28th September

Marjon Clinic

Supervisors: Alex and Mike

This session was the first of the year within the clinic at Plymouth Marjon university. As part of a placement module in 3^rd year, the clinic is based on the university campus to help achieve 200 hours needed to complete this module. During this placement, each week clients will be treated who have booked in for an injury consultation both online and face to face.

During this session, the group were provided with information on how the clinic was to run this year. This included how the online consultation process will be delivered, face to face appointments, the booking process and how the correct PPE is to be used including an apron, gloves, mask and visor.

Due to the recent COVID 19 pandemics, this was also important to be covered to ensure that the correct protocols were to be carried out. This included the ‘donning and doffing’ process of wearing PPE, social distancing, and the use of the one-way system within the clinic and sports centre and how to work with clients in this space.

Towards the end of the session, there was revision for various case studies and scenarios. This was especially useful as this meant we were able to discuss in groups and share information. Case studies involved both upper and lower limb scenarios. This had also helped to identify which areas that are needed to focus on within revision before beginning placement in the clinic.

3^rd June 2021 Marjon clinic placement reflection

Supervisors: Alex and Mike

Hours: 6 hours (3 clients) `

My first client was a female and initially appeared to be quite a straightforward case however for some reason I spent an initial 10-minutes with this patient, and do not think took full control of this consultation as she was very chatty, and I found it hard adding structure to this. She had GP diagnosed plantar fasciitis and wanted to talk about treatment (Tseng et al., 2021). She had tried physio exercises previously, had NHS insoles fitted and was trying to lose weight but despite all of that she still was symptomatic. We discussed various treatment options available from our clinic, which she appeared keen on. She also enquired about the use of steroid injections, which I advised may assist, but she should try exercises and stretching in the first instance. I learnt from this session that this patient was quite anxious, I also learnt that I must be more forceful; in a nice way, with chatty patients, as my time is precious to all my scheduled patients, and to achieve this I must be more methodical and structured led, otherwise I will delay booked clients appointments. As I am still lacking in experience, I am certain I will be able to speed my diagnosis times through better use of communications and will ensure I take full advantage of joining in with more experienced supervisors to get more tips. I conducted stretching (Fig 1) in conjunction with palpation, toe curls with towel, marble pickups and resistance band exercises, advising client to continue these at home (Pinrattana et al., 2021)

Fig. 1 Plantar Facia Stretch

My second client was a female, 3- weeks away from having hip replacement surgery. The client had previously been working with another therapist who no longer required hours, hence stopped attending. My supervisors transferred the client to myself and another student therapist as a back-up should one of us be unable to do it one day.

We both greeted the client, who was thankful she was being looked after. I complimented her on her jewellery accessories; she had lots of flowers and butterfly pins on her, which I really liked, but I also wished her to feel comfortable, as we were new clinicians to her.  When clients are swapped, I always feel it must be quite trying for the client having to meet new clinicians and personalities, so always go out my way to make them feel at ease.  We immediately took her onto the anti-gravity machine as this is the only way she can bare weight, owing to pain levels in both her hips. She was able to put the suit on herself by flexing her hips, which I personally thought was quite impressive, considering she could not walk. I have learned through experience I am able to determine with some accuracy, if a client really wants to get better quickly, and this woman certainly fell into this category, as she had a lot of fight in her.

My clinician partner increased the gravity on the machine, and we constantly communicated with her reference speed etc, which went smoothly. During this treatment, we took the opportunity to discuss with the client more details reference hip history, and generally how she was feeling. This lady worked with disabled children in a school, however since she could not walk anymore, her employer told her not to attend anymore, which she was upset about.  Clearly, I did not know all the details, but she was terribly upset about her situation, because she had good relationships with all the children, who were in wheelchairs. I consequently tried to make the conversation more positive after receiving this negative information, as I know how important it is for a patent to feel positive during recovery, as she was clearly feeling quite depressed (Lenzo et al., 2021). I moved the conversation onto her children and encouraged her to talk positively about them, whilst reassuring her that she will recover; I could tell she was feeling slightly vulnerable, which is completely understandable considering her present circumstances.

While she was walking, we continually checked her gait to ensure she was going through her foot and in a straight line. The client said because we had all been talking so much, she had forgotten that she was walking and felt her treatment went much quicker. I felt incredibly happy that I was able to help this lady in some way, even just through conversation. After a little while she advised she felt quite tired, and could we put it down, which we did. We got her to put the level down herself as we knew she was very capable of this, and it would be quicker, whilst she could also gauge her own comfort level. Unfortunately, I had to cut my time short with this client, as I had another client waiting, so I told her that I had to go and that it was genuinely nice meeting her. The other clinician carried on from there. I came away from this session feeling satisfied, that I may have helped by communicating more, but also slightly sad that this woman was in so much pain and distress, as I cannot imagine what it must be like waking up one day and not being able to walk, go into work or do anything she was previously used to. I really hope I can see her again, to assist her professionally.

My last client of the day was a pizza delivery driver complaining of pain in his lower back and down one leg. After the subjective assessment It sounded like he had sciatica and lower back pain. This was a different client than I was used to, as his health was sedentary, and visibly and verbally seemed to have given up on life a little bit, a bit depressed. I conducted an assessment on his joints; above and below, thoracic and hips. He had lots of pain in back movements and was very stiff in all ROM but advised this was normal for him.

The client was very nice, but clearly had poor hygiene standards, and smelled quite bad. I tried my hardest to ignore this and be as professional as I could, as I knew he had just got into bad habits, feeling down with his life, and appeared to be finding it hard to get motivated. I have no idea what has happened in his life, and he did not wish to discuss anything personal, which is perfectly acceptable as I am a stranger.

After my assessment, I advised my supervisors and they wished me to ask further questions that may assist. I did so, and my supervisor then came in to assist. My supervisor thought the symptoms were pointing towards a disc problem, and suggested we try repetitive movements to see if it eased the client’s pain. I had overlooked these movements, so my supervisor took charge and I observed. She first did repetitive prone lying hugging knees, then gentle cobra up and down, followed by a book under bum to relieve pain and finally a strengthening exercise for the core and hips, which was prone lying with alternate leg toe taps. She went through all of this slowly and made sure to get the client to do it with her whilst continually asking him how each movement felt and if it was helping. They all seemed to help, and he felt good about it.

Afterwards we went back to the clinic room and my supervisor had a talk with him about possibly going for some walks or exercise as previously when we asked him if he did any exercise, he responded that he was a pizza delivery driver and that was the only exercise he does, and on his one day off a week, he lies in his bed. My supervisor left and I continued the conversation with him asking if he liked music or podcasts and that he could listen to them whilst he walks, and perhaps he could set himself a short goal of walking at least once a week, as I advised him that will make a big difference. He seemed keen to do it, so I hope he does (Gable & Dreisbach, 2021).  After this appointment I felt quite sad as I could see this man was in a bad state in life, and I found it quite emotional to see someone like that. I wished I could have done more for him, but I know that we did the best we could and hopefully we helped in some way giving him some exercises and advice. If I were to do this appointment again, I would have done a better subjective assessment as I skipped it a little bit as I could see he felt uncomfortable.

References

Gable, P. A., & Dreisbach, G. (2021). Approach motivation and positive affect. Current  Opinion in Behavioral Sciences, 39, 203-208.

Lenzo, V., Quattropani, M. C., Sardella, A., Martino, G., & Bonanno, G. A. (2021).

Depression, anxiety, and stress among healthcare workers during the COVID-19 outbreak and relationships with expressive flexibility and context sensitivity. Frontiers in Psychology, 12, 348.

Pinrattana, S., Kanlayanaphotporn, R., & Pensri, P. (2021). Immediate and short-term

effects of kinesiotaping and lower extremity stretching on pain and disability in individuals with plantar fasciitis: a pilot randomized, controlled trial. Physiotherapy Theory and Practice, 1-12.

Tseng, W. C., Uy, J., Chiu, Y. H., Chen, W. S., & Vora, A. (2021). The Comparative

Effectiveness of Autologous Blood‐derived Products Versus Steroid Injections in Plantar Fasciitis: A Systematic Review and Meta‐analysis of Randomized Controlled Trials. PM&R, 13(1), 87-96.

.1^st 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,

99. 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.

962. (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.

14^th May. Duration:6 hours (4 clients)

My first client was a 29-year-old male recreational basketball player who was experiencing pain in their right foot on the back of their heel, with swelling at the top of his heel and lower Achilles’ area.  The client explained they had been training outside on a concrete court for several months during lockdown, and although he had felt pain previously in the same area and a tightness I his calf, it was much more painful after his last session, and he was now finding it difficult to put on his work shoes.  I was aware this could be related to gait pronation and a lack of stretching; hence I asked the client if he stretched before/after training/games, and he said not that often. Also, if he wore good supportive basketball shoes and he said he did, but they were quite old now. Through assessment involving passive/active ROM on his foot followed by a Thompson test, which displayed plantar flexion and palpation around the lower Achilles and heel, I noted the client was experiencing tenderness, which when depressed felt a bit spongy. I was a bit apprehensive to offer a diagnosis but advised it looked like Achilles’ bursitis (Aaron et al., 2011).

As the client was experiencing pain, I did not wish to exacerbate this so conducted a visual inspection of their arches, which were extremely low and a gait assessment (Lee & Erdman, 2021), using the ‘Wet Foot Test’ as opposed to a foot scanner or treadmill analysis, looking for overpronation, under pronation or neutral gait, which although not perfect, I believed would provide a rough estimate of pronation type.  The footprint indicted he was more inclined to have a flat or low arch, indicating overpronation (Fig 1; Fig 2; Fig 3).  I Was a bit apprehensive doing this test as it was the first time, I had used it, but it was relatively simple and produced good results.

Fig.1: Footprint Pronation Identification

Fig 2: Pronation Types

Fig 3: Wet Foot Test

The client’s calf muscle was also very tight; hence I conducted observation first and passive/active ROM, then provided STR to relieve the tension and pain and during this provided advice on a rehabilitation package involving protection, rest, ice, compression, and elevation (PRICE), in conjunction with passive stretching at home if there was no pain, involving resistance bands, wall stretches, and toe raises. NSAIDs could also be taken for 2-5 days if clients GP allowed, until the acute pain phase had passed, which would be followed by a programme of exercises at the clinic to stretch and strengthen the area. The client was advised to avoid footwear with a prominent heel area, hence sandals were suggested, and when shoes were used, to use orthotic insoles, particularly in the basketball shoes, which should be replaced if old, to reduce the strain on his Achilles tendon. On reflection, I could also have looked at their basketball and work shoes to see if wearing occurred on the insides to corroborate initial diagnosis.

On the clients next visit, stretching exercises, for the calf muscles will be done focussing on the larger gastrocnemius muscle and the lower soleus muscle to increase flexibility to decrease strain on the bursa at the back of the heel. Calf stretches will be done with the knee both straight and bent to stretch both the gastrocnemius and soleus muscles.  Although I was satisfied, I had provided the client with good advice, which would not exacerbate the injury, I could have advised them to make an appointment with their GP to eliminate alternative injuries and will do this in future.

My next two clients had sprained finger injuries (Appendix A), which occurred seven and nine days previously through the basketball hitting their fingers at pace during games. They were now coming to the clinic daily. Both patients had been x-rayed and no bones were broken but suffered painful injuries in the areas of the intermediate and proximal phalanges of ring finger (digitus annularis) and pinky finger (digitus minimus manus) finger (Williams et al., 2020). Existing finger buddy taping was gently removed to reveal all visible swelling had gone and passive/active ROM was conducted revealing joint movement was achievable with minimal pain, although some tenderness existed in parts.  Finger exercises were provided to gently stretch the flexor digitorum profundus tendons and increase ROM and strength using various putty ball and rubber band exercises to exercise extensor digitorum communis and extensor pollicis longus.  Wrist, forearm, and shoulder stretches were provided (if no pain on fingers were felt), to ensure no weakening occurred through lack of mobility.  The fingers were retaped on completion of the session to protect them (Zu Reckendorf et al., 2021).  I provided advice on using a tennis or sponge ball to use at home with advice not to participate in basketball exercises, which involved ball work with hands.  I got the impression both clients were keen to get back on the court hence I thought it appropriate to remind them that strengthening exercises at home for the hand/fingers, will really improve their overall strength allowing them to play better minus fear of a recurring injury, and importantly get back in action quicker.  I will progressively add weights (static holding with fingers only) and one arm dead hangs on a bar, into their rehabilitation once full ROM minus pain is achieved.

My next client was recovering from a previously diagnosed and treated navicular stress fracture on their left foot caused through sprinting. They had been out of the cast for 2-weeks and were walking minus pain. Through assessment using passive/active ROM, I looked at the foot, ankle, and calf areas, where it was evident mobility and strengthening exercises were required through lack of usage.  I started the session by giving STR (Balletto, 2019) to the general area to warm up, and gently stretch the muscles, followed by a visible gait analysis on the treadmill, which indicated a neutral pronation.  I believe my STR skills and knowledge have improved significantly through progressive clinical practice, where I have learned to listen more to the client and adapt my practice accordingly post conducting further research if required.  From experience, I was aware, pain radiated along the inside arch of the foot and went away quickly with rest, often returning as training resumes, hence informed the client to remain cognisant of this and not to ignore pain if it occurs in their haste to return to full time training.  I felt the client appreciated receiving this advice and felt personally satisfied I had built a level of professional trust in the relationship.

Calf raises and exercises for the small muscles in the foot were provided and STR in the calf muscles to restore them to normal function. Through experience, I knew it was also important to eliminate factors which could cause the injury to recur, hence discussed the client’s equipment and training methods to determine if I could assist, as training errors in technique or overtraining may have caused the injury. I also discussed the use of orthotic inserts in their shoes, and I believe I have developed my communications in this aspect i.e., suggesting ideas to assist and improve clients’ performances and health.  Full ankle mobility and basic strength of the joint could be achieved within a week when gentle jogging should resume to build up to resuming normal training loads over a period of 6 weeks.  I was very satisfied with this session, as the client appeared to really appreciate the professional service they had received and feel my confidence levels are improving.

My next client was in the final stages of shin splint rehabilitation, initially thought to have been caused through using a weighted vest to increase resistance whilst running. The client has started gentle running again.  I conducted passive/active ROM followed by STR on the muscle areas around the tibia followed by a calf massage using effleurage, petrissage, and deeper stripping techniques.  I think the client really appreciated the massage and was ready to conduct stretching and strengthening exercises of the gastrocnemius & soleus muscle.  I also discussed and offered advice on running periodization (Severo-Silveira et al., 2021) which the client, really appreciated.  I feel I am getting much better at achieving a balanced professional bond with clients, through shared health and fitness interests, which allows me to interact much better during treatment.  I am, however, very aware, some clients may not appreciate receiving guidance on certain aspects of their training, hence will ensure I only offer guidance as the situation dictates.

References:

Aaron, D. L., Patel, A., Kayiaros, S., & Calfee, R. (2011). Four common types of

bursitis: diagnosis and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 19(6), 359-367.

Balletto, J. J. (2019). Soft Tissue and Trigger Point Release. International journal of

therapeutic massage & bodywork, 12(2), 31.

Lee, A. K., & Erdman, M. K. (2021). Analysis of Gait. Hoppenfeld’s Treatment and

Rehabilitation of Fractures.

Severo-Silveira, L., Dornelles, M. P., Lima-E-Silva, F. X., Marchiori, C. L., Medeiros,

1013. M., Pappas, E., & Baroni, B. M. (2021). Progressive workload periodization maximizes effects of nordic hamstring exercise on muscle injury risk factors. The Journal of Strength & Conditioning Research, 35(4), 1006-1013.

Williams, D., Richmond, S., Black, A., Babul, S., & Pike, I. (2020). Evidence

Summary: Basketball.

Zu Reckendorf, G. M., Artuso, M., Kientzi, M., & Jean-Claude, R. (2021). Collateral

ligament sprains of the metacarpophalangeal joint of the long fingers: Results of a surgical series of 15 patients. Orthopaedics & Traumatology: Surgery & Research.

Appendices

Appendix A: Finger Sprain

11^th May. Duration: 4 hours (2-clients)

My first client was an online appointment who was having trouble with their right hamstring and ‘felt’ they had possibly pulled it, but advised they were worried it was something more serious and wanted to get it checked. I tend to be more cautious when a client advises they are worried their injury may be something else, as it raises the possibility, they already know it is and are seeking more clarification or a second opinion or they may just be a naturally anxious individual.

I went through an assessment online that primarily consisted of assessing passive ROM of the lower leg, hip, and foot, comparing it with the clients’ uninjured side. It is always more difficult to gauge and record exact degrees of movement using visual means only online, which was not aided through a weak signal. However, I continued regardless and kept the communications positive throughout. I was keen to try and rule out a rupture, which although difficult identifying if there was a palpable gap and was unable to conduct a physical test by contraction of the muscle during a resistance test, which is usually painful with obvious weakness (Rolf, 2007). As I could not do this online, I booked my client in for a face-to-face appointment the next day with another clinician. I believe this appointment went well considering the circumstances and was satisfied I had done the right thing re-booking an appointment for the following day, given this client appeared very anxious. If I could do anything differently, I would ask more questions reference injury history, and tried to pinpoint the exact pain site to get more of an understanding reference level of injury the patient may be suffering from. I was terribly busy today, and feel I may have rushed the appointment slightly, which I must try not to do in future, regardless of other commitments, as the patients wellbeing is paramount (Visser et al., 2021).

My second client was face to face with a male hockey player aged 22, who thinks he may have pulled a groin muscle the previous day in a training session, when he went off, but then returned to play 10-min later minus warming up (Mason et al., 2021).  I gathered as much history as I could, where he described the pain now as a throbbing mild discomfort, which came on straight away after sprinting, turning, and hitting the ball, where he experienced a sharp twinge on the inside of his right thigh, but little pain.

I assessed the injury by observation and conducted passive ROM whilst palpating the groin and thigh areas, where some tenderness was evident, and conducted active ROM tests on the hip and short groin muscles and resistance tests, which all indicated he had obtained a mild strain, likely in his abductor longus, where he was feeling most sensitivity (Serner et al., 2015).  As the injury was less than 48-hrs old applied a cold pad for 10-min followed by an elastic adhesion bandage wrap, showing him how to apply the wrapping, starting, and finishing on the thigh muscle, informing him to keep applying ice for 10 minutes every hour initially, until his symptoms start to get better, which should be within 2-3 days. I informed the client I thought he had a grade 1 groin strain, and this this will help to stop any internal bleeding, reduce his pain and swelling to speed up the healing process.  I was aware, he did not seem too keen on bandaging, hence advised he could also use compression shorts, which were not as good, but better than nothing. I informed the client to return in 3-days, where he would be assessed and if progressing, we would start a rehabilitation programme, inclusive of massage, but he must not exercise during this period, and get rest.  If I could have done anything differently, I would have asked more questions about any previous injuries he had had, as if this was repeat injury, the grading may be incorrect, and his treatment would differ, hence I will ensure when he returns, I do this.

References

Mason, J., Wellmann, K., Groll, A., Braumann, K. M., Junge, A., Hollander, K., &

Zech, A. (2021). Game exposure, player characteristics, and neuromuscular performance influence injury risk in professional and youth field hockey players. Orthopaedic journal of sports medicine, 9(4), 2325967121995167

Rolf, C. (2007). The sports injuries handbook: diagnosis and management. A&C

Black.

Serner, A., Tol, J. L., Jomaah, N., Weir, A., Whiteley, R., Thorborg, K., … & Hölmich,

1864. (2015). Diagnosis of acute groin injuries: a prospective study of 110 athletes. The American journal of sports medicine, 43(8), 1857-1864.

Visser, E., Den Oudsten, B. L., Traa, M. J., Gosens, T., & De Vries, J. (2021).

Patients’ experiences and wellbeing after injury: A focus group study. PLoS one, 16(1), e0245198.

7^th May. Duration:6 hours (4 clients)

My first client was part of an online triage. He had pain in his shoulder from climbing out of a loft 2 months ago. I started a full assessment starting with his shoulder ROM. I was fine with the passive movements, then resisted, but I almost forgot to do passive. It was not until my supervisor came over and asked how the patients’ passive movements were that I realised I had forgotten; I put this down to lack of clinic time, but have made a mental note to ensure I include this in future assessments.

I assessed the patients cervical, thoracic and bicep movements, which went well, and I managed to get through these assessments relatively quickly. The hard part was trying to diagnose the patient as I currently feel a bit anxious through lack of clinic time, hence, to ensure I was doing things correctly, I used my reference book, which contained special tests for the shoulder.  I explained to my client I was referring to the book, and he appeared fine and understood I was keen to find out more potential reasonings for his injury. From this I was able to go through lots of tests to help with the diagnosing. Three tests were slightly positive, but also had elements of negatives, which made it harder to narrow down what it could potentially be. However, it did provide further indications on what directions to explore further.  I am also aware the tests do not provide with 100% accuracy, exactly what the injury may be, but doing them clarified this to me.

When my supervisor came in, through further questioning, she discovered that he had been carrying on with his cross-fit exercise regardless of his injury. Listening to the client, I could tell he was quite sad as it was impacting on his daily life activities. It was also evident to me; he was somewhat in denial. My supervisor suggested he conduct some home exercises, and I consequently went through these with the client to end the session before rebooking another clinic in 2- weeks’ time, to gauge his progress. I am aware I need to be more organised (Alfano & Collins, 2021), and will aim to stick to a set script moving forward with assessments, but I am pleased that I stuck with it and achieved a good outcome, and importantly, my client appeared happy and grateful, which is always nice to see.

My next client was a footballer who had hurt his knee. I previously assessed him last week post having fallen on his hip. During that first session, he mentioned his knee, but I prioritised his hip injury as this was causing him the most pain at the time. On reassessment, his knee was feeling a lot better, although still not fully recovered.

I consequently assessed his hip, knee, and ankle. This patients’ injury is of interest, as he has a bump on his knee, just below his patella on the lateral side, which he described as painful to touch. My supervisor came and asked further questions including how old he is, as it could have been a symptom of osglood-shlatters (Fig.1). However, the patient was 24 years old, and usually this is prevalent on younger patients whilst growing, hence an open verdict had to be made, as the supervisor was not certain. I subsequently conducted further research and determined it was more likely to be bursa of the knee, also known as handmaids’ knee (Fig.2), but as this identified as inflamed and red, I am still unsure. My patient explained he had suffered with this for 2 years. However, literature suggests bursa normally dissipates after stopping the exercise that caused, but this patient has never stopped exercising, hence it could still be a possibility. However, after researching further and comparing bursa photographs against my patients lump, it does not look similar hence rather than take any chances with the patients’ health, I advised him to visit his GP. My assessment process went well this time, with several special tests conducted and a full ROM.

I sometimes struggle interpreting test results and end feels (Fig.3). I believe this is through a lack of practical hands on, but am aware a guess will not suffice, hence I will highlight this to my supervisor at every opportunity during clinic times, to gain further practical experience.  I now also insert every test result in my laptop as well as writing down results. I feel more secure and confident doing this now, but I am certain I will become more competent through practice. At this time, my short memory skills are limited, and with several tests to perform I believe this is the right thing to do. The clinic was terribly busy, and my supervisor was busy when I requested additional assistance on treatment and diagnosis, so I thought it prudent to seek guidance from another student who was free. He redid Test 3, and in his opinion, thought it could be patella femoral pain and meniscus. Although not fully convinced, from my results I was edging towards a diagnosis of meniscus, as most of his pain was produced on the medial side through all my tests.

I used K-tape on his knee to relieve pain using a taping technique to stabilise and keep the knee in the correct position and added tape over the pain points. I then gave my client 2 exercises, as I knew from experience of this patient, his adherence to prescribed exercises was not good. Clams and resistance band exercises were performed post demonstrating them and explaining how to set up the resistance band. He seemed happy and told me he would do these exercises. I also prescribed a plan for general overall strengthening of his body and recommended he stop playing football for at least one week. However, as this client appears to carry on regardless of the high pain, I am hopeful by stopping exercise for a week we will start to see if his pain dissipating.

This next client was a middle-aged married man with a bad back.  He had two children and coached kids in skateboarding. He apparently had a demanding full time physical job, and my first observations where his posture was poor. Through conversation, he appeared quite sad and stressed, which if correct, will not assist his back pain.  During our online assessment, he told me he was primarily looking for a sports massage, as that seemed to help him in the past. I initially intended doing this immediately, however, post further discussions, I felt I could help him by providing some simple home exercises. I suggested yoga and Pilates may benefit in easing his back muscles as he lacked mobility from a combined previous injury, stress, skateboarding and bad posture. He appeared willing to try. Through passive assessment of his ROM in cervical, thoracic and hips, it was evident he had limited movement and experienced pain everywhere, especially on his right side. The client explained he is in constant pain but has got used to it. I was aware, I had to remain focussed and positive to find a solution hence got him to do the ‘open book’ exercise, as from personal experience I find this helps to open up the shoulder and spine.  I demonstrated the exercise well and showed him that although I find this exercise painful to do, with repetition, it his mobility will improve. He observed and then he tried it himself finding it useful. It gave me great joy when he continued doing it minus my encouragement and to see his mobility improve after only 10 minutes, which he was overjoyed at. I then tried other exercises explaining if he did not like an exercise, he does not have to do it because exercises are about what feels right for your body. Sometimes I find that people give their patients exercises, and the patient does not like it., which does not help with adherence. We tried ‘cat to cow’ But he really struggled with the arching his back and lifting his head part and found It extremely uncomfortable. So, I decided to quickly regress that part of the exercise and get him to just lift his head and nothing else. He liked this. I then got a resistance band and got him to put it behind his back to stretch and open his back, he found this relieving. I decided to stop there as I felt that was enough exercises for the first session and did not want to overload him.

I moved onto the sports massage, which went well as I am greatly confident in massage. I made sure to communicate during the entire session ensuring the client was not in any pain. I like to explain to clients that although I have professional skills, they know their body better than anyone and can describe ‘good’ pain against ‘bad pain’ and must let me know if experiencing bad pain. Throughout the massage I asked my client more probing questions to try adding to my subjective without being invasive; I believe clients tend to relax as they get a massage, and during this found out the client had an extremely busy life.  I also tried to push the Pilates/yoga suggestion, suggesting YouTube 10-minute sessions, as I believe short goals are better than no goals. The client agreed and advised they would try it.

Overall, my client was incredibly happy and importantly advised he certainly felt a lot of pain relief. I was satisfied my performance. If I were to do anything differently, I would have carried out the ROM assessment immediately instead of hesitating.

Fig 1: Osgood-Schlatter disease

Fig 2: Bursa of Knee

Fig. 3: End Feel Assessment

My next client was suffering from a bruised calf contusion, which occurred the previous day when kicked during a 5-aside football match.  Through assessment I found his passive/active ROM was impacted with relative pain around the impact area.  He was limping slightly, and the impact and surrounding tissue area was tender to touch with surrounding muscles painful when stretching.  The client advised he had not applied ice to the wound, hence I immediately instigated PRICE. As this injury was only 24-hours old, I advised the client we could not apply massage until 3-days had passed, as there was a risk of myositis ossificans (Saad et al., 2021). I was aware through reading that myositis ossificans can occur through failing to apply cold therapy and compression immediately after the injury, hence advised the client to continue PRICE every 10 to 15 minutes hourly or as much as time allowed, over the next 2-days, when he could return to the clinic to be reassessed. In the meantime, he must ensure he uses a compression bandage on the area, and proceeded to demonstrate its application, emphasizing it must not be too tight to restrict circulation, and to elevate the leg as much as possible.

I will reassess the injury after 72-hrs has elapsed, and if safe to do so, start a calf rehabilitation programme, first checking for contraindications via signs of acute muscle strains or deep vein thrombosis (Naschitz, 2021).  I was aware not to alarm the client, hence advised contraindications were rare, but always a possibility, hence we should always err on the safe side.

I also advised the client, if he felt any increased throbbing or cramping pain in his leg in the calf or thigh area with additional swelling in his leg with a feeling of warm skin around the painful area and further reddening or darkened skin appearing around the painful area or his veins became swollen, hard or sore when he touched them, or if he felt breathless or had chest pain to call 999 immediately, as this could be deep vein thrombosis (DVT).  I ended the session advising the client I would see him again soon to start a rehabilitation programme and assured him DVT was rare.

References

Alfano, H., & Collins, D. (2021). Good practice in sport science and medicine

support: practitioners’ perspectives on quality, pressure

and support. Managing Sport and Leisure, 1-16.

Naschitz, J. E. (2021). The Swollen Calf of Reperfusion Injury. An Addition to the

Spectrum of Pseudothrombophlebitis. International Journal of Angiology.

Saad, A., Azzopardi, C., Patel, A., Davies, A. M., & Botchu, R. (2021). Myositis

ossificans revisited–The largest reported case series. Journal of Clinical Orthopaedics and Trauma, 17, 123-127.

4^th May. 4 hours. (2 clients)

My first client was a 61-year-old male suffering from pain in both knees, which often woke him up at night, especially when he lay on his side and one knee rubbed against the other.  Through passive/active ROM assessment, he described how he was diagnosed with mild arthritis in both knees, elbows, and hands, and to combat such liked to try and keep fit by walking 20km per week and once or twice a week some resistance training with light weights, and during these he did not feel any, or only slight pain once warmed up.  He advised he was physically active running marathons up until he was 45-years old but could no longer run through knee pain and constant muscle tears in legs.  During active ROM, I got the client to slowly bend his knees (using chair support), which caused pain in both knees, and through palpation he advised there was pain when I pressed along the joint line on the inside of his knees. McMurray (Goossens et al., 2015) test and Apley’s test (Yan et al., 2011) indicated the possibility of a medial meniscus tears, however, given the clients age, history, arthritis diagnosis, and current activity levels, I believed it was more likely cumulative injuries caused through wear and tear and his degenerative arthritis. I advised him to visit his GP and suggested an MRI scan, may identify if he had meniscus damage, perhaps caused through his degenerative arthritis (Xu et al., 2021).

During the assessment I was very aware, the client wished to continue keeping fit, was keen to do so, but upset he could not train at the levels he would like to. I did not wish to dampen his enthusiasm, but if my diagnosis were correct, realistically, he would have to ‘tone down’ his activity levels, hence I remained positive, and suggested some alternative exercises/sports (cycling/swimming), which may assist him to keep fit minus impacting directly on his knees whilst still allowing him to train at the levels he wished.  I believe the client appreciated hearing he would be able to continue training. I conducted mobility exercises (flexion-extension); heel slides with resistance bands and strengthening exercises (isometric hamstring contractions), static squat contractions, calf raises, hip abduction, bridges, half squats, and balance board. I also demonstrated some plyometric exercises (Arhos et al., 2021) and agility drills, for him to work on.  If I could do anything differently, I would have got him to use the static bike to see if he felt any discomfort in knees, as this may have provided more substance to our discussion, but regardless, I felt the session went very well, and I certainly learned a lot about mindset through speaking and listening to an older athlete.

My final client today was online.  An 82-year-old female who had slipped and fell whilst walking 3-days previously, bumping her head, and damaging her hand and fingers in the fall (Fig 1).  Her daughter was on the call assisting. She had attended Derriford A&E and no broken bones or concussion had occurred, but she had a badly bruised hand and arm with some stiffness in her right wrist from extending her arm to try and halt her fall.  I conducted a passive ROM assessment noting she had no obvious swelling, but some restricted mobility in her hand/fingers, which was likely a grade 1 sprain, hence post advising to conduct PRICE every 2-hours using crushed ice bag or frozen vegetable bag covered with a cloth until they had purchased a proper ice pad, I advised her we would do some gentle exercises, but not to do anything that caused her pain. I wished to increase her range of motion into pronation and supination, hence some gentle wrist flexor stretching was demonstrated, followed by her daughter assisting her to stretch and strengthen her supinator, biceps and brachioradialis muscles. I also demonstrated some hand exercises using play putty and some strong rubber elastic bands, which she liked, and advised purchasing a light resistance band (Fig 2 & 3), as (Di Lorito et al., 2021) recommended.

Fig 1. Bruised hand and arm

Fig. 2: Resistance Band grades

Fig 3: Example – Resistance Band Poundage (different manufactures may differ)

I was very aware and slightly concerned the lady may overdo these exercises, hence constantly emphasised to her daughter and her that she must take her time in her recovery to prevent further injuring herself.  In my limited experience of treating the elderly, I have learned that individuals and family groups supporting do not need superficial reassurance and that this could be perceived as patronising. I have become acutely aware some patients respond better to open and frank discussions; particularly elder patients, whilst some hang onto your every word and have real trust in your professional advice and abilities, hence this makes me even more determined to ensure I really make it safe for them and achievable, particularly if they are on limited budgets.  It is often more helpful to acknowledge their emotional distress and fears and reassure them that their response, whatever it is, is normal and expected. If I show that I can cope with their distress I can assist them to get the support, they need and this will be critical in getting the best outcome for clients like this elderly patient.

References

Arhos, E. K., Capin, J. J., Buchanan, T. S., & Snyder-Mackler, L. (2021). Quadriceps

Strength Symmetry Does Not Modify Gait Mechanics after ACL Reconstruction, Rehabilitation, and Return-to-Sport Training. The American journal of sports medicine, 49(2), 417.

Di Lorito, C., Long, A., Byrne, A., Harwood, R. H., Gladman, J. R., Schneider, S., …& van der Wardt, V. (2021). Exercise interventions for older adults: A systematic review of meta-analyses. Journal of sport and health science, 10(1), 29-47.

Goossens, P., Keijsers, E., Van Geenen, R. J., Zijta, A., Van den Broek, M.,

Verhagen, A. P., & Scholten-Peeters, G. G. (2015). Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. journal of orthopaedic & sports physical therapy, 45(1), 18-24.

Xu, D., van der Voet, J., Hansson, N. M., Klein, S., Oei, E. H., Wagner, F., … &

Runhaar, J. (2021). Association between meniscal volume and development of knee osteoarthritis. Rheumatology, 60(3), 1392-1399.

Yan, R., Wang, H., Ji, Z. H., & Guo, Y. M. (2011). Predicted probability of meniscustears: comparing history and physical examination with MRI. Swiss medical weekly, 141(4950).

30 April. Duration: 6 hours (4 clients)

I paired up with another clinician for my first client today who was in the late stages of recovery from an adductor strain. We assessed his passive/active ROM before the rehabilitation session to gauge progress. Previously angles had been recorded; using eye judgement, for the patient’s knee flexion and lying abductor flexibility, and we noted a difference of approximately 5-degrees today. I agree eye judgements for angles can be used depending on the individuals experience, as from personal dance experience, I am used to using angles for foot and hand placements, hence I am personally proficient at making accurate angle judgements, but of course if complete accuracy is required a double-armed goniometer, gravity-based inclinometers or increasingly smart phone technology should be used (Shin et al., 2012).

*Ranges are for people of all ages. Age-specific ranges have not been established; however, values are typically lower in fully functional elderly people than in younger people. Extension beyond midline

Fig. 1 A selection of ROM Angles

Through research, I found this site particularly useful for a starting point (URL link here): Normal Values for Range of Motion of Joints*  (Fig. 1). After recording the angles of ROM and discussing improvements, we chatted to the client who was incredibly happy with his progress.

I believe this is a good way to relay information, as it helps the client’s motivation to provide short term goals and achieving them. Rehabilitation followed using the Aspetar protocol (URL link here): Aspetar protocol .

The session went well, and we provided lots of encouragement and observed the client ensuring their technique was correct. I think it is important to constantly provide positive feedback to clients throughout their session, even when things may not be going well for the client.  After the last session, we decided the client may benefit listening to music with a beat to assist him with the rhythm during agility work with the ladder (Silva et al., 2021). This worked well and did help him improve and importantly relax and appeared to help with the apprehension he exuded during the previous session.  I did not ask the client, but I should have done, as I believe the music made distracted him enough minus impacting on the exercise, as it came more naturally to him, assisting his nervousness. If the client does not mind, I will use music with these types of exercises after seeing how well it assisted this client.

If I could do anything differently, I would have conducted more stretching at the end of the session, as I felt we did not do enough, as the client was in a rush to leave for another commitment. We could have planned the timing of the session allowing more time for the cool down stretches, as this is an important part of rehabilitation.

I will also use my watch alarm more, to alert me via prompts where I should be in the session, allowing ample time for a proper cool down in the future.

The next female client was via an online consultation who described having pain in her feet when exercising. I enquired about her footwear, as from experience, I know this is often a simple but disregarded element in fitness training, and therefore an important part in the diagnostics. The client advised she had been running in air max trainers for the last few months, which from personal knowledge, are not designed as a running shoe; although are marketed as such, and most probably did not give the client the support she needs. Difficulties looking at the client’s feet online, prohibited a proper examination, as I wished to see if the client had flat feet, as this is risk factor for plantar fasciitis (Neufeld & Cerrato, 2008).

The client was reluctant to show me her feet online, she did not say this, but I could tell by her mannerisms she felt uncomfortable when showing me initially. So, I did not labour on this, rather I spoke to her and conducted a subjective assessment. I think I did well to notice and acknowledge my patient’s feelings and adapted the appointment to suit her requirements. I believe it is important to take note of the client’s demeanour, as often by saying the wrong thing, could prevent them from seeking help, hence if it takes a bit longer with the diagnosis, so be it. I booked her in for a face-to-face appointment and suggested she elevate her foot as much as possible at rest and use PRICE. I also tentatively suggested she think about investing in properly supported running shoes. The client seemed happy with the suggestions. I will assess the clients foot mechanics and conduct a full lower body assessment at the next appointment. If I could have done anything different, I would have taken more time, as I feel I slightly rushed the appointment as I was personally feeling slightly anxious on this day, perhaps caused through having to discuss this online with the client rather than face to face, which I always feel lacks the personal touch.

The next client was a face-to-face appointment with a client recovering from an ankle sprain. They were in later stages of rehabilitation and a client of another clinician that unfortunately could not make it that day.  I reviewed the previous notes of the client and talked to my supervisor about their progress to plan the rehabilitation session, accordingly, negating a requirement for the client to explain everything to me, which I know may have frustrated them slightly causing demotivation, and regardless, it was the professional approach to take. With the client I went predominantly focussed on strengthening and proprioception work.

My favourite rehabilitation methodology is proprioception, which I find interesting, believing it is such an amazing skill to acquire with several challenges requiring focus to achieve aims (Khorjahani et al., 2021).  I planned the session starting with a passive/active ROM followed by a warmup, strength, mostly utilising the assisted squat machine, with calf raises and loading weights appropriately for the client’s ability. I ensured I was careful not to overload, but also use enough loading to achieve progress. I did not find this hard to do as I communicated well with the client and loaded the weights slowly to find the perfect load. I added tempo with the calf raises to progress the exercise as my client was very capable and had zero pain.

I moved onto proprioception and worked up to the unstable surface to make sure the client was ready to add the bosu-ball to their balances (Wang et al, 2021).  She was ready and once on the ball, she was very wobbly, but I was able to talk her through techniques to help her, which improved her balance in a short space of time. I did this through telling her to hold her core, find a spot on the wall to focus on and keep her body engaged but relaxed. Although it took longer than expected for my client to understand and comprehend what I was saying, she eventually grasped it. I believe I maintained good patience throughout this. I will work on finding a simpler explanation reference these techniques before the client attempts an unstable surface, to give them more confidence. I have noted this down and will try a different approach next time. Overall, the session went well, and I was pleased with how calm I remained during the session (Lucre & Clapton, 2021).

My final client was an online appointment with a 45-year-old male who informed me he was a long-distance runner. He explained he had noticed a slight swelling at the back of his knee, which he felt was stiffening up restricting his mobility. He said it was not particularly painful, but he had never felt this before, although he had had several knee injuries in the past.  I got the client to show me the site of the swelling (right leg) against his left leg, and although slight, I could see some swelling. I informed the client to perform PRICE on the site of the injury at this juncture, and rest as much as possible.  I booked him in for a face-to-face appointment in 2-days’ time, during which I would perform a full assessment.  I thought it prudent to inform the client there were several potential causes (popliteal cyst, underlying knee injury, such as meniscus, arthritis etc), to give him some confidence in my abilities.  I was also aware it may be a tumour or aneurysm hence although I did not relay this to the client, I advised him if he felt it was getting worse, had painful swelling, tingling or numbness anywhere, he should seek advice from his local GP or attend A&E in the first instance.   If I could have done anything different, I would ask the client if he was on any medical prescriptions related to blood disorders and have tried a bit harder to get the client in for a one-to-one check-up quicker, but he was adamant he was unavailable for 2-days.

References

Khorjahani, A., Mirmoezzi, M., Bagheri, M., & Kalantariyan, M. (2021). Effects of

TRX Suspension Training on Proprioception and Muscle Strength in Female Athletes with Functional Ankle Instability. Asian Journal of Sports Medicine, 12(2).

Lucre, K., & Clapton, N. (2021). The Compassionate Kitbag: A creative and

integrative approach to compassion‐focused therapy. Psychology and Psychotherapy: Theory, Research and Practice, 94, 497-516.

Neufeld, S. K., & Cerrato, R. (2008). Plantar fasciitis: evaluation and

treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 16(6), 338-346.

Silva, N. R. D. S., Rizardi, F. G., Fujita, R. A., Villalba, M. M., & Gomes, M. M.

(2021). Preferred music genre benefits during strength tests: Increased maximal strength and strength-endurance and reduced perceived exertion. Perceptual and Motor Skills, 128(1), 324-337.

Wang, H., Yu, H., Kim, Y. H., & Kan, W. (2021). Comparison of the Effect of

Resistance and Balance Training on Isokinetic Eversion Strength, Dynamic Balance, Hop Test, and Ankle Score in Ankle Sprain. Life, 11(4), 307.

27^th April. Duration:4 hours (2 clients)

My first client was a 23-year-old female rugby player who had been stamped on during a rugby ruck, around her right buttock, 3-days previously, and her trainer advised her to visit the clinic.  She told me she had been using ice daily, and through observation, bruising was evident, but not excessive, and during passive ROM she advised the area still felt a bit stiff and in active ROM her glute muscles were slightly tender to touch, causing mild discomfort when sitting down. I was aware of contraindications with this injury, including hematoma (Burton et al., 2021), compartment syndrome (Jackson & Schreyer, 2021), Compartment Syndrome Symptoms; spondyloarthropathies (Kiratiseavee & Brent, 2004), tumour or Infections of bone and joint, however, given the injury history, symptoms and observations, I was satisfied this was mild to medium bruising, which would dissipate with continued ice treatment, rest and gentle stretching. In treating this client, I was aware she had some apprehension reference her injury, which although having taken knocks elsewhere, had never had a buttock injury, hence was worried hence, I constantly reassured her it would be fine. I conducted some gentle stretching of the gluteus maximus in the supine position (front & back) on both sides, including leg raises.  I advised the client to continue with gentle exercises until pain free, when she should start loading the exercises with light weights on leg raises and/or use resistance bands, and to use a heat pad once all swelling has gone.  I finished the session advising the client if she felt the bruising was getting worse or the pain was intensifying, then she should visit her GP.  Having conducted pitch side support in rugby assisted me to communicate with this client, as I felt she was comfortable discussing her injury whilst talking about the sport, which she clearly loved.  I have learned communications, in conjunction with sport knowledge and anatomy, is a vital part of sports therapy, which must constantly be improved to put the client at ease quickly, as this often encourages clients relax more, which can engender greater knowledge of their injuries and concerns.

My final client today was a 32-year-old male who was at stage 4 of recovery from a groin strain received playing football.  The client advised he had suffered several groin strains over the past 10-years, which often indicates weak abductor muscles (Esteve ET AL., 2021; Serner et al., 2021). Through passive/active ROM the client had progressed significantly through phase 3 exercises (dynamic groin exercises with resistance band/cables and dynamic exercises involving movement against resistance) and had started functional exercises (side lunges/ wide leg squats using resistance bands (Beato et al., 2021). Having worked extensively with football teams in year one of the course, I felt confident providing a variety of functional exercises to enable this client to progress using progressive loading during strengthening and, proprioception training to improve awareness and balance.  The client wished to progress quicker, but through gentle reminders reference his injury history, I was able to get him to focus more on building his abductor muscles through stretching and importantly progressive loading, as it was clear this was a weak area in his muscles, which had failed him several times.  I believe being firm and honest with clients is often the best approach; particularly with younger clients, who often just want to get back playing and consequently have short-term goals.  If I could have done anything differently, I would have asked the client what position he played, as this does have a bearing on specific exercises i.e., left or right of park and activity on the park.  I will ensure I follow up with the client to determine this for his next session.

References

Beato, M., Maroto-Izquierdo, S., Turner, A. N., & Bishop, C. (2021). Implementing

strength training strategies for injury prevention in soccer: scientific rationale and methodological recommendations. International journal of sports physiology and performance, 16(3), 456-461.

Burton, H., Mossadegh, S., & McCarthy, R. (2021). Hockey: a pain in the butt!

Isolated superior gluteal artery rupture following blunt pelvic trauma–an unusual case. The Annals of The Royal College of Surgeons of England, 103(3), e91-e93.

Esteve, E., Casals, M., Saez, M., Rathleff, M. S., Clausen, M. B., Vicens-Bordas, J.,

… & Thorborg, K. (2021). Past-season, pre-season and in-season risk assessment of groin problems in male football players: a prospective full-season study. British Journal of Sports Medicine.

Jackson, J. R., & Schreyer, K. (2021). A Pain in the Butt: A Case Series of Gluteal

Compartment Syndrome. Clinical Practice and Cases in Emergency Medicine.

Kiratiseavee, S., & Brent, L. H. (2004). Spondyloarthropathies: Using presentation to

make the diagnosis. Cleveland clinic Journal of medicine, 71(3), 184-207

Serner, A., Hölmich, P., Tol, J. L., Thorborg, K., Lanzinger, S., Otten, R., … & Weir,

134. (2021). Progression of Strength, Flexibility, and Palpation Pain During Rehabilitation of Athletes With Acute Adductor Injuries: A Prospective Cohort Study. journal of orthopaedic & sports physical therapy, 51(3), 126-134.

23^rd April. Duration:6 hours. (4 clients)

My first client today was at stage 4 recovery from an ankle sprain caused through playing football, which has a propensity for these types of injuries (Waldrop et al., 2021).  I assessed his passive/active ROM on his ankle, which were particularly good and provided STR to both his calfs followed by functional football exercises.

Whilst working with a football team I was fortunate to have worked with and experienced several sports therapists, which in hindsight, was a fantastic learning opportunity, which I really enjoyed (Leeder et al., 2021). I was learning in a live sports environment, whilst observing the way football club physiotherapists take care of individual players/patients, observing their professional demeanour, reactions, quickly collecting, deciphering, and using the clinical information before administering treatment as quickly but safely as possible. I was also enlightened as to the responsibility and power they ultimately possess, as the decision to take someone off during vital games was always discussed directly with team managers, but ultimately, if the therapist decided it had to be done, it predominantly happened.

I have gained so much knowledge over the past three years, albeit Covid-19 lockdown, seriously impacted on my ability to learn in a practical setting, which did set me back somewhat, but regardless, I feel my confidence and experience levels are returning, and I am more aware of why and how things are conducted within a live sports therapist’s environment. I have always put patient care at the heart of my learning and through self-reflection (Iliff et al., 2021), adapting this with critical thinking has enabled me to make sound judgments, although I am aware, I still have so much to learn. Critically reflecting (de Schepper et al., 2021) on my experiences to date has shown me that communications with patients, physiotherapists, and their managers; in a sports environment, or within a family situation, produces the best outcomes.

My second client was a swimmer, and presented with a shoulder injury, which she described as an aching pain on the front and outside of her right shoulder joint, which had come on gradually over 4-5 days. I sometimes struggle diagnosing shoulder injuries, hence although I remained hesitant to confirm, from research conducted, this sounded like a clinical sign of impingement syndrome (Bolia et al., 2021). With support from resident clinician at hand, I continued my assessments and special tests (60-degree pain ark; Neer’s sign; Halkind Kennedy Test; Empty can test). I undertook a detailed history and explored their pain during the assessment of their passive/active ROM and found a clear pattern of restricted movement and pain symptoms, which objectively were pointing towards my initial thoughts. I think I need to work slower, and although time is always tight, if I can learn to work more methodically, working through all possibilities; perhaps using a mind map technique, this will assist. I calmed down a bit and was able to logically rule in and out structures at fault to dismiss certain injuries, which really assisted me to come to a clinical diagnosis to move to a treatment plan, which the clinician agreed with (PRICE), to be followed with mobility and stretching after 4-days.

My third & forth clients today were dancers recovering from piriformis syndrome (Fig.1) whom I last treated on 24^th March ’21.  It was good to see them both, and post passive/active ROM assessments, it was clear they were both recovering well.  As a professional dance teacher, I know have a soft spot for this profession, and continued to provide functional exercises to assist them to be more flexible and strengthen their weak areas.  I conducted STR on both clients in conjunction with foam rubber exercises.

Fig 1. piriformis syndrome

One important thing I have come to learn is to make time to get to know a client as I believe it is important that as sports therapist professional, we take time to listen to patients’ concerns. I also realize that it is important to provide the opportunity and setting for patients to feel comfortable providing honest feedback about the care that I or others are providing, as minus such feedback it may prove

difficult if not impossible to address potential problems. As a dancer, I knew these clients from teaching, and this certainly assisted to motivate them. I am aware personal rapport is naturally built between the client and the therapist, and sometimes find myself being asked to meet up for a coffee with clients post treatment. However, I know there is a professional and personal boundary line, which must be maintained, regardless of friendships, and in these situations, I have used jokes to lighten the atmosphere.

References

Bolia, I. K., Collon, K., Bogdanov, J., Lan, R., & Petrigliano, F. A. (2021).

Management Options for Shoulder Impingement Syndrome in Athletes: Insights and Future Directions. Open access journal of sports medicine, 12, 43.

de Schepper, J., Sotiriadou, P., & Hill, B. (2021). The role of critical reflection as an

employability skill in sport management. European Sport Management Quarterly, 21(2), 280-301.

Leeder, T. M., Warburton, V. E., & Beaumont, L. C. (2021). Coaches’ dispositions

and non-formal learning situations: an analysis of the ‘coach talent programme’. Sport in Society, 24(3), 356-372.

Iliff, S. L., Tool, G. M., Bowyer, P., Parham, L. D., Fletcher, T. S., & Freysteinson, W.

8. (2021). Self-reflection and its relationship to occupational competence and clinical performance in level II fieldwork. Internet Journal of Allied Health Sciences and Practice, 19(1), 8.

Waldrop, N. E., Cain, E. L., Bartush, K., & Ochsner, M. G. (2021). Ankle Injuries in

Football. In Football Injuries (pp. 59-79). Springer, Cham.