Trigger Point, Nerve Entrapment, or Radiculopathy

Summary

In this conversation, Dr. Beau, Dr. Alex, and Dr. Seth discuss the differentiation between trigger points, radiculopathy, and peripheral nerve entrapment. The docs present three cases of heel pain in runners and ask the audience to determine which condition each case represents. Dr. Beau emphasizes the importance of history taking and examination in making a diagnosis and highlights the need to rule out other potential causes of pain. He also mentions the use of different treatment interventions and adjunctive care for each condition.

Dr. Beau (00:00.406)

Zoom wouldn't let enough people in? No, the quality was terrible. And it kept, after the meeting change thing last time, I just fed up. So this will also allow us to like, it does everything automatically, transcript, all that stuff. So I just didn't think I could have this many people in it. And then you can add them at like audience.

Dr. Beau (00:26.321)

and audience.

Dr. Beau (00:35.018)

understand.

Dr. Beau (00:39.168)

Ugh.

There keeps the email open. Are we getting texts? What says all participants in audience to, so it's gotta be one other person on here. Are you on it or it's slung? We'll see that don't really matter. Six 14. We're not starting yet. Whoa, whoa, whoa. Pump the break. Ola's

Dr. Beau (01:07.623)

Oh, now it's 6 15. Time to go. Yeah. All right. Uh, Alex, you're a little blurry here. No, that's just, it's natural skin. It's got that soft glow skin. Natural. It's got a permanent Instagram filter. Yeah. She, Kaylee said it's her. She's the other one. Oh, so the people are in there. Hey, it's me.

Kaylee, I also heard that you liked boiled hot dogs.

Dr. Beau (01:40.898)

It's like seventh grade lunchroom. Her and Ebna. Seventh grade lunchroom. I'm just, we love you, but nobody loves boiled hot dogs. You're a chef. What are you doing with boiled? Is she a chef? Well, basically. Yeah, what? She said it's not fair, you can talk and I can't. You can type. We can chat. We can chat, you just gotta type quick. Okay, we can review 33. This one's gonna be a little bit different. To be honest with you, I thought it got a little stale when multiple cases are gone. Just.

probably too much just case stuff. I can't defend myself. You can defend yourself. And the way I would defend myself is to not eat boiled hot dogs. So I'm gonna do a little bit of a kind of lecture, but then tie in multiple cases and kind of have this, I don't know, guessing game. But as we, I'm gonna share our...

Dr. Beau (02:38.998)

over here. So I gave this out to people that were in or have been to an art of assessment course. So this is the exam flow chart. While I'm pointing this out is here in a second, I'm going to present three very short three cases. I'm not going to give you the whole case. I'm going to kind of give you the history of the synopsis. Then I'm going to go over what we're going over tonight. And I want you to kind of bank these cases in your mind and start using things like divergent thinking and this intuitive

red hat, if we're using the six hats process to start thinking just from what I told you in the topic of tonight, which one of these cases do you think are, which what we're going to overnight is trigger point, radiculopathy or nerve entrapment patterns, referral patterns. So I have a case that represents each one of those. You don't get a ton of information, but I almost guarantee you just based off intuitive feel and the facts that I'm giving you, you can start to kind of figure these things out.

I'm doing that for two reasons. So you can look at how important it is to follow your intuition, but also prove it with assessment and analysis and things like that. But also, so you can walk yourself through the process of maybe thinking that something sounded like a ridiculous opthia when it was nothing like that, which can be extremely common and not getting tripped up by that. I get that this is not, you don't have all the facts. That's not the point. It's just to kind of be like, yeah, that kind of sounds like it'd be this. Well, is it or not? We'll find out.

So getting back to it, as I said, the topic of tonight is the differentiation between those three things. I would say it's relatively easy. I know some people may be early in practice, would not think it's that easy. I think the reason it's easy is you have to kind of go back to fundamentals of what's creating each one of these things. So I'm gonna go through the cases first because I want you to kind of be front loaded with what's going on with each one of these things. So here we go.

You gotta remember these. If you wanna write them down, maybe I could type them in the chat. I don't think I can type that fast, but that's okay. So we have a 15 year old female track and field athlete that has heel pain that came on in the last week to the point that she had to stop running during the workout that she came to see me, the night that she came to see me. She's dealt with medial tibial stress syndrome over the past two plus years on and off, which we've been treating her for. Prior to track and field, she was a dancer slash gymnast, and that's all you get.

Dr. Beau (05:05.334)

So she has all of these people have heel pain. That's the commonality, okay? Second person, 42 year old male, they're all runners, has started running over the past few months and notes that his right heel is to the point where he can barely make it a mile before he stops. He has been foam rolling his calves and stretching upon questioning as a history of mild low back pain with intermittent flare ups. Also states that he has flat feet and uses orthotics. 53 year old female, trail runner, was put in a boot a few months ago due to,

air quoting, Achilles tendonitis has really upped her mileage over the last year. She had a laminectomy 20 years ago, lumbar laminectomy, L4, uh, notes that she is also dealing with left knee pain. It's on the same side as the Achilles issue, uh, for the past two to three weeks. She's been going to PT for Achilles for the past five to six weeks with no real change. So listening to each one of those, knowing that the choices tonight are radiculopathy, peripheral nerve entrapment, cutaneous nerve, same.

same, tonight, are trigger point referral. That's your three options. You should have some feeling of each one of those, which one is which. Big reveal later, okay? So, let's share this. I think this would be better.

Dr. Beau (06:26.182)

So this is a slide. Let's hit the play button so it looks.

Maybe that looks the same to me. Same, same, but different. Cool. Let's share this then. Same as you.

Dr. Beau (06:42.274)

Okay, so this is something I go over in our assessment of after we've kind of went through the soft tissue assessment portion and we went through trigger point, or sorry, nerve entrapment sites of the upper extremity, which I might go back through those here in a second. But I just try to point out that we have some easy things to start differentiating what's causing this referred pain. So the first one would be, well, you can have a central component.

Well, then you want to say, okay, what are all the things that can create a central component that can refer pain? What do you guys got? Disco, genetic, boom. You have some sort of cord impingement, lesion, cystic change, or you can have some disturbance of the nerve root, foraminal encroachment, assist on the nerve root. Uh, you could tear your nerve root if you're a local PT that's had cervical issues. Shit happens, I guess. Um, crazy.

crazy.

Dr. Beau (07:42.258)

Everybody needs a drink on that one. Or you could have peripheral and I'm trying to make this like very like, this is what you got option wise. So you're like, Oh, all of these presentations. You're like, this is the only thing you kind of got. And I get, we go back to school and say what tumor infection, whatever. Yeah. Pleonasm. Yes. It's not even pleonasm is using too many words to describe something. Seth knows that, but yeah.

It's an, it's an asm. Peripheral neuropathodynamic trigger point. And I'm putting entrapments in all those asterisks because technically that includes neuro pathodynamics. Just if you have a cutaneous nerve irritation, which I did a interview with Dr. Phillips now today, which he kind of talked about, maybe there's a pro dromal peripheral nerve irritation that's causing altered, uh, soft tissue changes. And then, uh, thereby altered Arthur kinematics. So maybe it's.

maybe not backwards from what we originally thought, but maybe there's some other mechanisms of play. So I could even throw that into neuropathodynamics and just say neuropathodynamics trigger point.

And when you distill it down to that, you're like, yeah, maybe I kind of feel like I'm overthinking things too much. So I use this as just a working exercise. We've already went through the six hats process, which we haven't talked about yet, but the six hats is this book we talk about by Edward DiMono that goes over, well, let's see if I can remember them. It's been a while. Maybe Seth, you might have to help me. The blue hat is your process hat, keeps you on task. The white hat is what we call our audits, our objective data hat.

The red hat is intuition. The green hat is divergent thinking. That's kind of this explosion of thought. The yellow hat is convergent thinking. It shrinks it back down. Then you have the black hat that is things that could be going wrong, red flags, initial in the case, or pivots later in the case. Using that process, the first thing that needs to happen if somebody came into your clinic with this, they're saying, hey, I have pain in the ventral aspect of my forearm, and it goes into my first and second digit.

Dr. Beau (09:50.274)

So you're, I mean, that's what they're telling you. Okay? So then you as a clinician are supposed to have this divergent brain explosion moment. They could say, it could be a radiculopathy. C5, C6, we talked about that, cool. It could be a trigger point from any of these muscles. But when you get into the specifics of some of these trigger point referral patterns, you're like, oh, that doesn't really make sense for going all the way into the digit. Maybe it's into the thumb, maybe it's just the wrist. So you could say, oh, these kind of look like it because they'll mimic this kind of, you know.

a referral pattern, but it's not exact. And they would say, yeah, neuropathodynamics radial nerve, and then the cutaneous nerves off the radial nerve. Could be anything like that. And then your exam, right, going through range of motion, soft tissue palpation, joint palpation, neurodynamics, you'll start to suss out which one of these McKinsey, get it, cool. Cutaneous nerve, like we said, lateral anabrachial cutaneous. So.

I just wanted to go over that to show you, we could take all of this, you know, we go over all of this fancy stuff in art of assessment to show you all of the options, all the nerve entrapment sites, all the cutaneous nerves. Reticulopathy, pretty easy to determine what's going on if it's associated with what? Neck pain. I would say motor weakness or reflex changes. And you're like, oh, that's legit Reticulopathy. Because you're not going to get that with trigger points or now peripheral nerve entrapment.

Maybe you could say you get some, we, I think that would be hard press for weakness for sure dysesthesia, peristhesia. You can still have that with trigger point, right? So I have that nerve entrapment. And then the hard thing with nerve entrapment trigger point is like, they're probably together all of the time. So then saying, Oh, it's this or this, and maybe it's both. And then you're just having an intervention point. So instead of using like a neurocentric dermal tractiony kind of cutaneous nerve, you focus on the trigger point.

And that was kind of cool. Would I, so look forward to that podcast with Phil snow. Cause it's kind of what we talked about today, which I didn't know that was what his thinking was and he had some interesting input on that. So breaking it down here, how do you determine just off hearing these short synopsis of a case, right? Cause when somebody is entering your clinic portal, we always talk about, well, we want to start having some sort of intuitive, right? Some sort of stereotyping. And we talk about an art of assessment, how that's not a negative thing, some stereotyping of what's going on.

Dr. Beau (12:09.93)

And then you play the game of proving yourself right or wrong. Hopefully right. Well, by the time somebody's walked in my office and told me stuff like this, which goes beyond the paperwork, or if it's a react or reactivation, which all of these were, um, you can say, well, trigger point is going to be, you can pick a lot of things out of the history. So in your guys's opinion, what are some things that would be, uh, commonalities that people may tell you if a trigger point is the culprit for some sort of

Dr. Beau (12:39.202)

how it presents, time of day, activities, things like that. Is there anything that sticks out? It's probably worse after the activity. Yeah. Well, I guess, go ahead. I was just thinking, I was thinking like, what it might present like in the history. Like if you were doing more, if you had a change in your training volume or something that was abnormal. Yeah. You just ran a lot more or I don't know. Maybe you ran trail and you're.

Probably running road. Yeah. I say if they also feel like they stretch and then it kind of feels a little bit better after they do that, but it comes right back. Yeah. Or maybe they can hit a spot with a little crossbow or something, even create referral, but they're like, it just doesn't go away or something. Which again, we're just not saying that's what it is, but all these things should start like again, diversion where you're like, Oh, I got to like lean into that. Well, actually I guess that's convergent. So if you.

mind explosion, then you hear these historical things, you're kind of already chopping in your mind. The thing that you can't do is what? Skip ahead in your exam and all of a sudden you're like, oh, missed that thing, right? So I'd say history, yeah, things like Alex said, we call it sub-threshold nociceptive input, right? They're doing a lot of work, it doesn't really cause pain, but all of a sudden that muscle's being overutilized, maybe as Phil Snell talked about today, it's actually peripheral sensitization of the cutaneous nerves that then alter motor output.

probably both. I would say if you know your trigger point referral patterns, they have relatively defined patterns. So it's one of those things when you start to learn them, you're immediately in your head when somebody's like, yeah, like they'll literally with trigger point stuff, they'll draw like the referral pattern. Whereas like ridiculous and stuff. I mean, they're usually just like, oh, god, it's like, it's just, oh, that's why I even say, like, ridiculous, these sticks out like source on like, it's just, you're gonna know it. And then if it has, like I said, you know,

uh, my atomal or reflex changes or anything like that. Um, so learn those patterns, realize that they're not exactly the same on everybody and they're not the exact same in every case. Uh, how do you elicit a trigger point response? Push on it. Palpate that bitch. Uh, yeah, you push on it. Is it always going to refer? No. Is it going to cause local pain even if it's not the, the culprit? Probably. So that's where you got to make sure that like it is the thing to work on.

Dr. Beau (15:01.55)

Um, and is it a trigger point? So if you think it's anterior scalene and you go up and there's no trigger point there, it's gone, like just that easy. Don't be like, I don't know if it was a trigger point just early in your career, make decisions. You might be wrong, but make a decision. Otherwise you have. How bad would it be if you ran an experiment and you're like, I don't know if that variable worked or not, but I'm going to go do another experiment and keep that variable in there. And then you keep adding variables personally, like you don't even know what the hell you're testing. Just make a decision.

Maybe the wrong experiment, but at least you ran a clean experiment. Anything else on trigger points that you guys would add in? I feel like you, another one to me, another presentation that you'll see me if it doesn't reproduce the pattern or they don't feel like it's tender. If I, if I think there's three points, they don't realize it's a, yeah. Um, yeah, like I think a lot of times seeing people with like that TL trigger point on an erector, they'll like literally twitch to the side. Yeah. And didn't know that was, oh, that didn't think that was that tender. Yeah. Especially your back. Cause let me.

you know, the, the feedback, like sensitivity of your back and stuff. Yeah. That's a good point. Um, almost like a ticklish type feel. Yeah. Which you will get, you know, I felt like I could go on any, how, and sometimes like the peripheral nerve as well. I feel like that can also get a little tickly. That's what I was going to say. Like I try to explain to patients like ticklishness is like altered neurofeedback. Like you're heightening your sensation because there's altered perception. So the best thing to do to protect it is make ticklish. They don't, everybody's like, really?

like think I'm lying and yeah, I just make up stuff to like make my day fun. Uh, but that's why kids are relatively ticklish. Their nervous system is still developing. So they're trying to like pick up better feedback. Uh, anything else on trigger points?

No. Yeah. And with all of these, I'd say trigger points, the least out of all of these treatment is part of the diagnosis. I think if you're sticking a needle in a muscle to determine if a trigger point's going on, you are terrible at your job. She'd be like, yeah, it's kind of tight. And like, no, you should be like, dude, trigger point right here, like light it up. If you're not to that point, like you shouldn't be using, you know, heavy tools like that. Are we going just purely off of history right now?

Dr. Beau (17:10.702)

for the cases. For what a trigger point is. Like, or what we're talking about, like trigger point. Oh, no, not at this point, no. I feel like reduced range of motion can't. Yeah, yeah, that's a good thing. Yeah, I would agree. But I would also say that any of these can create reduced range of motion. That is one tough thing, because you have a cutaneous nerve, like if you have a nerve entrapment, that's technically a pathoneurodynamic, which an overt sign is reduced range of motion or overt abnormal test, right?

Maybe it's pain that's reducing, it's not a legitimate reduction without that. Yeah, I'd say that's true most of the time. Yeah, trying to think of anything else.

If anybody has anything, let us know. We'll move on to radiculopathy. History, a huge one. I would say 90% of the time, radiculopathy is not gonna show up overnight. It's gonna be this kind of creeping thing that's getting worse and worse. I mean, sometimes you have that kind of like, yeah, I slipped on the ice, fell and slammed my neck into extension rotation, lateral flexion, and then you smack a nerve root or something, or protrude a disc.

Uh, but the history is also what positionally that not that a trigger point could be that positionally this thing just lights up, right? That it also may have what? Like, uh, some sort of, uh, alleviating position versus a trigger point. I mean, there's not many things you can do to get away from that thing. Once it's kind of, you're just like, Oh my God, like that's why people want to jab something in it. Ridiculous symptom. If you have

something besides an extrusion or a protrusion or sequestration that's like out in the canal that cannot be worked on mechanically, you can usually move yourself in a position where you're like, yeah, and that's what people will tell you. That would be the big historical presentation. That's why you come in and Antalgic. You're trying to offload or open the frame and or open the lateral canal. So that'd be the big history point on that for me. Obviously, if somebody tells you.

Dr. Beau (19:16.122)

Uh, it's getting hard for me to walk on my foot, slapping on the ground. You're going to see all the neurologic signs, he'll walk into walking. If anything like that's off, you're going to get it. That I don't think we need to go over that. Um, so I have in here, you know, dermal, total pattern. Right. I think you should know your ridiculous patterns. Just like we get taught in school. Uh, like I said, associated motor weakness, reflex changes, orthopedic findings. So I'm saying orthopedic because those are sometimes testing for ridiculous patterns like what. What's the orthopedic test for it?

mainly to suss out a ridiculous symptom. Slumps, slumps, maximal, framel compression. Uh, I mean, I guess on a lot of circles. Yeah. Kemp's yeah, maybe. Yeah. Let's say, yeah, maybe more sclerotogenous facet driven referral, but yeah. I don't even know what the, like, if there's a real name for it, but whenever we do the straight leg raise where you close the frame in.

Like bananas. Yeah. Is that like an actual? A lot of no, it's modification of drone dynamics. Yeah. Which neurodynamics means straight leg or a slump is neurodynamic maximum frame, no compressions, the rare ones are just closing out the canal and kind of seeing if it pegs them. Um, and then I would also say with a ridiculous opthia, like we're saying, I believe you had an impish in it. If there's a directional preference, which if they tell you or you find one, so I could send to the treatment, you know, can be part of the diagnostic process versus the trigger point. I don't think that's somewhat the case.

Peripheral nerve entrapments, as I said, I'm gonna throw in cutaneous nerve irritation, sensitization, entrapment in there because I think that's mainly what you're gonna see if it's just an entrapment. History presentation with this is, I would say largely activity dependent. So you have a nerve entrapment, it's usually like I go play tennis and I get radiating pain down my arm, I run for a while, my foot starts to burn down the side of my ankle or something like that.

You can have it positionally just like you'd have with radiculopathy, a little bit of trigger point, but I'd say it's more activity driven because of the interface, right? If you're testing neurodynamics, it's usually a big dynamic movement. The other thing is I asked Brett Winchester about this. Michael Shacklock talked about it when I had him on the podcast a long time. You usually have to have two areas of entrapment to have a true nerve entrapment because you're tugging on it at both ends. So that's like a...

Dr. Beau (21:34.89)

You know, it's not moving well in an open and closing dysfunction. And then you have some sort of trigger point or fascial distortion in the periphery. Uh, so what I would say is you can also get this with static positions, like sleeping, which is all of these would come on with static positions. I mean, how many people are you sussing out around shoulder stuff? I fall asleep and like my hand will now it goes down to pattern, right? Well, you could be cutting off oxygen by the muscle can't move. You could be closing down the frame and you could be, you know, closing down, break your plexus. Now you get a, that second.

I mean, all of those. So that history piece, maybe not as much, but I'd say the activity for sure. Also, I don't know if I've ever had a case where I was paying attention enough that if they have a true nerve entrapment, they're not pointing right to where like a cutaneous nerve like perforates the superficial fascia. Like we pay attention if somebody's like, dude, it just feels like I should. But if they're doing this kind of stuff and I'm, if you're not watching the video, I'm just rubbing vigorously over an area.

and it's a cutaneous nerve irritation, what are you probably doing? Pissing that thing off. But that's what most people wanna do, right? Whether it's around the anterior hip or around the elbow, the knee, maybe we don't see people crushing stuff in their knee, but foam roller, it's not out of their quad or stretching it. Again, stretching in these scenarios probably not gonna be the best thing ever. Could be associated with latent trigger points. What I mean by that is,

If you don't have an active trigger point, that would be something that's creating the pain of latent trigger point can alter, like we said, motor control, muscle output, joint, arthrokinematics, and then pretty soon, what are you doing? That nerve is getting tugged on or pulled around from both ends. And that's where I think latent trigger points. So then you have a decision to make. As I talked to Dr. Snell today, what's your intervention point is, you know, the stecho model would say, Hey, you got to get the, the myofascial slings moving so that nerve can move through them. Um,

I'm not saying versus, but maybe another approach is, hey, we desensitize the nerve, and maybe that desensitization of the nerve calms down the rest of the tissues. I don't know, pick a poison on that one. Associated skin findings, talk about all the time. Skin tension, your ability to actually roll the skin and pinch the skin. Trofedema, so that's that orange peel effect in the skin if it's got a lot of, or it hasn't moved a lot and you kind of get...

Dr. Beau (23:57.246)

Oh my gosh, lymph kind of trapped in with that superficial layer. And then just with any of these treatment findings, so if we use a neurodynamic test, you're probably gonna get an over abnormal test, you're probably going to use neurodynamics to jump in and treat that right away. I would say most of the time. So then you treat it, if you have a positive outcome, then you just solidified that as most of these would. Anything to add on peripheral nerve stuff? Trying to think.

And again, like DTM dermal traction is, I would say a pretty good diagnostic thing. If somebody has pain when they extend through their low back and you just grab their, you know, the skin over L four, L five, and you haven't do the same thing and they're like, yeah, I don't have any pain. Might be a good indication. Like clunial nerves are being irritated. Now, is that the only thing? No. But like, if I can change pain, I may change input, which changes output. And now here we go. We're on this like cascade. Uh, anything else?

Dr. Beau (25:01.022)

Now, one thing I will say on all of these, each one will garner a different treatment intervention, but then each one of them also garners different homework and adjunctive care. So sugar point, great thing. Let's say you find a sugar point and somebody is infraspinatus and we do a little bit of DNS, you throw some needles in it. I mean, you may say, hey, for the next day, don't do anything with that, but then like let's stekko around it. So I teach people a lot now.

that if the microphone is the trigger point that we can work on both sides of that microphone instead of working right on it and kind of pissing the trigger point off and get that kind of, the highlighter on it and running through there, get the fascia, heat it up a little bit next to it and you may just kind of keep that thing at bay. Because again, maybe we haven't had enough time to change motor control or whatever's causing the trigger point in the first place. Radiculopathy, you're probably not going to send them home sticking a lacrosse ball in there.

uh, in between their shoulder blade, if they got radiating pain, what are you going to be sending home? Probably in range loading, you know, McKinsey ask stuff, probably not a great time to send somebody home with nerve flossing or something like that. If they, so again, you can see once you have a clear diagnosis or you can like name like, Hey, it's this tissue that I think is causing it. And then yeah, there's functionality that you're going to work around it. There's dos and don'ts with all of these peripheral nerve entrapment. I mean, this is where like taping

And DTM, skin rolling, yapping, all these things come into play. Voodoo floss for you can be like, man, you can really crush symptoms. And again, especially after listening to the Dr. Snell today, I mean, maybe a big deal here is desensitizing the periphery to change output, right? Instead of always thinking like the periphery is sensitized because of something happening from the inside out. Um, and that's the research that Dr. Snell has been really diving into. So there's some interesting stuff that he's looking at that, uh, when

a very strange but, uh, intelligent mind on something like that. He'll come up with some interesting outcomes. Okay. Anything else, there anything else that causes referral patterns for sure clowered signs to the discs themselves. We looked up some Ligar. What was the ligament, uh, referral pattern? What was that guy's name? It's guy's name. You found a ligament referral chart and I was like, yeah, don't even worry about that. Uh,

Dr. Beau (27:24.738)

Huh? Clare. Clare me. Yeah, we'll look it up. Sclerotogenous referral patterns, visceral referral patterns. I mean, the list goes on and on. Most common culprits is what we talked about tonight. I would say the one thing to watch out for is making sure in your history that you don't have some viscerosomatic referral pattern going on. The big ones, heart. Yeah. And it, yeah.

Big ones like common gallbladder, like don't let somebody die of like a heart attack or a clot or something. Cause you're like, oh, your whole hand's numb. And you're like, yeah, let's work on this trigger point. Okay, your arm's a little red and swollen. That's okay. Yeah, so be a physician or that should be taken away from the second part of your moniker. So let's roll these out. So again, a review, we had the 15 year old female track and field athlete with heel pain.

week onset, 42 year old male that started running over the past few months has right heel pain to the point where he can barely run. History of some mild low back pain. And a 53 year old female trainer that was put in a boot a few months ago due to Achilles tendonitis. Now, I'll add something onto hers that kind of does matter. So maybe I slow played you. When I heard that she was in a boot, now she's in my office, she did PT and they said it was Achilles tendonitis. I just asked her, was it red or swollen or hot or anything like that at any point? No.

Firmly tell that patient you never had Achilles tendonitis. Did you have some sort of apathy with your Achilles? Maybe you definitely didn't have inflammation if you didn't have inflammation so you didn't have the ides is the ides Why is that important because? Dumbass doctors need to quit telling people shit. That's wrong. That's why and like don't let them get away with it Now don't be a jerk. I didn't want to make her feel Less than or dumb for having been put in a boot or listen. She's not she did what they told her and that is

why she did it because they hold authority. It's not on her at all. Um, but now that she knows if she has encounters again, it is on her. Um, so that's one thing. There was no inflammation, but I think that most people listening to this podcast, if we had somebody with Achilles pain that got stuck in a boot, you'd already be like, and calm bullshit. So here's the big reveal. So the 15 year old female track and field athlete honking trigger point remedial gastroc needle that puppy literally walked out of the office, no pain and ran attract me.

Dr. Beau (29:46.702)

Two days later, that was Thursday. So, how do we pull that out of that one? She dealt with medial tibial stress syndrome. So maybe there's some mechanical things that she likes to really get out in front of herself, maybe use the lower compartment a little more if she had. Where was I trying to mislead you? She was a dancer gymnast prior to getting in track and field. So now you already know that one of these other two isn't a trigger point thing, but maybe she had some low back stuff. You're like, oh, I gotta make sure I really rule out the low back, which you do. But I've seen her for a long time and I went with the most common thing and I.

palpated that and it referred pain into her medial heel. And I was like, I think that's it. And I know her history because I've treated her so much. So I didn't go back. Maybe I missed something and treat her low back. I threw a needle in that giant trigger point that her referral pattern was gone and it stayed gone. Now, if she was a brand new patient, it's a different way to approach that. The 42 year old male that started running had a heel pain. I was a dumb on this one. So he comes in the first visit.

I do some foot stuff with him because he, I mean, he can't do anything with his feet. He has no, you know, toe yoga is all off. I do that. Because the next time he's like, I'm kind of the same. Then in office, do a bunch of press ups. He gets up, he walks around and goes, you might, you don't hurt at all. I'm like, oh, cool. I'm like, I should have paid attention to him telling me that I've had my low back pain. Now he didn't say severe things. He didn't say he had a laminectomy, right? Which would red flag you this intuition's coming. But he did say he had back stuff.

with intermittent flare ups and he uses, he has flat feet and orthotics because I got led off course by that. Now let me pay attention to that, right? And he was asking me about shoes and what shoes you should get. So he kind of, he played a poker hand and I bet. So did some McKinsey based stuff, worked on some breathing stuff. We worked on some hinging because he was doing a little cross training. I haven't seen that guy in forever. Hopefully still running, but I saw him six, seven times. He was doing awesome. 53 year old runner. We only got one option left. What is it?

peripheral nerve entrapment. So putting a boot a few months ago, the Achilles tendonitis, where was her pain? I don't have the foot model, I should have shown it. Alex, you should just strip your sock off. No. If you go on, so I don't know if you can see this, but low. So we're saying below technically the insertion of your Achilles on the medial and lateral side of your heel. It's technically not even your Achilles. We're not in your Achilles.

Dr. Beau (32:07.554)

No inflammation, not on your Achilles, but you have Achilles tendonitis, get thrown in a boot and it was on the medial and lateral aspect. And she goes, the worst thing that I could do is squeeze it. Well, what's one thing that squeezing your calcaneus medial or lateral is could be indicative of? Stress fracture. It's actually the most common or the best test. But also what lives on the medial and lateral aspect. Well, your lateral and medial calcane or calcaneal nerve.

So they drape off that, what do they come off of? Tibial nerve. What was she also dealing with? Knee pain. Where did I get lead astray with her? I didn't get lead astray. I hit this one on the head, but I treated two prongs. She had a laminectomy 20 years ago, so I asked the question, have you had any back pain and anything going on? Because that hasn't been getting better. She's been doing PT and all this other stuff. So she goes, yeah, two, three weeks ago, my knee started bugging me where I can't flex it without it being really tight through the front. So I go, you know what? Let's not really treat your heel. I was almost certain.

that it was, you know, a peripheral nerve entrapment just based on presentation. I mean, there's, when there's no other anatomy there to cause pain, you kind of gotta be like, that's gotta be the thing causing it. So I said, hey, I'm not gonna treat your heel. I'm gonna tape it, right? So palliative stuff, we think it's nerve entrapment. I'm gonna give you knee gapping flexions because we determined on orthopedic tests that nothing was really going on with their knee other than, you know, restricted motion and flexion. And then I was like, you're gonna go home and do extensions for, you know.

two days and just see what happens. So she came in today. She did extension for two days, nothing happened. She did the flexions in her knee. She said she also did some other stuff and that's probably where her knee was better. But her knee was pretty much better. Her heel, interestingly enough, was better with the tape on and then worse than it was before when the tape came off. I don't think it was worse. I think she just had a refractory like, oh my God. Yes, exactly. So then she comes in. Well, how do I know it's better? Cause I could palpate it and there was no pain today. So today we did all the peripheral nerve stuff, voodoo floss, moving around.

taught her a tibial nerve flossing maneuver. And then that's what I sent her home with. So that again, all of them heel pain, all of them runners, all of them you could think like, oh my God, that's a low back case. Oh my God, that's, you know, whatever. Your intuition will get better and better, but like, it's not like I had a home run with the 42 year old dude, right? Like I was like, let's work on your feet. And it took me a visit to be like, hey, stop. Like I should have ruled out his low back. That was a new patient visit. I didn't do due diligence off of the history in the exam.

Dr. Beau (34:34.838)

So where are you thinking? Where are you thinking the knee came into that after the fact? Probably altered, probably altered running from what she said that her heel never bothered her when she ran. I mean, she was literally like, she couldn't jump without pain. She's in the boot. She was in a, so she hurt had Achilles pain in November of last year. She got out of the boot around the blood rock or right after blood rock.

She wasn't in the boot when she saw you? Yes. She's been out for a while. She did PT after the boot. So she was in the boot for about three weeks, then did five to six weeks of PT after that. They told her to just rest and wear the boot, which is also insanity that you don't do PT while you're in the boot.

10 inches magically. Yeah, I guess it just gets better. It just gets better. That itis that wasn't there just gonna go away. It's got a good job. You go do your thing. Stop freeloading. Yeah. Stop schmuckin'. I don't know, I thought this was kind of an error. We did this way back when in Grand Rounds. I kind of did this like multiple choice. What do you think's going on? Any input on any of those or different thoughts? And again, I gave you very little information on purpose. I didn't want to go through entire cases and suss it out. That's not what this is about.

How do you make a differentiation? Cause this is the stuff you're gonna see the most. And like, Snell said today, like, this is a bulk of his referrals because he's built a practice on people know that he deals with neuro stuff. So that's a lot of his referrals. Well, I think you could just like, you build a practice on gymnastics specialty feet. You could very easily be like, dude, I'm really good at sussing out like these, you know, paresthesia, referred patterns. People are not good at that at all. What?

in our profession, definitely in other professions, they're absolutely terrible. If you can point at pain, like these are all heel pain. We don't think of those as a referred pain or pointing at their heel. When you draw this ridiculous pattern, most physicians are gonna go, eh, it might be your neck. Well, maybe it's not. And that's where you can differentiate yourself. Now, how you sell that or market that, that's up to you, I don't know. I say you get one of those body suits and start doing YouTube videos, like on yourself, like the muscle suits.

Dr. Beau (36:49.519)

Yeah. I think that'll do really good. Yeah. Sticky note yourself. Sticky note. Yeah. Make yourself a cadaver lab nerve model actual pins. And then you can actually pull out your entire nerve. That'd be nice. All right. Well, that's all I got tonight. I wanted a fast and furious with this stuff. I didn't want to go another hour and 15 minutes. Um, I'm assuming.

I don't know, boiling boiled hot dogs is on here still. Kaylee and two other people are one. I think it's one plus two. So the sad announcement is, uh, still here thriving on boiled hot dogs. She's probably eating a hot dog right now. Um, and it's probably delicious. Actually, Seth and I were saying best hot dog ballpark, hot dog, wrapped in foil.

It's been marinating in its own juices. So the buns a little bit soggy to where he could literally just Kobayashi that thing and just, whoa, one bite. You don't like hot dogs? He doesn't like, he doesn't. He doesn't like hot dogs. I use it. Yeah, I see. Dude, I used to eat hot dogs raw when I was a kid, like Oscar Myers. Go in there and see one. Do you want to see one? Thank you. Get away with something. Oh, yeah. I'd be out of there. Gone. You can pipe down about three hot dogs at a ballpark in less than five. I could do a broad.

Like you guys ever microwave hot dogs in your kids? Nope. Just those things explode. Hot dogs did not happen in my house. They happen in my house. You know, it's technically super food. Sure it is. He literally looks peaked from talking about hot dogs. He does, he looks like a puke. I think the next ground round is we have Alex eat three hot dogs. See what happens. Kayleigh said, at least I didn't eat carnitas for literally 16 months straight. Too bad we've gone beyond that.

Not by much, Kaylee. Don't let him fool you. 16 months. 16 months ain't that long. I've been going on beef for about, and we're about ready to split a cow between the office. So you've had to beef it up. It's just going to be different cuts in there. Oh yeah. We're about to buy a grill. Kaylee, we're about to get sophisticated in this house, but the disappointing news is this is going to be the last live one. I, I especially love Kaylee. She's been here for every one of them.

Dr. Beau (39:07.998)

But we have to schedule these around our patient load and we try to do our best to make them a meaningful to everybody. But I mean, I'm just being honest, it's not worth it for this few people. So Kaylee, if you want, Alex probably has your address or something, I'll send you like a hoodie and a hat and stuff for being a beast and always being here. If the other person that's going unchatted wants to represent themselves and you've been represented and I'll do the same for you.

but we'll keep doing these. We're just not, we can do them live. I'm just not gonna try to make them at times that work for people. So it may get announced five minutes before. I'll still go live like this. Jayden's still here. Appreciate you, bro. And so there'll still be the opportunity. It's just not gonna be like a week in advance. I don't know. Somebody's hacking the system. They heard that we were shutting this down. My camera just bugged out.

So we love y'all, we'll still be doing residency stuff and releasing videos, but most of that's just gonna go on YouTube now, I think it's just better way. I'm gonna leave the Facebook forum up, I wanna keep having chats, and I think we had two people that commented on the what's your exam flow. So yeah, keep posting stuff in there if you want to. If you still wanna present a case, I'll still leave that open, you can go fill out the form or get ahold of us or something like that. And we'll see what goes on, now there's five people once I announce that it's going downhill, so.

Yeah, it's how it goes, but we love you. Uh, I don't know when the next one's going to be probably in two weeks, but it might be, I don't know, might be at 10 PM at the farm when we're all just turned. So let's see. 10 PM. I'd be upside down. I'd be upside down at 10 PM. Don't you have a baseball game or a softball game in it though? Um, I'm sure you're dirty. I'm sure we could go ask early that dude over here in the narrows for his inversion.

Yeah. He probably has no idea we exist, but I ran past a guy the other day in the neighborhood that's literally probably two or 300 meters away from the front door of this place. No clue. We exist. No clue. We exist. And he's hanging upside down on an inversion table in his garage. So that's what was about ready to go in there and Batman them. Just punch them right in the back. Adjust them. Walk out. Kick his knees backwards. So you just get more of that farther. Yeah.

Dr. Beau (41:21.486)

But we do appreciate everybody being on here tonight and everything before and like I said, we'll keep doing these just they won't be announced Quite so in advance, but look for those in the Facebook page when we do have a podcast coming Without further ado. See ya