I enjoyed a great weekend with a very attentive, active group of PT’s, OT’s and strength coaches in the relaxed and comfortable town of Coppell, Texas.  Lots of fun learning about inlet and outlet positions as they relate to clinical application learning to “guide the pillar posteriorly!”  Plates were full from the PRI buffet of information to apply!  Many thanks to the warm group at GO Sports Therapy for their participation and drive to learn about this science!

Hello triplanar thinkers!

For those wondering, the picture is relevant because it shows a technique not often considered for the condition treated:  keeping a severed hand alive by grafting it to the patient’s ankle, then later replanting the hand back on his arm. 

The conclusion of my story about Don didn’t involve any external fixators, but the treatment that he needed might surprise some of you.  To review, Don was the patient with left shoulder bicipital tendinosis whom I treated in part I (link) with the “gold standard” conservative orthopedic approach and part II (link) with the according postoperative approach as a good therapist has been trained to.  As mentioned, I outline this case to review the path that is so very accepted and yet, in my experience since I began training with PRI, not the most effective.  Don’s story concludes below:

Don returned to clinic 8 months after discharge with a new diagnosis of left shoulder pain with the remarks on the script “MRI negative” and “eval and treat.”  This is generally understood as physician lingo for “I have no idea what to do now…good luck with all that.” 

Upon evaluation, Don reported that these left shoulder symptoms started about 2-3 months after we discharged him from PT intervention in spite of his persistence with his HEP and “it was all back to the starting point three months later.”  He still tested as a bilateral brachial chain patient with a PEC pattern, again was positive with impingement tests—Hawkins-kennedy, empty can, Neer sign.  He was frustrated, unable to work in his wood shop or play his accordion for more than 10 minutes without severe pain.  At this point, the patient and I discussed that fact that I had let him down to a degree because I wanted to take a different approach before surgery, but didn’t want to irritate Don or his referral source.  He understood, accepted my apology and we moved forward.

During the first 3 visits, we established that his bilateral brachial chain pattern and according left shoulder dysfunction was not the root of his dysfunction, but rather the manifestation of a “bottom up” pelvis patient whose primary difficulty was in maintaining frontal plane position of his pelvis. 

The key to Don’s left shoulder function?  Right posterior inlet inhibition of his pelvis.  During the seven visits we treated Don using a PRI approach after the gold standard of orthopedic medicine and orthopedic physical therapy had failed to maintain his shoulder function for more than 3 months, his symptoms resolved.  He left the clinic a reciprocal, alternating, smiling woodshop athlete with bilateral HADLT tests of 4/5 at 72 years of age, “tickled” that he could play his accordion as long as he wanted without pain for the first time since before he first went to see the doctor more than two years prior.  Don is in occasional contact for the past 6 months with no return of symptoms, lots of activity and happy thoughts. 

Six-month follow-up with no return of symptoms after the rest of my conservative clinical skills, an appropriate surgery and present day gold-standard postoperative care was unsuccessful.  These are the types of outcomes that keep my passion for this science alive and accelerating.  Moreover, these are the types of patient successes that remind me to be gentle but bold about intervention that I know clinically to be the most effective tool I have in the entire tool chest.

Clearly, each patient is different, and no, I have not seen a consistent correlation over time between the diagnosis of left shoulder bicipital tendinosis and the need for right posterior inlet inhibition.  The objective tests guided me to find the appropriate treatment, not my innate ability to hear the pelvis or shoulder speak to me. 

The point here is not to create a case study for anyone to memorize to use in the future for that one seemingly random patient.  Rather, I hope that the take home is that there is a chance that this gentleman didn’t need as much intervention as he ended up having.  And, even in the face of the “old school” telling you exactly what they want from PT intervention, the risk is worth the reward if one can just take the first three or four visits to break down barriers to a different way of approaching an age-old mechanical dysfunction of a “shoulder.”

Thank you for reading, perhaps you can save a few visits for a few of your patients by way of my experience with Don.   My best to you!

Jess

Like most of you, I am a clinician when I enter this site.  But like many of you, I am a spouse, parent and community member as well—just a person.  These blogs are written as pragmatic, candid discussions about my experiences as a PRI practitioner.  Like you, my treatment style is a product of the training I have received.  That training has come from a wide variety of sources—so I certainly qualify as eclectic by definition.  However, every good clinician uses their most powerful and effective tools the most, whether they process that fact or not.  I am no different in that regard either.

From time to time over the years, I’ve fielded questions about whether I am a PRI “fundamentalist.”  This is a good question, and one worthy of discussion.  The well-intended question is “do you use ONLY PRI to treat your patients?”  The short answer is “No.”  The longer, slightly more complete answer is “when I treat a patient and they return to clinic objectively neutral with PRI functional tests that equate to the level of functional strength that they desire but still have focal symptoms, then I treat with focal treatment techniques.”  I use my most powerful and effective treatment techniques first and often times don’t need others.  And yes, the most powerful techniques I’ve ever utilized are PRI techniques.

That said, I think it best to discuss this concept by way of actual clinical examples.  The following is a story about one patient with the diagnosis of left shoulder biceps tendinosis who I treated intermittently over an 18 month span, the strategy I used to treat him and the clinical results that I found.  Names have been changed to protect the innocent and in order to maintain a readable text, I have grossly summarized the care of this patient.  The clinical findings listed are predominantly to give the reader a feel for the symptomology, goals of the patient and style/type of treatment used.

Don's Story:

Diagnosis:  "biceps tendinosis"
"Caused" by AC jt spurring, subacromial impingement according to his physician, the radiograph and MRI

The mechanism of injury was insidious, first becoming a limiting factor 3-4 months prior to evaluation.  The patient’s ROM was functionally limited into abduction, flexion and IR, less limited with ER.  There was noted adverse neural tension with median and ulnar nerve biased UENTT’s.  Neer sign, Hawkins Kennedy and empty can tests were positive.  Comparable sign with resisted elbow flexion and supination, active and resisted horizontal abduction.    PRI testing revealed a PEC patient who showed a bilateral BC pattern. 

The patient wanted to be able to raise his arms overhead to enable him to perform various ADL’s including woodworking, wanted to be able to again play his accordion, which he had been unable to do for several months.

This was a classic example of working with an “old-school” orthopedic physician and patient.  Good physician, hard-working patient.  I initially described the positional influence of the brachial chain because I knew it was most important and tried to treat the patient in that fashion.  However, the patient’s script for PT from the physician was specific and called for scapular stabilization, rotator cuff strengthening and the patient had discussed specifics about what PT would involve before arriving.  When what I felt was best for the patient was not supported by the patient or his physician, I chose to follow the script as directed.  I did what was comfortable and familiar to the physician, patient and myself—I used an ‘eclectic’ approach which included:  As much "PRI" as the patient would tolerate--a few non-manual techniques to attempt to reposition, Butler neuromobilizations to address adverse neural tension, Gr I-III joint mobilizations to inhibit tone and mildly increase posterior-inferior capsular length, MWM's to achieve end range pain-free ROM (IR and abduction most notably in this case), pain free rotator cuff, ST AND TS stabilization to the hilt.

After using this approach twice per week for 8 weeks, the patient had achieved all mobility goals, and all but one functional goal.  He still could not play his accordion for more than 5 minutes without having symptoms of left shoulder pain but was happy with his progress, reporting he was 90% better.  At his 8 week f/u with his physician, the decision was that he was "better enough" and was to discharge to HEP in short order.  I outlined his final HEP that he would agree to and wrote a semi successful discharge summary to "continue with independent HEP per physician's orders."

Sounds like a common 90% successful PT intervention, right? I had met all of the mobility and all but one of the functional goals that I had set and the patient and physician were pleased with my work.  I had done exactly what they had asked.  So why wasn’t I entirely happy?

To be continued...