Clinical Placement – 6th February 2020 for 5 hours

This week we had clients visit the clinic who had a history of sciatica, pain over the tibia where the pathology was unknown and medial meniscus damage.

Reflective Summary 

The first client of the afternoon had been experiencing sciatica for years, on the left side of her body, because of a herniated disc (L5, S1). 4 months ago, the protruding section of disc was removed during an operation, so allowed the sciatica symptoms to decrease, as the disc was no longer compressing on the sciatic nerve. The client no longer suffers with the neurological signs and symptoms of sciatica however, in the session they presented with tightness and stiffness in the shoulders (specifically under the medial border of the scapula), thoracic spine and lower back, with tenderness in the glutes. This tightness could have built up from the years of pain that the sciatica had caused the patient. The client also gets pain (not pins and needles, a dull ache) on the left side of the hip where the sciatica used to travel. There are two possible reasons for this; it could be psychological, as they could have got use to the feeling of an abnormal sensation in this area or it could be from the client sleeping on the left side of the body for long periods of time, especially as they are overweight. The therapist advised the client to put pillows down the left side of the body, so it could stop them from rolling onto this side. From this information soft tissue massage (STM) was used to release tightness, where slow deep movements were selected, in order to get deep into the glutes, especially over the origin, as this was the most tender area. The client was also encouraged to continue bracing which means that the core is engaged, in order to improve stability and in turn should ease the lower back pain and tightness.

The next client was a male runner who has tenderness on the anterior side of the right calf and medially, so over the tibia. The pain was very localised and at times they described the feeling as a pressure. We checked to ensure the client had no pins and needles or hot/cold sensation. From the subjective assessment we understood that the runner had changed their shoes a few weeks ago, but nothing else had changed regarding his technique and the intensity or frequency of his training. On palpation, the therapist was able to feel a palpable lump where the localised tenderness was. We struggled to detect what the problem was as the symptoms did not lead us to one specific pathology. Previously, the therapist thought that it could have been a stress fracture, so used a tuning fork to identify if this was the most likely issue, although this test was negative. Also, with this pathology you would have expected his training to have increased and a lump would not be present. It was also suspected that it could have been compartment syndrome due to the build of pressure that the runner was describing. With this syndrome you would expect the pain to radiate through the whole calves, not be localised. Before starting treatment, we went outside to look at his running technique in which he appeared very flatfooted which reproduced pain. We encouraged him to try and plant his heel first and then the toes, which actually decreased the pain. STM was used on his calf, focusing on the painful area. Slow deep movements were used in order to get into the compartment, as the other differential diagnosis was an issue with the soft tissues, possibly the extensor muscles. By the end of the session the therapist was still unsure on diagnosis, so advised the client to go to the doctors so it could be checked over.

The final client had come in a few weeks ago. We knew from previous sessions that he had suspected medial meniscus damage from contact a few years ago. His symptoms and muscle strength had been improving, however he had cut his hand open at work, so his progress was halted. Since the last session, he had been continuing with his rehabilitation and a vast improvement had been made. The client was able to do the prescribed exercises without any pain. The treatment included STM of the right quads, calves and hamstrings as this was the injured side so the muscles were tight. Mobilisations were performed on the knee using both accessory and physiological movements. The accessory movements consisted of lateral and medial patella mobilisations, while the physiological movement was lateral rotation of the knee. Once treatment was completed, we look at the rehabilitation exercises to see if there was any pain when performing them. This included squats, lunges, side lunges and jumping from one step to another where no pain was reported at the knee from the client. We also gave him some progressive exercises to further his rehab, so he can regain strength quicker.

Areas for further improvement 

My first area for improvement would be to revise the signs and symptoms for a variety of pathologies. This is essential because if it is obvious what the pathology is, the treatment will more than likely be effective. I could also begin to research exercises that can be prescribed during rehabilitation and how to progress and regress the activities, depending on the client’s progress and needs etc. It is also important to change exercises for children, ensuring they find them exciting to do, whereas the elderly may need them simplified.

Things to Remember:

  1. If pain or decreased ROM during flexion of the lumbar, it indicates a disc related problem. If pain or decreased ROM during lumbar extension, it indicates a facet joint problem
  2. If a patient presents with a disc problem, treatment could consist of a distraction technique, from the feet, using a belt
  3. With tendinopathies, the treatment protocol is always changing. It used to be advised that the patient should rest however, it is now suggested that load should be put through the area gradually
  4. It is best to sleep on one firm pillow and put another under the knees, so that the spine can be in a neutral position
  5. If you think the problem is compartment syndrome, check for any hot or cold sensations around the area
  6. If you have treated a client 3 times and you are unsure on what the problem is, refer them just so it can be checked by a doctor

 

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