Case Studies
In an effort to give you an insight into how our skilled physiotherapists work, we bring you a sample of actual cases and how they are managed. As each individual is different and complex, please consider that specific results may differ from person to person and this is not to replace actual human interactions!
Shoulder Pain after a Fall
History: A 21 year old male presents with an acute fall of his shoulder on grass during running. He felt immediate pain and he could not move his arm. What can physiotherapy do to help?
Clinical examination
The patient could not move his arm by himself due to pain. In the passive movement examination, his arm was able to be lifted forward and sideway to shoulder height before being stopped by pain. His arm across his body was the most painful and restricted movement. His shoulder internal and external rotation range is good, only mild pain is reported at end of range. His left acromioclavicular (AC) joint was the most painful on palpation. No step deformity was seen, which is a good sign for a lower grade injury.
His mechanism of injury and clinical presentation indicate an AC joint sprain (mild to moderate).
Management
Acute AC joint injury management includes supported immobilisation to allow the sprained joint capsule and ligaments to have time to heal. He was given a sling to wear during the day and his shoulder was strapped. He had trigger point muscular pain in the surrounding area such as upper trapezius and deltoid muscles, which is a common problem because these muscles are trying to compensate for the injured AC joint. This patient responded well with dry needling which helped him to alleviate resting pain and muscular ache.
Over the next two to three weeks, this patient improved well and was able to gradually reduce the usage of sling without symptoms. His horizontal adduction movement range was still restricted compared to the other movement which is common after AC joint injury because this is a stressful position to the AC joint. This would gradually improve with treatment and exercises.
He was given rotator cuff strengthening exercises and scapular stability exercises as a progression at a later stage of his rehabilitation.
In six week post injury, he was able to return to gym and perform his normal workout routine without issues.
If you have any questions regarding your specific problem or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
ACL Tear
History: A 15 year old female Miss K who is a netballer presents with a right ACL reconstruction surgery one week ago. Her surgeon has referred her to do physiotherapy. What does she need to do in rehab?
Clinical examination
The patient is walking with two crutches. Her knee is moderately swollen. Her wound is covered by wound dressings. Her knee extension range is -5 degrees (meaning it’s in a slightly bended position) and her flexion range is about 20 degrees, both motions are limited by pain and stiffness.
Management
It is expected that ACL reconstruction rehabilitation to be a lengthy process. It generally takes at least six months to twelve months to return to sports. Most surgeons would provide the patient and the physiotherapist a rehabilitation protocol, but it is common to have variations which depend on the graft choice and individual factors.
Initial stage of ACL-recon for Miss K focuses on swelling control and restoring her loss of knee extension range. This is critical as it allows her to walk with normal gait as soon as possible and avoid the development of compensation strategies. Her treatment includes manual therapy, compression therapy, and inner range closed chain quadriceps exercises.
In six weeks times, Miss K has recovered full knee extension and ninety per cent flexion range of motion.
Depends on the sports type, most patients can return to sports after six to twelve months. In between this six to twelve months, there is a variety of exercises need to be covered to allow successful return to sports. That includes improvement on proprioception, strength, balance, flexibility, agility, functional strength, plyometric ability and sports-specific skills.
As Miss K is very compliance to her rehabilitation program and keen to return to sports. She performs her exercises well and on schedule. She is able to return to low level netball in nine months.
If you have any questions regarding your post operative rehabilitation or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Ankle Sprain from Basketball
History: A 15 year old boy presents with a recent right lateral ankle sprain from landing on someone’s foot and rolled inwards during basketball. What should he do to facilitate return to sports?
Clinical examination
In observation, the patient has mild lateral ankle swelling but no bruises. He is able to walk without pain. Symptoms are provoked during eversion and lunging. His anterior talofibular ligament (ATFL) is tender on palpation. Ligament stability tests (anterior and posterior drawer tests) are negative.
The examination findings suggest that he has a low grade right ATFL sprain.
Management
A combination of education, RICE (rest, ice, compression and elevation) approach will be appropriate to manage his acute symptoms. In this scenario, his symptoms are able to further reduce with joint mobilisation and strapping.
Over the next two weeks, he is able to gradually progress his exercises from range of movement exercises to proprioception and strengthening exercises, specifically single leg balance and single leg heel raise. He was able to perform thirty repetitions in single leg heel raise which is clinically indicative for exercise progression and trial return to modified sports.
It is indicated from research that the reinjuring rate after the first ankle sprain within the first year is remarkably high, up to eighty per cent. It is also suggested that proprioceptive (balance) and ankle strengthening exercises will significantly reduce the risk of recurrence, and the exercises program should at least last up to two months. It is important to be aware that free of symptoms and ‘feeling good’ do not always mean the ankle function is fully recovered.
If you have any questions regarding ankle sprain and ankle braces, and need an assessment, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Shin and foot pain
History: An 11 years old female, national gymnast for NSW, has been going to physiotherapy for several weeks as a result of calf tightness and foot pain. She has not yet had any scans.
Her short terms goals are to be able to keep training in preparation for nationals with minimal pain, and to compete at nationals. Her long term goal is to be able to train with no pain in her feet.
She had an initial gym assessment 2 months ago, where she was found to have a Beighton hypermobility score of 1 (she can touch palms to ground), a knee-to-wall test of 8cm bilaterally (desirable 10cm), she can perform more than 20 single leg calf raises bilaterally, she has bilateral decreased FHL ROM (Thomasen’s sign), and bilateral tight rectus femoris and TFL on the Thomas test. She also has a history of shin and ankle pain.
Clinical examination
In May she presented with bilateral pain with single leg hopping, decreased dorsiflexion, bilateral tightness of calves, and pain around tibialis anterior and tibialis posterior.
The provisional diagnosis was navicular stress fracture, hair-line fracture, bony bruising, tibialis posterior strain, tibialis anterior strain, tendinopathy of tibialis posterior or tibialis anterior, plantar fasciatiis, spur, ankle sprain, anterior compartment syndrome, posterior compartment syndrome, patella-femoral pain syndrome, or tibialis posterior dysfunction. The MRI showed no stress fracture, normal bones, no ligament or ganglion abnormalities, normal tendons, no soft tissue injury L = R, and no abnormality seen that could account for pain. After ruling out knee, hip and back as origin of the pain, the problem was identified as coming from the ankle area: she had an exertional compartment syndrome associated with a plantar fasciitis.
Management
Her treatment consisted on education about her condition, and advice to modify activity that increases shin pain. She was advised to apply ice daily to reduce swelling, and recommended to take NSAIDs to reduce inflammation.
Soft tissue release technique and plantar fascia stretching improved her symptoms. A low dye taping with a modified reverse 6 was applied to alter navicular height and plantar pressures. This provided arch support and prevented excessive pronation, which relieved her symptoms.
Her pain gradually subsided and she was able to return to gymnastics after week. She was advised to perform plantar fascia stretching before training.
If you have any questions regarding shin or foot pain, and need an assessment, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Low Back Pain in the Office
history: A 35 year old office worker presents with a recent episode of lower back pain and left buttock pain from prolonged sitting at work. Is there anything physiotherapy can help with?
Clinical examination
In sitting, the patient finds it sore, stiff and tiring to sit upright. It is more comfortable to slouch at the beginning after it starts to hurt after a few minutes. In standing, the patient finds it painful to bend all the way forward and it is very stiff and painful bending backward.
Management
A combination of education, sitting posture adjustment and exercises help to address the cause of the problem and manage appropriately. Manual therapy helped to reduce the time it took become pain free.
As this is a sustained posture related issue, understand and be able to recognise ‘’prolonged sitting’’ is the most important part of the management. "Get up and move" will be a good first step.
After adding a lumbar support in sitting, the patient feels sitting is a lot more tolerable and less symptomatic.
The patient also responded well with repeated extension exercises, where his buttock symptom is centralizing (shifting towards the back) during exercises and the entire symptoms are abolished after the exercises. This particular symptom change often means a good prognosis for lower back pain.
Although extension exercise is commonly beneficial for lower back pain patients, this is not a one size fits all remedy. Please do not try it on your own without having an assessment done by medical professionals.
If you have any questions regarding your back pain or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Conservative Management of Meniscal Tear
History: A 47 year old male presents with an acute left knee injury from rotational standing up movement from a seated position at lunch. He felt immediate pain in the medial side of his knee and reports a locking sensation when attempting to straighten his knee. What can physiotherapy do to help?
Clinical examination
The patient was unable to weight bear on his left leg as he could not straighten his left knee due to pain and catching sensation. During passive range of motion movements, his knee could be flexed to full range, however was painful at end of range and when moving leg back into extension. Passive patella movement did not reproduce his symptoms, though symptoms reproduced upon palpation of medial border of knee cap and medial knee joint. No swelling was evident at time of review, however this is expected in the acuteness of his injury.
His mechanism of injury and clinical presentation indicate an acute torn flap of his medical meniscus.
Management
Small meniscal tears can be managed conservatively if a person’s range of motion is not greatly affected, have minimal swelling and are able weight bear. The first phase of conservative management of an acute meniscal tear includes maintaining knee extension range of motion and providing stability to the knee to reduce any risk of further injury. Small amplitudes of passive accessory movements were undertaken in attempt to normalise joint range of motion. He was provided with education regarding the importance in maintaining knee extension and encouraged to undertake light knee extension stretching techniques to aid in this. Kinesiology tape was used to strap his knee to promote healing, support, reduce swelling and assist in pain reduction. The patient responded well with dry needling to his hamstrings and calf muscles which assisted in off-loading the knee joint from muscle tightness. Following the initial treatment, the patient had a reduction in pain symptoms and ability to weight bear as tolerated through left leg.
Over the next two to three weeks, the focus was to eliminate swelling and achieve full range of motion and focus on hamstring and quadriceps strength. Through the completing all home strengthening and stretching exercise program, this patient improved well and could obtain full range of knee extension with a reduction of pain and an increase of muscle strength. He was provided with full range squats and lunges as a progression to his hamstring and quadriceps strengthening exercises with added endurance training program for his hip external rotators. After another few weeks, he could return to his home-based fitness program and work schedule without any issues.
If you have any questions regarding your knees or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Extensor Tendinopathy
History: A 53 year old female presented with gradual onset of pain to her right elbow localised to the lateral side of elbow and forearm. She described her pain to worsen with gripping, reaching and lifting tasks, especially when attempting to use scissors at work. What can physiotherapy do to help?
Clinical examination
At rest, with her forearm relaxed on a pillow the patient had minimal to no symptoms. During active and passive range of motion examinations, pronation (inward rotation) of her forearm with the elbow extended and flexion of the wrist were the most provocative movements. Resisted extension of her wrist and 3rd finger also reproduced her symptoms and she was tender upon palpation over the lateral side of her right elbow and presented with painful and decreased grip strength. No reproduction of symptoms was evident following a screen of her right shoulder and neck, indicating a non-referral pain diagnosis.
Her mechanism of injury and clinical presentation indicate an extensor tendinopathy or commonly known as “tennis elbow”.
Management
A multimodal treatment incorporating education, unloading of the tendon from aggravating factors, pain relief and restoring tissue capacity and control was used to manage her extensor tendinopathy appropriately. Pulsed ultrasound was firstly used to promote the initial healing of soft tissue. She had active trigger point pain along her forearm muscle, that is a common occurrence in the presentation of extensor tendinopathy. The patient responded well with dry needling to her right forearm muscles which assisted in relieving muscle tension and forearm pain. She was provided with education regarding the use of ice as a form of pain management and unloading strategies. Isometric muscle activation exercises and stretches were also prescribed to be completed at home. She was also provided with a counterforce brace to be worn during working hours to assist her in gripping with reduced pain.
Over the next couple of weeks, the main focus was to restore the tissues capacity to withstand loads with minimal to no pain. This is achieved through appropriate rest and unloading of the tendon. Completing a progressive home strengthening exercise program with appropriate loads and tendon stretching. These strategies allowed time for the patient’s tendon to heal appropriately and reduce the symptoms the patient was experiencing. Manual therapy techniques and dry needling were used in conjunction to relieve any associated muscle tension. Following a couple weeks, she was able to return to full work duties with minimal to no issues.
If you have any questions regarding elbow pain, and need an assessment, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Knee Pain whilst Running
History: A 43 year old female presents with recurrent knee pain after training at the gym or running on and off for a few years. The location of her knee pain is in the front of her knee near the inside. She does not have a history of knee injury. What can physiotherapy do to help?
Clinical examination
The patient does not have any symptoms walking and climbing stairs. Her knee pain is predominantly from squatting and worse in a single leg squat. While squatting, excessive knee adduction is observed. No flat feet are seen. Her knee joints are hypermobile but her right patella-femoral joint is not painful on palpation. Meniscus and ligament orthopaedic tests are negative. During quadriceps activation test, her vastus medialis oblique (VMO) was under-active and her patella was moving laterally. Her calves and hip external rotators are weak as well.
Her clinical presentation indicates a lateral tracking patella disorder.
Management
The cause of patella lateral tracking disorder is often multi-factorial. In terms of initial symptoms management, this patient responded well with McConnell Taping (medial glide of the patella with rigid tape), where she could squat without pain afterwards.
After a week, her knee pain settled. She then started a specific muscle training program focusing on activation, strength and endurance of the VMO, calves and hip external rotators. In her next review after another two weeks, there was noticeable improvement in her lower limb biomechanics since she started the exercises and she was happy with the results.
Clinically being able to have at least satisfactory closed chain lower limb biomechanics is very important to rehabilitation and injury prevention. For specific groups of people, such as runners and sports players, further dynamic, agility and plyometric assessment and training will be a key to their performance and sports specific injury prevention.
If you have any questions regarding your knees or are interested in seeing if we can help you, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Middle Back Pain and Left Arm Pain
History: A 50 year old female, Mrs L., presents with middle back pain and left arm pain gradually developed over the weekend without clear mechanism of injury. The only potential reason that she could think of was gardening. She had ongoing back stiffness; otherwise she is normally healthy and active. What could be the cause of her problem?
Clinical examination
Mrs L’s left arm pain is provoked when she is reaching forward. Her left shoulder range of movement is normal. She has reduced neck and middle back range of movement, specifically cervical retraction and thoracic extension.
In neurological examination, Mrs L’s biceps and triceps jerk reflex are normal. Her strength and sensation were also normal. On palpation, her left mid thoracic area is stiff and her arm pain is also provoked.
It appears that Mrs L’s left arm symptom is related to her left thoracic spine.
Management
Mrs L’s left arm symptoms and thoracic spine stiffness are reduced after some thoracic spine joint mobilisation. She was then given some cervical and thoracic mobility exercises to restore her loss of range of movement. Her symptom is almost completely abolished in two weeks.
It is not uncommon that sometimes the arm pain that patient experienced come from a different body part, typically cervical or thoracic spine. A systematic examination procedure will help identifying the source of the symptoms, and aid an appropriate management approach.
If you have any questions regarding suspicious arm pain and need an assessment, please give us a call at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.
Thoracic pain
History: A 39 year old female presents with a two week history of pain between her shoulder blades. The location of her pain is on her left middle back between her shoulder blades and left sided neck pain. She reported no mechanism of injury but conveyed that the pain commenced in her shoulder and then moved to her middle back and neck. No pins and needles or numbness was reported and her symptoms were aggravated by lifting up her arms and rotating. Mrs. X has a history of this complaint previously, which typically settles without intervention in a few days. Her past medical history included having her gallbladder removed (due to a benign tumour) 12 months ago with serious post-operative complications that required six additional surgeries. She also had a motor vehicle accident 2 years ago where, and she sustained a neck injury that was managed with physiotherapy. Mrs. X’s current goals of physiotherapy were to reduce muscle spasm and be able to perform activities of daily living without pain.
Clinical examination
On examination in sitting, the patient demonstrated reduced range of movement and pain in her cervical and thoracic spine, especially with rotation movements with her arms abducted. Cervical flexion, extension and left rotation were reduced and combined movements retraction and extension was reduced and painful. Cervical left rotation and extension provoked her scapular pain. When looking at her thoracic spine movements, left rotation was reduced and extension was reduced and painful. When examining passive accessory movements, her thoracic spine was stiff and painful with PA mobilisations and she was stiff with left unilateral PA mobilisations of her cervical spine.
DDx: Cervical derangement
Management
Mrs. X’s treatment included patient education regarding posture and about cervical referred pain was explained to Mrs. X to help her understand the cause of her symptoms. Mrs. X’s symptoms originating from the cervical spine were reduced with left unilateral mobilisations as well as retraction and extension mobilisations with movement (MWM). This increased her rotation range and reduced her scapular pain with arm movements. In supine, left lateral flexion PPIVM’s, repeated left rotation and extension, and retraction and extension further reduced her pain and following this treatment only reported slight pain at end of her rotation range and no remaining muscle spasms with arm movements. Other techniques including thoracic spine mobilisations and soft tissue releases of her upper trapezius muscles were also performed to reduce her stiffness in her back as a result of muscle guarding and avoiding movement for the last couple of weeks. Mrs. X was additionally encouraged to complete cervical retraction and extension movements 10 times, 3-4x day until her next consultation to maintain her progress.
If you have any questions regarding thoracic or neck pain, and need an assessment, please give us a call at (02) 8411 2050. Here at Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble