This clinic session I spent my time shadowing a graduate sports therapist doing clinical assessments for three patients in the Marjon injury clinic. The first patient (25-year-old female) came in with left shoulder pain complaints (started 1 week ago) with the feeling of it needing to click. Her job at Tesco’s requires a lot of heavy lifting including overhead reaching. As of this day she also has pain in her back. 1 week ago, she felt lost strength in her left shoulder/arm an felt shooting pain when reaching for her phone across her body. She was diagnosed with hypermobility 1 year ago. Objective assessment found that shoulder AROM for abduction and flexion caused pain on 90° and above. Pain on palpation on supraspinatus, +ve painful arc, +ve Hawkins Kennedy and +ve empty can tests. Diagnosis was shoulder (supraspinatus) impingement. Treatment was STM to infraspinatus and posterior shoulder area (reduce possible swelling and tightness) and strengthening exercises for the traps (standing rows), ES & QL (superman’s) and resisted eccentric shoulder adduction with dumbbell. General joint hypermobility has been shown to have a correlative relationship with glenohumeral joint instability (Cameron et al., 2010), which could have been a factor that contributed to the supraspinatus impingement, due to the rotator cuff muscles not being strong or balanced enough to keep the joint in the correct position.
The second patient was a 60-year-old female with right shoulder pain complaints in overhead movements. There was no injury, the pain come on gradually and it hurts when lying on it during night. Had a physio look at it but didn’t do the exercises he gave her as she wanted hands on treatment. Objective assessment found shoulder AROM flexion, abduction and internal rotation. Pain on palpation (Pop) on supraspinatus, upper trapezius. PROM was fine, RROM showed pain on abduction. +ve hawking’s Kennedy, +ve painful arc, slight scapula winging. Diagnosis was supraspinatus tendinopathy with a slight psychological factor coming into play. Treatment was STM to upper traps and supraspinatus (patient wanted hands on, so more for psychological aspect), strengthening exercises for supraspinatus (eccentric resisted adduction), standing rows for trapezius, and ROM exercises (broom sweeping).
The final patient (44-year-old male) came in with lower back pain which then gradually became more pronounced in left side running down to the left gluteus maximus. He lifts heavy during work, plays hockey 2/7 and goes to the gym 3/7 and runs 1/7. Movement helps with pain; it gets worse during prolonged sitting and has sharp pains with sudden movements. Previous massage to the lower back has eased symptoms. Objective assessment found external rotated feet and knees, pain during AROM lumbar flexion (reduced rom due to pain), extension and lateral flexion and a poor glute firing pattern specifically in the left side. Pop when performing PA glides on L-spine. Pop when performing left unilateral PA, but not on right side. Diagnosis was L-spine nerve compression due to facet joint dysfunction. Treatment was STM to lower back, unilateral PA to left transverse processes of l-spine and strengthening exercises for lower back and core (lying side bridge, bird dog) and mobility exercises for L-spine (supine hip rocking, chest hugging).
This shadowing session was interesting as it showed 2 patients with similar symptoms but two very different treatment approaches for each patient. The second patient was convinced that she couldn’t move her right arm above her head without pain, but this was confirmed to be psychological when she managed to do the brushing with broom exercise without any pain or restriction at all even with her arm being in the supposed painful overhead position. This suggests that there is a big psychological aspect when it comes to pain and how it is perceived. Pain catastrophising has been shown to be associated with increased behavioural expressions of pain as well as more frequent visits to healthcare professionals. The magnitude of this relationship is variable with some studies showing minimal variance in pain severity due to catastrophizing and others showing up to 31% of pain severity variance. This suggests that pain catastrophizing plays a large role in how patients perceive pain severity (Quartana, Campbell & Edwards, 2009). I will have to do more reading on the psychological aspect of perceiving pain for future clinic sessions.
Finally, for the third patient I thought that glute bridges should have been included in the exercise programme to really focus on getting the glutes to fire correctly before the hamstrings as well as strengthening them, as the other exercises did not focus on this aspect. After the session I looked up the correct firing pattern of a prone leg extension and found a study by Lehman et al. (2004) suggesting that gluteus maximus should fire first followed by hamstrings and then the erector spinae muscles.
Cameron, K., Duffey, M., DeBerardino, T., Stoneman, P., Jones, C., & Owens, B. (2010). Association of Generalized Joint Hypermobility With a History of Glenohumeral Joint Instability. Journal Of Athletic Training, 45(3), 253-258. doi: 10.4085/1062-6050-45.3.253
Lehman, G. J., Lennon, D., Tresidder, B., Rayfield, B., & Poschar, M. (2004). Muscle recruitment patterns during the prone leg extension. BMC musculoskeletal disorders, 5, 3. doi:10.1186/1471-2474-5-3
Quartana, P., Campbell, C., & Edwards, R. (2009). Pain catastrophizing: a critical review. Expert Review Of Neurotherapeutics, 9(5), 745-758. doi: 10.1586/ern.09.34