Nick Ilić
@NickIlic_Physio
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Musculoskeletal Clinician and Physio. I see 🐂💩 in healthcare and try not to get 😡, so I ✍️ evidence informed blogs:
Ngunnawal Land - Canberra ACT
Joined January 2011
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⭐ Blogpost
#36
: Take-off to Touchdown: A Pilot’s Checklist for the Clinician on the Management of Neck and Low Back Pain.
🛫A Checklist for the Clinician to take-off and cruise to better outcomes with back and neck pain patients, with a safe landing.🛬
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@ilove_aviation
Ahh yes, it's the midday flypast in Brisbane.
Since the big clock collapsed in 1952, the Royal Australian Air Force conducts this flyby to help workers in the city know to take their lunch break.
At 4pm, they release the crocodiles into the Brisbane River. That's Knockoff.
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My big tip for Clinicians who've been out for 2 years is to re-read and understand the difference in diagnosis and management of spinal:
Somatic Pain
Radicular Pain
Radiculopathy
Particularly if you've been unsatisfied your outcomes in patients with neck and back pain. /1
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Dear Tendons,
Thank you so much for producing focal areas of pain. It is very helpful in diagnostics.
Dear Nerves/Joints/Cartilage,
Be more like tendons. I love you but you have so much potential, particularly you nerves... so much (action) potentials.
Regards,
Clinician
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The concept of muscle "knots" gets my goat. 🐐
A "knot" is an area of localised sensitivity that the PATIENT feels. It's subjective.
A "knot" 🥨 (soft-tissue) looks the same under the microscope(biopsy) as a non-knot 🥖 (adjacent soft-tissue).
🧵 /1
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My thoughts on management of Patellofemoral Pain for the 'typical' patient (no trauma/instability/dysplasia).
A management and rehab pathway that is evidence-based yet as simple as possible giving me good results with my PFP patients.
/1
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Before considering telling a young uni student with insidious onset, unilateral mid back pain "your rib is out and rubbing against your spine", perhaps rule out Cervical Spine referred pain into the mid back.
/1
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Super easy to rule out too.
Yet "Tennis Elbow" is too often used as an umbrella term for any pain in region of the posterolateral elbow, incl posterior elbow impingement and cervical spine radicular pain - two of the most commonly missed conditions mislabeled as Tennis Elbow.
Orthopedic Truths:
Tennis Elbow
Stupid name
Most people who have it don't play tennis.
Nearly every person will get it.
The most common cause of lateral elbow/upper forearm pain.
It will resolve almost everyone on its own.
Without "treatment".
But it might take 6-12
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@ilove_aviation
To clarify, the "Knock-off Crocs" (as they're locally known) have had their teeth removed and can only firmly pinch swimmers in the bum, no locals or reptilians are harmed, except for riverside Drop Bears who miss tourists & inadvertently end up in the river & get swallowed whole
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Pictorial Essay on Rotator Cuff Interval:
If you like pretty pictures, and you like shoulder anatomy, and especially if you'd like to know about the Rotator (Cuff) Interval, then check this sexy article out:
Many nice ultrasound pics there as well.
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#Meniscus
Tears: I like the "blister vs callous" metaphor to explain joint surface injuries, such as meniscus or cartilage years.
Ideally over time we 'callous' the joint surfaces to gradual and progressive load (conditioning). Every now and then we get a 'blister' (injury). /1
Very good "medical googling" on
#Djokovic
injury by
@CWhitakerSport
on
@TennisPodcast
.
Meniscus tears are quite common, often don't need surgery in the 35+yr cohort, many found on MRI are older injuries.
What matters is the type/ location and if there is ongoing instability.
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I'll keep banging this 🥁.
If someone has vague (difficult to pinpoint) and unreliable (position changes) elbow pain, and it's worse AFTER activity rather than during:
Consider the Cervical Spine > Tennis/Golfers Elbow.
Elbow stuff is easy to rule out.
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Anterior knee pain that looks like Patellofemoral Pain but it isn't:
Pain with extension over pressure
Pain with Standing, sitting is fine
No pain with step up
No pain with knee extension testing
It's Hoffas Fat Pad Inflammation until proven otherwise.
Often mistaken for PFP.
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Have had a few of these lately:
Hip Joint Referred Pain prev mistaken as ITB Syndrome.
DIFFUSE* (not focal) lateral superior knee pain, NOT* just during running, NO DIFF* with downhill vs up hill running, not HIGHLY* irritable on palpation, in presence of local hip "tightness".
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Thanks
@thomas_jesson
for this IVD gem-analogy:
"a herniation is like putting chilli powder on your fingertip and poking, or even just touching, your eye. The contact is important, and more pressure is surely not desirable, but the pain is mostly caused by chemical irritation."
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BREAKING:
Canberra Bubble proven to insufficient as multiple icy missiles hit the Capital.
#hailstorm
#CanberraStorm
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/1 Nice review in March 24 issue of
@PhysioNetwork
by
@iangattphysio
.
"TFCC tear" is one of those well known therefore oft diagnosed injs.
My local hand Doc agrees:
MRI looks like one thing, then a scope finds another.
LT lig tears can masquerade like a TFCC, & ViceVersa.
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"Nothing helps Lateral Elbow Tendinopathy/Tennis Elbow" is doing the rounds again.
For many, Physiotherapy does help, but perhaps not the old "eccentrics" or "stretches".
My thoughts on the management of Lateral Elbow Tendinopathy/
#tenniselbow
here:
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It's amazing how often:
"Go get some Physio"
when said by another healthcare provider can often be a Synonym for:
"I have no idea what is wrong with your or what to do about it, I hope the Physio does"
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#AgedCare
staff levels are in such dire straits in this country when the wife of a disabled resident who is left in his bed until Noon (⬆️ing risk of pressure wounds, respiratory decline & more) complains to CEO, who can only 🤷♀️& personally go help her get her husband out of bed.
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Two patient guides I've published this week at
1 . Frozen Shoulder
2. The Shoulder in Mid-Life Crisis
My multi-disciplinary 'diagnostic and management pathway' for mid-life gradual onset shoulder pain.
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About 7 years ago I shifted my management of Patellofemoral Pain (PFP) from focusing on interventions based on frontal plane Patellar Forces to interventions based on sagittal plane Patellar Forces.
My thoughts on management of PFP here:
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"Tennis Elbow" is right up there as one of the most misdiagnosed and mistreated (⛔️cortisone) conditions in Musculoskeletal Medicine.
Especially as many are not tendon-related but ulnohumeral joint, radial nerve and sometimes cervical spine related.
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If a New Grad Clinician (GP, Physio etc,) asked me "What's the most important thing about managing 'Shoulder' Pain?"
iIt would be:
Pay attention to where the patient indicates where their "shoulder pain" is!
Know the diff between Glenohumeral Joint and C-Spine referral patterns.
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@Leo_Puglisi6
His op report mentioned only a minor complication, Surgeon was suturing up his knee surgical wounds however also decided to include closure of quite a large hole on the patients face that had a history of discharging infectious, pus-filled dribble.
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😍𝒴𝑜𝓊 𝒸𝒶𝓊𝑔𝒽𝓉 𝓂𝓎 𝑒𝓎𝑒 𝓌𝒾𝓉𝒽:
ꜱᴘɪɴᴀʟ ᴍᴏᴛᴏʀ ᴍᴀᴘᴘɪɴɢ
😻𝒴𝑜𝓊 𝒽𝒶𝒹 𝓂𝑒 𝓌𝒾𝓉𝒽:
𝚙𝚛𝚎𝚝𝚝𝚢 𝚙𝚒𝚌𝚝𝚞𝚛𝚎𝚜
Great article to reference when dealing with Lumbar Spine Radiculopathies causing significant motor dysfunction.
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@JohnIsner
Hi John,
Please provide reference to this "right", citing current Federal Australian Law.
Regards,
Australian Citizen, Resident and Healthcare Worker.
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@ActualMafia
@BadMedicalTakes
PerCentage = Per Hundred
31 males out of 100 males...
and 65 females out of 100 females wash their hands.
So 96 out of 200 people (100 males and 100 females)
48%.
Not even half.
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Q: What walks and talks like a Lumbar Spine or Hip Joint referral but isn't a Lumbar Spine Referral or a Hip Joint Referral?
A: An Sacroiliac Joint referral.
"It's never the SIJ", until it is.
If you're lucky, you'll catch the SIJ on hip plain XR.
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/1
I see many “wobbly shoulders” in clinical practice, usually "torn loose" from traumatic injuries like dislocations.
I'm going to share my insights from
@ElaineWilmore
et al. (2024) on Arthroscopic Shoulder Stabilisation Surgery (ASSS), with some of my fav shoulder experts.🧵
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If a 13-14yo tennis player presents with heel pain, think Calcaneal Apophysisitis (aka Severs Disease) before uttering the words "Plantar Fasciitis".
If you do think it's PF in a child, contact the nearest prestigious research journal for this v.rare case of paediatric PF.
🤦♂️🤦♂️
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💤Boring Diagnoses with Boring Management mistaken for 👠Sexy Diagnoses with Sexy Treatment:
❌Piriformis Syndrome ✅Hip Joint Referred (P)ain | Lumbar Spine Referred P| Proximal Hamstring Tendinopathy
❌Tennis Elbow ✅Cervical Spine Radicular P | Posterior Elbow Impingement /1
Have had a few of these lately:
Hip Joint Referred Pain prev mistaken as ITB Syndrome.
DIFFUSE* (not focal) lateral superior knee pain, NOT* just during running, NO DIFF* with downhill vs up hill running, not HIGHLY* irritable on palpation, in presence of local hip "tightness".
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My VERY laymans diagram on mechanism of tendinopathy, missing 99% of the complex chemical interactions, however quite a nice narrative for patients to understand what's happening at a micro-level, why they hurt, and why LOADing tendons may help.
Feel free to steal and bastardise
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🚨If you treat backs, know your hips.🚨
Had a "LBP Disc" patient which turned out to be hip joint pain referral from posterior acetabular deficiency (seen on past XR).
Thanks to
@alisongrimaldi
for knowledge sharing. Highly recommend her courses.
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Am I missing something?
What kind of knee meniscus surgery gives a patient in their late 30s the ability to return to tennis and a Wimbledon final within weeks?
Must be some sort of new technique that is yet to trickle down to the rest of us mortals.
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Two most common errors I see in the management of patellofemoral pain and "strengthening of quads":
1) Loading up cranky PF joints - they're pain-inhibited, not weak. Calm them down first.
2) Underloading PFP joints - 3x10 body weight squats every day is not enough. /1
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It takes thousands of patients as a healthcare professional to realise:
- You never "fix" anyone.
- You can probably help most patients.
- There's others who can help when you can't.
- Some patients don't get 100% and that's not your fault, it's reality, but you can still help
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I've had quite the week of a HIGHLY irritable anterior knee, I can see why past Fat Pad Inflammation patients have gone to ED/A&E, the pain was 10/10.
Mech: Kneeling on pavement
(ironically to help my dog who was limping and I was investigating its paw).
Almost 100% now.
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There are more things that Tennis Elbow and Golfers Elbow happening at the elbow.
It's very easy to spot something else happening, TE and GE both cause focal/well localised pain. Other stuff spreads elsewhere.
Have a Differential Diagnosis Hat on, especially with 2nd opinions.
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@drmiketodorovic
You think THAT is bad, someone did Cupping on this one
(ok that's enough jokes, back to work Nick)
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Dear Ultrasound Referrers:
NOT ALL THICKENED BURSAS ARE "BURSITIS"
NOT ALL THICKENED BURSAS ARE "BURSITIS"
NOT ALL THICKENED BURSAS ARE "BURSITIS"
NOT ALL THICKENED BURSAS ARE "BURSITIS"
NOT ALL THICKENED BURSAS ARE "BURSITIS"
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@cookerwatch
The "Veteran" is Glenn Agnew
Might rock up with my medals on and see if they kick up a fuss if a veteran pushes another veteran
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@pttimyyc
It helps to categorise the patients pain into
Focal Anterior: distal biceps
Focal Posterior: ulnohuneral, distal triceps, olecranon bursa
Focal Lateral: LET, RTS
Focal Medial: MET, Cubital Tunnel, UCL
Vague anywhere: Neural, referred there or local.
Not definitive,but it helps
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Seen a few of these patients lately:
Weird, vague pain at the knee in hard to locate spot
in the presence of
weird and unreliable vague pain and/or tightness at the anterior, lateral or posterior hip.
Welcome to the wonderful world of feelings referred from the hip joint.
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@LiamChong92
I had enough of it so I wrote about it, just need to put more good content out to fight the rubbish.
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I missed this one when it originally came out, holy moly... it's a fantastic read.
Authors - physio, physio, physio…🧐
I’ll just leave this here
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Patellofemoral (kneecap) joints love quads strength.
Sometimes even long-term knee extension force production deficits can take a short-time to correct and significantly increase knee extension force production.
More ideas on how to make a happy PF joint:
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@BenRothenberg
Novak vs Australia
Set 1 Goes to Novak Djokovic.
If Set 2 goes to the Australian Government, Novak will likely take an extended Bathroom Break, then return and win the 3rd set.
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🚨Jersey Finger🚨
Had one of these come in today, thought I'd put a PSA out there as it's important to 1) identify them, 2) refer them to surgery.
It's a bony avulsion or non-bony rupture of the FDP tendon which flexes the tip of the finger. "Make a fist" = finger sticks out. /1
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@JoshPughComic
I'd laugh, but I'm having difficulty activating my diaphragm without blowing up a balloon first.
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Patient: "...but what specifically is causing this pain in my back"
___
It can be a challenge to say to patients "I don't know exactly....." , and it's not a great idea to tell them "you have non-specific (area) pain".
How does you get the balance right?
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Thanks to
@TamePunk
my Brother-from-the-same-Mother
@danilic
has reached "excited Facebook friends let me know what my Brother is doing" level again.
This deserves a plug:
See
@ARationalFear
Live at the
@micomfestival
› ...
A Rational Fear - Live
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Who cares?? Well....YOU do, probably.
That's why you're in healthcare.
_______
But who cares about you? Who cares for those who care?
How do you 'Self-Care in Healthcare'?
_______
Tips on avoiding burnout for the newer private practice physios out there.
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@HandSurgeryAssn
Get consent first, they should know that any small fractures might be impacted by the attempted relocation.
Identify the direction of dislocation so central slip disruption can be monitored later.
Here's a pic of what I used to tell new physios when I was working in club rugby.
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It's surprisingly hard to explain to the public why a Physio who's great in a clinical environment at diagnosis & management/rehab of Msk conds isn't necessarily the best Professional to ask to travel interstate to an elite sporting event just to be a full time massage therapist.
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A not unexpected response from an orthopaedic surgeon, regarding the emergence of the Cross Bracing Protocol (CBP) conservatively managing some (not all) approp. ACL rupture cases & successfully so for the most part. From a country with the highest ACLR rates in the world. /1 🧵
1) A thread 🧵 about ACL Rupture: “When I get that feeling, I want… ACL Healing”
-> Inspired by Dr Kieran Richardson
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@KatieMe32017856
@virgosgrooviest
Turns out this condition (as well as many) was as prevalent before the Vax.
It's very easy to draw conclusions based on correlations that suit your biases.
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My Brother made a cooking show.
His Satire is baked to perfection.
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Anyone else starting to see a pattern?
🚨What is the most effective treatment of plantar fasciopathy?
1️⃣ Radial extracorporeal shock wave therapy (rESWT)
2️⃣ Sham-rESWT
3️⃣ Exercises + advice + customised foot orthoses
4️⃣ Advice + customised foot orthoses alone
NEW paper 🔥🔥
#OpenAccess
➡️
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@cookerwatch
Glen Agnew from Geelong.
I'm sure the
@GeelongRSL
down there will be interested to see one of its (possibly ex) members behaving so poorly.
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For those outside of
#SportsMedicine
wondering what injury
#Neymar
sustained in the
#WorldCup18
and what the spray was that helped him, Neymar sustained an Ankle Fakery Bullshitimus injury and the spray was Liquid Bullshit.
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@konstructivizm
Awww they're always so cute before they grow up and leave their extraordinarily academically gifted first wife to hook up with their first cousin.
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A simply managed condition can turn into an absolute long-term nightmare unless some very simple things are pointed out during assessment.
One of the most common errors is the miscommunication/misunderstanding around the word: "Shoulder".
More here:
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I think one of the reasons Cervical Spine referred pain is so commonly missed is because it can be completely fine on ROM and functional assessment, UNTIL it is locally and accurately palpated, which often reproduces the symptoms.
New Grads/Students rely on the ROM Ax too much.
Before considering telling a young uni student with insidious onset, unilateral mid back pain "your rib is out and rubbing against your spine", perhaps rule out Cervical Spine referred pain into the mid back.
/1
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"Which is it? Heat packs or Cold packs, that helps this injury recover faster"
A common question I get from patients with acute injuries that aren't too significant, especially athletes who are trying to get better asap.
For those, my answer is usually something like this /1 🧵
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New Blog:
🔎'When is a shoulder not a shoulder? (when it's a neck)' - why labels matter in the differential diagnosis of neck and shoulder pain.
One of those blogs that helps me sleep better at night hoping it may help one less patient get mismanaged.
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Not all Elbow pain patients feel during tennis is
#TennisElbow
* in fact, it's quite RARE for players to get Tennis Elbow from tennis, players are more likely to get Golfers Elbow or Posterior Elbow Impingement. 🧵 /1
*Lateral Elbow Tendinopathy, but 'Tennis Elbow" for brevity
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Somehow I spend a good chunk of my day working 5x harder and longer with patients who have been mismanaged by those who earn 5x more than me and spend 5x less with patients in their consults.
Something is out of whack here.
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For those who are stumped managing "tight upper traps" here is an blog which might be useful for you:
/3
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PLEASE query your MP about future commitments to wars. Be a good Australian Citizen. I feel embarrassed when "thanked" for my "service". I did sweet FA to furthering the security of my country 10,000km away. Only protected my mates next to me. Sound familiar?
#Gallipoli
#Vietnam
John Howard commited us to the war in Afghanistan in 2001. The Taliban have now won it. 41 Australians killed, 261 wounded. Unknown suicides. The cost in billions. It’d be interesting to hear Howard explain what we achieved:
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4K
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Great video by
@RunningReform
on Tendon Compression. Brilliant resource for patients when explaining why stretches may be exacerbating some conditions .
For more:
Thanks Kevin.
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Personal Trainers are now Healthcare Professionals, doing courses and applying interventions, in case you missed the memo....
🤯🙄
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@lisakeb007
@IanHall_CU
Yeah nah some of us used to believe that too... until 25milion hectares burned in the 🇦🇺 Black Summer.
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The "Get Some Physio" thing is trending again.
It's concerning when 2nd op patients almost had surgery because an ortho surg said "had physio, didn't work" when all that physio was 'heat packs, craniosacral therapy+ needling.'
Always get "different physio" b4 surgical opinion.
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@danilic
They were disbanded after evidence of Green Army war crimes came to air. Allegedly there was mistreatment and abuse towards captured carbon, which was a clear violation of the Greeneva Convention.
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Neck and Low Back Pain || MSK Cervical Spine and Lumbar Spine Referred pain.
BORING!!😴💤💤 Am I right?
Not sexy👠(like ACL injuries and tendinopathies 🤤)
But Csp/Lsp pain is very common & not easy to manage, so here's a checklist I made (+blog) to help
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I love finishing my day with back-to-back Patellofemoral Pain patients.
Here's a handy evidence-based blog that explains how we now manage kneecap-joint related pain (pain at front of knee):
(Hint: it's a little more than ITB rolling and VMO strength):
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@Martin_Nekkolai
A simple email summarising the main points of the session can be extremely valuable to some patients and help them consolidate on important concepts discussed.
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What Olympians say:
"If you believe it, you can achieve your dreams!"
What their Coaches say:
"If you believe it, have good family support, have the body for it, are coachable, have a good sports med team, have talent, have a good financial base....you might achieve your dreams"
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@PhysioTodd
I'm happy with a genuine handshake, a look in the eyes and a heartfelt thanks in person. Knick-knacks not needed. However, I want to feel like I've deserved it too, have I made a real difference to them, will they look back in 5 years and say "that guy really helped".
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@AdamMeakins
✅ look like LET.
🚫 cause LET.
✅ make LET feel worse.
Problem is there's a bunch of mangos in primary care who think "Tennis Elbow" is an umbrella term for any pain in the arm.
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