Complex Leg Pain and Quick Consults

[00:00:00] Welcome back to Untold Physio Stories Podcast. I'm your host, Dr. E. So recently, if you guys have seen or listened to my podcast with Mike Eisenhart, Proactivity, you would realize that I actually joined Proactivity. And if you don't know what that is, Proactivity is a company founded by physical therapists and some other people

[00:00:22] with the express intention of embedding themselves within utilities, businesses, large corporations for primary musculoskeletal health and injury prevention. So, you know, when I kind of thought of it initially, I basically thought I would just be a PT in a warehouse or

[00:00:47] something or a PT in a factory. But it's much more than that. Basically, it's small educational pieces of its presentations and teaching them how to stretch and to move. And certainly there are consultations. But I think that they are really onto something because basically, week after week, month after month, year after year, you are there giving small pieces of information,

[00:01:16] little actionable pieces like eating more fiber, getting more sleep, presenting them on what the latest evidence says about injury prevention and overall health. Say, for example, the difference between health span and lifespan in January, 2025, a lot of people were really interested in that. So even though you may be getting some kind of, you know, blowback or pushback initially, you're just continuously there. And maybe for the first several months, six months,

[00:01:46] something like that, your detractors might actually be, you know, not want to hear anything you have to say. But then all of a sudden, maybe their wife or someone they know actually has an issue. So anyway, it actually, of the consultations we end up doing, they lend themselves very well to my approach in terms of, you know, quick eval. It's kind of like the same kind of eval you would do

[00:02:12] on a friend at a party or a family member or something like that when you only have 10-15 minutes. So this particular case was a little bit more difficult than I thought. He was a larger guy, former athlete, really hard worker, but definitely had, you know, a bit of a belly, probably some inflammation going on. He had had a history of low back issues, but mostly leg pain

[00:02:38] radiating to below his knee, but it wasn't posterior. It was more anterior, but radiating to below his knee. Very diffuse. An issue mostly with weight bearing and standing. In the past, he had had two rounds of anti-inflammatories and that took it away each time, but this time they weren't really touching it. So we definitely touched upon the piece of, you know, maybe you need to include more fiber in your diet, cut back on the alcohol because he's a pretty big drinker.

[00:03:05] Um, and, uh, you know, he, he's trying to do that stuff, trying to get better sleep. Uh, but I also definitely wanted for more buy-in other than, you know, all the stuff you should be doing is I wanted to try to find a directional preference. And quickly I thought, well, if he has, you know, if he's better in sitting and he's worse in loading and he has a trouble with unilateral symptoms, I tried side glides first. Side glides really lit him up. Then I tried non-weight bearing loading.

[00:03:34] Slacking that side that also increased his symptoms. Um, and you know, I, I tried a couple other things like neurodynamic stuff, uh, maybe some femoral nerve mobilizations. I tried some lumbar gapping, um, before loading. And even though that relieved his pain, it didn't necessarily give him any weight bearing relief. He, he does have, um, very mild or no symptoms in non-weight

[00:04:02] bearing and in sitting positions. So I thought, well, why don't we try some repeated hip flexion? Because he was just doing some flexion based stretching and he said that that was relieving it. So I said, why don't you do like a captain Morgan stance, kind of like put your involved leg, which is his left leg up on a chair and really lean into that and kind of taking his hands behind his hamstring and really pulling his knee to his chest. So that really gave him a lot

[00:04:28] of relief, uh, that we tried sustained. And, um, you know, that actually enabled him to stand and walk. It centralized and abolished all his complaints, allowed him to stand and walk for at least maybe 10, 15 steps before symptoms started, uh, returning. That was the most relief that he'd gotten from any kind of stretch or position. And, um, that was the last time I had followed up with him since maybe

[00:04:53] early December and it is probably now, um, mid January at this point, uh, early to mid January. So it'd been several weeks since I've seen him. And in that time he had seen a chiropractor twice who adjusted him and did some tissue work and said, Hey, you know what? I can't help you. I want you to see this ortho. The ortho actually x-rayed his spine. Um, he was told he had lateral foramal stenosis and he, he kind of shrugged that off. He just like, well, I kind of figured ahead,

[00:05:21] you know, whatever they said was degenerative changes. And, uh, he is currently seeing a PT who has agreed with, uh, I'm not sure if the PT did their own eval or he told them that the flexion based exercises I gave him were helping minus more hip flexion, but the PT is also having them do a lot of repeated flexion and he's having them walk around in like a posterior pelvic tilt. Now he does get actually get relief from walking in a posterior pelvic tilt,

[00:05:46] but he's embarrassed, you know? And I said, well, unless someone actually sees you go into a posterior pelvic tilt, they're not really even going to notice, you know, most people don't really pay attention to these things. And I showed them, you know, the kind of subtle differences between an anterior tilt, what, you know, air quotes, neutral spine and a posterior tilt. And most people really wouldn't notice. So I said, if that gives you relief, that's great. I'm not necessarily convinced that it's actually, um, all lumbogenic. And I didn't have a chance

[00:06:15] to follow up with him because last time I saw him, he was just coming right off a break and he needed to get right back to his work. So I am going to follow up with him next week. And I'm wondering if it's a case very similar to what Dr. Malik Parker, one of my mentees had found earlier in my podcast. If you guys haven't listened to remember that episode, he had someone with a unilateral low back or SI like complaints. And the only thing that made them better was repeated hip flexion on one side

[00:06:43] and repeated hip extension on the other. And I think he was kind of doing like put them in, putting them in a Thomas test. And he found that really overpressure and repeated loading of hip flexion and contralateral hip extension is really what did it. So I'm also wondering if that, um, you know, because the PT again has him doing a lot of non-weight bearing flexion. And I'm wondering if he actually needs

[00:07:07] repeated hip flexion, just like that, um, that captain Morgan stance, right? Because the contralateral leg was actually going into extension as he was pulling himself into flexion. So I'm going to try that next and actually, um, look more closely at his hip extension on the involved side, because potentially if repeated hip flexion makes him better, but he has a loss of potential like

[00:07:31] thoracic issues and hip extension on that side, it could be, that's why, um, being upright tends to actually affect or sensitize that lateral for amal stenosis on the involved side. So let me know what you guys think of this case. And if you guys find it interesting, um, as always reach out, uh, if you have any interesting cases or physio failures, you can come on the podcast and be a guest, leave untold

[00:07:59] physio stories, five stars rate it on, especially an apple and Spotify as it helps our discoverability and you guys have a great day.