Physiotherapy Case Studies GP PTL A Physio’s guide to condition management in primary care 2nd May 2019 Humbernhsft www.humber.nhs.uk Caring, Learning and Growing

Patient 1 27 year old male with 8 month history of thoracic back pain Otherwise fit and well No injury. Gradual onset but getting worse Occupation: tiler Caring, Learning and Growing

Treatment to date OTC pain medication Seen by a junior physiotherapist and treated with stretches which made the pain worse. Caring, Learning and Growing

Differential diagnosis Mechanical back pain Referring from neck (cleared) Referring visceral pain (no other symptoms) Red flag for tumour (no other symptoms) Caring, Learning and Growing

Assessment Observation: well muscled, upright posture Range of movement – appeared normal but pain reproduced on rotation especially to the right Muscle strength - NAD Caring, Learning and Growing

However…… On closer observation and testing, his quality of range of movement was abnormal Normal expected: approximately 50% from spine and 50% from lower limb equalling about 180 degrees of rotation Observed: virtually 100% of his body rotation to the right came from his spine equalling 180 degrees (100 degrees to left) His pain came on with rotation to the right Caring, Learning and Growing

Unpicking the causes Work position – kneeling down with equipment always to his right and behind him He relied on rotation from his spine to reach his equipment behind. His pelvis and lower limbs were ‘locked’ by his kneeling posture This became his normal movement pattern for rotation even in standing Caring, Learning and Growing

Tiling Caring, Learning and Growing

Treatment Teach rotation to 90 degrees with spine and 90 degrees with lower limb ‘Create’ exercises that would correct this imbalance of movement Work out with patient how he could alter his work pattern – some equipment on left too; restrict equpiment to no more than 90 degree turn away Caring, Learning and Growing

Outcome 80% improved pain within 6 weeks No pain medication Caring, Learning and Growing

Case study 2 34 year old female with right knee pain for 3 months Anterior knee No injury but quick onset Ultra marathon runner (100 miles regularly) Some mild anxiety problems and used running to help. Caring, Learning and Growing

On assessment Full ROM knees Negative tests for cruciates; collaterals and menisci No swelling Good quads bulk Positive test for anterior knee pain Positive trendelenburg bilaterally, but R>L Caring, Learning and Growing

Unpicking the causes On closer testing her deficient gluteals (PGM) was allowing internal rotation of the knee and causing medial loading on the patella and then pain This became more pronounced with dynamic tests such as hopping and running So although she could run 100 miles, her gluts were not ‘strong’ Caring, Learning and Growing

Trendelenburg sign Caring, Learning and Growing

Trendelenburg with internal rotation of stance leg Caring, Learning and Growing

Treatment Thorough explanation to patient to gain her understanding PGM strength exercises Movement pattern correction - with mirror in standing Without mirror Dynamic correction Introducing running with correction Caring, Learning and Growing

Outcome Within 8 weeks had returned to ultra marathon runs with no knee pain Of note – “70% elite triathletes have a positive trendelenburg” Caring, Learning and Growing

Case Study 3 16 year old boy with right anterior knee pain Gradual onset but getting worse over 6 months No injury Worse with kneeling Caring, Learning and Growing

Differential diagnosis Osgood Sclatters Mechanical anterior knee pain Juvenile arthrits / other inflammatory arthritc conditions Tumour Caring, Learning and Growing

On assessment Large swelling under patella with very hard skin over the area. Similar over left knee but not as bad Full ROM (pain on full flexion) Cruciate, collaterals and menisci tested normally Pain on palpation over the patella swelling Not hot Caring, Learning and Growing

Housemaid’s knee Caring, Learning and Growing

Unpicking the causes Although he was still at school, he also offered a mole catching service to local farmers. He had built up 60 mole traps since he was 13 He spent 1-2 hours daily emptying them – on his knees. Caring, Learning and Growing

Mole catching Caring, Learning and Growing

Treatment Activity modification (enlisted help of younger brother) Knee pads Alter posture – to squat or use left knee some time Caring, Learning and Growing

Outcome Hard to get him to stop! It was a lucrative hobby However he did have reduction in symptoms with altering position etc Caring, Learning and Growing

Thank you Caring, Learning and Growing