Clinical Experience Monday 14th October 2019 – 5.5hours

Patient 1 –
patient overview: wrist injury from trauma and two previous fractures. Injury to other wrist may have caused over compensation and overuse of right wrist. Stiffness when inactive, pain doing Parkour.
Equally restricted flex and extension which indicates capsular pattern of wrist joint.
Joint mobilisations performed, incl. distraction and distraction with added flexion. Exercises to strengthen wrist; flex, ext, U/dev, R/Dev with resist. Ball squeezes, change position of thumb to vary exercise. EAB to support wrist.

I have not had any past encounters with wrist injuries and so my experience with wrist assessments is lacking. I have poor knowledge of the muscular components and therefore understanding of the wrist joint movements, however I was able to palpate the carpals and those most relevant in this patient, e.g the Scaphoid.
I was able to identify that this injury was likely a joint pathology, based on my objective assessment; capsular pattern, active and passive movement and pain characteristics. There were notable muscular issues too, but this could have been resultant of joint pathology; which came first, the chicken or the egg?
I performed some further research on the clinical assessment of the wrist joint and noted the reported interpretations of limited active range of motion, in particular flexion and extension and thus capsular pattern. A useful article also highlighted trauma and/or immobilisation of the joint as possible risk factors for joint pathology in the wrist, which links me back to my subjective and the patient’s history of trauma (Porretto-Loehrke, Schuh, & Szekeres, 2016).

As indicated by the assessment, I treated this pain as joint stiffness and associated muscle pain. After performing wrist mobilisations to help with joint mobility and pain, I was advised by my supervisor to apply some support tape so that the patient could continue with his Parkour training. As I have not treated a wrist injury before, I was not proficient in this modality and as such needed assistant. I have since researched the type of wrist taping possible and the rationale behind this, so that next time I am presented with this, I will feel confident in my approach.
The taping technique that I was advised to use was with rigid taping and was applied continuously around the whole joint and is recommended for the stability of ligaments and wrist joint capsule (Porretto-Loehrke, 2016). In reflecting my treatment, I had realised that I did not use any base layer tape so better comfort, as the rigid tape may be quite tough on the skin and uncomfortable, especially on a more delicate wrist joint. In future, I will take the time to apply the under wrap, so that the taping can be both effective and comfortable.

Patient 2 – This patient was a regular user of the clinic and often came for a soft tissue massage. However on this occasion, and with a comprehensive discussion with my supervisor, we decided not to treat him due to some new symptoms of dizziness and neck pain; instead we advised him to seek advice from his GP and return if given the all clear.
Although I feel as though I am able to perform a detailed and clear subjective assessment and ask the most relevant and appropriate questions needed to help in the diagnostic process, there are some elements to the questions that I do not fully understand, with neurodynamic testing and understanding creating a significant gap in my knowledge.

In this case, the patient presented with symptoms that are similar in those with Vertebrobasilar Insufficiency (VBI) including dizziness, and although based on a comprehensive medical history, his accumulative, chronic symptoms probably were not that of VBI, my supervisor and I felt more comfortable asking our patient to visit the GP before having further treatment of his neck area as this is a serious condition whereby blood flow could be restricted to the brain due to compression of posterior arteries during vertebral movements. The presence of other health issues, such as heart and blood pressure also contributed to our decision to not treat with any manual therapy techniques in this session.
This is because VBI or symptoms are a contraindicator to manual therapy and in particular cervical spine mobilisations and manipulations and therefore must not be performed, especially when combined with either anticoagulant therapy or unexplainable cervical symptoms, which was the case (Hutting et al., 2018).

Early research by Mitchell et al. (2004) found that blood flow via the posterior craniovertebral arteries was restricted in young asymptomatic subjects when neck is put in end range rotation and as such the tests for VBI were of clinical significance, especially when projected onto the wider, older population. However, a more recent study by Thomas et al. (2013) found that blood flow via the craniovertebral arteries was not restricted in asymptomatic subjects, findings that have since been supported and deemed likely, with recent studies reporting there to be no found negative effects of manual therapy on serious cervical pathologies (Hutting et al., 2018).

Patient 3 –
This patient presented with lateral knee pain after having completed a running course of ‘couch to 5km’ from having not previous taken part in running.
From our subjective assessment, it became apparent early on that Patella Femoral Pain Syndrome was a possibility. PFPS is reported as being the most common injury in runners and is seen in up to 13% of woman under 35 (Stickler et al., 2015) and as increase in physical activity is the biggest risk factor, this patient met many criteria before I started my objective. I therefore aimed to include relevant tests in my physical assessment.

However, I found it a challenge to recall the exact names and protocols for the knee exams, so as further learning, I revised the special testing procedures for the knee, especially those tests for PFPS.

The most relevant special tests for PFPS include eccentric step tests, patella apprehension test and the active instability test, all of which have reasonable specificity and sensitivity when performed alone but when they are combined, they were shown to have a 100% sensitivity with 100% negative predictive values; all three combined or patella apprehension with eccentric squat test (Arjun et al., 2017).
I did use a combination of these tests in my assessment, but I am now able to refer to them by name and I have a greatest understanding of their reliability and rationale behind their use.

As well as these initial tests for PFPS, I asked my patient to perform functional tests such as the single leg squat without standing on a step, to assess knee valgus by observation, a method found reliable in a study by Ugalde et al. (2015). From this I noted a hip drop and a great internal rotation of the hip than the contralateral, non-affected leg. The patient also felt shaking and not in control while performing this test, which indicated weakness in the hip and knee musculature.

The high prevalence of PFPS in woman may be due to the significant Q angle at the hip and as such its effect on the patella alignment. A study by Stickler et al. (2015) found that individuals with PFPS tended to have a greater increase in internal rotation of the hip which resulted in an even greater lateral pull on the patella. It has been common practice in rehabilitation to perform exercises to increase the strength of the lateral hip abductors, prevent a contralateral pelvic drop and hip external rotators to reduce the effects of this lateral pull on the patella.
With this is mind, I was able to go through a range of exercises for the patient to perform during the session and to continue at home.
I also included core strengthening to these exercises as these have been shown to reduce pain and improve balance in woman with PFPS (Chevidikunnan et al. 2016).

References –

Chevidikunnan, M. F., Saif, A. Al, Gaowgzeh, R. A., & Mamdouh, K. A. (2016). Effectiveness of core muscle strengthening for improving pain and dynamic balance among female patients with patellofemoral pain syndrome. Journal of Physical Therapy Science.

Porretto-Loehrke, A., Schuh, C., & Szekeres, M. (2016). Clinical manual assessment of the wrist. Journal of Hand Therapy, 29(2), 123–135.

Hutting, N., Kerry, R., Coppieters, M. W., & Scholten-Peeters, G. G. M. (2018). Considerations to improve the safety of cervical spine manual therapy. Musculoskeletal Science and Practice, 33(October 2017), 41–45.

Mitchell, J., Keene, D., Dyson, C., Harvey, L., Pruvey, C., & Phillips, R. (2004). Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Manual Therapy, 9(4), 220–227.

H. H., A., Kishan, R., M. S., D., & Chouhan, D. (2017). Reliability of clinical methods in evaluating patellofemoral pain syndrome with malalignment. International Journal of Research in Orthopaedics, 3(3), 334.

Stickler, L., Finley, M., & Gulgin, H. (2015). Relationship between hip and core strength and frontal plane alignment during a single leg squat. Physical Therapy in Sport, 16(1), 66–71.

Thomas, L. C., Rivett, D. A., Bateman, G., Stanwell, P., & Levi, C. R. (2013). Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy, 93(11), 1563–1574.

Ugalde, V., Brockman, C., Bailowitz, Z., & Pollard, C. D. (2015). Single Leg Squat Test and Its Relationship to Dynamic KneeValgus and Injury Risk Screening. PM and R.


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