all right special welcome to everybody who's tuning in tonight for another what I consider exciting ebfa webinar um excited to have Dr Perry Nicholson again joining us for our discovering differentials webinar series if this is your first time tuning in on the ebfa webinars how it works is we take approximately 30 minutes to go through the slides and then you're able to ask questions at the end which we will answer and if you have any continuing um questions after we finish you can always email either myself or um Dr Perry I'm sure he'll offer his email out if you want to learn more and we archive all of the webinars they are kept on the ebfa website which is ebfa fitness.com you can find the webinar link and that has all of our archives and don't forget to follow us on Facebook and Twitter which is ebfa Fitness so we are getting started again discovering differentials we are again very excited to have Dr Perry Nicholson welcome Dr Perry thank you very much doc I'm very honored to be back thank you so Dr Perry is a founder of stop chasing pain uh it's a great website he's very wise in the way that he approaches movement dysfunction and pain so I highly recommend that everybody checks out his website and his education that he offers both through podcasts webinars articles Etc he has lots of exciting stuff um which is can all be found on stop chasing pain so discovering differentials why I created this series is because I want to take a lot of the concepts that I learned going through medical school on when I approach a patient and when health and fitness professionals should approach their clients who present with pain and movement dysfunction the goal is to find what is the cause kind of the roots cause of their dysfunction so that you can improve your results and actually eliminate that pain and that dysfunction so the way that you need to do this is to have a powerful differential list in the back of your mind you need to systematically go through each of these differentials through a process of elimination start with the simplest okay you rule it out move on to the next possible cause or their pain and their dysfunction remember that you want to go through all systems considered vascular neurological immunological anything that could be causing your client or patient dysfunction and pain so the way that we're going to do tonight is a little bit different than our first discovering differential webinar is that Dr Perry is going to take some time and go through a case study or a case example the way that he assesses some differentials that he has in the the back of his mind and then the way that he treats that patient and then I will spend some time going through a similar case study so Doc it's all yours thank you very much doc well um yes I specialize in seeing chronic cases difficult hard to fix cases that most other Health Care Professionals have already evaluated and taken a look at so I naturally um go in looking outside of where most people have already looked so that's kind of the way I approach the body when I look at and I just assume 100% of the time that somebody has a movement dysfunction that was a cause of where their pain is um they just don't know it or they don't know where it is because most people have been too wrapped up and treating the side of pain as opposed to the source of pain so in my practice we treat both so this is kind of a the a way that you can see and how I clinically look at a patient and when you start to look get people this way it really uh kind of puts the excitement back into practice again so I'm going to go over one of the cases that was dear to me it was a um 35y old very active female who uh was chronic rided ILO tibial ban intensifi a lot of pain and she was a runner um Runners love to love love to run they just want to keep doing it and she could not so it was an emotional release for her so you know she was getting stressed because she couldn't do what she L to do and and she tried some traditional therapy and massage chiropactic medications even resting and it felt good for a little while but it always kept returning so that's the first hint right then and there that if you do anything in Your Arsenal to try to help someone get well and it just doesn't stick then you need to expand out your toolbox and look in other places and that's going to kind of give you a system to look at here so the prior history for her um she had given child birth to her first child B five years ago and she told me it was difficult birth so I knew there was some pelvic floor trauma and some SI joint instability so you know I kept that in mind with what I'm going to look for during my evaluation and she sprained her um left ankle 10 years ago anytime there's a ankle injury or foot injury no matter how long ago I really sends flags up for me and I'm sure the doc will agree with that and she had lower back pain and sciatica during her pregnancy do the last part of it and it pretty much everyone away but it was kind of kept maybe under the wire for pain with some regular chiropratic Chi but never really truly run away so um one of the things that tfl and ITB van syndrome it's a great uh condition that mimics other things and it's a tough condition to get rid of and a lot of people suffer from it and it's usually uh indicated with pain in the lateral hip and thigh usually ride around into the groin sometimes and referred pain to the knee a lot so people can get patellar pain pain on the lateral side of the knee some sometimes maybe known as runner's knee I see it a lot it mimics veritis so a ton of people I know have gone through uh treatments for btis and not really had any success and got cortisone injections and all sorts of things like that but my mindset for tfl and ITB band syndrome is that that's just the name of a syndrome that is not an official diagnosis in my opinion a diagnosis means that you found out what's causing it so you have to assume there's a microt traumatic onset very rarely if ever is a tfl ITV band injured from direct impact maybe in on the field or something but very rarely as that Happ most people say I don't know it just came out of nowhere automatically you should know there's a movement dysfunction somewhere there's inefficient movement and it doesn't always have to happen on the side where everything hurts and my my kind Benchmark is that if you do interventions on the painful side even when you Branch out to other areas then you need to jump over and look at the other side so just flip the coin over and look nine times out of 10 when you do something on the other side of the body you're gonna find that underlying cause like you can flip the slide for me okay so the biggest thing is uh you need to treat a person not a condition what I mean by that is that you're never going to cookie cut or care nobody should get the same kind of program uh for pain so if I have patient comes in with tfl or itbb syndrome it doesn't mean that I'm going to go to my file box and pull out the sheet for exercises for tfl and itbb can't do that there's so many things are going to go into and contribute to uh condition so part of the differentials that you need right off the bat is to take a an adequate intake history and examination so this is a great um graphic that Diane Lee who I follow a lot she do some great stuff on the pelvis is that you have to and doc said it before when she was going over differentials you have to look for articular dysfunctions neural even visceral internal organ referral pain or how their system is working to be able from the gut to hormones to everything to myofascial but some of the biggest ones are what's in the middle they individual story of what's happened in their life until they walked into your door and what therapies they tried because to me the therapies that you've tried and has not worked tells me a lot about the ones that are going to work so the last thing I'm going to do is what everybody else has done so you have to look at how they view pain how they view stress and that it brings in the kind of uh connection for their brain to body sometimes they have fear of movement and they're programmed to move dysfunctionally the brain's going to always move you and try to protect you and it's going to take the path of least resistance to do that so you need to keep that in mind when you're doing your evaluation you can change the slide that sorry that's okay so one of the things that I always do I just do some very basic tests and the single leg squat is is and single leg stance is one of my favorite alltime movements I like to see what's happening on one side of the body compared to the other side so I'm just going to have the client and stand up and show me what you can do on the painful side so on the painful itbb side and then do a little bit of a reach out so I can see what your control is when I challenge you with a little bit more stability requirement and then I'm going to have you do the other side and I'll tell you most of the time I'm going to see on the side that there's pain they'll hold that thing like it's in cement they won't move but there'll be a disaster on the opposite side and that tells me right then and there that the painful side is usually the one side that's compensating and making up for the other side that does not function well so the pain is just there because they're tired it's tired of of doing its job so this is one of the best assessments You' ever going to do so what I you can flip the slide for me that um one of the things you're going to look for in conjunction with that in a moment I get into is the overhead Squad test if I had to do one test in my office and I can only do one test on any client ever this is the one I would do this shows me right out of the gate what I'm dealing with and it's kind of like an eye chart if I put you in an I see can you see the big giant e and you tell me that you you can't even see that well then I know that there's a problem with the original okay so this is basically the vision chart so I'm going to put you on an overhead squat test and see what your body does with it can you control it can you move can you even figure it out do you lean do you twist I mean I can do a whole presentation just the overhead squat test but those two tests will tell you a lot about what you want to look for in ITB van syndrome you can flip the switch there down half kneeling chop and lift is my third favorite assessment so this one is an half kneeling position and you'll have the forward foot which is cut off on here I apologize down in line with the downward knee and that's going to give me an idea of can they control the hip can they control stability and then they'll I'll give them a stick in front at a 45 degree angle about and then I'm going to just move the stick kind of see can they control U perturbation can the reactive core reflexive core kick in and what you'll find is there'll be an asymmetry where they cannot control outside forces coming on them and they don't know what's happening so then I know they're dealing with a a crossbody core problem relationship to hip stability and you want to always check the hip on both sides when you're dealing with a tfl or ITB band syndrome fantastic test and man it can really send the bells off to clients so the intervention that I did in here is that uh for this client that I had seen um she actually had a problem on supination on the opposite side foot so I know that she was leaning to her symptomatic side and I just go through the kinetic chain looking at the fiber orientation and what I found for her is that she had a facilitated fibularis muscles used to be called the peronal which I still like to call them um and facilitated opposite quadrus slorm and and inhibited soas on the same side so basically what was happening is that she was getting too much too much work down on the um fibularis and she actually had an inhibited and weak tfl on the same side so people were stretching and doing trigger point release on her tfl that was symptom itic but that was making her worse because it was already weak and inhibited so all I did was go down and release the fibularis and the opposite Q out and uh then I got some strengthening into the soas on the same side and the tfl and what that did was you can flip the flip the slide do it just it kicked in the neural sequencing so I know when she moves everything is moving when it's supposed to because if she's doing that act of walking or running if there's a muscle that's offline and it's not going at the right time and the body's going to say okay well you want to run you want to do this and you know your tfl is not working then I'm just going to make everything else work twice as hard so what happens is that you just get you fall into this dysfunctional pattern that you don't even know it's there um until you do these tests and then you can become aware and they can become aware so they go from subconscious dysfunction to conscious dysfunction they like wow I didn't realize I was that messed up and then boom that's the switch where you go so I fixed her by getting her into rolling patterns I'm a big believer in neurodevelopmental patterning patterning so I regress back to get them on the ground and and make sure that she can sequence just a basic pattern of rolling over and this is a great way to involve that anterior chain so I know that she's going to be pulling from where she needs to as opposed to where she's been pulling from which is incorrect so if I get her down on the ground and she can't do this basic pattern on the top left then I know she can't control her body when she's standing up so a rolling pattern is a fantastic assessment and also a fantastic Rehabilitation both combined together you can flip the slide that I got one more after this sure yeah no I didn't see one more yeah okay that was it um but yeah to to wrap it up about this this client is the one thing that I tell people when they're doing differentials is um this automatically assume there is one and look at where it hurts but look on the opposite side of the body first and that's one of the biggest cues that I give to people and see how that's contributing to it and then whatever intervention you take next time you see the client you should notice a a significant Improvement and intensity frequency or duration of pain or that just means you got to change your approach or I kind of jokingly say you got punked by pain pain is faking you out and you have to take that consideration that pain is telling you something's wrong but it's not telling you what is actually causing the pain oh great doc I think that was um a great presentation and example on how how like you said you should look on the opposite side of where the pain is um you know how you had said in the single leg squat aside that they have the pain is actually more stable than the opposite leg which is where the dysfunction is I think that that's um a great point and how you don't use kind of a templated um treatment approach with every um you know tfl pain or you know it's not like you take out a sheet and you hand it to the the client or the patient and they they take it home um I think that that's uh a common thing that you see in especially in Podiatry is you just get these templated workouts and exercises and you give them to the patients for planter fasciitis here's my planter fasciitis um protocol and um it just shows that no condition is the same with every single patient um so I think that's a great point that you make thank you yeah I find that you know uh every day in practice is uh it really comes down to the individual the time you start to cookie cutter things and make assumptions is when you're going to get lost and uh the patient deserves better than that exactly um so before I go into my case stud you had said that that you you will release your this patients I'm going to call them paranal call them yeah I want call that too right can you can you tell everybody who's listening how you do that or just kind of like a quick little rundown just so they can um explore that a little bit more sure yeah well you know I'm I'm whatever manual therapy you feel comfortable with is really the key so I do a lot of stuff by hand but I would actually release that facilit muscle I'd do some deep tissue Leo therapy so I do that first but then I get in there and just some good oldfashioned um myofascial stripping and ACU pressure and whatever you choose to use is okay it's whatever you feel comfortable with but the key to it is that once you release that you have to actually find well what's inhibited in relationship to that I mean why is your body hanging on the peronal what's it doing that for so if you my point is that if you go in there and you do soft tissue intervention ions and they can be great but if you do soft tissue interventions and you always have to do the same intervention well you're on the wrong thing you're not doing what you're supposed to be doing you're getting punked by where that is coming back from so if I made an intervention on the pronal I have to say Okay well if it's on that lateral chain if the tfl and ITB band are not functioning properly and your body is going to hang on the pronal so what you have to do is release the pronal then you have to immediately Engage The tfl and ITB band and turn it on so you can actually communicate more like all it's like a software problem so your brain says okay well now I know I've got a ITB band and tfl that I can use when I need to so I'm GNA let the coronials off the hook for a little while so you have to understand why you're doing what you're doing and and follow it up so I don't even like people just chasing pain or spasm you always have to ask why okay well if I have this here why do I have it there and that's behind that type of approach okay that's great that's great thank you for presenting that um all right so I'm gonna move into my case and um we'll end with with this case and this is something that I see a lot in my office which is I'm a podiatrist so patients are presenting to me with an initial complaint of their feet and it usually often is associated with other um movement functions so um I'm presented with a 40-year-old male who complains of bilateral foot pain and siide joint pain so he feels like his feet and legs fatigue easily his pain along the inside of his right ankle and the patient has pain on ambulation particularly on the SI joint right side chronic pain fatigue that has led to increased um inactivity and weight gain so when I'm assessing this client and I get kind of a generalized foot fatigue low back pain I always do a full um open chain closed chain and functional assessment with every patient on open chain when I assess the patient I see limited ankle joint range and motion both feet he has a mild bunion or shift in the great toe on both feet but what I notice is that he has very good range of motion in that big toe so that's that's important to note that he has good range of motion non-weight bearing in both of his great toe the muscles strength five out of five or it's normal but he has decreased activation in the glutitis medius and glutitis Maximus isometrically when I do a muscle test is a positive Thomas test which is indicative of the tight hip flexors I stand them up Clos chain assessment resting foot position this is what you see um you can clearly see that his left foot is pronating so something something's going on in that left foot and then he has increased ccanal version AB duction all of these fall into under that pronation there's an anterior pelvis tilt on the left side and he has rotation on that left side as well so that's important to note as well functionally we have him do a double double leg overhead squat you notice he has an increased lumbar extension which would go with the Positive Thomas test that we did here's a slight vus rotation in the knees which would go with the pronation that we saw and then when I ask him to walk and I do my typical gate assessment I notice that he has very little hip extension when he walks which means that he's going to activate his hip flexors early he's actually a propulsive and he loses all of his dorsy flexion in his big toe on his left foot when he walks so open chain he had great range of motion in his big toe and then when he starts walking he loses all of that range of motion so something is going on in that big toe and because he has that lack of range of motion he now has lost his hip extension when he walks so what is going to limit hip extension when we walk and what is the sequele of limited hip extension so to walk in a normal sagittal range of motion you need adequate anterior hip mobility so if he has a positive Thomas test TI overactive hip flexors he's going to have a reduction in hip extension if he cannot get adequate hip extension he is going to pull his leg into propulsion or a hip flexion much faster what can also limit that hip extension that we see in this patient is that on open chain I noticed he did not have good ankle joint range of motion maybe that's causing the cause of his limited hip extension and then open chain he had this great range of motion in his big toe as soon as he starts walking walking he loses all of that range of motion if you can't get over your big toe there's no way that you can extend your hip back so in this patient is it the lack of anti hip mobility that's causing his limited hip extension is it the limited ankle Mobility or is it the limited great toe Mobility so considerations for this patient when you see somebody like this and I encourage Fitness professionals and um health and wellness professionals whenever they see a client or patient with low back pain underactive glutes they've got to go down to the foot you have to look at more than just the ankle you have to look at the big toe so if you think of sagittal gate our ankle and our big toe is what's going to control that sagittal hip extension when we walk so considerations for this patient he has an overpronated foot type is a knee valgus and he had a colle Ms indicating the weak external rotators the range of motion in his great toe um was great non-weight bearing as soon as he started walking he lost all of that motion in that great toe so it's blocked which it means he cannot get adequate hip extension compensation for this limited great toe Mobility is a propulsion you become a propulsive that means you're going to over recruit your hip flexors you over recruit your hip flexors and your glutes start shutting off if you start shutting off your gluteus maximus this is the primary muscle that stabilizes your SI joint and now we have the common SI joint dysfunction so in this patient and when you see um a client or a patient that presents similar to this you want to ask yourself is the SI joint dysfunction associated with this patient's lack of hip extension and if it is is the cause of this lack of hip extension because he has limited great toe mobility and if it is what is the most effective way to fix the great toe hypomobility so where where do you start with this patient you go straight to the glutes try and activate the glutes try and mobilize the hip get more hip extension but if you do not address that great toe you're going to keep going right back to where you were and I consider it the hand are going around in the wheel so what you're talking about here is called functional Helix limitus so this means that that patient and that client had great range of motion in the big toe when he was open chain loses that range of motion when he walks the key word when you think of this dysfunction is the word functional functional typically means when you're moving It's associated with muscle imbalances in the foot in this dysfunction what is the muscle imbalance that we're thinking of muscle melt that we're thinking of it has to do with the first Ray if you've never um studied and kind of delved into the foot mechanics the first Ray is what's formed by the great toe the first metatarsal the medial Cuma form so it's pretty much the the whole inside aspect of your foot and your first Ray actually has its own axis so it can dorsy flex and invert implant flex and E becomes a very complex but what's important to know is that your first Ray will dictate how much range of motion you have in your big toe and you must stabilize your first Ray by two different muscles one is a supinator and one is a pronator on top of your first metatarso you have your tibial anterior on the bottom you have your pronus longus you have a supinator which is the tibial San here you have a pronator which is the pronus longus what dysfunction leads to this imbalance between the superator and the pronator is pronation everything can be blamed on pronation so left foot pronating that's what they taught us in school anything what's the cause pronation so here he is over pronating on that left foot is this the cause of this imbalance between his tibial s and his pronus longus a lot of the research and the theory says yes and the reason is that when you pronate and your rear foot collapses you change the lever arm of your pronus longus which means that it cannot stabilize that first Ray if you cannot stabilize that first Ray your big toe cannot get over the first metatarsal that means you are going to lose all of that range of motion when you start walking and you bear weight so for this patient and I see this actually a lot in my office is if I approach this patient one I can give them a great pair of orthotics or two I like to use corrective exercise and more of a movement therapy approach is you cannot approach that SI joint dysfunction without first correcting that functional him Helix limitus you cannot correct that functional how limitus without correcting the over pronation and you cannot correct your foot over anation without addressing your hip specifically your hip external rotators so our intervention for this patient that's presenting with SI joint dysfunction starting with the foot in the hip and then start stabilizing the SI joint first you must mobilize and then we're going to activate so you have to mobilize your hip mobilize your ankle when you mobilize your ankle I've done several other webinars on ankle hypomobility you always want to find find out is it the gastrock is it the Solus that's tight does a patient or client possibly have a bony block or an anterior shift of their Tais so there's many causes for decreased ankle joint range of motion besides just tight calves so keep that in the back of your mind as well and explore other ways that you can increase ankle mobility increaseing in range of motion of the hips so that they can get adequate hip extension once you mobilize I always activate my patient's muscle so the muscle that I'm trying to strengthen you must first activate after you mobilize so we're going to activate the foot inverters which is your posterior tibialis and your Solus muscle and then we're going to activate the hip external rotators which will be your glutitis Maximus and your glues medius once you activate those muscles I do both concentric and Ecentric strengthening with my patients and with my clients why I do both phases is this is how we use our muscles every single time you take a step your body is going from an Ecentric to a concentric contraction so you need to train both of those phases and you need to train the timing of those phases and the conversion from one phase to the other phase so again the next time that you see a client or a patient who has SI joint pain or SI joint instability I advise you and encourage you to look at the ankle and look at the great toe watch them walk look how much hip extension they have if they do not have an adequate amount of hip extension try to look more um dist towards the ankle and the foot see if their anti hip is restricting them see if their glute Max is not firing if you do see that the glute Max is not firing you then have to explore some of the more um differentials on why the gluten mask does not fire so if you have any questions you can ask them for either Dr Perry or myself if not I encourage you to to check out some of the other ebfa webinars which are archived and we have some exciting workshops that are coming up in September and we have our online education portal which is full of research articles and um Dr Perry I didn't put your website on there but it's stop tracing pain.com and I don't know if you want to put them anywhere else no that'll pretty much launch to everything I've got online so if you type that in all my other links are at the top and then you can spider out from there so that's home base and you can email me from that w website as well okay great if you guys want a copy of the webinar or uh we record all of the webinars if you want to link to that as well you can email me at education at ebfa fitness.com again that's education at ebfa Fitness n.com or you can again catch them on the website follow us on Facebook and Twitter we have a new blog coming out um my next blog article I'm very passionate about because this is my injury I'm G to be talking about athletic pubalgia which is a groin injury that's common in High um high performance athletes such as hockey and soccer but there's common dysfunctions that lead to this so um I'm trying to increase the awareness of this injury just because I went through many loopholes to finally get to the right um diagnosis so any last words do Perry yeah actually I just wanted to follow up to say how much I enjoyed your case review and that um I really love how you implement the activation and corrective movements in with a client even when you give them supportive Orthotics I mean too too many times s in my office people do come in to see me and they have Orthotics and they were just given to them by could be anyone but that was all they did and it's almost like they think it's a magic fix but to me it's like a crutch that wearing a support belt for your back that you're just asking your muscles to not even work even more and they can't own that that new positioning of the foot so that is uh really wonderful to see that you're doing doing that with your clients and I'm sure that they get some positive results with that thank you yeah the um the Orthotics I'll just speak about this briefly is the Orthotics do get um kind of a bad reputation especially in um kind of the movement industry and fitness I A lot of people are anti- orthotic I like them in the cases of um they'll maintain proper joint alignment which is great so if I have a patient who's in pain I like the orthotics for managing and kind of restricting the mobility so then the tissue can recover and then I get all of my patients and clients out of their Orthotics to then strengthen and try and establish that that normal motor firing pattern so you know some people do need the Orthotics so they're not all that bad but um I do try and create that balance between movement and um a support of brace like an orthotic yeah and you know I got to say one of the other reasons why I like you so much is because you hit it right on the head with the big toe I when people see me um that's one of the first places I look um for them even if it's something all the way up in their head so you know I explain to them why I'm looking down there and I gota say that nine times out of 10 if I suspect that's a culprit I usually find it because most people are not key in to look there so what you guys learned today about focusing on that big toe that is a huge clinical Pearl that you really don't pick up until you've been out in the trenches for a while and you see it in action so that's wonderful advice there thank you and yeah assessing in both open chain and and closed chain or non-weight bearing and weight bearing huge and um there's some great articles I have it on the online portal is like a 10 page review on the first Ray which again is not spoken about much but by mechanically to understand the first Ray will really solidify the understanding of the great toe so um I encourage everybody to check out and read a little bit more on the first Ray or um I'll do a webinar on the first Ray we can explore it together yeah or hit one of your awesome workshops there you go thank you great so thank you guys so much and um again thank you Dr Perry you guys will be seeing Dr Perry again I'm sure on another future ebfa webinar thank you very much it was a lot of fun thank you take care everyone bye the organizer has