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

2. 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
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3. Treatment to date OTC pain medication
Seen by a junior physiotherapist and treated with stretches which made the pain worse.
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4. Differential diagnosis
Mechanical back pain
Referring from neck (cleared)
Referring visceral pain (no other symptoms)
Red flag for tumour (no other symptoms)
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5. Assessment Observation: well muscled, upright posture
Range of movement – appeared normal but pain reproduced on rotation especially to the right
Muscle strength - NAD
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6. 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
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7. 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
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8. Tiling
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9. 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
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10. Outcome 80% improved pain within 6 weeks No pain medication
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11. 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.
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12. 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
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13. 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’
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14. Trendelenburg sign
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15. Trendelenburg with internal rotation of stance leg
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16. 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
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17. Outcome
Within 8 weeks had returned to ultra marathon runs with no knee pain
Of note – “70% elite triathletes have a positive trendelenburg”
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18. 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
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19. Differential diagnosis
Osgood Sclatters
Mechanical anterior knee pain
Juvenile arthrits / other inflammatory arthritc conditions
Tumour
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20. 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
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21. Housemaid’s knee
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22. 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.
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23. Mole catching
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24. Treatment Activity modification (enlisted help of younger brother)
Knee pads
Alter posture – to squat or use left knee some time
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25. Outcome Hard to get him to stop! It was a lucrative hobby
However he did have reduction in symptoms with altering position etc
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26. Thank you
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