Date: 05/05/2021
Hours: 6
Total hours: 64
This session in the clinic began with observing another therapist with their client who had complaints of hamstring pain. The client had localised pain in both hamstrings at the muscle belly which did not radiate. The client frequently goes to the gym and takes part in cross fit, they aim to join the army for training in a month’s time.
Upon objective assessment, the client’s ROM was assessed at the hip, knee, and ankle joints. This was to clear the joints to rule out other pain or pathologies, there was no pain in any of these movements. There was a reduction in ROM during the straight leg raise (SLR) in the right hamstring compared to left. there was also some pain and reduced ROM during knee flexion in the right leg. When assessing the lower back, there was pain and reduced ROM in lumbar flexion and side flexion at both left and right.
Upon palpation, there was tightness in both hamstrings at the muscle belly and towards the hips. The lower back was palpated where there was a significant amount of tightness and some pain on palpation at the quadratus lumborum. The Lx spinous process L1-L5 was palpated where there was some stiffness at L2-L4. This tightness may cause some restriction during the client’s movement during exercise. The quadriceps were also then assessed with some tightness however there was no pain on palpation.
Functional movements were assessed where the clients squat and lunge performance were assessed however there was no obvious problems and both movements were completed with no pain.
Special tests were carried out to help identify the cause of pain. The Thomas test was completed to identify tightness at the psoas and hip flexors and tightness with the rectus femoris. Resisted movements at the hamstring in leg extension was also completed to identify a weakness within the right hamstring muscles. The client’s glute firing pattern was also assessed to identify whether there was a weakness in the glute and how it contracts, suggesting that the hamstrings may be over working.
The clinical impression was a hamstring tendinopathy due to the location of pain and the weakness of the hamstring. A differential diagnosis was a hamstring/glute weakness and lower back muscles overworking.
The therapist working with the client provided a soft tissue massage to the lower back and suggested some exercises which can help to increase strength at the hamstrings. Exercises included single leg RDL’s, hamstring bridge, and banded kickbacks to be completed 5-8 reps. 3 sets approx. 3 times a week until next appointment.
The next client was a follow up for left shoulder pain which radiates down the arm. The client has not had any improvements since last speaking during their triage the previous week.
Upon objective assessment, ROM of the Cx was assessed to clear the joint where there was no pain and FROM. The ROM of the left shoulder was assessed where there was pain experienced in flexion at 90 degrees, extension, abduction, and external rotation.
Palpations of the shoulder, Tx, Cx and clavicle were also completed where there was tightness identified in the rhomboids and deltoid. The spinous process of C7-T2 were found to be stiff with pain on the right transverse process of T2,T4,T5, T6. There was pain on palpation at acromion, GH joint and the supraspinatus which also recreated pain symptoms down the left arm.
Special tests were then completed. Neers was positive at 90 degress. Hawkins kennedy was also positive and recreated pain symptoms radiating down the arm. Painful arc and empty can tests were also completed however did not experience any pain. The two positive tests suggested that there was an impingement at the shoulder.
The clinical impression of this was tendinopathy of the pectoralis muscles. A differential diagnosis of this can be a shoulder impingement of the supraspinatus.
Exercises provided via email were as follows:
Iso wall press (press up position): 30s x 4
Iso wall press (hands above head): 30s x 4
Shoulder pro/re: 12 x 4
Wall assisted internal/external rotations: 12 x 4
To be completed every other day until next appointment.
In future sessions, the focus will be to strengthen the pec muscles and serratus anterior. Progress to eccentric work for the pecs, and general strengthening for the serratus anterior, to decrease force applied to pecs.