.1st June 2021 Marjon Clinic placement reflection
Supervisors: Mike and Alex
Hours: 4 hours (2 clients)
My first patient today was a female experiencing bilateral pain in both knees, which she described as preventing her achieving her goal of being able to run. A full assessment was conducted; inclusive of knees, on her joints above and below her knees (hips and ankles). The assessment progressed well, allowing me to go through applicable range of motion (ROM) tests. Through discussion, I discovered she had taken up Pilates post retiring in 2020, which explained why she demonstrated very good ROM and strength, considering her age and painful joints issue. She advised before she started Pilates, her range of movement and strength was poor. As I practice Pilates, I discussed how beneficial I believed Pilates was (Choi et al., 2021) and if it assisted her ROM and felt good, she should continue. The patient was incredibly happy I had provided positive feedback on her activities, and I could visibly see it had encouraged her to continue. I felt very satisfied I had in some small way made her feel good, which as I gain in experience, I have become increasingly conscious that a patient’s mental health is just as important as their physical health in aiding recovery. During gait assessment, the patient had slight valgus when walking and when the patient conducted functional movements, such as squatting, I observed she had valgus knees (da Costa et al., 2021). I requested her to do a lunge, whereupon she explained she did not like doing these, as they caused her pain. As an alternative, to lessen the pain, I got her to do a supported single leg squat, which also evoked pain.
However, the patient retained good balance and stable ankles, hence through deduction, I suspected her hip and knee stability were weakened, as her form during exercises was poor indicating her joints needed to be stronger to complete basic ROM minus valgus knees, which with exercises, should prevent or lessen her knee pain to allow her to achieve her running/jogging goal. Increased strength, ROM and form will lessen impact on her joints during this activity. Post patient assessment, I discussed my findings and initial diagnosis after conducting special tests: Thessaly test- positive; McMurray test-negative; patella grind test-negative and joint line tenderness- positive (Abdelgawad & Genrich, 2021; da Silva Boitrago et al., 2021; Karachalios et al., 2005) with my supervisor, explaining I suspected patella femoral pain syndrome, damaged meniscus, weak quads, and hamstring.
A positive discussion with my supervisors, enabled me to clearly and quickly explain my findings with the client whereupon applicable exercises were started (side plank with hip abduction). The patient tried however, was unable to lift her leg in this position, hence reverted to a side plank enabling the patient to build strength to work towards improving her strength. I did not wish to dishearten the patient so quickly started standing hip adductions and was satisfied I was able to think quickly and work with my client’s individual capabilities and needs, rather than just giving the exercises and minus considering the clients personal abilities. I used side lying clams to target the gluteal muscles, primarily gluteus medius to build and stabilise the pelvis and maintain balance, whilst providing support to the knees and lower legs. I lay down on the mats with my client and conducted all the exercises with her, which I believe is a good way of encouraging the patients to perform all movements whilst simultaneously correcting their placement and form, as they will remember this when conducting at home. The next exercises were hip drops off a stepper. The client struggled keeping their supporting leg straight, but through perseverance and my corrections, she completed the exercise. I felt I had explained and demonstrated simply maintaining good communications throughout with the client, particularly their likes and dislikes. I ensured the client felt the muscle stretches in the correct place for all exercises indicating they were being conducted correctly, in conjunction with their form and placement.
During the exercises I mentioned her knees could be supported with K-tape. The client really liked this idea, and consequently I placed K-tape on her as a ‘tester’, which if assisted, she could purchase and apply it herself whenever she completed exercises ( I placed two pieces of tape under the kneecap with zero stretch, another piece from the middle laterally of the bicep femora’s and across over the lateral side of the knee to the medial side of the knee and then the same on the opposite side). It was awkward placing the tape, as it was not sticking well and was a bit fiddly, however, I completed it successfully and the client was satisfied and comfortable. If I were to do this again, I would ensure to measure out the tape prior, to speed up this process.
My next client was a female suffering from what sounded like bilateral calf pain. The assessment went smoothly, and I was able to find out lots of information through good communication and empathy towards the client. Through deduction, I diagnosed medial tibial stress syndrome (Reshef, & Guelich, 2012) and general gastrocnemius weakness. The patient had her child with her who was a little bit hyperactive, hence I thought it would be best if I engaged the child (a boy) what I was doing, and got him involved by palpating the opposite side, which was fun and kept him entertained whilst also putting his mother at ease during the assessment minus worrying about her child.
Accommodating patients’ needs, who also have busy schedules, is always high on the agenda, and in this instance, I felt I handled this situation well, and the parent was certainly very appreciative, and once again it was a real-life learning situation, which I will remember for possible similar instances. I went through at home exercises with the patient, as through observation and ROM, she had good arches in her calf raises, and consequently was advanced enough to add tempo training (Wilk et al., 2021). I explained this and got her to perform the tempo training to ensure she understood. I also put an objector in reference how many toe-taps she could do in 30 seconds, to compare on her next appointment, after completing her at home exercises. I explained this to her and felt it was a good way of pushing her to adhere to exercise giving her goals. After the exercises I gave the client a 5-minute massage on each calf, as they felt tight, however post speaking to the client, I thought she was a bit stressed with her daily life and this would also release some tension. During massage, the client opened up about her child’s learning difficulties at school etc. I think I did a good job at letting her unwind, as she may not have such opportunities that often. The massage went well, and I ensured constant communications was maintained reference pain (good or bad). I have learned to ensure an explanation is provided reference pain tolerance levels and palpation pressure, as I have noticed some people; often male, tend to try and bear any pain rather than tell you, which could be attributed to a macho thing.
References
Abdelgawad, A., & Genrich, C. M. (2021). Sport Injury: Lower Extremity. In Pediatric
Orthopedics and Sports Medicine (pp. 199-222). Springer, Cham.
Choi, W., Joo, Y., & Lee, S. (2021). Pilates exercise focused on ankle movements for
improving gait ability in older women. Journal of women & aging, 33(1), 30-40.
Cui, J. C., Wu, W. T., Xin, L., Chen, Z. W., & Lei, P. F. (2021). Efficacy of Arthroscopic
Treatment for Concurrent Medial Meniscus Posterior Horn and Lateral Meniscus Anterior Horn Injury: A Retrospective Single Center Study. Orthopaedic Surgery, 13(1), 45-52. da Costa, G. V., de Castro, M. P., Sanchotene, C. G., Ribeiro, D. C., de Brito Fontana,
H., & Ruschel, C. (2021). Relationship between passive ankle dorsiflexion range, dynamic ankle dorsiflexion range and lower limb and trunk kinematics during the single-leg squat. Gait & Posture, 86, 106-111.
da Silva Boitrago, M. V., de Mello, N. N., Barin, F. R., Júnior, P. L., de Souza Borges,
- H., & Oliveira, M. (2021). Effects of proprioceptive exercises and strengthening on pain and functionality for patellofemoral pain syndrome in women: A randomized controlled trial. Journal of Clinical Orthopaedics and Trauma, 18, 94-99.
Karachalios, T., Hantes, M., Zibis, A. H., Zachos, V., Karantanas, A. H., & Malizos, K.
- (2005). Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. JBJS, 87(5), 955-962.
Reshef, N., & Guelich, D. R. (2012). Medial tibial stress syndrome. Clinics in sports
medicine, 31(2), 273-290.
Wilk, M., Zajac, A., & Tufano, J. J. (2021). The Influence of Movement Tempo During
Resistance Training on Muscular Strength and Hypertrophy Responses: A Review. Sports Medicine, 1-22.