Reflection: 30/11/2020

Reflection: 30/11/2020                                                                                                  Hours: 5

 What happened?

Today a patient came into clinic who was six days post op for a Gracilis and semitendinosus graft. I was shocked at her level of extension and lack of swelling; she had almost reached full extension compared to the contralateral leg and her swelling had decreased considerably in the six days (compared with a photo).  Achieving full extension and control inflammation are two of the key aims for the first phase of rehabilitation (van Grinsven et al., 2010). The game ready was used at this stage to reduce swelling and pain by applying compression and cryotherapy while the leg was straight, to allow gravity to aid extension. Although some research has suggested that ice is ineffective, a study by Dambros et al, (2012) concluded that cryotherapy was effective in the immediate postoperative period of ACL reconstruction to improve range of motion and reduce pain. Cryotherapy can also reduce the reduction of drug intake for pain relief, the length of hospital stay and the patients quality of life (Dambros et al., 2012). This suggests that cryotherapy still has value in ACL rehabilitation.

What were you feeling?

I felt really encouraged during this appointment, as often I feel disheartened by the concept of “if a patient’s condition is out of our scope of practice refer them on”. However, this case shows how much value a sports therapist’s role has in a patient’s recovery from an ACL reconstruction.  The rehabilitation process is essential after ACL reconstruction surgery; initially rehabilitation targets the reduction of pain, oedema and inflammatory process. Once this is achieved, rehabilitation focuses on improvement of neuromuscular control, muscle strength, range of motion, gait and proprioception (Dambros et al., 2012).

This is the first patient I have worked with post-op, so I felt quite anxious that their injury was more vulnerable due to the graft and therefore was reluctant to ask her to do too much. I feel the more experience I get and the more confident I become that this feeling will improve. The graft fixation is not as strong initially, so caution is advised with rehabilitation (Dambros et al., 2012), however it is also very important that we get patients performing active range of motion and weight bearing without crutches to get them to return to walking as soon as safely possible (van Grinsven et al., 2010).

In this session we focused on her walking with crutches and corrected a hip hinge that she had developed whilst being on crutches. We advised she tries to go through the full ankle range of motion and gradually load the ankle so that the muscles surrounding this joint don’t become weak.

We discussed how she was feeling, and she mentioned how she was suffering from altered sensation in her shin. I explained how this is not a cause for concern and is often experienced due to the trauma of the surgery, however she was confused and anxious prior to today’s session due to not being told this was a potential common symptom post-surgery. As the surgery is performed via arthroscopy (keyhole surgery) small nerves can accidentally be cut or stretched, leading to temporary numbness or altered sensation. The saphenous nerve (SBSN) is at a higher risk of injury during ACL reconstructions involving the hamstring graft (which this patient had). The saphenous nerve is closely involved with the Gracilis tendon, meaning it is at greater risk of damage during passage of the tendon stripper (Sanders et al., 2007).

What else could you have done? In future if it rose again what would you do?

Be less anxious and trust the phases of rehabilitation and tissue healing process while being safe and careful. Work with the patient and their ability and injury and remember that all individuals will be at different stages during the same time frame (due to psychological factors and individual differences).

2nd two hours:

What happened?

We had a demonstration on how to use the isokinetic dynamometer and force plates and how to interpret the data and pick out which values we need to use and compare.

What were you feeling?

It was helpful as often I feel like this area of our degree lacks value for me and consequently, I feel demotivated. I often think that unless I worked in an clinic in the future which has the facilities that the university does or if I worked with a professional team, then I would not use these skills as a sports therapist. However, I have now realised that although I may not be able to perform the tests with patients without access to a lab, the principles and physiology behind the test is useful for me to have knowledge on and will make me a better therapist. The force plates I may not always have access to, but it is still useful to get individuals to perform countermovement and box jumps while videoing them to assess their landing position and assess their return to play or monitor their progress.

What else could you have done? In future if it rose again what would you do?

I learnt that in the future, it is important to not get disheartened and to try and take useful learning points from all scenarios to improve as a therapist. I will be more open minded in the future.

Final two hours:

 What happened?

 I had an online triage with a patient as a follow up, who I have been seeing for the last month. This patient is suffering from Sever’s disease and has been working on improving his gait to stop him from going onto tiptoes when he is in pain. I have found it really interesting that the aim for treatment for this disease is to focus on reducing and managing pain rather than improving recovery. We discussed his progress and how he was really happy and grateful with how much he had improved and was confident to continue on his own over Christmas until he came in for a review in January.

What were you feeling?

I was feeling very proud that I had been able to help him manage his symptoms and improve his quality of life so that he didn’t have to miss out on being a 9 year old and was still able to go to hockey, do PE and have fun.

References:

Cohen, M. (2012). Effectiveness of cryotherapy after anterior cruciate ligament reconstruction. Acta Ortopedica Brasileira, 20(5), 285–290.

Sanders, B., Rolf, R., McClelland, W., & Xerogeanes, J. (2007). Prevalence of Saphenous Nerve Injury After Autogenous Hamstring Harvest: An Anatomic and Clinical Study of Sartorial Branch Injury. The Journal of Arthoscopic and Related Surgery, 23(9), 956–963.

van Grinsven, S. ., van Cingel, R. E. ., Holla, C. J. ., & van Loon, C. J. . (2010). Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 18(8), 1128–1144.

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