All Posts tagged Cert. MDT

Tough chronic hip pain: Explained and resolved

By 07 Aug, 2025 Exercise, Physical Therapy Tips, Uncategorized , , ,

The case study I would like to share with you today is only the second hip derangement of this type that I have seen.  “Jim” was a 55 year old male who presented with right hip pain that started for no apparent reason 5-6 months prior to coming to physical therapy.  He said the pain was provoked only when he was walking, but it occurred consistently at a distance of about 50 to 100 yards.  Often it was so painful he could not continue walking.  Jim figured out that changing his right foot position enabled him to walk a little further, albeit slowly, and then he could resume normal walking for another 50 yards or so.  He would change the foot position by stepping partway onto a curb or raised ground such that the outer edge of his foot was tilted up (eversion, as we therapists call it), and then he would angle his right knee inwardly.  That was the only way he had found to improve walking, but the hip just would not stay better.

In desperation, Jim said he had looked online and tried numerous “hip exercises” without any relief.  He consulted his doctor, who recommended MDT, which we do here at Nick Rinard Physical Therapy.

Assessment

The mechanical assessment was positive for only two findings:  limited and painful hip motion into flexion (folding the knee to chest), and weak and painful testing of hamstring resistance.  The protocol for ruling out a joint derangement is to repeat motions to determine if the baselines change.  The question is which motion to repeat.  One can move either into the most painful direction, go the opposite direction, or check rotations.  I chose to go into the most painful direction, in this case, flexion.  But before testing I wanted to establish how far Jim could walk in the clinic before his pain started.  By the time he walked one length of the hallway and back, he reported pain.  I then instructed Jim to bend his knee to chest (compressing the groin) repeatedly and after 20 to 30 times.  It produced his familiar pain initially, then the pain abolished and his motion increased.  I tested walking after that and Jim said there was no pain even after walking 3 lengths up and back through the hallway!  I gave Jim his exercises and scheduled him for 2 days later.

Progress

When Jim returned he reported that he could walk longer distances without the pain starting, however, he still got to the point where he had to modify his foot position in order to continue.  I knew we were on the right track, and the next step in treating a joint derangement is to progress forces.  I did this manually by applying over-pressure, and instructed Jim to do it in standing by folding his chest down to his knee with it supported on a bench or chair.  By the next visit, Jim reported that this had worked very well and he had not experienced any pain at all!  So, the derangement was reduced and I needed to wean him off the home exercises to see if it would return or not.  I gave him the weaning program and asked to see him back in 2 weeks.

Pain Free

After 2 weeks, Jim came back reporting that he had been able to walk unlimited distances!  He resumed walking his dog, going on walks for exercise, and walking wherever, and whenever he wanted.  He reported his longest walk lasted 4.5 hours.  He said there was no return of the original hip pain from which he had suffered for months.  However, on his last two walks, he had started noticing a new hip pain, this time in the front, not on the sides.  I re-checked his baselines and neither flexion motion nor resisted hamstrings were painful.  That meant it could not be a re-derangement.  Resisted hip flexion was painful, and that was new.  I concluded that his sudden ability to walk pain-free resulted in his over-doing it.  Jim had increased walking too fast and gotten a minor tendonitis.  That was easy to treat, and by his next visit, Jim was pain-free again and able to progress walking, though this time more gradually, which was safer.

Successful Treatment

Jim’s hip treatment was obviously a success.  It took only 4 visits.  This hip derangement was unique because the direction that reduced it (flexion); I have only seen one other hip derangement require flexion to reduce it.  The fact that Jim resumed normal activity too fast is typical of reduced derangements – the patient feels so good that they over do it.  Luckily in Jim’s case, we found the new problem and fixed it just as fast as we found and fixed his chronic hip pain.

More

What is the role of x-ray and MRI in physical therapy?

By 20 Apr, 2017 Physical Therapy Tips , , , , , , , , ,

Nick Rinard MPT Cert MDT Owner of Nick Rinard Physical Therapy“Should I get an x-ray or MRI before physical therapy?” This is a common question, and the answer is – NO. Why not? I hope to clarify that in this article, and give you a convincing reason to try physical therapy first.

First, physical therapists can make an accurate clinical diagnosis that will most likely match the radiological diagnosis. A 2005 study published in the Journal of Orthopedic and Sports Physical Therapy compared the agreement between what the physical therapist thought the imaging would show, and what doctors thought the imaging would show. “Clinical Diagnostic Accuracy and Magnetic Resonance Imaging of Patients Referred by Physical Therapists, Orthopedic Surgeons, and Non-orthopedic providers.” Physical therapists could predict the correct imaging diagnosis 74.5% of the time! That’s almost as accurate as orthopedic surgeons, and over twice as good as general practitioners!

  • Physical Therapists = 74.5% (108/145)
  • Orthopedic Surgeons = 80.8% (139/172)
  • Non-orthopedic = 35.4% (86/243)

So, only in a small number of cases, will you need an x-ray or MRI to help determine your condition if it cannot be determined clinically.

False positives

Second, there are a lot of “false positive” findings associated with imaging. A false positive is when the test (radiologic image) shows you have the disease or condition, when you actually don’t. Some of you readers may know of people who were freaked out by a “finding” on their mammogram that turned out (luckily) to not be cancer. How often does this happen in the joints or spine that a physical therapist treats? If you are talking about the neck, quite a lot of people with NO NECK PAIN have a “major finding” on MRI. It is broken down below. (From The Journal of Bone and Joint Surgery 1990 “Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation”)

For people less than 40 years old:

  • Major abnormality in 14%
  • Herniated disc = 10% (of subjects)
  • Foraminal stenosis = 4%
  • No “major” bulging discs were seen
  • Narrowed disc space / degenerated discs = 25%
  • Cord abnormalities = 9%

For people older than 40 years:

  • Major abnormality in 28%
  • Herniated disc = 5%
  • Foraminal stenosis = 20%
  • Only 1 subject “major” bulging disc was seen
  • Narrowed disc space / degenerated discs = 57%
  • Cord abnormalities = 1%

Remember, these are findings in people with NO NECK PAIN. If you have neck pain, there is a good chance that you might have one of these findings, but it would not be the source of your pain. The study authors conclude: “The prevalence of cervical spine pathology in asymptomatic (pain free) individuals of a wide-range of ages, points out the danger in ordering surgery or invasive procedures, or even giving the patient an ominous-sounding diagnosis, without first correlating these MRI findings with clinical signs and symptoms.”

Imaging the lumbar spine can also lead to errors as there is even greater incidence of false positive MRI findings in asymptomatic subjects in the lower back as compared to the neck…

“Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.” J Bone Joint Surg Am. 1990

  • 33% had a “substantial” abnormality

60 years old:

  • 36% had a disc herniation
  • 21% had spinal stenosis

Accurate Diagnosis with your Physical Therapist

If you are still reading this article, then you must be interested in getting an accurate diagnosis of your problem, and you might think a physical therapist could be the one person who can do that. You would be right. Plus, a physical therapist will offer you treatment for your condition, not surgery or drugs. I have been convinced beyond a doubt in my 20 plus years of practice that one should start with a good physical therapy evaluation and possibly treatment before turning to x-ray or MRI. A good physical therapist knows when the clinical diagnosis is complete and correct and when imaging is needed to help fill in the blanks. Don’t get an x-ray or MRI first. It might point you in the wrong direction and bias the clinician trying to arrive at the correct diagnosis and treatment. If you truly need imaging, your physical therapist at Nick Rinard Physical Therapy can help guide you in that decision.

More