Thursday 15th June. Marjon clinic. (5 hours) 2 clients
My first client identified with pain at the back of his knee, with tenderness in his calf muscle just below the back of his knee, which he described as quite severe when it happened during his last game of hockey four days previously. The client was limping slightly when he walked into the clinic and advised he had used RICE over the past 4-days, and although it had reduced some swelling, the throbbing pain persisted. Although this sounded like a Grade 1 tear (Fig.1) as there are numerous potential causes of calf strains, I thought it prudent to take my time over this diagnosis. I conducted palpation on full length of both calf muscles, inclusive of the aponeuroses gastrocnemius, which on the injured leg identified with tenderness in the area he said he felt the acute pain previously, some swelling and thickening present in the medial belly or the musculotendinous junction. At this stage although not certain, I was starting to discount a possible soleus strain as the identified area of pain was outside of the soleus area (Fig.2), however I also conducted a Thompson Test (Schaarup et al., 2021) to try and pinpoint the area of most pain, which also pointed to the gastrocnemius muscle, and during ROM tests when his knee was in full extension the pain was increased (Bojsen-Møller et al., 2004). I also used Trigger points on the gastrocnemius to pinpoint pain (Fig.3):
- The two medial trigger points lie in the medial head of the gastrocnemius, with the upper trigger point found just below the crease of the knee, and the lower trigger point an inch or two below it.
- The two lateral trigger points in the lateral head mirror the positioning of the medial trigger points, except that they lie slightly more distal (towards the foot) by about a half-inch.
I advised the client to refrain from further exercise at this point whilst continuing to rest and provided some very light massage with stretching exercises for the gastrocnemius muscle along with several exercises to work on at home advising if it does not start to feel better within 4-5 days, to visit his GP, who may provide medication or referral for MRI.
I was confident my diagnosis was correct but still feel slightly uncomfortable diagnosing patients with tricky areas minus an MRI diagnosis, I may be wrong, but my confidence levels are definitely increasing around patients, although I occasionally like to refer to my supervisor, notes and internet for support, which I suppose is all adding to my knowledge base. I really feel that my patient handling skills and assessments are progressing and speed of diagnosis increasing although when I look at some of my supervisors, they appear to get through patient much quicker, but having only recently returned to the clinic, I am sure I will get faster.
Fig.1 Grading of Calf Strains
Fig. 2: Gastrocnemius and soleus muscle areas
Fig. 3: Gastrocnemius Trigger Points & Referred Pain
My second client today online and a returnee whom I had previously treated at the clinic for Achilles bursitis caused through overpronation. She advised her heel pain was gradually getting better, and the exercises prescribed; in conjunction with insoles, were working. It was a good feeling knowing my diagnosis and treatment plan were working, which after worrying about my diagnosis abilities, made me feel more confident today. I sometimes feel that back -to-back appointments force one into making decisions, but perhaps it is just my brain going into overload that makes me feel like this in the knowledge that in conjunction with my clinical notes, I must write up my reflections! However, I know deep down that in discussion with my supervisors, I am constantly developing, and every patient I see will be getting a more experienced clinician treating them.
References
Bright, J. M., Fields, K. B., & Draper, R. (2017). Ultrasound diagnosis of calf
injuries. Sports health, 9(4), 352-355.
Schaarup, S. O., Wetke, E., Konradsen, L. A. G., & Calder, J. D. F. (2021). Loss of the knee–ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon. Knee Surgery, Sports Traumatology, Arthroscopy, 1-10.
Bojsen-Møller, J., Hansen, P., Aagaard, P., Svantesson, U., Kjaer, M., & Magnusson,
- P. (2004). Differential displacement of the human soleus and medial gastrocnemius aponeuroses during isometric plantar flexor contractions in vivo. Journal of applied physiology, 97(5), 1908-1914.
I have never been one to feel comfortable with the unknown. I like the blacks and the whites in life and feel reassured when I have read around a subject adequately to feel I understand it. Grey areas are unsettling for me and leave me with a sense of frustration and, frankly, confusion. This is the root cause of why this week has felt ‘awkward’ and unsettling at times. My handling skills and patient assessments are clearly progressing; I have already completed follow-up appointments alone with my week one patients and successfully managed to assess and treat ‘complex’ diagnoses as my educator affirmed to me in feedback. So why then, do I feel confused, unassured and almost as though I am ‘winging it’ in every appointment? Back to back appointments, with every minute used in the cubicle with the patient, has left me short of time to write up my notes. It also ensures I am scuttling around the department looking far busier than the reality of the three patients I see in a row! Qualified professionals around me, even the newly qualified ‘band 5 rotational physiotherapists’, are seeing upwards of ten patients a day. This isn’t possibly attainable for me, surely? The fact remains, in discussion with my educator, I am constantly developing and every patient is getting a slightly improved version of me each time. My need to know and understand everything, all of the time, is unrealistic and indeed an unnecessary pressure placed on me only by myself! Those I talk to in the department confess they are learning everyday; those who claim to know everything are those that should retire or leave I am told.
My first client was a returning client from another clinician who had diagnosed her with Radiculopathy Facet Dysfunction (Anaya et al., 2021) with a differential diagnosis of shoulder impingement syndrome (Sharma et al., 2021).
I conducted a full assessment; inclusive of ROM, for the cervical, thoracic and shoulders where I identified which body positions were limited and painful and discovered a slight difference from the other clinician’s notes. Through experience, I now know this is not uncommon, as the clinician may have been busy on the day or the patients’ symptoms were not as acute on a given day, but regardless, it reminded me to be as thorough as possible and not to take others notes as the definitive.
From the notes, the patient had deteriorated since her last assessment, however on questioning, she said she felt as though she had improved slightly, hence in this case, I believed that the last clinician may not have recorded the ROM correctly, as the notes explained she had no pain in internal ROM of the shoulder. However, this was the level of movement that caused the greatest pain and had the least strength in.
Through deduction, I decided the most appropriate special test should focus on internal impingement. I was aware of the Hawkins-Kennedy test, but decided to do a quick search of YouTube to find another test for internal impingement, and found the posterior impingement test, which although it had a weak accuracy scale, may assist (Kamalden et al., 2021).
I was able to perform both tests successfully, despite it being a long time since I last conducted them. I also performed the Neer test for subacromial pain syndrome (SAPS). I had a little bit of trouble turning her arm inwards, but eventually got the correct placement of my hands. Post the assessments, I realised I need to practice conducting more special tests on the shoulder, to enable me to cut down the time with the patient, but more importantly, ensure the correct diagnosis is being made. After the ROM assessment I went onto palpation, which highlighted the patient did not actually have any pain, which indicated it may be mainly deep rather than superficial. I moved onto soft tissue massage focusing on trapezius and rhomboids. The client had a very crunchy feel in the inferior angle of their scapula, subscapularis, and rhomboid muscles. I consequently sought guidance from my supervisor who explained it was connective tissue; dense pockets of muscle, which almost every person has where connective tissue assists in supporting muscles. I believe it is good practice to seek guidance or a second opinion from a more experienced clinician, which also relays to the patient, we are doing everything possible to help them.
During the massage I continually asked (checked) if the pressure was OK. She was very polite and informed me the previous clinician was a bit too hard, and the pressure I was submitting, was much more comfortable. However, she did mention she did not inform the clinician to ease off, so I deduced she may be the type of person who would just accept the pain, so I made sure to not do too much pressure, as she has quite a small frame (Rodrigues et al., 2021).
My next client was online, where I shadowed another clinician with a patient with knee pain. He did a full assessment, which went well as the clinician demonstrated the ROM exercises well and was able to see his movement limitations on the screen. As this was an online assessment, it was chiefly subjective. From observation, I believed it could have been prepatellar bursitis (Samhan et al., 2021), previously commonly known inappropriately as housemaids’ knee. Overall, the patient performed well, and I believe was quite satisfied. If I were to do anything differently, I would probe more to try and narrow down the pain site, however, it was a subjective assessment, which I believe was performed well (Douglas‐Morris et al., 2021).
My last client today was also conducted shadowing a clinician. The patient presented with a possible diagnosis of Medial Epicondylopathy (Finnoff et al., 2021; Hodge & Schroeder, 2021); an overuse of the wrist extensors. It was a useful reminder for me when the clinician referenced TENS machines settings, and consequently I found the advice interesting, but also beneficial, and a good reminder to me that a sports therapist must have a broad range of up-to-date knowledge and experience, when discussing the clients home TENS machine (Park et al., 1984). We discussed acupuncture use as being more inclined to be used for chronic pain relief (Sheikh et al., 2021). For treatment, the clinician also used soft tissue massage utilising a technique called ‘transverse friction massage’, also known as cross-friction and cross-fibre massage, which is a technique that promotes optimal collagen healing by increasing circulation and decreasing collagen cross-linking, thus decreasing the formation of adhesions and scar tissue (Mylonas et al., 2021).
References
Anaya, J. E., Coelho, S. R., Taneja, A. K., Cardoso, F. N., Skaf, A. Y., & Aihara, A. Y.
(2021). Differential diagnosis of facet joint disorders. RadioGraphics, 41(2), 543-558.
Douglas‐Morris, J., Ritchie, H., Willis, C., & Reed, D. (2021). Identification‐Based
Multiple‐Choice Assessments in Anatomy can be as Reliable and Challenging as Their Free‐Response Equivalents. Anatomical Sciences Education.
Finnoff, J. T., & Johnson, W. (2021). Upper limb pain and dysfunction. In Braddom’s
Physical Medicine and Rehabilitation (pp. 715-726). Elsevier
Hodge, C., & Schroeder, J. D. (2021). Medial Epicondyle Apophysitis (Little League
Elbow).
Kamalden, T. F. T., Gasibat, Q., Rafieda, A. E., Sulayman, W. A., Dev, R. D. O.,
Syazwan, A. S., & Wazir, M. R. (2021). Influence of Nonoperative Treatments for Subacromial Shoulder Pain: A Review Article.
Mylonas, K., Angelopoulos, P., Tsepis, E., Billis, E., & Fousekis, K. (2021). Soft-Tissue
Techniques in Sports Injuries Prevention and Rehabilitation. In Recent Advances in Sport Science. IntechOpen.
Park, S. P., Thomas, P. S., Chen, L., Yuan, H. A., Frederiekson, B. E., & Zauder, H.
- (1984). Transcutaneous electrical nerve stimulation (Tens) for postoperative pain control. Pain, 18, S68.
Rodrigues, M. G. D. R., Pauly, C. B., Thentz, C., Boegli, M., Curtin, F., Luthy, C., … &
Desmeules, J. (2021). Impacts of Touch massage on the experience of patients with chronic pain: A protocol for a mixed method study. Complementary therapies in clinical practice, 43, 101276.
Samhan, L. F., Alfarra, A. H., & Abu-Naser, S. S. (2021). An Expert System for Knee
Problems Diagnosis. International Journal of Academic Information Systems Research (IJAISR), 5(4).
Sharma, S., Hussain, M. E., & Sharma, S. (2021). Effects of exercise therapy plus manual therapy on muscle activity, latency timing and SPADI score in shoulder impingement syndrome. Complementary Therapies in Clinical Practice, 44, 101390.
Sheikh, F., Brandt, N., Vinh, D., & Elon, R. D. (2021). Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care. Journal of the American Medical Directors Association, 22(6), 1199-1205.