Day 20 – Sports Therapy and Rehabilitation Clinic
Duration: 3.5 hours Cumulative hours: 172.15
Preparation before clinic
I spent some reading through by first patient’s notes. He is a long-distance runner who would some help with improving his speed to achieve his goals of achieving PBs at 10K, half marathon and marathon distances. He is also beginning his journey as a triathlete. His first triathlon at sprint distance is in August 2021 and his first half iron-man is in July next year. He asked for a clinical assessment and gait analysis. I went through the gait analysis workshop notes and accompanying literature.
I also attending a meeting on teams with my clinic supervisor and the senior technician for the sports lab about performance testing to establish maximum HR. He explained that we could run a VO2 lactate threshold performance test to establish our athlete’s maximum HR to guide his training in the correct HR zones. Due to COVID restrictions the university are not able to run performance testing in the lab until 21 June 2021. Each performance test is quite time intensive and uses materials that the university has to pay for so the test would be charged for. Whilst this is very intensive this was not what I originally had in mind. I could run a field test on a running track that would only cost me and the athlete time. The test that I planned to run was getting the athlete to run 4 x 2 minutes fast with 1 minute recovery and record the athlete’s maximum heart rate after the fourth interval. I could work out the heart rate zones using the following equation:
206.9 – 0.67 x Age (Gellish et al., 2007)
Patient 2
I read through my second patient’s notes. I have been helping this patient with rehabilitation of chronic insertional Achilles tendinopathy. If rehabilitation has gone well my intention was to add higher intensity plyometric exercises to increase the stiffness in the tendon.
Wednesday Clinic – 12.05.21
Patient 1
I carried out a clinical assessment of the patient’s hip flexor flexibility, glute strength, lumbopelvic stability, calf strength and flexibility and single-leg stability. I also carried out a gait analysis and baseline body composition analysis.
The patient’s goals were to achieve personal best times at the following running distances:
- sub 42 minute 10K – current PB 42:12
- sub 90 minute half marathon – current PB 1 hr 32 minutes
- sub 3 hr 15 minute marathon – current PB 3:27:56
The patient is training for a sprint triathlon in August 2021 and has also entered the Manchester half marathon in October 2021 and a half ironman in June 2022. He isn’t currently following a specific training programme.
The results of the clinical assessment revealed
- Patient has tight hip flexors on the right side.
- Ankle dorsiflexion is restricted as reflected in the Knee to Wall results.
- Eccentric phase of the calf raises was quick and uncontrolled. Patient was stronger isometrically
- Strength in left adductor is < than the right.
- Glute Max strength is weaker on the left side.
- Single-leg stability could be improved on both L & R sides. Stability is < on the left side.
During the gait analysis the patient’s trunk was upright and he ran lightly on the forefoot. The patient was recorded running on the treadmill from the side for 1 minute and from the back for 1 minute. When observing the patient from behind, it was noted that the left hip was slightly higher than the right. I will be able to establish how much of a difference when the video footage is viewed via the HUDL app. Body composition data was also collected.
The plan is to analyse the clinical assessment results, the gait analysis video footage and the body composition data to inform the design of an S&C programme to address muscle imbalance in the hips and adductors, increase flexibility of hip flexors and improve single-leg stability.
The patient also confirmed that he was willing to undergo performance testing on the treadmill after 21 June 2021.
I found it very interesting to go through the running clinical assessment and strength testing, the gait and body composition analysis. I must try to remember what objective measures that I can use to help establish if improvements have been made, especially after the patient has completed an S&C programme. Future muscle strength testing can be done with a hand-held dynamometer or isokinetic dynamometer. Also include other objective measures such as a patient questionnaire and Rate of perceived exertion (RPE) during the strength testing. Also explore the strength of the hamstring/quads and redo body composition analysis in 4-6 weeks post-training.
Patient 2
When the patient arrived in clinic I observed a slight limp in the right leg.
The patient completed a VISA-AT questionnaire. The score had improved from the previous weeks and was currently 68. It was clear the tendinopathy was improving.
The Patient confirmed that he had received the couch to 5K running programme that I sent to him by email however he hasn’t been able to run because he has had a fungal nail infection in the big toe on his left foot. The infection has cleared up but the patient now has pain on the medial side of his right knee. In certain positions the pain is sharp. The patient reported that
the pain is not inside the knee, but it ‘feels more like it is on the outside’ of the knee. He does not experience pain when walking up and down stairs and there is no locking or giving way of the knee. Occasionally the patient does experience LBP but the pain does not radiate down the legs.
He is doing the home-based exercises to rehab the chronic insertional achilles
tendinopathy in the left ankle. He hasn’t been able to perform the knee extension exercise with the resistance band on his right leg. The exercise aggravates the pain in his right knee.
We began going through the exercises from the patient’s home-based exercise programme however the first exercise, which was double-leg pulses aggravated the patient’s right knee. I carried out a clinical assessment of the knee.
I began with active ROM. I made a rookie mistake and forgot to test the unaffected side first, however it was clear that the left knee is unaffected. The patient felt pain in knee extension (1/10 NPRS) and tightness with slight pain in knee flexion (1/10 NPRS). Pain was not aggravated further with overpressure. The patient experiences tightness in the right knee during internal and external rotation but no pain. I palpated the joint line, tibial plateaus, lateral condyle, tibial tuberosity & soft tissue above the patella, none of which elicited any pain. However when I palpated the medial condyle the patient jumped and complained of pain. I palpated the medial condyle on the left knee and there was no pain. The pain was very localised on the medial, right knee. There was some slight discolouration (redness) and some minor effusion. Temperature of medial side of the knee was cool to touch with inside of forearm.
My first impression of the injury is that the MCL had been put under stress as a result of compensatory movement by the patient to avoid putting pressure on the left big toe when walking. Other differential diagnoses could be the meniscus but the patient had no pain when I palpated the tibial plateaus and around the joint line of the knee. The other possible injury could be pes anserine bursitis, but the patient experienced pain on the medial epicondyle which is slightly higher up the limb than the pes anserine bursa.
I revised the patient’s home-based exercise programme by removing the resistance band from the knee flexion/extension exercises and the side-lying abduction/adduction exercises. The patient to continue with the eccentric loading protocol for the Achilles tendinopathy by performing the concentric part of the heel raises double-legged and the eccentric part single-legged with a bent knee:
Eccentric Loading Protocol on flat surface.
3 sets of 15 reps, twice per day, 7 days per week.
– Straight Leg Heel Drop .
– Bent Leg Heel Drop.
Isometric exercises for hips and upper thigh – unloaded. Exercises to be slowly taken to end of range, held for 5 seconds, and slowly returned to starting position.
3 sets of 15 reps, twice per day, 3 days per week.
– Quad Extensions
– Standing Hamstring Curls
– Side lying abduction,
– Side lying adduction
In the event that the right knee does not improve when the patient attends his next appointment, I will carry out a clinical assessment of the knee, a
Valgus Stress Test to rule out MCL laxity. If the MCL is injured it can be treated with ultrasound to enhance the healing process. If the injury is pes anserine bursitis and inflammation is present – inflammation can be reduced with ultrasound.
For chronic insertional achilles tendinopathy – the patient will be asked to complete a VISA-AT questionnaire and to perform knee to wall test as objective measures to establish if there has been an improvement in the tendinopathy and ankle dorsiflexion.
I checked with the patient about how he was feeling about the setback in his progress and he was quite upbeat. He just said that it was ‘life’ and he just ‘had to get on with it’ but he wasn’t unhappy. He was going away on holiday with his family towards the end of May and was looking forward to it. I believe this was contributing to his more positive frame of mind.
References
Gellish, R. L., Goslin, B. R., Olson, R. E., McDonald, A., Russi, G. D., & Moudgil, V. K. (2007). Longitudinal modeling of the relationship between age and maximal heart rate. Medicine and Science in Sports and Exercise, 39(5), 822–829. https://doi.org/10.1097/mss.0b013e31803349c6