Eclectic…