Hours gained: 6
Total hours: 47
I had one initial consultation appointment and two follow-up appointments this week. The first client, an initial consultation, came in complaining of pain in his right shoulder and neck. The pain came on about two weeks ago and was mainly felt on the top and outer side of the shoulder which when moving became a sharp pain into the arm. He mentioned he struggled with lifting his arm up over his head especially and that he can’t lie on that side when he’s sleeping. I asked what activities he did, he mentioned going to the gym every day for two hours mainly for resistance training. He had a desk job and so was sat in front of a computer from 9am-6pm. During the objective assessment, I found that the client struggled with abduction past 60°. He also didn’t like external rotation. The client had internally rotated and elevated shoulders. His ROM in his neck showed reduced range in left lateral flexion and rotation. The first pathology I wanted to clear was Thoracic Outlet Syndrome which I did through the special test. The differential diagnoses that I came up with were shoulder impingement or rotator cuff tear. I did the Hawkins-Kennedy test, Neers test, and internal rotation resistance strength test. The first two tests were positive and the last was negative. However, these tests are specific to shoulder impingement and also test positive for rotator cuff tears (Hegedus et al, 2008).
I also checked the scapular rhythm and found that there was scapular dyskinesis. The superomedial border of the scapular was also more superior. This led me to believe that due to scapular dyskinesis (type III) there’s an impingement of the shoulder. I started the treatment with an STM to the neck, shoulders, and thoracic back as they were very taut and he complained of “tight” muscles. I worked specifically into the upper trapezius and levator scapulae as they are commonly tight with this injury. I gave some stretches to help lengthen the levator scapulae and upper trapezius whilst giving strengthening and activation exercises for the lower trapezius. The stretches included seated upper trapezius stretch, seated levator scapulae stretch, and isometric ROMs of the neck for pain relief. The strengthening exercises included shoulder external rotation with theraband (both shoulders at the same time), Bruegger’s postural relief, and 90/90 scapular stabilisation. I also wanted to tape the scapula to help with the position however, we ran out of time and I had a client right after this one.
Overall I felt like I did really well in this session. The exercises I gave have high muscle activation and so were the best for the client. The 90/90 scapular stabilisation exercise was researched into by Maenhout et al (2016) and they found that exercises in prone had a higher muscle activation. The Brugger’s postural stretch helped in teaching the client the correct position his body should be in and was also very easy to incorporate into his life. During the STM I explained to the client that when training resistance, he needs to train his whole body and not focus on one area as he had been. I told him to start stretching the upper trapezius and strengthening the mid-lower fibres of it. I think the postural tape would have been beneficial for the client but due to poor time management, on my end, I couldn’t do it. I did add it into the future plan section though. I also felt like I should’ve checked cervical myotomes to clear cervical radiculopathy which could have been a differential diagnosis.
The next client I had was a follow-up and so I gave myself five minutes to read up on his notes to gain an understanding of what the pathology was and what the plan left behind was too. This case was a disc prolapse pathology and the treatment that was happening started off with an STM, then reviewed the exercises. When I went through the subjective assessment, the client mentioned that the STM helped him relax a little and that was what he mainly came here for. He mentioned that he doesn’t really do the exercises all the time and that they were a bit boring. I enquired about whether there was any pain, pins or needles down the legs and there wasn’t. I went through the objective assessment and found that ROMs and SLR were exactly the same as before and so there wasn’t much progression in that sense. However, the client did mention that his pain was reducing. I started the treatment with an STM and worked deep into the muscles as they were taut and adhesions were felt. I reviewed the exercises given to him to see that he didn’t know what they were as he never did them. He was given glute bridges and cobra position. I showed him how to do the exercises and then watched him do it. I added on another exercise to the program which was the cat and camel stretch. He laughed while he was doing it as it reminded him of twerking.
Overall I thought I could have added more imaginative exercises for him as he mentioned he found them boring. Hopefully, since he laughed at the cat and camel, he’d do it more often. I should’ve also started McKenzie’s extension position as I had used it on a lot of clients and it had worked.
I had this hour free and so I shadowed one of the other therapists. She had an initial consultation with an elderly gentleman, who was suffering from pain him his left ankle. He felt the pain on the lateral aspect of his ankle and walked with a cane. Through ROMs, we saw that there was an increase in inversion and a decrease in eversion. He mentioned that he used to fall over a lot and so they gave him a cane. She asked whether he used to go over his ankle a lot and he said that that was the cause of nearly all his falls. She did the chronic ankle instability questionnaire with him which showed he had chronic instability. She taped up his ankle to help provide some stability and then gave him strengthening exercises for his left leg. She started with seated calf raises and then worked a lot with balance and proprioception. She worked without the cane to try and help him strengthen and balance on that ankle. She started working on single-limb exercises and stretches straight away. I thought this was too soon as he found it hard to stand on two let alone one.
I had a follow-up appointment after this and found that it was one of my previous clients. I had treated him for tennis elbow the week before. After going through the subjective assessment, I found out that he had improved drastically. He had decreased the amount of golf he played found it had already started getting better. He also mentioned that the exercises he had were getting easier for him and he thought he needed harder ones. The objective assessment was very quick as I only needed to check his ROMs of wrist and elbow, and palpate the lateral epicondyle to see whether it was still as tender as before. The pain was still there at the end of the extension of the wrist and elbow however it was less. I massaged the forearm again and then used tape again for decompression. I reviewed the exercises and found that he didn’t need the resisted flexion and extension of the wrist anymore. I only added one more exercise as it had only been a week. I added weighted flexion and extension of the wrist. I started with very light weights and this seemed to be enough for him.
The other two hours were spent shadowing other therapists in the clinic. One case was a follow-up of medial tibial stress syndrome. In this case, he reviewed the exercises given and then increased the weight on farmers walks and added weights onto calf raises. The other case was also a follow-up but this client was suffering from facet joint stiffness in joints T5, T6, and T8. The client had a desk job and so was sitting down most of the time. He also wasn’t active at all and was overweight. The therapist tried to encourage the client to start getting active as it was putting too much pressure on his joints but he didn’t listen. This conversation helped me understand that if someone doesn’t want to do anything, then you can’t change their minds.
Hegedus, E. J., Goode, A., Campbell, S., Morin, A., Tamaddoni, M., Moorman III, C. T. and Cook, C. (2008) Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.
Maenhout, A., Benzoor, M., Werin, M. and Cools, A. (2016) Scapular muscle activity in a variety of plyometric exercises. J Electromyogr Kinesiol. Vol. 27: 39–45.