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CASE STUDYStudent nameJessica PalmerSchoolThe Massage Training SchoolCourse codeMTS20Submission date25th Nov 2018Case study number - 1Category - from list of 6 - each case study must be from a different categoryAthlete (recreational or competitive)Physical disabilityAged over 70Post-acute injury or surgeryChronic injuryMedical conditionAthleteGeneral information - first name only, age, gender - do NOT include any personal identity informationMike, 51, MaleOccupation - describe the physical aspects of their job and also their level of occupational stress or other relevant factorsCarpenter – Spends his working day crouched over, on his knees a lot, very physically demanding, climbing ladders, general carpentry work.Sport - in detail if this is in the Athlete categoryBasketball player – Has been playing basketball for 10 years, has previously had a problem with his knee pain but never sought medical advice or actual diagnosis. He trains twice a week and also adds in middle distance running training up to and around 5-10 km once a week.He plays basketball with friends for fun.He generally feel fits however knee pain is becoming increasingly painful and stiff.Medical history - in detail if this is in the medical condition, physical disability or over 70 categoryNo previous medical history and considers himself healthy and fitInjury history - in detail if this is in one of the injury categoriesHis knee pain began over a month ago and hasn’t sought previous helpLifestyle - family, hobbies, activities, lack of activity, diet, smoking, social life, etcHe has a family consisting of 3 kids and his wife, he is very active with his children and continuing this is very important to him. He plays football with his son and runs with his daughter mostly of road trail running.He lives a relatively healthy life, eats well, doesn’t smoke and drinks socially once or twice a week.He also plays guitar in a local band, and practices once a week.Treatment goalsClient - what the client hopes to achievePrimary (eg treat the main injury) Secondary (eg treat another problem, get back to playing sport, lose weight and get fitterPrimarily my client wants to be pain free, reduce the pain in his knee and not feel restricted so that he can live his life freely again.Secondary to this my client would like to understand how he can maintain the best possible outcome for his knee so that he can learn to look after it and prevent/limit its return as he ages.TherapistAre client’s goals achievable? Yes I believe the clients goals are achievable if he is prepared to maintain and work on flexibility, including using a proper warming up regimen before and after activity. Understanding how to improve his functional movement patterns which I will work on with him.How many sessions may be needed and over what timescale?I think I would like to see him once a week with homework given for the remaining of the week, once a week for 3-4 weeks depending on improvements made then if to plan I would look reduce how often I see him depending on his progression.If/when you would consider referring the client to a medical practitionerI would refer to a medical practitioner if he started to display symptoms or pain that are non-musculoskeletal in origin.If/when you would consider referring client to another discipline such as Pilates, sports coach, podiatristI would consider referral to a podiatrist if I felt this would benefit him for his gait cycle. I am a very experienced sports coach, movement specialist and yoga for sports trainer so I wouldn’t refer if I though any of these would help him.AssessmentCurrent symptoms - client’s account of their symptoms - pain, restricted movement etcSpecific anterior/laterally located knee pain felt during basketball and sitting for too long aggravates the knee pain and during running. Pain described as a diffuse ache. Client also feels like the knee cap moves laterally at times.Posture - neutral, lordotic/kyphotic, flat-back, sway-back or other noticeable featuresNeutral no noticeable discrepancies. Spine - either normal or describe the degree of excessive lordotic/kyphotic curvature (cervical, thoracic, lumbar, sacral)Normal curvature of the spine, no abnormalities found. Pelvis - either normal or describe the degree of excessive anterior/posterior alignment (left and right sides) and lateral alignment (one side higher than the other)Pelvis has a lateral drop Shoulders - either normal or describe the degree of protraction/retraction, elevation/depression (right and left sides)Shoulders show normal, no retraction, protraction issues, no elevation or depression issues to note.Leg/arm alignment - either normal or describe any features such as hyper-extended knees, over-pronation or other foot issues Increased right knee valgus, increased during the gait cycle (midstance)Mobility - which joints or spinal sections appear to have a restricted range of movement or are hyper-mobile Hip mobility is restrictedRange of movement (ROM) testsThe joints or spinal sections you apply active, passive and/or resistive ROM tests (or any other tests) toConclusionsActive Knee – flexion, extension, internal, external rotation No pain – restricted flexion Passive Knee – flexion, extension, internal rotation, external rotation No pain – restricted flexion Active Hip – Flexion, extension, internal , external rotation No pain – restricted internal rotation Passive Hip – Flexion, extension, internal and external rotation Hip external rotator strength test Hip abductor strength testHip internal hip strength testFlexibility of ITB/TFL test (modified Thomas test)No pain – restricted internal rotation End feels as normal LimitedLimitedLimitedKnee Anterior Glide: Anterior drawerNo pain/movement Posterior Glide: Posterior Drawer No pain/movementLateral rotation No pain/movement Medial Valgus stress test Adductors AbductorsGastrocs No excessive gapping Restricted 10-15 degrees compared to other side No restriction compared to the other side and normal range foundRestricted slightly at the proximal end.Palpation and observation - which muscle areas look and/or feel hyper/hypo-tonic Observation – supine. Looking at lower limb alignment, effusion, position of patella and any signs of patella tilt or rotation. Nothing found out of the ordinary on observation. The VMO is much bigger and over developed.Palpation – the patella and the medial and lateral facets highlight slight tenderness on the lateral facet.Palpation – over the inferior pole of the patella, patellar tendon attachment and the infrapatellar fat pad. = Nothing out of the ordinary was found.Palpation – quadriceps = Vastus medialis over developed and solid, vastus laterallis under developed no tenderness found.Tfl – Hyper tonicITB – very tight and guitar string like.Passive movement – patella glide. Patella moved medially, laterally, superiorly and inferiorly – good quality of movement compared to the other side.Assessment summary - describe what you think the problem is, based on the above assessmentsI think at this stage that I am looking at increased knee valgus, inadequate strength in external hip rotators, hip abductors, quadriceps, hamstrings. Altertered neuromuscular control of; external hip rotators, abductors. And slight rom deficits in the hip internal rotators.Treatment planWhat measurable improvements are you hoping to make to the symptoms?Firstly reduce pain, To reduce the feeling of tightness in the adductors, reduce the pain on the lateral side of the patella and decrease the tightness along the itb by working on the tfl and biceps femoris and glute medSESSION 1General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Prone: effleurage and petrissage to the lower limb to warm up and prepare them for deeper work using soft tissue techniques. Some deep friction massage to the areas of tightness like the IT band, sartorious, adductors.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Positional Release of the tissue on the lateral side of the patella and adductors STR + STR PIR – Glute medius, TFL, Adductors, Quads, Bicep femoris, gastrocs.Myofascial movement – sartotius, quads, adductors.Why did you pick each of these particular techniques and what were you aiming to achieve?To relieve tight lateral structures and compliment medial structures, reduce quadriceps activity specifically vastus medialis. Reassessment - describe any changes that have resulted from the treatmentChanges in the flexibility of the glute medius, tfl, adductors and quadriceps, hamstrings and gastrocs.Advice - what advice or exercises did you give to the clientTraining discussed, shoes extrinsic factors that maybe responsible for placing additional load like jumping at a game on the VMO. Exercises given to retrain flexion and extension of the quads. Hip muscle stability exercises to stabilise the lateral pelvis and control internal hip rotation non weight bearing. Training of external hip rotators using the contralateral leg pushing into a wall and externally rotating the weight bearing leg.SESSION 2How long after Session 1?2 weeks Client feedback - what client says about their condition since the last treatmentPain and feeling of restriction greatly reduced, feels much more optimistic and happy that treatment is helping. Found exercises challenging enough without feeling overwhelmed.Reassessment - describe any changes that have occurred since last treatmentITB/TFL improved flexibility, less tightness over the lateral side of the patella, vastis medialis is less hypertonic, biceps femoris flexibility improved. Better strength test results through the hip strength tests as on first treatment. General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Effleurage/petrissage generally over the leg supine/side lying and prone. Applied friction along the itband, positional releases over the tfl and glute med, and laterally on the quads.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Why did you pick each of these particular techniques and what were you aiming to achieve?STR+PIR glute medius, adductors, quads, biceps fem, calfs.Reassessment - describe any changes that have resulted from the treatmentAdvice - what advice or exercises did you give to the clientProgressed hip muscle strengthening to weight bearing load, flexion tasks like lunge, step up and step down, maintaining neutral pelvis position.SESSION 3How long after Session 2?2 weeksClient feedback - what client says about their condition since the last treatmentClient feels improvement made that he has returned to basketball without any pain, running is much easier and feels very pleased with the results. He will continue to strengthen and work on areas of restriction and/or weakness.Reassessment - describe any changes that have occurred since last treatmentITB/TFL functions within normal flexibility range, vmo is much less dominant, when client performed a single leg squat the pelvis did not move laterally, client maintained full control of the movement and the knee tracked forward successfully. Thomas test was performed and normal outcome was recorded.General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Effleurage/petrissage generally over the leg supine/side lying and prone. Applied friction along the itband, positional releases over the tfl and glute med, and laterally on the quads.Soft tissue techniquesWhere did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?Why did you pick each of these particular techniques and what were you aiming to achieve?STR + PIR quads and adductors only, no pain felt but just wanted to give another treatment.Reassessment - describe any changes that have resulted from the treatmentClient reassessed all the tests done at session 1 and performed well on all, no restrictions, no limitations accept the adductors still a little hypertonic.Advice - what advice or exercises did you give to the clientTo increase load, jumping plyometrics on single leg, hopping etc, keep working on lateral strength.Conclusion - summarise results and future plans (if any) with the clientI have advised and rebooked my client to return to me in 4 weeks time with the plan of reducing frequency over the next few months.ISRM use onlyMarkerinitials% mark for this case studyCommentsAverage % for three Case Studies ................
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