Orthopaedic Physiotherapy Grand Rounds 19 - Beyond the Back: Differentiating and Treating Complex Leg Pain

Overview

What do you do when a young, active patient presents with insidious leg pain that doesn't fit a clean diagnostic picture?

This course takes you inside Orthopaedic Division Grand Rounds 19, where a panel of expert clinicians work through a genuinely complex case: a 23-year-old IT worker and cricket player whose left back and leg pain has brought his sport to a halt. Through a meticulous walkthrough of subjective history, objective findings, manual therapy application, and imaging interpretation, this session models the kind of systematic clinical reasoning that separates good clinicians from great ones.

The Grand Rounds format, with live panelist discussion and debate, makes this an unusually rich learning experience that goes well beyond a standard didactic lecture.

Learning Objectives

By the end of this Grand Rounds course, participants will be able to:

1. Analyze subjective and objective clinical findings in a young adult patient presenting with insidious left leg and back pain, including how sport-specific biomechanics (cricket bowling mechanics) elevate risk for specific spinal pathologies.
   
   
2. Evaluate neurodynamic testing results, including the Slump test and Straight Leg Raise, to distinguish between discogenic pain, foraminal involvement, and neural tension as drivers of radiating leg symptoms.
   
   
3. Interpret the significance of centralization versus peripheralization of symptoms as a key indicator of active disc involvement and a guide for treatment progression.
   
   
4. Formulate and critically appraise a manual therapy treatment plan targeting the lumbar spine and sacrum, including recognizing when temporary relief signals a more complex underlying pathology.
   
   
5. Interpret basic X-ray findings, including congenital pedicle shortening and Schmorl's nodes, and understand when imaging findings may be incidental versus clinically significant, and when advanced imaging such as MRI is warranted.

Audience

This course is designed for physiotherapists, physical therapy students, orthopaedic specialists, and allied healthcare professionals who want to sharpen their clinical reasoning around complex spinal and leg pain presentations. It is particularly valuable for clinicians working with active adults and athletes, where return-to-sport goals add an additional layer of complexity to differential diagnosis and management planning.

Why This Course Matters

Leg pain that originates beyond a straightforward lumbar disc herniation is one of the most diagnostically demanding presentations in orthopaedic physiotherapy.

This case, involving suspected sacral torsion, neurodynamic sensitivity, congenital canal narrowing, and a sport with high rotational spinal loading demands, illustrates exactly why systematic clinical reasoning matters more than pattern recognition alone. The panelist discussion format models interprofessional clinical dialogue at its best, exposing learners to how experienced specialists weigh competing hypotheses, integrate imaging, and know when conservative care has reached its limits.

This course is part of the Orthopaedic Division Grand Rounds series — all recorded sessions are available on Embodia.

Case Presenter

Michael Monks, PT, BKin. (Hons), MSc. Kin., MSc. PT., CSEP-CEP, ACCDN

Originally from Newfoundland, Michael completed both his Bachelor of Kinesiology (honours) and Masters of Kinesiology at Memorial University in 2014 and 2016, respectively. During that time he also completed his Clinical Exercise Physiologist (CEP) certificate from the Canadian Society for Exercise Physiology (CSEP). In 2018 he completed his Masters of Science in Physiotherapy from Dalhousie University. Since finishing school, Michael has been working in the private sector and has been working towards obtaining his FCAMPT credential through the AIM system. He was the recipient of the Cliff Fowler Memorial Education Scholarship in 2023.

Panelists

Karen Decker, BScK, BScPT, Dip. Sport PT, Dip. Manipulative Therapy

Karen completed her Physiotherapy and Kinesiology degrees at Dalhousie University in 1991. She has attained the post-graduate specialization Diploma in Sport Physiotherapy and the Diploma of Manipulative Therapy. As a Sport Physiotherapist, Karen has worked with all levels of athletes in the clinic and on the field. She has attended seven Canada Games, three Olympics, the Commonwealth Games, the Pan American Games, and travelled internationally with Canada’s National Teams. She has been the Chief Therapist for many games including the 2011 Canada Games held in Halifax where she resides.

Audrey Long, BScPT, Dip MDT, Clinical Specialist MSK

Audrey graduated with a BScPT from WU in 1984. She attained her Diploma in Mechanical Diagnosis and Therapy (MDT) in 1993 and has been an Instructor with the McKenzie Institute Canada since 1997.  In order to keep herself well rounded she continue to enjoy attending non-MDT courses.  In 1996 she completed a Certificate in Adult Education from the University of Calgary. In 2012, Audrey received the designation Clinical Specialist in MSK.  Audrey has published extensively on MDT and continues to consult on MDT related projects.  Her paper “Does it matter which exercise” published in 2004 is considered one of the key MDT research papers. She is a Reviewer for the Journal of Manual and Manipulative Therapy and Physiotherapy Canada.  Audrey continues to work in Calgary in private practice 3 days a week.

Jill Robertson, BScPT, MScPT, FCAMPT, Clinical Specialist MSK

Jill Robertson has been a practicing physiotherapist for 37 years. She was a part-time academic instructor at Dalhousie University for 26 years.  Jill is an instructor and Lead Examiner for the Orthopaedic Division and a Clinical Specialist in Musculoskeletal Physiotherapy. She is a past Chair and Treasurer of the National Orthopaedic Division and the Canadian Academy of Manipulative Physiotherapy. Jill’s Master’s thesis measured the effects of manual therapy and exercise on hip active range of motion.