Unlocking the Mystery: Shoulder Pain, TMJ Dysfunction, Missed Spondy - WIR Episode 13

Full Transcript

0:17

All right, we're back after how many weeks break?

4 weeks. 5 weeks. 5 or 6.

I was thinking about doing seasons, but for logging purposes of people trying to find episodes, I think it's easier to just keep them rolling.

0:32

So this is episode 13 should be.

And before we get rolling, we have Daniel, Monica, myself, Sloan, Maddox, Seth and Alex in the studio audience here so they have an applause sign.

Up.

I hope that is so loud in that in that podcast.

0:50

The Woot.

Woot.

Yeah, like an alarm.

OK, let's get going.

So to start things off, I'm going to read a review from Katniss and GAIL.

Yes, yeah.

As a student halfway through Cairo school, I can't thank you guys enough.

1:07

I've been looking for the style of a podcast for a while.

I love how you talk about patient presentation, exams, your impressions, and explain how to tie MPI, MB, TDNS&DS, FM, s s, FM A, etcetera into a visit.

I like how they listed that many acronyms before the etcetera, just kind of I.

Like it Ironic.

1:23

They knew I was going to read it.

It gives us a blueprint on how to integrate all of that into a visit.

I've taken multiple seminars so far and understand the material to an extent, but I've struggled trying to piece together and actually apply it.

Please keep making more, even if you think the cases are not exciting.

Well, thank you, Katniss and GAIL.

1:39

Yeah.

Thank you, I just love those.

I know I've said that before, but I really really enjoy.

Those That's what I'm going to do for Sloan's Valentine's cards.

Is just review.

Write me a review.

I'm starting an iTunes account.

It's just random, random noises that makes for episodes and then I just write a little, you know?

1:57

That's a three.

Star episode was not good.

Besides that I wanted to give a quick little I don't know public service announcement APSA couple times in the past few weeks.

We outsource all our imaging, X-ray, MRI, CT, all that.

2:18

The reason we do that is dual fold or maybe trifold decrease their liability because medical radiologist reads it, we're supposed to read it as well.

And we're going to talk about that in a second, second.

The cost burden, right?

We don't have the equipment on somebody to do imaging things like that.

2:36

But probably the biggest thing is just like it's getting cheaper and cheaper.

There's now MRI places that are like 399.

No.

So it's going to get to the point where it doesn't make sense, I believe to have the equipment in your office.

2:52

It's just going to be like, oh, there's somebody right next door to you.

All that to be said, we sent out for more Mris and X-rays because if somebody's getting something done in here, it's probably beyond that.

They may have already had some imaging, but we've had a couple cases where what we put down as the diagnosis or you know, the perceived issue and then list that on their imaging request.

3:17

The image comes back with a clean bill or a clean slate, and then we look at the image.

Yeah, clean.

Bill of sale yeah, we look at the image and exactly what we thought was going on is going on so then we have to have a conversation with a medical radiologist to again, I'm not pointing fingers of profession but let's just talk about the fact that it's MD and everyone wants to call out that we're the dummies but what I'm trying to get to here is you better be looking at your images if you're sending stuff out and not just going off the report B.

3:46

If you don't know how to read an image right, if you're not really comfortable reading an MRI, you probably shouldn't be sending anybody for an MRI at all.

You should be referring them to an ortho neurosurgeon and let them do it.

Because then if you get an image, you go off the report and then you continue to treat all the liability that you were trying to shield yourself from now completely gets reversed.

4:05

So I don't want to go into the details on this cases just again if.

It's ironic you bring it up because it's actually part of mine.

Yeah, so there you go.

So I'm going to talk about it a little bit beyond that we're going to get in some cases.

And I'm going to let Doctor Monica because we haven't been on the podcast since she graduated from Cairo school.

4:23

So golf clap.

Yeah, wow.

The studio on it No claps.

Thanks.

Guys, so we're going to go ahead and let her throw her first case as a doctor onto the show here.

All right, it's pretty simple hopefully, but I had a 52 year old female who came in complaining of left shoulder pain.

4:44

The pain began in March with no known onset.

She said She's had it before previously, but kind of comes and goes and it came back with a vengeance in March.

Things that are provocative, lifting, reaching, taking off her bra.

This is a big thing for her.

4:59

She kept saying like I can't take off my bra, I have to have my husband help me, etcetera.

It is a little rescue.

I mean, taking taking the sports bra off is like a feat in itself.

That's an athletic feat.

So that's pretty important.

Especially post workout.

Yes, Sweaty.

5:15

Yeah.

Nothing is really palliative other than avoiding those painful movements.

She describes it as sharp but occasionally just achy and sometimes she'll feel it travel down to the mid arm.

Doesn't go to the elbow, just general mid arm.

5:30

She can't really trace it.

She reads it 7 out of 10 on the pain scale and experiences it 80% of the time.

She denies numbness and tingling, denies neck pain.

She's had Vertigo previously and occasional headaches, and I think that's about it as far as history goes.

5:51

She sees a functional medicine specialist, Doctor Sam Petrie.

Yes.

So she hit, she's on a few supplements.

Nice little regimen, yeah?

As far as exam goes, neuro was normal.

I did the SFMA top tier so everything was DN or dysfunctional.

6:08

Non painful except for upper extremity.

One on the left was painful.

So that's extension, adduction, internal rotation, same movement that you do to take off your bra and multi segmental flexion was functional.

Max foraminal compression was negative.

6:25

Weiner's cluster for verticulopathy was negative.

Movement loss was noted in cervical retraction and extension.

Passive, active and resisted.

ER and IR of the shoulder at 90° was within normal limits and non painful.

6:41

Shoulder range of motion other than ER and IR was within normal limits and all other order tests for the shoulder were negative other than empty can.

There was no tenderness to palpation of the left shoulder.

I didn't notice any hypertonicity really.

No active chair points and so we started with chin retractions to see if that was going to help the shoulder pain at all immediately.

7:05

And that showed decreased symptoms and increased her ability to get her hand behind her back in that same fashion of taking off her bra.

Nice.

I want to point out real quick, we get emails from our malpractice company explaining like situations that people got sued.

There is a doctor that a woman told him that taking her off her bra caused her pain and he said that that was a functional outcome and had her take her bra off.

7:28

So just a tip.

Yeah, you want to watch him squat, do things like that.

Somebody said, hey, I got Pingo in the bathroom.

I bet you don't watch him go to the bathroom.

So just take your functional outcomes down by notch.

That's hilarious.

OK.

Sorry about that.

Did she fall for it?

I'm guessing so if she sued him for it, that's interesting.

7:44

So yeah, where's the responsibility like?

So at this point, I'm just rolling with the ruling out cervical spine.

So we're going down the MTDMDT route of cervical spine involvement.

At this point, my working diagnosis is just somatic referred pain from the cervical spine with my functional audit being the reaching behind the back and taking off the bra.

8:05

That's her goal.

That's what we're going to work towards too, towards treatment just consisting of MDT.

So I've seen her a few times after we've been progressing forces.

I think last time I saw her, we were doing just patient over pressure, really queuing to get CT extension.

8:24

She's kind of has like a little dowager's help, which seems to be fairly common.

So we're really trying to get ACT extension.

We've been adjusting CT and just thoracic spine and extension.

And then we've been doing some DNS for a deep neck flexion and CT extension as well.

So as far as her treatment pain goes, we're just going to continue with the cervical spine until I find the reason that it may not be coming from the cervical spine and then I will look at the peripheral and see maybe is it shoulder, is it something else, but still going with the cervical spine.

8:58

So had it's impossible to say because we were still on a hypothetical end.

There really wasn't anything positive on the shoulder exam, right?

Except.

Except empty can and then I re evaluated empty can again, I think last visit and it didn't cause out any.

Pain so sensitive movement or resistive force.

9:15

So would you let's say there were more?

And again, it's hypothetical, so it's hard to say.

Let's say there were more shoulder orthopedic tests and more pain.

Would you have still went with chin attractions?

Just rule spine out.

Like even if it showed like I'm just again, hypothetical, like let's say you do like a labral scour test.

9:36

You do empty.

Can you do your descents?

All those are positive.

Are you still going after central sensitivity first?

Yes, solely because I mean especially R2P they always say like central and then go peripheral roll up the spine.

9:52

I feel like especially shoulder above the elbow like you always should realize cervical spine first.

It doesn't take very long just to do like a set of 15 inch interactions to see if it changes anything.

I'm going to say it's a super simple weed out method, right, Yeah, you I wouldn't jump to that first.

10:08

You know, I'd, I'd do all those exams and then follow up with that.

Yeah, hypothetical.

Not thinking through this positive empty can, knowing that knowing the percentage of people walking around with a super spinatus pathology, she may have like a dual cynosis there, right?

10:30

But one is perhaps sensitizing the other so.

Let's talk about that for a SEC.

Is that really a dual diagnosis?

What do you?

What do you?

What's your question there?

So she had reduced extension, What else?

10:45

Cervical spine rotation.

Retraction.

OK, Rotation spine.

So you can have a joint derangement with this, sensitizing a tissue that's already damaged.

That's what I'm saying.

So do we say?

I wouldn't.

I wouldn't, no, I wouldn't put that as another diagnosis within the ICD 10 code.

11:04

Yeah, yeah.

But then when we classically say diagnosis, that's I mean it's just conversation have like if we're talking, we're going after like that to me is like functional audit.

Then if you're like, man, what's actually like if I had to eventually, let's say that it didn't work, right, she fell out of care at six visits.

11:20

What would you then be sending her to an orthopedic with, you know what I mean?

Like what would you be relating those?

6 visits Has Monica then treated her shoulder?

Well, let's just stay on the servant like it stays the same, right?

That it's just that one positive empty can sign.

11:38

It's still, you know, pattern one and then those just stay painful.

You do all the cervical, you know, even extension gets better and everything, but the shoulder doesn't.

Like do you still say, well, I think there's cervical derangement that since tightening this because pain gets better, let's say every time I think it's worse, they just come in there like not getting better between all of those people's shoulders, right?

11:58

It's better during they come back.

It's worse.

Like do you send them with just possible rotator cuff strain sprain or do you say, Hey, I think there's a cervical component to this.

Do you send them for a cervical MRI or shoulder MRI?

Good question to ask, right, And these are hypotheticals.

12:13

But why I ask is you and again, as you went through care, you figured out like knowing what's the next step if they do fail?

That's why I'm always like, you know, just coaching us on like really be sure which you are because it's worth.

But let's say it didn't man.

12:29

If it does fail, what am I synonym for imaging for?

Who am I referring to?

If it's cervical spine, possible neurosurgeon, shorter ortho, right.

So you're already kind of having to be like, I don't know, I.

Still feel like at this point I have the option to still look at your shoulder more so I still have more options before I think about imaging.

12:47

Feel like after I did that I would have a better idea of what I would be sending them for in.

Big hypotheticals.

I was just kind of given a scenario.

How many?

Visits I.

Think it's been 3.

And I think I feel like that's around the mark where you kind of see like, yeah, at least with me, I feel like you see by that time if it's fine or if it's extremely and if.

13:07

It's appreciable, like it's lasting.

Yeah.

Cool.

Good one.

Who wants to go next, Daniel or?

Thanks.

Yeah, I'm going to.

I'm going to feed Maddox for 10 minutes and then I'll jump in with mine.

OK, yeah, so I had a man in his 50s come in two weeks before Christmas around 8 to 12 months ago.

13:32

I can't remember.

I didn't write down the exact date, but he had shoulder surgery followed by 8 weeks of PT.

He originally went to Andrews, who Andrews didn't want to operate him on on him.

They didn't want to.

13:47

They didn't think he needed it.

So we then he found a new surgeon and of course, if you look long enough, some surgeons going to operate.

So that surgeon supposedly cleaned out his shoulder even though we didn't really say what was going on.

Followed by again like I said, 8 weeks of PT.

14:05

So he comes in and sees me, no change.

So after surgery and PT still the exact same movement and pain and feeling in his shoulder.

He reports.

So my exam is of course I started with the SFMA upper extremity one and two dysfunctional, painful on the right, multi segmental flexion, extension and rotation.

14:31

I put them both all three is DN shoulder abduction.

And for me to write all of this, it kind of made me laugh here in all of Monica's how detailed she's was.

But shoulder abduction was around 75° before pain.

Flexion was maybe a little bit better, 0° of external rotation.

14:50

There was no change in pain or function going through the the McKenzie protocol nothing cervical wise orthopedic test that I was a note almost everything I took him through outside of like muscle testing for his rotator cuff was positive for his shoulder.

15:14

So like Andrew slammed tear empty can none of the biceps.

How do you do against B vitamins when you muscle tested them or thyroid medication?

Positive on all.

Oh cool.

All right.

So but yeah, basically lack of range of motion everywhere.

15:30

So I kind of left it as in I looked at him and said, hey, you've already had surgery, you've already had eight weeks PT.

Let's just see what three to four weeks of care will do.

I've seen him three times.

So I kind of gave him just a diagnosis of adhesive capsulitis, which I think it's like a catch all.

15:52

I think it's I think yes, like there's some adhesion in his capsule, but I also think that he has some like CT derangement stuff he could possibly have a little bit of a slap tear, couple other things.

So I said let's just go through and let's go through a treatment We'll we'll go from there.

16:13

So on his first treatment, we adjusted his thoracic region, which is kind of difficult when you can't really move your right arm at all.

So you just got to change it up a little bit from how you would normally go A to P if that's how you decide to adjust.

And we decided to go three month prone seated, which was really nice because we just got through having DNS here.

16:34

Shout out one Chester with Neurodynamics through my exam there.

None.

None of them were positive though his pain kind of showed auxiliary nerve distribution.

Then we did a little bit of shoulder extension just as and I'm thinking how can we move his humerus further in his capsule.

16:54

And then we did a little bit of dry needling around it through the through with a few common areas to like lat a little bit of trap and three treatments later he is in his arm.

17:09

His shoulder is roughly, roughly around 120°.

I didn't measure it before.

It brings on his pain and his pain's like one of those where like he has difficulty putting on a shirt, anything like that.

His abduction is around 110 and so we are just grooving along.

17:29

I kind of told him that I'm never going to ask him about pain and then I'm just going to keep changing his function and then we'll go from there.

And so his function keeps improving pain.

His chance helped be already minimally, but a lot more function out of it.

17:47

Let's.

Back up to exam.

So his initial flexion abduction was, would you say 7070?

5 is.

That passive or active or both active?

And then I I couldn't maybe 5 or 10° better with.

Passive passive because I was just trying to pair up that he's capsulitis thought process with like passive burst active, right?

18:08

And that was pain that stopped him on passive or just range of motion.

There was more pain, is what he reported, that stopped him.

Like if he went any higher than this, it was almost like difficulty.

Like if I went to here, it was a complete shoulder shrug everything and it's hard.

18:24

To tell sometimes because they guard so much right So what I know what you was all the stuff that you said you did in treatment was that also what he did at home like 3 month prone so.

What he did at home was three month prone.

I showed him auxiliary nerve neuro dynamics and then I told him shoulder extension and I said I just really want you to get your neck and T spine moving.

18:45

So we kind of did some seated rotations for his thoracic and seated extensions, but I thought, I don't want to get all these moving as in it's not going to hurt him.

All right, cool.

Do you want to go or?

And again, we're all going like a little bit faster with obviously patients coming in and yeah.

19:05

There was a bad accident, traffic was backed up, so we're all trying to get it done, no.

You guys are going fast because you know that I'm going to take a long.

Here we go.

So I I joked with Monica before before we started that mine really should be very quick because it doesn't include any kind of treatment.

19:21

But knowing me, it'll be long winded, so buckle up.

OK, so I had a 10 year old gymnast come in this past week and I've seen her in the past, probably about a year and a half ago at this point.

She was eight.

I guess that would make her 8 1/2 and it was for low back pain and she was a pretty one of the more entry level levels for gymnastics at this point.

19:42

So you're not a ton of training 8 years old when you tell me your back hurts, you know, it's alarming.

An 8 year old shouldn't have back pain, but at the same time, how, how serious do you take possible pathology, You know, 8 years old coming tonight.

20:02

I'm not going to automatically think this this gymnast has a Spondylo.

You know what, 813 absolutely, but not at 8.

So.

She was extremely timid.

She was to say she was terrified of me would be very accurate.

Yeah.

20:18

It was kind of a first, to be honest.

But she was just, she's been through a lot in as far as medical care goes.

She's a type 1 diabetic, so she had been kind of navigating that route in that world within healthcare and whatnot.

20:34

And so she was just intimidated by another doctor.

So it was really hard to examine her at that point.

It's pretty nonspecific, like flexion, extension, all things that I didn't hear were not painful.

But she said gymnastics was starting to make her back ache.

20:50

So, you know, getting to know her personality and with her mom, we, we decided, let's take this, you know, really easy, let's do minimal treatment.

Let's see how she responds to one or two visits before we think about pulling the trigger on an X-ray or doing something like adjustment.

So we did really little stuff.

21:05

We, we, if I remember correctly, a year and a half ago, we did some early stuff, early DNS and we did some manual therapy and she responded very fast, very quick.

And she moved on.

I have not seen her since.

So here she is 10 years old.

21:21

She has really drastically increased the amount of gymnastics that she's doing.

She went from a level 4 gymnast to a level 7.

And in the world of gymnastics, that's a very big leap and no pun intended there.

And it's all but in within the last year.

And you got to think also this year has been COVID.

21:38

So not only has it only been a year, it's been less than that because they weren't able to practice for very long.

You know, they had this big reduction in practice due to quarantine for for a while.

So she jumped 3 levels, drastic levels in in less than a year, which is a really important part of her history to take into account.

22:06

This episode of low back pain has been present for about 3 months.

She said it started with extension, so started with back walkovers, started with a standing backhand string on the beam and now it's progressed to pretty much any time that she's in the gym.

22:21

Any kind of skill that she's doing, any sort of pounding or landing is very painful.

It started as only present at the gym but now it's at home after gym.

She didn't report any kind of pain at night or and and denies any kind of radiating into either lower extremity.

22:38

She does report both sides of her back hurting a lot of times with gymnasts, I find it's one, it's unilateral, like it's only my right low back that hurts when I do a back walk over.

But she was very insistent that it was both sides.

So I knew early on that we were probably going to end this visit with an X-ray thinking that she's 10 years old sitting on an X-ray.

23:00

And I'm not, you know, not a huge fan of it, but I'm, I'm glad that we did in the in the end of this and we'll talk a little bit about kind of why I chose the X-ray.

And especially if students are listening to this, I think it's an important conversation to have.

So her exam, she everything tested normal as far as neurologic exam goes, Myotomes, dermatomes, all normal, all flexion based orthopedic tests were completely negative.

23:26

In fact, she said it felt really good to round out her lower back.

Tell her that she will.

Die if she does that, because rounding your lower back leads to her death.

She picked up her shoe actually off the ground with a rounded back and I I cringed.

I've seen.

23:45

People explore and and remember back to the year and a half ago when she was extremely timid and and very scared of me.

It's lessened, but she's still very timid with my exam.

So all of this was a little I had to kind of coerced her to do some of these positions.

So I said all flexion based orthopedics were negative.

24:02

However, any kind of extension was was not just positive, but very positive.

And and she was very emotional about this.

It hurt and she let me know.

So Stork test positive bilateral, however, worse on the right and then just a full body standing extension pattern.

24:19

You could tell she had very obvious avoidance of extension.

You know, the hips did not translate forward.

She didn't move much through her low back and it was all in her shoulders and and almost I mean, it was just not extension.

I told her to arch backward.

For a gymnast that's doing back hands and back hands around the beam, standing arch shouldn't be a big deal and she just would not do it.

24:41

We did some pro and press up just one or two on the on the table and this was extremely painful as well.

So at this point, you know, I end the exam.

I think I need to have an X-ray before I I move forward with any anything.

And because of such intensity and the emotion of the extension based back pain, I wanted to rule out a part's involvement at 10.

25:01

It just kind of kills me to think that that's what I'm ruling out.

But we needed to do it.

So before I send her off for an X-ray because like Bo said, we don't have we don't have X-ray here because we take that liability off of us and it's just we don't do it enough to justify.

25:19

So before I send her off for X-ray, we performed some breathing drills, which she did recall from a year and a half ago and then applied some just instrument assisted soft tissue just just for maybe to mitigate a little bit of pain until we receive the results.

25:35

Also, it was important to note that we discussed modifying her practice until we received results.

She's someone that's practicing every day and typical personality trait of a gymnast or maybe any athlete is that they're wanting to please like they're people pleasers and they're also stubborn as can be.

25:56

So they're going to push through pain and they don't want to disappoint parents, coaches, even if it's an even if that's, you know, self put on themselves, you know, not actual reality.

They don't want to disappoint anybody.

So they barely they rarely stop because of pain.

So it's very important to have a plan in place that they modify once they return back to practice.

26:16

So we took extension and any sort of hard landings out of play.

So I sent her off to X-ray.

X-ray report comes back before I see the image itself.

And it was completely negative, which I was so relieved by.

I'm like, oh OK, we can move on to typical care and we can get this girl out of pain and back into practice.

26:38

And before I call the parents though, I need to look at the images.

So I pull it up and within seconds you see pretty pretty blaringly obvious pars fracture.

Then I pull up the opposite side, oblique pars fracture on that side as well.

26:55

And then lateral shows a slight anterior listhesis.

So we have bilateral pars defect with a spondylolisthesis in this 10 year old.

So at this point she's out of my care.

I have to refer to ortho.

That's outside of my scope.

27:11

So she's headed to ortho.

I'm suspecting they're going to complete rest her for at least like six weeks.

A lot of the orthos in the area won't brace here, which I see eye to eye with, but then she'll return here for rehab.

So to go through this case, I really think it's important that we ask a couple questions.

27:33

Is a 10 year old presenting with this?

Is this the sport?

Is this like her coaching, her planned workouts, her training?

Or is this just a 10 year old athlete in today's age?

You know, Bo and I asked these questions to each other the other day and we've we've had similar views.

27:53

But Monica, Daniel, I wanted to get y'all's opinion on this.

Do you think you'd find this in another sport?

No.

Depends.

I think we'd find it cheerleading, yes, I think we absolutely want so.

I think every sport nowadays, with kids being little haystacks of whimpering pus, you're going to find in each sport, it has its own thing and that's just the way it is, you know?

28:21

It's it, it goes back back to just kind of our underlying health.

Are we, are we raising a generation that's not adaptable?

You can't.

Up the ante on sports and have less healthy kids than your break.

Even if you up the ante on sports with this same population, it's going to break the bubble.

28:39

And then if you have the same level of sports and unhealthy kids, it's going to go the same way.

So I it's perfect Storm again.

So it's tough to say, but yeah, I don't think it's normal whatsoever.

Yeah.

I don't think it's just gymnastics.

I do think gymnastics plays a huge role in this, but I do think that it's a generation as well.

28:57

And I did send one of my best friends, Tuscaloosa, who's probably stronger than everybody in this room combined, picture of his cousin, a picture of his cousin who couldn't even do like a a push up that was recorded.

And I said, like, are you going to allow this in your family?

And it was it was almost just like really you can't do a push up or just team that like AI don't know 1011 year old boy and you're like, that seems like the easiest thing.

29:21

Ever Well, this girl can do several, but I wanted to go back to something that I had mentioned in her history that I found really important was the fact that she jumped a a ton of levels in this in this shortened year, this abbreviated year.

And I really what, what that means is she's doing more dramatic and, and tougher skills, but she's also practicing a lot more hours during the week.

29:45

So I think we are not allowing in this sport, gymnastics and perhaps other sports as well, we're not allowing the athlete to adapt to the load that they're placing on their body.

And I think in gymnasts, you see that she can move really, really well.

Like I could put her through a movement assessment before this, before she actually achieved this pathology and she may pass it.

30:09

I'm putting air quotes up, pass it with fine colours.

But if you if you increase the workload on that body, you're going to break down somewhere.

So I think I think a lot of it has to do with just not allowing the body to adapt with enough time.

Wanted to also say this.

30:27

Both mentioned earlier that we don't do a ton of imaging here, but I find myself being one person out of the group of us that maybe images the most and I've found I just need to with gymnast.

Someone also said she's the worst power painter out of all of us.

I can't feel that fracture under my fingers.

30:45

I'm sorry.

Whatever.

OK.

But I wanted to mention, I wanted to mention an article that was posted Dan Pope.

He's a physical therapist.

He he posted an article Dan Pope.

Dan.

Pope Dan Pope, I thought you were talking.

31:02

About, so it's.

Statistic.

This was.

This was.

This was released in 2006.

So it's it's pretty old, but it says 47% of youth, which is under 18 years old, athletes with low back pain present with a spondylo spondylolysis.

What percent?

31:17

47%.

So coming coming out of our schooling, I think it was really pushed on a certain population, maybe, perhaps maybe more of our minded population that we can avoid X-rays, we can avoid imaging like we can imaging is we over image in healthcare, which I absolutely agree, But I think it's really important that we don't neglect those red signs or red flags that would indicate when to image.

31:44

You know, we had a conversation, Monica and I had a conversation this past weekend about what schooling teaches us and it's when to be a doctor.

So you can do all the great therapies and treatments in the world that make sure that you are diagnosing and being a doctor first.

32:01

OK, there's my I'm stepping off my Andre.

Agassi's autobiography Open and I didn't realize he had a congenital spondyloisthesis and like dealt with it.

And then that's why you're retired when he was 36.

So you woke up every day and like had to spend like 2 hours just getting moving well.

32:17

That's another thing, another thing, I mean, this could be congenital on her part too, but say, I would have went straight for the adjustment because she's 10 and she doesn't have any pathology the.

X-ray didn't really look like it was congenital though.

No it did not.

Yeah, but more and more common.

32:32

It's a good stat.

I wonder what it is updated, especially with the population.

But it's right.

But.

Like after generation is changing, is that statinum get worse?

Yeah.

And that's something that's not, you know, that's Fais gets called into question all the time Of you look for it more, do you find it more?

32:48

Is it actually that it's more common or it's always been that common?

You know, like that Would be interesting to see updated stats.

Cool.

So give us give us a handful of weeks and then perhaps I'll update on on her case.

Yeah.

All right, last one, so we have a history here for 23 year old female with 10 plus years of temperament, mandibular dysfunction, headaches which are weekly slash monthly, not really migraine even though she's somewhat using we're going to see here in SAC anxiety and antidepressant medication for headaches as well.

33:29

Notes that she grinds actively even though she's aware that she does.

She's seen a chiropractor who I know personally for a while and it's become more relief, right, that nothing ever kind of gets fully remedied that it's just like, you know, it helps, but it's always coming back.

She also has seen an oral facial surgeon who specializes in TMD who built her a night splint, which has been really his only recommendation, right.

33:52

There hasn't been any like, hey, we get to this point.

This is what we do next.

It's just hey, use this night splint, which she's had for almost I believe going on two years and she self-reports that she's grinding through the night splint, which for everybody that is going to treat TMDTMJ issues, realize you're grinding through your night splint.

34:11

It's the wrong night splint or you don't need one at all or it's in there for the wrong reason.

Because a lot of times when we're looking at like mechano reception to your teeth or approximation, the fact that you're still trying to find approximation by grinding, which can be for a lot of reasons, and you're wearing through a nice plant, even though that's to protect your teeth, it's going to set you up for worse things later on.

34:31

Especially pain, muscular dysfunction, headaches, all that stuff is still occurring on top of all of the, you know, there's technically no primary complaints to the patient, right?

They're all primary complaints.

If you talk to an insurance company said that she deals with fatigue and soreness with long bouts of opening, right, like a dentist or something like that, but also has some like general aches and pains.

34:55

We talked about the headaches.

She's had her jaw locked open a couple times, right?

So there's a differentiation there between when it locks closed versus locked open, what's happening and how to go about handling it.

It's one of my.

Biggest fears?

That's the weirdest fear ever to have.

35:12

Your mouth just gets stuck open.

It's stuck.

Open or stuck?

Closed.

I think it's like a spiders.

Clowns fear of mouth getting stuck open I don't have.

A fear of spiders or clowns?

Well, you.

Should because if your mouth is open then a spider can fall in there.

A mouth of poke is like weird finger in there with a white glove on.

Oh man, unsubstantiated fears.

35:30

We'll talk about that in the next episode.

She has a history of PCOS, anxiety and depression, so think about it.

We got somebody who knows they grind, they're anxious, I mean depressed.

We talked about all this PCOS, kind of general aches and pains, headaches.

35:48

So we could very easily start to kind of say, I'm going to have the pain neuroscience talk, right?

We got to go through the rest exam.

So on exam, and this is really specific to TMD cervical because we'll talk about a little bit of some of the other parts exam, but there's just a lot to cover here.

36:04

So less than two knuckles on, opening on.

And again, don't have somebody take off their bra.

Also realize that's their knuckles, not yours.

So don't.

And when she does open fully, it's slight protrusion of the jaw, which is the opposite of what we should see happen, right?

36:21

So we shouldn't see that.

Your jaw kind of extends forward in space.

There's also right lateral trusion.

So her jaw is going to kind of go out into the right as she opens on full opening.

There's pain on the right side of her jaw.

There's no opening.

Click on 1st exam painful opening.

36:36

Like I said, secondary respiration pattern.

I'm going to call it a facial squinch.

Monaco was watching like this is really just probably tone, but you're going to change bone structure if you deal with something for 10 years that the right side of her face is literally look shorter than the left.

36:52

And if you get into the whole was it myofascial orofacial, there's a whole network where it's dentist, oral facial surgeons, chiropractors, PTS.

They talk a lot about this, about one eyebrow being higher in the other.

And it's not like facial structures literally pulling yourselves in these patterns, just like if somebody has scoliosis, right?

37:10

It's not always just like they're born that way.

They could like develop it on.

So that's just a piece of information.

She had lack of control on the Sagil plane in general.

So when we're doing like, you know, kind of a Milgram's test, we're looking at her just doing a cervical flexion test from Supine hypotonicity and milohyoid and digastrics just on the right, right.

37:37

This is an important thing.

So we have that right lateral intrusion.

Left side's kind of like it's out to lunch because you do have digastric milohyoid activity obviously on opening, but when she's at rest, just hypertonicity on that right side.

And let's remind everybody the digastric action is what we got.

37:55

Two students here.

Yeah.

What's your digastric do?

So it's going to be opening of the jaw.

Yeah, but it's only when your master and temporalis are relaxed.

So there's kind of a neurologic feedback loop there, right?

So think if there's excess tone, then you already have two of your minor openers, right?

38:14

Versus the main opener of your jaw, which is what Students.

Yeah, you got three main closers, 1 main opener.

Yeah.

So lateral terravoid has to then do all the work against master and temporalis because now you don't get the backup help, which is for a good reason, right?

38:32

That goes way into glossopharyngeal cranial nerve stuff and choking and all that.

So she's also a baton hypermobility score of nine, which she had never been talked to about how like PCOS, hormone issues, phenotype, and all these things can kind of add up to things like headaches, migraines, all that stuff.

38:49

But also you have to have the conversation I think you do with a patient about, hey, your jaw pain is probably not just from your jaw.

It's like you may have the stability strategy that you're creating tension around your jaw because it's important and we have to work on other areas, right, to actually get that to remedy.

And that's why I have that conversation, which we'll get into.

39:07

So let's go into the functional audits.

I have kind of second, third visit and stuff in here.

So functional audit pretty easy on this decreased opening less than three knuckles.

Well, I'm going to get into the second visit on this because it didn't happen on the first one, but second visit she came in, had a reproducible click on the right, right.

39:25

And this was with opening.

So that's part of my functional audit.

The other part is by the third visit, the reproducible click goes over the left side.

This is a huge piece of information.

So this is probably my biggest functional audit right now.

We'll talk about that in a second.

And then the suboccipital tension and trigger points, right?

39:40

She has to throw herself into upper cervical extension to open her jaw or open her mouth.

And then pain audit is just TMJ pain, right?

Maybe headaches, but that's kind of harder to assess, at least in a visit and then diagnosis temporomandibular dysfunction, obviously, but you call this an opening dysfunction, right?

39:59

If you're being more specific, if we're going to send them for splint or you know, to a dentist.

So let's get into treatment on the first visit.

So we went first visit exam, first visit treatment.

We had to go over breathing, resting position of the jaw, which she kind of knew, right?

40:15

She's self reported like nose, I clenched.

So we give her something else to think of, right.

We talked about atomic habits.

You don't get rid of a habit, you actually replace it.

So let her think about something and think of not instead of thinking of not doing it.

We work on DNS three months supine and prone focus on a relaxed jaw and tongue.

40:32

Big deal.

So in particular people that are in three months prone, you'll notice it even if you don't have TMJ issues that you'll protract your bottom teeth and your front teeth, right?

You're trying to create that deep neck flexion.

If you don't do that very well, guess what?

You're going to use Milo Hyoid Digastric to try to do that stuff.

40:50

So you're trying to literally turn those on and like drive your head back so you don't know how to use deep neck flexors.

All right, Kobe, So then it's almost a year.

The stuff that I sent her home with which gets into the last drill that we did, one of those things was right to left TMJ lateralization.

41:11

So this isn't PRI or anything which we do sometimes.

It's literally as she open, she's just gently guiding her jaw from right to left, right with kind of the sole of your hand.

So it was going home with breathing DNS prone in three months and we use the DNS three months supine for the breathing drill specifically and then just those lateralizations of the jaw.

41:32

So second visit, she comes in slight pain at full opening, almost 3 knuckles of drastic improvement just first and second visit.

But now like I said, reproduce will click end range opening on the right, which was not present whatsoever.

But that's present because why?

41:48

She's actually getting further, but the mechanics aren't so great.

So she's kind of running into the condyle or zygoma there.

So second visit, what do we work on for homework?

We started getting into tongue opening.

So what's a tongue opener?

It's where you're putting tongue on the roof, your mouth as you try to open as far as you can.

42:06

Why do we do that?

What kicks on when you put your tongue on the roof?

Your mouth guy, gastric smile, highway, right?

So automatically turns on.

It's like a feed forward.

Well.

Yeah, and you don't want somebody to get overworked here, right?

But it should be you try to put the tongue on the roof, your mouth and open as far as you can.

42:25

But that's going to keep her from protruding as well.

Yeah, Monica's given us a really good example here.

Now it feels goofy and you can't open that far.

But we're just, it's like if I told if you could tell somebody turn on your straight as anterior and then do this thing right?

You're just kind of given this little pattern.

So then third visit exam and I'm going to see her today for the 4th visit.

42:46

But third visit exam, we have full opening SO3 knuckles, no pain.

Now there's a reproducible click on the left and Maddox is getting super excited that she's out of pain.

Full opening, greatly reduced tone in suboccipital region.

43:02

And then one of the issues she was having in three months prone was trying to get that Third Point of contact elbow, elbow pubic synthesis way better at that.

She also told me in this exam that she is starting to strength train.

So before it was just kind of, you know, I don't know what should elliptical and stuff like that.

43:18

Now she's getting into lifting weights, and we had to have a conversation about like the importance of breathing, but also what you're doing with your jaw when you're lifting weights because she's going to try to find stability and approximation, probably the way she shouldn't, but much better control on that.

43:33

Three months prone, which is a really good sign.

But that's why, in my opinion, she's getting so much relief from suboccipital region because what are we thinking about here?

That it's regional interdependence, right?

You kind of lock your neck up because you lack the central stability.

And that's the pattern she's been in.

43:49

And then that third visit, homework we started going through and Monaco saw me working with her on this because remember, one of her bigger deals is that was blockading her from opening was this protrusion mechanism, right?

So we started going through guided or traction opening where you literally try to just imagine your mouths to gape, relax, you kind of gently retract your jaw and push it back.

44:08

As you open, you continue to push your jaw back.

She was amazed at how far I mean beyond three knuckles when she would open be like, Oh my gosh, and no pain and no click and no click.

But as soon as she did it on her own without the retraction guide, you know, decreased opening, even though it's better from the beginning, but that reproducible click.

44:26

So let's explain really quickly how that your the kind of condyle or the top of your manble, it has to go over or out of that inner condular notch of the zygoma.

It's supposed to kind of unhinge over the disc and the disc kind of goes with it.

44:41

It actually moves right.

The disc moves back and forth with the top of that condyle.

At first I thought she had a pseudo disc, which means she's created so much trauma that she's actually calcifying the posterior aspect of the disc, right?

And it's kind of getting stuck, right?

That's why there's no click.

At first we found out, oh, that's not the case.

44:57

She came in, it could open better.

Now it's starting to click.

So then what's going on?

It's literally just a dysfunctional pattern from how she's kind of using her whole upper cervical spine.

Does that make sense?

So imagine for somebody that's listening, if you just stuck your head straight out in space and then put your chin to the sky and now try to open your mouth as far as you can.

45:17

It's not very easy, right?

You get fatigued really.

And that's she's doing that all the time.

But if we could get her in a deep neck flexion off lower up cervical spine, a lot easier to open.

So that's what we're working with and we'll see how she's doing today.

Hard thing here is you do everything with your jaw, right?

45:33

You're, you know, all these things.

So you're constantly going back to default.

It's not like running where you say take a two week break, but 10 plus years of doing the same stuff and three visits having a pretty stellar effect.

The one thing that I didn't mention, I had to get rid of her night splint.

45:49

I wanted that because I I don't think it's a good move for her, but I didn't want any other variables.

And I think once we get her to a certain stage, we'll determine does she need something to help at that point?

But that's, you know, we're not there yet.

Sound cool?

46:07

Any questions?

No.

You're so thorough.

It's so thorough and.

Extended plans, that's on our template here for week in review.

It's just she's going to get into weightlifting more.

So we're going to work way more on central stability stuff, right?

So hopefully we get her out of the mindset of it's just, you know, TMD stuff like, hey, you're working on this because you're a more flexible person.

46:25

You want to get strength training.

Stuff's going to show up strength.

Training may be the best thing for her.

You said she's high in baton mean that's going to be.

Well, more patients are walking in the door to give us more fodder to put on the show, so we'll have to get off here and we'll talk to you guys next time.

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