Posts by Damien Howell
When the “Protective” Position Isn’t Protective: A Counterintuitive Observation in Rotator Cuff Tendinopathy
A single-patient observation suggests that muscle–tendon length may influence shoulder pain more than we assume. A Counterintuitive Patient Response A patient’s answer to a simple question about her shoulder pain stopped me in my tracks. When I asked what eased the pain, she replied: “When I position my arm above my head, it feels…
Read MorePain Severity vs Pain Irritability: Why the difference matters in musculoskeletal care
A recent patient with shoulder pain persuaded me that pain intensity does not always reflect the clinical seriousness of a condition. Pain irritability – how easily pain is triggered and how long it lasts – often matters more for guiding treatment decisions. A 65-year-old male reported right shoulder pain. When queried, when did it start…
Read MoreHow to mitigate risks & enhance benefits of DIY care of non-traumatic musculoskeletal pain
My January 2026 visit to my healthcare provider was shocking: my coinsurance deductible is twice as much as last year. My health insurance company increased my premium by 25%. Around the same time, I am doing a “do-it-yourself” repair of my Wi-Fi system. My Physical Therapy practice is a one-man shop. So, one of my…
Read MoreHow Horizontal Body Proportions “Inverted Triangle” Can Relate to Back Pain
A current patient with recalcitrant back pain is challenging me to look for innovative strategies for treatment. This 29-year-old male has a 3-year history of low back pain. The pain occurs daily, with an average intensity of 3 out of 10. The symptoms are worse with prolonged sitting. Worse on days that he is more…
Read MoreEscaping the Drama Triangle: Practical Tactics for Direct Dialogue Between Physical Therapists & Surgeons.
Earlier in my Physical Therapy career, I joined a pain management team at a teaching hospital. Team members included an Anesthesiologist, Primary Care Provider, Physical Therapist, Psychologist, and others. We held team meetings to discuss chronic pain patients. Few would dispute that face-to-face real-time communication was a particularly effective way to provide care. Unfortunately, the…
Read MoreDownsides of steroid injections for hip pain – What 3 patients taught me
Three patients with chronic hip pain prompted me to dive deeper into the effectiveness and risks of the common intervention of corticosteroid injection for musculoskeletal pain syndromes. Patient A complains of difficulty lifting his leg to put his pants on when standing and difficulty lifting his leg to transfer into his car. He had a…
Read MoreFalling Off the Wagon Isn’t the End: Learning from Lapses in Exercise & Recovery
During a routine follow-up, my patient “Larry Lapes,” who has chronic ankle and back pain, asked me a question that stopped me in my tracks: “Do you have any strategies that help your patients stick to their exercise routines?” His question prompted me to reflect more deeply on lapses and relapses in behavior change. Behavioral…
Read MoreHip-Spine vs Spine-Hip vs Both – 3 Case Examples Lessons Learned
An 80-year-young woman visited her primary care physician with “pain going down my leg”. She had difficulty grocery shopping, picking up her small dog. X-rays showed osteoarthritis in her lumbar spine, and she was diagnosed with “sciatica.” The doctor referred her to a spine surgeon, who ordered an MRI and gave her an x-ray-guided spinal…
Read More“Take my wife, please” – patient centered care consider significant others
After completing an initial Physical Therapy consult with a 62-year-old gentleman with osteoarthritis of the knee, I asked, “Do you have any questions, confusion, or concerns that we should go back over?” Before he could respond, a voice chimed in from the next room. “Tell him that you look like an old man when walking,…
Read MoreUnderstanding Delayed-Onset Exercise-Induced Pain in Individuals with Chronic Pain Syndromes
Introduction Two patients with chronic musculoskeletal pain and Ehlers-Danlos Syndrome (EDS) recently demonstrated similar but unexpected responses to routine exercise interventions. Their experiences prompted me to reexamine my understanding of exercise-induced pain in individuals with chronic musculoskeletal conditions. Patient Case Studies Patient A: During a physical therapy session, a patient with EDS performed a spinal…
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