Running Total of hours: 177

Patient 1 – Knee Pain
My first patient reported with pain in her right knee, more specifically over the pes anserine tendon.
From earlier research I discovered an effective array of tests including the patella apprehension test, the active instability test and the eccentric step tests which, combined, both have a sensitivity and negative predictive value of 100% (Arjun and Chouhan, 2017), however this remained inconclusive with pain very localised to a small area on her medial proximal tibia and I did not feel as if this was fully indicative of a patella issue, as most commonly reported with anterior knee pain. As I have previously found the single leg squat to be an effective observative measure of lateral hip muscle weakness and hip internal rotation during a more functional movement (Ugalde, Brockman, Bailowitz and Pollard, 2015), I asked the patient to perform this.
In the initial squat, I was unable to observe significant excessive angles or pain, so I asked the patient to perform the movements continuously up to 15 times to reproduce the most repetitive motions of her sport; walking netball and to reproduce an element of fatigue which is more likely to bring on or exasperate the patient’s poor technique, pain and/or excessive internal rotation and knee valgus. After the first 5 squats, the patient did start to experience greater levels of pain and more exaggerated hip angles and therefore I was able to explore the options of rehabilitation to include lateral hip strengthening, but potentially while in a more fatigued state so as to condition the muscles in a more task specific manner.
In my previous reflections I read about the importance of core stability in the treatment and prevention of anterior knee pain (Ferber, Bolgla, Earl-Boehm, Emery and Hamstra-Wright, 2015) and the prevention of lower limb injuries in general (De Blaiser et al., 2018) and as such looked to incorporate this early on in this patient’s treatment. I was reassured to learn that she had already started a program prescribed to her by her doctor called the ‘Escape Pain App’ and I took the time to go through this with my patient as it seemed to be a great means to enhance patent adherence. The App had goals, targets and checklists, which had all been fully utilised by the patient. As the patient has reported improvements since the start of this program with much of the focus on core stability, I can be assured that clinically and for pain reduction and lower limb stability, core exercises such as bridges and side lying bridges are an effective strategy. As I have previously found supporting evidence for abduction exercises to increase hip abduction strength, I included the use of a resistance band around the patient’s ankles during side lying abduction to increase the resistance and also around the patients thighs during the bilateral bridge as this has also been found to increase abductor muscle activation (Choi et al., 2015).
I also understood the need to add varying exercises to the patient’s rehabilitation plan as at least they have a fall back option in case they are unable to remember the technique of one of the exercises for example, so in this case I gave the patient a range of exercises to target the abductors, including the clam exercise, which has also been found to activate and strengthen the hip abductors (Macadam, Cronin and Contreras, 2015).
This patient wanted reassurance that she was able to re-join her walking netball club and continue to play knowing that she would not be causing any damage to the structures in her knee, to which I was able to reassure her that this would be a positive and recommended move forward providing that she was continuing to strengthen her hip and knee to facilitate her knee stability and reduce her excessive hip angles.

Patient 2 and 3 cancelled their appointments before the clinic session so unfortunately I was not able to gain any extra practical, hands on experience on this occasion, however I used the time to create a learning opportunity for myself and other patients by discussing our knowledge and understanding of dermatomes and myotomes, an area that I struggle with, as unfortunately due to the nature of my completion of my foundation degree, this is not an area we cover in depth.
Whenever there is a gap in treatments and all notes are up to date and checked, I ensure that I take the time to visit other students within the clinic between their patients to ask them about their case studies and to discuss their methods of treatment.
In the theory sessions of clinical practice, we are currently going through various different case studies and I have found this incredibly useful. Each individual case is different and from practicing a thorough breakdown of assessments, including objective and subjective information, I learn new ideas of how to identify diagnostic clues unique to each case.
For example, each sport has different biomechanical demands on the athletes and by breaking down their movements and asking them to perform their sporting actions can lead to clues in their dysfunction; findings from static and single plane tests may be indicative of pathology but never conclusive without a more dynamic, sports or activity specific movement breakdown whereby symptoms may be reproduced. In the instance of pain, analysis of specific sporting movements may identify muscular imbalances, dysfunction and/or compensatory responses, which are often the primary culprit and clue as the cause of the pain.
With this in mind, engaging in a discussion with other students about the unique nature of their cases and diagnostic findings may help to add extra ideas and tools for myself to potentially explore in my initial assessments, especially with patients who take part in sports requiring very specific movement patterns.

Patient 4 – Follow up hip and lower back soft tissue massage
This was a regular patient who visits the clinic and receives a maintenance treatment for lower back and hip pain and as much as I advise this patient on the benefits of self-maintenance, this patient is more than happy to continue to visit the clinic for symptom management. I used this time to practice my massage techniques, but this use of manual techniques on a strong individual such as this patient was an important opportunity to maintain my levels of fitness.
It is usual in this practice to have to treat patients back to back who require a significant amount of physical treatments such as soft tissue massage and joint mobilisations and in this particular case, manual hip traction. I find this particularly difficult and labour intensive and I am aware of the impact that this treatment may have on myself as a therapist. It is widely reported that work related musculoskeletal disorders and pain are prevalent among physical therapists (Vieira et al., 2016) and because of the varying nature of the treatments that I offer, from physical therapy to simply verbal communication and patient education and advice, the inconsistency does not always give me the chance to keep fit enough to follow through an entire treatment session of massage and to avoid developing my own injury. From my experience and research, I have come to develop my techniques in this area to avoid fatigue or injury, however there are certain treatments that I may always find difficult, whatever technique I adopt. For example, I found that I was unable to perform the hip traction technique for the length of time that I felt was required for this patient. From this, I should aim to develop my general strength and stamina outside of the clinic, but also to fully utilise these sessions as a way to do this.

Patient 5 – Follow up Scheuemann’s Kyphosis; management of symptoms and a strengthening program
This patient is also a regular at the clinic and is currently following a rehabilitation program that focuses on relieving symptoms of forward shoulder posture and excessive thoracic spinal curvature by way of stretching the posterior capsule and strengthening upper back muscles such as the rhomboids and lower and middle trapezius muscles.
From my reflections in my previous session with this patient, I highlighted the need to remain vigilant in identifying any changes in symptoms and to be aware that I do not become complacent in my approach to this subject because of the frequency of his appointments. I therefore made sure to carry out a full assessment of his shoulder, similar to his initial appointment, to ensure that nothing has been missed and any improvements or deficits are identified.
Interestingly, where there was previously a small bilateral deficit in internal rotation, tests showed a much more significant restriction in this movement on both sides; lack of internal rotation was very obvious to the extent that bilaterally, there was very little ROM. In between appointments with myself, this patient had an appointment with another therapist who performed deep tissue massage to the sub scapular muscles, which felt painful to the patient at the time, but relief was reported from three days after the treatment. If I had been more vigilant, I would have associated this pain with potential weakness and looked to treat the potential cause of the pain, as opposed to treat the tight symptoms by massage. These findings will have a significant impact on the focus of the patient’s rehabilitation for the coming weeks and also an impact on the direction of treatment for this particular session, highlighting the need to be consistent and through at each session, despite the time it may take and potential repetitiveness of this process. From these findings, therefore, in addition to this patient’s regular treatment, I looked into incorporating additional exercises that will help to increase internal rotation before continuing with strengthening the shoulder muscles.
I suggested the sleeper stretch and explained to the patient about the need to hold the stretch for at least 30seconds. When I explained this to the patient, he was genuinely surprised to have learned that he was not holding his stretches long enough. I usually stress the importance of holding the strength for at least 25-30seconds and I also ensure that I write this on their rehabilitation card, however it was clear that I did not explain this concept well enough to this patient early enough and as such, previous stretches may not have had the desired effect. This further highlights the need to review not only the exercises themselves and how well the patient can perform them, but review the patient’s understanding of the reasons why they are doing them and why they follow particular methods.
It will be interesting to review any potential progression in ROM in internal rotation over any following sessions, but also in his posture by way of the door frame stretch and lengthening the area of his chest associated with the length of his pectoralis minor (Carvalho et al., 2019; Finley et al., 2017; Rosa, Borstad, Pogetti and Camargo, 2017).

In previous weeks I have also discovered theories suggestive of the benefits of scapular alignment in relation to shoulder muscular imbalances that can contribute to varying movement patterns and weaknesses in the shoulder, for example in research by Cools et al. (2014) and Lewis (2011). I have learnt that although muscle activation patterns are maintained throughout entire movements, such as through flexion and extension (Reed, Cathers, Halaki and Ginn, 2016), that is not to assume that the correct levels of activation are being achieved in the initial movements and as well as ensuring that this patient is improving internal rotation ROM before more strengthening, I wanted to ensure that his scapular stabilisation and movement patterns were not causing additional dysfunction. I am new to the concept of scapular dyskinesis but as I have developed a theoretical trust in this identifying feature to possible shoulder pain and dysfunction, I was enthusiastic to incorporate this into my assessments. In order to identify any dyskinesis, I asked the patient to perform bilateral forward flexion of the shoulder, followed by bilateral shoulder abduction with a dumbbell in each hand, a method derived by McClure, Tate, Kareha, Irwin and Zlupko (2009). Because the patient was over 68kg in weight, the dumbbell weight was 2.3kg (1.4kg for patients over 68kg). From this, I identified both early protraction and early elevation of the scapular. This test was found to have good intra rater reliability and therefore of clinical relevance in this instance (McClure et al., 2009).
I am yet to fully understand whether the prematurely protracted and elevated scapular is of significance in this particular case, as the movements dysfunction is bilateral and it is unclear as to whether this contributed to excessive kyphotic posture or whether the scapular muscle weaknesses have occurred as a result of the onset of Scheuemann’s kyphosis.
Apart from being a great opportunity to develop my confidence in my ability to identify dysfunction, but by carrying out this method of analysis/observation, it was a chance to explore other treatment directions, especially as this patient has had little to no relief in muscular pain in the muscles stabilising and assisting in moving the scapular; specifically the rhomboids. I am able to suggest that, although the findings of the scapular dyskinesis test led me no further forward in understanding any potential imbalances, it did allow me to identify a bilateral weakness in his rhomboids and as such I felt confident in suggesting more scapular stabilisation exercises, such as low rows and Y and L shoulder exercises, as advocated by Liebenson et al. (2011). Due to the high levels of gym activity of this patient, I suggested that he perform these exercises lying prone on an exercise ball, so as to advance this to incorporate additional core stability and balance and coordination, areas usually of weakness amongst the general population (De Blaiser et al., 2018; Huxel Bliven & Anderson, 2013). I also explained the importance of correct scapular alignment and use of correct muscle groups and posture when doing these exercises and used posture ETT in order to enhance sensory reception and subsequent consciousness of posture. (Han, Lee and Yoon, 2015; Shaker, Keshavarz, Arab and Ebrahimi, 2013). This patient has always returned to the clinic reporting significant benefits from the use of kinesiology tape and requests this as an additional element to treatment. Whether the effects of this tape are due to placebo, as commonly reported (Poon et al., 2015) or whether the benefits of this patient were felt as a result of the treatment itself as opposed to the tape, patient satisfaction prevails in this instance and I was confident in the efficacy to apply ETT as an effective mode of treatment.

References –

Arjun, K. 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. https://doi.org/10.18203/issn.2455-4510.intjresorthop20170902

Carvalho, L. A. C. M., Aquino, C. F., Souza, T. R., Anjos, M. T. S., Lima, D. B. M., & Fonseca, S. T. (2019). Clinical Measures Related to Forward Shoulder Posture: A Reliability and Correlational Study. Journal of Manipulative and Physiological Therapeutics, 42(2), 141–147. https://doi.org/10.1016/j.jmpt.2019.03.006

Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2015). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology, 25(2), 310–315. https://doi.org/10.1016/j.jelekin.2014.09.005

Cools, A. M. J., Struyf, F., De Mey, K., Maenhout, A., Castelein, B., & Cagnie, B. (2014). Rehabilitation of scapular dyskinesis: From the office worker to the elite overhead athlete. British Journal of Sports Medicine, 48(8), 692–697. https://doi.org/10.1136/bjsports-2013-092148

Craig Liebenson, D. C. (2011). Y exercises for correcting the most common faulty movement pattern of the shoulder/neck region. Journal of Bodywork and Movement Therapies, 15(3), 391–394. https://doi.org/10.1016/j.jbmt.2011.05.001

De Blaiser, C., Roosen, P., Willems, T., Danneels, L., Bossche, L. Vanden, & De Ridder, R. (2018). Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2017.08.076

Ferber, R., Bolgla, L., Earl-Boehm, J. E., Emery, C., & Hamstra-Wright, K. (2015). Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: A multicenter randomized controlled trial. Journal of Athletic Training, 50(4), 366–377. https://doi.org/10.4085/1062-6050-49.3.70

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

Han, J. T., Lee, J. H., & Yoon, C. H. (2015). The mechanical effect of kinesiology tape on rounded shoulder posture in seated male workers: A single-blinded randomized controlled pilot study. Physiotherapy Theory and Practice. https://doi.org/10.3109/09593985.2014.960054

Huxel Bliven, K. C., & Anderson, B. E. (2013). Core Stability Training for Injury Prevention. Sports Health. https://doi.org/10.1177/1941738113481200

Lewis (2011). Shoulder Symptom Modification Procedure ( SSMP ) V2 Date : Symptomatic movement or posture 1 : Symptomatic movement or posture 2 : (1), 2011.

Macadam, p., Cronin, j., & Contreras, b. (2015). An examination of the gluteal muscle activity associated with dynamic hip abduction and hip external rotation exercise: a systematic review. International journal of sports physical therapy.

McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying scapular dyskinesis, part 1: Reliability. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-44.2.160

Poon, K. Y., Li, S. M., Roper, M. G., Wong, M. K. M., Wong, O., & Cheung, R. T. H. (2015). Kinesiology tape does not facilitate muscle performance: A deceptive controlled trial. Manual Therapy. https://doi.org/10.1016/j.math.2014.07.013

Reed, D., Cathers, I., Halaki, M., & Ginn, K. A. (2016). Does load influence shoulder muscle recruitment patterns during scapular plane abduction? Journal of Science and Medicine in Sport, 19(9), 755–760. https://doi.org/10.1016/j.jsams.2015.10.007

Rosa, D. P., Borstad, J. D., Pogetti, L. S., & Camargo, P. R. (2017). Effects of a stretching protocol for the pectoralis minor on muscle length, function, and scapular kinematics in individuals with and without shoulder pain. Journal of Hand Therapy, 30(1), 20–29. https://doi.org/10.1016/j.jht.2016.06.006

Shakeri, H., Keshavarz, R., Arab, A. M., & Ebrahimi, I. (2013). Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: a randomized, double blinded, placebo-controlled trial. International Journal of Sports Physical Therapy, 8(6), 800–810. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24377066%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3867073

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. https://doi.org/10.1016/j.pmrj.2014.08.361

Vieira, E. R., Svoboda, S., Belniak, A., Brunt, D., Rose-St Prix, C., Roberts, L., & Da Costa, B. R. (2016). Work-related musculoskeletal disorders among physical therapists: An online survey. Disability and Rehabilitation. https://doi.org/10.3109/09638288.2015.1049375