Dhinu J. Jayaseelan

Rehabilitation of Proximal Hamstring Tendinopathy Utilizing Eccentric Training, Lumbopelvic Stabilization, and Trigger Point Dry Needling: 2 Case Reports

STUDY DESIGN Case report. BACKGROUND Proximal hamstring tendinopathy is a relatively uncommon overuse injury seen in runners. In contrast to the significant amount of literature guiding the evaluation and treatment of hamstring strains, there is little literature about the physical therapy management of proximal hamstring tendinopathy, other than the general recommendations to increase strength and flexibility. CASE DESCRIPTION Two runners were treated in physical therapy for proximal hamstring tendinopathy. Each presented with buttock pain with running and sitting, as well as tenderness to palpation at the ischial tuberosity. Each patient was prescribed a specific exercise program focusing on eccentric loading of the hamstrings and lumbopelvic stabilization exercises. Trigger point dry needling was also used with both runners to facilitate improved joint motion and to decrease pain. OUTCOMES Both patients were treated in 8 to 9 visits over 8 to 10 weeks. Clinically significant improvements were seen in pain, tenderness, and function in each case. Each patient returned to running and sitting without symptoms. DISCUSSION Proximal hamstring tendinopathy can be difficult to treat. In these 2 runners, eccentric loading of the hamstrings, lumbopelvic stabilization exercises, and trigger point dry needling provided short- and long-term pain reduction and functional benefits. Further research is needed to determine the effectiveness of this cluster of interventions for this condition. LEVEL OF EVIDENCE Therapy, level 4.

Cervicothoracic junction thrust manipulation in the multimodal management of a patient with temporomandibular disorder

Temporomandibular disorder (TMD) is a common condition that can be difficult to manage in physical therapy. A number of interventions, such as manual therapy, therapeutic exercise, and patient education have typically been used in some combination. However, the evidence regarding thrust manipulation of not only the local but also adjacent segments is sparse. Specifically, the use of cervicothoracic (CT) junction thrust manipulation has not previously been described in the management of individuals with TMD. In this case report, CT junction thrust manipulation, in addition to locally directed manual therapy, exercise, and postural education, was associated with immediate improvements in neck and jaw symptoms and function in a complex patient with TMD. The patient was seen for seven visits over the course of 2 months and demonstrated clinically significant changes in the neck disability index (NDI), the numeric rating of pain scale (NPRS), and the global rating of change (GROC) scale. The purpose of this report is to describe the successful physical therapy management of a patient with TMD utilizing manual therapy, including CT junction thrust manipulation, education, and exercise.

The effects of joint mobilization on individuals with patellofemoral pain: a systematic review

Objective: To investigate and synthesize the effects of joint mobilization on individuals with patellofemoral pain syndrome. Data sources: Five electronic databases (CINAHL, the Cochrane Central Register of Controlled Trials, PubMed, Scopus, and SPORTDiscus) were used. Review methods: Each database was searched from inception to 1 November 2017. Randomized controlled trials investigating a manual therapy intervention, with or without co-interventions, for persons with patellofemoral pain were included. Two reviewers independently screened the retrieved literature and appraised the quality of the selected studies using the PEDro rating scale. A third reviewer was used in cases of discrepancy to create a consensus. Results: A total of 361 articles were identified in the search. Twelve randomized trials with a total of 499 participants were selected for full review. Within-group improvements in pain and function were noted for the manual therapy groups. Between-group improvements for short-term outcomes (three months or less) were greatest when joint mobilization was directed to the knee complex and used as part of a comprehensive approach. Conclusion: In the articles reviewed, joint mobilization appears to be most effective in improving pain and function when coupled with other interventions, although its discrete effect is unclear due to the reviewed studies’ design and reporting.

Atypical Clinical Presentation of Rapidly Progressing Femoral Head Avascular Necrosis

A 51-year-old man presented to an urgent care facility 2 weeks after onset of left lateral hip and buttock pain. Radiographs were noncontributory. An orthopaedist referred him to physical therapy, but due to the worsening clinical presentation, he was referred back to the orthopaedist for additional evaluation. Magnetic resonance imaging was ordered and demonstrated abnormal femoral head and acetabular contour, extensive bone marrow edema, and a complex joint effusion. He was diagnosed with femoral head avascular necrosis. J Orthop Sports Phys Ther 2017;47(3):217. doi:10.2519/jospt.2017.6483.

The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review

Objectives: Plantar heel pain is common and can be severely disabling. Unfortunately, a gap in the literature exists regarding the optimal intervention for this painful condition. Consequently, a systematic review of the current literature regarding manual therapy for the treatment of plantar heel pain was performed. Methods: A computer-assisted literature search for randomized controlled trials in MEDLINE, EMBASE, Cochrane, CINAHL, and Rehabilitation & Sports Medicine Source, was concluded on 7 January 2014. After identification of titles, three independent reviewers selected abstracts and then full-text articles for review. Results: Eight articles were selected for the final review and underwent PEDro scale assessment for quality. Heterogeneity of the articles did not allow for quantitative analysis. Only two studies scored ≥7/10 on the PEDro scale and included joint, soft tissue, and neural mobilization techniques. These two studies showed statistically greater symptomatic and functional outcomes in the manual therapy group. Discussion: This review suggests that manual therapy is effective in the treatment of plantar heel pain; however, further research is needed to validate these findings given the preponderance of low quality studies.

Manual therapy and eccentric exercise in the management of Achilles tendinopathy

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT. Level of Evidence: Case series. Therapy, Level 4.

Manual therapy in the management of a patient with a symptomatic Morton's Neuroma: A case report

Patients with Mortons neuroma are rarely referred to physical therapy. This case reports the resolution of pain, increase in local pressure pain thresholds, and improvement of scores on the Lower Extremity Functional Scale and Foot and Ankle Ability Measure following a course of joint based manual therapy for a patient who had failed standard conservative medical treatment.