Tough to Treat

Pelvic floor physical therapy can be life-changing — but sometimes it only gets patients part of the way there. In this episode, I discuss a client who was referred to me by a pelvic health therapist after presenting with bilateral hip pain that pelvic floor work alone couldn't fully resolve.

I talk about why I see so many of these referrals, and how the pelvis is deeply connected to other regions of the body that aren't always considered "pelvic" but absolutely influence pelvic function and pain. I dig into the bigger picture of what else might be contributing when pelvic-focused treatment plateaus.

If you're a patient who's done pelvic floor PT but still isn't feeling 100%, or a clinician trying to figure out what comes next after pelvic-focused care, this episode will help you think more broadly about the regions connected to the pelvis and how to evaluate them effectively.

🎧 Tune in to learn how to look beyond the pelvis without losing sight of it.

Connect with Erica Meloe

• Follow on Instagram
• Check out Erica's website
• Submit your questions to [email protected]
• Purchase Erica's book

Shoulder pain doesn't always start in the shoulder. In this episode, I break down a real client case where the true driver of persistent shoulder pain was actually coming from the lower extremity — not the shoulder itself.

I walk through the theory behind this concept and explain how dysfunction in one part of the body can show up as pain somewhere else entirely. I tell you how I connected the dots and identified the lower extremity driver that was contributing to her upper extremity pain.

Finally, I cover the exercise progression I used to address the root cause first — and how that approach led to real, lasting relief for her shoulder.

Whether you're a patient trying to understand why your pain hasn't gone away with typical treatment, or a clinician looking to sharpen your evaluation and clinical reasoning skills, this episode gives you a practical look at why treating the site of pain isn't always the answer.

🎧 Tune in to learn how to think beyond the obvious and start looking at the body as a connected system.

Connect with Erica Meloe

• Follow on Instagram
• Check out Erica's website
• Submit your questions to [email protected]
• Purchase Erica's book

Do you ever have patients or even yourself, that are chronically gripping their back? Using their back muscles for practically everything? It's fairly common, but can get in the way of a very strong and thoughtful rehab program.

You've seen this before. Everything is braced, stiff and locked down — they are essentially planking through their entire day. In this episode, Erica breaks down this pattern, why it develops, and most importantly — how to change it. From using your environment and simple props to reduce guarding, to a practical exercise progression to retrain movement, this episode gives you a clear roadmap.

This is a movement pattern we see frequently in clinical practice. But how do you train someone out of this habit? Take squats, for example. Then squats, holding a pillow in front of you. Same movement, but you're holding onto a pillow to reduce some of your back gripping. Erica talks about how to develop a reference for center and some strategies for weightlifting when you're on a incline bench in the gym.

This is an important episode to listen to because this is such a common pattern and often prolongs rehab when not addressed early on.

Her back hurt. But her back wasn't the problem. This is where the nuance comes in.

In this episode, I dive into a fascinating clinical case involving a hypermobile pole dancer presenting with low back pain — where the lumbar spine was the pain generator but not the driver. The real culprits? Her knee and foot. Surprised?

I walk through the clinical reasoning process that shifted the treatment focus away from the low back and down the kinetic chain, and explore what that looked like in practice through progressive exercise programming geared towards her real drivers.

This patient had a history of ACL surgery with lateral meniscus repair, along with a torn right AND left hamstring. If you don't think that is relevant to her low back pain, think again. Make the connection.

✅ Always ask youself: "Is this the pain generator or the driver?"

✅ In hypermobile patients, control and stiffness are often the missing ingredients — not flexibility

✅ Pilates offers an exceptional framework for graded loading in hypermobile movers when applied thoughtfully

✅ Treating distally can resolve proximal pain — trust the kinetic chain

✅ Know your patient's sport or art form — it shapes everything about your programming

If you have patients or are a person who "does all the exercises," gets stronger, and still doesn't feel better—this episode is for you. In this episode, Erica dives into how to advance exercise prescription for patients who are often labeled as "tough to treat." These are the individuals who don't respond well to traditional strengthening or mobility programs and may experience pain, guarding, or flare-ups with exercise.

She explores how exercise positioning, load selection, and movement strategy can dramatically change outcomes. Rather than defaulting to more reps or heavier weights, she discusses how altering body position and the relationship to gravity can allow patients to move with less threat, better control, and more efficiency.

One aspect of this episode is working with people who chronically grip or brace their low back muscles. She talks through practical strategies to reduce excessive tone and reintroduce movement without reinforcing protective patterns that limit progress.

Erica also discusses the role of advanced exercise positions and Pilates-based approaches, highlighting how these methods can be used thoughtfully to improve load tolerance—especially for patients who need more than basic exercises but aren't ready for high-demand training.

This episode challenges the idea that "tough to treat" patients need more effort or tougher exercises, and instead reframes progress around smarter positioning, intentional loading, and movement quality to help people move with confidence again.

Related links:

• Erica's Website

• Susan's Website

In this episode, Erica explores how clinical reasoning informs decision-making across diverse areas of physical therapy practice. This is a clinical pearls discussion that will save you lots of time in the clinic.

From CKC to OKC brain mapping in an MMA fighter to exercise progression in ACL rehabilitation to thoracic dysfunction in a post partum runner experiencing hip pain and incontinence, she highlights key clinical reasoning strategies that guide effective treatment and exercise progression.

For example, if your patient has a bracing strategy in their lumbar spine where they always "grip" their back when they sit, stand and even go supine, how would you prescribe exercise to "take out" that strategy to give them more options for movement? Many people do this in our "sit up straight" culture. This will make a huge difference in your practice!

Related links:

• Tough To Treat Website

• Erica's Website

• Susan's Website

How long should you keep treating a patient? And what's the best approach when they're skipping their home exercise program? In this listener Q&A episode, Erica shares practical strategies—illustrated through two real patient cases, one a golfer and the other a cyclist—for answering the tough question of treatment length and for addressing non-compliance.

She highlights how building a strong therapeutic relationship can improve follow-through and make these conversations more productive. Erica also highlights the most important phases of an exercise program to ensure efficiency and compliance.

To close, Erica offers a brief update from her doctoral research on menopause, focusing on the role of muscle power in older women and why it may be a more critical predictor of function than strength alone.

Related links:

• Tough To Treat Website

• Erica's Website

• Susan's Website

In this episode, Erica dives into a fascinating case of a patient experiencing neck pain and how that seemingly isolated symptom actually traced back to an old foot injury. This case exemplifies the deep, interconnected nature of the human body. For those you have been listening for a while, this should not surprise you.

She unpacks the biomechanical and neural links between the foot and cervical spine, exploring how altered load distribution and compensatory patterns can persist long after the original injury appears to have healed.

A key focus of the discussion is the role of the center of mass—how shifts in its control can influence motor strategy and postural control, ultimately impacting regions far from the original site of injury.

Erica also covers exercise options, including progressions that integrate both the foot and cervical spine. How to adapt your treatment when load transfer is compromised is a key factor in this patient's outcome.

This episode is a reminder that in rehab, it's rarely just about the joint that hurts—it's about the whole system that moves around it.

Related links:

• Tough To Treat Website

• Erica's Website

• Susan's Website

In this episode, Erica talks about how to approach care when a patient has a long history of injuries and a body chart that seems to be "lit up" everywhere. It can feel overwhelming—for both the patient and the clinician.

She focuses on the importance of prioritization: identifying what's most clinically relevant right now. This involves connecting the dots to perhaps an old injury to what the current problem is.

In this particular case, frequent bilateral ankle sprains, an ACL reconstruction plus a continued pattern of bilateral issues help you nail down your focus to what is important for you to assess and what is important for the patient to feel.

These patterns not only shape your clinical focus—helping you decide what truly needs assessment—but also give the patient a clearer sense of what their body is trying to communicate. What is relevant to you may not be important to them. It's up to you to explain to them why.

Key takeaways include:

· Avoiding the trap of chasing every symptom.

· Establishing a hierarchy of concerns using patient input and objective findings.

· Acknowledging the complexity of the history without letting it dictate the entire plan.

Related links:

• Tough To Treat Website

• Erica's Website

• Susan's Website

This episode dives into some of the evidence on resistance vs. high-velocity power training in postmenopausal women and its impact on bone mineral density (BMD). Research is highlighted showing that high-speed training protocols may stimulate bone more effectively than traditional resistance training by increasing strain rates and promoting osteogenic adaptation. You'll learn how moving with speed and control helps strengthen bones and prevents age-related decline better than slow, heavy lifting alone.

Some of Erica's research for her doctoral dissertation is discussed and she then presents a case study of a menopausal patient with insidious-onset shoulder pain and offers some clinical pearls as to why, especially in anyone who has played a racquet sport, the shoulder is not the only driver. She also highlights a few targeted interventions that allowed this woman to weight lift and strengthen her shoulder without feeding into her symptoms.

The content contained therein, including text, images, audio, or other formats, were created for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Related links:

• Tough To Treat Website

• Erica's Website

• Susan's Website