Total Hours: 190
External Hours: 50
Clinic Hours: 140

Patient 1 – Pain on dorsal/medial surface on foot when running; possible overuse
The following is a summary of the relevant information from assessment:
S: patient has reduced running load since Christmas from 40km per week to 16km approx. which initially I couldn’t see a problem with, however even though the frequency of running has reduced and overall mileage, the patient explained that he was still running long runs, but at a higher speed and with longer rest in between.
Although reducing load is not normally indicative of overusing or overloading a tendon,
other factors such as general health may also have played a role in the development of a tendon pathology as the body’s ability to regenerate collagen and repair itself is compromised in conditions that affect inflammatory responses (Curtis, 2016), such as those associated with the thyroid. Although there is no direct evidence on the effects on hypothyroidism and tendon pathology (Oliva, Berardi, Misiti, & Maffulli, 2013), the thyroid has been found to affect the development and maintenance of metabolic systems has been found to increase collagen type I as well as cartilage oligomeric matric protein, both of which are associated with tendon alignment (Berardi et al., 2014).
This patient does take medication for hypothyroidism names as thyroxine and as such we discussed his susceptibility and/or increased risk of tendon pathologies and the need for a careful training program. Thyroxine reportedly facilitates synthesis of collagen and is given to patients with hypothyroidism to help reduce the effects of this hormone on tendon health; those with the condition and reduced thyroid gland function have been found to have an increased risk of calcification in the tendon.
It is advised that by medication, managing the thyroid disorder would be the most effective treatment in tendinopathies, however this patient was already in control of his condition. This lays the focus of treatment on a program of exercise whereby the patient develops a more consistent running plan; increases frequency but reduces speed and distance. By doing so, the tendon is not overloaded sporadically throughout the week, but given a more gradual and progressive load.
To facilitate this, I also found exercises to strengthen his foot as a whole complex to be effective in previous treatments of non-specific tendon type pain not only as a way of better supporting the ankle and foot muscles as a whole, but by prescribing a plan for the patient that brings a new dimension to his training, to add focus and additional motivation for continued progress. Exercises such as those found to be effective in the strengthening of the arch muscles, such as the tibialis posterior, the peroneals as well as flexors and extensors were all given to the patient with reps to stimulate fatiguing responses and therefore more realistic of the functional and continuous motions of running (Lee & Choi, 2016).

I also educated the patient on cadence and to consider increasing this to reduce ground reaction forces each time her plants his foot (Hafer, Brown, deMille, Hillstrom, & Garber, 2015). I felt confident that my knowledge on pre disposing risk factors of tendon injuries gives me plenty of information to share with my patients to make sure that they are well informed of how to reduce their risk of injury or manage their training loads. By sharing this information, I am able to empower the patient to take better care of themselves by the simple fact that they understand the factors involved with the development of injury.

Patient 2 – Group discussion on case experiences while carrying out clinic duties
My second patient who was due to attend the clinic could not make the session but without prior notice, as is unfortunately a common occurrence. I was not alone in my lack of patients and so I sought discussion from other students. While we folded towels and carried out other clinic duties, such as refilling lotions, cleaning and writing notes, we engaged in a discuss on how we demonstrated our exercises to patients and by what means do we provide the information. At present, I write down the exercises onto a rehabilitation sheet, as per the protocol of the clinic but I also ensure that I demonstrate each exercise and ensure that the patient can perform them too. Quite often, I have explained an activity to a patient who has expressed their understanding, only for them to be unable to perform it when asked! And as mentioned before, with patients who I have prescribed a plan to but did not spend time demonstrating and practicing the exercises, they have self-reported lower adherence rates.
Other students used similar methods and found the same issue with some patients. It is most likely not uncommon to see a variety of patients whereby some need more motivating that others, so having a wide range of resources could prove useful in the future. Generic go-to hands out may be quite useful for me to create and have readily available to pass on to patients for specific conditions that I may find quite common in the clinic or for the population group that I will be working with most. Conditions such as non-specific lower back pain, tendon injuries and general muscle weaknesses could all have their own hand out which demonstrates pictures and visual guides to what is expected, as well as a blank space for sets and reps to be added in order to personalise the program.

It was suggested by one of the students that a website by Ex Rx (https://exrx.net/) had proved invaluable in their learning of exercises and was an excellent resource to use, either to learn from or to direct patients to.
I will take it upon myself to spend my final weeks at Marjon taking and collating a variety of photographs while using the rehab area (as this will provide a good professional environment) to derive such information hand out sheets. I understand that this will take time as I develop my understanding of exercise prescription and associations with certain injuries, however if I gradually take photos and collect information from websites such as this, I can slowly create a small catalogue of information to pass on to clients which could also include adherence tables, all of which will help to increase compliance and adherence to rehabilitation programs, an important factor in the successful outcome of programs (Picha & Howell, 2018).

I would not have known about the website with these fantastic resources on them, had I not have spent time asking other students of their sources and what their clinical intentions may be when they finish this course. I am excited to derive my own information sheets but also look at the potential benefits to creating a website with this information too.

References – 

Berardi, A. C., Oliva, F., Berardocco, M., la Rovere, M., Accorsi, P., & Maffulli, N. (2014). Thyroid hormones increase collagen I and cartilage oligomeric matrix protein (COMP) expression in vitro human tenocytes. Muscles, Ligaments and Tendons Journal. https://doi.org/10.11138/mltj/2014.4.3.285

Curtis, L. (2016). Nutritional research may be useful in treating tendon injuries. Nutrition. https://doi.org/10.1016/j.nut.2015.12.039

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

Lee, D., & Choi, J. (2016). The Effects of Foot Intrinsic Muscle and Tibialis Posterior Strengthening Exercise on Plantar Pressure and Dynamic Balance in Adults Flexible Pes Planus. Physical Therapy Korea, 23(4), 27–37. https://doi.org/10.12674/ptk.2016.23.4.027

Oliva, F., Berardi, A. C., Misiti, S., & Maffulli, N. (2013). Thyroid hormones and tendon: Current views and future perspectives. Muscles, Ligaments and Tendons Journal. https://doi.org/10.11138/mltj/2013.3.3.201

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