With Acute Pain Like This, Who Needs Chronic?

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[00:01:19] Welcome to Untold Physio Stories Podcast. Your perfect commute resource with Physio failures, successes, interesting cases and more from the physio and rehab world. With your host, Dr. Andrew Rothschild and person, Relicioso. Welcome back to Untold Physio Stories. I'm your host, Dr. E with Mytermanial Therapy Edge Mobility

[00:01:46] System. My co-host, Dr. Andrew Rothschild can't be with me today so we're going to do another asynchronous episode where he comments on my case. So this case, in particular I talked about maybe a year or two ago,

[00:02:01] she was a chronic rib pain case. She went to another physical therapist to try it as best to leave her rib pain severe after propbing herself up on a boat. I guess it's actually a common injury because this happened to one of my friends earlier this year

[00:02:21] when people are in a lake or the water and they try to lift themselves up on a boat almost like a man up, sometimes the edge of the metal boat gets caught on their ribs. So anyway, she had

[00:02:34] severe rib pain. I also had a history of S.I.J. Fusion so definitely some lower quarter issues. Back then, a couple years ago, I was able to improve her 70% by doing a lot of

[00:02:46] isometric in rotation and side bending, some pain-free, QL inhibition with breathing and I taught her self-reotations. She was an ecstatic because she just got so much improvement after having years

[00:03:01] and years of pain. So just recently about a month ago and again all her rib pain has been cleared up she's been able to complete her resets and get back to strengthening and doing all kinds of

[00:03:12] active things. So recently, though, she was an an MVA and she was driving. So she came to me saying that initially her rib pain was severe and so her rib pain was severe. It was in the same exact place

[00:03:34] around the right lower 12th rib or so. Actually, excuse me, higher about T6, T7, rib and whereas previously when I saw her, most of her pain was posterior. Now, she said her posterior area just felt tight but it was not really painful. Most of the pain was now

[00:04:04] anterior around the cost-throw caundroid junction and her motion was full. By the time she came to see me, pain had improved about 50-75%. And I concluded that it was probably a sprain or strain and possibly even contusion. One of her main complaints was just underneath her

[00:04:30] breast. She had severe tenderness to touch and I didn't really touch there just because I tried to avoid those places and if I do, if I do palpated anything, I also have them hold their

[00:04:43] breasts too so they feel safe and protected. So I thought, well, that might just be a contusion because of the seat belt went across your chest and with you going forward into that rapidly,

[00:04:57] again, being at an MVA and she actually teaboned someone who cut her off. I think the seat belt could have done that. So even though her pain initially five days ago from the time of the

[00:05:11] valve, so she was still in the cute phase, she had difficulty breathing at 7 to 9 at a 10 but the time she saw me, it was probably only about three or four so it was definitely improving.

[00:05:21] I said, you know, if this is a sprain, let me give you a piece of kinesiotape and you can just try taping your rib for a little support and I think that will help with some of the pain.

[00:05:32] So she tried applying some of the tape and again, I didn't really give her any resets because her resets weren't really helping with the pain anyway and I thought it was a cute and her motion

[00:05:44] and her strength were all fine. She said after, within a day of applying the kinesiotape wrapped along the entire T6 T7 ribs, she said that the pain became so severe that she could barely breathe

[00:05:59] it was about 8 or 9 at a 10 and that extreme tenderness and, here early, was even more severe to palpation. I tried doing some very light isometrics and some very light mobilizations. Often she was concerned about her rib being out of place, just even though she read

[00:06:21] Greg Lehmins, recovery strategies book and she mostly believed the stuff about patho anatomy, not really being relevant to pain and things not going in and out of place. Easily, a couple

[00:06:33] sessions from her previous bout of PT, I did palpate just to a piece her and said that the isometrics were helping stabilise it. I tried some very light isometrics, some very light mobilizations

[00:06:50] just in case she happened to have anything more than a fracture so I said hey you know what? At that point she had to remove the tape and let's just give this a break. Try it to avoid

[00:07:03] doing the exercises that I gave you and if this still hurts because it was still the acute phase at this point only may be six or seven days after the accident and I had just seen her five days after

[00:07:15] the accident. So this was the first follow-up still within that week. I said if this is still painful by the end of the week that it's seen around Monday, I think you should go to your doctor and ask

[00:07:24] her an x-ray because you may have a contusion or potentially even a fracture based on the tender severe tenderness. I'm talking about a couple ounces of pressure being severely tender. Then I got a text reverence and said you were right. I have an anterior, non-displaced

[00:07:43] rib fracture and I'm not allowed to exercise or at lift heavy weight for about a month or so. So Andrew let me know what you think of that. I just told the patient basically that I was sorry

[00:07:56] I was right about it being a fracture because she loves working out. Hey, Harrison. I was fun to hear another one of your unique stories. They certainly are usually more interesting than mine. I'm pretty confident in. And this is the thing with acute

[00:08:18] patients. It's always, I think, PT's in general. We gripe about treating chronic pain and treating patients who come in four months after an injury and why did you come in earlier? I mean, so much easier to treat. But there's that fine line of women's like almost too acute

[00:08:37] because you have a especially with an MBA, you have a known mechanism of injury. Certainly at high rates of speed and obviously with car accidents, so many different forces acting in different directions. Sometimes hard to ask for pain. What exactly happens, the patient

[00:08:53] sometimes doesn't remember exactly what happened and what position they were in and how they were they were jostled and moved. But I think this goes with any acute pain, especially with a known

[00:09:06] mechanism is always one of the areas on the side of caution, especially if there's nothing that had been done from a radiological standpoint. And if they're that acute with palpation with such light pressure or even something as simple as breathing certainly it makes sense that a

[00:09:24] rib fractury intercostal sprain, a contusion of course, a very logical explanations for those symptoms and that certainly makes sense that they would not respond to certain maneuvers interventions that would otherwise respond to just because it can you're dealing with an acute

[00:09:43] inflammatory condition you're dealing with pathological tissue and in the very early stages inflammation and healing. So it's you know even though it's not the news that the patient wanted to hear sometimes that's you know, sometimes our jobs to tell patients what they need to

[00:10:01] hear and not what they want to hear. And sometimes these patients are the harder ones to treat and this is where it's like sometimes I don't want to see patients even sometimes when it's that

[00:10:12] acute especially with a known mechanism you know what we're waking up one day with that pain or neck pain is one thing when there's no maybe known mechanism just some over-use stuff versus a trauma

[00:10:23] it's almost like you have to let kind of things settle themselves, go through the natural sort of course of healing so the natural history and then whatever remains after an expected period of

[00:10:33] time if there's things that are lasting longer than what you would expect and that's a little bit of a different story but at the same time especially in the states where you have good direct

[00:10:44] access we are going to be sort of the maybe the front line practitioners for dealing with must-go skeletal issues so we have to be able to have good differential diagnosis skills and part

[00:10:56] of our job is to ascertain is the patient that I'm seeing a might the right person that she should be seeing and whether right healthcare provider because this might be something that goes beyond

[00:11:07] my scope and I need to refer out which is basically what you end up doing and realizing that yeah there's this might be something going on here that is a little bit more serious and needs to be

[00:11:18] understood first before we go any further like you said this is putting news for her but something that will heal and something that she should be able to recover from and get back to her active lifestyle and if there's still some lingering issues after everything is healed then

[00:11:36] some of the things that you would normally do maybe some of the stuff that had worked in the past will be appropriate and then effecting at that point but always a good story and can't

[00:11:45] wait to talk to you again in person thanks for your thoughts Andrew I definitely disagree with you having less interesting cases I think you have less overall interesting cases as in less frequent

[00:12:00] but your cases are always interesting and always your insight is always welcome so if you guys like this episode have any physio failures or any cases if you're only want to share hit

[00:12:12] Andrew or I up on social media email us through the sites please hit that subscribe button on Spotify or Apple and give us a rating five stars on each we greatly appreciate it share on told to

[00:12:24] the stories with all your colleagues and friends as always you guys have a great day and a wonderful and blessed holiday season