External Placement Exmoor Osteopaths Thursday 17th October 2019 – 4hours

During my placement today, three patients were attending follow up treatments and one was a new patient with an initial appointment. This was a great opportunity for me to get involved in the diagnostic process and getting used to performing special tests. In this instance, the patient presented with shoulder and neck pathology and presented with neurological symptoms. I am not confident in my knowledge of nerves and associated dysfunctions and as such, I was not afraid to acquire plenty of assistance from my supervisor. The notable unilateral neurological symptoms were that of pins and needles radiating from her shoulder, down the arm (Popinchalk & Schaffer, 2012).
Because of this subjective assessment, we proceeded to test for impingement of the shoulder and performed the following tests; crossover impingement test, supraspinatus “empty can test”, Neer’s, Spurling and Hawkins-Kennedy Impingement test (Bakhsh & Nicandri, 2018; Innocenti et al. 2018). Other upper limb neurodynamic tests ULNT) were performed, the reliability of which have been deemed good by Schmid et al. (2009). All of these tests were negative and my supervisor and I were unable to reproduce symptoms, however we were able to identify muscular imbalances, tenderness, tension of the shoulders and neck as well as restrictions in specific ROMs. In the absence of an exact diagnosis, we based our treatment on our thorough subjective and objective assessments and performed soft and deep tissue massage and mobilisations and exercises to increase movement in her shoulder (Dong et al., 2015; Peek et al. 2015) and neck (Lascurain-Aguirrebeña et al., 2018) with the aim to reduce any neurological symptoms that may occur due to impingement.
It has been reported that most symptoms will eventually subside regardless of treatment, however physical therapy such as soft tissue massage, stretching, strengthening and mobilisations such as traction are found to be most effective (Childress & Becker, 2016).

I am now becoming aware of the importance of objective markers in assessments and as such I made sure to test her ROM after treatment. Both measurements and patient feedback was very positive and as such felt that, although we could not give the patient a precise diagnosis, we were able to alleviate her symptoms and prescribe a stretching/exercise program to be performed at home to help maintain her ROM.

With each client, I have the opportunity to fully assess certain joint restrictions and, with the help of the supervisor, notice specific areas of restrictions, compared with previous patients and with contralateral sides. Being able to practice end feels and observing restrictions in movement on each patient and discussing findings with my supervisor has really helped me to gain experience in diagnosis not only the presence of a joint dysfunction, but more precisely, which joint (Pellecchia et al. 1996; Warth & Millett, 2015).

References – 

Bakhsh, W., & Nicandri, G. (2018). Anatomy and Physical Examination of the Shoulder. Sports Medicine and Arthroscopy Review. https://doi.org/10.1097/JSA.0000000000000202

Childress, M. A., & Becker, B. A. (2016). Nonoperative management of cervical radiculopathy. American Family Physician, 93(9), 746–754.

Dong, W., Goost, H., Lin, X.-B., Burger, C., Paul, C., Wang, Z.-L., … Kabir, K. (2015). Treatments for Shoulder Impingement Syndrome. Medicine. https://doi.org/10.1097/md.0000000000000510

Innocenti, T., Ristori, D., Miele, S., & Testa, M. (2018). The management of shoulder impingement and related disorders: A systematic review on diagnostic accuracy of physical tests and manual therapy efficacy. Journal of Bodywork and Movement Therapies. https://doi.org/10.1016/j.jbmt.2018.08.002

Lascurain-Aguirrebeña, I., Newham, D. J., Casado-Zumeta, X., Lertxundi, A., & Critchley, D. J. (2018). Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial. Musculoskeletal Science and Practice. https://doi.org/10.1016/j.msksp.2018.10.003

Peek, A. L., Miller, C., & Heneghan, N. R. (2015). Thoracic manual therapy in the management of non-specific shoulder pain: A systematic review. Journal of Manual and Manipulative Therapy. https://doi.org/10.1179/2042618615Y.0000000003

Pellecchia, G. L., Paolino, J., & Connell, J. (1996). Intertester reliability of the Cyriax evaluation in assessing patients with shoulder pain. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.1996.23.1.34

Popinchalk, S. P., & Schaffer, A. A. (2012). Physical Examination of Upper Extremity Compressive Neuropathies. Orthopedic Clinics of North America. https://doi.org/10.1016/j.ocl.2012.07.011

Schmid, A. B., Brunner, F., Luomajoki, H., Held, U., Bachmann, L. M., Künzer, S., & Coppieters, M. W. (2009). Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system. BMC Musculoskeletal Disorders, 10, 1–9. https://doi.org/10.1186/1471-2474-10-11

Clinical Experience Tuesday 15th October 2019 – 5.5hours

Patient 1 and 2 –
Patient 1 and 2 both reported with restrictions in shoulder ROM and associated pain and as such I was able to go through protocols with them which helped to improve my confidence in explaining and demonstrating the exercises.

These two patients, however, were very different in their subjective assessments. Patient 1 was an elderly woman who is quite inactive, whereas patient 2 was very active and significantly younger. I am comfortable identifying differences in patients; however, I find it more challenging adapting the exercises to suit their specific needs.
For my younger male patient, I was able to perform mobilisations and soft tissue massage before taking him through a session of exercises to improve strength and mobility of the shoulder joint; a treatment option supported by a number of studies including by Riaz et al. (2018) and Yildirim et al. (2016).
With the older female patient, it wasn’t possible to perform these mobilisations due to her discomfort while in lying supine or prone on the treatment couch; this patient specifically requested a soft tissue massage of her shoulders and neck only. This was a returning patient who found previous treatment of this nature effective and as such was beneficial enough to warrant a follow up treatment. However, I wanted to understand whether there were any physiological changes or measurable benefits of reducing pain and increasing ROM so that I may be able to use this method again in future patients. Sönmezer et al. (2018) found pain reduction, increase ROM and reduced tenderness in trigger points after massage, heat packs and exercises but no additional affects were noted when mobilisations were included.

Patient 3 – this patient had reported falling down the stairs ten days prior to the session and presented with pain in her ribs with some movement restrictions in thoracic and lumbar spine and her left shoulder, but there was not effusion or bruising noted from conducting my objective assessment. It became apparent from resisted movements that the latissimus dorsi and intercostal muscles were the primary affected musculature and that there was potential joint stiffness which may have been caused by the trauma and/or subsequent immobility.
The patient reported improvements but wanted reassurance that she can continue to carry out every day tasks and attend regular exercise classes, dependant on pain.
Although there was some restrictions in movement, both subjective and objective assessments revealed no obvious diagnosis and due to the ever improving nature of the symptoms and from seeking advice from my supervisor, it was decided that the best course of action was to perform mobility exercises of the thoracic and lumbar and shoulder to maintain current movements and gradually increase movements in all planes, relative to the decreasing of pain. We advised the patient to continue with physical activity but due to the more explosive nature of her exercise classes (Body Pump), we suggested that this should only be performed when pain has mostly subsided and to carry out strengthening exercises of Latissimus Dorsi and core muscles in the meantime, to support the injury site.

Patient 4 –
This patient had a history of Achilles tendon rupture, which was treated conservatively and a rehabilitation plan well adhered to. However, since returning to netball, pain has been felt in the lower back and sciatica symptoms and calf pain have occurred down the contralateral leg, which has affected motion and the patient cannot fully integrate back into training.
When performing an objective assessment, the patient had limited and painful lumbar spine extension, however I was able to identify an anterior pelvic tilt and resultant hyper lordotic curve of the lumbar spine. When I asked the patient to actively engage her gluteal and abdominal muscles, educating her on this excessive tilt, then re performing extension, the pain had subsided and range of motion was less restricted. It has previously been reported that an excessive anterior tilt of the pelvis is related to the presence of lower back pain (Król et al., 2017) and so it may be relevant that when this tilt is corrected, the pain may reduce or subside.

I felt confident that neurological tests were required due to the patient’s sciatica symptoms in order to identify lumbar disc herniation or other lumbar neuropathy and to use this as an objective measure in our treatment. The passive straight leg raise with added dorsiflexion is commonly used and in this instance it produced positive results for the reproduction of pain, however research has suggested that the reliability of this test is limited due to the similarities and difficulties in distinguishing between symptoms of other conditions such as shortened hamstring muscles and nerve root compression (Capra et al., 2011 and Sciaca et al. 2012). Although the test proved to identify possible neuropathy, whether it is nerve root compression or lumbar disc herniation, our treatment would remain the same at this stage as we felt that the possible cause of the patient’s joint stiffness and possible nerve compression may also be due to her pelvic tilt.
After performing mobilisations of the lumbar spine to treat the patient’s joint stiffness, we demonstrated a range of exercises for the patient to do at home, including bridging exercises with additional resistant bands around both lower limbs for added abduction, as his has been found to increase gluteus maximus muscle activity by 21.1% and reduce excessive anterior pelvic tilt (Choi et al., 2015).

References –

Capra, F., Vanti, C., Donati, R., Tombetti, S., O’Reilly, C., & Pillastrini, P. (2011). Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. Journal of Manipulative and Physiological Therapeutics. https://doi.org/10.1016/j.jmpt.2011.04.010

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

Król, A., Polak, M., Szczygieł, E., Wójcik, P., & Gleb, K. (2017). Relationship between mechanical factors and pelvic tilt in adults with and without low back pain. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-140177

Riaz F, Haider R, Qamar MM, Basharat A, Manzoor A, Rasul A, et al. Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain. BLDE Univ J Health Sci 2018;3:85-8.

Sönmezer, e., Tüzün, e. H., Eker, l., & Yüksel, i. (2018). Effectiveness of mobilization therapy for treating cervical myofascial pain syndrome. / servikal miyofasiyal ağrı sendromunun tedavisinde mobilizasyon tedavisinin etkinliği. Journal of exercise therapy & rehabilitation, 5(1), 25–32. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=130680661&site=ehost-live

Yıldırım, A., Akbaş, A., Dost Sürücü, G., Karabiber, M., Eken Gedik, D., & Aktürk, S. (2016). Miyofasiyal ağrı sendromuna bağlı boyun ağrılı hastalarda mobilizasyon uygulamalarının etkinliği: Randomize bir klinik çalışma. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi, 62(4), 337–345. https://doi.org/10.5606/tftrd.2016.95777


Clinical Experience Monday 14th October 2019 – 5.5hours

Patient 1 –
patient overview: wrist injury from trauma and two previous fractures. Injury to other wrist may have caused over compensation and overuse of right wrist. Stiffness when inactive, pain doing Parkour.
Equally restricted flex and extension which indicates capsular pattern of wrist joint.
Joint mobilisations performed, incl. distraction and distraction with added flexion. Exercises to strengthen wrist; flex, ext, U/dev, R/Dev with resist. Ball squeezes, change position of thumb to vary exercise. EAB to support wrist.

I have not had any past encounters with wrist injuries and so my experience with wrist assessments is lacking. I have poor knowledge of the muscular components and therefore understanding of the wrist joint movements, however I was able to palpate the carpals and those most relevant in this patient, e.g the Scaphoid.
I was able to identify that this injury was likely a joint pathology, based on my objective assessment; capsular pattern, active and passive movement and pain characteristics. There were notable muscular issues too, but this could have been resultant of joint pathology; which came first, the chicken or the egg?
I performed some further research on the clinical assessment of the wrist joint and noted the reported interpretations of limited active range of motion, in particular flexion and extension and thus capsular pattern. A useful article also highlighted trauma and/or immobilisation of the joint as possible risk factors for joint pathology in the wrist, which links me back to my subjective and the patient’s history of trauma (Porretto-Loehrke, Schuh, & Szekeres, 2016).

As indicated by the assessment, I treated this pain as joint stiffness and associated muscle pain. After performing wrist mobilisations to help with joint mobility and pain, I was advised by my supervisor to apply some support tape so that the patient could continue with his Parkour training. As I have not treated a wrist injury before, I was not proficient in this modality and as such needed assistant. I have since researched the type of wrist taping possible and the rationale behind this, so that next time I am presented with this, I will feel confident in my approach.
The taping technique that I was advised to use was with rigid taping and was applied continuously around the whole joint and is recommended for the stability of ligaments and wrist joint capsule (Porretto-Loehrke, 2016). In reflecting my treatment, I had realised that I did not use any base layer tape so better comfort, as the rigid tape may be quite tough on the skin and uncomfortable, especially on a more delicate wrist joint. In future, I will take the time to apply the under wrap, so that the taping can be both effective and comfortable.

Patient 2 – This patient was a regular user of the clinic and often came for a soft tissue massage. However on this occasion, and with a comprehensive discussion with my supervisor, we decided not to treat him due to some new symptoms of dizziness and neck pain; instead we advised him to seek advice from his GP and return if given the all clear.
Although I feel as though I am able to perform a detailed and clear subjective assessment and ask the most relevant and appropriate questions needed to help in the diagnostic process, there are some elements to the questions that I do not fully understand, with neurodynamic testing and understanding creating a significant gap in my knowledge.

In this case, the patient presented with symptoms that are similar in those with Vertebrobasilar Insufficiency (VBI) including dizziness, and although based on a comprehensive medical history, his accumulative, chronic symptoms probably were not that of VBI, my supervisor and I felt more comfortable asking our patient to visit the GP before having further treatment of his neck area as this is a serious condition whereby blood flow could be restricted to the brain due to compression of posterior arteries during vertebral movements. The presence of other health issues, such as heart and blood pressure also contributed to our decision to not treat with any manual therapy techniques in this session.
This is because VBI or symptoms are a contraindicator to manual therapy and in particular cervical spine mobilisations and manipulations and therefore must not be performed, especially when combined with either anticoagulant therapy or unexplainable cervical symptoms, which was the case (Hutting et al., 2018).

Early research by Mitchell et al. (2004) found that blood flow via the posterior craniovertebral arteries was restricted in young asymptomatic subjects when neck is put in end range rotation and as such the tests for VBI were of clinical significance, especially when projected onto the wider, older population. However, a more recent study by Thomas et al. (2013) found that blood flow via the craniovertebral arteries was not restricted in asymptomatic subjects, findings that have since been supported and deemed likely, with recent studies reporting there to be no found negative effects of manual therapy on serious cervical pathologies (Hutting et al., 2018).

Patient 3 –
This patient presented with lateral knee pain after having completed a running course of ‘couch to 5km’ from having not previous taken part in running.
From our subjective assessment, it became apparent early on that Patella Femoral Pain Syndrome was a possibility. PFPS is reported as being the most common injury in runners and is seen in up to 13% of woman under 35 (Stickler et al., 2015) and as increase in physical activity is the biggest risk factor, this patient met many criteria before I started my objective. I therefore aimed to include relevant tests in my physical assessment.

However, I found it a challenge to recall the exact names and protocols for the knee exams, so as further learning, I revised the special testing procedures for the knee, especially those tests for PFPS.

The most relevant special tests for PFPS include eccentric step tests, patella apprehension test and the active instability test, all of which have reasonable specificity and sensitivity when performed alone but when they are combined, they were shown to have a 100% sensitivity with 100% negative predictive values; all three combined or patella apprehension with eccentric squat test (Arjun et al., 2017).
I did use a combination of these tests in my assessment, but I am now able to refer to them by name and I have a greatest understanding of their reliability and rationale behind their use.

As well as these initial tests for PFPS, I asked my patient to perform functional tests such as the single leg squat without standing on a step, to assess knee valgus by observation, a method found reliable in a study by Ugalde et al. (2015). From this I noted a hip drop and a great internal rotation of the hip than the contralateral, non-affected leg. The patient also felt shaking and not in control while performing this test, which indicated weakness in the hip and knee musculature.

The high prevalence of PFPS in woman may be due to the significant Q angle at the hip and as such its effect on the patella alignment. A study by Stickler et al. (2015) found that individuals with PFPS tended to have a greater increase in internal rotation of the hip which resulted in an even greater lateral pull on the patella. It has been common practice in rehabilitation to perform exercises to increase the strength of the lateral hip abductors, prevent a contralateral pelvic drop and hip external rotators to reduce the effects of this lateral pull on the patella.
With this is mind, I was able to go through a range of exercises for the patient to perform during the session and to continue at home.
I also included core strengthening to these exercises as these have been shown to reduce pain and improve balance in woman with PFPS (Chevidikunnan et al. 2016).

References –

Chevidikunnan, M. F., Saif, A. Al, Gaowgzeh, R. A., & Mamdouh, K. A. (2016). Effectiveness of core muscle strengthening for improving pain and dynamic balance among female patients with patellofemoral pain syndrome. Journal of Physical Therapy Science. https://doi.org/10.1589/jpts.28.1518

Porretto-Loehrke, A., Schuh, C., & Szekeres, M. (2016). Clinical manual assessment of the wrist. Journal of Hand Therapy, 29(2), 123–135. https://doi.org/10.1016/j.jht.2016.02.008

Hutting, N., Kerry, R., Coppieters, M. W., & Scholten-Peeters, G. G. M. (2018). Considerations to improve the safety of cervical spine manual therapy. Musculoskeletal Science and Practice, 33(October 2017), 41–45. https://doi.org/10.1016/j.msksp.2017.11.003

Mitchell, J., Keene, D., Dyson, C., Harvey, L., Pruvey, C., & Phillips, R. (2004). Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Manual Therapy, 9(4), 220–227. https://doi.org/10.1016/j.math.2004.03.005

H. H., A., Kishan, R., M. S., D., & Chouhan, D. (2017). Reliability of clinical methods in evaluating patellofemoral pain syndrome with malalignment. International Journal of Research in Orthopaedics, 3(3), 334. https://doi.org/10.18203/issn.2455-4510.intjresorthop20170902

Stickler, L., Finley, M., & Gulgin, H. (2015). Relationship between hip and core strength and frontal plane alignment during a single leg squat. Physical Therapy in Sport, 16(1), 66–71. https://doi.org/10.1016/j.ptsp.2014.05.002

Thomas, L. C., Rivett, D. A., Bateman, G., Stanwell, P., & Levi, C. R. (2013). Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy, 93(11), 1563–1574. https://doi.org/10.2522/ptj.20120477

Ugalde, V., Brockman, C., Bailowitz, Z., & Pollard, C. D. (2015). Single Leg Squat Test and Its Relationship to Dynamic KneeValgus and Injury Risk Screening. PM and R. https://doi.org/10.1016/j.pmrj.2014.08.361


Exmoor Osteopathy Clinic – External Placement Thursday 10th October 2019 4 hours

1. Positioning of the therapist during mobilisations
During today’s session, my supervisor was able to talk me through the techniques that she uses to perform assessments and treat patients. I often find it hard to position myself alongside my clients and as such find it manually very exhausting to carry out some manoeuvres. I was reassured that if I practiced my technique, I would be able to maintain positions and treatments for longer periods of time with more effective force and without too much strain on myself. For example, the use of my knee to carry the weight of a patient’s lower limb while performing traction of the hip, resting a patient’s arm on mine and holding them between my arm and hip so that I can use two hands when mobilising the shoulder joint, or simply moving my body when performing soft tissue massage, as opposed to putting the force through my fingers or wrists. Patient feedback provided gave me an indication that I was not able to put as much pressure on the patients and as such needed to use my body more. Throughout the treatments, I continually asked for feedback and asked the patients to compare my pressure and technique to that of my supervisor and as such was able to adjust accordingly. I found that with assistance, I was able to practice better technique and learn some invaluable body positions that I can take away into my own clinical practice.

2. Soft tissue massage before mobilisations is more effective?
It is usual practice at Exmoor Osteopathy Clinic to either perform soft tissue massage before or in conjunction with mobilisations. From experience, my supervisor has found that mobilisations and manipulations are more effective in treating joint mobility after a period of massage or in conjunction with, as a way of increasing tissue temperature and pliability.
Very little evidence is available on the effectiveness of massage on tissue and although some studies suggest that massage has no effect on the biomechanics of the gastrocnemius muscle (Thomson et al., 2015) there have also been conflicting studies to suggest that massage reduces muscle stiffness in the gastrocnemius. For example Eriksson Crommert et al. (2015) found reduction in stiffness immediately after treatment, which lasts for as little as 3minutes.
Although the latter findings show only immediate changes in muscle biomechanics, this is all that is needed for the clinician to then perform mobilisations and manipulations to the joint.
For a more fluid treatment, I will hope to combine these two treatments to maximise effectiveness when my goal is to increase ROM and reduce joint stiffness.

3. SI joint testing

One of our patients presented with lower back pain and from our subjective we included a test to identify SI Joint dysfunction (SIJD).

From the treatments that I observed, I noticed that most patients who presented with lower back or hip pain had undergone the standing flexion test, which was reported to have low reliability (von Heymann et al. 2018) and a sensitivity of 17% and a specificity of 79% (Soleimanifar et al., 2017). I am not confidence in my understanding of these terms and therefore was not able to interpret these figures, but know that they carry much importance when considering which test to use on a patient and how results must be understood and validated. I therefore carried out some further research to build upon my understanding and by doing so, I found an article explaining the terms specificity and sensitivity (Lalkhen & McCluskey, 2008).
I now better understand the limitations of a test having a sensitivity of 17%, as this means 83% of individuals with an SIJD will be left undetected. A higher specificity of 79% means that only 21% of tests will result in false positives but this doesn’t boast excellent scores and I would therefore question the test’s use when there are other motion and pain provocation tests with higher specificity and sensitivity figures. It has been recommended that pain provocation tests, particularly the gluteal irritation test was the most efficient but that the previously derived three out of five positive pain-provocation test model was the most effective when the gluteal irritation test was included, with a 93.8% sensitivity and 78.1% specificity (von Heymann et al., 2018).
Other pain provocation tests I could use in combination with the irritation test could be FABERS and the resisted abduction test, which both have 100% specificity (Soleimanifar et al., 2017).

Regardless of the reported sensitivity and specificity of the tests, the standing flexion has been a consistent objective marker of the treatment performed in the session; each time, there have been notable changes after treatment.
The session consisted of mobilisations, soft and deep tissue massage of the hips, glutes and lower back, mobility exercises and manipulations and the SIJ retested with improvements in symmetry observed.

MET stretching techniques of the surrounding hip and lower back musculature were also applied; a treatment previously found to help motor recruitment and stability (Fryer, 2011). A combination of MET stretching and exercises have been found to be effective in the treatment of SIJD (Dhinkaran et al. 2011) and as such can provide a basis in understanding of our treatment.

As well as lower lumbar spine mobility exercises, the patient was also given a series of exercises for both core stability and their glutes. It has been reported that individuals with SIJD also often presented with weakness in gluteal muscles but after a program of glute specific strengthening, experienced increased strength in their glutes and reduced lower back pain (Added et al., 2018).

References –

Added, M. A. N., de Freitas, D. G., Kasawara, K. T., Martin, R. L., & Fukuda, T. Y. (2018). Strengthening the Gluteus Maximus in Subjects With Sacroiliac Dysfunction. International Journal of Sports Physical Therapy, 13(1), 114–120. https://doi.org/10.26603/ijspt20180114

Eriksson Crommert, M., Lacourpaille, L., Heales, L. J., Tucker, K., & Hug, F. (2015). Massage induces an immediate, albeit short-term, reduction in muscle stiffness. Scandinavian Journal of Medicine and Science in Sports. https://doi.org/10.1111/sms.12341

Lalkhen, A. G., & McCluskey, A. (2008). Clinical tests: Sensitivity and specificity. Continuing Education in Anaesthesia, Critical Care and Pain, 8(6), 221–223. https://doi.org/10.1093/bjaceaccp/mkn041

M, D., A, S., & T, A. (2011). Comparative analysis of Muscle Energy Technique and conventional physiotherapy in treatment of sacroiliac joint dysfunction. Indian Journal of Physiotherapy and Occupational Therapy. An International Journal.

Thomson, D., Gupta, A., Arundell, J., & Crosbie, J. (2015). Deep soft-tissue massage applied to healthy calf muscle has no effect on passive mechanical properties: A randomized, single-blind, cross-over study. BMC Sports Science, Medicine and Rehabilitation, 7(1), 1–8. https://doi.org/10.1186/s13102-015-0015-8

von Heymann, W., Moll, H., & Rauch, G. (2018). Study on sacroiliac joint diagnostics: Reliability of functional and pain provocation tests. Manuelle Medizin, 56(3), 239–248. https://doi.org/10.1007/s00337-018-0405-6

Soleimanifar, M., Karimi, N., & Arab, A. M. (2017). Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders. Journal of Bodywork and Movement Therapies, 21(2), 240–245. https://doi.org/10.1016/j.jbmt.2016.06.003

Clinical Experience 8th October 2019 – 5.5hours

Patient 1 –
Patient Overview:
Chronically restricted neck movement, but no pain
Very RROM in all neck movements, Passive no diff; restricted in all movements, no Px just tension. R more restricted than L. Little to no ability to extend neck.
Shoulder ROM restricted, R more than L. Int. rot very restricted in L more than R (difficult to put on jacket).
Tx bilaterally equal in rotation and no Px. Lx flexion and extension ok but less than expected.
No pain on palpate of any area.
Suspected joint stiffness in Cx, and Tx in particular but unable to perform mobs due to inability to lie prone.
Tension and bulk in muscular surrounding Cx and shoulders. Patient moves shoulders instead of neck during daily, functional movements; needs to increase mobility in neck.

This patient has booked in with me next week and in preparation, I wanted to research into the best exercises to improve neck and shoulder strength and ROM. I also wanted to find research to support the use of mobilisations in helping to increase her should ROM, in particular, internal rotation so that she can find it easier to put on her jacket.

It was advised by my supervisor that a duration test may be a good indicator of neck extensor strength and as such, I should perform that In the next session to use measurements as a baseline in progress.
The Duration test consists of the contraction of the neck muscles bringing chin to chest and the length of testing is measured in seconds until the patient can no longer hold that pose. A good outcome will be to improve this time over the progression of rehabilitation.

There are a number of studies that have found cervical mobilizations to be effective in reducing myofascial pain syndrome, including that conducted by Yildirim et al. (2016) who concluded its effectiveness alongside other treatments such as soft tissue massage. Sonmezer et al. (2018), however found that treatments such as heat therapy and soft tissue massage both reduced pain in the neck, as well as increasing range of motion and associated disability but that mobilizations did not have any effect. This is useful to note with this patient, as she did not feel comfortable lying on the treatment table in a position that allows for the correct mobilisation procedures.
As this patient does not currently experience any pain associated with this limited range of movement, it is therefore appropriate to treat with soft tissue massage, stretching such as MET and exercises, as this combination has been found to improve ROM, decrease pain, improve Neck Disability Index (Ghodrati et al., 2017).

In the initial consultation, I found it difficult to assess the patient’s neck due to such limited ROM and inability to lay on the treatment table and therefore was unable to reach a proper clinical diagnosis and as such I treated the limited ROM with massage and neck active mobility exercises and suggested a stretching program. Soft tissue massage has been found to increase range of movement of the shoulder, improve function and reduce pain (Van Den Dolder & Roberts, 2003).
Based on my research, in the next session I will aim to perform more soft tissue massage and go through some more exercises to help increase neck extension and ROM.

With regards to the limited ROM in the shoulder, I will perform shoulder mobilisations in order to help most specifically with internal rotation; functionally, this is causing the patient most inconvenience when putting on items of clothing.
The glenohumeral joint capsular pattern is restriction in external rotation, followed by abduction and then internal rotation and in order to increase internal rotation, posterior glide mobilisations can be performed (Loudon et al. 2008).

Exercises such as the ‘Y’ overhead exercise for shoulder mobility can be demonstrated and performed (Liebenson & Dc, 2006) to help reduce shoulder elevation/shrugged shoulders and forward shoulder posture.

Patient 2 –
Patient overview:
P1: R 2012 full rupture of achillies and gastroc strains . P2: full rupture of achillies, torn soleus. Neither surgically repaired. L = 7/12 recovery time, R = 11/12 recovery time.

This patient presented with a history of Achilles tendon rupture in bilateral ankles and is currently undergoing rehabilitation for the reinjury of L Achilles 5 months ago.

I was interested to note that neither of these injuries were surgically treated, despite the severity of the tears. Although it is within our duty of care to rehabilitate the patients by means of the prescribed protocol or suggested program by the surgical team, I wanted to understand whether there was much difference in the outcome of each program.
In my research, I found there to be a number of studies comparing the outcomes of surgical and conservative treatment. For long term outcome and return to play, the non-operative/conservative approach has a greater rate of re-rupture and a lowered return to previous sport, whereas operative risks include infection, which was positive reinforcement for this patient.
However, although it has been found that the surgical option reduced reinjury rate (Deng et al. 2017), compared with the surgical management of other orthopaedic injuries, return to play rates after a repair is the lowest (Wang et al. 2017). This knowledge in itself led to a barrier in my own confidence with a successful outcome for this patient, as her goal was to return to activity as soon as she could.
I was able to find research suggesting that the accessibility of functional rehabilitation is more likely to contribute to conservative treatment being preferential to operative (Wu et al., 2016) and as such, reassured me that providing a functional rehabilitation program was the best we could do for this patient.

Due to currently progressing through an extensive program of rehabilitation already, this patient came in just as a means to maintain healing by way of therapeutic ultrasound (US).
Ultrasound is a commonly used practice used by clinicians in the management of sports injuries as a way of promoting the normal progression of the inflammation process and therefore normal tissue repair (Watson, 2008). In studies to support its use, Watson (2008) found that the newly formed collagen fibres after US treatment were more efficient and better orientated and that the treatment encouraged the formation of more tensile type I fibres as opposed to type III, allowing for longer lasting effects of the remodelling phase in the healing process.
In an evidence review by Eberman et al. (2013), very little evidence was found to justify its use in musculoskeletal injuries and suggested that tradition and beliefs were the motivation for its use; only effects of increased tissue temperature and possible decreases in fracture healing time were reported.
There is also little evidence to suggest optimum tissue temperatures for healing and as such, it is not possible to conclude whether heating chronic tissue has any effect on the healing process.

The patient requested this method of treatment due to past experience of a positive outcome and as such, providing the dosage is set to ensure there are no negative consequential and/or detrimental effects to the healing of the tendons, the use of this treatment was justified. The patient was also attending this session to complement a separate eccentric exercise program for rehabilitation. There is still very little evidence to support the benefits of US for tendon healing and as such I will keep up to date with future publications to support treatment of this type of injury.

Patient 3
Patient overview:
Shoulder injury from overload of work and exercise. Improving, low irritability. Chronic. Resistance band exs, can’t do press ups, definite improvement from exercises and taping.FROM, low Px around coracoid process and described as in shoulder joint during abduction and flexion and elbow flexion. very slight restriction in int.rotation.
Review of exercises, went through new ones for biceps; functional squats/lunges with weight and arms flexed – can curl bicep with resistance to progress. K-tape to R shoulder as requested.

This patient has been doing excellently throughout his rehabilitation program and was able to perform almost all movements with good range and no pain. The patient did show slight restriction in movements involving the biceps brachii. I felt confident that with my sensitive approach to the subjective and objective assessments, I was able to discuss his progress and symptoms and interpret them from a psychosocial perspective. The patient gave me a very lengthy history of his injury and reported mostly positive progress and, after going through some exercises with him, it became apparent that the pain was more likely to be more apprehension and as such, my ability to reassure him of his muscular capabilities and praise him on progress was enough to allow a huge progression in what he felt he was able to achieve; his self-efficacy.

Throughout the rehabilitation program, the patient was focusing more on the shoulder joint as a whole and putting very little force on his biceps, the area of most pain and dysfunction. In early rehabilitation, this is beneficial as it allows the strengthening of the whole shoulder joint and ability to access whole movement ranges without putting too much force through the biceps prematurely and increasing the reinjury risk, as found in a study on EMG analysis of different rehabilitation exercises for the biceps brachii muscle (Cools et al., 2014); exercises not involving bicep brachii specific movements result in much lower muscular activity than those designed to target those movements of flexion and supination.
As this patient had good range of movement and little pain throughout the shoulder joint, the progression to these bicep specific movements will prove beneficial as these would illicit the most force and muscle activity in order to build strength in this muscle.

Resistance band exercises were used initially for the early progression from isometric to isotonic strengthening with a continuous option to adjust resistance by way of band colour/strength and repetitions and sets, a method supported by Mullaney et al. (2017). This patient adhered excellently to the program and his progress has been credited to this. I felt confident that I was able to give appropriate positive feedback and encouragement throughout this session.

Patient 4 –
Patient Overview: 3/52 strain, 3x this year hx. Not properly recovered. Seeing physio, 6 weeks Rx to return to physical fitness; cross trainer 15/20mins, weighted calf raises, single leg. Started to do minimal explosive rehab. No scans, bruising/effusion at time of injury.
Foam roller, advised to have STM, physio again for 1RM exercises and trampoline 2/7. Improving, moderate irritability.
N/A, STM Only, comprehensive Rx with Army Physio, next session 2/7. Tenderness over strain during palpation, “able to palpate muscle scarring” mid region of posterior gastroc.
In process of comprehensive army rehab for recurring gastroc strain (most recent 3/52). Needs STM as maintenance to facilitate exercise sessions with occupational physio.

This patient requested a soft tissue massage of bilateral gastrocnemius muscles, as recommended by his physio. I was aware that he was undergoing a comprehensive treatment program with him occupational physiotherapist already and as such was reassured that this patient was receiving the best treatment.
I was able to perform the treatment with good strength and confidence, based on my previous experiences of soft tissue massage. I did recommend the use of a foam roller to help in the maintenance the effects of a soft tissue massage in between treatments, which I have since found to be advocated as an effective treatment by Aboodarda et al. (2015) in a randomised control study that found roller massage to effectively reduce perceived pain in muscle tender spots.
As my patient self-reported pain and tender spots, I confidently suggested this option.


Aboodarda, S., Spence, A., & Button, D. C. (2015). Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Musculoskeletal Disorders, 16(1), 1–10. https://doi.org/10.1186/s12891-015-0729-5

Cools, A. M., Borms, D., Cottens, S., Himpe, M., Meersdom, S., & Cagnie, B. (2014). Rehabilitation exercises for athletes with biceps disorders and SLAP lesions: A continuum of exercises with increasing loads on the biceps. American Journal of Sports Medicine, 42(6), 1315–1322. https://doi.org/10.1177/0363546514526692

Deng, S., Sun, Z., Zhang, C., Chen, G., & Li, J. (2017). Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Foot and Ankle Surgery. https://doi.org/10.1053/j.jfas.2017.05.036

Eberman, L., Schumacher, H., Niemann, A. J., Adams, H. M., & Kahanov, L. (2013). Research evidence for therapeutic ultrasound effectiveness. International Journal of Athletic Therapy and Training. https://doi.org/10.1123/ijatt.18.4.20

Ghodrati, M., Mosallanezhad, Z., Shati, M., Rastgar Koutenaei, F., Nourbakhsh, M. R., & Noroozi, M. (2017). The Effect of Combination Therapy; Manual Therapy and Exercise, in Patients With Non-Specific Chronic Neck Pain: A Randomized Clinical Trial. Physical Treatments: Specific Physical Therapy Journal, 7(2), 113–121.

Liebenson, C., & Dc, Ã. (2006). Self-management of shoulder disorders—Part 3.pdf. 65–70. https://doi.org/10.1016/j.jbmt.2005.10.003

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

Mullaney, M. J., Perkinson, C., Kremenic, I., Tyler, T. F., Orishimo, K., & Johnson, C. (2017). Emg of Shoulder Muscles During Reactive Isometric Elastic Resistance Exercises. International Journal of Sports Physical Therapy, 12(3), 417–424. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28593096%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC5455191

SÖNMEZER, E., TÜZÜN, E. H., EKER, L., & YÜKSEL, İ. (2018). Effectiveness of mobilization therapy for treating cervical myofascial pain syndrome. / Servikal miyofasiyal ağrı sendromunun tedavisinde mobilizasyon tedavisinin etkinliği. Journal of Exercise Therapy & Rehabilitation, 5(1), 25–32. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=130680661&site=ehost-live

Wang, K. C., Cotter, E. J., Cole, B. J., & Lin, J. L. (2017). Rehabilitation and Return to Play Following Achilles Tendon Repair. Operative Techniques in Sports Medicine, 25(3), 214–219. https://doi.org/10.1053/j.otsm.2017.07.009

Watson, T. (2008). Ultrasound in contemporary physiotherapy practice. Ultrasonics, 48(4), 321–329. https://doi.org/10.1016/j.ultras.2008.02.004

Van Den Dolder, P. A., & Roberts, D. L. (2003). A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Australian Journal of Physiotherapy, 49(3), 183–188. https://doi.org/10.1016/S0004-9514(14)60238-5

Wu, Y., Lin, L., Li, H., Zhao, Y., Liu, L., Jia, Z., … Ruan, D. (2016). Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. International Journal of Surgery, 36, 305–311. https://doi.org/10.1016/j.ijsu.2016.11.014

Yıldırım, A., Akbaş, A., Dost Sürücü, G., Karabiber, M., Eken Gedik, D., & Aktürk, S. (2016). Miyofasiyal ağrı sendromuna bağlı boyun ağrılı hastalarda mobilizasyon uygulamalarının etkinliği: Randomize bir klinik çalışma. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi, 62(4), 337–345. https://doi.org/10.5606/tftrd.2016.95777

Clinical Experience 7th October 2019 – 6 Hours

Patient 1 –
Patient 1 overview – started running from inactivity 8/52, pain in post. ankle/lower gastroc 2/52 P1 L, P2 R foot. Ran 10km 1/7, now Px intermittent 4/10 P1 R, P2 L. Px 2/10 at rest. EMP. NSAIDS has helped.
All FROM, FPROM, FRROM of ankle and knee. Slight Px in eversion of R ankle but difficult to reproduce. Very acute, effusion, redness no heat.
Palpations – Px over peroneal tendons. Clinical Impression: peroneal tendonitis due to sudden increase in load, intensity and frequency of running and possibly resultant of new shoes.

This patient had a very acute injury from a 10km run the day before. Although we were able to test A, P and R ROM, due to subjective we were able to devise an immediate plan of treatment and exercises based on this, without aggravating the inflammation. It was advised that the patient maintains their range of motion and starts to incorporate a strengthening program for the peroneal muscles by way of resisted eversion and resisted eversion with hell raises to allow for additional plantar-flexion.

The supposed analgesic effects of cryotherapy has been justification enough of it widespread use in the treatment of soft tissue injuries. It is suggested that the reduction in tissue temperatures reduce the conduction of nerves and subsequent stretch-reflex mechanisms, as well as reducing secondary tissue death by the resultant tissue adaptations by way of lower temperatures, resulting in slower rates of chemical reactions and subsequent metabolic demand for ATP and energy synthesis (Hubbard et al. 2004).
Other physiological effects include analgesia, vasoconstriction, reduction in swelling and inflammation (Malanga et al. 2015).

However, reviews by Hubbard and Denegar (2004) and Bleakley et al. (2004) found that in spite of proposed physiological mechanisms, there was a lack of clinical evidence, by way of randomised clinical control studies surrounding the use of cryotherapy and suggested that this could have been largely as a result of the inability to use blind subjects when applying ICE and as such subsequent research trials have still yet to be completed.
In a more recent review by Malanga et al. (2015), it was also found that there is still very little evidence to support cold therapy and its use on acute soft tissue injury treatment with regards to healing times and effectiveness. Collins (2008), later also reported that there remained insufficient evidence in support of cryotherapy having any effect of the outcome of soft-tissue injuries.
With such a significant lack in supporting evidence by way of randomised control studies, I found it hard to justify my use of this modality with this patient. My rationale behind it’s use was to reduce swelling and induce the effects of vasoconstriction and analgesia, however In order to justify this, I needed to find some supporting evidence. The only current study in support of cryotherapy, by way of cold water immersion (CWI) in mice, was recently conducted by Furtado et al. (2018), in which he found CWI an effective treatment option after high intensity exercise, encouraging a more efficient anti-inflammatory response from the injured tissue.

With the physiological effects of cold therapy on tissue healing and the recent findings from Furtado et al. (2018) in mind, in conjunction with updated recommendations from Bleakley et al. (2012) and previous reports from Hubbard and Denegar (2004) of cold therapy’s analgesic effects (even just for 30minutes) and the knowledge that ice application is not at the detriment of tissue healing, I feel confident that our decision to use the game ready as cryotherapy was supported and justified enough, considering the acute nature of the injury and our inability to continue with any other progressive exercise treatment with the current presence of effusion.

However, I will continue to keep up to date with newly released findings, should they become available, on the efficacy of RICE modalities and be open to discovering new methods of managing soft tissue inflammation. As guidelines are constantly changing, for example, in a review by Vuurberg et al. (2018) it was found that the commonly used ICE treatment for acute lateral ankle sprains is now not recommended.

In future treatments, it could be useful to follow principles published by Dubois and Esculir (2019) has recently published a short report on the need to re-evaluate the current guidelines of ice and move to a new way of thinking; PEACE & LOVE. Protect, Elevate, Compress, Educate then subsequent Load, optimism, Vascularisation and Exercise after the initial inflammation has subsided; none of which has any mention of ice or cold therapy.

Patient 2 –
Patient 2 overview – Started running 11/52, completed 10 week course, ended 2/52 ago but continuing running 2x week. Increased load quickly from nothing. Bilateral ‘tension’ in post. lower legs/gastroc. Ant. pain over tibia bilaterally. Px 3/10 dull ache, intermittent. Stretching helps, running agg. Static, not improving.
FROM, FPROM, FPROM. No other observations. Px on palpation of bilat. distal 2/3 of tibia. Medial Tibial Stress Syndrome possible in bilat. tibias. Muscle tension in gastrocs due to the increase in load over past 11 week.STM of triceps surae, predom. gastroc. STM of tib ant. K-tape over tibia with decom over area of most Px.
Isotonic/eccen. exercises to strengthen tib. post to improve muscular and strengthen arch and eventually stop using insoles (e.g tennis ball squeezes during heel raises, then heel drops). Continue running.

In an attempt to help the patient manage her flat footedness which the patient reported the need for the orthotic insole in her shoe, we suggested that tibialis posterior exercises would prove useful (Carmody et al., 2015). This review by Carmody et al. (2015) reported that tibialis posterior dysfunction was the leading cause for flat footedness and interestingly, also found it to be more common in middle aged overweight woman, which matched my patient.
In a study by Lee and Cho (2016) whereby 16 young subjects with pes planus were given a 6 week program of either intrinsic muscle strengthening exercises (control group) or intrinsic exercises and tibialis posterior foot exercises for 30 minutes, 5 times weekly. This study found that the combination of intrinsic foot and tibialis posterior exercises did improve plantar pressure and subsequent dynamic balance.

Similarly to tibialis posterior dysfunction, medial tibial stress syndrome was also found to be more prevalent in the female population (Moen, Tol, Weir, Steunebrink, & Winter, 2009) and could be as a result of the weakness in the tibialis posterior and resultant pes planus (Griebert et al., 2016). This patient also presented with symptoms showing medial tibial stress syndrome and from both the subjective and objective assessments, it became a diagnostic possibility, especially as 13-17% of running injuries and 35% of leg pain is caused by medial tibial stress syndrome (Griebert et al., 2016) and this is how the symptoms occurred.

STM was performed as treatment for tension in her triceps surae group and the exercises for tibialis posterior were demonstrated and given for rehabilitation at home in order to help strengthen the arch. In the meantime, I was able to apply K-tape to the medial shins, which in a study on 20 healthy subjects were compared to 20 with previous medial tibial stress syndrome were assessed walking over a pressure plate before and after k-tape application with findings showing a decease in medial pressure after the tape application (Griebert et al., 2016). I am therefore able to provide some evidence to the effectiveness of the kinesiology tape with regards to both the pes planus and symptoms regarding pain in the anterior tibialis.

Patient 3 and 4 –
Both of these patients presented with very similar symptoms and the treatment was also very similar. The clinical impressions were joint restrictions in Cx, Tx and Lx, tension in posterior musculature and shoulder and neck tension due to a history of previous joint or soft tissue pathology, possible malalignment and resultant muscle imbalances. Treatment, therefore was very similar and involved Bilat. Tx Grade IV mobs, Lx mobs, shoulder strengthening exercises, for example seated rows, resisted rows and pully for rhomboids etc, TheraBand resisted exercises, such as triphasic to include eccentric, isometric and concentric. I educated the patient on exercises to improve strength in posterior upper Tx musculature Exercises to open up and increase mobility.

From this treatment, I wanted to find out and fully understand the rationale behind performing both lumbar and thoracic mobilisations and not specifically cervical one, even though one of the patients reported improvements in the tension in their cervical spine and mobility in subsequent movements thereafter. From further reading, I was reassured to find out from one randomised clinical trial by Cho et al. (2017) of which recruited 32 subjects, 1 group for cervical mobilisations and the other for thoracic to compare the two for the treatment of forward head posture. In this trial it was found that the subjects who had thoracic mobilisation intervention as well as mobility exercises, compared with the cervical group, recorded improvements in a number of measures, but most relevantly to my patients, a decrease in the pain scale measurement scores (NPRS) and an increase in neck extension.
These findings help support my use of thoracic spine mobilisations and exercises for my patients’ neck pain and restricted cervical ROM.

Overall evaluation of clinic performance – I found that throughout the duration of the clinic session, I was taking too long with each client and each session, therefore, was running into the next. I have always found that time management has been a weakness and as such I will look to try and improve this; something that I am confident can be achieved as I gain more experience over the course of the year and as such be able to progress with treatment much more efficiently and confidently.

References – 

Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220–221. https://doi.org/10.1136/bjsports-2011-090297

Bleakley, C., McDonough, S., & MacAuley, D. (2004). The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials. American Journal of Sports Medicine, 32(1), 251–261. https://doi.org/10.1177/0363546503260757

Carmody, D., Bubra, P., Keighley, G., & Rateesh, S. (2015). Posterior tibial tendon dysfunction: An overlooked cause of foot deformity. Journal of Family Medicine and Primary Care. https://doi.org/10.4103/2249-4863.152245

Furtado, A. B. V., Hartmann, D. D., Martins, R. P., Rosa, P. C., da Silva, I. K., Duarte, B. S. L., … Puntel, G. O. (2018). Cryotherapy: Biochemical alterations involved in reduction of damage induced by exhaustive exercise. Brazilian Journal of Medical and Biological Research, 51(11), 1–8. https://doi.org/10.1590/1414-431X20187702

Griebert, M. C., Needle, A. R., McConnell, J., & Kaminski, T. W. (2016). Lower-leg Kinesio tape reduces rate of loading in participants with medial tibial stress syndrome. Physical Therapy in Sport, 18, 62–67. https://doi.org/10.1016/j.ptsp.2014.01.001

Hubbard, T. J., Aronson, S. L., & Denegar, C. R. (2004). Does Cryotherapy Hasten Return to Participation? A Systematic Review. Journal of Athletic Training.

Hubbard, T. J., & Denegar, C. R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training.

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

Malanga, G. A., Yan, N., & Stark, J. (2015). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine. https://doi.org/10.1080/00325481.2015.992719

Moen, M. H., Tol, J. L., Weir, A., Steunebrink, M., & Winter, T. C. D. (2009). Medial tibial stress syndrome: A critical review. Sports Medicine, 39(7), 523–546. https://doi.org/10.2165/00007256-200939070-00002

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F. W., Van Den Bekerom, M. P., Dekker, R., … Kerkhoffs, G. M. M. J. (2018). Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106

Exmoor Osteopathy Clinic pre-clinical experience induction and clinical experience agreement – Thursday 4th October 2019

Throughout my first placement session with Exmoor Osteopathy Clinic and after my initial induction, I was fortunate enough to be able to shadow Katrina during her morning treatments. From this I was able to begin to get a sense of her treatment style and clientele.
Before I commenced my first session at Exmoor Osteopathy, I wanted to understand what Osteopathy was and it’s role within patient care and appreciate the significance of their existence in relation to both the athletic and non-athletic population.
I therefore posed my initial question: what is Osteopathy and how is it different to other therapies?
Osteopathy can be practiced as complementary or within conventional, mainstream healthcare and involves manual therapy in a similar capacity as sports therapists and other musculoskeletal health practitioners by way of similar, evidence based rational with techniques including, but not limited to, soft tissue techniques, joint mobilisations, muscle energy and exercise therapy (Steel et al., 2017). At BSc level of qualification, high velocity low amplitude manipulations (HVLA) are not within the scope of a sports therapist without further, more extensive training, however these techniques are often used within a Osteopath’s typical treatment session and as such provide a different course of treatment for the patient (Steel et al., 2017). Osteopaths, including Katrina at Exmoor Osteopathy, can also offer cranial-sacral therapy, when suitable qualifications are obtained and so I hope to develop an understanding of the nature of this treatment.

In a research report, Grace et al. (2016) concluded that Osteopathic reasoning, compared with that of other health professions, is focused more on the guiding of treatment itself and less on clinical diagnoses. Although in a similar vain to Steel et al. (2017), this particular research article did not find much in the way of differentiating between the reasonings of Osteopathy and other health professions.

During my first session I also took the time to derive a set of important goals and discussed with my supervisor what I hope to achieve over the 50 hours of this placement and how I will go about obtaining these with time frames for added structure and motivation. With the support from my supervisor, I hope to achieve the following goals by the end of this term;

Goal: To further enhance my ability to recognise the movements within a joint and their associated capsular patterns. I hope to achieve this by experiencing different end feels and joint movements over a wide variety of patients with a wide variety of joint pathologies.
I hope to be able to identify different capsular patterns and be confident in identifying joint injuries and differentiate these from soft tissue injuries.

How I will achieve this: by involving myself in the diagnosing process and ensuring that I test the joints alongside my supervisor, asking questions and entering into discussions about my understanding and ability to recognise joint movement.

How I will measure this: By the end of the placement, I hope to be able to confidently identify joint pathologies and understand the appropriate associated treatment by way of an effective assessment process, as a result of evidence based and hands on experience.

2. To become more confident when using techniques to manual handle joints for mobilisations and joint testing; as present, I find it difficult to correctly manoeuvre my way around a patient and their joints.
By better understanding range of motion and joint movements, I should hopefully have a more comprehensive understanding and therefore ability to fully assess a joint in a correct and efficient manner.
How I will achieve this: I will observe the methods used by Katrina to handle patients during exams and treatment. Katrina is petite and as such needs to utilise an effective and safe way of treating, especially when faced with larger patients with heavier limbs and more difficult treatment requirements, such a spinal mobilisations.

How I will measure this: I will hope to maintain good working posture to ensure that I do not injury myself or develop discomfort when treating patients and feel comfortable throughout all treatments as much as is practicable.

3. To build a solid working relationship with Katrina and her partner, Ed in order to continue my professional development with a thriving local business and to maintain this relationship to allow me a base from which I can enhance my learning experience as a Sports Therapist.
From an association with Exmoor Osteopathy, patients can be passed on where necessary when necessary treatment is not within my scope of practice, or visa versa.

How I will achieve this: I will maintain a professional manner throughout my entire placement and always show enthusiasm and willingness to learn, asking questions and contributing when necessary and by communicating my goals and aspirations with my supervisor, Katrina. I will be punctual, respect all clinic procedures and policies and fulfil all that is expected of me, while being considerate of the sensitive nature of the clinic and their patients.

How I will measure this: I will communicate regularly with my placement supervisor and ask for feedback when possible, about my conduct and development over the 50hours. I will do all that I can to learn from this feedback with dedication and within the placement timeframe and as such complete the placement with a good relationship with the Osteopath clinic. I will work hard to maintain this link during my professional career thereafter.

I am looking forward to embarking on this challenge and hope to use this fantastic opportunity to learn as much as I can from a very professional clinical environment with a very well-established client base and reputation.

References – 

Grace, S., Orrock, P., Vaughan, B., Blaich, R., & Coutts, R. (2016). Understanding clinical reasoning in osteopathy: A qualitative research approach. Chiropractic and Manual Therapies, 24(1), 1–10. https://doi.org/10.1186/s12998-016-0087-x

Steel, A., Blaich, R., Sundberg, T., & Adams, J. (2017). The role of osteopathy in clinical care: Broadening the evidence-base. International Journal of Osteopathic Medicine, 24, 32–36. https://doi.org/10.1016/j.ijosm.2017.02.002


Clinic Tuesday 1st October 2019 – 6 Hours

Client 1: Sports Massage of quadriceps
Overview of Patient: very regular client with multiple ongoing issues but has specifically requested a soft tissue massage of bilateral quadriceps. FROM and happy to proceed.
Throughout this treatment, I wanted to ensure that I was providing the patient with an adequate amount of pressure and so made sure I was able to use effective communication to receive feedback. I am confident with communicating with my patients which enables me to adapt my session or to revise treatment based on their individual needs and at their request.

I suggested that the patient continue to experience the benefits outside of the clinic, not only by continuing with his current exercise plan, but by incorporating a use of a foam roller at home to reduce muscle soreness and increase flexibility (Wiewelhove et al., 2019)

Client 2: Shoulder Pain
Overview of patient: 12/12 ago acute possible R/C strain, minor niggle since then. Px since 2/12 after increasing intensity of tennis over summer. Joint feels bruised at sub scap attachment, tender in joint and coracoid process but Px during tennis and daily funt. movements such as driving, cooking.

From a subjective and objective evaluation, a clinical diagnosis was not given, however the pain is most likely due to the weaknesses in the rotator cuff musculature when faced with the increase in loading over the last 3 months of significantly increased tennis activity. With supervision, I was able to talk to the client and educate on the importance of joint strength with increased loading and we worked through a program of strengthening exercises to be performed as a rehabilitation program over the coming weeks. However, I found that I did not have a good repertoire of rotator cuff exercises to prescribe and explain to my patient in detail. I therefore researched a number of articles within which were discussions about the important role of each individual rotator cuff muscle and effective strengthening exercises associated with that muscle. Escamilla et al. (2009) for example, details torque in abduction as 35-65% deltoid, 30% subscapularis, 25% supraspinatus and 2% is from anterior deltoids. Knowing that the rotator cuff muscle abduct, internally and externally rotate the glenohumeral joint, it is then possible to devise an appropriate program to enhance the strength in these actions by way of specific exercises. Ellenbecker and Cools (2010) analysed the effectiveness of a number of rotator cuff exercises and from this I have been able to gather some interesting exercise protocols and find rational in their use; I now feel more confidence when discussion shoulder rehabilitation with my patients and know that I am able to adapt exercises where necessary. Plyometric exercises and scapular stabilisation techniques for both home based programs and clinical sessions were described and justified in this article.

Client 3: Shoulder Pain
Overview of patient: 2/52 ago, shoulder press acute trauma on return phase; felt twinge in between shoulder blades R side of Sx. Improved over 2 weeks but sudden sharp Px opening car door, feels like something needs to click in shoulder. Sharp Px shooting up from scapular to base of R Cx/base of occiput.
Constantly turning but in evening feels stiff.
Worse at night, wakes him up at night. Improves after movement but feels like it needs to click.

After a thorough subjective and objective, I was still unable to fully understand the potential diagnosis of this injury. Due to the nature of the range of motion, for example passive range of motion being as limited and painful as active range of motion, I considered the possibility of a joint issue and as I am not yet confident in diagnosing and treating joint stiffness and injury, I requested a consult with the clinic manager. I was reassured that it was a joint issue, as opposed to soft tissue and mobilisations at the costovertebral joints were performed.
I learnt a great deal of practical application from this client, as I was able to palpate the area of pain and differentiate between soft tissue and joint pain and learn how to perform grade IV mobilisations over these costovertebral joints. By the end of the treatment, I had become more familiar to the depth and feel of the oscillations required at this thoracic region of the upper back and of the rationale behind these mobilisations (Basson et al., 2017; Shum et al., 2013).

Similarly to client 2, this patient was prescribed a number of exercises to help increase the strength of the rotator cuff muscle group. However, prior to I found that it may have been necessary to help loosen up the soft tissue surrounding the shoulder to help increase range of motion and reduce pain in order to better facilitate the course of rehabilitation exercises (Ellenbecker & Cools, 2010).

References – 

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The effectiveness of neural mobilization for neuromusculoskeletal conditions: A systematic review and meta-Analysis. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2017.7117

Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. British Journal of Sports Medicine, 44(5), 319–327. https://doi.org/10.1136/bjsm.2009.058875

Escamilla, R. F., Yamashiro, K., Paulos, L., & Andrews, J. R. (2009). Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Medicine, 39(8), 663–685. https://doi.org/10.2165/00007256-200939080-00004

Wiewelhove, T., Döweling, A., Schneider, C., Hottenrott, L., Meyer, T., Kellmann, M., … Ferrauti, A. (2019). A meta-analysis of the effects of foam rolling on performance and recovery. Frontiers in Physiology. https://doi.org/10.3389/fphys.2019.00376


Clinic Monday 30th September 2019 – 4 Hours

Client 1: LBP/Lumbar disc herniation
This session was very interesting as it showed me the importance of educating the patient and ensuring that they have a full understanding of the mechanisms of their injury and as such, I felt more comfortable in questioning their reasonings behind what treatment they come into the clinic for. For example, this patient has had a history of back issues and has experienced chronic back pain of which has been treated with soft tissue therapies at the clinic. The patient requested a lower back soft tissue massage. Before treating the symptoms of pain and discomfort, a back assessment performed which identified pain in extension of the lumbar spine, more specifically when returning back to anatomical position. It was observed that the patients pelvis was tilted anteriorly, which may be closing off the joint space in the lumbar region and although his ROM was good and general fitness was excellent, it caused the patient pain and did not allow for his FROM.
This could be down to the nature of his job as a marine and the sheer weight that is carried in training exercises. It is possible, therefore that the patient has weakness and tightness in the hip flexors and glutes.
Within this session, it was necessary to perform joint mobilisations to grade I and IV to try to open up the join space over the lumbar region of the spine and to perform nutations of the sacrum.
mobilisations can be described as oscillatory movements

I found that research has been unable to show effectiveness of mobilisations on mobility and range of movement of the lumbar spine over the previous decades but reports of the effectiveness in reports of pain has been documented. Earlier research by Goodsell et al. (2000) found that posteroanterior mobilisations had no effect on the mechanics of the lumbar spine in a study of 26 participants, although there were some improvements in pain.
Stamos-Papastamos et al. (2011) conducted a study on 32 asymptomatic individuals and found no significant different in flexion and extension after posteroanterior mobilisation treatment.
Shum et al. (2013) were able to further support the positive effects of anteroposterior mobilisations on influencing pain but also reported a significant increase in active flexion and extension in their study of 20 asymptomatic subjects, also concluding that this method as highly repeatable.
In a much larger and more recent study of 75 subjects by Krekoukias et al. (2017) it was found that mobilizations were the preferred treatment for pain associated with lower back pain and disc degeneration. Basson et al. (2017) was also able to support the use of mobilisations in reducing neck and back pain within a systematic review the same year. However a year later, Coulter et al. (2018) found moderate evidence that mobilisations are less effective than manipulations or other treatment methods. These findings are useful as they are able to help me understand the rationale behind lumbar spine mobilisations in their treatment of pain and potential uses In increasing range of movement, in particular flexion and extension, although I still need to find more up to date research to further support this, due to the conflicting conclusive evidence in the aforementioned studies. It would be interesting to know if the effectiveness of the mobilisations on pain are only due to placebo effects (Goodsell et al., 2000) or whether the reduction of pain is subsequently responsible for the increase in joint range of movement and reduction in stiffness (Shum et al., 2013).

It was important to also prescribe this patient with exercises to strengthen gluteus muscles, quadricep and hamstring strength and to lengthen and strengthen hip flexors in order to better stabilise the pelvis with the goal to reduce pain in his lower back and therefore discomfort in function extension.

Client 2: Chronic ankle sprain
Overview of patient: Chronic ankle pain due to history of lateral ankle ligament injury. Patient had no diagnosis or treatment of lateral ankle sprain at time of injury but reports pain has started to increase when running.
FROM, no pain at rest, no inflammation, pain only when running.

This treatment allowed me to investigate the long lasting effects of a past untreated ankle injury and to devise an appropriate rehabilitation plan to increase strength in the ankle joint to withstand greater impact forces while running, to reduce the likelihood of reinjuring his lateral ligaments, and manage pain during functional running motions.
I understood the process of improving proprioception but wanted to understand the rational behind recommending this as a rehabilitation program, but also back this up with evidence. From the research, I found that while Schiftan, et al. (2015) highlighted the prevalence of ankle sprains, noting them to be the most common sports-related injury in their evidence review, they found proprioception programs to be effective in reducing the risk of future ankle sprains in athletes and in research by Lazarou et al.  (2018), it was determined that balance and proprioceptive neuromuscular facilitation programs are recommended to help reduce pain, improve range of motion and function of the ankle and in particular, Hanci et al. (2016) demonstrated the effectiveness of eccentric – concentric isokinetic training in improving proprioception after just a 6 week program on 13 male subjects with ankle instability.
In future, I will be able to advise the patients on specific proprioception programs based on a number of studies and be more specific in my delivery. For example, incorporate eccentric/concentric tasks, as opposed to generic activities involving uneven and unexpected surface running, such as an obstacle course or trail running.

References – 

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The effectiveness of neural mobilization for neuromusculoskeletal conditions: A systematic review and meta-Analysis. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2017.7117

Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine Journal, 18(5), 866–879. https://doi.org/10.1016/j.spinee.2018.01.013

Goodsell, M., Lee, M., & Latimer, J. (2000). Short-term effects of lumbar posteroanterior mobilization in individuals with low-back pain. Journal of Manipulative and Physiological Therapeutics, 23(5), 332–342. https://doi.org/10.1067/mmt.2000.106867

Hanci, E., Sekir, U., Gur, H., & Akova, B. (2016). Eccentric training improves ankle evertor and dorsiflexor strength and proprioception in functionally unstable ankles. American Journal of Physical Medicine and Rehabilitation. https://doi.org/10.1097/PHM.0000000000000421

Krekoukias, G., Gelalis, I. D., Xenakis, T., Gioftsos, G., Dimitriadis, Z., & Sakellari, V. (2017). Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. Journal of Manual and Manipulative Therapy. https://doi.org/10.1080/10669817.2016.1184435

Lazarou, L., Kofotolis, N., Pafis, G., & Kellis, E. (2018). Effects of two proprioceptive training programs on ankle range of motion, pain, functional and balance performance in individuals with ankle sprain. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-170836

Schiftan, G. S., Ross, L. A., & Hahne, A. J. (2015). The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis. Journal of Science and Medicine in Sport, 18(3), 238–244. https://doi.org/10.1016/j.jsams.2014.04.005

Shum, G. L., Tsung, B. Y., & Lee, R. Y. (2013). The immediate effect of posteroanterior mobilization on reducing back pain and the stiffness of the lumbar spine. Archives of Physical Medicine and Rehabilitation, 94(4), 673–679.

Stamos-Papastamos, N., Petty, N. J., & Williams, J. M. (2011). Changes in bending stiffness and lumbar spine range of movement following lumbar mobilization and manipulation. Journal of Manipulative and Physiological Therapeutics, 34(1), 46–53. https://doi.org/10.1016/j.jmpt.2010.11.006

Clinical experience 24th September 2019 – 2 Hours

Graduate therapist Mike Pyrnn Peroneal longus Subluxation

Overview of injury: twisted ankle bowling 1 week ago (inversion, abduction). AUDIO POPPING
A & E xray, no #, NWB, no driving
MOI was that of sprain but not classic presentation, no swelling, minimal bruising

Tests: AROM, PROM, RFOM, OTTAWA , all -ve but severe Px PROM inv. L ankle and RROM ever. L ankle.
Visual subluxing of peroneal longus tendon over lateral malleolus and associated Px.

Subjective: Peroneal longus subluxation, poss. Avulsion # although no pain at base of 5th so unlikely, tear of peroneal?
Tx: referral to GP to be referred for specialist Tx
EAB tape to attempt to hold peroneal tendon in place to stop it subluxing.

Immediately post injury, this patient attended the accident and emergency department for a suspected ankle fracture or sprain, where assessment took place and an x-ray was taken and a fracture was ruled out. The patient was then advised about ankle sprains, given walking aids and this concluded hospital treatment. The mechanism of injury (inversion of ankle joint) may have led the practitioners to their diagnosis, however the presentation of the injury is not that of a typical ankle sprain; the patient did not have typical associated swelling or bruising. The current available advice on the Ottawa rules for ruling out a fracture in lateral ankle injuries was discussed by Bachmann et al. (2003) and Vuurberg et al. (2018) stating a specificity of 25-46% but a sensitivity of 86-99% and as such demonstrating to be the most reliable. It is understandable for the misdiagnosis of ankle sprain due to the mechanical nature of the injury and therefore often mistaken for lateral ligament injuries (Heckman et al., 2009).

After an assessment in the clinic, a peroneal subluxation became apparent. This is when either or both of the peroneal tendons has become detached from the retromalleollar groove; this was evident in the patient due to the mechanism of injury (combined inversion and dorsiflexion), the visible and palpable movement of the peroneal tendon over the lateral malleolus and associated pain during eversion and dorsiflexion movements and the history of a pop sound when the initial injury occurred (Heckman et al., 2009).

For this patient, a referral letter was passed on to his GP in the hope of a more firm diagnosis and further treatment, which could be of a surgical nature. It was stated that non-surgical treatment had a 50% success rate and as such surgical intervention was recommended as the most effective treatment, most specifically when repair of retinaculum and groove deepening was performed (Saxena & Ewen, 2010).

From this patient, not only did I visually experience the assessment and diagnosis of an uncommon injury, but it was brought to my attention the importance of keeping an open mind when diagnosing injuries due to the similar presentation of symptoms and different outcomes of provocation tests. For example, the positive anterior drawer test with a sensitivity of 84% and a specificity of 96% (Vuurberg et al., 2018), to indicate lateral ankle ligament instability can show as positive in this instance and as such could result in a misdiagnosis or inability to understand the connected nature of these two injuries (Heckman et al., 2009).

Graduate therapist Alfie Jones Follow up for shoulder pain
Overview of patient: Previous A/C sprain after skiing fall 18months ago, 6/7 rockwood SCALE (8 fully detached, less is torn major ligaments). Suspected rotator cuff tear or impingement at present due to stabbing pain in shoulder, pins and needles and tingling down to upper arm. Had treatment 3 weeks ago but tests inconclusive and no diagnosis, but given exercises to improve general shoulder mobility and strength, in particular rotator cuff muscle group.

During the session, a Spurling’s provocation test was performed to determine whether the patient had any cervical radiculopathy as it was important to rule this out, especially as this patient was presenting with neurological symptoms such as pins and needles and tingling. I was unsure as to the nature of this test and the rationale behind it’s use, so in further research I was able increase my understanding of how it is used in clinical testing. The Spurling’s test is used to diagnose disc herniations at the cervical spine and according to Chhanalal Shah and Rajshekhar (2004), boasts a sensitivity score of 92%, specificity and positive predictive value of 95% and 96.4% respectively with a negative predictive value of 90.9%, warranting it’s use in a clinical setting.
In research by Anekstein et al. (2012), it was suggested that the Spurling’s test was able to determine the presence of nerve compression as opposed to other symptom mimicking pathologies such as brachial plexitis or shoulder impingement, which in this patient was likely due to a negative Spurling’s result.
This study also determined the best method, out of 6 proposed and currently used methods, of performing the Spurling’s test by way of effectiveness in relation to pain scales; extension and lateral bending of the cervical spine was found to best reproduce the symptoms (Anekstein et al., 2012).

A diagnosis remained unclear but clinical signs were suggestive of scalene tightness, tension in the upper back and shoulders and brachial plexitis

In an investigation into the treatment of rotator cuff tears by (Baumer et al., 2016), it was found that after an 8 week physical therapy exercise plan given to 25 participants with symptomatic rotator cuff pathology, ROM, all measured joint measurements apart from scapulothoracic tilt and pain scores increased. The types of exercises performed in this study included those to improve ROM and strength and were performed up to 3 times a week.

Soft tissue massage was also performed to relieve tension to the patient’s upper back and therefore help in allowing greater ROM of the shoulder and allow for more effective strengthening exercises thereafter.

Interestingly, a study on A/C injury (Pallis et al., 2012) found the prevalence of injury to be twice as common in men than woman.

References – 

Anekstein, Y., Blecher, R., Smorgick, Y., & Mirovsky, Y. (2012). What is the best way to apply the spurling test for cervical radiculopathy? spine. Clinical Orthopaedics and Related Research, 470(9), 2566–2572. https://doi.org/10.1007/s11999-012-2492-3

Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & Ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: Systematic review. British Medical Journal.

Baumer, T. G., Chan, D., Mende, V., Dischler, J., Zauel, R., van Holsbeeck, M., … Bey, M. J. (2016). Effects of Rotator Cuff Pathology and Physical Therapy on In Vivo Shoulder Motion and Clinical Outcomes in Patients With a Symptomatic Full-Thickness Rotator Cuff Tear. Orthopaedic Journal of Sports Medicine, 4(9), 1–10. https://doi.org/10.1177/2325967116666506

Heckman, D. S., Gluck, G. S., & Parekh, S. G. (2009). Tendon disorders of the foot and ankle, part 1: Peroneal tendon disorders. American Journal of Sports Medicine. https://doi.org/10.1177/0363546508331206

K Chhanalal Shah & V Rajshekhar (2004) Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test, British Journal of Neurosurgery, 18 (5), 480-483

Pallis, M., Cameron, K. L., Svoboda, S. J., & Owens, B. D. (2012). Epidemiology of acromioclavicular joint injury in young athletes. American Journal of Sports Medicine, 40(9), 2072–2077. https://doi.org/10.1177/0363546512450162

Saxena, A., & Ewen, B. (2010). Peroneal Subluxation: Surgical Results in 31 Athletic Patients. Journal of Foot and Ankle Surgery, 49(3), 238–241. https://doi.org/10.1053/j.jfas.2010.02.007

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F. W., Van Den Bekerom, M. P., Dekker, R., … Kerkhoffs, G. M. M. J. (2018). Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106