Cameron Tudor
@camtudor
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Clinical Director @westlondonphys | Thoughts on health, pain, and injury.
🇦🇺 in London, UK
Joined August 2012
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Case study 5. Short thread. 58yo gardener. 2 year Hx of increasing left knee pain. Difficult to work, unable to squat. Pain with stairs. Waking at night. Walking tolerance of 10-15 minutes. XR/MRI confirms OA, with bilateral narrowing and extensive Gd 3/4 changes. 1/
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When patients say their pain is greater than 10/10, what they are really communicating is a fear that you won’t understand the impact it is having on their life.
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Core stability remains myth that needs debunking.
Clinicians still support a flawed philosophy (I used to be one of them) that spawned an entire industry promoting the concept of a rigid spine.
Here are 5 ideas that may change your practice. 🧵👇
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Always worth reading the great papers from the past. The simple Cloward referral patterns are often overlooked. Instead patients are often told that 'their ribs are out of place'. 🤔
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State sponsored snake oil.
The body behind NICE guidelines decides to treat patients with fairy energy from pink unicorns.
In an environment of limited resources this is shameful
@NHSEngland
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A leg length discrepancy of 1 cm is normal and doesn’t need correcting.
But if patient finds a heel lift helps their pain - for whatever reason - then let them use it. What harm is there?
Don’t let being ‘right’ be the enemy of being effective.
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Case study
#2
: 38 yo female presented with 3/12 Hx of increasing right shoulder pain. Gradual onset, nil obvious incident. Most noticeable when holding arm elevated. E.g. when hanging washing. During history she moved from describing 'pain' to describing ‘weakness’. 1/
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Case study 11: When it looks like a 🦆, swims like a 🦆, but isn’t a 🦆.
45 yo. 6/12 Hx right lat knee pain. Onset while 🚴♀️. No change with physio. GP ➡️ ortho surgeon. MRI: 'inflamed' bursa b/w ITB and lat condyle. Dx: ITBFS. Steroid no help. Referred for 2nd opinion..🧵 1/13
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Short thread: Independent Ax is important. This is me. Fell on my head 3yrs ago skiing. Acute neck pain. Pain +++ for a minute, then settled to a 3/10 soreness. Went to lunch and skied in the arvo. I developed mild right thigh symptoms. I assured myself it wasn’t too bad. 1/5
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Runner presents with 1/12 of worsening hip pain. Unwilling and unable to hop. Told previously that it’s ok to keep running with pain. Referred for imaging. Tension side NOF stress #. 🤦♂️
The fad of routinely attaching chronic pain principles to acute injuries is harmful.
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Thread. “Sensitised nervous system” and “non-specific pain” are poor descriptors of a patient’s problem for a few reasons. But mostly, because they don't align with what they feel. Patients can find it hard to understand the interplay between emotions, anxiety and pain. 1/13
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Your rib joints aren’t ‘out of place’.
➡️ Instead consider the Cloward’s referral pattern. Often overlooked.
Always check out the neck in patients with thoracic pain.
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Diagnostic nihilists fall into one of four groups.
1. Academics who don’t see patients.
2. Clinicians working in chronic pain.
3. Those who believe what is good for public policy is good for the individual.
4. Those who think we’ve reached the limit of our understanding,
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Balance declines with age and plummets as we approach 60 increasing fall and fracture risk.
➡️10% of people die within a month of hip fracture
➡️1/3 will die within a year.
Balance is easy to assess with options available (strength and balance exercise) to help mitigate the
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Most patients don’t use reason to form their beliefs. So using reason to change them isn’t likely to work. The limbic system is too dominant.
You need to engage emotionally with patients to facilitate change. It’s why rapport is so important.
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A patient who reports 11 out of 10 pain is really telling you they’re petrified that you won’t understand the impact their pain is having on them.
They’re not mad or bad with maths. They’re just scared you won’t listen.
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Case study 1. 41 yo female presents with 2/52 history of mild neck soreness, bilateral arm pain to elbow, and bilateral vague ‘wooly feeling' in feet. Previously diagnosed elsewhere – via telehealth - with ‘stress related neck pain, and sensitised nerves’. No neuro exam. 1/
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Interesting re VM:VL timing in anterior knee pain.
AKP has been my clinical specialty for 20+ years. Many of the ‘failed physio’ patients see a big ⬇️ in pain when we introduce one thing.…👀low demand VMO iso exercise 😬. Can that be done? Yes, notice how VL stays quiet.👇 1/3
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Often used to reassure patients that their MRI findings are normal and nothing to worry about. But many of these findings can also be the primary cause of their problem.
What may be reassuring to one can be dismissive to another.
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UK physio undergrads aren’t getting the clinical MSK ed they need.
Contacted by one this morning asking to shadow….because he has had NO MSK outpatient experience.
And we wonder why so many new grads leave the profession. They’re graduating very green in too many areas.
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Short thread. Non-specific pain is a poor descriptor of a patient's problem for a number of reasons. But mostly, it's because it doesn't align with what they feel. It should be used less in both he clinical and research settings. 1/5
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Short thread: On Strength and Persistent pain. Most people should be encouraged to do strength exercise, with one exception. When strength exercises are prescribed for problems unrelated to weakness; i.e. most of those with persistent pain. Why? 1/8
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Always amazed how effective manual therapy can be in the Rx of cervicogenic headache.
Patients commonly present with weeks/months history of unilateral occipital -> frontal headache and reduced upper cx rotation.
Yet, their symptoms frequently resolve after only 1 session.
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Case study: A sordid little story of anterior knee pain, manual therapy and K-tape..with consent.
60yo patient presents with 6 months of worsening anterior knee pain and swelling. Pain at rest. Worse with with stairs and rising from chairs. Unable to jog or play singles tennis
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⛷season = falls = fractures. One of the most commonly missed is a greater tuberosity fracture. They often present weeks after injury with good range and relatively mild/mod pain. Don’t be fooled. Mechanism is important.
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Regulatory sanction for "unprofessional" speak is akin to a gag order that suppresses those with loud but dissenting voices who try to shake up the status quo. Adam might rub you the wrong way, but if you're offended, it's ok to be offended.
I disagree with him on a range of
So my HCPC hearing into my ‘fitness to practice’ that’s been ongoing since 2018 due to a coordinated attempt by those who hate me the most is finally back on after being cancelled last year!
However, they are now telling me that all the previous testimonies and character
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Too many OA patients are told they've failed rehab, when in fact rehab has failed them. They often don't improve because they weren't given permission or guidance to push themselves. Not all patients will, but all should be given the chance. 13/
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Lesson 2. When clinicians sustain significant injuries, recommend they seek independent advice. We can blind ourselves with an inflated self-belief. As Richard Feynman said. ‘The first principle is that you must not fool yourself and you are the easiest person to fool.’ 5/5
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Outcome:
- 6/52 sleep was undisturbed.
- 3/12 climbing stairs pain free.
- 12/12 full function restored, and working without restriction.
- 2 years he cycled Mt Ventoux!
- 8 years later. Still cycles regularly, works out in the gym x 2/week, and still has his own knee. 12/
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Physiotwitter undermines the great learning ops otherwise available on MSK twitter.
Handful of physios engaging constructively with case studies and thoughtful insights; the others a bunch of chippy bully boys in men’s bodies.
Doesn’t seem to occur in radiology/ortho/SEM..why?
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Pathologising natural body asymmetries in those without pain is one step from selling them snake oil.
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👇 Fatty atrophy of lumbar multifidus
Atrophy of the quads in an OA knee ➡️ resistance training.
Yet for those with CLBP, and extensor weakness +/- atrophy it's rare to see patients who have been given extensor resistance training.
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In patients with knee OA, steroid 💉 can be appropriate in the right patient at the right time for the right reasons.
Clinical judgement and shared decision making instead of absolutes.
The debate article below highlights the nuance.
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Arguing that an MSK diagnosis is unnecessary - because the outcome doesn’t change - misses the point.
Humans are largely irrational.
For many, knowing what’s wrong satisfies an emotional need that can’t be satisfied by rational explanations that they don’t need to know.
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Ralph Cloward did some pioneering work in the 50's.
Always worth excluding the neck as a source of persistent thoracic symptoms. The cloward's referral pattern is common. 1/2
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5. Patients respond better to graded exposure of movement they find painful or are fearful of. Core exercises may still be useful here; but likely for exposing to movement than strengthening any core. We shouldn't demonise normal movement. Bending with a flexed spine is ok. 6/6
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Blood flow restriction training is a clumsy solution to marginal problems.
Like Pilates, Swiss balls, and lumbar rolls it is over-prescribed therapeutic paraphernalia.
Has its uses, just not that many of them.
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Significant degenerative change can exist in ‘quiet’ joints without pain.
(By definition ‘arthritis’ requires presence of pain/inflammation)
X-ray taken to exclude injury from a fall.
Besides the odd ache in the past the pt is largely asymptomatic and active.
Keep moving.
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Lesson 1. Be very suspicious of high speed or high force injuries. Investigate them. With traumatic mechanisms, discount the symptoms being reported. There is often less pain than you'd expect. Mechanism, mechanism, mechanism. 4/5
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This is complete nonsense. The professional scope of an MSK physio is to assess, diagnose, triage and manage (and refer as appropriate) non-traumatic MSK pain….I’d happily have you sit in clinic or provide you with some CPD to help develop your understanding.
@KyleRoys
@DrCarolineMWF
@rcgp
The only time I feel physiotherapists can be first contact is if there is a very clear history of injury - e.g. if a patient twisted their ankle
For undiagnosed & first presentations of pain e.g hip pain, shoulder pain etc they should all be triaged by a doctor first as there
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It's generally held that the ITB ‘rubs over' or compresses the lateral condyle at 30° flexion.
But for some it occurs at increased flexion ranges. This variation may be a reason why some have pain with running but not cycling. And vice versa. 👇👇
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Fracture myth buster
#1
. 👇
➡️ Being able to move an injured joint or wiggle your fingers, does nothing to exclude fracture as the injury.
Pt presented 7 weeks after fall. Mild wrist soreness and stiffness since. XR ➡️ impacted distal radius fracture.
Rule of thumb: Fall +
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3. Cycling: He bought an exercise bike. Cycled for 20-30 minutes. Every. Single. Day. Good evidence that lubricant secreting cells in synovial joints respond well to cyclical movement. But also a great exercise for restoring belief in the legs, and modulating his knee pain. 8/
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1. Consciously ‘contracting your core’ before movement is not how we work. Subconscious postural reflexes occur in anticipation of external force or movement. We can't consciously recruit with correct timing or force. To attempt to do so can cause more problems than it solves. 2/
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Patients suffering OA are too often coddled (like many other age related problems); advised to take it easy, with fear avoidance behaviours imposed upon them. This isn’t the way. Some will need TKR, but many can delay or avoid completely with comprehensive rehab. 14/
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3. Neurological symptoms require a neurological exam.
4. Telehealth consults have their limitations. End.
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There are two types of people.
1. Those who are aware that the available knowledge base is incomplete, so blend it, best they can, with their experience.
2. Those who think an obscure research abstract represents the full spectrum of wisdom, and promote it with certainty.
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Marathon season and hip pain.
Simple rule for avoiding catastrophe:
👉 if hopping reproduces hip/groin pain, assume bone stress injury until proven otherwise.
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On group classes; much needed in public health. But generic classes aren't enough. They need to be individualised.
@DrChrisBarton
and the team at my old stomping ground LaTrobe are doing great work with individualised group care via the
@GLAD_Australia
program. Check them out. /
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Telling injured kids to rest from their sport to recover, usually means you’re taking away their social life and away from the thing that builds their self-esteem.
Make an effort to speak to coaches to see how they can stay involved.
Treat the kid, not just the injury.
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Insights: 1. Be an advocate for patients. Safety net them. Particularly those who are falling through cracks or incompetencies in the system. I give my number to patients I’m concerned about. They don’t tend to use it unless they need to. But it’s an invaluable saftey net. 6/
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Missed one of these early in my career; Misdiagnosed as a groin strain🤦♂️. Any kid with sudden onset groin/hip pain/pop while kicking or sprinting is an avulsion until proven otherwise. Need imaging. 👇🏻👇🏻
With consent
15 yo footballer - power kick & pop / pain in groin
POCUS great for dynamic assessment of apophyseal (growth plate) injuries
Image shows subtle avulsion of fragmented RF direct head apophysis at AIIS
Don’t forget indirect head - intact here
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Is a public health service (NHS) aiming to replace its MSK physio workforce with software (AI physio)? They’ve started the trial.
Here’s how they’re doing it in 7 steps….🧵👇 1/
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Any failures from you? I’ll start. I Dx a 28yof with calf pain post flight with a calf strain. I was naive so sent her home with a stretch. She had a massive PE.
Most post cases here to help others. Others don’t for fear of being shamed. You’ve much to offer. Why not post one?
Don't be silly. This is twitter. You will only hear about success stories. We see a lot about diagnosis but much less on outcome. Creating the illusion of success.
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A real clinician who deals with real people in the real world. The sniping from the academic purists can take a toll on good clinicians who put in a shift each day and still use their spare time to help others be better. The best still get battle weary.👇
@suzy_speirs
@GatesPhysio
Yeah, I've sort of lost interest in being generous with my time & dropping my priority work to help others where I can on Twitter since being shown zero respect from the 'pillars' of the physio world.
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Endometriosis was once thought to be imagined by mad and ‘hysterical’ women. Some were treated with straightjackets.
Medicine has a long history of assigning blame to our brain (emotions, stress, etc) when the actual cause remains unknown. 🧵 1/
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If your patient is habitually inactive it's unlikely they'll perform your efficacious exercise program.
It's ok to be more effective using less efficacious interventions.
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4. Evidence is lacking of a relationship between strength and chronic lower back pain. In other words, even if we could reliably define and detect ‘core weakness’ we cannot predict whether that person will have back pain. So why would we prescribe it in folks with CLBP? 5/
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3. The spine stiffens against external force when movement isn’t desirable and facilitates motion when it is. The spine is designed to move; with agility, not rigidity. Retrain movement, not muscle. 4/
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2. Understand specificity principles. When we practice tennis we get better at tennis. When we ‘pull in our core’ we get better at that. There is no evidence of carry over into other tasks. Balancing on a Swiss ball to improve running is likely a waste of time. 3/
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Physio input remains underutilised.
Physios are best placed to manage and triage most mild/moderate MSK issues.
Not with passive ‘therapy’ but by imparting knowledge to patients, guiding them with supported self management, and sign posting when they need onward referral.
Physiotherapy drastically reduces surgery waitlists. Trial showing surgery wait times can be reduced by 75 percent to go nationwide next year.
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Liz works hard to develop her area of interest, then busts a gut to translate it in a way that is useful & interesting to others. It takes character to do that, and the best some can do is criticise her efforts for not teaching something new. Don’t be part of the problem mate.
@lizbayleyphysio
@KarimKhan_IMHA
People didn’t think to strengthen the foot-shank complex for ankle instability 15 years ago? Again, nothing new here
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Not a single relocating 🇦🇺🦘or 🇳🇿applicant for our current physio vacancy. First time in 15 years.
Biggest jump is in applicants coming from the NHS who are disillusioned that they can no longer provide the care they think patients need.
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Time to move on from the circular arguments of manual v exercise & over v under diagnosis? Good clinicians apply whichever tools are appropriate to the individual in front of them.
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Patients with low bone density are often coddled and told to avoid lifting.
Fearful of load they slowly lose strength before one day suffering a fracture as they sit in a chair.
Supervised loading, lifting and resistance training are part of the treatment, not the things to
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5. Specific signs – frank weakness, swelling, loss of movement, etc - usually have specific causes. Endeavour to uncover them. Contrary to an increasingly dominant narrative, specific problems often require specific management. End.
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6. Strengthening: *Controversially* we used open chain resistance.🤯.an exercise demonised like few others. But they can be invaluable in patients with atrophied quads who struggle with WB load. Used sensibly they’re fine, and offer a step to heavier WB load. 11/
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@marklaslett_NZ
@AdamMeakins
That argument doesn’t quite hold….So many patients with knee pain are aggravated by walking…that doesn’t make walking the underlying cause of the problem.
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Allowing knee effusions to settle post op/injury is far more important than pushing load bearing strength.
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2. When we're busy or unsure of the diagnosis, don’t jump for the non-structural/non specific label too quickly. When a presentation just doesn’t feel right, trust your intuition. 7/
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The resolution that will work for most 👇
Forget the 1%: ice baths, detox’s, supplements, wearables.
Focus on the 99%:
- lift weights 1-2 weekly.
- do some cardio exercise🚶 🏃 🚴♀️ a few times/week
- meet friends and laugh.
- don’t eat rubbish.
Don’t complicate the simple.
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@GregLehman
You’re meant to be an educator Greg. You know the work that goes into it. Liz put herself out there and you tried to clip her wings, questioning why she needs to keep up with research etc. I’m no white knight, but I’m happy to tell an MSK bro when he’s being a prick.
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What did we do? Five key pillars.
1. Educate. In detail. To succeed, patients with moderate/advanced knee OA need to embark on a fairly demanding rehab program. So they need to understand their condition and the reasoning behind everything they'll be doing. 6/
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The key to a good clinical career? Build an interesting personal life.
Most clinical work is 90% routine, 10% wtf is this!? Or as a surgeon friend says, 90% boredom, 10% panic.
The more interesting your personal life, the more fulfilling you’ll find your professional life.
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@AsafKlaf
@JaredPowell12
While that’s my bias, those able to incorporate that amount of regular exercise into their diary will likely be in a higher socioeconomic bracket and have less occupational stress.
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The path to patient self management usually requires repeat contact with clinicians over time.
It is not seeing them once to hand them a sheet of exercises, tell them structures don’t cause pain, or that imaging won’t show it.
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2. Medication: 1/12 course of Naproxen. Oddly, had not tried NSAID’s previously. Immediately helped his night pain. Sleep is important for many reasons, but it’s particularly important during intensive rehab, and can help break a pain cycle. 7/
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2. It's important to adopt ‘fresh eyes’ with patients you know well, but who present with new problems. 8/
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MSK trends, by decade.👇
80’s: ultrasound & frictions
90’s: lumbar rolls & extensions
00’s: Swiss balls & eccentrics
10’s: Pilates & pain ed
20’s: deadlifts & K-tape
Did they help, or were they useless?
The answer is yes.
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@PeteOSullivanPT
@MarkHancockPT
@jpcaneiro
@kieranosull
@JanHartvigsen
@MaryOKeeffe007
@AdamMeakins
@apaphysio
@WimDankaerts
@kjartanfersum
@CGMMaher
Great work. Hopefully undergrad medical/physio programs integrate it into their curriculum rather than leave it for the post grad CPD circuit.
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Why do patients pursue treatments that “don’t work”?
Consider which statement is more persuasive.
1. Busy Physio/Dr: “there is no evidence that X helps pain.”
2. Patients trusted friend/relative. “X cured my pain”.
Stories from those we trust influence us more than stats.
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When you first meet a patient…
- smile, introduce yourself.
- ask them how you can help.
- don’t interrupt them.
That will better build rapport more than everything else combined.
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4. Restore extension: poor extension = poor result. We used *manual therapy* to help. 😬. Twice/week. 😬🤯. For 6 weeks..FFD’s can be hard to change, so he was pushed pretty hard. Patient needs to stretch. A lot. Multiple times daily for at least 5 minutes per time. 9/
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5. The physio sessions weren’t just ‘hands-on’. Also a combination of coaching and motivation. It’s important for patients to see incremental ‘wins’ to help sustain them through a long rehab. In the initial stages progress can be slow, so in person sessions are invaluable. 10/
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3. Allow patients to talk openly without interruption. Where able, avoid priming patients with your own words. I initially asked about pain. It was only after speaking freely herself that she referred to weakness. 9/
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We are at the foothills of our understanding.
Sometimes it’s ok to simply say ‘I don’t know’ rather than assign a label that means everything and nothing; a label often helpful to health systems and clinicians but less so to patients.
Keep looking. 4/4
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In MSK clinical practice, imperfect clinicians integrate imperfect knowledge with imperfect patients. We use evidence to inform us, but our assessment of patients can be iterative over weeks; trial and error is a big part of that. For young clinicians it’s ok to try things out.
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The graft isn't ready. ACLR patients can look ready, but the risk of re-rupture (even when passing clinical tests) is simply too high at 6/12 for return to high pivot sports. With a previous fail and meniscal repair the risk benefit isn't favourable. Thoughts?
@DanBockmannDC
My 17-yo patient in white jersey, 6 mos post-op ACL reconstruction + complex meniscus tear...after previous failed reconstruction.
3 rehab sessions with us, released & beating guys down the field 💪
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Management reasoning:
1. There is frank and unexplained weakness. If we don’t know the cause, don’t muck about. Patient must be investigated. It’s rare (I've never seen one in 25 years) to see insidious and pain free cuff tears in middle age. 7/
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4. There are many instances where 'Chronic pain' can respond quickly if the underlying cause is correctly identified. Symptom duration is not sufficient to label a condition chronic. End.
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Patients struggle with onerous rehab if they need motivation.
Most people lack the discipline needed to be consistent, so design programs that are short and simple to perform.
Perfection is the enemy of good enough.
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Always worth reading the thoughts of those who came before us. Maitland was under recognised for his teaching on communication and critical thinking. 👇
Better to learn how to communicate before learning how to K-tape.
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The docs heard the same story I’d told myself. And yet they immediately gave me a full spine CT/MRI, confirming 4 fractures from C7-T3. One was concerning. Immobilised for 6 weeks in a Miami J, yet lucky. My stubbornness and elevated self-belief almost led to a poor outcome. 3/5
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4. Keep psychosocial factors in mind, but don’t reach for them too early in the process of coming to a diagnosis. Particularly in those already living with a label of Chronic Pain. 10/
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2. When the history doesn’t align with your provisional diagnosis, revisit your diagnosis. Patients often tell you the diagnosis only for an examination red herring to confuse us. Always return to your subjective exam to ensure it aligns with your exam findings. 11/
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@GregLehman
@das_shield
It does both. It stiffens against external force when movement isn’t desirable, and facilitates motion when it is.
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3. Did we uncover the underlying likely structural cause in the lumbar spine? No. Does it matter? So long as symptoms resolve...No. 12/
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@Retlouping
The McKenzie approach is a self correcting model. Don’t see why controversial.
At its simplest: Does this help? Yes. Do more of it.
Does this make it worse? Yes. Don’t do it.
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