Pt. Who Has A Simple Issue I Probably Cannot Fix, Here's Why...

I am working with a patient in her 30s who has had SI joint pain and Achilles tendinopathy for over a year.

Clinically, this should be pretty straightforward for me. I would normally put her on my protocols and generally expect her to improve.

The problem is she is not responding to either rehab program. Problem after problem after problem.

This is unusual for me because I do this all day, every day, and I honestly can't remember the last time I saw this. Some patients improve and then have a flare-up in the middle of treatment, but to not feel any different at all is very strange for me.

When I realign her SI joints, she has no pain. When I perform a posterior mobilization of her talocrural joint, her pain is immediately relieved. This confirms that these mechanical issues are contributing to her symptoms. Now I just need to make the changes "stick," if you will.

I taught her several acupuncture points to stimulate with a TENS unit, which immediately relieved her low back pain. As soon as I showed her, her response was the same thing I've been hearing for weeks:

"Yeah, but it's so bad."

I put an SI belt on her and it instantly relieved her pain. I told her to use it until we could strengthen her adductors to help control the outflare. She replied:

"Yeah, but it's so bad."

No matter what solution I provide, I hear the same response.

I've had patients who couldn't perform the Mulligan bike-tube mobilization for posterior capsule tightness because the tube irritated a tender area. In those cases, I simply reposition the tube and the problem is solved. I find a workaround.

With this patient, she says she simply cannot do it. I've honestly never seen anything quite like this one.

I'm starting to suspect that she may be subconsciously sabotaging the rehab process. It resembles classic pain catastrophizing: you provide a solution, and the patient immediately focuses on why it won't work without ever really trying it.

These patients are not as common as I think many providers believe, but when I encounter one, my heart sinks.

I occasionally see similar patterns in personal injury cases when litigation is involved. My belief is that, at a subconscious level, some patients may associate remaining injured with potential financial gain.

Recently, I had a personal injury patient who improved significantly and then asked whether anyone would see my notes documenting how much better he had gotten.

Have you encountered patients like this?

If so, what strategies have you found helpful?

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