VQC7009 Musculoskeletal Injury & Rehabilitation

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Case Study 

VQC7009

Musculoskeletal Injury & Rehabilitation

MSc Strength and Conditioning

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessmen

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

2. CASE STUDY 2

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

3. CASE STUDY 3 

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

4. CASE STUDY 4

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

5. CASE STUDY 5

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

6. CASE STUDY 6

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

7. CASE STUDY 7

Name
Sex
Age
Sport
Position
Playing level
Years playing

Assessment

i. Subjective Assessment

ii. Objective Assessment

Intrepretation

Planning

Implementation

Evaluation

Appendix One

AIPIE

Assessment

i. Subjective Assessment

This section is for subjective reporting of how your client says they are feeling during the session and what they report about their current symptoms. It can also contain information gathered from family members and reviews of past medical records.

Many health practitioners focus on what’s known as a “Chief Complaint”(CC) or the presenting problem in this section. 

Even if the client reports multiple CC’s, it’s important to try to identify the most compelling problem so that you can ultimately provide an effective diagnosis. 

Some general areas of inquiry as you try to identify the primary CC may include: history of present illness, medical history, review of systems, and current medications.

Here are some questions to ask to help uncover your client’s Chief Complaint:

1. Describe your symptoms in detail. When did they start and how long have they been going on?

2. What is the severity of your symptoms and what makes them better or worse?

3. What is your medical and mental health history?

4. What other health-related issues are you experiencing?

5. What medications are you taking?

Make sure any opinions or observations you include in the section are attributed to who said them — whether it’s yourself or your client. Because this is a subjective section, you don’t want to pass off any of this information as fact.

ii. Objective Assessment

This part of your SOAP note should be made up of physical findings gathered from the session with your client.

Some examples include:

· Vital signs

· Relevant medical records or information from from other specialists

· The client’s appearance, behavior, and mood in session

Note: This section should consist of factual information that you observe and not include anything the patient has told you.

ROM

Strength

Balance

Functional

Special Tests

Interpretation

Provide a provisional diagnosis;

- Muscle weakness

- Muscle stiffness

- Inhibited muscle

- Overactive muscle

- Sprained ligament

- Strained muscle/tendon

- Instable joints

- Muscle imbalance

Plan for treatment

This is where you outline your plan for next steps to treat the patient. Include the dosage of your treatment (FITT). Design an intervention program for 7 weeks that include:

- Resistance training

- Stretching

- Balance & Proprioception

- Taping

- Sport massage

- Cold/Hot treatment

- Functional training

Intervention program must include short and long term goals (SMART) for your patient and be as specific as what you plan to work on in the next session or as general as your expectations for the duration of treatment.

Implementation

Implement your intervention focusing on the ability of your client (regress if needed) and progress timely. Also focus on quality of movement and the right posture when performing the exercise.

Evaluation

Don’t forget to re-evaluate your client’s capabilities based on your findings during Assessment.

Appendix 2

Assessment Procedures

HAND EXAMINATION

Instructions

1. Introduce self, gain consent, co-operation and conform ID of patient.

2. Perform hand hygiene, roll up sleeves, and remove watch.

3. Explain procedure to patient.

4. Rest the patient’s hands on a pillow on their lap.

5. Expose both arms to above elbow.

6. Look:

a. Ask patient to hold palms down.

b. Inspect for swellings (articular and extra-articular), deformity, muscle wasting (interossei) and scars.

c. Look for rashes, skin thinning and bruising.

d. Look at nails for pitting onycholysis nail fold infarction or vascular compromise of the finger tips.

e. Symmetry and distribution of any joint abnormalities.

f. Ask patient to turn hands over.

g. Assess whether supination is a problem for them.

h. Ask patient to hold palms up.

i. Inspect for thenar or hypothenar muscle wasting Look for palmar erythema.

7. Feel:

a. Palpate any tender area to establish from which anatomical structure it is arising.

b. Assess any intra- or extra-articular swellings.

c. Ask patient to hold palms up.

d. Check radial and ulnar pulses.

e. Check capillary refill.

f. Check bulk of thenar and hypothenar eminence.

g. Test median / ulnar nerve sensation. Is it equal over thenar and hypothenar eminence and the index and little finger?

h. Ask patient to turn palms down.

i. Test radial nerve sensation – web space between thumb and index finger.

j. Assess temperature over forearm, wrist and MCPs.

k. Look for sites of joint swelling CMC joint of thumb or MCPs / PIPs.

l. Compare with own joints for size. Squeeze MCPs gently – watch face for pain.

m. Palpate any swollen MCP PIP DIP joints bimanually – is it synovitis? = warm swollen and tender or is it bony? = hard, no temperature change.

n. Bimanually palpate wrists for swelling, warmth and tenderness.

o. Run hands over extensor surfaces for rashes and nodules.

8. Move:

a. Check active movement – wrist, fingers and thumb.

b. Check passive movement – See general principles above.

c. Feel joints for crepitus.

d. Assess Pain, ROM, Strength, Balance, Function

9. Special tests:

a. Phalen’s Test (forced wrist flexion) in carpal tunnel syndrome (CTS).

b. Tinel’s Test (tap over median nerve at wrist crease) for CTS.

c. Allen’s Test for radial and ulnar artery function.

d. Assess power grip (squeeze 2 of examiner’s fingers.

e. Assess precision grip (Pick up coin from palm surface).

10. Thank your patient.

11. Consider your findings and how to present them in a logical and fluent order.

12. Then consider the possible clinical significance of these findings.

HIP/PELVIC EXAMINATION

Instructions

1. Introduce self, gain consent, co-operation and conform ID of patient.

2. Perform hand hygiene, roll up sleeves, and remove watch.

3. Explain procedure to patient.

4. Firstly, examine the patient standing in the anatomical position (Can choose to assess GAIT first if desired).

5. Patient requires to be stripped to underwear (or shorts).

6. Look

a. Assess muscle wasting (gluteal).

b. Ask patient to change position to lie face up on the couch.

c. Compare legs for an obvious flexion deformity at the hip

d. Assess leg length (with tape measure):- Apparent shortening – this is when one leg looks shorter than the other but the underlying reason is that the pelvis is titled (this may be fixed or correctable).

e. Test – square the pelvis first to see if this corrects the shortening. If the pelvis is fixed then measure from the umbilicus or xiphisternum to the medial malleolus of each ankle and compare.

f. True Shortening – this is when one leg looks shorter than the other and the underlying reason is a true discrepancy in length between one femur or tibia and the other.

g. Test – Measure from the ASIS to the medial malleolus of each leg and compare.

h. Check for scars (hip replacements – longitudinal scar on lateral aspect of thigh).

7. Feel

a. Check for tenderness over greater trochanter.

b. Palpate any tender area to establish from which anatomical structure it is arising.

8. Move

a. Perform active and passive motion combined by gently guiding the patient’s leg as they move it actively then pushing it a little further if possible passively.

b. Assess flexion - Flex knee and hip together – watch face for pain.

c. Assess abduction – Place one hand on the opposite ASIS as you abduct the leg to make sure that the pelvis does not tilt. Tilting of pelvis indicates the limit of hip joint abduction.

d. Assess Adduction – Place one hand on the ipsilateral ASIS as you adduct to make sure the pelvis does not lift. Lifting of pelvis indicates the limit of hip adduction.

e. Assess internal and external rotation in flexion and extension.

f. A fixed flexion deformity at the hip can be masked by a hyperlordosis at the lumbar spine which tilts the pelvis in order to flatten the leg. This can be

unmasked by Thomas’ test :- Hand under the lumbar spine – you should feel the gap of a lumbar lordosis Flex the normal hip up as far as possible – this tilts the pelvis back flat and abolishes the lumbar lordosis which you should feel by pressure on your hand. If the other leg lifts off the bed (usually it will bend at the knee rather than lift entirely into the air) this indicates a fixed flexion deformity of that hip.

9. Function and special tests

a. Ask patient to walk.

b. Assess gait: Antalgic – painful. Limps with short stance phase. Stiff knee – swings leg out to side; Foot drop – lifts leg higher than other side to clear foot; Trendelenberg – waddling gait that shifts weight form side to side.

c. Perform Trendelenberg test (assesses gluteal muscle strength).

d. Stand in front of patient and place your hands on their ASIS while they grasp your forearm.

e. Ask patient to stand on one hip at a time.

f. A positive test is the pelvis level falling on the non-weight-bearing side.

10. Thank your patient.

11. Consider your findings and how to present them in a logical and fluent order.

12. Then consider the possible clinical significance of these findings.

KNEE EXAMINATION

Instructions

1. Introduce self, gain consent, co-operation and conform ID of patient.

2. Perform hand hygiene, roll up sleeves, and remove watch.

3. Explain procedure to patient.

4. Firstly, examine patient standing. Can choose to assess GAIT first if desired.

5. Patient requires to be stripped to underwear (or shorts).

6. Look

a. Assess symmetry and alignment of both knees

b. Look for deformity valgus (knock knee) or varus (bow legged)

c. Examine the patient lying on the couch

d. Look for flexion deformity – where knee cannot straighten on the couch

e. Look for erythema, intra- and extra- articular swelling, muscle wasting (quadriceps), rashes and scars

7. Feel

a. For heat – back of the hand compare knee joints with mid calves

b. Palpate any tender area to establish from which anatomical structure it is arising

c. Assess any intra- or extra-articular swellings

d. Palpate for tenderness around patella, patella tendon and tibial tuberosity.

e. For Baker’s cyst behind the knee in popliteal fossa between the hamstring muscles

f. Perform patellar tap

g. Slide one hand down the thigh to push fluid out of supra-patellar pouch

h. Push firmly on patella - does it tap against femur?

i. If patella tap negative try cross fluctuation test for small effusion Firmly stroke medial side of knee joint upwards to move fluid into joint cavity and suprapatellar pouch

j. Then stroke the supero-lateral aspect of the knee downwards - watch medial side for a bulge of fluid if there is an effusion.

k. Flex knee to 90 degrees

l. Palpate joint line from anteriorly to posteriorly

8. Move

a. Check active movement

b. Check passive movement – See general principles above

c. Feel for crepitus

d. Test integrity of extensor mechanism by asking patient to lift extended leg off bed.

9. Function and special tests

a. Stability Tests – consider how sore patient is before performing these.

b. Flex knee to 90O and check for knee falling backwards (posterior cruciate ligament laxity).

c. Perform Anterior draw test.Place thumbs on tibial tuberosity and hands round upper tibia with index fingers tucked behind the hamstrings. Stabilise the tibia with your forearm and pull tibia forwards (anterior cruciate ligament laxity).

d. Hold knee at 15O with the hand behind the knee.

e. Stress medial and lateral collateral ligament by gently pushing other hand against each side of the knee.

f. Ask patient to stand – look for valgus and varus deformity

g. Ask patient to walk – look for antalgic or stiff knee gait

10. Thank your patient.

11. Consider your findings and how to present them in a logical and fluent order.

12. Then consider the possible clinical significance of these findings.