Clinical Experience Tuesday 22nd October 2019 – 4hours

Patient 1 –
Patient Overview: 8 weeks postop for fractured tib/fib, (has screw and tightrope).
This patient had requested a progression assessment for rehabilitation and for a session of Anti-gravity Treadmill Training (ATT), however unfortunately could not make their scheduled appointment. I made full use of my time in clinic by researching the value of ATT and finding evidence-based articles to support its use. In my research I found that ATT is used as a way of maintaining cardiovascular fitness, but with reduced ground reaction forces (Figueroa et al., 2011) and gradually allowing the increase of weight baring load, which has been reported to theoretically reduce the time taken to return to a normal pattern of loading (Liem et al. 2013).
Due to the nature of the injury and subsequent surgery, immobilisation (and therefore muscle wasting) could become apparent and increase healing times (Henkelmann et al., 2017). Traditional cross-training methods for non or partial weight baring injuries, such as Deep Water Submersion (DWS) have been shown to be effective in reducing ground reaction forces and therefore is a useful method of improving range of movement and incorporating resisted strengthening exercises, however due to the water drag, running or other higher intensity cyclic activities or cardiovascular activities cannot be performed, whereas ATT has been able to address those issues and be an effective rehabilitation option for post op injuries of the lower limb (Patil et al., 2013).
I was disappointed that I couldn’t use this equipment on this occasion but I after having developed understanding of the rationale behind it’s use, I may better appreciate Its value in the clinic and I feel more encouraged to consider this in any future clients who meets the required criteria in their injury management.

Patient 2 –
Medial Epicondylitis is a condition effecting the flexor-pronator tendon and is most likely caused by repetitive forces through flexion and pronation of the forearm (Amin et al., 2015).
When I examined the patient, effusion was noticeable and pain was felt on palpation around the medial condyle with resisted flexion and pronation also reproducing the patient’s pain. All findings, along with a detailed subjective assessment, were suggestive of Medial Epicondylitis (Amin et al., 2015; Fleck et al., 2017).
Non operative treatments are the most recommended treatment option for medial epicondylitis (Fleck et al., 2017) and as such I continued with a conservative treatment plan.
Due to the chronic nature of this case and the characteristics of tendonitis, we administered therapeutic ultrasound. Both therapeutic ultrasound and intensive therapeutic ultrasound have been shown to be effective in reducing pain and enhancing grip strength in individuals with lateral epicondylitis (Shaheen et al., 2019; Slayton et al., 2018). However I was not aware of the benefits of applying kinesiology tape, which has also been recommended for producing the same effects, but to an even greater degree (Shaheen et al., 2019) and therefore in future I will consider kinesiology tape in the treatment of epicondylitis.
I could also have considered the use of mobilisations as this too has been found to increase grip strength and function and decrease pain in lateral epicondylitis (Reyhan et al., 2019).

In order to measure the patient’s progress and the effectiveness of the exercise program that I prescribed, I recorded his grip strength; a method reported as the most reliable objective measure of epicondylitis (Shaheen et al., 2019). I felt confident in prescribing a plan of eccentric strengthening exercises for the associated tendons as these exercises require less perceived demand for greater loads compared with concentric exercises (Quinlan et al., 2019) and therefore the patient could start to strengthen the injured elbow more efficiently and with less perceived load.

Patient 3-
My final patient of the evening presented with symptoms indicative of Patella Femoral Pain Syndrome (PFPS). I have had a number of experiences in performing assessments to diagnose this injury and I felt confident that this was of a similar nature. Once my supervisor and I agreed on a course of action by way of strengthening exercises, I was able to prescribe a comprehensive plan for our patient to perform in the clinic and take with them to do at home.
An example of some exercises have been published in a case report by Welsh et al. (2010), within which core and hip muscles were successfully used in a rehabilitation program to treat a female dancer with PFPS. Exercises such as crab walks with resistance bands, single leg squats with functional movements such as rotation of hip with added resistance were all found effective in this particular case study.
Because of the available research available, such as that by Welsh et al. (2010), I have a good range of exercises in mind to adapt for my patient’s rehabilitation plan, however, I was unsure as to the ‘return to play’ protocol or when running can be resumed again, as this was a major concern for my patient. As the patient had reported improvements in symptoms over the last week from resting, we advised to continue resting for another week before gradually building up miles again to ensure that she does not overload or over train, as this may have been a risk factor for the initial onset of PFPS. I also felt it important to discuss running technique with my patient and in particular, running cadence as increasing this has been found to reduce PFPS (dos Santos et al., 2019) and decrease stride length and hip abductor angle (Hafer et al., 2015). It quickly became apparent that the patient was aware of her self-reported low cadence and as such we discussed ways of improving this, such as the use of a metronome. From the objective, I had noted the internal rotation of the hip when the patient was lying supine on the treatment couch and also exaggerated knee valgus in standing posture. Interestingly, a study by Neal et al. (2018) found that when cadence was increased by 7.5%, PFPS symptoms improved, but most relevantly, hip adduction and internal rotation was reduced, potential explaining the mechanism behind the improvements in symptoms.

It was also interesting to read research by Bonacci et al. (2018) which found that combining an increase in cadence with a more minimalist shoe was effective in reducing joint force and symptoms in individuals with PFPS. This is suggestive of more cushioned shoes being an extrinsic risk factor to this mechanism of injury.

Other –
During the time between patients, when I was not writing up notes I took it upon myself to better understand the upper limb neurodynamic test (ULNT) protocols as I am very unfamiliar with these and have required supervisory assistance when performing these in past sessions.
I have devised a set of help revision cards with the simplified protocols on as a way of a quick help reference during my appointments and as revision of my exams.

Here is a link to the videos and their associated links to relevant research.

References –

Amin, N. H., Kumar, N. S., & Schickendantz, M. S. (2015). Medial epicondylitis: Evaluation and management. Journal of the American Academy of Orthopaedic Surgeons, 23(6), 348–355. https://doi.org/10.5435/JAAOS-D-14-00145

Bonacci, J., Hall, M., Fox, A., Saunders, N., Shipsides, T., & Vicenzino, B. (2018). The influence of cadence and shoes on patellofemoral joint kinetics in runners with patellofemoral pain. Journal of Science and Medicine in Sport. https://doi.org/10.1016/j.jsams.2017.09.593

dos Santos, A. F., Nakagawa, T. H., Serrão, F. V., & Ferber, R. (2019). Patellofemoral joint stress measured across three different running techniques. Gait and Posture. https://doi.org/10.1016/j.gaitpost.2018.11.002

Fleck, K. E., Field, E. D., & Field, L. D. (2017). Lateral and Medial Epicondylitis in the Athlete. Operative Techniques in Sports Medicine, 25(4), 269–278. https://doi.org/10.1053/j.otsm.2017.08.005

Liem, B. C., Truswell, H. J., & Harrast, M. A. (2013). Rehabilitation and return to running after lower limb stress fractures. Current Sports Medicine Reports. https://doi.org/10.1249/JSR.0b013e3182913cbe

Hafer, J. F., Brown, A. M., deMille, P., Hillstrom, H. J., & Garber, C. E. (2015). The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of Sports Sciences. https://doi.org/10.1080/02640414.2014.962573

Henkelmann, R., Schneider, S., Müller, D., Gahr, R., Josten, C., & Böhme, J. (2017). Outcome of patients after lower limb fracture with partial weight bearing postoperatively treated with or without anti-gravity treadmill (alter G®) during six weeks of rehabilitation – A protocol of a prospective randomized trial. BMC Musculoskeletal Disorders, 18(1), 1–6. https://doi.org/10.1186/s12891-017-1461-0

Neal, B. S., Barton, C. J., Birn-Jeffrey, A., Daley, M., & Morrissey, D. (2018). The effects & mechanisms of increasing running step rate: A feasibility study in a mixed-sex group of runners with patellofemoral pain. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2018.05.018

Patil, S., Steklov, N., Bugbee, W. D., Goldberg, T., Colwell, C. W., & D’Lima, D. D. (2013). Anti-gravity treadmills are effective in reducing knee forces. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.22272

Quinlan, J. I., Narici, M. V, Reeves, N. D., & Franchi, M. V. (2019). Tendon Adaptations to Eccentric Exercise and the Implications for Older Adults. Journal of Functional Morphology and Kinesiology. https://doi.org/10.3390/jfmk4030060

Reyhan, A. C., Sindel, D., & Dereli, E. E. (2019). The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/bmr-181135

Shaheen, H., Alarab, A., & S Ahmad, M. (2019). Effectiveness of therapeutic ultrasound and kinesio tape in treatment of tennis elbow. Journal of Novel Physiotherapy and Rehabilitation, 3(1), 025–033. https://doi.org/10.29328/journal.jnpr.1001025

Welsh, C., Hanney, W. J., Podschun, L., & Kolber, M. J. (2010). Rehabilitation of a female dancer with patellofemoral pain syndrome: applying concepts of regional interdependence in practice. North American Journal of Sports Physical Therapy : NAJSPT, 5(2), 85–97. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21589665%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC2953389

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