Tough to Treat

Shoulder pain, like any other joint can present as primary pain and can be the #1 reason a client may be seeking help! In many cases, treating the obvious joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes. Join the conversation as Susan and Erica explore the various reasons and important timelines in the client's history that has led to her shoulder pain. Most importantly follow the clinical reasoning that led to the real driver of this issue. Bonus - we also offer a great discussion of a good exercise progression!

A glance at this episode:

• [1:39] Shoulder pain and internal rotation

• [7:52] Which side of the table should you work from

• [12:40] Learning to tape the wrist

• [20:00] Opening the hands

• [22:46] Using the blocks for yoga blocks

• [27:58] Grip strength as a sign of health

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

In this episode, Erica discusses the why behind shoulder problems, comparing the unique challenges faced by tennis players and non-tennis players alike. She explains why traditional shoulder treatment often fails these types of patients. A significant relationship between the shoulder and another region of the body is often missed. Erica also tells the story of one of her patients who does play tennis and the reason why he can do a full pushup but can't lift his arm over his head. For our physio listeners, oftentimes you can progress patients through a full range of CKC exercises but the OKC piece does not progress as quickly.

A glance at this episode:

• [0:01] Erica's Summer Vacation and Introduction to the Episode

• [2:30] Clinical Pearls for Tennis Players

• [6:15] Assessing Upper Thorax and Glenohumeral Joint Compression

• [12:53] Treatment Approach for Upper Thorax and Glenohumeral Joint Issues

• [15:54] Progressing Patients with Glenohumeral Issues

• [16:14] Clinical Pearls for Closed Chain Exercises

• [20:37] Conclusion and Encouragement for Practitioners

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the client's primary complaint. How does the stiffness of the MTP joint affect gait and lower quarter movement of all kinds? We spend some great time discussing differential diagnosis and practical interventions and sharing some new discoveries. Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.

A glance at this episode:

• [0:01] Introduction and Podcast Rebroadcast

• [2:13] Overview of Stiff First MTP Joint

• [4:21] Compensation and Adaptation

• [6:30] Assessment and Treatment Approaches

• [23:22] Exercise and Proprioception

• [25:47] Shoe Recommendations and Adaptations

• [34:17] Conclusion and Final Thoughts

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

What is the cause of bilateral calf pain in this young fencer? From start to finish, it shows the power of a thorough evaluation, a specific exercise progression, and a return to the sport she loves. When it comes to exercise progression in persistent pain, think about context. How can you improve optimal movement patterning by changing the context? Think about this one. You can intervene via the visual system, eyes open, eyes closed. How about changing their base of support? Wide to narrow. And why not have them do their exercises to their favorite music? These are just some examples. Look at your patients through a different lens and then see positive change.

A glance at this episode:

• [0:01] Introduction and Case Overview

• [7:46] Initial Assessment and Clinical Reasoning 

• [10:27] Hypermobility and Initial Treatment

• [20:14] Progression and Additional Techniques

• [32:40] Advanced Techniques and Future Plans 

• [52:04] Conclusion and Reflection

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

How similar are the neuromuscular responses to pain with Chronic low back pain and GI pain? Join Susan and Erica in a great discussion of the role of the diaphragm and how this changes with pain and inhibiition/over-recruitment in the system. In chronic low back pain and abdominal bloating/distention the diaphragm becomes a postural control muscle which greatly limits the respiratory ability and is an ineffectual model for spine stiffness and visceral organ pusher. This is an excellent discussion following the podcast episode 185. 

1) Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):352-62. doi: 10.2519/jospt.2012.3830. Epub 2011 Dec 21. PMID: 22236541. 2) Villoria A, Azpiroz F, Burri E, Cisternas D, Soldevilla A, Malagelada JR. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May;106(5):815-9. doi: 10.1038/ajg.2010.408. Erratum in: Am J Gastroenterol. 2011 Jul;106(7):1405. PMID: 21540894. 3) Sicilia-Gomez C, Fernández-Carnero S, Martin-Perez A, Cuenca-Zaldívar N, Naranjo-Cinto F, Pecos-Martín D, Cervera-Cano M, Nunez-Nagy S. Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain. Diagnostics (Basel). 2022 Oct 18;12(10):2530. doi: 10.3390/diagnostics12102530. PMID: 36292219; PMCID: PMC9600311. 

A glance at this episode:

• [0:01] Diaphragm function, GI dysfunction, and postural control

• [7:51] GI dysfunction and its impact on abdominal wall muscles and posture

• [13:39] Abdominal dysfunction and diaphragm movement in relation to chronic low back pain

• [20:36] Treating chronic low back pain through abdominal wall retraining

• [25:09] Abdominal wall deficit and diaphragm dysfunction in chronic low back pain patients

• [32:07] Treating gas and bloating through diaphragm therapy

• 36:32] Treating GI dysfunction through breathwork and positioning

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't.  Doing the right thing at the right time is clinical expertise.

A glance at this episode:

• [5:13] Hypermobility and pain management for a 24-year-old woman

• [11:26] Hypermobility, muscle imbalances, and control issues in a patient with back pain

• [19:00] Shoulder subluxation and its relation to past injuries and yoga practice

• [23:57] Diaphragm recruitment in back pain patients

• [27:47] Addressing short girl syndrome in a dancer

• [32:03] Using tape and Pilates equipment to improve abdominal strength and stability for a hypermobile patient

• [35:51] Improving posture and flexibility through exercises on a reformer machine

• [39:23] Exercises for a spin instructor with tight hip flexors

• [43:34] Exercises for hypermobile individuals to improve motor control and recruitment

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

If it walks like a duck and quacks like a duck - it must be a duck, right? Low back pain is a descriptive term at best, indicating where symptoms present. Join Susan and Erica as they explore this Tough to Treat client with low back pain and mild stress urinary incontinence. Discover the history and the movement system examination and interventions that led to the successful reduction of symptoms. *Hint: this really isn't a duck!

Visit our website: toughtotreat.com

A glance at this episode:

• [0:01] Low back pain and pelvic health issues, client with gradual onset of stress urinary incontinence

• [2:16] Pelvic health and trauma history after a recent fall

• [7:21] Patient's foot and leg issues, including supination and knee pain

• [13:08] Addressing knee issues through breathing and positioning

• [15:50] Knee and back pain treatment using bridging and lunge exercises

• [22:01] Treating knee pain and low back pain through exercises and manual therapy

• [27:45] Treating patients with movement system changes to address low back pain and pelvic health issues

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

Now, this is a CHALLENGING one! Ever have those patients who have been everywhere, had everything done to them (injections, surgeries, acupuncture) and nothing helped?  Well, this is your lucky day because this episode really takes us down the chain from head to toe with someone who had low back pain. Pretty standard, right?  But this was FAR from standard. Hint: her low back was not the source of her problem. Why do you think that is? Remember, we bring all of our compensations to our life events. And our movement and injury history sets us up and our dominant patterning keeps us there.

Visit our website: toughtotreat.com

A glance at this episode:

• [0:01] Complex medical history and treatment options

• [7:06] Chronic pain and potential causes

• [12:14] Pelvic issues and postural compensations

• [18:41] Pelvic and foot issues, possible nervous system impairment

• [23:21] Decompression techniques for a patient with nervous system issues

• [26:31] Yoga and physical therapy for a patient with neck pain

• [29:13] Treating a patient with chronic pain using movement patterns and cranial work

• [35:07] Standing and carrying issues, loading exercises suggested

• [40:07] Exercises for back pain relief, including cycling, Nordic walking, and rock climbing

• [42:28] Using yoga and rock climbing to improve standing tolerance for a client with chronic pain

• [47:30] Treating patient with chronic pelvic pain

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

What do you do when a client presents with a myriad of LQ symptoms without a clear regional driver? Look to the history and keep asking questions even further back than the recent onset or episodic flare. Join us as we discuss complex neurology of a visceral driver that has signs of dysfunction and a somatic pain presentation. Once again, the history is so important!

A glance at this episode:

• [0:01] Left lower quadrant pain, nociceptive input from visceral driver

• [2:23] Pelvic pain and potential visceral driver

• [8:05] Bladder issues and pelvic floor tension

• [10:49] Bladder irritants and pelvic health with a patient

• [16:49] Lower back pain and posture with a physical therapist

• [20:04] Pelvic floor exercises and visceral manipulation for pelvic pain relief

• [24:34] Pelvic floor exercises and core strength for bladder control

• [26:45] Improving driving skills and addressing bladder issues

• [32:49] Visceral mobilization and pelvic floor issues

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript

Golf is a sport of weight shifts and a narrow base of support. What happens when your knee can't adapt to an altered base of support? This is what exactly happened here with this case. This young golfer, in standing (and standing is VERY relevant for the golf swing) had an 80/20 load, R/L in this position. And it stayed that way throughout the golf swing. This begs the question: Did you know that right knee pain can be caused by an imbalance in your center of mass? If you continuously load your painful side, that has some serious implications for loading. Erica and Susan discuss in this episode how treating the left hip as well as the left side of the low back, got rid of this young golfer’s knee pain. He needed options for movement to his left side. A functional and interactive evaluation really hones in on where the true source of his knee pain lies. Remember: for persistent, unsolved problems, correlate the patient's history with your objective assessment. Hint: this patient had a history of concussion. You think that would alter his BOS?

A glance at this episode:

• [0:01] Chronic knee pain in a junior golfer, analyzing the cause and treatment options

• [4:48] Golf injury treatment and diagnosis

• [12:19] Golf swing mechanics and potential issues with a young golfer

• [17:03] Assessing a 12-year-old golf player with knee pain using a thorough history and clinical reasoning

• [23:49] Using visual aids and manual therapy to help a golfer improve his swing by shifting weight to the left leg

• [31:33] Using mirror therapy for knee rehabilitation

• [39:25] Rehabilitating knee injuries via changing the center of mass

• [43:34] Rehabilitation program for golfers with variance in exercises to improve adaptability

• [47:36] Physical therapy for a young golfer with a focus on listening and meeting clients where they are

Related links:

• Tough To Treat Website

• Erica’s Course: Decoding the Complex Patient

• Susan’s Pelvic Health Education Subscription

• Access the Transcript