25.04.19 Clinical Hours

This clinic session I spent my time shadowing in the Marjon injury clinic. The first patient (92 years old) came to the clinic for a full assessment due to lower back pain and previous leg conditions including a cracked patella. As the therapist went through the subjective assessment it became more and more clear that the patient was there more for a chat than having an injury. This was reinforced with the objective assessment findings showing no ROM, specific pain or strength problems in lumbar spine or legs. Walking gait was assessed via walking along a line and was fine. However, his hamstrings tended to cramp up when flexing the knee past 90° especially with RROM. This could be due to inadequate water intake as most people don’t tend to drink the optimal dietary reference intakes which is 3.7 L/day for men (Grandjean, 2004). As his strength, proprioception and ROM were good for his age the treatment was more just talking to maintain and stimulate mental wellbeing. The therapist did prescribe 2 exercises (step ups, single leg stance) just to give the patient something to work on which would stop him from overthinking his wellbeing as nothing was physically wrong with him.

The second patient (33-year-old female) came into the clinic for her initial consultation. Subjective found that her right knee had been locking out which caused pain. She also said her legs visibly shook when exercising. She works a 9-5 job which is desk based. She said she walked every day and went to the gym once a week. Objective assessment found that she had flat feet with a tendency for valgus knee when walking and performing lunges with occasional clicking in the left patella. Treatment was strengthening exercises to improve the arch of her feet (sit with ball under foot and rotate knee outwards) and split squats & wall sits to improve the quadriceps muscle strength with the aim of better supporting the knee joint. I was interested if there was a connection between flat feet and knee pain, so I found a study suggesting that flat feet can cause or contribute to knee pain (Gross et al., 2011) by malalignment of the knee, which would coincide with the patient’s tendency for valgus knees.

In the third hour me and a few other therapists discussed a case study on patella pain which had not been diagnosed due to uncertainty. We concluded that the diagnosis was most probably due to overtraining (50 miles run per week, trained every day). The last patient who I shadowed then turned out to be that same case study we were discussing. The therapist went through a brief subjective & objective to clarify symptoms. He had pain on the left patella on the lateral side. Has been doing prescribed exercises for glute strength with which he notices DOMS. Found larger muscle mass on his left leg. Meniscus and patella special tests came back as negative. Treatment was releasing (NMT) Gluteus maximus, strengthening exercises (calve raises, split squats, side lying leg raise) to address leg size differences. After this clinic session I did some reading on patellofemoral pain in runners and found a study by Willson, Sharpee, Meardon & Kernozek (2014) that compared patellofemoral joint stress and pain between a long step length group and a short step length group. The long step length group increased joint stress by 31% but was decreased by 22.2% in the short step length group. Furthermore, despite more steps required to run the mile, the short step length group showed 7.5% decrease in joint stress per mile compared to the other group (14% increase). This suggests that running with shorter stride lengths and thus increasing the number of steps, reduces the loads put on the knee and could be a viable treatment/management option as well as helpful in diagnosis for patellofemoral pain.

This clinic session was interesting as it taught me that often the mind plays a huge part when it comes to injuries. It seems that talking to a patient and really listening to what they have to say really benefits them not only mentally but can sometimes reduce their symptoms. For the future I will investigate the psychology and perception of injuries to try and gain a better understanding of how this benefits patients.

References:

Grandjean, A. (2004). Water requirements, impinging factors, and recommended Intakes. Retrieved from https://www.who.int/water_sanitation_health/dwq/nutwaterrequir.pdf

Gross, K. D., Felson, D. T., Niu, J., Hunter, D. J., Guermazi, A., Roemer, F. W., Hannan, M. T. (2011). Association of flat feet with knee pain and cartilage damage in older adults. Arthritis care & research63(7), 937–944. doi:10.1002/acr.20431

Willson, J., Sharpee, R., Meardon, S., & Kernozek, T. (2014). Effects of step length on patellofemoral joint stress in female runners with and without patellofemoral pain. Clinical Biomechanics29(3), 243-247. doi: 10.1016/j.clinbiomech.2013.12.016

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