Strained Popliteus? (Full Version)

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ysumpt2006 -> Strained Popliteus? (November 29, 2006 7:31:00 PM)

Ok, here is the deal. I work at a hospital based outpatient ortho facility and the "BMOC" sports-med doc is well liked by all of the hospital execs. He has a history of not taking any images of injuries until a person goes through PT for 4 weeks.

Well the Regional VP of the hospital is due in for an eval of a strained popliteus muscle. His mechanism of injury is pulling his foot from a collection of mud while hiking. Felt a pull, pain and it was better as he jogged out of the woods.

Presently he has no difficulty with ascending stairs, descending stairs; but has difficulty controlling his descent while walking down hills/mountains. Feels unstable.

Now, I have yet to see this patient, but I'm just trying to get a feel for what to look for. I have never personally dealt with a "strained popliteus" muscle and wonder how the doc can ascertain the dx without imaging?

With the instability while descending as well as the forceful pull of the leg/foot from the mud (perhaps the tibia was stabilized enough to allow the femur to translate forward) I'm inclined to think PCL.

What do y'all think.

Like I said, this doc's MO is to utilize PT as a differential diagnosis tool as his POC is: "exam", PT, Cortisone shot, imaging. I don't agree with this, but he is also not too keen on PT's questioning his diagnoses.

I know--two things in the thread, but just wondering what people think.

Thanks all




ehanso -> Re: Strained Popliteus? (November 29, 2006 8:33:00 PM)

Is the PCL test positive? Is the popliteus tender? Which ever one is positive will help with the correct treatment. If the popliteus is the problem, it will repsond very quickly to Jone's counter strain.




ysumpt2006 -> Re: Strained Popliteus? (November 29, 2006 8:44:00 PM)

I havent' done the eval, yet--just talked to him casually while scheduling him.

Where would i find Jones's counter-strain information?




rv36116 -> Re: Strained Popliteus? (November 30, 2006 11:10:00 AM)

Ask him what makes him worse/better and if since the M.O.I., if it's getting better/worse/same. That's a good start at least to get an idea for a few of his baselines...




Sean Weatherston -> Re: Strained Popliteus? (November 30, 2006 11:58:00 AM)

Ken,
Haven't seen a lot of PCL injuries, but my gut tells me it takes a lot more force than getting stuck in the mud to damage that big ol' ligament.

Just to play devils advocate, if it was a popliteal strain, the screw home mechanism may be altered and without solid knee extension in gait, the knee could feel unstable.

Sean




steve -> Re: Strained Popliteus? (November 30, 2006 12:37:00 PM)

I actually think that the physician is making a good call here - If there is ligamentous instability, particularly the PCL, they typically don't operate as it is lengthy recovery with poorer outcomes than ACL surgery. In the grand scheme of things, diagnosis based on clinic examination of the knee is usually not very accurate and treatment will likely be based on your assessment findings - ie increasing ROM, proprioception, decreasing inflammation not a specific diagnosis.

Steve




PhysioThis -> Re: Strained Popliteus? (November 30, 2006 5:32:00 PM)

Hold it.

From the info given, the structure identified was the popliteus. Nothing about PCL or possible PCL. The mechanism does not even hint of a possibility it could be PCL.

The mechanism, if you can picture my image of how it may have played out, fits with a knee flexor injury - foot stuck in mud, likely behind you, you attempt to extract it by hip hiking, hip flexing, and knee flexing, maybe have the distal LE and foot in a little bit of external rotation relative to the femur - you activate all the muscles to carry this out to save yourself, against strong resistance and pop, something gets strained - perhaps the little guy in this case. He JOGGED out of the woods and felt better - can you jog on an acutely ruptured PCL???

Am I totally forgetting something or is the screw home mechanism a non-issue with gait? At what point do we achieve terminal end range of motion during the gait cycle? And the popliteus - isn't this the dude who unlocks the screw? how would that mechanical impairment affect gait? No matter - the patient appears to be is primarily complaing of stair descent and grade descent (mountains) - more likely affected by antigravity muscles of the LE (quads/hip extensors, plantarflexors) AHHH - plantarflexors - knee flexors - perhaps there is some soleus/gastroc involved here, and they are getting inhibited and are unable to produce the required eccentric control for the mentioned activities, giving the sensation of LE instability -

No matter, we are all making way too many assumptions without seeing the patient or having eval data.

This MD actually sounds hip to me. - I'd rather a doc have the confidence in himself as well as the PT's to whom he refers to get patients going right away, rather than have them wait to get an MRI, the results, and then perhaps PT. Besides, a lot of times MRIs just muddy up the waters by riling up the patient with nice to know rather than need to know info. This guy RAN after his injury - he can do stairs - it does not sound like he's had any give way or falls - an MRI off the bat is a waste of resources.




FLAOrthoPT -> Re: Strained Popliteus? (November 30, 2006 8:08:00 PM)

I agree with what I have read. I love this MD!! Especially as a surgeon! What a smart guy! Do some functional testing, some conservative treatment, and then look at MRI if not getting better. what a good way to justify an MRI and then justify surgery. Way worse the other way around.

But besides that. Do you treat diagnosis or dysfunctions? I have never been taught how to treat a diagnosis, or better yet, I have learned the pitfalls of treating a specific diagnosis. Do a thorough eval, what is wrong? Is it laxity, hypermobility, pain, altered gait, altered motor control, poor stability, weakness, poor timing and recruitment, etc. Identify the impairments and treat them with the dysfunctions. Really who cares if it is popliteus, what if it were gracilis would it totally change your treatment? What if a small part of the biceps femoris? Treat what is presented in front of you with this case and with everything and you will ge people better because of your decision making not in spite of it.
Ben Galin, PT, DPT, OCS




FLAOrthoPT -> Re: Strained Popliteus? (November 30, 2006 8:11:00 PM)

ps is this doc from canada? that is more of standard procedure in canadian medicine, treat first, mri later




Tom Reeves DPT ATC -> Re: Strained Popliteus? (November 30, 2006 8:23:00 PM)

I agree with Sean, Physiothis and Ben. The PCL gets torn when the tibia hits the dashboard in an MVA, not when pulling your foot out of mud. I also agree that we are a better first step than a $1000 MRI.




ehanso -> Re: Strained Popliteus? (November 30, 2006 10:15:00 PM)

Ken, With the pt supine and involved knee flexed 50* to 90* sit on the involved side with your hip at the toe to stabilize. Palpate the popliteus and find a tender point (not necessarily painful but tender) it will also feel a bit firm to touch. Then rotate the tiba internally while gently probing the tender point until you feel the firmness and tenderness leave. Keep your palpating finger over the tender point and gently probe the point a couple of times while you hold this position for at least 2 minutes. You will feel at slight Therapeutic pulse after 20-30 seconds. After 2 mintues SLOWLY relax the rotation and gently straighten the leg. If you did it correctly, the tenderness and pain are gone. Good luck, Ed




ysumpt2006 -> Re: Strained Popliteus? (December 1, 2006 5:01:00 AM)

Thanks all, I guess my "new grad" naivete has kicked in.

I see him next week, but I like to be somewhat prepared if possible. After I posted this, I thought of the flexor injury, knowing that a med dx is not the treating point, it is the other "stuff" that is happening.

Upon further review, the PCL is less likely, but that is one of the things that a more seasoned clinician at my site suggested. At the time, it made sense.

I guess I got the whole "VP of the hospital" thing too much into my psyche.




ehanso -> Re: Strained Popliteus? (December 1, 2006 1:10:00 PM)

Easy take into acount the status of the pt. Do your best to treat him like everybody else and you will do just fine.




ysumpt2006 -> Re: Strained Popliteus? (December 5, 2006 9:10:00 PM)

Ok, did the eval today. Everything went well. The history (after a lot of digging) revealed a 30 year injury that was not revealed to the doc for some reason--an injury in a backyard football game the involved the patient being clipped from side and behind driving his knee into flexion and his tibia forward. Sounds like a classic ACL tear to me.

Current injury involved the patient walking forward, seeing something ahead and pivoting 135 degrees with his foot stuck in the mud, THEN he pulled it out. Had 9/10 pain at that point.

Currently has pain with any pivoting action. Apprehensive to bend his knee during SLS secondary to feeling of instability.

Lachman's positive, Ant Drawer positive, Apley's positive, valgus/varus negative.

No imaging done, but all tests point to a possible (probable) ACL tear from years ago that was exacerbated with the new injury.

No quad weakness or hamstring weakness, but definite apprehension.

Gonna do a lot of functional training and go from there.

Wish me luck.




ehanso -> Re: Strained Popliteus? (December 5, 2006 10:17:00 PM)

Ahhhhhhhhhhh, a little history and it clarifies the picture. A physician who was one of my instructors said "If you listen well enough the patient will tell you not only what is wrong but what needs to be done". He was very wise.




Shill -> Re: Strained Popliteus? (December 6, 2006 8:12:00 AM)

The art of the subjective interview rears its head. Sometimes the digging for information requires the use of a spoon, and sometimes, one of these [IMG]http://www.castironrepair.com/images/dynamic/large-front-end-loader.jpg[/IMG]




FLAOrthoPT -> Re: Strained Popliteus? (December 6, 2006 7:41:00 PM)

funny, should show you eval and treat what is front of you, don't get bogged down in naming or treating the diagnosis!
Good job
Ben




ysumpt2006 -> Re: Strained Popliteus? (December 14, 2006 1:26:00 PM)

Well, the patient was seen casually by the referring physician and told him he feels pretty unstable. The message I got from the patient was that the MD talked to me and thought I was "full of it" in terms of the possibility of the ACL damage. Well, the doc re-checked him and low and behold, saw what I saw--excessive anterior translation of the tib. Immediately ordered an MRI, fit him for a brace and so forth.

I saw both the patient and doc today and the doc did not even mention anything to me about it. I got all of my information from the patient. Well, the patient looked straight at the doc and told him that I had discussed everything with him that the doc had done and that he had "the man" on the case.

Anyway---not a bad thing at all when the hospital exec is happy that the "new guy" was on top of things.

Then again, my boss kinda got into me about not informing the doc before today about my results. I told him that if it wasn't for the delay in our dictation system, he would have known a little earlier.

I asked my fellow workers who have more experience with the doc and they all told me he doesn't care too much for PT's questioning his diagnoses.

Anyway--you're only as good as your last treatment session--so my head is big for the time being.

Short form:

Doc suggested popliteus strain
I suggested ACL involvement
Doc told patient I was "full of it"
Doc checked him again and confirmed possible ACL
Pt thinks I'm great

Chalk one up for the New Guy/PT




PhysioThis -> Re: Strained Popliteus? (December 14, 2006 10:14:00 PM)

Nice Job, Ken.

Regardless of this MD's BMOC status, he, like so many other orthopods out there, has a very insecure little boy inside of him, who can make him behave in strange ways.

From what you have described, he sounds like a very ethically practicing MD, and the PT profession would be far better off if his method was the norm. Remember also, that "questioning" a diagnosis is ill advised in any situation - few MD's of any specialty are likely to enjoy it. However, communicating your findings in an unthreatening, informative and collaborative way can be extremely productive. Having said that, you should always mind the way you discuss your findings with the patient, especially knowing that they will discuss what you say with the MD. Sometimes, it's best to keep your suspicions to yourself, tell the MD ASAP, and let him be the "hero". The dividends paid in terms of your reputation with the MD and others (they talk to each other) can be much higher.

Enjoy the big head for a day, then get over it. Do not fool yourself into thinking that B/C you are the "hands on" clinician that he, or any other orthopod lacks or has less clinical diagnostic skill than you. The patient may have presented a very different clinical picture at the time of MD visit (guarding, effusion, etc.) and may not have shown any sort of instability. You did mention that the patient failed to report an old injury to the doc, no?

From a professionalism standpoint, blaming the dictation system is not an excuse for not communicating with the doc about potentially new findings. You have a phone, he may even have an office nearby you could stop into. From a PR standpoint VIP patients should get "ultra" blue ribbon treatment - the doc should have been called after the eval and the day before or of his follow up visit. You will viewed far more competent by the doc when he can tell the pateint, "I spoke to Ken about you today", and when the patient can come back to you and say "I heard you spoke to Dr. BMOC about me", rather than engaging in clinical diagnostic pissing matches.

Your best move from this point forward, forget this episode and begin interacting with this and other MD's on a level as I describe above. Give it 6 months, watch your rise to BMOC.




ysumpt2006 -> Re: Strained Popliteus? (December 15, 2006 3:52:00 PM)

Great advice. I have already forgotten about the incident. I learn from every interaction and I have learned from this one.

Still finding myself in this profession, lol. School and clinicals don't teach everything.




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