Tough to Treat

In this episode, Erica explores how clinical reasoning informs decision-making across diverse areas of physical therapy practice. This is a clinical pearls discussion that will save you lots of time in the clinic.  From CKC to OKC brain mapping in an MMA fighter to exercise progression in ACL rehabilitation to thoracic dysfunction in a post partum runner experiencing hip pain and incontinence, she highlights key clinical reasoning strategies that guide effective treatment and exercise progression. For example, if your patient has a bracing strategy in their lumbar spine where they always "grip" their back when they sit, stand and even go supine, how would you prescribe exercise to "take out" that strategy to give them more options for movement? Many people do this in our "sit up straight" culture. This will make a huge difference in your practice!   Related links: Tough To Treat Website Erica’s Website Susan’s Website        

How long should you keep treating a patient? And what’s the best approach when they’re skipping their home exercise program? In this listener Q&A episode, Erica shares practical strategies—illustrated through two real patient cases, one a golfer and the other a cyclist—for answering the tough question of treatment length and for addressing non-compliance. She highlights how building a strong therapeutic relationship can improve follow-through and make these conversations more productive. Erica also highlights the most important phases of an exercise program to ensure efficiency and compliance.  To close, Erica offers a brief update from her doctoral research on menopause, focusing on the role of muscle power in older women and why it may be a more critical predictor of function than strength alone.   Related links: Tough To Treat Website Erica’s Website Susan’s Website    

In this episode, Erica dives into a fascinating case of a patient experiencing neck pain and how that seemingly isolated symptom actually traced back to an old foot injury. This case exemplifies the deep, interconnected nature of the human body. For those you have been listening for a while, this should not surprise you. She unpacks the biomechanical and neural links between the foot and cervical spine, exploring how altered load distribution and compensatory patterns can persist long after the original injury appears to have healed. A key focus of the discussion is the role of the center of mass—how shifts in its control can influence motor strategy and postural control, ultimately impacting regions far from the original site of injury. Erica also covers exercise options, including progressions that integrate both the foot and cervical spine.  How to adapt your treatment when load transfer is compromised is a key factor in this patient’s outcome. This episode is a reminder that in rehab, it’s rarely just about the joint that hurts—it’s about the whole system that moves around it.   Related links: Tough To Treat Website Erica’s Website Susan’s Website    

In this episode, Erica talks about how to approach care when a patient has a long history of injuries and a body chart that seems to be "lit up" everywhere. It can feel overwhelming—for both the patient and the clinician. She focuses on the importance of prioritization: identifying what’s most clinically relevant right now. This involves connecting the dots to perhaps an old injury to what the current problem is. In this particular case, frequent bilateral ankle sprains, an ACL reconstruction plus a continued pattern of bilateral issues help you nail down your focus to what is important for you to assess and what is important for the patient to feel.  These patterns not only shape your clinical focus—helping you decide what truly needs assessment—but also give the patient a clearer sense of what their body is trying to communicate.  What is relevant to you may not be important to them. It's up to you to explain to them why. Key takeaways include: ·       Avoiding the trap of chasing every symptom. ·       Establishing a hierarchy of concerns using patient input and objective findings. ·       Acknowledging the complexity of the history without letting it dictate the entire plan.   Related links: Tough To Treat Website Erica’s Website Susan’s Website      

This episode dives into some of the evidence on resistance vs. high-velocity power training in postmenopausal women and its impact on bone mineral density (BMD). Research is highlighted showing that high-speed training protocols may stimulate bone more effectively than traditional resistance training by increasing strain rates and promoting osteogenic adaptation. You’ll learn how moving with speed and control helps strengthen bones and prevents age-related decline better than slow, heavy lifting alone. Some of Erica’s research for her doctoral dissertation is discussed and she then presents a case study of a menopausal patient with insidious-onset shoulder pain and offers some clinical pearls as to why, especially in anyone who has played a racquet sport, the shoulder is not the only driver. She also highlights a few targeted interventions that allowed this woman to weight lift and strengthen her shoulder without feeding into her symptoms.   The content contained therein, including text, images, audio, or other formats, were created for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.    Related links: Tough To Treat Website Erica’s Website Susan’s Website        

In this episode, Erica dives into the latest research exploring how menopause affects physical performance in women—highlighting changes in power and strength. These findings are reshaping how we approach exercise and rehab in midlife women. Next, she shares an update on her dissertation, which compares premenopausal and postmenopausal women on key physical performance metrics. Erica discusses early patterns emerging from the data, including potential implications for exercise training and rehab prescription. She wraps up with a clinical case involving a woman in menopause experiencing persistent neck and shoulder pain, along with difficulty breathing. She breaks down the history along with a few clinical pearls outlining how past injuries have and continue to contribute to this woman’s issues. Erica also breaks down her exercise program, discussing the do’s and don’ts of exercise progression.   Hormonal changes can contribute to musculoskeletal tension and diaphragmatic dysfunction- we know this. But do we really educate our patients on this? Many do not. Whether you're a clinician, researcher, or someone navigating midlife changes, this episode offers insight, evidence, and strategies for supporting well-being during menopause.   Related links: Tough To Treat Website Erica' Website Susan's Website

In this episode, we answer the most common questions we get from listeners. We dive into course recommendations, highlighting resources for continuing education, mentoring and evidence-based practices.   A key focus is on clinical reasoning strategies—how to approach complex cases and integrate patient-specific factors into your decision-making. We also discuss the value of spending the majority of your first session taking the patient’s story.   Your patients will make you a better physical therapist, if you listen to them. Be curious and let it lead you towards mastery.   A glance at this episode: [2:27] Courses and Continuous Learning [12:11] Starting the Podcast and Building a Community [13:17] Mentorship and Clinical Reasoning [19:10] Treatment Sessions and Client Engagement [22:56] The Role of Patients in Clinical Learning [26:41] Reflecting on the Year and Planning for the Future   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Clients self-refer for many reasons and we find ourselves on the front line of health care screening. Join Susan and Erica as they uncover key elements in a client's history and narrative around long-standing shoulder pain. Simplistic presentations usually mask true underlying considerations including the client's beliefs and red flags.   A glance at this episode: [1:41] Client's Initial Presentation and History [4:07] Exploring Past Injuries and Chronic Bike Riding [6:56] Impact of Corporate Life and Breast Cancer on Health [13:08] Concerns About Bone Health and DEXA Scan [15:21] Addressing Left Shoulder Pain and Movement Dysfunction [17:51] Implementing Modified Exercises and Pilates [39:28] Discussing the Power of the Narrative and Patient Advocacy [40:13] Connecting Patient Goals to Treatment Outcomes [45:17] Final Thoughts and Episode Closing   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, we explore the surprising journey of a boxer battling chronic shoulder pain that left him struggling to do even the most basic workout. Despite focusing on his shoulder, it turns out the root of his problem lay elsewhere—his elbow. Is that surprising? It was in his injury history. Do not discount the power of an old injury that could come back and haunt you. And think about the load on the elbow when you're doing a push or pull-up. Join us as we clinically reason through this interesting case from start to finish.   A glance at this episode: [0:01] Introduction and Patient Background [7:03] Initial Assessment and Observations [11:56] Exploring the Root Causes [14:12] Addressing the Pull-Up Challenge [32:06] Implementing Exercise Program [36:32] Final Thoughts and Key Takeaways   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Susan and Erica are back together for the Fall season! Chronic knee pain can be much more than a regional event. Susan presents a client with an extensive timeline and clinical reasoning as to why it is important to consider the entire system in this integrated approach. The key here is also maintaining relevance and sustainability for the client.   A glance at this episode: [1:18] Explanation of Episode Structure and Content [2:59] Introduction to the Client Case Study [5:30] Client's Medical History and Injuries [12:47] Initial Assessment and Observations [13:33] Treatment Plan and Initial Intervention [31:02] Follow-Up and Client Feedback [31:17] Advanced Treatment and Future Plans [31:31] Conclusion and Encouragement for Listeners   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica explores the often-overlooked relationship between hip pain and knee function during walking when the patient does NOT have knee pain. Join in as she dives into the role of the knee in compensating for hip dysfunction, and how a thorough knee assessment can uncover hidden contributors to hip discomfort. Remember: old injuries have a way of sneaking up on us and becoming one of the drivers of our current problem. An old hamstring tear 5 years ago as a contributor to this patient's problem? Think again.   A glance at this episode: [2:23] Patient Background and Injury History [3:46] Assessment and Initial Findings [6:33] Knee and Hip Mechanics [10:11] Terminal Knee Extension and Treatment Approach [20:43] Clinical Reasoning and Patient Outcome [20:58] Conclusion and Call to Action   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Shoulder pain, like any other joint can present as primary pain and can be the #1 reason a client may be seeking help! In many cases, treating the obvious joint dysfunction (because it checks all of the boxes) may not result in optimal outcomes. Join the conversation as Susan and Erica explore the various reasons and important timelines in the client's history that has led to her shoulder pain. Most importantly follow the clinical reasoning that led to the real driver of this issue. Bonus - we also offer a great discussion of a good exercise progression!   A glance at this episode: [1:39] Shoulder pain and internal rotation [7:52] Which side of the table should you work from [12:40] Learning to tape the wrist [20:00] Opening the hands [22:46] Using the blocks for yoga blocks [27:58] Grip strength as a sign of health   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

In this episode, Erica discusses the why behind shoulder problems, comparing the unique challenges faced by tennis players and non-tennis players alike. She explains why traditional shoulder treatment often fails these types of patients. A significant relationship between the shoulder and another region of the body is often missed. Erica also tells the story of one of her patients who does play tennis and the reason why he can do a full pushup but can't lift his arm over his head. For our physio listeners, oftentimes you can progress patients through a full range of CKC exercises but the OKC piece does not progress as quickly.   A glance at this episode: [0:01] Erica's Summer Vacation and Introduction to the Episode [2:30] Clinical Pearls for Tennis Players [6:15] Assessing Upper Thorax and Glenohumeral Joint Compression [12:53] Treatment Approach for Upper Thorax and Glenohumeral Joint Issues [15:54] Progressing Patients with Glenohumeral Issues [16:14] Clinical Pearls for Closed Chain Exercises [20:37] Conclusion and Encouragement for Practitioners Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

One of the most overlooked joints in the lower quarter is the first MTP joint unless that is the client's primary complaint. How does the stiffness of the MTP joint affect gait and lower quarter movement of all kinds? We spend some great time discussing differential diagnosis and practical interventions and sharing some new discoveries. Hint: the exam and intervention do not always center around the stiff 1st MTP - there is likely a primary driver elsewhere.   A glance at this episode: [0:01] Introduction and Podcast Rebroadcast [2:13] Overview of Stiff First MTP Joint [4:21] Compensation and Adaptation [6:30] Assessment and Treatment Approaches [23:22] Exercise and Proprioception [25:47] Shoe Recommendations and Adaptations [34:17] Conclusion and Final Thoughts   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

What is the cause of bilateral calf pain in this young fencer? From start to finish, it shows the power of a thorough evaluation, a specific exercise progression, and a return to the sport she loves. When it comes to exercise progression in persistent pain, think about context. How can you improve optimal movement patterning by changing the context? Think about this one. You can intervene via the visual system, eyes open, eyes closed. How about changing their base of support? Wide to narrow. And why not have them do their exercises to their favorite music? These are just some examples. Look at your patients through a different lens and then see positive change.   A glance at this episode: [0:01] Introduction and Case Overview [7:46] Initial Assessment and Clinical Reasoning  [10:27] Hypermobility and Initial Treatment [20:14] Progression and Additional Techniques [32:40] Advanced Techniques and Future Plans  [52:04] Conclusion and Reflection   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

How similar are the neuromuscular responses to pain with Chronic low back pain and GI pain? Join Susan and Erica in a great discussion of the role of the diaphragm and how this changes with pain and inhibiition/over-recruitment in the system. In chronic low back pain and abdominal bloating/distention the diaphragm becomes a postural control muscle which greatly limits the respiratory ability and is an ineffectual model for spine stiffness and visceral organ pusher. This is an excellent discussion following the podcast episode 185.  1) Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):352-62. doi: 10.2519/jospt.2012.3830. Epub 2011 Dec 21. PMID: 22236541. 2) Villoria A, Azpiroz F, Burri E, Cisternas D, Soldevilla A, Malagelada JR. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May;106(5):815-9. doi: 10.1038/ajg.2010.408. Erratum in: Am J Gastroenterol. 2011 Jul;106(7):1405. PMID: 21540894. 3) Sicilia-Gomez C, Fernández-Carnero S, Martin-Perez A, Cuenca-Zaldívar N, Naranjo-Cinto F, Pecos-Martín D, Cervera-Cano M, Nunez-Nagy S. Abdominal and Pelvic Floor Activity Related to Respiratory Diaphragmatic Activity in Subjects with and without Non-Specific Low Back Pain. Diagnostics (Basel). 2022 Oct 18;12(10):2530. doi: 10.3390/diagnostics12102530. PMID: 36292219; PMCID: PMC9600311.      A glance at this episode: [0:01] Diaphragm function, GI dysfunction, and postural control [7:51] GI dysfunction and its impact on abdominal wall muscles and posture [13:39] Abdominal dysfunction and diaphragm movement in relation to chronic low back pain [20:36] Treating chronic low back pain through abdominal wall retraining [25:09] Abdominal wall deficit and diaphragm dysfunction in chronic low back pain patients [32:07] Treating gas and bloating through diaphragm therapy 36:32] Treating GI dysfunction through breathwork and positioning Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

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.   A glance at this episode: [5:13] Hypermobility and pain management for a 24-year-old woman [11:26] Hypermobility, muscle imbalances, and control issues in a patient with back pain [19:00] Shoulder subluxation and its relation to past injuries and yoga practice [23:57] Diaphragm recruitment in back pain patients [27:47] Addressing short girl syndrome in a dancer [32:03] Using tape and Pilates equipment to improve abdominal strength and stability for a hypermobile patient [35:51] Improving posture and flexibility through exercises on a reformer machine [39:23] Exercises for a spin instructor with tight hip flexors [43:34] Exercises for hypermobile individuals to improve motor control and recruitment   Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript

If it walks like a duck and quacks like a duck - it must be a duck, right? Low back pain is a descriptive term at best, indicating where symptoms present. Join Susan and Erica as they explore this Tough to Treat client with low back pain and mild stress urinary incontinence. Discover the history and the movement system examination and interventions that led to the successful reduction of symptoms. *Hint: this really isn't a duck! Visit our website: toughtotreat.com   A glance at this episode: [0:01] Low back pain and pelvic health issues, client with gradual onset of stress urinary incontinence [2:16] Pelvic health and trauma history after a recent fall [7:21] Patient's foot and leg issues, including supination and knee pain [13:08] Addressing knee issues through breathing and positioning [15:50] Knee and back pain treatment using bridging and lunge exercises [22:01] Treating knee pain and low back pain through exercises and manual therapy [27:45] Treating patients with movement system changes to address low back pain and pelvic health issues Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

Now, this is a CHALLENGING one! Ever have those patients who have been everywhere, had everything done to them (injections, surgeries, acupuncture) and nothing helped?  Well, this is your lucky day because this episode really takes us down the chain from head to toe with someone who had low back pain. Pretty standard, right?  But this was FAR from standard. Hint: her low back was not the source of her problem. Why do you think that is? Remember, we bring all of our compensations to our life events. And our movement and injury history sets us up and our dominant patterning keeps us there.   Visit our website: toughtotreat.com   A glance at this episode: [0:01] Complex medical history and treatment options [7:06] Chronic pain and potential causes [12:14] Pelvic issues and postural compensations [18:41] Pelvic and foot issues, possible nervous system impairment [23:21] Decompression techniques for a patient with nervous system issues [26:31] Yoga and physical therapy for a patient with neck pain [29:13] Treating a patient with chronic pain using movement patterns and cranial work [35:07] Standing and carrying issues, loading exercises suggested [40:07] Exercises for back pain relief, including cycling, Nordic walking, and rock climbing [42:28] Using yoga and rock climbing to improve standing tolerance for a client with chronic pain [47:30] Treating patient with chronic pelvic pain Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript  

What do you do when a client presents with a myriad of LQ symptoms without a clear regional driver? Look to the history and keep asking questions even further back than the recent onset or episodic flare. Join us as we discuss complex neurology of a visceral driver that has signs of dysfunction and a somatic pain presentation. Once again, the history is so important!   A glance at this episode: [0:01] Left lower quadrant pain, nociceptive input from visceral driver [2:23] Pelvic pain and potential visceral driver [8:05] Bladder issues and pelvic floor tension [10:49] Bladder irritants and pelvic health with a patient [16:49] Lower back pain and posture with a physical therapist [20:04] Pelvic floor exercises and visceral manipulation for pelvic pain relief [24:34] Pelvic floor exercises and core strength for bladder control [26:45] Improving driving skills and addressing bladder issues [32:49] Visceral mobilization and pelvic floor issues Related links: Tough To Treat Website Erica’s Course: Decoding the Complex Patient Susan’s Pelvic Health Education Subscription Access the Transcript