Clinic Tuesday 1st October 2019 – 6 Hours

Client 1: Sports Massage of quadriceps
Overview of Patient: very regular client with multiple ongoing issues but has specifically requested a soft tissue massage of bilateral quadriceps. FROM and happy to proceed.
Throughout this treatment, I wanted to ensure that I was providing the patient with an adequate amount of pressure and so made sure I was able to use effective communication to receive feedback. I am confident with communicating with my patients which enables me to adapt my session or to revise treatment based on their individual needs and at their request.

Client 2: Shoulder Pain
Overview of patient: 12/12 ago acute possible R/C strain, minor niggle since then. Px since 2/12 after increasing intensity of tennis over summer. Joint feels bruised at sub scap attachment, tender in joint and coracoid process but Px during tennis and daily funt. movements such as driving, cooking.

From a subjective and objective evaluation, a clinical diagnosis was not given, however the pain is most likely due to the weaknesses in the rotator cuff musculature when faced with the increase in loading over the last 3 months of significantly increased tennis activity. With supervision, I was able to talk to the client and educate on the importance of joint strength with increased loading and we worked through a program of strengthening exercises to be performed as a rehabilitation program over the coming weeks. However, I found that I did not have a good repertoire of rotator cuff exercises to prescribe and explain to my patient in detail. I therefore researched a number of articles within which were discussions about the important role of each individual rotator cuff muscle and effective strengthening exercises associated with that muscle. Escamilla et al. (2009) for example, details torque in abduction as 35-65% deltoid, 30% subscapularis, 25% supraspinatus and 2% is from anterior deltoids. Knowing that the rotator cuff muscle abduct, internally and externally rotate the glenohumeral joint, it is then possible to devise an appropriate program to enhance the strength in these actions by way of specific exercises. Ellenbecker and Cools (2010) analysed the effectiveness of a number of rotator cuff exercises and from this I have been able to gather some interesting exercise protocols and find rational in their use; I now feel more confidence when discussion shoulder rehabilitation with my patients and know that I am able to adapt exercises where necessary. Plyometric exercises and scapular stabilisation techniques for both home based programs and clinical sessions were described and justified in this article.

Client 3: Shoulder Pain
Overview of patient: 2/52 ago, shoulder press acute trauma on return phase; felt twinge in between shoulder blades R side of Sx. Improved over 2 weeks but sudden sharp Px opening car door, feels like something needs to click in shoulder. Sharp Px shooting up from scapular to base of R Cx/base of occiput.
Constantly turning but in evening feels stiff.
Worse at night, wakes him up at night. Improves after movement but feels like it needs to click.

After a thorough subjective and objective, I was still unable to fully understand the potential diagnosis of this injury. Due to the nature of the range of motion, for example passive range of motion being as limited and painful as active range of motion, I considered the possibility of a joint issue and as I am not yet confident in diagnosing and treating joint stiffness and injury, I requested a consult with the clinic manager. I was reassured that it was a joint issue, as opposed to soft tissue and mobilisations at the costovertebral joints were performed.
I learnt a great deal of practical application from this client, as I was able to palpate the area of pain and differentiate between soft tissue and joint pain and learn how to perform grade IV mobilisations over these costovertebral joints. By the end of the treatment, I had become more familiar to the depth and feel of the oscillations required at this thoracic region of the upper back and of the rationale behind these mobilisations (Basson et al., 2017; Shum et al., 2013).

Similarly to client 2, this patient was prescribed a number of exercises to help increase the strength of the rotator cuff muscle group. However, prior to I found that it may have been necessary to help loosen up the soft tissue surrounding the shoulder to help increase range of motion and reduce pain in order to better facilitate the course of rehabilitation exercises (Ellenbecker & Cools, 2010).

References – 

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The effectiveness of neural mobilization for neuromusculoskeletal conditions: A systematic review and meta-Analysis. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2017.7117

Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. British Journal of Sports Medicine, 44(5), 319–327. https://doi.org/10.1136/bjsm.2009.058875

Escamilla, R. F., Yamashiro, K., Paulos, L., & Andrews, J. R. (2009). Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Medicine, 39(8), 663–685. https://doi.org/10.2165/00007256-200939080-00004

 

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