Learning Scenerios: Lower Limb

This scenario is based on knowledge of a 3rd year/rotational level Band 5

LOWER LIMB

CASE 1:

A 18 year old woman presents with intermittent left knee pain which is aggravated with dancing. Since commencing university 3 months ago she has begun dancing 3x weekly for 1 1/2 per session. She c/o pain on the lateral border of the patella and describes pain as dull but this can be sharp.

Key Subjective questions:

When is pain worse? Be specific – 20 mins into training? immediate? During a specific move? Try to work out the mechanics and when is it aggravated. Pain that comes on after exercise can indicate an inflammatory component. Pain that comes on through a specific move – what structures are loaded in these positions? Is it later in training when the muscles are fatigued? Does she dance in different shoes which may effect biomechanics?

In this case pain occurred towards the end of friday training. Monday training she worked on pole however on further questioning pain was bought on towards the end of dance following friday training sessions where she danced on a hard wood ballet floor. When asked the moves she had been working on she described high kicks and slides on her knees across the floor.

This certainly gives us a better idea of suspected hypothesis and what we need to rule out!!

Hints and tips Hints and tips

Remember its the LEFT knee.

Be specific with your hypothesis : ie mechanical, thermal, chemical // noiceptive //inflammatory, neurogenic, peripheral nerve irritation etc ….

Check out the latest research in manual therapy techniques. You will score higher marks if you can quote that your treatment is evidence based. Bear in mind limitations of the study ie if the study population was of elderly patients the tissue integrity and therefore effectiveness of treatment may be different to that of a 18 year old dancer!

 

Tasks on model:

  • List 3 potential hypotheses for left lateral border of patella knee pain and perform a test which would help you to differential between them. If this is too difficult simple perform 3 knee tests.
  •  Palpate the knee and explain to your partner bony and soft tissue landmarks.
  • Teach your patient a single leg squat giving information of the kinetic chain and its importance.
  • Choose a hypothesis and demonstrate one treatment technique for this.
  • Justify your choice of treatment to the examiner and possible progression of treatment.
CASE 2:

A 30 year old lady presents with a longstanding history of hypermobility and multiple joint subluxations/dislocations. She reports that 2/52 ago she awoke with severe pain in the right posterior hip and feels that she may have subluxated it. She reports this happens frequently. Pain has now settled to a VAS 2/10 however she would like some advice on strengthening exercises/advice to prevent re occurrence.

Tasks on the model:

  • Demonstrate how you would assess hip range of movement.
  • Show the examiner on your model which muscles lie on the posterior/ lateral aspect of the hip and give origin/insertion for at least one.
  • Demonstrate an appropriate strengthening exercise of the hip that will help provide stability around the hip.
  • Justify your choice of treatment to the examiner and possible progression of treatment.
Hints and tips Hints and tips

Remember its the RIGHT hip.

Which movements would you assess carefully ie most likely to dislocate?

Static exercises may be best to begin with and progress to open chain exercises as strength improves. Is there any evidence that supports this approach?

CASE 3

A 70 year old woman has fallen over yesterday and come to see you privately.  She has not seen her GP yet. She reports immediate pain and swelling on the lateral aspect of her hip. Her pain is VAS 8/10 and she is having difficultly weight bearing on it. Severity and irritability are high. There is no obvious deformity.

Tasks on the model:

  • Gain as much subjective information as possible to give you clues as to hypotheses of pain mechanism/cause.
  • The patient was unable to get an appointment with the GP therefore you have advised the patient attend A and E and provided a letter with the subjective information gathered. An X-Ray confirms no fractures however right hip OA and following a review with her GP she is referred back a 2 weeks later.
  • Demonstrate how you would assess ROM of the hip.
  • Demonstrate a manual treatment techniques suitable for the managements of this patient (assuming your hypothesis is right hip OA).
  • Justify your choice to the examiner.
Hints and tips Hints and tips

Questions you should be asking:

Has this lady had a trauma large enough to cause serious injury? ie fracture, severe soft tissue tear/strain/haematoma?

Is this woman at risk of fracturing easily ie age/osteoporosis?

Immediate bruising/ swelling usually indicates large trauma.

Why did she fall? Has she become unsteady? Does she require further mobility aids?

 

 

CASE 4

A 30 year old woman presents with right ankle pain following a ‘Spartan challenge.’ She reports an inversion injury which she was able to continue through. There was significant bruising and swelling at the time of injury. Two month later this has failed to settle. Symptoms are non irritable and non severe.

Tasks on the model:

  • Palpate and name 3 structures that can be damage on lateral aspect of the ankle during an inversion injury.
  • Explain your hypothesis and demonstrate a manual therapy technique that could be used to treat these symptoms/ structure.
  • Teach the patient 2 exercises for home.
  • Justify your choice to the examiner.
Hints and tips Hints and tips

Review your anatomy. Knowledge of surface anatomy and the structures that lie beneath will improve confidence of which structures are dysfunctional.

 

 

CASE 5

A 20 year old man was playing football 6 weeks ago. When kicking the ball he was tackled and twisted his right knee (Mechanism of injury : Foot planted with valgus and rotational force to the knee). He had to stop playing and reported immediate swelling and some bruising on the posterior aspect of his knee. His GP has referred him for physiotherapy and he’s keen to get back to football but finds that his knee has become unreliable and he often finds it gives way. He has noticed some crepitis/clicking in the joint but reports no locking.

Tasks on the model:

  • Formulate 3 hypothesis of posible structures affected and perform a test for each of these.
  • Explain to the examiner what you are looking for.
  • The patient reports that the knee gives way frequently and you suspect an ACL rupture. You refer back to the GP to consider further investigations. Teach and explain 2 exercises for the patient to begin as part of a home exercise program.
  • Justify your choice of technique to the examiner.
Hints and tips Hints and tips

Review your anatomy.

Practice your assessment.

MCL, ACL, PCL, LCL test – Become comfortable with these if your going into the sporting world you will use them a lot!!

TASK: Using the keywords in bold above perform a medline search. We all hate evidence to begin with but the more familiar you become with it the easier it is to allow this to be the underpinning of your clinically reasoning and choices. If someone has already been successful using a treatment you are more likely to be!!

Case 6 (TENS)

A 70 year old lady is complaining of a left hip pain. Symptoms are intermittent but severe (VAS 7/10) and irritable. You decided to use ‘Acupuncture-like’ TENS as part of their management program. She has confirmed left hip OA. The machine has been tested and there are no contraindications to its use.

Task on the model:

  • Demonstrate how you would position the patient to teach them the use of TENS and explain to the patient the reason for using TENS in the management of their symptoms.
  • Teach the patient how to apply ‘Acupuncture-like’ TENS in the management of a right hip OA.
  • Justify the use of TENS in the management of lower quadrant neuromusculoskeletal dysfunction.
Hints and tips Hints and tips

Research pain mechanisms.

Revise ‘acupuncture-like’ TENS and its effects on opiod mediated analgesia.

To find out more about TENS click here

Thoracic Spine   Acquired Brain Injury    Upper Limb    Lower Limb

Tables can be useful when gathering your thoughts and  building a record of your revision. The table below offers a framework and a check list.  Reflection and constructive criticism from a colleague will help improve your performance. By familiarising yourself with the routine of an examination will help reduce nerves within the exam.

 

 

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