Physical Therapy

[SouthPod7]

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Hi,

How do you guys pitch/offer physical therapy as an effective modality of treatment for your patients? I’m not talking about post op PT that usually is incorporated into the course of treatment, but I’m talking about PT for arthritis, chronic instability, pain, etc.

I work at an FQHC and the majority of my patients are on Medicaid or Medicare and many of them have diffuse or chronic MSK complaints frequently with a lower back or sciatica component and I think oh this might do well with PT but I almost always get shot down. Is it how I’m pitching it? I had a lady today with functional ankle instability and I gave her a brace and offered her PT and she declined the PT and then said “So there’s no treatment options for my ankle then?”

 

[Adam Smasher]

Usually commercial plans are a harder sell, because it's a copay every session. Surprising for Medicare/Medicaid.

I guess tell them "If you can't do PT then you should try a home exercise program, but I think you would benefit from a structured rehab program" Point out that they have some limitation of strength, range of motion, or balance, and PT is the perfect modality to restore this deficit. You may already be doing this, and your pts may be looking for a quick fix (narcotics).

 

[Feli]

You need gray hair, balding, age 40+, or glasses.

If you can't hit the first 3, try glasses?

Your patients will do what you say... or they'll at least be nice enough to lie and say they will do/fill/try what you say. 🙂

 

[Hybrocure]

“I think at this point physical therapy would be a great plan. I’ve had a lot of patients with your condition who did well with PT after failing “x” to get better.”

I’ve had very very few patients shoot me down for PT honestly. And I am very liberal with sending my patients to PT.

 

[Toenail]

I’m booked out about 2 months for surgeries, so, either complete a course of PT first and then they can get on the waitlist or go find someone else — no sweat off my back, I’m already loaded to the gills. This weeds out a lot of noncompliance too. Obviously I’m not putting folks with bunions or ankle arthritis through PT because that’s a waste of their time.

 

[Hybrocure]

Also sometimes old people just don’t want to face the fact they’re getting old. Yeah you play pickleball at 75 years old I’m probably not going to be the guy to rebuild your lateral ankle ligaments. To PT you go.

 

[air bud]

Also sometimes old people just don’t want to face the fact they’re getting old. Yeah you play pickleball at 75 years old I’m probably not going to be the guy to rebuild your lateral ankle ligaments. To PT you go.

Actually an internal brace is great for an active 75 year old....the whole point it that is strong as crappie right away and they need minimal PT after

 

[Hybrocure]

Actually an internal brace is great for an active 75 year old....the whole point it that is strong as crappie right away and they need minimal PT after

I’ll send my oldies over to you

 

[Weirdy]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy.

Anything else I'm missing?
Literature says eccentric PT, maybe shockwave

Have considered Zadek, tendon lengthening when indicated

I am not very trigger happy on doing full detach reattach on these people.

 

[Hybrocure]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy.

Anything else I'm missing?
Literature says eccentric PT, maybe shockwave

Have considered Zadek, tendon lengthening when indicated

I am not very trigger happy on doing full detach reattach on these people.

Ozempic

 

[air bud]

@Retrograde_Nail is going to tell you still operate on them but do the MIS speed bridge that's his new go to I'm going to start trying it also

 

[Retrograde_Nail]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy.

Anything else I'm missing?
Literature says eccentric PT, maybe shockwave

Have considered Zadek, tendon lengthening when indicated

I am not very trigger happy on doing full detach reattach on these people.

MIS Achilles speedbridge. Learn it. Love it. Live it.

 

[Weirdy]

MIS Achilles speedbridge. Learn it. Love it. Live it.

Done a few times in residency. Been a while.
Will consider it.

 

[Boba Foot]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy.

Anything else I'm missing?
Literature says eccentric PT, maybe shockwave

Have considered Zadek, tendon lengthening when indicated

I am not very trigger happy on doing full detach reattach on these people.

I do 1 cm heel lift or shoes with equivalent heel to toe drop, Medrol pak, meloxicam for 6 weeks. About 50% respond. For the rest I put SpeedBridge on the table if they're a candidate and MRI shows the need.

But also, in Texas, as @Hybrocure said, Ozzy would actually solve a lot of these people's plantar fasciitis, tendinopathy, etc. in the long run.

 

[heybrother]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy.

Anything else I'm missing?
Literature says eccentric PT, maybe shockwave

Have considered Zadek, tendon lengthening when indicated

I am not very trigger happy on doing full detach reattach on these people.

1. Achilles stretches, eccentrics etc.
2. NB / Hoka / Brooks etc.
3. Posted prefab orthotic that cost $15-20 a piece and can be sold for more than that.
4. Meloxicam 7.5 mg -> etodolac 400 mg bid
5. PT if interested, but normally not for at least a few visits in because of cost.
6. Shockwave if interested. $100 a session. I don't perform it.
7. Juggerknot. I'm too stupid for SpeedBridge.

I never write oral steroids anymore. Medrol dosepack courses are too short.
I would make a lot more money if I put everyone in a CAM boot but I don't.
My preference is the patient simply beats the pain walking normally.
I really enjoy doing Achilles detach/repair, but I almost never have to.

 

[Bluecollarmed]

Love a good MIS zadek or MIS speedbridge. Game changers and some of the happiest patients in the clinic.

 

[Feli]

What are you guys doing for insertional Achilles tendinopathy?

BMI 40+ and usually non compliant. Poor surgical candidates.

Boot, meds, physical therapy. ...

I don't do anything surgical for Achilles on the bigtime eaters unless they are proven to be super compliant. I'm happy to refer those ruptures or even simple insertion Achilles pain ones out for morbidly obese. I will do gastrocs on flat foot, but even those people have to be near normal BMI and generally healthy.

It's not a skill thing... just that it's a pain for anesthesia to do the huge ppl prone and big complications can happen. The wound complications are common in the big folks... they can't stay off of it and just don't heal as well. Not my cup of tea.

Surgery has enough issues that can sideswipe your weekend or evening or clinic day even when you pick mostly good candidates. I'd let someone else have the wide-as-they-are-tall heifers and the buffet Billys. Jmo.

You have to remember there are night and day differences between VA/IHS (tort reform) versus normal hospital employed (attendings, residents, fellows) versus employed PP (ortho/msg/pod/solo). For the hospital or govt employ folks, they can get a suit or bad complication or even BKA off elective, and they still have a fat salary guaranteed or the facility just picks up the insurance rate increases. For PP on those same awry cases, that is a lot of missed time dealing with complications, dealing with deposition or case review, and you get hit with the malprac rate increase for years to come can affect your job security or profitability... possibly bad reviews or slander also. It's pretty different world for different employ situations as to how frustrating and consequential complications or litigation are - or are not.

 

[Hybrocure]

I don't do anything surgical for Achilles on the bigtime eaters unless they are proven to be super compliant. I'm happy to refer those ruptures or even simple insertion Achilles pain ones out for morbidly obese. I will do gastrocs on flat foot, but even those people have to be near normal BMI and generally healthy.

It's not a skill thing... just that it's a pain for anesthesia to do the huge ppl prone and big complications can happen. The wound complications are common in the big folks... they can't stay off of it and just don't heal as well. Not my cup of tea.

Surgery has enough issues that can sideswipe your weekend or evening or clinic day even when you pick mostly good candidates. I'd let someone else have the wide-as-they-are-tall heifers and the buffet Billys. Jmo.

You have to remember there are night and day differences between VA/IHS (tort reform) versus normal hospital employed (attendings, residents, fellows) versus employed PP (ortho/msg/pod/solo). For the hospital or govt employ folks, they can get a suit or bad complication or even BKA off elective, and they still have a fat salary guaranteed or the facility just picks up the insurance rate increases. For PP on those same awry cases, that is a lot of missed time dealing with complications, dealing with deposition or case review, and you get hit with the malprac rate increase for years to come can affect your job security or profitability... possibly bad reviews or slander also. It's pretty different world for different employ situations as to how frustrating and consequential complications or litigation are - or are not.

💯

My thoughts entirely about PP and it turns out most people I come across in PP with Achilles pathology are obese