therapeutic skills scenario 10

THERAPEUTIC SKILLS EXAMINATION CARD 10


Note, we have been given a handout on cryotherapy, this piece entails that handout plus additional information and dialogue to be expected

Soft tissue trauma to lateral ligament of ankle

Cryotherapy: ice pack to be applied
Iniatally note that you have assessed the enviroment for health and safety

Physio:
Explain procedure
I have assessed your ankle and I have concluded that you have suffered soft tissue trauma to your lateral collateral ligament of your ankle.
With your permmission I would like to apply an ice pack to the damaged area.
The purpose of the ice is to decrease the anti inflammatory response,swelling and to decrease the pain levels

2. Question patient

Do you have any contraindications that would prevent me from applying the ice pack
Have you had any other treatment on the affected area to date??

3.  Collect equipment

wash hands first
check freezer
dry towels, plastic sheeting, paper sheeting
damp towel for ice
oil
extra pillows ( as appropriate)

4. Position patient
adjust bed height
using the position selected for effectiveness ( elevate approp,support patient comfortably, protect the treatment area, prepare an additionl dry towel (to insulate pack)
expose body part to be treated

Place there leg on pillows

put paper sheets under there foot
drape the patient to preserve modesty
ensure draping will catch any melted water from ice pack



5. Inspect part to be treated
Verify no open wounds or rashes

Check for pulse posterior to medial maleolus
Hot / cold sensory test with hot and cold water in different test tubes
Rube test tubes on affcted area and ask patient can they distinguish between the two temperatures with out looking
Squeeze big toe to chech for ciculation, blood should return immediately, tests for pvd
Hammer and pin, soft side rub and prick with pin
Apply baby oil to foot, acts as an extra layer between foot and ice

6. Prepare ice pack with crushed ice
Wrap crushed ice in a damp towel
This allows ice to be at 0 degrees and not below
Usually below when taken out of freezer

7.Application
Warn the patient of the expected sensations
Aplly ice pack
Insulate the ice pack by putting a light towel over it
Check the patients response by asking how it feels after 2 mins, then after every 5mins complete a visual check
Ice should be on for no longer than 20mins

8.Complete treatment

Remove ice pack and dry area with a towel
Remove towels used for draping
Clean treatment area and dipose of ice

9.Assess treatment efficiency
Ask patient how the ankle feels
Visually inspect the area for any adverse reactions and tell patient that everything looks fine
Cont with next stage of treatment and ask patient to dress
Perform functional tests as appropriate




Second part of scenario
Partial weight bearing gait pattern

1st measure the crutch length

get patient to stand up against the bed with the assistants help as the physio measures from the ulnar styloid to the ground. 

the patients arms must be flexed to approx.15 degrees

the handle should be equal to this height

get the patient to sit back up onto the bed and the physio demonstrates the partial weight bearing gait

1) place the two crutches out in front first, have them slighty out in a triangular pattern

2)tell them to slowly bring there affected leg forward, putting a bit but not to much pressure on it

2)then tell them to bring there unaffected leg forward

3) teach them how to turn- one crutch in front, one behind

Ascent of stairs:

Bring one crutch around and horizontaly place it on the outside against the vertical one

Hold onto banister
Place good/unaffected limb on step ( as patient is partial weight bearing)
Hop up onto the step with good limb while holding banisters 

Then bring the crutch up

physio behind ,assistant in front

Coming up - good leg, bad leg, crutch,       good up to heaven

Descent of stairs:

Again have the crutches as above

Hold onto the banister

Place crutch onto the middle of the step

Then put affected foot on the step

Finally put unaffected leg on the step

Coming down- crutch, bad leg, good leg,     bad down to hell

When teaching physio must be behind patient at all times while the assistant stands at the side of patient

Third part of scenario

Functional activity of step-up with emphasis on hip joints

Start:

Double limb stance

Good base of support with two feet planted

Most stable at this point

COG going straight through from head to foot
Leading with left leg for arguements sake
Left hip flexion

Single limb stance

Less stable at this point

line and centre of gravity is shifting forward
Going through saggital plane and coronal axis

Concentric muscle contraction
Hip flexors ® psoas major, pectineus, rectus femoris, iliacus, sartorius

Hip extension as leg is going down onto step

saggital plane and coronal axis

When coming back down, COG is lowering becoming more stable
Eccentric muscle contraction
Hip extensors ® glut max,biceps femoris, semitendinosus, semimembranosus

Foot becomes planted on the step

Double limb support, more stable

As this occurs the right hip is in extension
The right hip is taking all the force of the body until the left leg is planted and is the base of support while the left hip is in swing
The right hip then follows the same pattern as the left hip as it steps up

As it does so the left hip is extending more and more and is the primary base of support

Again this is an unstable phase

Note; watch out for patient tilting, side flexing etc and mention this if it occurs

musculo scenario 3

Case study 1 – ankle and foot

Subjective assessment
History of present complaint:

The patient is a 32 year old male who has sustained a sharp pain in his right heel 3-4 months ago. He was running on average 60 miles per week and he is also a postman by trade so he is constantly on his feet. He noticed a gradual ache on the medial aspect of his right heel which has gradually increased over time due to his work and running. The patient complains of most pain in the morning and has slight limitation in ROM of dorsiflexion and extension of the toes due to mild pain. X-ray showed no bony injury. The patient has been diagnosed with plantar fasciitis and has been advised to rest from running for 2 weeks.

Past medical history: nil
Drug history: nil
Social history: lives with wife and 2 young children in 3 bedroom house.

Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia that supports the arch of the foot. It can also be caused by biomechanical faults that cause abnormal pronation of the foot.
Typical symptoms :
· Pain is usually felt on front and bottom of heel.
· Most intense pain with first steps of day.
· Brought on by long periods of weight bearing.
· Patients are often over the age of 30.
· Pain may be sharp, like a stone bruise or throbbing.
· Condition usually develops over a period of days/weeks/months.
Causes:
· A change or increase in activities.
· Lack of flexibility in calf muscles.
· Long periods of standing/walking in poor shoes.
· Arthritis
· More commonly affects overweight people and athletes.
· Loss of natural tissue for cushioning under the heel.

Plantar fascia supports the arch of the foot by acting as a “bowstring” to connect the ball of the foot to the heel. Its function is to invert the heel (turn inwards) for propulsion.

After speaking about the pathology go on to talk about the anatomy of the the foot. Give a brief description of the bone structure of the foot i.e the tibia and fibula articulate with the talus and medially and laterally form the malleoli (its up to you how much detail you want to go into but keep in mind the problem is on the medial side of the heel ). The calcaneus should be mentioned here along with its medial and lateral tubercles....... basically show them that you know the structures involved etc

the most important part of the anatomy to be familiar with for this pathology is the ankle dorsi flexors and plantar flexors. Talk about these muscles and their functions in realtion to the foot.

dorsiflexors: tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius.
plantarflexors: gastrocnemius, soleus, tibialis posterior, flexor hallucis longus.

these work as agonists and antagonists against each other. if either of them are tight then it will have an affect on the way our foot hits the ground. If the foot is not landing correctly then it will not use its shock obsorbers correctly and the foot ends up slapping off the ground which puts extra pressure on the heel.

The calf muscles are very important as tendons deep to gastrocnemius insert into the quadratus plantae muscle at the base of the foot. If gastrocnemius is tight then this could be the source of the problem.

Objective assessment


Ask the patient to lie on the plinth in the supine position. Observe the area around the heel and check for contraindications such as swelling, skin colour and muscle bulk. Palpate the area and feel for tenderness etc. Ask the patient to walk and observe their gait pattern. Watch out for heel-toe strike and the pronantion and supination of their foot. If the patient is landing relatively flat on his/her foot then their gait pattern could be affecting their condition (watch a clip on youtube). Possibly ask the patient to walk up a few steps of stairs to examine functional ability.

From there ask the patient to lie on the plinth in supine position to begin observing active and passive movements.
Make sure the bed is at a correct level as to not cause any discomfort in your lower back. Explain to the patient exactly what you want them to do and also tell me why they are doing this. Before each passive movement and resisted test make sure you are in the correct position and handle the patients foot in an appropriate way giving adequate support throughout the movement. Talk through every movement and continually ask patient about levels of discomfort or pain.
The active physiological movements the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. Eversion
5. Extension of the toes
Observe these movements on both feet so as to compare and contrast the range of movements.

The passive physiological movements the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. Eversion
5. Extension of the toes
Again observe these movements on both feet to compare any differences.

The resisted tests the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. EversionThese tests also need to be completed on both feet for same reasons as above.

Case Study 9 - musculoskeletal (shoulder impingement)

Case Study 9 - musculoskeletal (shoulder impingement)
Robert Simons is a 24 year old student who has experienced increasing problems with his left shoulder over the last 4 weeks. His GP has referred him to Physiotherapy with a diagnosis of Impingement Syndrome. The problem began with a sharp twinging pain over the deltoid region whilst working shelf stacking in the library. The symptoms have now worsened to a constant ache and are made worse by racquet sports and overhead activities at the gym. Robert lives with his parents and younger brother and sister who are both of school age. He is otherwise fit and well and takes no medications.Subjective24 year old maleDiagnosed with impingement syndromeIncreased problem in left shoulder for past 4 weeksPain first started in deltoidPain used to be intermittent but now it fairly constantOverhead exercises is especially painful (badminton, stacking shelves in library)PMH - NilDH - NilSH - Works in a library stacking shelves, lives with parents and brothers and sisters.

Demonstrate these where appropriate on your model.
bony parts:
clavicle, coracoid process, spine of scapula,acromium process, medial border of scapula, acromium process, inferior border of scapula,bicipital groove, greater tuberosity (lateral of bicipital groove ) & lesser tuberosity ( medial to bicipital groove ) of humerus surgical and anatomical neck of humerus
Muscles -
origin/insertion - action - demonstrate these on your model
Levator Scapulae - C1-C4/upper medial scapular border - elevates scapula
Rhomboid Minor and Major - C7-T1/
medial scapular border - retracts scapula
Serratus Anterior - upper 8,9 ribs/anterior scapular fossa - protracts scapula
Pectoralis Major - clavicular & sternal heads - adducts & medially rotates shoulder
Teres Major- inferior lateral border scapula/bicipital groove - medially rotates adducts shoulder Teres Minor- lateral border scapula/posterior of greater tubercle of humerus
Deltoid- clavicle,acromium,scapula/deltoidtuberosity-flex,extend,medial,lateral abduct shoulder Supraspinatus - hollow above sacpular spine/greater tubercle - initiates abduction
Infraspinatus - below scapular spine/greater tubercle - laterally rotates shoulder
Joints :
Shoulder Joint - ball and socket Acromioclavicular joint - gliding joint Sternoclavicular joint - double arthroidal joint

Shoulder impingement syndrome is caused by compression of the tendons of the rotator cuff between a part of the shoulder blade and the head of the humerus. This can become a chronic inflammatory condition that may lead to a weakening of the tendons of the rotator cuff, a situation that may result in a torn rotator cuff. Initial treatment for an impinged shoulder includes rest, ice, and anti-inflammatory medications (sometimes including steroid injections)

Impingement Syndrome can be classified as external or internal:

External impingement, which can be either primary or secondary:
Primary
Is usually due to bony abnormalities in the shape of the acromial arch.
Can sometimes be due to congenital abnormalities (known as os acromiale), or due to degenerative changes, where small spurs of bone grow out from the arch with age, and impinge on the tendons.

Secondary
Usually due to poor scapular (shoulder blade) stabilization which alters the physical position of the acromion, hence causing impingement on the tendons.
Is often due to weak serratus anterior and tight pectoralis minor muscles
Other causes can include weakening of the rotator cuff tendons due to overuse (e.g. throwing and swimming) or muscular imbalance with the deltoid muscle and rotator cuff muscles.

Internal impingement
Occurs predominantly in athletes where throwing is the main part of the sport (e.g. pitches in baseball)
The under side of the rotator cuff tendons are impinged against the glenoid labrum – this tends to cause pain at the back of the shoulder joint as well as sometimes at the front.

Symptoms of impingement syndrome:
External impingement symptoms:
Primary
Pain at the front and/or side of the shoulder joint with overhead activity such as throwing, front crawl swimming.
Secondary
Pain at the front and/or side of the shoulder joint with overhead activity such as throwing, front crawl swimming.

Internal impingement symptoms:
Pain at the back and/or front of the shoulder when the arm is held out to the side (abducted) and turned outwards (external rotation)

Objective
Sit patient on plynth
Observation: Skin colour, Swelling, Posture, Muscle Bulk, Deformity

Active Physiological Movements:
Shoulder Girdle
Depression
Elevation
Protraction
Retraction

Glenohumeral
Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation
Horizontal flexion
Horizontal extension
Hand behind back (HBB)
Hand behind back (HBN)

Passive Physiological Movements
Applying extra pressure to the active movement the patient is already doing is a simple way of checking the passive range.

Resisted Tests - Glenohumeral
Flexion
Extension
Abduction
Adduction
Lateral rotation
Medial rotation
Horizontal flexion
Horizontal extension

Shoulder Girdle
Depression
Elevation
Protraction
Retraction

Always ensure you do the movements to both shoulders so you are able to compare the differences between the two.

Special Tests
The Hawkins Kennedy test is used to assess shoulder impingement. In this test the physio stabilizes the patients shoulder with one hand and, with the patient's elbow flexed at 90 degrees, internally rotates the shoulder using the other hand. Shoulder pain produced by internal rotation represents a positive test.Range of motion can also be measured using a genometer and pain levels can be measured.

Possible treatment for this injury is ice therapy or even a sling if the shoulder needs rest.

Therapeutic Skills.
Examination Card 3.

Introduce yourself and your assistant to the patient, wash your hands properly before you begin.....

1. Explain what you are going to do with the patient and the benefits of using axillary crutches:
Help take the weight bearing strain/benefit away from the lower limbs and transfer it to the upper limbs – alleviate pain from joint, muscles and ligaments in right affected leg.
Increase body’s base area of support – body more stable and promotes overall balance.
Important to keep weight off leg to allow bones to heal.

2. Measuring crutches:
Explain what you are going to do and ask the patient to lie down on their back on the bed, keeping their shoes on.
There are 8different ways to measure the fit of crutches, though these are the most accurate:
5cm from axillary fold to the heel in supine.
Height minus 16inches.
Adjust handgrips so elbows are flexed to 15 degrees.
Ensure rubber ferules are fitted.

3. Inform patient of maintenance and safety issues:
Check ferrules aren’t worn down and if they are advise them where to go to change them, for example a Disabled Living Centre.
No splinters or cracks.
Check the measurements are suitable.
Keep a good posture – no weight bearing on affected right leg.
Axillary crutch should not press into axilla as this may damage the axillary artery and nerves. Instead it should be held in against the chest wall.
Support areas should be padded.
Check screws and clips aren’t broken.
Warn patient to be careful using crutches during adverse conditions.

4. Teaching the patient to use the axillary crutches:
Sitting to standing position:
· Demonstrate sitting on the edge of the bed, hold the crutches together in right hand (side of the affected leg) with the screws on the same side. Stand up on the left good leg and take the outside crutch and place it under your right arm. Remember the triangular base is very important!
· Tell the patient never to lean on the crutches inappropriately as this would damage the axilla. In a resting standing position the crutches should be out in front and to the side and the patient should not be leaning on them.
· So as the patient themselves attempts to move from a sitting to standing position you must ensure you are close to them and are stabilising them efficiently, make sure your assistant is doing this as well. Also remember to give some encouragement and support and at this point take a final check for height comfort and balance.
· Rest may be necessary at this point.
Walking:
· Position a chair an appropriate distance from the patient.
· Demonstrate using a 3point gait – used for non-weight bearing on one leg, hop too and hop through.
· Turning around or moving backwards – 1crutch forward, 1 crutch back and a little hop.
Practice a step then a gait cycle then progress forward and
again when patient is attempting this make sure to support them at all times.
· Sit down.
Ascending and descending the stairs:
· Always one stair at a time and helps to remember good leg to heaven bad leg to hell.
· Ask patient which side banister is on at home – have crutches opposite side.
(Assuming banister is on right hand side) Demonstrate.
Take crutches in left hand, one under arm normally and the other placed horizontally across the other crutch. Take hold of the banister with your right hand and hop up with your left leg, following with the crutch. Do not stand on right affected leg. Once you have reached the top of the stairs turn and move the crutches to your opposite side and take hold of the banister ready for descending.
· Descending the stairs stick your right affected leg out first and place the crutch on the stair below. Hop down on your good left leg keeping a firm grasp on the banister.
· As this patient then practices this you should be supporting from behind as they ascend the stairs ensuring that your assistant is also supporting from the side. Descending the stairs you should be in front of the patient with your assistant again beside them.


Functional Analysis of sit to stand – hip, knees and ankles.


· Phase 1 – Preparation phase – Model is sitting on chair with legs at right angle to trunk.
- Hips 90˚ flexion, knees 90˚flexion, ankle in neutral.
- Base of support is large, chair and legs with feet on floor.
- Centre of gravity is at the hips.
- Line of gravity is within your body – stable position.
- Forces, gravity is always present. Friction between and seat, and feet on floor.

· Phase 2 – Execution phase A – Begins as model initiates flexion of hips, bringing trunk forward and finishes when trunk flexion has finished and knee extension is initiated.
- Further flexion of hips as trunk moves forward, angle increases. Further flexion of knees, angle increases. Ankle moves into dorsiflexion, decreasing angle.
- Hip flexors – Sartorius, pectineus, rectus femoris, psoas major, iloiacus. Knee flexors – semitendinosis, semimembranosus, biceps femoris, gastrocnemius, gracilis, Sartorius, plantaris, popliteus. Ankle dorsiflexors – tibialis anterior, extensor digitorum longus, extensus hallucis longus, peroneus tertius.
- Body moving in sagittal plane in a frontal/coronal axis.
- Base of support remains large as bum still on seat at this point.
- Centre of gravity moves outside body as trunk moves forward.
- Line of gravity is now outside the body making it less stable.
- Forces, greater effect of gravity – assisting downward motion of trunk.

· Phase 3 – Execution phase B – begins as model initiates knee extension, hip extension bringing trunk forward. Finishes with the end of hip extension.
- Hip extension is initiated as trunk begins to straighten, angle decreases. Knee extension initiated and angle decreases. Ankles move back into neutral, angle decreases.
- Hip extensors – gluteus maximus, semitendinosis, semimembranosis, biceps femoris. Knee extensors – rectus femoris, vastus lateralis, vastus intermedius, vastus medialis, tensor fascia lata.
- Body moving in sagittal plane and frontal/coronal axis.
- Base of support decreases as bum is off seat.
- Centre of gravity still outside body.
- Line of gravity still outside body making body unstable.
- Forces, gravity resisting upward motion – reduced impact of friction with bum off seat.

· Phase 4 – End phase – movement has finished and model is stood up straight.
- Hips, knees and ankles in neutral. 180˚ between trunk and legs.
- Base of support smaller – only feet.
- Centre of gravity moves back within body.
- Line of gravity within body – anterior to body of second sacral vertebrae – body now stable.
- Forces, gravity and friction between feet and floor.

Musculoskeletal M2

CASE HISTORY 2 ® THE KNEE

 

 

SUBJECTIVE

 

Pathology:

 

NOTE BACKROUND- when looking at this case study there is two key components to note.

Osteoarthritis

Patella-femoral joint

 

In this case study the patient is diagnosed with early osteoarthritis of the patella femoral joint.

The patient is definitely suffering from patella-femoral syndrome. This can be caused by a various number of factors.

One of the special Q’s asked in knee pain is “do you experience pain on ascending or descending stairs”.

If yes, like in this case study then the patient has patella femoral syndrome.

Also the pain is experienced in the front/anterior part of the knee.

And comes from behind and below the knee.

This correlates to the symptoms of the syndrome.

 

 

OA is caused by trauma (sudden fall/accident) and genetics.

The patient’s subjective assessment states no family history of OA and also says that no trauma was suffered.

 

However OA and patella femoral syndrome can both develop as a result of repetitive microtrauma (overuse)

 

This patient has an active lifestyle including sports and gym activities. This syndrome can affect overzealous (excessively enthuasiastic) recreational athletes.

 

Therefore it is the overuse of muscle’s which results in muscle weakness and tightness. This muscle weakness can lead to a tracking problem of the patella, leading to patella femoral syndrome. (explained below)

 

OA is described as being caused by “wear and tear”, so the repetitive activities accounts for this.

 

However I asked gerr if the patella femoral syndrome could lead to OA and he said yes. Im goin to double check with him asap. So I think bout pathologys are acceptable- microtrauma (overuse) and the contd effects of patella femoral syndrome.

 

PATELLA FEMORAL- ANATOMY AND BIOMECHANICS:

 

The patello-femoral joint refers to a specific part of the knee joint.

It is the joint space between the patella and the femur.

The patella is connected to the quadriceps tendon at the top of the patella.

The quadriceps tendon attaches to the quadriceps muscle which attaches to the pelvis.

The patellar tendon goes from the bottom of the patella to the front of the tibia known as the tibial tubercle.

When the quadriceps muscle contracts (shortens), it pulls the patella which in turns pulls on the tibial tubercle, which causes the knee to straighten (go into extension).

As the knee moves, the patella glides across the front of the knee joint in a shallow groove on the front of the femur which is known as the trochlear groove of the femur.

 

Abnormalities that occur at the patella:

 

1.   dislocate (slip out of place)

2.   sublux (partially slip out of place),

3.   fracture,

4.   develop degenerative arthritis,

5.   develop a tracking problem.                                   

A tracking problem refers to the fact that the patella            remains in front of the knee, but it no longer remains centered in the front part of the femur known as the trochlear groove.

 

4 and 5 are to be focused on in this case study.

 

The tracking problem has develop due to overuse, leading to muscle weakness and therefore muscle imbalance.

 

 

 

PATHOLOGY

·      When tracking problems occur, the kneecap develops an abnormal set of biomechanics that results in abnormally increased pressure on the underside of the patella (patellar articular surface).

·      Normally, the patella sits centered in the groove.

·      However, if it begins to move towards one side of the groove, the amount of pressure on the underside of the kneecap (patellar articular surface), changes.

·      This results in the development of pain

·      The centering of the patella in the trochlear groove is related to the strength of the vastus medialis obliqus (a part of the vastus medialis muscle) and the medial patello-femoral ligaments which pulls the patella towards the opposite knee while the vastus lateralis and lateral patello-femoral ligaments pull the knee cap towards the outside (lateral) aspect of the knee.

·      When all of these forces are in proper alignment, the patella is centered in the trochlear groove of the femur.

·      If an imbalance develops with weakness of the vastus medialis muscle and/or weakness of the medial patello-femoral ligaments and/or over-development of the vastus lateralis muscle and/or tightness of the lateral ligaments of the patello-femoral joint, then a force imbalance develops.

·      When this happens, the patella begins to move laterally (towards the outside) within the trochlear groove.

·       As the knee flexes, the tension increases on the tight lateral structures. In turn, this causes pain with bent knee activities.

·      This results in abnormally increased contact between the femur and the patellar articular surface which may eventually result in arthritis. If the imbalance is overwhelming, then the patella may actually slip out of place (dislocate).

 

 

 

OSTEOARTHRITIS:

 

Pathology:

 

 

Osteoarthritis often called degenerative arthritis or OA. OA is low-grade inflammation of the joint caused by degeneration and damage to the cartilage. It is commonly referred to as “wear and tear”. The cartilage covers the area of bone that meets the joint and acts as a ‘cushion’. In osteoarthritis, the surface of the cartilage becomes roughened, fissured and even starts to shred into small fragments. These fragments "float" around the joint and cause more damage. The bone tries to protect itself by producing small bony prominences called osteophytes which actually in the end cause the joint damage and pain worse.

Any kind of sports participation can increase the incidence of osteoarthritis due to increased twisting forces, high impact, muscle weakness or over-development and joint instability which causes abnormal peak pressures and greater stress in certain areas of cartilage which can lead to osteoarthritis.OA commonly affects the knee as it is a large weight bearing joint. 

two types:

primary- related to aging (cartilage losses water becomes less resilient)

secondary-caused by another pathology (patella-femoral syndrome)

 

 

 

 

 

 

Signs and symptoms:

 

·      It causes acute pain

·      restricted movement

·       stiffness around the knee This can occur due to the decrease in smooth glide between the bones which was once provided by the cartilage.

·       The symptoms are commonly accompanied by swelling, creaking and grating noises.

·      sharp pain

·      burning sensation can also be felt. This pain is felt in associated muscles and tendons.

·      Pain on flexion

·      Pain on ascending stairs

 

A lot of the symptoms are caused by inflammation (heat, swelling etc)

 

Aggravating factors:

 

Patient: what is said in the case history

Additional: other expected symptoms that arent in case history but are likely to be present.

 

Patient: Varies between activities. Particularly sharp on ascending stairs and sometimes kneeling.

 

Additional: Prolonged rest is determental to OA by causing stiffness and muscle weakness.

Sitting with flexed knees can also bring on sysmtoms  due to the increased pressure between the patella and femur.

 

 

Easing factors:

 

Patient: No pain during walking.

 

Additional This is because gentle exercise will not cause joints to wear. Regular walks can reduce joint stiffness and keep associative muscles strong.

 

Mechanism of injury:

 

Patient: no trauma or genetics mentioned

 

Conclusion: progressive onset caused by various contributing factors including microtrauma and patella femoral syndrome.

( consenus on cause is not yet agreed in medical world)

 

 

patellafemoral joint overuse and dysfunction

biomechanical problems

muscular dysfunction

 

 

 

 

OBJECTIVE

 

Physio likely to see:

 

Restricted movement

Stiffness

Swelling

Grating noises

 

Tests:

 

During the physical exam a number of areas are checked

1. tracking of the patella

2. strength of the muscles around the knee cap,

3. tightness of the tissue and ligaments around the kneecap,

4. areas of tenderness in the soft tissue,

5. areas of tenderness on the underside of the patella, the location of the patella, med and lat displace patella and palpate undersurface

6. the presence of abnormal grinding of the patella as it moves

7. the ability of the patella to be subluxed or dislocated.

8. grasp both sides of the patella and ask patient to contract quadriceps- discomfort

9. check for heat

 

 

 

Ask patient to actively flex and extend at knee joint

 

Then passively flex and extend at the knee joint

 

Flexion 0-135 degrees +

Extension 0 degrees

 

Apply resisted tests through static flexion and extension

Apply resisted tests through full rom of flexion and extension

 

Noting at what rom the patient is weak and symptoms are produced

 

Palpate knee to exam any abnormalities, differences or heat

 

Things to look for:

 

High positioned patella

Foot hyperpronation in walk or stand (biomechanical problem)

Atrophy vastus medialis

Increase Q angle

Patients feet together- note if valgus or varus

View from side- hyperextending or not (quad weakness)

 

 

 

Fairbanks apprehension test:

 

Tests patellar subluxation and dislocation

 

Procedure ® patient supine with knee in 30 degrees flexion and quads relaxed. Passively glide patella laterally

 

Positive sign ® patient apprehension or excessive mvt

Therapeutic Scenario 8

Examination Card 8, Therapeutic
Hoisting From Wheelchair to Plinth.

Firstly introduce yourself and assistant to patient, explain what you are going to do in relation to hoisting from chair to plinth, how you will carry it out etc. That you are then going to carry out passive mvts on lower limbs, and then finally you are going to analyse the components of rolling from supine to side lying.

Ensure you have all the equipment near by necessary 4 hoisting. Check and observe the patient to determine what size sling will be required and sling suits hoist, also check that the hoist being used is suitable for the patient (weight capacity). Position two philislides on bed so when patient laid down they are lying on them. You are then going to position the sling down behind the patient in the chair, ask patient to sit forward in chair changing their centre of gravity,(get assistant to support patient as they lean forward so the don’t fall forward) ensuring the end with the leg support go 1st, put sling down as far as possible, sit patient back, loops on back of sling should be between scapulas and then lift patients leg and rest their foot on your knee and pull sling under legs, with the straps on the end of the leg support, loop 1 through the other. The straps at shoulder are free also and not stuck behind patient. Then move the hoist around the chair, asking assistant to hold the head of the hoist still so it doest swing and catch the patient, spread the legs if necessary to fit around the chair. Connect the straps to the hooks on hoist, (as you want them in a supine position on bed, you are going to go to the 1st or 2nd loops) Warn patient when you are going to start lifting, let them now they may feel like their slipping in the sling 4 a second, but not to worry they will be fine. Slowly start to lift, when patient is lifted of chair, get assistant to remove wheelchair, you can either higher hoist to bed height or get assistant to lower bed, ensure bed is flat. Then move hoist into position then move patient in line with plinth in the direction you want them lying using rotating head on hoist. Lower patient slowly until they are completely flat on plinth, lower until there is slack on the sling and are able to remove sling from hoist. Position in an appropriate position toturn them into side lying for hip extension etc.Can leave the sling under patient. Talk to patient then and ask them are they comfortable, do they want extra pillows for behind head etc. CAn use philislides to also position patient.


Passive Movements of Lower limbs
Describe clearly to the patient what you are going to do and the benefits of it. It involves the physio doing the following movements without any help from the patient, abduction and adduction, flexion & ext of hip, knee and ankle, internal & external rotation, also bilateral abduction and adduction (compare each side to each other). These movements will be performed to full available ROM. These movements will help with circulation, proprioception, sensory awareness. Make patient aware the movements should cause NO pain and if they do ensure to let you know. Complete relaxation is required and slight overpressure may be applied at end of range. Ask for any contraindications such as pain or inflammation etc and obtain consent.

1. Hip and Knee flexion – Hand positioned behind ankle and other at popliteal space, as u move from extended knee and neutral hip, hand at popliteal space will slide out to lateral side of knee stops leg abducting and allows extra pressure to be applied to movement to feel end feel. Once this point is reached patients limb is returned to staring position.

2. Hip flexion and knee extension – Keeping knee extended flex the hip, One hand behind ankle and other just above patella, so to maintain knee extension. This will test the hamstrings and there elasticity, never push past the end feel and stop if uncomfortable for patient.

3. Hip abduction – Patient in supine, hands placed at ankle and popliteal space, take leg away from mid line of body. Physio has to aware of base of support and posture. Come out to end feel and den return towards mid line.

4. Hip Adduction – To adduct for example left hip.abduct right leg slightly and then adduct left leg bringingleg across midline

5. Hip External Rotation – Hands supporting ankle and medial aspect of the popliteal space. Flex knee and hip to approx about 90degrees, then keeping knee stable, move foot across the body,keeping knee and hip flexed

6. Hip Internal Rotation - Hands supporting ankle and lateral aspect of the knee. Flex knee and hip to approx about 90degrees then move foot outwards as much as possible not as much movement as in external rotation

7. Hip extension – Role patient into side lying position, knee in flexed position,physio supporting leg appropriately and then extends the hip.Ask assistant to support patient at shoulder and just above hip while physio carrying out movements

8. Dorsiflexion – Place hand on calcaneus and run forearm of same hand along plantar surface of foot and with other hand stabilise distal tibia (just below Knee). Then pull down on calcaneus and with forearm push on plantar surface.

9. Plantarflexion – Place one hand on dorsum of foot and other on distal tibia, using hand on dorsum push down on foot. NB avoid pressure over the toes

10. Ankle Inversion - Stabilise calcaneus and then with other hand invert the foot
Same for eversion but evert the foot when hands are in position.

11. Phalangeal Flexion and Extension – One hand on dorsum, other hand around toes

In Passive movements you must always be aware of your own posture, very important. Also state how many times you will be doing each movement to patient, 5-10. Ensure to have communication with patient to ensure the movements are ok for them and keep an eye on expressions for any sight of pain that they might not want to mention.


Functional Analysis From supine to side lying position.

It is important for everyone to know that everyone’s functional analysis of this movement is going to be different. What you are meant to look at though is joint movement the muscles involved in these movements. What we are mainly looking at though is axial components (trunk – Spine)
Hopefully your patient will roll in a similar way as you turned them for passive movements.

Form the top of the spine it is divided into cervical, thoracic, lumbar, sacrum and coccygeal. The cervical is made up of 7 vertebrae and is lordotic in shape; the body of the vertebrae is the smallest out of the thoracic and lumbar, lumbar being the biggest. Thoracic has 12 vertebrae and is kyphotic in shape. Lumbar has 5 vertebrae and is lordotic. Sacrum has 5 vertebrae but they are all fused together and the coocygeal has 4.
The movements of the spine are flexion, extension, lateral flexion and rotation. These are what you are looking for when the patient rolls to side lying and any changes that may occur in the spine curvature. And also muscles involved in these movements.

Sternocleidomastoid is involved in lateral flexion of the head and rotates head to opposite side.
Semispinalis extends and rotaes the neck.
Splenius capitis and spenlius cervicis extends and laterllay flexes neck and head, rotates to the same side.
Erector Spinae are involved in extension and lateral flexion of trunk and neck. This muscle runs down along spine.
Longissimus and Iliocostalis extend and laterally flex trunk, neck and head.
Multifidus rotates, extends, lateral flexion and stabiliser.
Rectus abdominus flexes trunk
Transverse abdominus flexes and laterally flexes trunk
External obliques flex and laterally flex trunk, more noticeable in bringing shoulder to knee.
Internal obliques flex and laterally flex trunk, knee to shoulder


PHASE 1: Start Position:
Head flexed due to pillow, shoulders on bed and thoracic spine. Although due to the curvature shape of the lumbar spine (lordotic) it is slightly off the bed.

PHASE 2: Head flexes further (saggital), rotation (transverse) and is then placed back on pillow and for this to happen, head & neck is laterally flexed (saggital), muscles working eccentrically for head to lower.

PHASE 3: Flexion of knee and hip causes the reduction of lordosis in the lumbar spine (saggital)

PHASE 4: Pelvis is lifted (saggital plane) off the plinth and rotation occurs at the lumbar (transverse). Base of support at this point is made less stable. Gravity is working down on the body

PHASE 5: Thoracic spine then follows the lumbar. Transverse plane. Friction occurs at the turning shoulder between the bed. Base of support is made smaller from supine lying to side lying. COG also changes

PHASE 6: Knee then follows to allow stability in side lying; with knees being flexed the lumbar lordosis is reduced further. COG changes.