Derek Petit

@NickHoopes_ I really hate clamshells. Most people cheat with their hip flexors, never actually works for the patients I see. Much prefer sit to stand and step ups

I have a rehab confession. 3 of my favorite exercises to give as an HEP are: -Clamshells -Supine Hamstring Stretch -Bridge 3x10 Why? Because they require no equipment, take minimal time, and address common clinical findings for a variety of issues (hip/knee/back).

@DrMarwanAl_D Before neck I would want EMG. I was actually thinking wrist/hand to assess the tendon

@DrMarwanAl_D If the 3rd digit FDP is intact, it would push me less towards nerve - but even then you could theoretically get fascicular sparing. Wonder if an MRI would help at all

@DrMarwanAl_D Seems too isolated for a TIA - I would check FPL and wrist pronation, both innervated by AIN as well. Could be mononeuritis multiplex, neuralgic amyotrophy, C8 radic. Great case to refer for EMG

@ZachBailowitzMD Holy

6 months of pain/paresthesias lateral leg. Tinels + fibular neck. MRI ordered by PCP neg, sent to me for further eval. US shows clear neuroma/nerve sheath tumor of SPN just distal to the bifurcation. MRI unfortunately didn’t cover the affected area…

@DrJN_SportsMed I’m wondering, but in your experience - does steroid add much here? I suppose it theoretically makes sense if there is muscle “edema/inflammation”, but I’m curious if LA alone would yield similar results

Consent ✅ Ballet dancer - deep seated R buttock pain on single leg activities, attitude derriere (see pic), arabesque, pigeon stretch Positive ischiofemoral impingement test (side lying hip ext & adduction) MRI - oedema in quadratus femoris Not improving despite offload & rehab - therefore US guided CSI & LA both diagnostically & therapeutically (see video - avoiding sciatic nerve on central / left of screen adjacent to the ischial tuberosity) I've inverted the MRI image so marries up with injection video orientation.....

@JameyEisenberg Big fan of your work Jamey, thought I’d leave this here, never had a loss on a kneel before

Jayden Daniels is awesome. And the Bengals defense is atrocious.

@DrJN_SportsMed Does he have an Achilles reflex? The pain with coughing and pretty convincing disc bulge makes me think the radiculopathy is #1 here

Consent ✅ Middla aged Ironman Months of L inferior gluteal pain that radiates into posterior thigh to knee - burning / throbbing Recent 'pop' in gluteal region with sudden hip & lumbar flexion Worse on - running / fast walking, sitting, cough / sneeze +ive proximal hamstring tendinopathy tests +ive adductor magnus bias tests +ive SLR neural tension Pain LSp flexion, limited POCUS & MRI - interface tear (peel away lesion) of proximal hamstring but remaining tendons intact, so no retraction LSp MRI - L sided disc bulge irritating L S1 nerve root So - concurrent pain drivers? Or one injury mimicking the other? PHT pain can refer pain distally into hamstring. What next after 3 months rehab / load mods & no change? 🧐 Patient will return with symptoms provoked - then US guided LA only injection to proximal hamstring tendon - then re-test - easier & safer to rule out / in tendon driven symptoms first before considering spinal options.

@DrJN_SportsMed Lateral head has a bit of L5, medial head better S1 “proper” muscle - could explain US. Completely agree re: fatty infiltration and recovery. The horse has left the barn at that point, recovery will be minimal, if at all, in this case. Axonal recovery occurs for 12-18 months

NCS / EMG can give prognostic information re nerve injury In the electrophysiology report, lateral head of gastroc severely affected as well…. But - ultrasound of the lateral gastroc was completely normal Do we underestimate imaging as a key indicator of recovery potential? If profound fatty atrophy on POCUS or MRI, surely chances of the muscle recovering for this are minimal? And vice versa?

@TTRAmyloid @DrMarwanAl_D @SportsDocSkye True, the clinical presentation does. EMG is still is key, because if picked up early and severe denervation/no recovery within 3-4 months, can discuss nerve transfer surgery, which according to our center has better outcomes when done within 6 months

@DrMarwanAl_D @SportsDocSkye EMG does not confirm PTS just shows there’s brachial plexus injury. Doesn’t tell you cause.

@DrMarwanAl_D @FemboyElonMusk Truthfully in an acute pain presentation, unlikely there is a mass there - in my centre we don’t always image these if the clinical fits. You can see “hourglass” nerve bundles on high resolution, but it does not add much

@DrMarwanAl_D @RyanVrindtenDPT @MBeasleyMD About 50% of these patients have ongoing pain after 1 year - big reason is the scapula-stabilizing musculature is weak. So GHJ subluxation, fatiguability, trigger points… tough to manage in chronic setting, in PM&R we discuss PT/bracing and even tendon transfers sometimes

@physionerdAU @DrMarwanAl_D @AdamMeakins Absolutely not. In fact I’d venture most young males. I have seen 5-6 of these in EMG clinic last 2 years, including a 19 year-old perfectly healthy male with no correlation whatsoever to a recent vaccine

@NickIlic_Physio Don’t disagree with the Spondys - but in practice, I see way more the other way. It’s generally overcalled, and a common site of referred pain. “Please inject left SIJ”, only it’s glute tendinopathy, LSS, hip OA, hamstring tendinopathy, etc…

Q: What walks and talks like a Lumbar Spine or Hip Joint referral but isn't a Lumbar Spine Referral or a Hip Joint Referral? A: An Sacroiliac Joint referral. "It's never the SIJ", until it is. If you're lucky, you'll catch the SIJ on hip plain XR. ncbi.nlm.nih.gov/pmc/articles/P…

@UBC_PMR @Paris2024 That’s awesome! Congrats Julia 🥳

It doesn’t get better than punching your ticket to Paris. Congratulations to our own PMR resident, Julia Hanes, on qualifying for @paris2024. We can’t wait to cheer you on!

@DocOfSports @tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ I generally feel like an isolated muscle injury (piriformis, ischiofemoral impingement, IO) has another primary explanation - training error, increased load, referred from another source. I really want to make sure I’m not missing a 2ndary cause for their “piriformis is tight”

@PetitDerek @tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ Agreed. I almost always start out with ruling out referred pain from lumbar spine and then hip OA. It’s once those two have been ruled out that I am still trying to figure out the best diagnostic/treatment process. Radic and OA are somewhat easy to confirm and target. Others 🤷

Posterior hip pain differential diagnosis This is a complex area so I teamed up with @TheHipPhysio to create this with feedback from @TaylorAlanJ to improve the section on vascular symptoms. Please note pain locations are approximately & will vary between individuals

@DocOfSports @tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ I like to have a functional approach - i.e. biomechanics patterns. Helps identify a tendinopathy and more. Otherwise I go by risk factors: - Women, pregnancies, hypermobility: SI joint/pelvic instability - Vascular risk fx: PAD - Young: AxSpa - Old: Osteoporotic fracture

@DocOfSports @tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ It’s surprising how radics can be hard to pick up sometimes, especially in equivocal imaging. Hard to expand with character limit, but my approach is like yours with hip + spine (including facets) 1st. I need to be convinced it has appropriately been ruled out or assessed

@DocOfSports @tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ One of the highest yield diagnoses I’ve found in these is an L5/S1 radiculopathy. I always do a careful Neuro exam in glute pain NYD and will not hesitate to image the spine or order EMG. A subset of patients have sensory/demyelinating radics which makes it even more challenging

@tomgoom @DrJN_SportsMed @TheHipPhysio @TaylorAlanJ One of the biggest challenges with these cases is figuring out deep gluteal pain. It’s an umbrella diagnosis that includes a handful of other diagnoses (so simply naming it isn’t the end of the diagnostic road). I would love to hear how people approach diagnosing and treating DGP

@BluesteinLinda @dianajovin Many examples, but ex. having an approach to cervico-cranial instability. Management of POTS. Pathophysiology of MCAS and mimics. Pain concepts as they apply specifically to HSD patients. I could go on! Made me confident in my messaging and gave me more tools to share with them

@PetitDerek That is so wonderful to hear and I’m sure editor @dianajovin will be happy also. If you are able to elaborate on how the book has been most helpful with the patients you are seeing, that would be great. 🧬🦓❤️‍🩹

Would you like to win a copy of "Disjointed: Navigating the Diagnosis and Management of hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders” (US shipping)"? To enter -Follow @HypermobilityMD -Subscribe free at HypermobilityMD.com -Tag a friend here.