Hours gained: 5
Total hours: 16
The first client I had this week was an initial consultation. A man had been struggling with two pathologies for three months, his right ankle and lower back. The pain in the right ankle was worse so we focused on that first. He experienced pain in his Achilles tendon when playing football but it eased after a while. He didn’t feel any pain when he was resting. The onset of the injury was gradual and he couldn’t remember a specific time it started hurting. The only easing factor he had was rest. He tried thermotherapy and cryotherapy however it did not help him. When palpating the Achilles tendon, there was an increase in pain over the mid-portion of the tendon. There was also a 10° difference between left and right dorsiflexion and all movements increased pain in the right ankle. There was very limited movement (AROM and PROM) in eversion and inversion as well. This could be because of a mechanical problem. I didn’t carry out any special tests as I knew it would be an Achilles tendinopathy in the reactive stage. de Jonge et al (2011) found that 35% of all Achilles tendinopathies occur within the mid-portion of the tendon. The pain also only came on with exercise and reduced almost immediately after. These are some of the reasons I thought this would be tendinopathy. I massaged the calf to release the muscles and to help relax it whilst having a conversation about what tendinopathy is and how to manage it. I spoke about the importance of rest and recovery. This came easy as I had dealt with tendinopathy last week. The client mentioned that he couldn’t come back to the clinic as he will be able for a few months so I prescribed some exercises with progressions as well.
The back pain started a couple of years ago and had slowly built itself into a problem. He felt pain when running and any rotational movements felt “tight”. I palpated all the muscles around the lumbar spine and they didn’t increase pain, they also didn’t feel taut. I ensured there wasn’t any peripheral pain down the legs and that the pain was localised. After last week I researched and practiced PA’s (passive accessory movements) for the facet joints so this is what I started with. When doing central PA, the pain was on L5 and unilateral PA was painful on L5 (left). This was the treatment I used as well. Both PA’s were done at grade 2 for 60 oscillations, 3 sets. This is due to the total amount of oscillations equating to 180 (Ganesh et al., 2015). Exercises that were given to this client were: bear crawl exercises (3 sets of 12), plank (3 sets of 30 secs, increasing the hold time as they can), glute bridges (3 sets of 12) and calf raises (3 sets of 15, going from double leg to single and then adding weight when necessary).
I was very apprehensive about my second client because she had Chronic Fatigue Syndrome (Fibromyalgia) and I had never treated someone with that before. Alex decided to brief me about common symptoms of the condition and how patients usually present themselves which I didn’t know about. The symptoms include; musculoskeletal pain through the whole body, disturbed sleep, fatigue, psychological distress (including depression, anxiety) and tenderness (Abeles et al., 2008). Beforehand I knew some of the symptoms however, I was completely unaware of the psychological effects Chronic Fatigue Syndrome had. The client came in on a wheelchair and this increased my apprehension to treat her. I spent 45 minutes doing the subjective assessment as I knew clients suffering from this syndrome tend to want to offload and talk to someone. During the objective assessment, I found that I couldn’t conduct a full assessment of the lower back, which was the problem area. Based on the subjective assessment I found that the main problem is her legs going numb and not being able to move in the mornings due to this. This indicated to me that she may have a disc prolapse. She also felt pain when flexing the lumbar spine with peripheral pain and numbness going down her leg. Her main pain was felt on the right at the hip joint. She requested STM on her lumbar back and hip area to help release the muscles. During the massage, she explained to me about her syndrome and how she had to “deal with it” and move on with her life. She spoke about how she had to deal with the psychological aspect of the syndrome and how that affected her life with her son. I learned a lot through this time as I understood more about how a sports therapist could help someone who is already dealing with a lot. About how a sports therapist could use different techniques and strategies to help with a client’s psychological state and how it could help them unwind.
I also had a client who requested a massage to his legs as he had training yesterday and they had been feeling a bit “tight”. I checked hamstring length through straight leg raise (SLR) and found that both legs only went to 60°. This led me to believe that the hamstrings needed to be massaged and their length and flexibility needed to be improved. To do this, I used muscle energy techniques (MET) which is said to improve muscle length when compared to just static stretching (O’Hora et al., 2011).
The main problem I encountered with both clients was time management. For the first client I overran by 15 minutes as I had two pathologies to look at, I felt like I was rushing the session and so did not get time to do extra objective assessments such as functional and special tests. The second session overran by 45 minutes which was because I took everything a lot slower than I should’ve. I was a lot more apprehensive and so wasn’t so confident in my decisions or tests which increased the time for my objective and subjective assessment. This could be a problem in the future as the tests might be necessary to reduce differential diagnoses to one. I also might have clients back to back and so would have to have time to disinfect the plinth. To help this in the future I could focus on one pathology properly and if there is extra time, look a the second one. If there isn’t then I could ask the client to come in again.
Abeles, M., Solitar, B. M., Pillinger, M. H. and Abeles, A. M. (2008) Update on Fibromyalgia Therapy. The American Journal of Medicine. Vol. 121, No. 7: 555-561.
de Jonge, S. D., Van Den Berg, C., Van Der Heide, H. J. L., Weir, A., Verhaar, J. A. N., Bierma-Zeinstra, S. M. A. and Tol. J. L. (2011) Incidence of midportion Achilles tendinopathy in the general population. British Journal of Sports Medicine. Vol. 45, No. 13: 1026-1028.
Ganesh, G. S., Mohanty, P., Pattnaik, M. and Mishra, C. (2015) Effectiveness of mobilization therapy and exercises in mechanical neck pain. An International Journal of Physical Therapy. Vol. 3, No. 2: 99-106.
O’Hora, J., Cartwright, A., Wade, C. D., Hough, A. D., Shum, G. L .K. (2011) Efficacy of Static Stretching and Proprioceptive Neuromuscular Facilitation Stretch on Hamstring Length After a Single Session. Journal of Strength and Conditioning Research. Vol. 25, No. 6: 1586-1591.