08 December- Marjon clinic. (4 hours) 2 clients

My first client today was online with a young female who described a mild pain in her thigh after playing badminton the previous day (Yu et al., 2021).  I enquired if she had any previous injuries on this site or if she was on medication, which she said no. During our consultation, she described feeling a sharp pain when lunging forward, which was painful for a few minutes, but then appeared to go away, only for it to be painful later that night. From her description, she was not able to get to a laptop to allow me to view the limb, it sounded like a quadriceps muscle tear, possibly Rectus femoris (Fig 1), but I would have to conduct physical tests to be certain of the grading (Fig.2), hence booked her in for 2-days’ time, during which I advised PRICE and strapping minus any physical activity.  I was aware badminton had a high prevalence of injuries through a friend who played it, hence I would conduct some more research prior to seeing the patient (Pardiwala et al., 2020).

Fig.1 Muscles of Thigh

Fig.2: Grading of Thigh (quadriceps strains)

I will ensure I conduct a careful examination including observation, palpation, strength testing, and ROM at our next session. I know from experience, strain injuries of the quadriceps can present with an obvious deformity, such as a bulge or defect in the muscle belly. Signs (ecchymosis) may not develop until 24 hours after the injury, hence giving her 2-days should reveal any delayed onset of injuries. I will palpate the anterior thigh to locate the area of maximal tenderness, looking and feeling for any defect in the muscle. Strength testing of the quadriceps will include resistance of knee extension and hip flexion with strength testing of the rectus femoris inclusive of resisted knee extension with the hip flexed and extended both in the sitting and prone-lying positions. Pain is typically felt with resisted muscle activation, passive stretching, and direct palpation over the muscle strain. Assessing tenderness, any palpable defect, and strength at the onset of muscle injury will determine my grading of the injury, providing direction for potential further testing and/or treatment.

I am still wary of conducting interim diagnosis assessments online, as although it is a great means of reaching patients, I find it can be very subjective; I know it is meant to be, but I much prefer the 1:1 interaction of a physical assessment, where communications really come into their own. If I could have done anything differently, I would have enquired how much badminton she plays and at what level, as from experience, this can often provide more information, particularly on muscle strength etc.

My final client today was a 33-year-old male, who advised he was a keen runner, but was currently suffering knee pain. He described it as an aching pain somewhere in the front of the knee, under his kneecap (patella), which he said was slightly inflamed and he felt more when sitting down after exercise.  On palpation he had some tenderness along the inside border of your patella (Fig. 3).  He also advised he felt some crepitus when bending his knee, which felt a bit strange but was not that painful.

Fig. 3: Patellofemoral Pain Syndrome (PFPS)

I conducted a gait assessment, which was normal and a general knee assessment including ACL test, modified Lachmans Test for PCL, Medial & Lateral Minisci using compression, Thessaly’s test, duck waddling, Clarkes test, which were all negative, however on patellar apprehension test, this was positive as was the patellar compression test, which was also positive and patellar grind test, which was positive on quad contracting, and patellar glide test, which was slightly painful for the client.  I found this video online, which I found extremely useful as a reminder on basic special tests: Knee Special Tests  I spent quite a bit of time conducting all the tests, which left me slightly confused as the injury could have been a combination of things, but I stuck to my notes and eliminated everything I thought was not relevant and determined patellofemoral pain syndrome (PFPS) was the most likely diagnosis, as his patella did appear to be rubbing on his femur bone underneath. As I was not certain I asked a supervisor to assist, and she recommended conducting a Q-Test (Fig.4) to gauge the angle between the quadriceps muscles and the patella tendon, to assist ref. information about his general alignment of his knee joints.  In this case knee valgus was normal, but it was good to do the test, as I had only discussed it previously so putting into practice was good.  However, I sensed the client was getting a bit anxious with so many tests, hence decided based on evidence to date to treat the injury as PFPS.  I used patella taping (Whittingham et al.,2004) to support the knee hence got the client to do a squat (he had some pain) and then applied taping & do another squat (no pain).  I advised client to conduct stretching & strengthening exercises once the pain had subsided in conjunction with PRICE. 

Fig. 4: Q Angle of the knee

If I could have done anything differently, I would explained to the client it took a bit of time to conduct all required tests prior to embarking on them and tried to speed up the testing during this assessment, as I felt the client was getting a bit anxious, however, the client was satisfied with the attention he received, and appeared happy I had provided a diagnosis for him.  I will research the knee further, as although I was satisfied, I had done all I could, I still had a nagging feeling that I may have missed something, but with the treatment provided, I am confident I wont be doing any further harm.

References

Kobal, K. L., Rubertone, P. P., Kelly, S. P., & Finley, M. (2021). A Comparison of

Instructional Methods on Clinical Reasoning in Entry-Level Physical Therapy Students: A Pilot Study. Journal of Physical Therapy Education, 35(2), 138-145.

Pardiwala, D. N., Subbiah, K., Rao, N., & Modi, R. (2020). Badminton injuries in elite athletes: a review of epidemiology and biomechanics. Indian journal of orthopaedics, 54(3), 237-245.

Passarelli, A., & Kolb, D. (2021). 6 The Learning Way. The Oxford Handbook of Lifelong Learning, 97.

Whittingham, M., Palmer, S., & Macmillan, F. (2004). Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy, 34(9), 504-510.