19th March. Duration: 5 hours (3 clients)
Supervisors: Alex and Mike
My first client was as online consultation where the client was experiencing pain in their left shoulder due to an impact injury from lifting weights overhead (Taylor & Lavallee, 2020; Zatsiorsky et al., 2020). They had limited range of motion (ROM) in internal and external rotation of the shoulder and some pain. From experience, I know this symptom is usually associated with external impingement of the shoulder as the client was having a lot of trouble lying on his injured side, and explained they were experiencing most of the pain at night, which my client explained was his biggest annoyance at that moment.
Although online, I was able to assess passive and active ROM and was able to demonstrate each movement to the client clearly enabling the client to copy me (Vakanski et al., 2017), I feel I was able to get a lot of information from the client through allowing him to speak freely, as he was very talkative, whilst his wife was inputting from the side lines, which was wholesome and enjoyable, but I was careful to focus on the clients explanations rather than his partners interpretations. I found that my client had been experiencing this for 2 months but believe he may have been in a slight state of denial for a while, until it impacted on his ability to perform his daily life. I got the client to point out the area of most pain, and this appeared to be the coracobrachialis, in the anterior deltoid region (Tamborrini, 2021). Whilst doing this, the clients symptoms appeared to ease slightly, which I was not sure what this potentially indicated, and unfortunately my supervisor was not free for me to ask, however, I did have a trigger point book next to me, which suggested the diagnosis could point to a rotator cuff tear, subacromial bursitis, supraspinatus tendonitis, acromioclavicular joint dysfunction and/or carpal tunnel syndrome.
I felt I had made a good initial connection with my client and ascertained they had already seen a medical professional who had given them exercises, but they did not appear to be helping the client, so, I know that my client will benefit from a full assessment in person to help to try and attain a proper diagnosis. If I were to do this again, I would have given my client advice to not continue with his exercise classes as he does cross-fit now which is very intense. The client advised he is avoiding press-ups and burpees, but I advised they may benefit from total rest before he receives an assessment to see if this assists the injury, and to determine if regardless of rest, it deteriorates, which should provide a better indication of what the injury may be. I conducted research post this session to determine if there were specific tests, I could perform at the clients next session. There are several injury possibilities, as (Abrassart et al., 2020; Hermans et al., 2013; Rolf, 2007) highlighted:
- Ext impingement- Pos. Hawkins test. Jobes test for rotator cuff pos. differential diagnosis- nerve root compression from cervical spine. Frozen shoulder. Painful to sleep on one side.
- Internal impingement- provoking the position that causes the pain in repeated tests. Jobes test and SLAP tests. Functional tests- press against wall test and test of thoracic scapular control.
- Frozen shoulder- middle aged sudden or gradual onset. Shoulder possibly restricted in movements in all directions and very painful.
My next clients had returned to the clinic to have his strapping replaced & do some remedial stretching and exercises. The client was in his 2nd week of recovery from a turf toe sprain on his great toe, which he thinks was caused when jumping barefoot on a trampoline. I was aware to avoid hallux rigidus (stiffness), he had to constantly stretch his ligament, hence on taking existing tape off, conducted passive and active ROM tests on both feet/toes, doing toe lifts, which indicted reasonable flexibility, with a bit of stiffness in his injured toe when gently dorsiflexing, but no pain. STR was performed on calf area followed by some toe dorsiflexion exercises without and with a light resistance band working his large tibialis anterior muscle and some pencil lifts to improve flexibility and strength followed by proprioception using foam, to increase his spatial awareness after having his toe locked straight in a few weeks, his balance may be impacted. I was aware the client did not appear too keen on doing these basic but required exercises, hence tried to add a bit of fun into the exercises by competing with him on the pencil picking up exercises, which assisted to lighten the mood, and did assist to invoke a bit of enthusiasm. I will try and do more of this type of rehabilitation on other injuries if the competition does not cause client to overexert themselves. Strapping was replaced on completion, with advice on wearing inflexible footwear at this stage to protect the toe. I have learned so much about strapping, knowledge of which can only be gained practically, and am much more confident in my competence levels since attending clinical sessions again.
Fig. 1: Strapping Turf Tow
The final client had suffered a thigh contusion one week previous during a football game and had quite a severe ‘dead leg’ and bruising from the impact of studs, which had been classed as a grade 2 injury. She was able to walk properly now, but some pain and stiffness remained. I conducted observation and passive/active ROM tests, which were positive, and conducted STR on thigh followed by pain-free static quadricep exercises, hip flexors, knee extensions using resistance band, gentle lunging and squats and finished off with more stretching. This client was very motivated, and wished to progress quickly, which was good to see, hence I included some football exercises (cone work) into the session, which went well. Through experience, I now know sports clients react much better to rehabilitation if an element of their sport is included in the plan, hence I will continue to investigate suitable exercises and activities applicable to each sport within my repertoire/bank of knowledge, to try and make the sessions more interesting.
References:
Abrassart, S., Kolo, F., Piotton, S., Chih-Hao Chiu, J., Stirling, P., Hoffmeyer, P., &
Lädermann, A. (2020). ‘Frozen shoulder’is ill-defined. How can it be described better?. EFORT Open Reviews, 5(5), 273-279.
Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L., & Bierma-
Zeinstra, S. M. (2013). Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. Jama, 310(8), 837-847.
Rolf, C. (2007). The sports injuries handbook: diagnosis and management. A&C Black.
Tamborrini, G. (2021). MUSCLES OF THE UPPER EXTREMITY. Ultrasound of the
Musculoskeletal System, Nerve Ultrasound, Ultrasound Guided Interventions and Arthroscopy Atlas: Musculoskeletal Sonoanatomy Guidelines, 26.
Taylor, S. E., & Lavallee, M. E. (2020). Weightlifting. In Sports-related Fractures,
Dislocations and Trauma (pp. 975-980). Springer, Cham.
Vakanski, A., Ferguson, J. M., & Lee, S. (2017). Metrics for performance evaluation
of patient exercises during physical therapy. International journal of physical medicine & rehabilitation, 5(3).
Zatsiorsky, V. M., Kraemer, W. J., & Fry, A. C. (2020). Science and practice of strength training. Human Kinetics.