Reflective Practice 1

April 15th, 2017 3 hours

This is a short, informative Case Study about a knee surgery that could have been
averted if a thorough orthopaedic assessment at the initial consultation. Presented
here as an annotated letter sent to operating surgeon (for completeness I have
added the Muscle Imbalance paragraph). Salient clues are highlighted in bold.
The letter ends with a line like this:
___________________________________________________________

Personal details are withheld to preserve anonymity of patient and surgeon

TO: Mr X, Consultant Orthopaedic Surgeon,

Re: XXX XXXX
d.o.b.: 12/12/1912
Address:
Date of surgery (Knee, arthroscopy/wash-out): 11.12.13

Dear Mr. X
Thank you for referring this patient for physiotherapy. She presented for
physiotherapy 10 weeks post-arthroscopy (L knee) c/o what appeared to be two
separate knee problems: the first at the lateral aspect of the tibia (this is her
original, pre-surgical or primary pain), and the second at the arthroscopic surgical
sites.

She stated that her primary pain was more or less the same as it was before surgery
and described it as constant and burning (Duration: 24/7) at the lateral aspect of
the tibia just distal to the knee joint. When asked, she indicated that the site of her
original pain was over Gerdys tubercle.

Overall, she rated her pain at approximately 4/10 on a standard pain VAS. The pain
was worsened by walking down stairs, eased by Ibuprofen and tended to worsen in
the pm. She stated that her knee occasionally gave way but denied frank locking and
lower quadrant dysaesthesias.

Her pre-op x-ray showed some degeneration in the Tibio-femoral and Patello-
femoral joints.

On examination:
Knee extension and flexion range of motion were slightly limited (mild discomfort
on over-pressure at end-range F/E) this is consistent with a post-arthroscopic
knee and is probably self-limiting. She confirmed that the main difference between
her post-surgical discomfort and her initial primary complaint of lateral knee pain
was the addition of the post-surgical component.
Knee joint testing at initial assessment did not reproduce her presenting pain OR
her pre-surgical symptoms.

However, her lateral knee pain was reproduced by tests of ITB syndrome, SLR,
prone knee bend test (PKB) and slump test in sitting. She had a limited lumbar spine
ROM, particularly extension; L lateral flexion left quadrant testing. She was tender
to palpation at L2-3 on the left side.

Muscle Imbalance:
Tight ipsilateral TFL, R-femoris, QL and ITB. Hypertonic ipsilateral lumbar erector
spinae and vastus lateralis. Weak Gluteals. Entire fascia lata tender to palpation.

Palpation of myofascial trigger points in her lateral hip musculature reproduced

some of her pain. So did tests of lower quadrant neuro-meningeal irritation (e.g.
SLR).

Impression [1]:
ITB syndrome
Gerdys tubercle bursitis
Referred pain from lumbar spine with positive tests of neuromeningeal irritation on
clinical testing
Patello-femoral dysfunction

Physiotherapy Treatment Plan:

Reinforce and progress patients post-surgical rehabilitation
Treat lumbar spine dysfunction and lower extremity neuromeningeal irritation
Address muscle imbalance in entire lower quadrant that might be predisposing to
irritation of soft-tissue structures around Gerdys Tubercle
Treat myofascial trigger points
Home exercise programme

Treatment at first visit:

Taught stretches for TFL
Manipulation of Lumbar Spine [2]

Subsequent Treatments: Total 4

Lumbar spine manipulation to L2-3
Stretches for ITB, R-femoris and self-mobilization for PKB/femoral nerve irritation
Flossing for Femoral Nerve
Needling for TFL, G-min
Home programme

At final visit today, patient pain free for over one week with full ROM
No pain on functional movement
Tenderness over surgical sites only

Yours sincerely, Richard Shortall MISCP

________________________________________________________________
 Reflective Practice 3

Annotations
Reflective Practice:
I did this case study to demonstrate the importance of a thorough History and
Physical Examination it is NOT about Physiotherapy treatment at all. Its about
assessment.

This patient primary (Medical) diagnosis prior to surgery was (or should have been)
Iliotibial Band Syndrome (ITBS). Knee OA was not her primary problem.

Her Physiotherapy Diagnosis was Lumbar Spine Dysfunction and Left Lower
Quadrant Dysfunction presenting as NMI [3] and ITBS. The Physiotherapy diagnosis
supersedes the Medical diagnosis because it generates explanatory hypotheses and
these guide treatment and re-assessment.

It is unlikely that the surgery was warranted because:

1. The assessment suggested that the original medical diagnosis was
incorrect
2. The nociceptive source (lesion) was outside the knee, not inside it
3. The presenting pain was in the wrong place
4. The surgery did not improve her condition
5. Her long-standing CLINICALLY STABLE problem resolved with a short
course of physiotherapy aimed at her actual presenting complaint (lumbar
and lower quadrant dysfunction presenting as ITBS)

Take Away Lessons

1. It is important to encourage the patient to INDICATE (with one finger no vague

gestures) where the pain is - particularly with the knee area.

2. Patient presentations that mimic OA of the Tibio-Femoral articulation are often of

lumbar or hip origin.

3. The real problem was probably OUTSIDE the knee joint itself (PFD, Tib/Fib joint
or ITBS as well as referred pain from the spine, pelvis, hip or limb musculature).

4. Segmental referral is NOT the sole mechanism by which the lumbar spine (or hip)
can cause knee pain. Dysfunction in the spine (pelvis or hip) can alter lower limb
mechanics and cause problems lower down in the kinetic chain. Not all distal
problems are referred pain.

5. Imaging of the spine and hip is NOT sufficient to rule out proximal causes of knee
pain.
6. A thorough HISTORY and EXAMINATION is essential to prevent un-necessary
surgeries.

7. The assessment suggested a significant neuro-meningeal component

8. Physiotherapy treatment is not directed at the Medical Diagnosis (ITBS) but at the
patients impairments and problem list [4].

Take Away Tips

I.
A patients verbal description of the location of pain is seldom if EVER sufficient
Instead, have the patient POINT AT or draw out the location of the pain, preferably
using ONE FINGER. This is because patients tend to resort to vague sweeping
gestures of the hand rather than being precise. In presentations like this, it is vital to
correctly locate the pain. I know this is considered Untrendy in some
physiotherapy circles but I think this precaution alone might have prevented the
surgery and some things are so important that one may consider bucking trendy
trends in the patients interests.

I have pain in my knee, Doctor is NOT sufficient.

I say it like this: Using ONE finger, show me EXACTLY where it is POINT at it (or,
Draw it out with ONE finger)

II.
Dont treat the x-ray (synecdoche for all imaging and other diagnostic tests) treat
the Patient. In this case, as in many others, the degeneration seen on the patients
imaging studies was basically an artefact. The assessment of this patient was
strongly suggestive of a problem OUTSIDE the knee joint.

Questions:

1. Is this important or am I being pedantic?

It IS important it is likely that if the surgeon had done a thorough Orthopaedic

assessment (or even just asked the patient to POINT at the bit that hurt) the correct
diagnosis would have been reached, the patient could have avoided an un-necessary
surgery and after 4 visits to our clinic, her pain would probably be gone (as it is
now).
AND Im being pedantic, so what?

2. How do you know the Physiotherapy did the trick and not the surgery?

Lots of reasons:
 Reflective Practice 5

I. the patient had the same pain before and after surgery

II. she had the SAME pain for many weeks post-op 24/7

III. Her pain was substantially reduced immediately after her first physiotherapy
visit [5]

IV. The surgery did not alter her primary complaint her pain was gone after four
physiotherapy treatments

V. The standard neuro-orthopaedic assessment strongly suggested that the original

diagnosis was incorrect

VI. Physiotherapy was directed at the correct diagnosis the outcome was
predictable and congruent with the explanatory hypothesis (physiotherapy
impression)

FOOTNOTES

[1] Phrasing like this gives the impression that the examining physiotherapist
concluded that the patient has ONE of (in this case) FOUR diagnoses. As any manual
therapist knows, the REALITY is that the patient probably has ONE problem that
MANIFESTS as if it is FOUR different things. In fact there were signs of a few other
diagnoses in the patients presentation (probably with the same single cause) but
there is no point in listing them all in a letter of this nature. The apparent
multiplicity of diagnoses in patients like this (a common presentation by the way) is
often a medical artefact: what one is often looking at is several manifestations of the
same problem. This explains why diagnoses like trochanteric bursitis are
disappearing and why patients who consult with several clinicians frequently get
several different diagnoses what they are often getting from each clinician in
turn is his/her current favourite artefact.

[2] Immediately (SECONDS) after the bilateral HVLA of L 2-3 the patient stated that
her burning pain was noticeably better and on post-HVLA re-testing, her PKB was
better. I cant say that I see rapid improvements like this every TREATMENT - but I
DO see them every day (of every week, every month, every year for DECADES), so
when I read articles written by researchers and academics (people who often
havent regularly treated patients for years, or even decades) that advocate a
hands-off approach ... well I can be excused for having a jaundiced view of their
opinions and recommendations. In fact, given the quality of much of the research in
our area, I believe the jaundiced opinion might be the only appropriate one.

If you dont do skeptical thinking then you are probably not thinking at all.
[3] Neuro-Meningeal Irritation (formerly adverse neural tension sometimes still
referred to as a trapped nerve)

[4] I describe my Nuts And Bolts Physiotherapy approach to patients

[5] This is one (of several) reasons why I am distrustful of those one year follow up
periods so beloved of researchers and academics I frequently see significant (yes,
and lasting!) improvements in patient pain and function within minutes of
treatment sometimes within seconds. If were so fond of a one year follow up
period, why dont we go the whole hog and have a two year one.. or even a 10 year
one? I bet with a 10 year follow up period, we could prove that core strengthening
(or porridge) is really effective for lumbar spine problems!