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anterior thigh symptoms

 
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anterior thigh symptoms - October 26, 2011 2:53:41 PM   
ally82

 

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I am hoping for some treatment ideas for my patient.
No major PMH, hx of right tibial plateau fx 2010.
53 y/o female referred to PT for back rehabilitation. 4 weeks ago, onset of left knee pain, no MOI. Symptoms escalated to the point she was having difficulty walking/weakness & pain, numbness, tingling, pain in the left anterior thigh/knee. ED completed CT scan L-spine, "facet subluxation L4/5, DJD, foraminal narrowing L5/S1. No LBP since onset. Unable to lie on R side at all.
Objectively: No tenderness or symptoms reproduction with palpation Lumbar paraspinals or with PA mobs to Lspine. Pitting edema bilaterally 2+, recent onset.
ROM: Flexion FTF 7 inches with reproduction of symptoms, Extension 75% loss with reproduction of symptoms, full rotation bilaterally-no symptoms, sideglide left 50% loss with reproduction symptoms, right 50% loss with reproduction of symptoms.
Myotomes: hip flexion Left painful and weak 4/5
Other neuro: SLR 45 degrees bilaterally with numbness reproduced and "tightness"
With positioning supine or prone symptoms disappear, but do not remain so once she is weightbearing.
Treatments: long axis distraction with IR of LE, Lumbar roll mobilization (sidelying left), prone>POE>PPU, significant time on posture/body mechanics.
So far, I feel I am having difficulty keeping symptoms decreased/true centralization, just flexing iliopsoas (getting in/out car, bed mobility, walking sometimes) increases symptoms.
Any advice?? I am thinking mechanical traction.
Post #: 1
RE: anterior thigh symptoms - October 27, 2011 8:33:08 AM   
Shill

 

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How severe were the DJD findings, the foraminal narrowing, and how is the "subluxation" quantified? If the word severe is not used, potential for improvement goes way up. With symptoms from the anterior thigh to the knee, some prone knee flexion/femoral nerve tension testing is in order. This can be used as a gentle treatment as well if prone knee flexion reproduces any of the symptoms she has. She can simply lie prone and do active hamstring curls to the point of tension then back off. Let her experiment with this to see what she feels, as long as she moves slowly and carefully, she can be assured that she is not damaging anything. She improves with unloading the spine when she lies supine or prone. How often each day does she unload? I would have her doing it 5-7x per day for perhaps 3 minutes each time. It is possible that this can be used as a densensitizing technique and help her become more tolerant to her day by simply breaking up the loading that leads to greater discomfort. Generally, the pain upon returning to weight bearing takes longer and longer to come back on.
Teach her active splinting (paraspinal contraction/lordosis maintenance) to use while getting out of her car. Each episode of pain that you give her control over helps to reduce irritability. Let her know that these are TEMPORARY movement changes to help reduce this irritability, and once reduced you will help her restore movements that she doesnt have to think about. Right now, these careful and planned are necessary, but for a good outcome, she needs to be able to move without this constant planning, and it is reasonable to expect this to occur in as little as 6 weeks.

(in reply to ally82)
Post #: 2
RE: anterior thigh symptoms - October 27, 2011 2:29:16 PM   
ally82

 

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No reproduction of symptoms with prone femoral nerve testing. Despite this, I did do gentle on/off passive flexing of the knee.
The only time we get symptoms in NWB is with getting in and out of bed.
We did try long axis distraction on the LLE today, dramatic increase in symptoms. She did tolerate RLE long axis distraction (could not do IR of the leg=pain, only ER was tolerated). Felt better after this treatment in weightbearing.

I am attempting to get her unloaded several times per day (every 2 hours).

CT:
"There was slight anterior subluxation of L4 on L5 by approximately 3.3 mm. No spondylolysis was seen, but there were degenerative changes of the facet joints which likely are allowing for the mild anterior subluxation of L4 on L5. There was some broad-based posterior disk bulging at L3-4 extending into the spinal canal 3.3 mm without focal herniated component evident or spinal stenosis. The neural foramina were moderately narrowed at L3-4 due to posterolateral disk protrusion and degenerative changes of the facet joints.

At L4-5, in addition to the anterior subluxation, there was broad-based posterior disk protrusion extending into the spinal canal 4.0 mm not producing spinal stenosis. More prominent disk projection was present into the neural foramina on the right at the L4-5 level producing moderate to severe neural foraminal narrowing. This area was not as well delineated on the sagittal reconstructions, however.

At L5-S1, there was also posterior osteophytes and broad-based disk protrusion extending into the spinal canal 4.3 mm not producing focal protrusion or spinal stenosis."

(in reply to Shill)
Post #: 3
RE: anterior thigh symptoms - October 27, 2011 2:37:14 PM   
ally82

 

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Sorry for the intially incomplete information on the CT.

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RE: anterior thigh symptoms - October 27, 2011 3:22:17 PM   
rwillcott

 

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Were the CT scan results explained to the patient? If so there is a chance that some of these benign findings have contributed to her pain and disability.  Many of these findings are normal and can be found in asymptomatic population.  One good rule of thumb is 'Don't treat the x-ray'.

(in reply to ally82)
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RE: anterior thigh symptoms - October 27, 2011 4:33:18 PM   
ally82

 

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She had an appt with a spine specialist who explained her issues were on the right. It took her a long time to buy into the idea that her symptoms are stemming from her back and we need to treat her back. I have not gotten into her CT scan. She is not fixated on her CT at all.

(in reply to rwillcott)
Post #: 6
RE: anterior thigh symptoms - October 28, 2011 10:06:30 AM   
Shill

 

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quote:

I am attempting to get her unloaded several times per day (every 2 hours).


Great. Is the attempt succeeding? This is unfortunately an inconvenient exercise, and we all know how likely our patients are to do something that is inconvenient. Yet if it relieves pain, they should want to do it despite the inconvenience. It goes without saying, (then why am I saying it?) that of course she needs to be accountable for doing what you ask her to do until she either improves or finds that the suggestions are ineffective.

(in reply to ally82)
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RE: anterior thigh symptoms - October 28, 2011 1:51:17 PM   
ally82

 

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She is not getting better. She completed 2 steroid packs. Now that she is off the steroid, her symptoms are worse. I have a strong feeling that she is not unloading as often as I'd like. She states that this is such a long process, getting in/out of bed. I will work a lot on the basics next session, maintaining lordosis with getting in/out of car and in/out of bed with log roll.

(in reply to Shill)
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RE: anterior thigh symptoms - October 31, 2011 10:34:41 AM   
totalmotionpt

 

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Ally82 - if I may she sounds like a good candidate for trying to do some exercise/treatment away from the area of injury.

My first question is she able to move one of her legs without issue? In other words can she do a leg raise without pain on the non-injured side [knee pain side]? Can she weight bear on one side without discomfort when compared to the other side? If the answer to both of those is no - then I would work up in the trunk and then the upper extremities. I do believe I saw that you mentioned she had equal trunk rotation. This may be a great place to start. First make sure you determine an issue motion that you want to see it improve. Such as lifting the injured leg or weight bearing [pushing on the floor] with it. Then Ask her to compare left trunk rotation with right trunk rotation. If she says they are equal then ask her if she had to rotate toward one side for the next 2 hours, which one would cause more discomfort. From there - have her do 4 sets of 15 to 20 seconds of her twisting further and further into end range [pain free]. Then retest her Issue of her injured area. If it improved continue until she no longer has any improvement. If this works - email me at totalmotion@gmail.com and I can provide further treatment options.

Tom

< Message edited by totalmotionpt -- October 31, 2011 10:36:46 AM >

(in reply to ally82)
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RE: anterior thigh symptoms - October 31, 2011 12:02:16 PM   
ally82

 

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She can complete standing hip flexion on the right, but has weakness/pain with the left. SLR as a neuro test is bilaterally an issue.

(in reply to totalmotionpt)
Post #: 10
RE: anterior thigh symptoms - November 2, 2011 11:53:14 AM   
totalmotionpt

 

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When she does standing hip flexion on right - this is ok - correct? No pain or issue? Go ahead and have her do standing hip flexion for 3 sets of 15 seconds lifting further and further into end range. Retest the left side. Do 3 more sets of 15 and then retest left. Is it better?
Because SLR causes issue bilaterally I would not do that exercise.
I would now go up into trunk and in sitting have her twist to right [go as far into end range as possible] and then go to left [go as far into end range as possible]. Tel her she must pick a bad side [if she had to do one for 2 hours which would she pick as harder] - the bad side does not have to increase her issue and may not at all. We are simply comparing trunk twist. Once she has a bad and good side. Treat to the good side for 3 sets of 15 seconds - pushing further and further end range [not reps]. Retest bad test and then retest her SLR neural test and what ever else was an issue for her.
Let me know how she does and please email me at totalmotion@gmail.com and we can continue our communication. I don't always check this forum

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RE: anterior thigh symptoms - November 2, 2011 9:11:52 PM   
proud

 

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quote:

ORIGINAL: totalmotionpt

When she does standing hip flexion on right - this is ok - correct? No pain or issue? Go ahead and have her do standing hip flexion for 3 sets of 15 seconds lifting further and further into end range. Retest the left side. Do 3 more sets of 15 and then retest left. Is it better?
Because SLR causes issue bilaterally I would not do that exercise.
I would now go up into trunk and in sitting have her twist to right [go as far into end range as possible] and then go to left [go as far into end range as possible]. Tel her she must pick a bad side [if she had to do one for 2 hours which would she pick as harder] - the bad side does not have to increase her issue and may not at all. We are simply comparing trunk twist. Once she has a bad and good side. Treat to the good side for 3 sets of 15 seconds - pushing further and further end range [not reps]. Retest bad test and then retest her SLR neural test and what ever else was an issue for her.
Let me know how she does and please email me at totalmotion@gmail.com and we can continue our communication. I don't always check this forum



Hello Tom?

Remember posting this back in I think 2006?

quote:

Currently we have a DPT student from USC starting a research project the end of the summer and probably won't be in the literature until Dec 2007. Drexey has been tracking some case studies and a few others have expressed interest in further research.


Can you update us on this?

(in reply to totalmotionpt)
Post #: 12
RE: anterior thigh symptoms - November 14, 2011 4:46:36 PM   
totalmotionpt

 

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The latest info on research is:
We have spent 2 1/2 years working with a professor at the University of Texas who has been trying to get approval to begin a series of research projects on TMR.  He got the green light to move forward earlier this year. 

The USC student I lost track of.  He ended up having to change his project to be more of a analysis of research that has already been done about the underlying concept.  He discussed many of the research articles already on our website. 

As for Drexey - I am in touch with her and she has written me about some wonderful cases yet was too busy to continue the extra leg work needed.  She travels to 3rd world countries teaching therapists what she knows.  She has sent me some wonderful pictures of entire clinics learning the TMR process.  She had one therapist in Peru that was able to watch our Live Online seminar for TMR 1 & 2 and take it back to her staf. It was such a treat to be part of helping out an entire community. 

Thanks for asking!

Tom

(in reply to proud)
Post #: 13
RE: anterior thigh symptoms - November 14, 2011 7:26:20 PM   
proud

 

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So 5 years latter and no data to support the claims ...just more testimonials.

Got it.

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Post #: 14
RE: anterior thigh symptoms - November 14, 2011 11:24:58 PM   
bonez

 

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quote:

ORIGINAL: proud

So 5 years latter and no data to support the claims ...just more testimonials.

Got it.

Proud I'm surprised I suspect your critique would have been more stern if it was a Chiro back again with three whole posts all referencing the posters business!

(in reply to proud)
Post #: 15
RE: anterior thigh symptoms - November 15, 2011 10:17:05 AM   
jesspt

 

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quote:

ORIGINAL: totalmotionpt

The latest info on research is:
We have spent 2 1/2 years working with a professor at the University of Texas who has been trying to get approval to begin a series of research projects on TMR.  He got the green light to move forward earlier this year. 

The USC student I lost track of.  He ended up having to change his project to be more of a analysis of research that has already been done about the underlying concept.  He discussed many of the research articles already on our website. 

As for Drexey - I am in touch with her and she has written me about some wonderful cases yet was too busy to continue the extra leg work needed.  She travels to 3rd world countries teaching therapists what she knows.  She has sent me some wonderful pictures of entire clinics learning the TMR process.  She had one therapist in Peru that was able to watch our Live Online seminar for TMR 1 & 2 and take it back to her staf. It was such a treat to be part of helping out an entire community

Thanks for asking!

Tom


Tom,

Wouldn't you be helping out the entire rehab commuinity by subjecting the method to critical/scientific inquiry? Getting a review board to approve your study isn't cheap unless you're hooked up with a university of facility that has their own board, but perhaps some of the profits from the TMR courses could be set aside.

Research might allow you to access a very large and significant portion of your profession that currently won't come within ten miles of your course due to the lack of any outcomes data. That alone may be worth the investment...

_____________________________

Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy

(in reply to totalmotionpt)
Post #: 16
RE: anterior thigh symptoms - November 15, 2011 7:10:23 PM   
proud

 

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Joined: March 23, 2006
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quote:

ORIGINAL: bonez

quote:

ORIGINAL: proud

So 5 years latter and no data to support the claims ...just more testimonials.

Got it.

Proud I'm surprised I suspect your critique would have been more stern if it was a Chiro back again with three whole posts all referencing the posters business!


First...glad to see you posting again Bonez.

Second...do a search and see my (and others) dismanteling of "total motion" back about 4-5 years ago. We ripped Tom a new one. The thing about Tom is he always remains polite and claims the "research is on the way"....

I think it's pure BS.....but it became difficult to shred such a polite fellow.

(in reply to bonez)
Post #: 17
RE: anterior thigh symptoms - November 16, 2011 9:57:20 AM   
SJBird55

 

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Hey Tom... who's going to undertake the project at University of Texas?

(in reply to proud)
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RE: anterior thigh symptoms - December 5, 2011 4:09:34 PM   
mugal

 

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Regarding original post, Have you screened her pelvis and SI joints? I know it's rare but check to see if a L downslip is a possibility, esp given her dramatic increase in symptoms with distraction of LLE. Downslips can cause radiating and sciatic type symptoms and weakness. They may also cause appearance of upslip due to muscle guarding, abdominals and quad lumborum pulling pelvis up into sidebending. A couple links to check out, Hesch method: and another one here

(in reply to SJBird55)
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RE: anterior thigh symptoms - December 5, 2011 6:54:31 PM   
rwillcott

 

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mugal,

Could you explain how one goes about checking for an L downslip of the pelvis? Also, do you have any research indicating that this downslip causes radiating symptoms?

(in reply to mugal)
Post #: 20
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