Tough to Treat

Susan Clinton and Erica Meloe

Welcome to Tough to Treat: A Physiotherapists’ Guide to Managing Those Complex Patients! Podcasts are hosted by Erica Meloe, PT, OCS, COMT, MBA, MA and Susan Clinton, PT, DScPT, OCS, WCS, COMT, FAAOMPT, who discuss how they successfully treated patients that others could not.

All Episodes

Why can't this athlete get rid of his low back pain? "Running- I have no problem with" "Lateral-side to side-movements really aggravate me". " Why?" How do we make a differential diagnosis here? And with significant unilateral calf weakness to add into the mix. Four ankle sprains and a 4th metatarsal fracture later, plus a "stress reaction" at L5, why wouldn't his low back be the source of his problem? Join us as we clinically reason through multiple facets of his case. Check us out: Toughtotreat.com

Sep 24

55 min

A recent article on various depths of squats revealed information that a full squat is more beneficial than partial squats in improving function and pain over time. Have a listen as we explore interesting comments/bias/evidence on why we rely on the squat as a revealing part of our examination and interventions. Follow link: https://www.tandfonline.com/doi/abs/10.1080/17461391.2019.1612952?journalCode=tejs20 Check us out: Toughtotreat.com

Sep 10

34 min

Another case with elbow issues! This case involves neural tension, pins/needles, and catastrophization. What is the best way to begin to work with someone who has multiple issues around fear of neural symptoms without neuro changes? Join us as we discuss dosing, position changes, problem solving and fear reduction in this interesting case. Check us out: Toughtotreat.com

Aug 27

43 min

Tennis elbow is one of those conditions that is extremely frustrating for both patient and practitioner alike. It turns into a persistent problem very fast. This was another one of our popular FB Lives we did recently. We unpacked the myths and theories around tennis elbow and what to do to treat it. Is it neurally driven? Cervical Spine driven? Does it emanate from poor shoulder mechanics? Or does it come from poor thoracic control? The key word here is "myths". Your pain generator may be the elbow, but the longer it persists, the driver(s) behind this frustrating problem migrate away from the elbow pretty quickly. Where do they go? Check us out: ToughtoTreat.com

Aug 13

41 min

We all have patients for whatever reason, who always come back for the same problem over and over again. Even if they haven't been back for over 5 years. Our bodies tend to take the path of least resistance and more often than not, when someone has fully recovered and they're back doing what they want, something happens and they return with the SAME problem in the SAME place. Why? Is that their achilles heel, so to speak? Or has their strategy changed because of something new in their life? Check us out: Toughtotreat.com

Jul 30

37 min

Your client has low back, hip, or pelvic girdle pain as examples, and you determine that the foot is the driver for these symptoms. What types of exercises would you prescribe to get them back to where they want to be? This is where you take the clinical reasoning to the next level! Whether it's loaded or unloaded, movement re-patterning requires you to really "connect the dots" in the body when it comes to moving someone through a sound exercise progression. This was initially recorded as one of our popular FB lives and we decided to share it as a podcast as well!! Check us out: Toughtotreat.com

Jul 16

34 min

What happens when your patient/client forgets to tell you key pieces to their history? It happens alot - and sometimes can have great impact on our decision making within the evaluation or treatment sessions. It is not their fault, it is just the way the central nervous system prioritizes events. Helping our clients remember and string these events together can not only help them solve their problem, but might be just the piece they need to integrate for healing. Check us out: Toughtotreat.com

Jul 2

49 min

This episode is about a weightlifter who suffered a T1 avulsion fracture, had surgery to remove the fragment and still had symptoms. Why? Because the avulsion was not the cause for this patient's lingering symptoms. Neuromuscular holding strategies as well as poor motor patterning were still there post-operatively. Think about what a weightlifter does before he performs a heavy lift and it will give you a clue as to what we needed to change. Check us out: Toughtotreat.com

Jun 18

53 min

Let's continue with the 3 powerful questions in determing the direction and priority of intervention. Immediate post-partum females can present with a myriad of complaints that often go "unheard" or "untold". The fears surrounding these symptoms can greatly change the person's ability to move forward with confidence in their body and their ability to achieve their life vision. Join us as we explore simple, but powerful ways to help this individual change her beliefs and tackle her fears while gaining confidence in her movements.

Jun 10

51 min

What do you do when your patient tells you she has not sat for 9 months? And furthermore, a healthcare practitioner told her this! How do you "debunk" this myth of not sitting while at the same time give her body the ability to toelrate sitting postures? Imagination, contextual change as well as letting the patient take control of the session. What? The patient takes control? Listen as Susan and Erica talk about giving the patient new and novel ways of movement while at the same time changing the patient's unhealthy belief that sitting is bad for you. Check us out: Toughtotreat.com

May 21

44 min

What are your three powerful questions that you use with your clients? Join Erica and I as we talk about working with clients from a full biopsychosocial approach. Does this mean all you do is pain education? How do clinicians best use the total approach to help clients regain self efficacy and manage their symptoms. There are also some great pearls around pelvic girdle pain in pregnancy as well. Check us out: Toughtotreat.com

May 7

47 min

Who hasn't heard this? This patient was seen in the clinic once just prior to the COVID-19 crisis and then progressed virtually from there. When someone says, " I hurt everywhere" and their symptoms appear randomly, how do you find a meaningful movement to assess? In particular, one that encompasses the whole body/whole person. Not an easy task, for sure, especially for someone who has significant amounts of anxiety related to movement and exercise. And with a past medical history of concussion, trauma and failed treatments. Listen as Susan and Erica take a deep dive into what is really going on here. Check us out: ToughtoTreat.com

Apr 23

59 min

What do we really know about the achilles tendon and the various forms of tendonosis? What do you do when the eccentric exercise programs outlined in the literature do not bring about a significant change of symptoms? Join us to explore some of the facets of tendonosis and a clinical discussion on changing interventions. Check us out: Toughtotreat.com

Apr 9

34 min

Success-your patient's original symptoms are gone and you are moving along with their program. They are progressing to higher loads, higher impact as well as incorporating tri-planar movement into their exercise. Then another region of the body starts to hurt. Why? Secondary and even tertiary drivers can appear at higher loads; even when they do not appear at the beginning. Be aware of this as your patient progresses. Susan and Erica discuss this fun case as they paint the clinical picture and offer many options for treatment. Check us out: Toughtotreat.com

Mar 26

45 min

Have you ever had a patient where the story and the problems they were having were easy to solve, but your thoughts were - "It can't be this simple?" Follow along with us as we discuss the differentials and treatment of a gentleman with numbness on the balls of his feet. It may not be what you are thinking - and then again, maybe it is! Check us out: Toughtotreat.com

Mar 12

34 min

This patient has had low back pain since she was a child. She has coped well until the birth of her own children. The innate response to threat here is the inabillity to arch her back. Her system cannot lengthen and she cannot do a back bend or sit and perform an anterior pelvic tilt. But she can get into prone on elbows and extend no problem. Post-partum is ALWAYS post-partum and her standing strategy is reflective of this. Check us out: Toughtotreat.com

Feb 27

40 min

What goes through your mind in pattern recognition when you hear the word heel pain? What do you begin to think - and then their story actually does not reflect the functional limitations expected. Join the co-hosts as they discuss the impact of multimodal issues that could be affecting this clinical presentation. Check us out at: Toughtotreat.com

Feb 13

33 min

One main symptom but 3 potential drivers. Is this person's glute pain coming from his hip? Low back? Pelvis? In this episode Erica and Susan discuss the differential diagnosis of a patient's butt pain which gets worse with sitting and driving. They discuss how multiple exam findings can lead you to one diagnosis but when all the pieces of this clinical puzzle are put together, a different story appears. Check us out at: Toughtotreat.com

Jan 30

41 min

What do you do when you run into a true hip joint limitation with persistent pain. altered patterns of movement and loss of the closed pack position? Join us as we explore the update of the female injured on her boat in Podcast #37 - what has improved, what has changed! Most importantly - how to help someone really work a new movement pattern and achieve ROM/Mobilization in some non-threatening ways! Check us out on ToughToTreat.com

Jan 16

41 min

Is a lateral shift a reaction to an irritated nerve root? Or is it part of a functional scoliosis? Or neither? This patient experienced persistent right shin pain with prolonged walking. A year ago she noticed a significant shift in her pelvis to the right. This episode highlights the importance of identifying the non-optimal movement strategy and prescribing exercise to correct it. We discuss how to re-pattern her movements with a focus on the "why" she moves a certain way vs just training a muscle in an isolated non-meaningful exercise. Visit our website: Toughtotreat.com

Jan 2

42 min

What happens when you are an athlete and have endured many injuries in your life that have all healed, and now you have a back injury that is stubborn and is now a persistent pain issue. Compound this issue with a diagnosis of a torn lumbar ligament and the thoughts of instability/grinding joints/bone on bone and other thoughts take over the movement system. Join us as we explore some strategies and option for changing fear and moving in novel ways. Visit our website: Toughtotreat.com

Dec 2019

38 min

We have all been through this-as providers or patients. One day your low back hurts on the right, the next day it's the left, and 2 days later it's your right hip and the saga goes on and on and on. Why? Is it because there is a movement control problem and you are just running out of options? Or is there perhaps another systems impairment that is contributing to all of this? Join us as we clinically reason through a male patient of Erica's who is experiencing these symptoms. Hormones are not just the domain of the female. More information at www.toughtotreat.com

Dec 2019

45 min

What flashes through your mind with a diagnosis of SUI - muscle weakness? That is certainly one hypothesis! Listen in on this episode where we explore another client with a "systems" problem that is much more involved than just simple pelvic floor muscle exercises. More information at www.toughtotreat.com

Nov 2019

43 min

Failed epidurals, back surgery and you still have buttock pain along with foot pain. Why? We all know back surgery is not always the answer, but why would someone's symptoms persist after all these interventions? Why would walking barefoot in the sand make this person feel better? Is the strategy different or is the nerve root still aggravated after all these interventions or both? Visit www.toughtotreat.com for all episodes

Oct 2019

44 min

Join us on this podcast as we work through the differentials of this complex post-partum client with the onset of elbow joint pain. Issues that have become so problematic, it's interfering with her sleep. Is it the elbow or the cervical spine - or neural tension? www.toughtotreat.com

Oct 2019

41 min

How does someone who has had 4 sessions of PT somewhere else become complex? The answer: She got the wrong treatment. And what happened? It sensitized her nervous system to the point that she was afraid that she was never going to get better. Ever hear of less is more? If you intervene at the right time with the right treatment, less is DEFINITELY more. More episodes at www.toughtotreat.com

Oct 2019

36 min

Explore the narrative of this client with persistent hip and leg pain for over 20 years. In this episode we explore the behaviors and mitigating factors that have increased the symptoms and are slowly turning this person with confronter behavior into an avoider. Sometimes the small changes can have a huge impact. Find out more at www.toughtotreat.com

Sep 2019

42 min

You have not run in over a year because of a foot and hip injury. Finally, it's all coming together-you have less hip pain and your foot pain has been gone for weeks. You are cleared for a return to run program and then after 2 minutes into it, you leak. Does this sound familiar to you or your patients? In this episode we bring in the patient who has these symptoms. This is a rare glimpse into "real time" clinical reasoning. We highlight some unique treatment ideas as well as provide the patient with a strategy she can tap into when she does leak. Physical Therapy with Tough To Treat hosts Erica Meloe and Susan Clinton

Sep 2019

57 min

Your patient cannot sit and cannot squat in the gym without lateral hip pain. They believe it is their overactive TFL. But is it the cause of the problem? Most likely, it is NOT. Why would someone have increased tone in a muscle? Think about a movement pattern where someone's center of mass is shifted to one side because of an old contralateral foot injury? You injure your foot and you weight shift off of that side where you stay that way for YEARS. Until one day, you run out of options. Sound familiar? Visit our website at www.toughtotreat.com

Aug 2019

49 min

Shoulder pain - or neck pain? Does it really matter to the intervention? What does the client believe and expect? How do you manage client expectations in this scenario? Join us in a rich discussion about this client's self-efficacy and managing expectations while reducing fear. Sound clinical reasoning shows you the value of asking the right questions to guide you in your treatment. www.toughtotreat.com

Aug 2019

38 min

Searing shin pain, low back pain, night sweats, unable to sleep or walk-is it the disc? The nerve root? A sensitive nervous system? Or something else? Or all of the above? Join us as we make a differential diagnosis on this gentleman's problem. Once again, listening to his story will give you clues as to how to begin the objective exam. Find out more at www.toughtotreat

Jul 2019

40 min

Do you ever wonder if there is a better way to evaluate the complex patient?  What do you do when the body diagram is full with a long history? I think we all are used to hearing our client's stories - but do we really listen to their full narrative? This can be the key to finding out what's important to them and sometimes, the simplest solution is revealed through their story along with the physical exam. Have a listen to this story and the key components! Sign up for our newsletter at www.toughtotreat.com We have some awesome free PDF's on assessing and treating complex patients!

Jul 2019

36 min

Do you want better outcomes with your patients? What do you do when a patient has plateaued? Or they're not improving as fast as they should be? One of the answers could be your exercise progression. Are you truly treating the source of the patient's problem with a specific movement program geared towards the SOURCE and NOT the symptom? What is the key to effective exercise progression? In this episode, Erica discusses what has been a real game-changer in her practice. That is: appropriate exercise progression for common drivers that she sees. She shares clinical pearls from her caseload and tools of the trade that have really helped her. Visit our website:  www.toughtotreat.com

Jun 2019

44 min

What happens when someone's thigh goes numb and does not go away? The nerve is obviously angry but what is the driver? What could possibly cause someone's thigh to go numb? Do hormones play a role in this case? Is it hypermobility? Is it the foot? Susan and Erica discuss all the possibilities for this particular patient's presentation and present SPECIFIC movements/exercises that the patient will do in order to calm that thigh down. Visit our website: www.toughtotreat.com

Jun 2019

42 min

Low back pain - the need to stretch and fear avoidance complications. What happens if the movement or postures you believe to be good are really problematic? We have delved into low back pain and the constant need to stretch, but sometimes it can also become more complex due to our thoughts and beliefs. Here are some good strategies for helping someone move and confronting their beliefs. Visit our website: www.toughtotreat.com

May 2019

37 min

What happens when someone suffers a traumatic injury, then lives with it for 8 months? Listen to this episode and find out. Susan and I discuss a former patient of mine who lived with hypersensitivity, bruising and swelling in her lower limb for months!! Think about what that does to your system? We also discuss developing a hypothesis/diagnosis based upon the subjective history. It is something we should do with every single patient. That is what makes you an expert. Furthermore, what happens when a patient's objective signs are worse after your treatment? I mean, right after, before they leave your office. We give you some tips and strategies to avoid this situation and give your patient a much better outcome. Visit our website:  www.toughtotreat.com

May 2019

38 min

Join in on this differential diagnosis and use of evidence to help determine the underlying cause and progressive movements to help this very strong and resilient female overcome nagging hip pain for over 5 years. Pain can be complex and contextual, it can also have a metabolic component as well. Consistency is the key to addressing her issue and progressing her program. Visit our website at www.toughtotreat.com

Apr 2019

45 min

Does this dancer with persistent left-sided pelvic girdle pain need to have her SI joint manipulated all the time? The answer is an obvious no! In this episode, we discuss how a professional dancer was able to get rid of her pelvic pain by looking up the chain. Remember- it is the movement strategy that counts. Digging deep into the demands of her performance, was the key to finding a solution for her. We also address the relevant exercise progression. If the symptom is the pelvis and the cause is somewhere else, how would you design a movement program for her? Listen and find out! Visit our site at www.toughtotreat.com

Apr 2019

50 min

This episode features a gentleman with complex metabolic issues, neurogenic pain and an interesting cross-section of mechanical MSK issues. Join us as we sort out the history and discuss the treatment interventions based on his unique story and the best way for him to function. Visit our website: toughtotreat.com

Mar 2019

48 min

Tough To Treat Masterclass: In this episode we have guest PT, Alaina Newell, who presents us with one of her tough male patients with a primary complaint of abdominal issues. Sometimes what our patients present with is only the tip of the iceberg. We clinically reason through the evaluation but move very quickly into diagnosis and movement. It is interesting how the story of this complex case unfolds over time. We brainstorm some great treatment ideas and various ways to change this gentlemen's fear avoidance. This is a fascinating story that can teach us all a lesson that healing is very individual. Visit our website at www.toughtotreat.com

Mar 2019

58 min

What do you do when your patient tells you that she hurts everywhere? In this episode, Susan and I discuss a patient with an EXTENSIVE injury history who happens to be a runner. Do these compensations over the years end up being what is the root cause of the problem? Or are there some cognitive and emotional barriers to recovery? The main issue here is hip pain. This is not your ordinary hip issue. Subjective includes, "ripping", "burning" and "a dead leg". Does the pelvis play a role? The foot? An old clavicle fracture? Listen and find out!! Visit our website www.toughtotreat.com

Feb 2019

49 min

Tough To Treat Masterclass: In this episode we have guest PT, Daria Oller, who presents us with one of her tough spinal patients. Is spinal stenosis a mystery? Not really.... We clinically reason through the evaluation but move very quickly into diagnosis and movement. We brainstorm some great treatment ideas and various ways to change this gentleman's compromised movement pattern. And it's not just the physical, this person has a significant fear based component to his problem, which can potentially prolong healing. Visit our website:  www.toughtotreat.com

Feb 2019

54 min

Professional dancers tend to push through tightness, discomfort and pain. Not surprising!   Often times the care they seek does not really address the driver(s) of their symptoms. More often than not, it is treat the painful part and move on.  That is not a recipe for long term relief.   Listen to this girl's story and see how we evaluated and addressed her symptoms.   Sometimes less is more. Visit our website www.toughtotreat.com

Jan 2019

33 min

Does elbow pain really emanate from the elbow? Sometimes it does. But the longer people wait to seek help, the higher the likelihood there is another driver. And therein lies the challenge. Join us as we clinically reason through this patient's elbow/arm pain and the ensuing treatment progression and exercise prescription. Visit our website:  ToughtoTreat.com

Jan 2019

45 min

What happens when someone gets injured while living on their sailboat at sea? This episode explores the clinical reasoning and intervention process from a virtual platform to help this lady through an unexpected injury to her hip and back and navigating the functions needed on a sailboat. Visit our website: toughtotreat.com

Jan 2019

47 min

When does motor control come into play when someone has persistent shoulder pain?  Is it soft tissue related, a joint problem or a neuromuscular repatterning issue? Or something else?   How does our nervous system adjust?  In this episode we talk about the multiple sources to this person's shoulder pain and how retraining his arm lift was the key to his recovery. Visit our website: toughtotreat.com

Dec 2018

38 min

There are many ways to approach pelvic pain and symptoms of urinary urge incontinence, but did you know that how the MSK system moves can affect these symptoms as well?  On this podcast, we take a dive into the movement system, past/present autoimmune history and post-partum process while changing this client's symptoms as well as her urinary incontinence.  In turn she regains control over her pelvic pain! Visit our website: toughtotreat.com

Dec 2018

55 min

How do you rehab someone who is VERY hypermobile and suffers from persistent low back pain? Carefully and specifically! This episode highlights the beauty of a specific exercise progression tailored to the patient's meaningful movement. Listen as we go through the clinical reasoning process to determine what types of movement patterns will work and what ones won't. Doing the right thing at the right time is clinical expertise. Visit our website: toughtotreat.com

Nov 2018

49 min

Explore the origin of this client's shoulder pain as we discuss a biomechanical vs. systemic history and how the pain experience had changed her ability to fully participate in life and exercise. Visit our website: toughtotreat.com

Nov 2018

38 min

When a 12 year old comes to you with complaints of posterior thigh pain that is not going away, your radar should go up.  Especially, when she presented with knee issues previously which were alleviated within 3 visits. Being a good listener is extremely important; but in this case, being a good questioner provided the answer.

Oct 2018

34 min

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