08.05.19 Clinical Hours

Today’s clinic session I was scheduled in for 4 hours to shadow. However due to circumstances described below I spent only 1-hour shadowing and the other 3 hours hands on. The first hour I shadowed a 46-year-old male with left hip pain who came into the clinic for an initial assessment. The pain was localised in the gluteus medius and tensor fascia latae (TFL) in left hip. Pain got worse in the morning but got better during exercise. Objective assessment found a weak and painful left gluteus medius (+ve glute medius strength test) and + Trendelenburg test shown in Konin, Lebsack, Valier & Isear (2016). Diagnosis was gluteus medius and potential TFL tendinopathy. Treatment was glute-bridges, donkey kicks and side lying leg raise with a focus on the eccentric component of the exercises. I was curious about the effects of eccentric training and found a study by O’Sullivan, McAuliffe & DeBurca (2012) who found that eccentric training not only provides strength benefits but that it can improve muscle flexibility as well. This suggests that eccentric training should be used if tolerated and would be the ideal strengthening exercise if the target muscle was both weak and tight.

During the second hour there were no patients to shadow, instead I helped maintain the clinic and then discussed rehabilitation exercises for the rotator cuff by using the TRX system. One exercise we came up resembled a rowing motion combined with external rotation of the shoulders. This would target the trapezius and rhomboids, but also the infraspinatus and teres minor which are 2 of the rotator cuff muscles in the shoulder. This would be an exercise to include in more of a late stage rehabilitation setting due to its complexity and intensity. An example of this exercise can be seen here:

In the last two hours, I was meant to shadow another initial assessment but there was a double-booking issue in the clinic, and I was told I had to conduct the assessment myself. I found this stressful as I had no time to prepare, all I was told is that it was related to low back pain. The patient was a 34-year-old male with low back pain (LBP) which radiated down the left leg. Easing factors were diving which could be due to the decreased load on spine. Pain on palpation on left transverse processes of L4, L5 and S1, S2 but no pain on right side indicated facet joint dysfunction. Painful movements were lumbar extension only which indicates facet joint disfunction. However, the pain started 3 weeks ago (chronic) which indicates that it is more a vertebral disk problem. Straight leg raise was +ve at 20° indicating sciatica (Sensitivity 52%, specificity 89% in Majlesi, Togay, Ünalan & Toprak, 2008). After this patient I did some reading and found a great video below that explains the straight leg raise test and when it is positive. I found out that I wrongly assumed the test was positive at 20°. The test is positive with indication of sciatica if sciatic type pain is found in the range of 35-70° not 20°. As such I will do some further reading to make sure I correctly utilise this important assessment test in the future.

Palpation of piriformis reproduced pain symptoms as well. Diagnosis was sciatica due to a cluster combined of facet joint dysfunction, L4, L5 vertebral disk problem and tight piriformis all compressing the sciatic nerve. Treatment was Unilateral PA on right transverse processes of L4, L5, STM to quadratus lumborum & erector spinae, and lumbar mobility exercises (knee hugs, knee side to sides, pelvic tilts). I spent quite a while writing up the clinic notes for this patient and thinking of what I could have done better. One thing I forgot to add was a soft tissue release for the tight piriformis to reduce sciatic pain. Furthermore, I should have gone through dermatome and myotome testing for the lumbar spine to help in my diagnosis. Finally, I need to go over lumbar spine assessment protocol again because I did not feel like I was comfortable in my knowledge during the assessment which caused me to feel out of my depth. After the session I found an interesting article by Allegri et al. (2016), explaining the differences between diagnosing different back pain causes including facet joint dysfunction and disk bulges. I will use this for future low back pain cases.

References:

Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., … Fanelli, G. (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research5, F1000 Faculty Rev-1530. doi:10.12688/f1000research.8105.2

Konin, J., Lebsack, D., Valier, A., & Isear, J. (2016). Special tests for orthopedic examination (4th ed., pp. 364-390). SLACK incorparated.

Majlesi, J., Togay, H., Ünalan, H., & Toprak, S. (2008). The Sensitivity and Specificity of the Slump and the Straight Leg Raising Tests in Patients With Lumbar Disc Herniation. JCR: Journal Of Clinical Rheumatology14(2), 87-91. doi: 10.1097/rhu.0b013e31816b2f99

O’Sullivan, K., McAuliffe, S., & DeBurca, N. (2012). The effects of eccentric training on lower limb flexibility: a systematic review. British Journal Of Sports Medicine46(12), 838-845. doi: 10.1136/bjsports-2011-090835

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