Clinical Experience Tuesday 10th December 2019 – 5 hours (15:00-20:00): 156.5 total

Running total of hours 156.5
Patient 1 – Previous history of strain in erector spinae
All assessment of this patient indicated the muscular involvement was most likely. The pain was localised and muscle testing provoked pain with resisted movements and any passive motions unprovocative. No indication of joint pathology and due to the chronic nature of the pain and subjective onset last year, I was confident that this treatment would be strengthening based, with passive modalities such as STM and stretching feasible options.

One of the most important elements to treatment and rehabilitation is the goal of the session and regardless of what stage of injury the patient is in, what they hope the outcome to be, determines the course of treatment and our approach as therapists.
At present, the pain in this patient’s back was low and of minimal irritability, but his anxieties led him to believe that he may not fully enjoy his sport again due to the constant feeling of discomfort. This apprehension and anxiety will only serve to hinder progress and potential exercise adherence and so with some motivation and positive communication, my aim was to encourage this patient to commit to a more regular exercise schedule.
The patient showed little enthusiasm and belief in the effectiveness of strengthening exercises in the treatment of his pain at the beginning of the session, however after taking the time to through each exercise and explaining the rationale behind them, he left the clinic feeling more empowered; the patient commented on his renewed motivation since returning to the clinic.
The exercises that I prescribed included glute bridges with additional resistance bands around the thighs to activate the lateral abductor muscles (Gasibat et al., 2017), as this patient also presented with weakness here as well as a dull pain in his lateral thigh.

I did not feel comfortable knowing how to test this patient’s source of pain, which is undoubtedly the result of poor anatomy knowledge and have since worked to develop this. I have found the following video incredibly useful in knowing how to individually test each quadricep muscle and other muscles on the lower leg.

This video by the PhysioTutors also helped me to consider a more accurate approach to muscle testing. I have previously thought that muscle testing and grading was a difficult skill acquired from experience, as I have never felt myself an accurate judge of muscular strength, however this video differentiated between each grade with specific and easy to understand guidelines.

Other exercises included the side plank with hip abduction (Gasibat et al., 2017)and the deadlift squat (Camara et al., 2016).
I was unsure as to whether this patient needed to perform this squat with bent or straight needs and I asked for guidance, however I was able to work out the mechanism in this movement and therefore the rationale between each; deadlifting with bent knees excludes the hamstring in this motion, so in order to isolate the erector spinae alone, the patient should keep their knees bent.

It was also suggested that the patient consider the possibility of using a hexagonal barbell instead of a straight one in order to maintain a more even load throughout, as recommended by Camara et al. (2016) in a study that found differences in outcomes between both the hexagonal and straight barbells when performing a squat; the hexagonal barbell was found to better distribute load throughout the joints compared with the straight bar bell. Although deadlifting with a straight bar is generally good way to increase lumbar strength, in the case of lower back pain, prescribing an exercise which predominantly activates lower back and hamstrings may only aggravate symptoms.

Patient 2 –
Achillies Tendonitis Exercises
I had plenty of time before this patient arrived and fortunately the clinic was quiet, so myself and two other students engaged in a conversation on tendinopathies to help us to understand the pathology behind the condition so that we can fully appreciate our treatment subscription.

Fortunately, we had also attended a lecture in recent weeks which focused heavily on the differences between tendonitis, tendinopathy and tendinosis, so I was able to recall some knowledge on this to help enhance my ability to differentiate between the pathologies during the diagnostic process and prescribe the correct rehabilitation. This was especially important in this patient as this patient had left a note on his booking which informed me of his main goals for the session which was to receive an appropriate exercise plan to facilitate his return back to running.

We referred back to the lecture notes from Gary Schum to look to derive an appropriate exercise prescription. Early research by Fahlström et al. (2003) found that eccentric exercises were useful in reducing pain and improving symptoms in chronic mid portion tendinopathy, as was the case with this patient.
In the presence of symptomatic pain, it is recommended that isometric contractions should be used, as these have been reported as inhibiting pain responses (Naugle et al., 2012; Rio et al., 2015), specifically low duration with low to moderate intensity (20-50% contractions).
The benefits of isometric contractions are that they can be performed without the reduction of strength and as found by (Rio et al., 2015) in a study on patella tendinopathy, isometric contractions were effective in reducing pain for up to 45minutes after the exercises.
It is important to differentiate between insertional and mid portion tendinopathies as this would determine the treatment prescription in so much as stretching and exercises must not effect areas that may compress the insertional aspects of the tendon. It may be useful to perform other means of lengthening and stretching of associated musculature, such as the triceps surae group by way of foam rolling or STM.
In this case, the pain was very much localised to the mid portion aspect of his achillies tendon and as such exercises that may increase compression of this area were not excluded and stretching could be performed by this patient, even in the reactive stage.

Recently in my reflections, I delved into the different stages of tendinopathy, however I was not fortunate enough to come across an article by Cook and Purdam (2009) of which I have found extremely useful.

Often in my practice, I am aware of the available research and therefore rationale behind the treatment and rehabilitation, however I am not always able to explain the pathology behind the injury and therefore without this knowledge, it is difficult to rationalise the treatment. Instead, I rely too heavily on research findings are recommendations, without a depth of knowledge as to why this evidence was found.
In this particular case of achillies tendinopathy, I am confident in considering eccentric exercises to aid in the strengthening, but I am unsure as to why.
It is also important to know at which point to start the patients on eccentric strengthening but with more knowledge as to the rationale behind them, I may be able to understand this better.
As reported by Cook and Purdam (2009), load is the main variant in tendon health and in most cases, according to Quinlan et al. (2019), appropriate loading of the achillies tendon results in physiological adaptations of the tissue. The theory behind the continuum, as reported by Cook and Purdam (2009) is that varying loads can determine the progression or regression of a tendon pathology.

When the tendon is overloaded acutely it is most likely to be reactive tendinopathy and although some structural changes occur in the matrix, such as collagen deformation, it is unlikely to be observed or relevant at this stage. However, in the case of tendon disrepair, matrix breakdown becomes greater and neovascularisation does start to occur and can be seen on diagnostic imaging (Cook & Purdam, 2009).

NB: the group discussion during clinic today was very useful, as I was not sure exactly what neovascularisation was and as it is relevant to achillies tendinopathy, I am pleased we were able to clarify what this was.

This stage is more the result of chronic overload and would likely be the stage in which this patient is in due to his subjective history. The fact that this patient had been overtraining over the course of many years in spite of severe pain and inflammation would suggest that chronic overload should be considered a probably and likely cause.

I was initially confused by the fact that this patient had rested for the previous year and wondered why this had not had an positive effect on his tendon. It was explained that the chronic overuse was in fact accumulative and that although he had stopped, the damage had already occurred and physiological adaptations would likely have taken effect (such as matrix breakdown and neovascularisation).
it was reassuring to read however that these changes could be reversed with the correct loading program (Cook & Purdam, 2009).

A recent review by Quinlan et al. (2019) was unable to differentiate between concentric or eccentric exercises and could not conclude whether one was more effective than the other however, it was suggested that the use of eccentric exercises for older patients could be useful as it required less perceived effort.

It is reported that loading can have an effect on the tendon up to three days after intense loading and therefore it may be that in order to prevent excessive loading, the patient could ensure a period of at least three days of rest before further loading the tendon as opposed to training on a daily basis (Cook & Purdam, 2009).
If loading is the issue, which it most likely is in reactive tendinopathy it may be recommended that low impact, low elastic training be performed such as cycling or swimming as opposed to activities that require running or jumping mechanisms. Educating the patient on stride length may also be appropriate.

When this patient has visited other professionals, he was recommended to load the tendon, with exercises prescribed which were all predominantly eccentric. I would previously have done the same, as it has been widely reported that this is the most effective treatment. However, now that I am more understanding of the continuum model, I am more aware of the differing nature of the pathology and the need to adapt the rehabilitation accordingly.

Patient 3 – Lower back pain and core stability
This patient presented with generalised and non-specific lower back pain and has requested a STM to treat the symptoms of this. The patient had reportedly tried strengthening programs and other means such as stretching and mobility exercises to help manage his symptoms but to no avail. In all previous appointments where I have managed to find recommended exercises of good feasibility, I have yet to fully appreciate their effectiveness because I am early on in their rehabilitation programs; I have not seen the patient enough times to fully notice any long term improvements.
But, if this patient is now failing to notice and improvements in symptoms in spite of a comprehensive exercise program, as well as reviewing this program and looking for potential reasons for it’s ineffectiveness, for example making an adjustments to his technique, I could look to find an alternative route of treatment. For example core stability.
According to Gordon & Bloxham (2016), although improving lumbar spine and hamstring flexibility reduced chronic lower back pain by 18.5 to 58%, core stability exercises were found to be more effective than stretching. It was also found that core strengthening reduced chronic lower back pain by up to 76.8% whereas muscular strength exercises, although also effective, reduce chronic lower back pain by just 61.1% (Gordon & Bloxham, 2016). A study by Chang et al. (2015) reviewed previous research findings on the effectiveness of core exercises and their specific nature, reporting the following as effective with the general pattern of up to two sessions a week for between six to ten weeks.
Trunk exercises while quadruped or otherwise (such as sitting or kneeling but not standing), segmented stabilisation exercises and more dynamic movements such as the cat camel, concentrating on breathing in particular, were all incorporated in these programs.
It was interesting to read the consideration of breathing techniques as I did not take this into account when prescribing this to my patient, yet it is a very important aspect of these exercises.
This may be common sense, but it was also reported that the length of the core stability program was also a factor in its effectiveness, with a three week program proving less effective than an eight week one (Gordon & Bloxham, 2016) and as such I will look to educate future patients in the importance of maintaining their programs beyond their perceived need and beyond as a way of ensuring long term benefits and reducing regression. This patient was now fully aware of the advantages of maintaining an exercise program for longer periods of time and to persevere with this until symptoms may start to reduce (and beyond). Also, I felt that we could add another dimension to the program by way of core stability and as such I incorporated some exercises to enhance this.
Exercises such as the bird dog, bridges and side planks were all prescribed with high volume and repetitions with the aim to improve muscular endurance rather than strength.

Patient 4: STM of lower back, glutes and piriformis release with additional PA of L4/5

Extra Reading and discussion during time between patients:

Core stability in general – is it effective?

In any scenario within my practice, I will look to include core stability exercises in rehabilitation. My rationale behind this is due to the enhanced risks that poor core stability brings to an athletes. De Blaiser et al. (2018) highlights the risk factors in athletic injury of the lower limb, finding that neuromuscular control, core strength, endurance and proprioception all increase the likelihood of injury and that core exercises can be used to either prevent injury or help to facilitate back to play in rehabilitation programs.

In an article by Huxel Bliven and Anderson (2013), a table of core stability exercises was created which includes the specific muscle recruitment and therefore specific areas of strengthening.
I will print this off as a reference guide for me to use in clinic and the findings in this study can be referred to as a means to rationalise the use of these exercises, should this be questioned.
I could not upload the table to this blog as the quality was poor, so please see the following link to the article with reference to p. 520.

References –

Camara, K. D., Coburn, J. W., Dunnick, D. D., Brown, L. E., Galpin, A. J., & Costa, P. B. (2016). An examination of muscle activation and power characteristics while performing the deadlift exercise with straight and hexagonal barbells. Journal of Strength and Conditioning Research.

Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of Physical Therapy Science, 27(3), 619–622.

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine.

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.

Fahlström, M., Jonsson, P., Lorentzon, R., & Alfredson, H. (2003). Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surgery, Sports Traumatology, Arthroscopy.

Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24.

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22.

Huxel Bliven, K. C., & Anderson, B. E. (2013). Core Stability Training for Injury Prevention. Sports Health.

Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. Journal of Pain.

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.

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283.




Clinical Experience Monday 9th December 2019 – 5.5 Hours (15:00-20:30): 151.5 total

Running total: 151.5

Patient 1 and Patient 2 – both my first and second patients in this session were follow ups from previous weeks who requested soft tissue treatment; the first usually attends the clinic weekly and the second has recently started returning on a fortnightly basis.
These sessions were requests and neither patient had considered the potential for further investigations or alternative treatment options and as such I fulfilled their requests and provided them with their treatment.
It was brought to my attention that the patient had a comprehensive injury history to his hip, which was of interest to me and as such I used the time that I was administering STM to ask about his condition as well ask about his experiences.
The patient had a history of a labral tear and femoral acetabular impingement (FAI) and underwent a hip arthroscopy two years prior to this session.
I had little prior knowledge of acetabulum labral tears or FAI and the management of these within a clinical setting, but did some follow up research to better understand this patient’s current rationale behind his ongoing and recurrent visits to the clinic.
Interestingly, acetabular tears are common and are often seen in young and physically active individuals (Smith et al., 2011). Due to the recurring nature of this patient’s discomfort and how he is unable to manage this through home rehabilitation, I had wondered whether this was typical in patients with previous labral injuries. Specifically, I was intrigued as to how much surgery and/or a labral tear effected hip stability. In a study by Smith et al. (2011) which set out to test whether labral tears significantly affected hip stability, it was found that although removal of at 2cm of the acetabulum by means of a labrectomy removal results in instability, the presence of labral tears or up to 1cm removal of acetabulum had in fact no effect. This research was only done of a cadaver, however so it does not take into account surrounding muscle activation in the aid of movements and stability and the effects of surgical intervention on these structures.
In this particular case, the patient had an arthroscopy, which is reported as being successful in treating patients who experience pain and reduced function after FAI surgery (Philippon, Briggs, Yen, & Kuppersmith, 2009; Sardana et al., 2015). The labral tear may have been debrided in the same procedure but unfortunately, I did not ask the patient about the full extent of the surgical treatment he had undergone because I did not have enough knowledge at this point to fully understand.
The arthroscopy would have been initially performed to treat the impingement but any other pathology would have been assessed and treated where possible, in the same procedure.
Interestingly, out of a study group of 7,351 subjects who attended a follow up appointment two years post hip arthroscopy, 11.7% ended up needing total hip arthroplasty (THA), of which 3% were under 40 (Schairer et al., 2016). It was also found that on average a THA was performed 16 months post arthroscopy (Philippon et al. 2009).

According to Philippon et al. (2009), restoration of excellent functional ability can be influenced by the patient’s participation in rehabilitation and in this study it is simply recommended that the course of treatment immediately post-surgery ensures the restoration of passive before active movements and then strength training with additional hip pendulum exercises. I do not know if the patient followed a prescribed exercise plan after his surgery but I will discuss this with him during his next appointment as I would be interested to know whether this has impacted on his functional ability now. I have understood from this research the need to be prepared for the prospect of a THA but also I have gathered confidence that a successful outcome is viable and as such I will continue to treat this patient as requested in the hope that a more long term management plan is created or improvements are made.
I learnt from this particular research that in order to determine FAI, the following tests are recommended;
FABERS, Quadrant Test, ROM, specifically flexion, adduction and abduction and both internal and external rotation.

As I wrote about earlier in my reflections, I struggle with time keeping. Unfortunately, I ran out of time at the end of this session and found it difficult to end the conversation with this patient meaning that the session overran into the next.
I believe that much of this patient’s need stems from a psychosocial perspective and that he really would like some company, something he even mentioned earlier in the session.
I am not very comfortable with cutting people short when they are engaging in a conversation with me, especially as I feel like I was providing him with a listening ear for his potential anxieties. However, I know that in order to fulfil all appointments today and maintain structure and professionalism, I needed to wrap up the session. From reflecting on this, although there are circumstances whereby a patient will continue to talk regardless of my influence, I feel that in order to end the session on this, I should look to wind down the conversation earlier.
I do feel as though this has improved over the past 3 months, but I am still looking to consider other strategies, such as the use of body language and physically bringing the conversation or session to a close by slowly tidying up from the session and making my way to the reception.
After having spent many hours observing and working alongside Kat Stenner at the osteopathy clinic, I have been able to pick up on how she addresses this issue and admittedly, sometimes this scenario is unavoidable and in these cases, the patient’s wellbeing really is more important than a schedule and providing an listening ear is more important, however similar strategies such as tidying up and discussing payment starts to effectively channel the conversation to a close but in a polite and subtle manner.

Patient 3
– Follow up for thoracic spine mobility and shoulder pain
This was the third appointment for this patient in the clinic, with this session being his follow up. Unfortunately, as my previous patient was late leaving on this occasion, I had very little time to pre-read this patients notes and thought I could do this while engaging in a follow up conversation, but this was not the case and instead, I found myself having to apologise for not remembering much of this case. I was so sure that my poor memory of his injury and rehabilitation and lack of pre reading was noticed by him and I felt as though I wasn’t giving him the best possible treatment at that time.
I feel as though it is a more personable experience when you are greeted by your practitioner who has obviously either remembered you or have done some pre reading on your case. In my future practice, I will make a point to thoroughly read through previous notes, even if this makes me even later in starting the next appointment. I did apologise to the patient for my forgetfulness and explained about the previous session overrunning but took responsibility for my lack of preparation and as I was able to recall his information eventually, the patient was understanding and we made a joke of it.

As mentioned before, this is the third time that I have seen this patient and although progress has been made, it is slow and the symptoms have returned each time.
I was very excited to be able to incorporate some theory that I learnt from lectures in recent weeks regarding the shoulder as this was most relevant in this case. I feel as though I wish I had been able to apply this knowledge much earlier on in this patient’s rehabilitation, as he may not have needed to return by now because not only would we have treated symptoms but we would have looked at his whole kinetic chain and therefore multidimensions of shoulder and thoracic movements, assessing, diagnosis and subsequently correcting any possible underlying causes of symptoms.
For example, scapular stabilisations, thoracic curvature and humeral head procedure as outlined in the Shoulder Symptom Modification procedure (Lewis et al., 2005; Lewis et al., 2009; Lewis, 2011). Using this model I first assessed him thoracic spine, which showed good clinical outcomes and I was able to observe full ROM with no pain or restrictions; this may have been due to his excellent adherence to the rehabilitation for increasing his thoracic mobility over his previous sessions. Instead, I looked at his scapulars only to find them both upwardly rotated which was indicative of weakened serratus anterior and lower traps and/or over active upper traps.
I advised the patient to perform scapular stabilisation exercises against the wall and educated the patient on the best position and how to obtain this. I was confident that the patient was aware of how to correct his scapular positions and our intended outcome and explained the need for these simple closed kinetic chain exercises in order to build endurance of the stabilisation muscles of the scapular before progressing the exercises to more dynamic, isotonic open kinetic exercises which may alter the scapular kinematics; until the patient can maintain stabilisation by way of increased muscular endurance in the right postural muscles such as the lower and middle traps and serratus anterior, more functional motions will be difficult to perform and technique may be compromised.

I suggested that after a short program of wall stabilisation exercises, the patient could progress to doing them on floor and incorporating push ups which a maintained technique. This would provide the patient with a more dynamic approach to his rehabilitation, as he is already an active individual with reasonable levels of fitness.

Patient 4 – Scoliosis follow up
I was really looking forward to seeing this patient again, as I had conducted a great deal of research surrounding this condition. In the previous session I videoed his forward flexion and observed the curvature in this movement, which really fascinated me. I started the session by performing a follow up subjective and objective assessment which was all positive, however when asked to perform the single leg stance, it became apparent that the patient had made no progress in stability or in developing symmetrical strength in his stabilising muscles in his back; he was unable to maintain a steady stance and was significantly wobbly throughout the movement. When I asked the patient about the exercises given to him to improve this, he informed me that he did not do them. Fortunately we did perform a clinical objective measure of the single leg stance and so I was able to explain to the patient, through observation, what the outcomes of his rehabilitation was and as it was obvious to see no improvements in this exercise, I was able to help him to understand the implications in his low adherence. Although I was happy that the patient was performing all other exercises, it was this particular one that would have enabled progression through to more functional, dynamic exercises. However, as the patient was still unable to perform the single leg stance in a stable manner, we could not progress.
I wanted to ensure that the patient was happy with his program, to which he responded positively and merely that he had forgotten to include this particular exercise.
From having researched this condition and from having communicated what I had learnt to the patient, I feel more confident that the he had acquired more knowledge and possibly empowered him a little giving him more hope as to his possibilities to live in less pain.
In future I will make sure that we double check that the patient has a good exercise plan to refer to and to review before they leave to clinic to ensure that they know to complete all exercises.

Because he had progressed well in his thoracic mobility exercises, I did add another exercise to enhance this further but to also look to improve his core stability. This was the bird dog. I used this time to practice coaching this technique and as he was not fully able to perform it at first, I needed to adjust the routine; his coordination was the limiting factor instead of his core strength, so instead of the usual opposite leg and arm at the same time, I regressed this to one movement at a time.

I am looking forward to the next session, where we will look to progress his exercises further and hopefully observe improvements.

Extra time between patients – I used this time to physically perform all of the exercises that I had so far prescribed in my clinic session. Unfortunately I did not have any other students to discuss and practice these with as they were all busy with clients, but I was able to use all of the equipment and have a go. I find explaining exercises very difficult as I usually have only read about them in theory and have no actually tried them out myself. Sometimes manoeuvring myself around the equipment, especially the gym balls is quite a challenge, so demonstrating this to patients seems slightly more difficult than it should be. By taking the time to use the equipment, I am also able to fully appreciate how difficult some exercises can be to master and therefore I can start with more simpler ones for some patients; some are much harder than they look, such as a bilateral hamstring curl, especially for myself who is not used to this type of demand!

References –

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259–264.

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

Lewis, Jeremy S., Wright, C., & Green, A. (2005). Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic and Sports Physical Therapy.

Philippon, M. J., Briggs, K. K., Yen, Y. M., & Kuppersmith, D. A. (2009). Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up. Journal of Bone and Joint Surgery – Series B, 91(1), 16–23.

Sardana, V., Philippon, M. J., De Sa, D., Bedi, A., Ye, L., Simunovic, N., & Ayeni, O. R. (2015). Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review. Arthroscopy – Journal of Arthroscopic and Related Surgery.

Smith, M. V., Panchal, H. B., Ruberte Thiele, R. A., & Sekiya, J. K. (2011). Effect of Acetabular Labrum Tears on Hip Stability and Labral Strain in a Joint Compression Model. American Journal of Sports Medicine.


External Placement Exmoor Osteopathy Thursday 5th December 2019 – 4 Hours (09:00-13:00): 146 total

Running total of hours: 146

Patient 1 – STM and maintenance of fibromyalgia patient
As this was the second time I have encountered this patient, I was much more aware of the presentation and nature of fibromyalgia and as such I felt more confident in delivering a safe and effective treatment that required sensitivity of the patient’s physical and psychological needs.
I knew to communicate wit the patient to gain continued feedback on how the patient was feeling, and although this is usual practice, in this instance, it was even more important to ensure that I was not exasperating the patient’s pain.
I am relatively strong and have always felt the need to perform soft tissue treatment with much force and I often try to apply too much pressure as a result of this, however after a discussion on my practical application of sports massage, Kat suggested that I do not need to use so much pressure, but to take each individual differently; it is more the patient’s tolerance and also need for tissue mobilisation. Instead of just giving a generic sports massage, it is important to feel the individual’s muscle tension and requirements and massage accordingly and this is something I often do not consider. I feel that sometimes I become too complacent when performing soft tissue treatments as I do this on a regular basis and feel proficient at this and as such requires less thought. However, this complacency may be affecting my ability to provide a treatment that is specific to the individual and I should refer back to my rationale of treatment.
This patient benefits hugely from a more gentle approach and with low muscle tone, it is important to apply massage with gentle pressure.

Patient 2 – Scoliosis –
This patient was a regular at the clinic, receiving maintenance and review sessions for the continued treatment for scoliosis.
Earlier in my practical clinic experience, I encountered an individual who was likely to have a slight scoliosis in his spine, however the degree of his curvature probably fell short of a clinical diagnosis of scoliosis (Cheng et al., 2015). This patient was around 15 years older, but had received a clinical diagnosis at a younger age and presented with a greater degree of curvature and a much more obvious curve.
I was able to ask many questions about her experience of the condition and the options that were given to her at a much earlier age than my previous patient.
I found this case especially interesting as the patient had a brother, who had scoliosis to an even greater degree.
As the diagnostic criteria and subsequent treatment for scoliosis is determined by the degree of curvature, it is likely that this patient’s curve did not warrant surgery at the time of assessment when she was thirteen due to the likely low risk of progression for individuals with curvature less than 20 degrees, however her brother’s curve probably did exceed 20 degrees, although the degree of her brother’s curve was unknown to the patient (Trobisch et al., 2010).
Because of the prospect of a genetic element to this case, the siblings were approached to be involved in research, however this was not materialised and still today, little evidence has been published on the inherent aspect of this condition. However it has been highlighted in a review that genetics probably do present as a possible factor, with up to 70% chance of scoliosis presentation of monozygotic twins (Trobisch et al., 2010). Unfortunately I did not ask the patient if her brother was her identical twin, but he is a relative at least.

The patient found the information that I had learnt from my previous reflections interesting and had given her a small insight into her condition, however I was shocked when she explained that she had never looked into the condition. When talking with patients about research I am careful to cite only reliable sources, so as not to provide false or unreliable information, especially when it may change their course of treatment or rehabilitation focus or motivation. I also make sure that the patient knows to conduct their own research on the subject to further expand their knowledge, because patient education is one of the most important elements to successful rehabilitation adherence in physiotherapy type treatments (Bassett, 2015). I am also careful to ensure that they too learn from reliable sources and remain open minded.

This patient’s brother did undergo the surgery to correct his spine, which provided a successful outcome and the curve is no longer present, however he still experiences the same pain as before of which is of a similar degree to his sister, even though she did not undergo surgery; the only difference between the two individuals is now the aesthetic spinal deformity, which does not seem to cause an issues for the sister.

When taking into account psychological issues that may arise from this abnormal shaped spine and the probability of progression in more obvious curves, it is understandable why some adolescents undergo surgery, but as I have seen in this case, it is not always the most effective in the treatment of pain and the management is usual conservative throughout their lives, hence the continued visits to the clinic.

As I am experiencing with my young male patient in the clinic, I strongly believe that educating the patient on the best exercises to perform at home is the best course of action to develop their own ability to maintain their strength and reduce pain associated with any muscle imbalances. From my understanding of this particular patient and her current rehabilitation plan, the focus is not on exercise or exercise education, but on a repeated cycle of soft tissue manual therapy and although this can be effective in facilitating rehabilitation, it may not provide the patient with long term benefits. If this was my patient in my own setting, I would start to decrease her reliance on the soft tissue passive therapy and keep this to a minimum as per her request, but schedule in regular gym sessions whereby our attentions are on strengthening of the weakened or lengthened areas affected by the curvature.

Patient 3Back Pain; considering hypermobility
The final patient due to attend the clinic during this session was unable to make her appointment and therefore I had an hour in which to practice any skills I have learnt or to talk through elements of practice with my supervisor.

Throughout my studies into sports therapy, I have rare has the opportunity to be the patient and as such do not know what it feels like to be on the receiving end of the assessment and when Kat suggested performing an assessment of my back, I took that as a fantastic opportunity to experience what my patients experience, as well as continued discussion on the findings of my lower back assessment.
I learnt a considerable amount from my experience of being the patient. One of the first things I experienced was the nature of physical contact; I find it uncomfortable with physical contact from others and although this was an environment within which I was clearly consenting to a physical assessment, it still came as a shock when Kat put her hands on my lower back and hips and I felt quite uncomfortable. This is what I do every time I see a patient and have to use a hands on approach with my assessments, however I never think to consider constant reassurance and communication as to my actions. I now know that it may just be good practice to reassure my patient of my intentions to place my hands on them and also explain to them in more of a step by step manor.

Patient Overview: Constant lower back ache 3/10 for at least 6 years, previous trauma to back 15 years ago after falling from horse onto a curb.
Recurrent severe lower back spasms that last for up to 10seconds sporadically throughout the day for up to 3 days at it’s worse, improves after 7 days on average.
Often comes on after running and having sat down but this occasion the onset was gradual over one week.
Spasms cause leg muscle weakness and pins and needles when sitting. No indication of root involvement from assessment.
Cannot flex or extent Lx, unable to stand straight and can only lean to right side (Pt slight forward flex and right side flex only comfortable position when walking).
muscle guarding causing severe muscle spasms, particularly in pelvic movements.
At present, Pt noticing improvements but still cannot straighten lower back.
Generally hyper mobile joints, stiffness in Lt SI joint, could not manipulate. Coccyx pain constant; feels like it’s “bruised”.

In this instance, it was hard to perform a thorough assessment as the muscle spasms were so acute and I was apprehensive as to the provocation of these, however an initial assessment ruled out significant nerve root or discogenic involvement as this point, but anatomical abnormalities in the alignment of the vertebrae were noted; significant in this instance or not, some spinous processes protruded more than others. In the absence of other findings or observations, it was suggested that the joint laxity could be a area to consider in the pain element of my injury and as such I researched this.

Hypermobility, prevalent in around 3% of the population, is a condition that can present itself as joint pain, joint laxity and skin changes and is caused by the hyper extensive mechanics of the musckoloskeletal connective tissue (Kumar & Lenert, 2017).
The causes of hypermobility are disputed and under reported, with suggestions of genetics and environmental factors all being considered; gene mutations can be found in up to 10% of those presenting with hypermobility as reported by Kumar and Lenert (2017) with biomechanics and proprioception also thought to be associated with the condition.
Whether hypermobility disrupts posture and/or altered gait, often patients seek treatment because of this and as such hypermobility is then found.
However, although joint mobility is common, the condition of hypermobility is only characterised when pain is present and of those with joint mobility, only 3.3% experience associated pain (making up that 3% of the population) (Kumar & Lenert, 2017).

There is currently a wide catalogue of evidence to suggest the link between hypermobility and sports injuries, as the laxity and flexibility in the ligaments preventing joint sprains (Nathan et al., 2018), however the more specific link to lower back pain is less researched with a lack of published evidence and I found it difficult to make a link between the two.
I did manage to come across research that may start to associate the prevalence of hypermobility amongst individuals with myofascial pelvic pain and lower back pain.
and although this was a small study conducted on 19 subjects, the results were still significant and food for thought.

Regardless of whether the back pain is the caused in this instance, the general advice for treatment includes a management program of exercises to strengthen areas of pain or weakness to help maintain or increase joint stability (Kumar & Lenert, 2017) and as previously found, treatment for non-specific back pain is also most commonly treated by strengthening exercises, for example glute bridges and clams for glute max. and med., (Gasibat et al., 2017) and as such, this is the treatment route most likely to result in the most effective outcome, in the absence of a clear evidence of and/or protocol for the treatment of lower back pain with any possible hypermobility involvement.

Interesting fact one: Joint pain is also known as arthralgia which I did not know.
Interesting fact two: Not related to this particular case but while researching hyper mobility I found out a great deal of interesting information, of which could prove useful in my future practice as a sports therapist. I was surprised to learn from a study by Fagevik Olsén et al. (2017) that joint pain where present in subjects due to receive weight loss surgery, specifically in the hands, ankles, shoulders and feet was increased after weight loss compared with the subjects who had surgery but did not present with hypermobility.
although weight loss is always advocated, especially in individuals experiencing joint pain as a result of this, this study perhaps indicates the need for patient education into the controlled manor in which weight loss should occur and the expectations of the outcome. Although this study was not primarily researching the effects of weight loss on hypermobility, it is an insight into the possible implications of the effects of weight and ligament laxity on joint mobility and pain.

References – 

Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111.

Cheng, J. C., Castelein, R. M., Chu, W. C., Danielsson, A. J., Dobbs, M. B., Grivas, T. B., … Burwell, R. G. (2015). Adolescent idiopathic scoliosis. Nature Reviews Disease Primers.

Fagevik Olsén, M., Brunnegård, S., Sjöström, S., Biörserud, C., & Kjellby-Wendt, G. (2017). Increased joint pain after massive weight loss: is there an association with joint hypermobility? Surgery for Obesity and Related Diseases.

Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24.

Kumar, B., & Lenert, P. (2017). Joint Hypermobility Syndrome: Recognizing a Commonly Overlooked Cause of Chronic Pain. American Journal of Medicine.

Nathan, J. A., Davies, K., & Swaine, I. (2018). Hypermobility and sports injury. BMJ Open Sport and Exercise Medicine.

Trobisch, P., Suess, O., & Schwab, F. (2010). Die idiopathische skoliose. Deutsches Arzteblatt, 107(49), 875–884.


Clinical Experience Tuesday 3rd December 2019 – 4.5 Hours (16:30-21:00): 142 total

Running total of hours: 142

Within this session, I was able to work with returning patients. I enjoy their follow up appointments and their progress interests me a great deal. I feel as though I do not always provide the patient with an effective enough program and do not yet have the confidence in my own ability to correctly prescribe the right volume and intensity of exercises. I understand that much of the time, treatments can be adapted and varied, depending on progress and that trial and error is often an effective means, providing I have adequately and comprehensively reflected on my practice and learnt from any errors. It is not always possible, however to develop an ongoing plan of which can be adapted each session, as the nature of the clinic and the individuals seen do not always allow for follow up appointments. When working with athletes, for example, it is in their best interests to maintain a longer term, continued plan, not only to help reduce pain but to help reduce further risk of injury. With nonathletes and general members of the public however, I have found that often they are satisfied when slight progress is made and as long as their pain subsides and if they are reassured by a diagnosis, then they do not tend to always return.

Patient 1 –
Follow up for insertional achillies tendinopathy
Patient Overview:
Although this patient felt really positive about her previous treatment and noticed considerable change in her symptoms straight afterwards and later on as a result of her exercise prescription, her initial symptoms had returned two days prior to this session and were of similar severity; a sharp pain in her posterior aspect of her heel, most likely the insertion site of the achillies tendon and also around her medial malleolus. Other symptoms, such as the stiffness and feeling of ‘wooden feet’ in the mornings also returned so I felt as though the patient was back at square one with her injury and with no obvious explanation as to why this may have happened, I was left rather confused.
Although the treatment plan on the patients notes on Cliniko suggested a follow up appointment consisting of further sports massage and progression of exercises to facilitate her return to running, because no real progress was made, I decided to conduct another thorough assessment to be sure that my initial diagnosis was still feasible.
From her subjective and objective assessments, it became clear that the tenderness was
more apparent in her tibialis posterior and the patient was adamant that this was exactly the same as her previous treatment, however from the notes and my memory of the session, there was no recollection of this. I did not question the patient and accepted that it will remain unclear as to whether this was a new symptom or not, however it would be reasonable to assume that this irritation of the tibialis posterior may be due to her excellent adherence to her arch strengthening exercises for the treatment of pes planus.
I was unsure as to whether this was a symptom which would be expected or not but was reassured by my supervisor that this pain may start to decrease over time and that we did not have to modify her exercises in the meantime. The tibialis posterior was the cause of the patient’s pain this week and as such it was recommended that STM be performed. When treating this injury in previous appointments, the advice that I was given by my supervisor was to avoid administering any treatment that may irritate the inflamed tendon, instead allow for freer motion and build strength in the associated musculature; addressing the ‘tightness’ in the calf felt by the patient and most likely restricting ankle movements and subsequently creating friction of the structures.
However, on this occasion I had a difference supervisor who advised that I should perform firm deep tissue massage and soft tissue release over the most painful site of pain, with rationale being to desensitise the area to help reduce pain.

I have since tried to find supporting evidence to support this treatment. Although Bowring & Chockalingam (2010) suggested deep tissue massage for tibialis tendinitis, the study also noted that there was no real evidence in support of this for the reduction of pain or increase in function and strength but merely supported theoretical potential for the breaking down of scar tissue and the facilitation of tissue healing. A more recent review by Joseph et al. (2012) which, although some evidence existed on some effectiveness of deep friction massage, the researchers struggled to make a conclusion from their findings. Much of the research was not conducted using deep friction massage as the only treatment modality and so it was suggested that further research was needed in order to test this method alone.
Two years later, Loew et al. (2014) did just that and attempted to test the originally derived theory by Cyriax of deep friction massage treatment for tendinitis, having tested the method on two separate studies consisting of 40 participants with lateral elbow tendinitis and 17 participants with iliotibial band friction syndrome. Of the two studies, neither injuries showed deep friction massage to be effective and although the number of participants in the study was not large, with no significant differences and previous lack of evidence in support of this treatment, I have struggled to find sufficient rationale behind this method.

Conversely, and more specifically, in the case of tibialis posterior tendinosis, a review by Bowring & Chockalingam (2010) recommended rest as a potential treatment for acute tendinopathy as well as the use of orthotics and exercises. At the acute stage, stretching of the gastrocnemius and soleus would aid in increasing dorsiflexion when indicated, however it was suggested that strengthening of the tibialis posterior and should be given when the acute inflammation has subsided.
This could be where this treatment is limiting progression. Because in my objective assessment I found the patient to exhibit pes planus, I wondered whether this may have contributed to the achillies pain, so I prescribed arch strengthening exercises, however this is contraindicated by this review in the early stages of tibialis posterior dysfunction. Whether this pain had only just started to occur from the incorporation of strengthening exercises, or whether it was here from the beginning, it may be advised to stop this exercise for the foreseeable weeks until the inflammation has subsided. The heel raises that I prescribed to help increase eccentric and concentric strength of the achillies tendon and subsequent pain reduction would also activate the tibialis posterior and so this may explain why this caused further irritation to the patient; I will look to reduce these from her exercise routine until the inflammation has subsided also (Bowring & Chockalingam, 2010).

Although strengthening of arch support muscles such as the tibialis posterior and strengthening and stretching of the gastrocnemius and soleus muscles was recommended (Lee & Choi, 2016; Ridge et al., 2018), it may be advisable to wait until the acute swelling and inflammation has subsided and so a period of immobilisation and then controlled mobilisations to increase range of motion may be a more sensible and staged progression in this instance (Bowring & Chockalingam, 2010).

During this treatment, and as advised, I performed two modalities in order to achieve the same outcome. Both of which I tested for effectiveness.
The aim of the treatment was to increase range of motion in the ankle joint, reducing any stiffness and potential friction on the tendons, specifically the achillies and tibialis posterior tendons and surrounding soft tissue. To address the possible joint involvement indicated by the feeling of wooden feet, stiffness and pain in the joints in the mornings, mobilisations with movement was performed to increase dorsiflexion of the ankle joint. There is an abundance of research published, supporting the positive effects on mobilisations with movements for increasing ankle dorsiflexion and reducing pain in individuals with lateral ankle injuries (Loudon, 2014; Nisha et al., 2014) and in knowing that there is also evidence to suggest that limited dorsiflexion can alter running kinematics (Mason-Mackay et al., 2017), this is a modality worth considering.

To address the possible soft tissue involvement indicated by the feeling of tightness in the patient’s lower posterior legs, soft tissue massage was performed to lengthen the triceps surae muscle group (Stefansson et al., 2019).

In order to test which treatment was more effective, we used the knee to wall test, as previously found to be effective as a clinical measure for ankle dorsiflexion and mobility (Hoch & McKeon, 2011; O’Shea & Grafton, 2013).
After the mobilisations with movement, precisely 3 sets of 60seconds, testing in between each set, the patient’s range of movement increased by a third. I then performed the soft tissue release of the tibialis posterior and deep tissue massage of the triceps surae, only to find a reduction in range of motion, most likely due to the irritation of the inflamed tendons and possibly the patient’s apprehension in performing the test due to the increase in pain intensity. This lead to the conclusion that mobilisations with movement was the most effective treatment in this instance and these findings were therefore reflected in her notes, suggesting mobilisations only for a follow up appointment.

However, I am led to question the original rationale behind administering the deep tissue massage and soft tissue release over the painful area, as this was supposed to reduce pain sensitivity in the area but instead, pain levels increased during treatment.
Also, I later noted that after the patient’s previous appointment, improvements in pain and function were reported but that the pain only returned two weeks later, suggesting that the treatment was effective and so It will be of great value to me in my learning to find out whether the more hands on treatment working directly on the inflamed tendon is more effective long term, even if not on during the treatment.
I do understand, however that I have added two variables to the rehabilitation, deep tissue massage directly over the tibialis posterior and insertion area of achillies, as well as mobilisations. If the patient reports improvements in her next session, I will be unlikely to be able to differentiate between the two treatments.

Patient 2 – Unfortunately, my second patient did not arrive and this was the second session that he missed. I was made aware of the traffic delays in the city, so hope that his was a factor but had hoped that basic politeness would result in a courtesy call of apology.
I have noticed that over the past month, the clinic has experienced a number of cancellations at the last minute, giving little or no chance for the therapists to arrange for alternative appointments. It is within the clinic policy for the patient to provide notification of a cancellation at least six hours in advance. I am sympathetic to the fact that there are some occasions that are unavoidable and that sometimes any notification is impossible or that sometimes mistakes happen and that appointments get forgotten. In these occasions, businesses have to accept the loss of income or wasted time. However as this seems to be becoming a common occurrence, it may be useful to make alterations to the policy. It has been suggested that although there is no set time of which patients should notify cancelations, if no-shows are common then any increases in policy time could serve to reduce those instances (Huang & Zuniga, 2014).
As a group of five students without patients in this hour of the session, we all gathered around together to debate and discuss efficacy of soft tissue massage and it’s role within the clinic environment or sports therapy and rehabilitation. I have reasonably strong opinions on the psychosocial benefits of massage in any form, as often made obvious within this blog, regardless of the physiological aspects of this treatment and was able to provide some references for this, which will serve me well when discussing this area of treatment with patients in the future.
I found this type of ‘debate’ environment very useful, as it mimicked how I would imagine a discussion would develop on this type of subject with a patient or another health care professional, who perhaps needs extra understanding on our role as sports therapists or on our treatment rationale.

Free hour between patients – I used this time to catch up on my notes from my previous session and was able to join another student sports therapist who was conducting an initial appointment for shoulder pathology. This is an area that I find challenging, so I was happy to work together with another student to help diagnose this patient with possible rotator cuff tendinopathy and offer my skills in developing an effective strengthening program, which is something that I do feel confident doing.

Patient 3 – 13 year old rugby player, pain in thoracic spine, specifically on palpating T2.
This was another patient under the age of 16 who attended the clinic with his parent. I felt a little more comfortable treating this patient, having experienced treating a child the day before, however, fortunately on this occasion, the parent sat in waiting room and left the patient to be assessed by himself. I felt much more natural speaking with the patient on a one-on-one environment as opposed to balancing the conversation between myself, parent and child and felt as though the patient could open up more to me without the judgement or interruptions from his parent.
The patient was experiencing upper thoracic pain and on palpation, we established that it was on the spinous process of T2 specifically. This pain was noticed since a heavy weekend of playing and now occurs during physical activity and sometimes at rest. After seeing his team physiotherapist, who the patient reports as too busy to see for the foreseeable, he was assured that it was tight muscles and was advised to visit a sports therapist for a soft tissue massage.
However, although I wanted to oblige to his request of a soft tissue massage, I wanted to be sure that there was no underlying issue that could be contributing to his pain rather than just treating the symptoms. I conducted an assessment, with the patient’s permission. Initially, I did not find a reason for the pain and was confused as to why the most painful palpable area was on the spinous process.
Baffled, I requested the assistance of the clinic supervisor who, on entering the cubicle immediately spotted his hyper lordotic seated posture, of which was the most pronounced that I had ever seen. I was very surprised that this had not occurred to me and that I had not noticed this, especially as I had recently attended an informative lecture on posture and shoulder/thoracic pain. I can only think that the reason this was missed, is because the patient was so young and that not only my observational skills and common sense were clearly lacking in this assessment, but that I had unconscious predisposed misconceptions that poor posture is developed over time and not present in children so young. Now that I know the possible benefits of considering alterations in posture when addressing shoulder and thoracic pain, I would be doing my patients huge injustices if I made this incorrect assumption regarding the younger individuals; correcting poor posture early on could prove paramount in future risk factors for injury, serving to prevent muscle imbalances, skeletal deformities and developmental dysfunctions, with early poor posture habits contributing to future deterioration and musckoloskeletal strain (Kim et al., 2015).

One of the most useful exercises I learnt from the aforementioned shoulder lecture was the method of asking a patient to place their finger on their sternum then using their chest to push those fingers away as a means to inadvertently correct their shoulder posture. I found this incredibly useful in helping my young patient acquire a method to remind himself of the posture that he would be aiming to achieve through re-education and strengthening; just one motion created the desired effect and with the need to adjust technical language for younger patients to understand, this was a very useful tool.

I was also able to use other information acquired from the shoulder lecture regarding hyper kyphosis as this was the first part of the shoulder symptom modification procedure (Lewis, 2009; Lewis, 2011). I found this video by the Physio tutors very helpful in understanding this procedure:
As modifying this patient’s thoracic spine by way of reducing the kyphotic curve, reduced his symptoms, according to this procedure, this indicated the need to focus on strengthening the thoracic spine and as such, I looked to prescribe some of these newly learnt techniques to help reduce this. I prescribed a posterior capsule stretch, as recommended by Lewis (2009) and attempted to recommend strengthening. Although I have a wide range of mobility exercises for the thoracic spine of which I was able to show the patient, including the lawn mower and threading the needle, I only had one exercise on building muscular strength for the back muscles; the low row specifically targeting the rhomboids and lower and middle traps. It is especially important that I develop and repertoire of exercises, especially ones that require no specialist equipment, for patients who do not have access to a gym to use a row machine.

I found an excellent video demonstrating a good exercise that can be done at home and one I feel more comfortable prescribing in the future.

References –

Bowring, B., & Chockalingam, N. (2010). Conservative treatment of tibialis posterior tendon dysfunction-A review. Foot.

Hoch, M. C., & McKeon, P. O. (2011). Normative range of weight-bearing lunge test performance asymmetry in healthy adults. Manual Therapy, 16(5), 516–519.

Huang, Y. L., & Zuniga, P. (2014). Effective cancellation policy to reduce the negative impact of patient no-show. Journal of the Operational Research Society.

Joseph, M. F., Taft, K., Moskwa, M., & Denegar, C. R. (2012). Deep friction massage to treat tendinopathy: A systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation.

Kim, D., Cho, M., Park, Y., & Yang, Y. (2015). Effect of an exercise program for posture correction on musculoskeletal pain. Journal of Physical Therapy Science, 27(6), 1791–1794.

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.

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259–264.

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

Loew, L. M., Brosseau, L., Tugwell, P., Wells, G. A., Welch, V., Shea, B., … Rahman, P. (2014). Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database of Systematic Reviews.

Loudon, J. K., Reiman, M. P., & Sylvain, J. (2014). The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: A systematic review. British Journal of Sports Medicine, 48(5), 365–370.

Mason-Mackay, A. R., Whatman, C., & Reid, D. (2017). The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport, 20(5), 451–458.

Nisha, K., Megha, N. A., & Paresh, P. (2014) Efficacy of weight bearing distal tibiofibular joint mobilization with movement (MWM) in improving pain, dorsiflexion range and function in patients with post acute lateral ankle sprain quick response code. Int j physiother res.

O’Shea, S., & Grafton, K. (2013). The intra and inter-rater reliability of a modified weight-bearing lunge measure of ankle dorsiflexion. Manual Therapy.

Ridge, S., Henderson, A., Bruening, D., Jurgensmeier, K., Olsen, M., Griffin, D., … Davis, I. (2018). Midfoot Angle Changes During Running After an 8-week Foot Strengthening Program. Foot & Ankle Orthopaedics, 3(3), 2473011418S0040.

Stefansson, S. H., Brandsson, S., Langberg, H., & Arnason, A. (2019). Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthopaedic Journal of Sports Medicine, 7(3), 1–10.


Clinical Experience Monday 2nd December 2019 – 5 hours (15:00-20:00): 137.5 total

Running total of hours: 137.5

Unfortunately, this session was somewhat setback by an ongoing lower back issue of mine and so I was not able to fully apply myself physically to administer any manual treatments, however as I really enjoy attending the clinic and feel a responsibility for my patients I did not want to miss the opportunity to treat and attended to gain further practical experience, but with occasional manual help when needed; to start with I worked with another student for 2 patients for the first part of this session until I felt I could manage, offering advice where I could and taking an equal part in the appointments.

Patient 1 – Neck Injury and STM
This patient was a student who rugby player sustained a neck injury during a game one week ago and this was her follow up appointment.
It is reported that concussion, most likely occurring during a tackle, is the most common injury in rugby union (Cross et al., 2019).
Initially I was anxious about assessing a neck injury but by going through her previous notes, I was reassured by her previous appointment with Alex Walker, the clinic supervisor; the notes were thorough and clearly stated the need to revisit A & E, where the patient was further assessed and any serious injury was ruled out.
The first assessment was performed one day after the injury and it was obvious that the patient was concussed. Because of this and coupled with the very acute nature of her symptoms, no tests were performed, however her visit to A & E ruled out any neurological involvement and a thorough test was carried out.
If this was my patient alone, I would probably have subjected her to a full assessment, including any neurodynamic testing of the cervical spine, however the therapist in this appointment chose not to do this based on the absence of any indicative symptoms. I would agree that this is good rationale for not putting this patient through another session of testing, as she had already been subjected to a number of assessments within the week prior to this session and has simply requested a STM.
The muscle testing for this patient was strongly indicative of muscular tension and resultant pain, so this coupled with the mechanism of injury and with the improving nature of the pain and ROM, a deep tissue massage with passive and active passive stretching was performed to help facilitate the increase in ROM.
I often forget to include objective measures within my treatment, but in this instance, because I perform ROM tests as part of the basic assessment, I am able to use this as a marker, as long as I remember to retest at the end of the treatment.
This patient reported increases in pain and ROM after the massage and stretching treatment and as such, we knew that this treatment was the most effective treatment for her and prescribed some further stretches to complete at home, as well as a strengthening program for her to start when ROM is back to full range and when pain has mostly subsided.
We felt confident that this individual would adhere to any home exercise programs prescribed because of her passion to return to rugby and her need to be fit to play again.
We also discussed the importance of taking the advised time off of her sport, due to her concussion. It is important to educate individuals about the dangers and risk factors involved with concussion and to be aware of a number of factors associated with this type of traumatic injury. A study by Bussey et al. (2019) found that neuromuscular control can be altered during rugby tackling within twelve months of sustaining a concussion which can pose as a potential future risk factor for subsequent concussions.
Initially, I had naively thought that by increasing muscular strength of the neck muscles, future injury or concussion risk may be reduced, however a review by Benson et al. (2013) found no evidence in support of this, nor any evidence advocating the use of mouth guards or helmets. A recent study suggested that tackling position and acceleration and speed of the tackler can be altered as a way to reduce the risk (Cross et al., 2019) but these as external factors that are beyond the control of the therapist. From this, the only advice that I was able to offer this patient was to follow guidelines provided by the national governing body of her sport, in this case rugby and to take the suggested time off by the physicians at the hospital.

Patient 2 – STM and Traction at hip
This patient was returning for another session of STM of the back with additional piriformis release and manual hip traction.
After his session three weeks previous, he remarked on his improvements, having felt a significant relief from his usual tension.
After my previous session with this patient on 11th November, I looked into the value of this treatment and ways in which this could be done at home to save his time and money. Reiman and Matheson (2013) supported the use of a home-made device that simply connects the foot with an anchor, such as heavy furniture or gym equipment so that the individuals can apply a long axis distraction force of the hip. I suggested this option to my patient so that he could start to rely less on treatments and self-manage his discomfort, however he immediately responded with his dissatisfaction at any self-performed treatment and explained that he was aware that he could potentially administer his own treatment.
It is in my opinion that as long as the patient is aware of the transient nature of the STM and traction and as long as we, as therapists, provide the patient with exercises to progress through and educate them on their injury and rehabilitation plan, if they continue to want these passive treatments then this is completely justified. It would be unethical, however if I were to provide this basic level of treatment on its own, unaccompanied by a more long term correction and patient education.
I am aware of the short term, transient nature of soft tissue treatment and the need to incorporate strengthening exercises as the most part of any rehabilitation plan for developing and enhancing functional movements, however I am also of the opinion that these two are transient; when exercises are stopped, muscles become weakened again. So, in my view both strengthening and passive soft tissue therapy are transient, the difference is that the patient is more able to perform the strengthening exercises at home and become fully empowered to sustain their own musculoskeletal function, compared with the more specific requirements of STM and the need to see a specialist for a more satisfying experience, as experienced by this patient.
People pay to get their hair or nails treated, but there are no long term benefits of this to their health, so as long as people are attending their appointments knowing that they are receiving treatment to help with their pain and ROM in the short term then I feel like the treatment is entirely justified. We should always provide the patients with information about how they might be able to maintain their function outside of the clinic but also we must be aware that this may be of no interest to some patients and that short term relief is their only need.

Patient 3 – Osgood’s Schlatter’s Disease
This was my first experience of treating a child under 16 and although initially I felt uncomfortable, I soon became more confident and was able to communicate well with both the patient and his mother.
I was aware that I needed to keep my language simple and any complicated jargon to a minimum. I did find myself talking to the patient’s mother on more occasions that I think was necessary however and as such the patient may have felt uninvolved in the assessment procedure. I was able to pick up on this early enough and changed my approach, which soon brought the attention back to the young patient, who may then have felt more empowered in this initial stage in his rehabilitation.
It became apparent early on, just from the subjective assessment that Osgood’s Schlatter’s disease (OSD) was the most likely diagnosis; bony prominence in both tibial tuberosities, pain in all dynamic sporting movements, high volume of exercise, specifically football, pain when kneeling and the age of the patient being 13 (with the most likely age in the develop of this condition being between 10 and 15 (Vaishya et al., 2016)). I continued to conduct a throughout assessment, remembering to clear joints above and below and then felt the need to seek additional advice from a supervisor, as this patient was so young.
When the supervisor initially joined us in the assessment process to offer further advice, the first thing mentioned was the bony ‘lumps’ under both of the patient’s knees. It was quite abruptly mentioned that the lumps will stay but the pain will go, to which both the mother and the patient were taken aback. At first I was surprised at their reactions but now understand why this may have caused some distress; the lumps in the patients’ knees are quite obvious and if they had always visualised this to reduce over time, to find out that the lumps would remain, would have come as a shock. I did take the time later in the appointment to explain that some of the prominence may have been down to acute inflammation, effusion and heat and also more obvious due to the lack of muscle tone in the patient’s leg and from this conversation, both the patient and his mother felt more relaxed about this aesthetic element to the injury. In cases where those prominences are extreme, there is a procedure known as closing-wedge osteotomy, which was found to be an effective means of managing the bony prominence on the tibial tuberosity which is formed as a result of Osgood-Schlatter’s disease (Pagenstert et al., 2017).

Figure 1 shows the location and aesthetic appearance of the bony prominence of Osgood’s Schlatter Disease, as well as an x-ray image (Vaishya et al., 2016 p.4;p.5).

Interestingly, only 25% of individuals report pain in the tibial tuberosity (Vaishya et al., 2016) so this is not necessarily the only symptom to consider in this condition.

Osgood’s Schlatter’s Disease is characterised by the inflammation of the patella tendon, precisely over it’s insertion into the tibial tuberosity (Vaishya et al., 2016).
Pathogenic risk factors for OSD are vast, with Watanabe et al. (2018) reporting the following all possible contributors to the disease;
1. Height
2. Weight
3. BMI
4. Quadriceps tightness in kicking leg
5. Soleus, gastrocnemius and quadriceps tightness in non kicking, support leg
6. Centre of gravity
7. Medial Longitudinal Arch measurement

It has been found in a study on 20 subjects with a mean age of 13.4 years old, the same age as the patient that stretching of the quadriceps muscles, in particular, the rectus femoris would help to reduce OSD symptoms (Tzalach et al., 2016), however when I performed the Thomas Test it showed nothing but excellent flexibility in the patient’s hip flexors and knee extensors, specifically the quadriceps.

I have since read, however that although the modified Thomas test, shown in figure 1 has been found to be a reliable measure of hip flexor flexibility, it is reliant of a controlled pelvic tilt (Vigotsky et al., 2016).
I do not recall having taken pelvic tilt into account on this occasion, so may not be able to use this as a valid test in this instance unless I retested to account for this variable. However, just from observing, I would be comfortable in suggesting that quadricep flexibility was probably not an issue for this individual.
Instead, we prescribed exercises to strengthen gluteal muscles and hamstrings and educated him and his mother on workload and advised to incorporate plenty of non-sporting days to facilitate his growth but without applying excessive loads. Vaishya et al. (2016) also recommended quadriceps strengthening in addition to the above, so if this patient were to return, I would look to incorporate this element into the rehabilitation program, considering also the lengthened muscles in this case; this may be an indicator of weakness, as opposed to flexibility and I should have taken this into account when assessing this.

With the aim to reduce pain and manage swelling, we advised him to treat any inflammation as and when needed and to continue in his use of ICE and another other relieving modalities, which may also help to reduce the inflammation of the OSD but also of other conditions that may also be present or likely in this particular case, such as patella tendinitis or infrapatellar bursitis, as reported by (Vaishya et al., 2016).
Often, the presence of both of these aforementioned conditions are likely alongside OSD but sometimes these conditions may be the cause of the symptoms but mistaken for OSD; of these, however, it is hard to make an accurate differential diagnosis due to their similar epidemiology and presentation although treatment is often similar (Vaishya et al., 2016). In this case, however, the obvious prominence, an example shown in figure 1, allows for us to assume OSD as the primary condition but be aware of and treat any secondary issues that may arise.

It was also advised that surgery may be viable option, should conservative treatment not be effective and if the condition remains restrictive and debilitating (Vaishya et al., 2016), however this is rare and usually the symptoms reduce or diminish over time and as previously mentioned, only the prominence will remain.

It will be interesting to know whether the symptoms do start to resolve over the coming weeks, in spite of his plan to continue in his activity levels; he seemed (and understandably so) reluctant to reduce his football hours and so progress may be slower. However, with the exercises prescribed and after receiving information on the condition, the patient and his mother may have a better awareness of how they are able to manage the condition, should the symptoms worsen.

Extra Research in my final hour in clinic – 
Initially, after his mother informed us that the patient had been taking Non-steroidal Antiinflammatory Drugs (NSAIDS), specifically Advil, in order to continue to play, I was concerned and was unsure as to whether this was the most appropriate course of treatment to take. As I had no prior knowledge on this, I did not provide any further advice to either advocate the use of these or otherwise. However, according to recent research on OSD, NSAIDS are suggested (Kolodychuk, 2018) and as such perhaps a personal choice by parents of which is beyond my scope of knowledge or area to advice.

References –

Benson, B. W., McIntosh, A. S., Maddocks, D., Herring, S. A., Raftery, M., & Dvořák, J. (2013). What are the most effective risk-reduction strategies in sport concussion? British Journal of Sports Medicine.

Bussey, M. D., McLean, M., Pinfold, J., Anderson, N., Kiely, R., Romanchuk, J., & Salmon, D. (2019). History of concussion is associated with higher head acceleration and reduced cervical muscle activity during simulated rugby tackle: An exploratory study. Physical Therapy in Sport.

Cross, M. J., Tucker, R., Raftery, M., Hester, B., Williams, S., Stokes, K. A., … Kemp, S. (2019). Tackling concussion in professional rugby union: A case-control study of tackle-based risk factors and recommendations for primary prevention. British Journal of Sports Medicine.

Kolodychuk, N. (2018). Tendinosis as the under lying pathology of osgood-schlatter disease: imaging similarities and treatment implications. International Journal of Orthopaedics Sciences.

Pagenstert, G., Wurm, M., Gehmert, S., & Egloff, C. (2017). Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease. Arthroscopy – Journal of Arthroscopic and Related Surgery.

Reiman, M. P., & Matheson, J. W. (2013). Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. International Journal of Sports Physical Therapy.

Tzalach, A., Lifshitz, L., Yaniv, M., Kurz, I., & Kalichman, L. (2016). The Correlation between Knee Flexion Lower Range of Motion and Osgood-Schlatter’s Syndrome among Adolescent Soccer Players. British Journal of Medicine and Medical Research.

Vaishya, R., Azizi, A. T., Agarwal, A. K., & Vijay, V. (2016). Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus, 8(9).

Vigotsky, A. D., Lehman, G. J., Beardsley, C., Contreras, B., Chung, B., & Feser, E. H. (2016). The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled. PeerJ.

Watanabe, H., Fujii, M., Yoshimoto, M., Abe, H., Toda, N., Higashiyama, R., & Takahira, N. (2018). Pathogenic Factors Associated With Osgood-Schlatter Disease in Adolescent Male Soccer Players: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine, 6(8), 1–8.

External Placement Exmoor Osteopaths Thursday 28th November 2019 – 4 hours (09:00-13:00): 132.5 total

Running total of hours: 132.5

During my session at the Osteopath clinic, Kat and I spent the majority of time with returning patients requiring follow up treatments, all of which self-reporting improvements. Due to the demographics in the area of the clinic in Minehead, most patients attending the clinic are of the older generation and from conversing with them and from hearing Kat’s experiences, they seem more reluctant to engage in any exercise program away from the clinic and although they accept this as a huge limiting factor in their progress, they also seem to be under the false understanding that as they are of age, they cannot improve their physical status and are happy to visit the clinic on a regular basis for passive treatment.
As much as I am an advocate for the use of massage, even if the benefits are psychological due to the absence of a stock of high quality evidence, I truly believe that their quality of life will significantly improve if they became more active in their own treatment.
I wonder if because Kat has now been treating the same individuals over a relatively long length of time, having been at the clinic for over seven years, her attempts at encouraging some of the individuals to be more proactive have lessened.
In my final three weeks here at this clinic, I hope to instil a sense of belief into those particular clients, reinforcing the benefits that may arise should they start to incorporate strengthening, even if only generalised and nonspecific, into their everyday lives.
I could attempt to speak with the clients about why they feel they cannot become more physical active and look to come up with strategies to encourage exercise adherence, such as finding ways to incorporate exercises into their daily routines, as found to be effective by Bassett (2015).
With one particular patient during this session, gardening was their means of physical activity, but was also one of the main causes for the onset of pain. With patient education and endorsement of better technique and adding in extra movements, such as side walking, squatting for gluteus muscles, the conveniently named lawn mower or chopping manoeuvres for thoracic strengthening, then the everyday activity becomes more specific but yet without any perceived additional effort.

I will also look to provide each patient with a new specific exercise plan after each treatment and discuss a way individualised to them, that may enhance their cooperation.
I do not want to undermine the current treatment plan from Kat and must ensure that the exercises I prescribe are suitable and positively facilitate this, so I will be sure to consult with both the patient and Kat beforehand.

Of all the patients we saw during this morning session, including sacroiliac joint pain and dysfunction, non-specific lower back pain and shoulder tendinopathy (although now I may have approached this differently, having read more into shoulder kinematics and scapular dyskinesis), the highlight of this session for me, was discovering a new injury of the spine, Spondylolisthesis, of which I reluctantly admit, have never heard of before.
I was unsure as to the exact pathology in this patient and as such required additional assistance from the Osteopath. Very early on, the word “Spondy” was thrown around as though it were a common injury and as such I did not show my lack of knowledge in front of the patient by asking for clarity, instead I waited until the end of the consultation to question Kat. In hindsight, I should have expressed my willingness to learn something knew and rise above my lack of knowledge as it would have been really informative to have gone through the basics, for example just palpating the vertebrae; in future there will be instances when I will not know the issue and in these cases, so the more open and honest I am with the client, the more trusting they will be of my integrity and ability to provide an honest and evidence based treatment.
I took the time outside of the clinic to research Spondylolysis and how I may be able to assess for this in the future.
I needed to identify the symptoms that would indicate this and how I would be able to treat the patient.
It is advised that in cases of radiculopathy whether back pain is present or not, spondylolysis should be considered (Watters et al., 2009). Due to the age of this patient, it is most likely that this is of a degenerative nature and so in this instance, pain may be minimal or less apparent.
According to Watters et al. (2009. p.611) spondylolysis is the “anterior displacement of one vertebra over the subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring”.
In this patient, the displacement occurred at L2 and I was able to briefly palpate a protrusion. At first I thought this protrusion could be of the affected vertebrae, but in fact this vertebrae only feels protruded relative to the anteriorly displaced one above. The most accurate way to diagnose this condition is radiography and as reported by Watters et al. (2009), this condition often presents itself alongside (and is often thought to cause) spinal stenosis (Zhu et al., 2017), which can be further identified by magnetic resonance imaging (MRI) with surgical treatment by way of decompression being the most supported option among specialists. In a study by Weinstein et al. (2013), in which the non-operative treatment was compared with the conservative treatment for this condition, improvements in pain and function were greater experienced in the operative group for up to four years post surgery.
Although GP referral would be a considered as a likely course of action for myself as a therapist, recent research by Zhu et al. (2017) recommends application of conservative treatment first but also highlights the lack of understanding in the mechanisms behind the development of this condition and as such a specific focus on treatment has not been fully developed. Zhu et al. Strengthening and stretching exercises of the extensors and flexors of the spine to develop and maintain spinal stability are advised by Zhu et al. (2017), which addresses the lack of stability in the spine which has been commonly reported as a contributing factor.
It is also suggested that lower discogenic back pain could result in weakened spinal stabilising muscles and therefore eventually lead to degenerative spondylolysis (Zhu et al., 2017), allowing the assumption that strengthening these structures could improve the overall stability of the spine and associated pain.

Having had the opportunity to experience a clinical suspected diagnosis of spondylolysis and with my better understanding behind the mechanical presentation of the condition, I would be more aware of the need to consider this within future assessments, especially in the older population.

References –

Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111.

Watters, W. C., Bono, C. M., Gilbert, T. J., Kreiner, D. S., Mazanec, D. J., Shaffer, W. O., … Toton, J. F. (2009). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis†. Spine Journal, 9(7), 609–614.

Weinstein, S. L., Dolan, L. A., Wright, J. G., & Dobbs, M. B. (2013). Effects of bracing in adolescents with idiopathic scoliosis. New England Journal of Medicine.

Zhu, R., Niu, W. xin, Zeng, Z. li, Tong, J. hua, Zhen, Z. wei, Zhou, S., … Cheng, L. ming. (2017). The effects of muscle weakness on degenerative spondylolisthesis: A finite element study. Clinical Biomechanics, 41, 34–38.

Clinical Experience Tuesday 26th November 2019 – 2 hours (15:00-20:00): 128.5 total

Running total of hours: 128.5

Patient 1 – For my first patient of the session I performed a soft tissue massage treatment for a frequent visitor to the clinic, with this being her sixth session. The assessment was very similar to previous sessions in that small ROM differences were observed and treatment options were discussed; I wanted to ensure that the patient was aware of the transient nature of the massage and that there are other options to be considered, such as mobilisations and exercises. However, the patient was happy to receive a STM only, as this was all she was comfortable with. From previous sessions, I have become aware of the psychosocial element to this patient’s clinic visits and as such feel more than happy to accommodate her in this; by coming in on a weekly basis, this elderly woman has a means to talk about her week and to offload her difficult current situation in a confidential environment in which I am able to provide her with my under divided attention and genuine regard for her wellbeing and happiness. I feel like I have developed a positive and friendly relationship with my patient and I hope I am enhancing her week by being able to listen to her with care. The patient has tried to complete her rehabilitation exercises at home and small improvements to her ROM have been noticed, however not as much as I would like. I would hope to facilitate changes in her physical, as well as her mental wellbeing but I also know that this may take time and perhaps a change in one may lead to a change in the other.
I will continue to encourage her participation in her prescribed home based exercises and advocate their benefits in the hope that she will have a better quality of life through better ROM of her shoulders and neck.

Patient 2 – During my clinical experience in my previous session, I applied kinesiology tape, now known as elastic Therapeutic Taping (ETT) to the patient’s shoulder as requested and as advised by the patient’s previous therapist. The patient reported the tape as beneficial by way of reminding him to correct his posture (mechanoreceptors) and he felt his pain was subsequently reduced.
I applied the tape with full stretch from anterior to posterior without much regard for the location; the patient was in full stretch of his pectoralis muscle group with shoulders as far back as possible, so the tape, regardless of location, would serve to act as postural taping.
I am not confident in my opinion or understanding as to the effectiveness of ETT and therefore efficacy of its and therefore I took the time to conduct some research on this topic, in order to be able to advocate its use in clinic, but also so that I can educate the patient more confidently about the rationale behind this treatment.

Although there are some supported claims of the benefits of kinesiology tape, such as increase in strength, range of motion and proprioception, there is not enough high quality evidence to support its widespread popularity and use in the sports injury context (Williams et al., 2012).
In the treatment of musculoskeletal injuries, a systematic review concluded that ETT did not have enough evidence in support of its use on sports injuries, but that potential perceived effects were noted (Mostafavifar et al., 2013).
Konishi (2013) found that ETT acted to compensate muscle weakness, proposedly by affecting afferent neurophysiology by way of sensory input. This study consisted of two groups, a taping group and a non-taping group with the results showing greater muscle contraction in the taped muscle compared with the non-taped muscles of the knee, particularly the quadriceps femoris. Although these findings seem to support the use of ETT in injuries presenting with muscle weakness, in this particular case of the knee, the design of the study, whereby the control group were not taped, allowed for the potential of the tape having a placebo affect on the intervention group, i.e. the presence of tape alone was enough to benefit the subject.
The suggestion of ETT having a placebo effect is long debated and the subject of controversy and conflicting research. A study by Poon et al. (2015) claimed that any positive effects of ETT should be assumed the result of a placebo effect, with this study finding that this tape did not enhance or assist in muscle strength and performance of the quadriceps.
However, a single-blinded randomized control pilot study in the same year by Han et al. (2015) was conducted on 14 male office workers with rounded shoulder posture using a control group, providing some evidence of its effects by ruling out possible placebo and crediting any positive benefits on forward shoulder posture and increased pectoralis minor length to its mechanical support; the control group subjects had tape applied but with no stretch whereas the intervention group had 35-40% stretch.
More recent research by Shih et al. (2017) also found that both exercises and ETT provided positive improvements to forward head posture, with no significant differences between the two treatments, as conducted on a study on 60 subjects.

Although the purpose or benefits of ETT are unclear and although there is not enough supporting evidence on this treatment in the management of sports injuries or enhancing sports performance, there are studies providing high quality evidence supporting its use on specific sports injuries, such as lateral epicondylitis. In particular, a study by Shamsoddini & Hollisaz (2013) reported a significant difference in grip strength and extension force as well as the reduction in pain in 30 subjects with lateral epicondylitis, compared to the same treatment on the unaffected arms, which provided control data). Another study on the effects of both ETT and therapeutic ultrasound on lateral epicondylitis, finding that this taping modality did have significant effects on pain and more so than the ultrasound (Shaheen et al., 2019).

More specifically, in the treatment of shoulder injuries, the only research I found supporting its effectiveness in postural correction were case studies and provided very poor evidence for its use. However, from the research I have found, as ETT is not likely to cause any harm to the patient, I would consider using this as a treatment method for any control of pain or posture, where neurology becomes a factor and continue to use it on a case by case basis; if the patient reports improvements in their symptoms or performance, then I would continue to use it in their treatment program.

References –

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.

Konishi, Y. (2013). Tactile stimulation with Kinesiology tape alleviates muscle weakness attributable to attenuation of Ia afferents. Journal of Science and Medicine in Sport.

Mostafavifar, M., Wertz, J., & Borchers, J. (2013). A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Physician and Sportsmedicine.

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.

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.

Shamsoddini, A., & Hollisaz, M. T. (2013). Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow. Trauma Monthly.

Shih, H. S., Chen, S. S., Cheng, S. C., Chang, H. W., Wu, P. R., Yang, J. S., … Tsou, J. Y. (2017). Effects of Kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation.

Williams, S., Whatman, C., Hume, P. A., & Sheerin, K. (2012). Kinesio Taping in Treatment and Prevention of Sports Injuries. Sports Medicine.

Clinical Exprience Monday 25th November 2019 – 5 Hours (15:30-20:00): 126.5 total

Running total of hours: 126.5

Patient 1 – The first patient in this session did not attend his appointment, so in order to fully utilise my time within the clinic, I shadowed a post graduate student; this was a fantastic opportunity for me to offer any of the knowledge that I have developed from the previous week of shoulder treatments and to assist where possible.
This patient experienced sharp non localised pain in his shoulder joint when bringing his arm up above his shoulder passed 90degrees of flexion and in active internal and external rotators.
A hand grip test was performed in order to identify any discrepancies between the two shoulders and the scores were recorded to test effectiveness of treatments; we will retest again in any follow up sessions. The scores were 36.5 on the right side and 35 on the L.
The patient reported symptoms suggestive of neurological dysfunction, such as tingling in his fingers and muscle weakness and therefore a neurological examination was conducted, consisting of upper limb tension tests of the median, ulna and radial nerves. Dermatomes and motor control was also assessed, all of which produced negative results and therefore with these findings, coupled with the pain exhibited in active movements, muscular dysfunction was suspected. From the pain onset and presentation in the subjective assessment and the limited and painful external rotation and flexion in the objective assessments, the therapist recorded a clinical diagnosis of bicipital tendinopathy with secondary teres minor tendinopathy.
Rotator Cuff tendinopathy is the term used to classify pain and dysfunction in the tendons of the shoulder and although it is commonly diagnosed, it is not widely understood (Littlewood et al., 2013). It is suggested that tendinopathy of the shoulder develops progressively, starting with acute tendinitis through to tendinosis, with classification of tendinopathy in the stages between (Seitz et al., 2011), each stage presenting with different symptoms and requiring specific treatment depending on whether the factors are intrinsic or extrinsic.

In the instance of rotator cuff muscle tendinopathy, the amount of load applied to the tendon is one of the most significant factor in the progression or regression of the pathology. As shown in the continuum below, when a normal tendon is not generally loaded properly, when intensity or frequency of load is increased suddenly, this may lead to overloading of the tendon and subsequent reactional tendinopathy. Similarly, when a normal loaded tendon is subject to a relative increase in load frequency and/or intensity, this may also lead to reactive tendinopathy. Whether the tendon is adequately loaded prior to excessive overload or not, the outcome is the same and results in reactive tendinopathy.
If this overload is not addressed and decreased, then further degeneration can occur and the condition goes beyond a sub-acute nature to a condition known as tendon disrepair, resulting in swelling and structural changes to the tendon, such as separation of collagen fibres which eventually leads to degeneration of the tendon, resulting in glenohumeral joint degeneration and large partial, full or massive thickness tears ( Lewis & Lewis, 2015).

According to Lewis (2009), the main goals in tendinopathy rehabilitation are load control, pain management, preventing further injury, patient education.
Based on the model created by Lewis (2009) and as shown in the following image:

and in the following link (I couldn’t upload a quality photo of the model), loads placed upon the tendon, whether too much or too little, can have an effect on functioning ability and is a risk factor for tendinopathy.
Load reduction for reactive tendinopathy, therefore is paramount in preventing further degeneration, however load is still required in order to allow the tendon to increase capacity to withstand further loading.
It is recommended that load is increased gradually and within the capacity of the individual, so as not to irritate any acute inflammation or cause further regression in function and pain;
isometric, concentric and eccentric exercises are advised and as such the following exercises were given, targeting the affected tendons;
Isometric bicep contractions using resistance band 3-4 sets x15-40seconds
Isometric external rotation at 90 degrees 3-4sets x 15-40secs
Closed kinetic chain exercises for flexion and abduction by table slides 2-3sets x 12-14 reps.

I also took this patient’s posture into consideration; he had a slight kyphosis of the thoracic spine and as widely reported, this can contrite to upper body pain and dysfunction.
It is suggested that increases in thoracic kyphosis can have an effect further down the kinetic chain, for example it can cause downward rotation and protraction of the scapular which can in turn compress the sub acromial bursae or rotator cuff tendons (Lewis and Valentine, 2010). This was further supported by Seitz et al. (2011) who listed glenohumeral kinematics and scapular alignment as significant external risk factors for shoulder tendinitis, as well as external and internal impingement. This is just a small incite into the association between postural abnormalities and shoulder pathology, but worth considering in this case. We educated the patient on posture and gave appropriate stretching and advise on how to improve this. I have a lecture on shoulder rehabilitation approaching, which will delve far deeper into the kinetic chain models and muscle firing patterns of the upper body and limbs, which will hopefully provide me with far more understanding on the mechanisms and risk factors in the development of shoulder injuries and pain.

The information I found regarding rotator cuff tendinopathy was found in my second hour in this clinic session from internet research, to detailed discussions with Mike Prynn and two other students; speaking with others about these theories are very helpful and although I feel as though I lose confidence, comparing my knowledge to others’, I feel as though it highlights my gaps in knowledge, so I can go away and conduct further research.

Patient 2 – My patient did not attend this session and fortunately there were other students in the clinic who also had time between appointments, so I took the opportunity to practice the upper limb neurodynamic tests.
In shadowing the previous treatment, I observed the application of a number of neurodynamic tests and although I had previously spent a significant amount of time researching the sensitivity and specificity of these tests and also watching a number of videos of how to perform them, I felt completely unable to carry out the tests and was unable to contribute to the session and instead just watched. I approached the therapist who I shadowed and asked him to go through the tests with me so that I was fully able to appreciate the exact procedure and he was kind enough to go through these with me.
The movements involved in this testing must be accurate as slight variations can change the test outcome; for example, incorporating scapular depression or blocking the scapular movement can result in either an earlier or later neurological response respectively (Legakis & Boyd, 2012).
I then spent time with fellow therapy students trying to navigate my way through the steps. I find it very difficult practicing provocation tests on healthy individuals who would not reproduce any symptoms and therefore provide positive findings for me to identify. However, I was able to identify if I was applying the correct movements and limb positions by the nature of nerve vs muscular capacity; if, during a ULNT a stretch is felt in the limb musculature for example, if I ask the individual to side bend their neck contralaterally, the ROM and sensation should be the same as before the neck same sensation. My understanding of this is that by adding the side bending of the neck to the contralateral side the nerves are put on more stretch and as such would inhibit the limb movements more than without the side bending. If no change is noted with the additional side bend, no cervical neuropathy is suspected.

The photograph in figure 1, is of me practicing the ulna nerve, although the photographer obviously did not capture the most exciting shot. Of all of the tests, I found this to be the hardest and could not replicate the movements as shown in the video I followed, which was as follows;
After a few attempts, I decided to try to on another student, as I wondered whether this students hypermobility and flexibility might have influenced my inability to produce the expected stretch sensation in her forearm. This is an interesting point for discussion; was I just unable to perform the test properly, or does hypermobility and flexibility in a patient affect the ability to perform this test on an individual asymptomatic of upper limb neuropathy. My assumption is that this test would be physically possible if there was a positive test, as the nerve would produce the movement and pain restrictions instead of the muscular components of the arm.

My inability to perform these tests highlights the importance of physically practicing any practical elements of physical therapy and that watching videos alone, although very informative, are not enough to develop my practical skills. I can use the videos as a visual guide to go through the procedure step by step but I must practice this on other students before being able to perform them on live patients.

Patient 3 – Follow up for shoulder. Reported excellent progression with completely pain free motions and full ROM.
I believe the excellent progress can be credited to the compliance of the prescribed exercises; this patient was vey keen to return back to his recreational sports and as such fully adhered to the program we prescribed. Although he had a slight setback, due to trying to progress too quickly at one stage, by regressing the exercises we were able to start making progress again. I was really pleased that this patient returned to the clinic and to see the progress of this patient.
Unfortunately, however, as a result of occupational lifting, he sustained a back injury since his last treatment. This back injury led to complete inactivity for up to five days and the pain was described as agonising. Although this pain is greatly improved, the patient wanted to receive some advice on how to strengthen these now weakened structures. The patient also requested advice on a previous groin strain.
I performed an assessment on the patient’s back, from which I determined probable weaknesses in the gluteal muscles, particularly on the right side.
For the patient’s back pain, I prescribed some core stability exercises, glute strengthening as well as lumbar mobility exercises as these were all found to be effective in the treatment of lower back pain (Chang et al., 2015; Education, Gasibat, & Simbak, 2017; Purepong et al., 2012).
During the objective assessment it was clear that the patient’s pain was now localised to the right gluteal muscles and that the patient was no longer feeling any of the back pain or discomfort that disabled him two weeks prior to this session.
It was also observed that the patient had a slightly anteriorly tilted pelvis and as such I prescribed glute bridges with added isometric abduction exercises using a resistance band around the thighs (Choi et al., 2015).
From researching the effects of gluteal strengthening for the treatment of lower back pain, I came across a very useful article by Gasibat and Suwehli (2017), which reported positive effects of a number of exercises isolating the glutes and surrounding musculature.
This article also highlights the link between gluteal strength and lower back pain; any inactivity or guarding of the lower back during acute bouts of pain can lead to weaknesses in the gluteal muscles and therefore by strengthening these muscles, the risk of any changes in muscle activity due to pain and the evading of pain reduces (Gasibat & Suwehli, 2017).
One of the exercises that was advocated was a side plank for hip abduction, as shown in figure 2.

This would not only strengthen his abductors, including Gluteus Medius muscles, but his core muscles too. In order to add in some strengthening to the adductors too, to ensure that he can start running again soon without the apprehension of pain in the groin, we added resistance to this exercise by way of a chair. The up foot was to be rested on the chair while the lower leg is kept straight and raised off of the floor. This exercise can help to strengthen multiple muscle groups of which require attention in this particular patient.

In my reflections in the previous week, I wrote about the benefits and usefulness of squats and deadlifts in the strengthening of the lower extremity muscle groups and how I had hoped to be able to incorporate these into my clinic sessions and practice my ability to teach the correct technique to a patient.
I was very pleased to be able to use something new that I had recently learnt in this session and although weightlifting and any form of strength and conditioning is a new realm of knowledge for me, I knew that I would only learn by doing.
For this patient, deadlifts were prescribed with the aim of strengthening the erector spinae muscles (Schellenberg et al., 2015)and as he does not have any access to a gym, we suggested using a backpack, within which he can add more weights if needed.
As he also presented with low level pain in his adductor muscles, I suggested incorporating back squats into his routine as well, but as recommended by Schoenfeld (2010) I remembered to adapt the squat, making sure the patient perform these with a wider stance.

Patient 4 – This session was a follow up session for a condition known as Scheuermann’s Kyphosis. The patient reported improvements in pain presentation from previous sessions of anteroposterior mobilisations of the thoracic spine, stretching of the pectoralis muscles, thoracic spine soft tissue manipulation and mobilisations. The patient also felt that postural Elastic Therapeutic Taping (ETT) was useful, as it provided the patient with a physical reminder to correct his posture by way of mechanoreception. I didn’t know much about this condition, so I took the time to develop my knowledge, should I encounter this condition again in the future.
According to a paper by Loughenbury & Tsirikos (2017), Kyphosis is now a disease believed to be the result of inheritance but often the cause is thought to be largely unknown (Sardar et al., 2019) and presents itself as hyper kyphosis most usually in the thoracic spine and is diagnosed by an x-ray identifying a thoracic curve of 20-45° and other objective factors such as vertebral wedging, the narrowing between intervertebral discs and deformities in the effected vertebrae themselves. The wedging would be classified within the realms of this disease if it is of more than 5° of anterior wedging in three or more vertebrae (Sardar et al., 2019). The condition occurs in up to 10% of the population (Sardar et al., 2019) and causes pain and an obvious cosmetic deformity by way of an exaggerated curve of the thoracic spine, as shown in figure 3 (Loughenbury & Tsirikos, 2017).

The aforementioned studies highlight the fact that much of this condition is unknown, including how and why it occurs and as such, there is no clear consensus over treatment options, however it is reported that conservative treatment is effective and exercises can prove valuable in symptom management and inhibiting progression by way of strengthening the trunk muscles to improve balance and posture, increasing flexibility in the hamstrings and improving neck and shoulder mobility (Loughenbury & Tsirikos, 2017).
This is the same approach to the rehabilitation plan prescribed for this patient and so it will prove very interesting to watch his progression over the coming weeks with regards to pain and mobility throughout his spine and every day functional movements.

My final hour – I spent this time catching up on my clinic notes and discussing the treatments with the manager as a way of verbally evaluating and reflection on my performance as a therapist, as I was unable to complete this during my treatments; I still run over my session times and end up having to catch up by the end of the night. Due to the time of finish, it is within our duties to tidy and clean up the clinic before we leave. I feel as though we are becoming more proficient at this at the end of each session and are still maintaining good levels of cleanliness as seen at the start of the year.

References – 

Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of Physical Therapy Science, 27(3), 619–622.

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.

Gasibat, Q., & Suwehli, W. (2017). Determining the Benefits of Massage Mechanisms: A Review of Literature. Article in Journal of Rehabilitation Sciences, 2(3), 58–67.

Legakis, A., & Boyd, B. S. (2012). The influence of scapular depression on upper limb neurodynamic test responses. Journal of Manual and Manipulative Therapy.

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259–264.

Lewis, Jeremy S., & Valentine, R. E. (2010). Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain. BMC Musculoskeletal Disorders.

Lewis, Jeremy S, & Lewis, J. S. (2015). Rotator cuff tendinopathy : A model for the continuum of pathology and related management Rotator cuff tendinopathy : a model for the continuum of pathology and related management. Br J Sports Med.

Littlewood, C., Malliaras, P., Bateman, M., Stace, R., May, S., & Walters, S. (2013). The central nervous system – An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. Manual Therapy.

Loughenbury, P. R., & Tsirikos, A. I. (2017). Scheuermann’s kyphosis: diagnosis, presentation and treatment. Orthopaedics and Trauma, 31(6), 388–394.

Purepong, N., Jitvimonrat, A., Boonyong, S., Thaveeratitham, P., & Pensri, P. (2012). Effect of flexibility exercise on lumbar angle: A study among non-specific low back pain patients. Journal of Bodywork and Movement Therapies, 16(2), 236–243.

Sardar, Z. M., Ames, R. J., & Lenke, L. (2019). Scheuermann’s Kyphosis: Diagnosis, Management, and Selecting Fusion Levels. The Journal of the American Academy of Orthopaedic Surgeons.

Schellenberg, F., Taylor, W. R. ., & Lorenzetti, S. (2015). Exercise specific loading conditions and movements of squats, lunges, goodmornings and deadlifts. 33rd International Conference on Biomechanics in Sports.

Seitz, A. L., McClure, P. W., Finucane, S., Boardman, N. D., & Michener, L. A. (2011). Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clinical Biomechanics, 26(1), 1–12.



Exmoor Osteopathy External Placement Thursday 21st November 2019 – 4 hours (09:00-13:00): 121.5 total

Running total of hours: 121.5

During this session, had the opportunity to carry out two initial diagnostic assessments alongside my supervisor. Before I started this academic year, my weakest area of knowledge and practical ability was by far the vertebral column, so taking up an opportunity to work for Exmoor Osteopathy was a very positive decision in the development of this area in my knowledge. The number of patients who walk through the door with back pain is vast and as such, I have been able to experience various different presentations of a wide range of spinal dysfunctions, injuries and pathologies.
According to Gordon & Bloxham (2016), between 60 and 80% of adults will have lower back pain in their lifetimes, a condition which is responsible for 12.5% of work absences and costs the NHS £1.3 million each year.
The lower back pain patients attending this clinic are usually presenting with non-specific pain, which is thought to make up 85% of all back-pain cases (Gordon & Bloxham, 2016).

Throughout the treatments of LBP in this particular clinic, conservative passive treatments such as soft tissue and joint mobilisations, manipulations and massage are most commonly performed and are evidence based to some extent, but I try to offer my thoughts on including additional rehabilitation strategies such as stretching and strengthening, as well as patient education in order to allow the patient the opportunity to manage their lower back pain more independently and without the need for continual appointments at the clinic.
Throughout my reflections I have cited many studies that provide a large body of evidence suggesting that mobilisations, manipulations and massage etc are useful in reducing pain, improving flexibility and function, however these results are often short term or have not been proved to provide benefits that are beyond transient and as such more long term exercise programs are now more commonly recommended.

In a review by Gordon & Bloxham (2016), it was concluded that exercise is beneficial for individuals suffering lower back pain, but that no one exercise was better than the other; each case should be tailored for individually and should include strengthening, stretching and cardiovascular fitness as lower back pain can be reduced by up to 76.8% by core strengthening, 20% by cardiovascular fitness at 40-60% of heart rate reserve and 58% by flexibility training of the lumbar flexor and extensor muscles.

From reading this particular review, I was interested to learn the basic role of cardiovascular exercise in the management of pain; it is thought to stimulate the production of endorphins, which alters pain perception by way of binding to opiate receptors in the brain and spinal cord. Exercise also increases blood flow and nutrients to around the body and thus to the injury sites, which enhances the healing process by way of increasing mobility and enhancing the healing process (Gordon & Bloxham, 2016).
I am always an advocate for exercise of any form, so this was another incite as to the physiology behind it and another way I can help to explain on a basic level and reinforce physical activity in my future patients who may not be as physically active as they perhaps should be.

I also came across a randomised controlled clinical trial of 109 subjects, which found kinesiology taping effective in reducing pain in non-specific lower back pain (Kelle et al., 2016). Whether this is down to a placebo effect or not and knowing the role of perception in pain presentation, a study like this is very useful in developing a basic level of confidence in this modality and I would personally feel more comfortable suggesting this treatment in future, to facilitate further exercise rehabilitation programs.

Although I enjoyed going through the assessment process for back pain and identifying possible treatment options based on each individual presentation, as I now feel more confident approaching this, the highlight in this session was our final patient attending for a follow up appointment about her knee.
Patient overview – this patient came to the clinic with knee pain and pain radiating down the lateral aspect of her lower limb (as far as 1/3 down the leg following the course of the peroneals). This was most likely degenerative and is now causing pain in functional, every day movements. This patient is over 60 but an active walker.
Conservative treatment for the past 2 months has not been as effective as hoped; soft tissue massage, mobilisations and stretching exercises were all performed but the patient only reported minimal improvements, with little difference in pain experienced in functional movements.
Katarina, the supervising osteopath discussed the possibility of a meniscal tear and the prospect of a referral for surgery. In many areas of musculoskeletal therapy, surgery is often avoided as much as possible and conservative treatment is our most favoured option with many soft tissue injuries due to the cost of surgery, the fear of longer rehabilitation times and the adverse associated risks of surgery. However, evidence suggests that in some injuries, the earlier the surgical intervention, the better the outcome of the injury in relation to the delays in future pathology. For example, with a meniscus tear, if surgery is performed early and is successful, future degeneration can be delayed and the occurrence of osteoarthritis of the knee comes later than if surgery is not performed and as such further inevitable surgery, such as a knee replacement is put off for more longer (Vaquero & Forriol, 2016).
In order to fully assess the knee and to diagnose a meniscus injury requiring surgery, this patient would need to undergo magnetic resonance imagining (MRI), which according to Vaquero & Forriol (2016) is 90.5% sensitive and 89.5% specific or an arthroscopy which is used to both diagnose and treat via a keyhole surgical method.
The location and degree of the tear can vary the surgical treatment and there are many contraindicators that can also restrict surgical outcomes and therefore surgical intervention is not always the most suitable treatment. The cost and time involved in a referral for the patient can be extensive and as such Katarina would not suggest this lightly. The purpose of further investigations would be to identify the need for surgery or to rule out anything that may require surgery, in order to fully trust the route of conservative treatment.
A study by Kise et al. (2016), comparing the outcome of physical therapy vs. arthroscopic partial meniscectomy found no significant differences between the two options, however thigh muscle strength was found to have improved more in the conservative approach and therefore the non-surgical route is recommended, supporting earlier findings by Stensrud et al. (2015) in a study showing improvements in isokinetic quadriceps strength after a 12-week exercise program for the treatment of degenerative meniscus tears.
Knowing the specific criteria for surgery and effectiveness of physical therapy programs, it would usually be appropriate to continue with strengthening, however because this individual patient was not experiencing any benefits from the physical therapy, it was worth suggesting a referral.
If surgery is not indicated, we will know that we can continue to treat this patient in a conservative manor, but unlike before the referral, I will hope to add a more strengthening heavy exercise plan, rather than the more passive treatment previously administered as this provided the patient with minimal strengthening rehabilitation.

References –

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22.

Kelle, B., Güzel, R., & Sakalll, H. (2016). The effect of Kinesio taping application for acute non-specific low back pain: A randomized controlled clinical trial. Clinical Rehabilitation.

Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. BMJ (Online).

Stensrud, S., Risberg, M. A., & Roos, E. M. (2015). Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears. American Journal of Physical Medicine and Rehabilitation.

Vaquero, J., & Forriol, F. (2016). Meniscus tear surgery and meniscus replacement. Muscles, Ligaments and Tendons Journal.