Clinical Experience Monday 21st October 2019 – 6hours

Patient 1 –
Patient overview: medial compartmental knee arthritis
This patient presented with medial knee pain and a self-diagnosis of osteoarthritis (without any other medical opinion or intervention), based on his occupational medical knowledge and a similar occurrence in his contralateral knee 28 months previously. Although the patient was sure of what was causing the pain, I continued with a thorough assessment. With a subjective of normal degenerative changes, previous history of osteoarthritis (OA) and a very recent sudden increase in physical activity with associated pain along the medial joint line, the possibility of meniscus injury or aggravated degenerative pain become apparent, with further testing including Thessaly’s confirming this (Loudon et al., 2008; Picha & Howell, 2018).

During the session, the sensitive topic of weight loss initially instigated by the patient and discussed further and although it is difficult to make this suggestion, it is recommended that individuals with OA have a body mass index (BMI) of less than 25 (Jevsevar, 2013). At present, the patient’s BMI exceeded 30, but we ensured that he fully understood the impact that this has on his joint and in particular his knee pain. Although uncomfortable with the prospect of using the body composition machine in the clinic, he was comfortable with fully adhering to a weight management plan. Further to this, we recommended a program of low impact strengthening exercises of the knee and hip extensors as well as functional movements such as squats, with pain guided progression to single leg squats (Howell et al., 2014; Jevsevar, 2013). Hip exercises were also included as individuals with OA have been found to have deficits in hip muscle strength and strengthening programs have been recommended (Hinman et al., 2010).

When discussing treatment options, I had offered to administer a course of therapeutic ultrasound treatment over the patient’s knee, to which he sceptically declined and I was unable to give him any evidence for it’s use. However, since this session I have been able to find a review, reporting that ultrasound has been found to be effective in the treatment of knee OA by reducing pain and improving physical function (Rutjes et al., 2010; Zhang et al., 2016).

Throughout my treatments, I have found an ongoing issue of poor time management and I often overrun most appointments. This session was my most challenging with regards to keeping to my allotted hour, as I finished 15 minutes late. Although the patient may feel as though they have my full commitment to the outcome of the session (as I do not finish until the patient and I are both confident that the session is fulfilled), this is at the detriment of the next patient and as the patients are booked one after the other, the knock on effect of this continues for every patient. Most significantly, my second patient on this occasion had only her lunch break for her appointment and as such her treatment time was affected.

At present, I am asking many questions of my supervisors so that I can fully understand the diagnostic process and as such many discussions take place. It may be beneficial to my practice if I am able to keep my questions relevant and enough to fulfil the practice only, but then advance on this at the end of clinic, writing down more in-depth questions to ask at a later date.

I hope that as my experience in the clinic continues, I will not only further my knowledge and reduce the need to ask so many questions, but also be able to move through the session more fluidly without the need to pause and request supervisor input. In the meantime, I should try to end the session with at least five minutes to write up clinic notes, but understand that follow up appointments may be needed for the continuation of sessions if not everything can be done in the initial time slot; the diagnostic procedure is very important and therefore cannot be rushed and as such, I must be prepared for this aspect to overrun throughout most of the session and compromise the treatment time, not my next patient’s appointment.

Patient 2 – This patient requested a STM as the final treatment out of three from an occupational referral program. Over the past two treatments with the same therapist, the patient had reported an increase in ROM and a decrease in tension of her upper back and shoulders and as such was very keen for similar treatment. In order to maintain continuity with this patient and provide her with treatment to the same positive effects, I made sure to read her notes thoroughly and ask for feedback throughout the session. I wanted to ensure that the pressure and area of massage was at least as effective to the previous therapist. The patient was pleased with the immediate relief of my treatment and felt satisfied by the end of the session. I also wanted to ensure that I had done everything that I could have for my patient, so that they could maintain this relief after the program stops and so provided the patient with a stretching treatment plan for her pectoralis muscles to add to the exercises she had already been prescribed (Finley et al., 2017; Rosa et al., 2017).

I have since been approached by this patient and was given excellent feedback regarding the treatment; a very satisfied patient.

Patient 3 – This patient did not arrive at his appointment so in order to make full use of my time in clinic, I shadowed another student and assisted in the diagnostic process of a knee injury.
From the subjective and objective assessments, we arrived at the same suggestion of a meniscus injury; most notably because of the painful palpation of the Tibiofemoral joint line, which has a sensitivity of 63-87% (Howell et al., 2014) and a positive Thessaly’s test.

A combination of the Apply’s compression, Grind and McMurray’s test were all negative, but due to their low sensitivity and early stage of this patient’s injury, we wanted to perform another more function test to try and reproduce the pain symptoms and therefore a Thessaly’s was performed, showing a positive result.
When used alone, meniscus tests have low sensitivities, leaving many meniscus injuries undiagnosed. It has been within my usual practice to perform at least three provocation tests, however I did not know whether this improves diagnostic accuracy or not.
From further reading, I found that the Thessaly’s test was not any more valuable to clinicians than other tests for meniscus injury, with a sensitivity of 0.62, a specificity 0.55 and an accuracy of 54% and with McMurray’s, Appley’s and joint line tenderness tests all having similar scores of between 53-55% accuracy (Blyth et al., 2015). Furthermore, a combination of both the joint line test and McMurray’s was not found to be any more accurate than one of the tests alone (Galli et al., 2013).

We advised that our patient should continue to exercise but reduce workload for up to at least 2 weeks, however due to his occupation in the Navy, this was not a possible course of action and therefore we needed to take this into consideration when planning a rehabilitation program. Exercises of muscular endurance rather than stretch could be implemented to continue to increase muscle strength but without overloading the meniscus. A physical therapy program including strengthening of hip musculature, quadriceps and hamstrings, with proprioception was given to the patient as this has been found to reduce knee pain and improve knee function (Howell et al., 2014).

Patient 4 –
This patient presented with foot plantar region pain over the metatarsal phalangeal (MTP) and proximal interphalangeal joints (PIP) of the second and third toes. After a thorough subjective, we discussed the possibility of onset being cased by a sudden change in footwear within slow build up of running mileage and with palpable tender points in our objective, allowing us the probably diagnosis of Metatarsalgia.
From further reading, I have learned that a very important aspect to the assessment of Metatarsalgia is a gait analysis, as it has been reported that up to 90% of injuries are due to biomechanics (Besse, 2016). Although we weren’t able to perform a thorough analysis, his walking gait was observed in which there were no obviously abnormalities and we were able to deduce that footwear may have been the underlying reason behind this condition, with improvements been felt since returning back to his previous footwear.

After performing anterior-posterior and posterior-anterior mobilisations and DTM to relieve some joint stiffness and pain, I prescribed a program of mobility and strengthening exercises for the tibialis posterior muscle and peroneal muscles and also stretches for toe flexors.

Stretching exercises for the Tricep Surae muscle group was also recommended by Besse (2016) as shortened gastrocnemius muscles have been found to increase the risk of equinus deformity and subsequently metatarsalgia (Morales-Muñoz et al., 2016). Although we have obtained a possible cause, not associated with equinus of the foot, it would still be beneficial to manage any potential risk factors so that recovery from this condition is not hindered.

This patient was very active and reluctant to rest from his running activity as advised so in order to ensure that he does so, we had a discussion on methods to fulfil his fitness needs without the need of overloading his feet. We suggested a plan of swimming and cycling, which the patient seemed to respond to in a much more positive manner.

References – 

Besse, J.-L. (2016). Review article Metatarsalgia. 103, 29–39. https://doi.org/10.1016/j.otsr.2016.06.020

Blyth, M., Anthony, I., Francq, B., Brooksbank, K., Downie, P., Powell, A., … Norrie, J. (2015). Diagnostic accuracy of the thessaly test, standardised clinical history and other clinical examination tests (Apley’s, mcmurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis. Health Technology Assessment. https://doi.org/10.3310/hta19620

Finley, M., Goodstadt, N., Soler, D., Somerville, K., Friedman, Z., & Ebaugh, D. (2017). Reliability and validity of active and passive pectoralis minor muscle length measures. Brazilian Journal of Physical Therapy, 21(3), 212–218. https://doi.org/10.1016/j.bjpt.2017.04.004

Galli, M., Ciriello, V., Menghi, A., Aulisa, A. G., Rabini, A., & Marzetti, E. (2013). Joint line tenderness and Mcmurray tests for the detection of meniscal lesions: What is their real diagnostic value? Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2012.11.008

Hinman, R. S., Hunt, M. A., Creaby, M. W., Wrigley, T. V., McManus, F. J., & Bennell, K. L. (2010). Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis Care and Research. https://doi.org/10.1002/acr.20199

Howell, R., Kumar, N. S., Patel, N., & Tom, J. (2014). Degenerative meniscus: Pathogenesis, diagnosis, and treatment options. World Journal of Orthopaedics, 5(5), 597–602. https://doi.org/10.5312/wjo.v5.i5.597

Jevsevar, D. S. (2013). Treatment of osteoarthritis of the knee: Evidence-based guideline, 2nd edition. Journal of the American Academy of Orthopaedic Surgeons. https://doi.org/10.5435/JAAOS-21-09-571

Loudon, J. K. (Janice K., Swift, M., & Bell, S. (2008). The clinical orthopedic assessment guide. SciTech Book News. https://doi.org/10.1111/j.1440-6055.2007.00596.x

Morales-Muñoz, P., De Los Santos Real, R., Barrio Sanz, P., Pérez, J. L., Varas Navas, J., & Escalera Alonso, J. (2016). Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia. Foot and Ankle International. https://doi.org/10.1177/1071100716640612

Picha, K. J., & Howell, D. M. (2018). A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy. Musculoskeletal Care. https://doi.org/10.1002/msc.1194

Rutjes, A. W., Nüesch, E., Sterchi, R., & Jüni, P. (2010). Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd003132.pub2

Zhang, C., Xie, Y., Luo, X., Ji, Q., Lu, C., He, C., & Wang, P. (2016). Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: A systematic review and meta-analysis. Clinical Rehabilitation. https://doi.org/10.1177/0269215515609415

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