This scenario is based on knowledge of a 3rd year/rotational level Band 5
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!!
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!
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.
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?
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.
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?
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.
Review your anatomy. Knowledge of surface anatomy and the structures that lie beneath will improve confidence of which structures are dysfunctional.
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.
Review your anatomy.
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.
Research pain mechanisms.
Revise ‘acupuncture-like’ TENS and its effects on opiod mediated analgesia.
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.