Tough to Treat

Latest Episodes:

Physical Performance Decline in Menopausal Women: Strength vs Power Jun 03, 2025

Show notes

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.

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Building Better PT Practices: Courses, Clinical Reasoning, and Mentoring Insights Nov 28, 2024

Show notes

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

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Complex shoulder pain - how the narrative and red flags paint a different picture Nov 07, 2024

Show notes

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

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Shoulder Pain With Pull Ups or Push Ups? The Elbow Changes Everything Oct 24, 2024

Show notes

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

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Chronic Knee Pain - Where to Begin! Oct 10, 2024

Show notes

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

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Assessing Knee Health For Hip-Related Walking Pain Sep 26, 2024

Show notes

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

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When shoulder pain is dominant, but not the driver! Sep 12, 2024

Show notes

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

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Beyond Tennis: Exploring Shoulder Compression Across Sports Sep 05, 2024

Show notes

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

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A Stiff 1st MTP Joint can Affect Everything! Aug 29, 2024

Show notes

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

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Fencer with Bilateral Calf Pain Aug 22, 2024

Show notes

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

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