17th March. Duration: 3 Hours (2-clients).
supervisors: Alex and Mike
My first client had pain near their Achilles, which was making it increasingly hard for the client to walk on (Rolf, 2007). Through assessment I found that the tenderness was based on the mid portion of the Achilles tendon. The client also had pain along the Achilles tendon into the gastrocnemius head. For this I gave STR to the calf to help release the tension, which the client found quite tender but bearable, but it did ease the tension and reduce the pain. I also provided the client with advice and practical ways to stretch out at home.
As my client was struggling to walk, and I knew they were in the early stages of rehabilitation, stretching the calf muscles and getting the ankle mobilised was the most appropriate treatment at this stage. From one’s own reading I knew there is a continuum model for tendons, and if overloaded too soon, the tendon could go into a degenerative tendinopathy stage (Zhang & Wang, 2014), which could mean the damage was irreversible. I knew when working with this client I needed to be extra careful not to overload the tendon too soon. The three stages on the continuum are:
- Reactive tendinopathy
- Tendon disrepair
- Degenerative tendinopathy
I believe I conducted the session well, providing the correct advice and treatment, ensuring to provide various stretches, not only for the gastrocnemius but also the soleus, which is sometimes forgotten about. To stretch this, instead of the typical calf stretch with a front bent leg and straight back leg, you also get the client to bend their back leg, which impacts the soleus muscle.
I was able to explain and communicate this to my client and felt through the provision of more education, made the client more informed, which assisted them to adhere diligently to doing the stretches/exercises at home, as they understood why they were doing them, and the benefits provided. My client is booked in for next week where I will assess their progress, and hopefully a reduction in pain will be evident, so we can start loading the calf with body weight.
If I could do anything different, I would have assessed the clients foot placement a little more, as post researching, I discovered that excessive pronation of the foot can contribute to this injury and if proved the client may benefit from orthotics and exercises to correct this (If they had it). I will assess this next time and make sure to do this assessment with all clients moving forward. I am currently not certain what the best exercises to do for overpronation, so I will also research this.
My next client was in a late stage of rehabilitation from a groin injury (Charlton et al., 2017). I was shadowing another clinician that had been working with this client for the past 3 months. The injury diagnosis was adductor tendonitis. He was a footballer, and this is a common football injury. Firstly, the clinician assessed his passive ROM and then active knee range of motion (ROM) and hip ROM. Both had improved dramatically since the start of treatment and the client was incredibly happy. I really enjoyed seeing how happy the client was with his progress, which reinforced to me how incredibly important these sessions are to clients, and the trust they place in their therapists. The clinician and I then took the client into the gym for a rehabilitation session. We utilised the protocol by using the Aspetar for acute groin injuries (Fig 1) table. As I was shadowing, I watched the other clinician train someone, which was especially useful, seeing how someone else runs their sessions and to take away things I liked or disliked. The clinician was a qualified PT, with over 6 years’ experience, so, I learned and took away a lot of valuable information from this session.
Figure 1: Aspetar treatment protocol
Note: During, S. R. T. S. Aspetar Clinical Guideline.
When performing the active flexibility at the start (Harris-Hayes et al., 2020), I would normally get my clients; under control, to separately swing their leg side to side, to open out the hip and turn out their legs, however, this clinician told the client to keep the leg turned inwards. Previously, I had not thought how this could work different muscles and be beneficial. So, I will incorporate both techniques into my sessions moving forward.
I particularly liked how calm and smooth the session was going, owing to the clinician’s manner i.e., stayed calm, professional and in control of the session. As the session moved onto more advanced agility work using the ladder, the client started to exhibit a little apprehension. I believe it may have helped if the clinician was a little more encouraging at this point, as it was clear that it was not the client’s ability causing this, rather more to do with their confidence levels. However, the clinician did let the client do the agility a little slower than previously demonstrated, so that he could build up his confidence. When the client started to get a little frustrated with himself the clinician changed the exercise so that the client was not dwelling too much, which I felt really helped the overall situation. As I am a professional dancer, I sometimes count out loud during exercises to assist in keeping a rhythm, which I believe would have assisted in this session, as the client was struggling slightly to perform the movement at a good pace and some additional guidance may have assisted. However, I fully understand not everyone may be comfortable counting, and may wish the movement to be performed more freely. I will take this into account and assess each client individually on their preferences i.e., if they enjoy doing this and importantly if it is of benefit. Upon reflection I also believe that some calming music would have helped; in liaison with the client, as the client felt slightly embarrassed and awkward at the intense focus on him and the exercise. I believe if music were involved the session may have felt more relaxed and fun (Yetasook & De Virgilio, 2021).
References:
Biel, A. (2015). Trail Guide to Movement: Building the Body in Motion (p. 265). Books
of Discovery.
Charlton, P. C., Drew, M. K., Mentiplay, B. F., Grimaldi, A., & Clark, R. A. (2017).
Exercise interventions for the prevention and treatment of groin pain and injury in athletes: a critical and systematic review. Sports Medicine, 47(10), 2011-2026.
Harris-Hayes, M., Steger-May, K., Bove, A. M., Foster, S. N., Mueller, M. J., Clohisy,
C., & Fitzgerald, G. K. (2020). Movement pattern training compared with standard strengthening and flexibility among patients with hip-related groin pain: results of a pilot multicentre randomised clinical trial. BMJ Open Sport & Exercise Medicine, 6(1), e000707
Yetasook, A., Terrell, J., & De Virgilio, C. (2021). Creating a Harmonious Operating
Room: The Role of Music and Other Sounds. Surgery in Practice and Science, 100035.
Zhang, J., & Wang, J. H. (2014). PRP treatment effects on degenerative
tendinopathy-an in vitro model study. Muscles, ligaments and tendons journal, 4(1), 10.