Edited by Garcia-Sanchez PC

First Edition, 2015©

Second Edition, 2016©
Edited by Pablo C. Garcia-Sanchez

This book pretends to be an e-book and be read through electronic devices. Think it twice if you
want to print it. If you do so, be sure that it is printed using recycled paper.
This book is under a Creative Commons License:

Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

You are free to share — copy and redistribute the material in any medium or format. Learn more
about this CC license at creativecommons.org or in our web:

physiotherapyreflectivecases.wordpress.com

Notice

Medical and clinical knowledge are constantly evolving and changing. Readers of this book are
advised to check the most current information provided on procedures featured. It is the
responsibility of the therapist, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosage and the best treatment for each patient, and to take all
appropriate safety precautions. To the fullest extent of the law, the authors do not assume any
liability, loss or any injury and/or damage to persons or property arising out of or related to any use
of the material contained in this book.

The authors
2

Edited by Pablo C. Garcia-Sanchez

3
 CONTRIBUTORS
Mª Dolores Alcalá
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Iscia Bertrand
4th year student of Physiotherapy,
4
Universidad Europea de Madrid, Spain
Pablo C. Garcia-Sanchez
Physiotherapist, Lecturer, Department of
Physiotherapy and Podiatry, School of Health
and Sports, Universidad Europea de Madrid,
Spain
Gema Gallardo Sanchez
Physiotherapist, Physiotherapy Unit,
Fuenlabrada University Hospital, Spain
Juan Antonio Gonzalez Garcia
Physiotherapist, Physiotherapy Unit,
Fuenlabrada University Hospital, Spain
Rossella Guido
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Marta Javier
3th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Greete Kriik
2nd year student of Physiotherapy,
Metropolia University of Applied Sciences,
Finland
Guadalupe Pérez
3th year student of Physiotherapy,
Universidad del Valle de México, México
Laura Ponce
3th year student of Physiotherapy,
Universidad del Valle de México, México
Marie-Anne Rannou
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Andrea Tiberi
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Ainhoa Uria
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
Davide Violati
4th year student of Physiotherapy,
Universidad Europea de Madrid, Spain
5
 FOREWORD TO THE FIRST EDITION
La asignatura “Terapia Manual Ortopédica III” pertenece al plan de estudios del Grado en Fisioterapia
de la Universidad Europea de Madrid, siendo la última asignatura a cursar dentro del itinerario
curricular en “Terapia Manual Ortopédica”. Las asignaturas que lo conforman son optativas y
refuerzan la formación en Terapia Manual basada en la evidencia.
6
Este proyecto pretende reflejar el desarrollo del pensamiento crítico y reflexivo, tan necesario para
acometer un buen diagnóstico y abordaje terapéutico del paciente a través de la Terapia Manual
Ortopédica. Y qué mejor manera que comenzar con los intentos que hace el estudiante con los
primeros pacientes a los que se enfrenta en la práctica clínica real. En esta experiencia vivida de forma
intensa por el alumno, éste desarrolla competencias como la adaptación del tratamiento a la evolución
del paciente, el replanteamiento constante de los objetivos terapéuticos, o la autocrítica, habilidades
básicas para cualquier profesional de la salud. Con este proyecto no se consigue únicamente un mejor
aprendizaje por parte del estudiante, sino que, nosotros los fisioterapeutas con años de experiencia
clínica, tomamos conciencia y recordamos la importancia del razonamiento clínico. La metodología
docente utilizada es el Método del Caso, procedimiento que se adapta especialmente bien al
desarrollo de las competencias descritas anteriormente; además, la labor del docente, que ha
acompañado y guiado al estudiante a través de preguntas constantes, ha permitido la adquisición de
un conocimiento más profundo.

Nos gustaría destacar la labor del docente, en primer lugar, por plantear este proyecto tan ambicioso
y enriquecedor para todos; y en segundo lugar por acompañar y motivar permanentemente a los
estudiantes. Él ha sido el motor de este proyecto, gracias a su constante inquietud en innovación de
diferentes metodologías en el aula, situando siempre al alumno en el centro de su aprendizaje.

Por último, nos gustaría reconocer y agradecer el esfuerzo de estos alumnos que se han implicado de
forma completa y que han acometido este reto como una oportunidad de crecimiento profesional y
personal; pensamos que esta actitud os permitirá tener una vida más plena.

Mónica de la Cueva, Beatriz Ruiz, Raquel Díaz-Meco y

PhD , Physiotherapists , Lecturers, Department of Physiotherapy and Podiatry, School of Health and Sports,
Universidad Europea de Madrid, Spain
FOREWORD TO THE SECOND EDITION
In this second edition of the book, we were supposed to include more case studies from the students,
but the number of students attending the subject during 15-16 course were too small, that we have
decided to included their work at the end of this new season.

Amazing projects could be launched in Education and Health, thinking out-of-the-box, and using 7

wisely the new tools available for physiotherapists, patients and educators. For this second edition, I
have invited Juan Antonio and Gema, for writing a chapter about their lovely experience about the use
of a reflective diary, and the social media in the education of our students. They are in the paramount
place to teach (clinical placement) and in one of the best times to impact the student (last year of
university). Thanks for accept my offering.

I hope you will be delight with the reading and get inspired for your daily work.

Pablo C. Garcia-Sanchez

Physiotherapist, Lecturer, Department of Physiotherapy and Podiatry, School of Health and Sports,
Universidad Europea de Madrid, Spain
8

To our beloved patients, who open their lives to us.

Pablo

To our teacher, to make this happen.

2015 OMT3 students

9
 PART 1: INTRODUCTION

Chapter 0: Introducing the project: using case reports to improve Reflective Practice and
Clinical Reasoning in Physiotherapy, Garcia-Sanchez PC.

Chapter 1: Use of the reflexive diary, blog and twitter in the practicum: our experience,
Gonzalez Garcia JA. and Gallardo Sanchez G.

10
 INTRODUCING THE PROJECT: USING
CASE REPORTS TO IMPROVE
REFLECTIVE PRACTICE AND CLINICAL
REASONING IN PHYSIOTHERAPY
11
GARCIA-SANCHEZ PC.

INTRO AND CONCEPTS To share their own clinical experiences to

teachers, clinicians and peers, could be an
The ability to reflect about our actions and
essential activity to develop metacognitive
decisions is irrevocably linked with the basics of
abilities in the learning process (Sefton, Gordon
our improvement and learning system. This way
& Field, 2008). Remains in the educator to plan
to approach learning and practice experiences
and create the required spaces for feedback and
try to get beyond the bare experience as a unique
reflection during the course period.
improvement tool, once the therapists have
started their professional work, demanding the According to Rivett and Jones (2008) “Skills in
apprentice to critically look over their own clinical reasoning can only be developed in the
practice, with the goal of improve it. context of clinical cases” (Rivett, Jones, Loftus &
Christensen, p. 477). The use of case reports to
It is considered as a corner stone in the
teach clinical reasoning is well covered by Rivett
development of expertise within a knowledge
and Jones in that chapter. The type of case
area (Jensen, Gwyer, Hack & Shepard, 2007) and
reports carried out in this project were “written
it is progressively being incorporated to the
cases”, with the particularity that were peer
graduate and postgraduate health science
developed with the supervision and questions
curricula.
prompted by another student and the educator.
Clinical reasoning and reflective practice are
Peer learning is an educational method to
linked through the metacognition level of
improve knowledge and understanding, and is
reasoning and according to Jones and Rivett
broad defined in the literature. The type of peer
(2004) reasoning could be seen as a reflective
learning method chosen for this project was
process (Jones and Rivett, 2004).
what Ladyshewsky described in 2000 and
 developed through past century, specifically
using the metacognition as a reflective method
(Ladyshewsky and Jones, 2008).
THE PROJECT AND INSPIRATION
This book is the final product of a collaborative
project among international physiotherapy
12 students attending "Orthopaedic Manual
Therapy 3", an elective subject included in the
4th year of the Bachelor Degree in Physiotherapy
at Universidad Europea de Madrid.
The completion of a reflective case was one of
the activities included in the final grade of these
subject, but the presence of their cases in the
book relied on their own decision. It was guided
by me as a teacher, but the decisions of the
whole project were made by the students. It was
completed in 3 months on the spring of 2015.
thinking and reasoning through real cases. This
book doesn´t intend to emulate our pioneers,
and probably the depth of the student´s
reflections won´t be the same compared with
these well-noun physiotherapists. But these
student´s reflections will be productive for them
and will give an instant insight about what is
happening in the therapist-mind during the
management. We hope this could be useful for
others.
As we seen, Reflexive Practice is a key skill to
develop Clinical Reasoning in manual therapies
and other disciplines. It is one of the tools these
students had learnt during their stage in the
university on the last courses, to improve their
understanding and practice. Giving support to
our clinical decisions will allow us to improve as
professionals and as profession.

The project is inspired in the book "Clinical We hope you´ll find this interesting for your own
Reasoning for manual therapists" (Jones and, practice and be inspired to cultivate this wise
Rivett, 2004). In that book relevant activity as a teacher, as a student or as a graduate
physiotherapist show us their knowledge, physiotherapist.

REFERENCE LIST

1. Jensen, G. M., Gwyer, J., Hack, L., & Shepard, K. (2007). Expertise in physical therapy practice.
2. Jones, M. A., & Rivett, D. A. (2004). Clinical reasoning for manual therapists. Elsevier Health
Sciences.
3. Ladyshewsky, R. K. (2000). Peer-assisted learning in clinical education: a review of terms and
learning principles. Journal of physical therapy education, 14(2), 15.
4. Rivett, D., Jones, M. A., & Higgs, J. (2008). Using case reports to teach clinical reasoning. Clinical
reasoning in the health professions. 3rd ed. Philadelphia: Elsevier, 477-484.
5. Sefton, A., Gordon, J., & Field, M. (2008). Teaching clinical reasoning to medical students.
Clinical reasoning in the health professions. 3rd ed. Edinburgh: Elsevier, 469-78.
USE OF THE REFLEXIVE DIARY, BLOG
AND TWITTER IN THE PRACTICUM:
OUR EXPERIENCE
13

GONZÁLEZ GARCÍA JA. AND GALLARDO SÁNCHEZ G.

INTRODUCTION The essential philosophy of the EHEA is that

the student becomes the centre of the system.
The authors are clinical teachers of Practicum
The overall effort of the student is valued, not
II in Fuenlabrada University Hospital ten years
only physical presence in a class or practices in
ago. During this period, elements of
healthcare settings, as well as the
participation that assume the philosophy of
management of tools of learning, rather than
the European Higher Education Area (EHEA)
the mere accumulation of knowledge
have been incorporated. This chapter explains
(Universia Spain, 2016). It is intended that the
our experience of promoting a model of
future professional will be responsible for
effective learning.
learning on their own, to locate, analyse,
Rey Juan Carlos University and University manage, synthesize and transmit information
Hospital of Fuenlabrada work together in by him/herself.
teaching students in clinical practice. Physical
In this context the teaching guide of the
therapy students visit our unit in their fourth
subject Practicum II proposed as a teaching
course. It was considered that the orientation
strategy “knowing in action”, which can be
of the training should be directed towards the
achieved with reflective practice. The teacher
imminent inclusion in the real work
or tutor has the task of stimulating this
environment. This mean a promotion of
reflection in action.
autonomy in the performance of patient care,
integrating all their knowledge previously If we understand learning as an active process,

acquired. we need to take awareness of it. We must

 know about the different kinds of strategies for
learning, thinking, and problem solving.
Students should become aware of their
strengths and weaknesses as learners, writers,
readers, test-takers, group members, etc.
Students have to put metacognition into
practice. The metacognition is a complex
14 concept that has different definitions.
Metacognition is, put simply, thinking about
one’s thinking. More precisely, it refers to the
processes used to plan, monitor, and assess
one’s understanding and performance.
Metacognition includes a critical awareness of
a) one’s thinking and learning; and b) oneself
as a thinker and learner. Major and its group of
study (Labatut Portilho, 2004) say
metacognition is the cognition of the cognition,
that is to say, the knowledge of your own
knowledge. The knowledge is the object of the
cognitive activity. The way a therapist clinically
reasons their findings can strongly influence
how the case is interpreted. It seems clinical
reasoning need of the sum of the thinking and
decision-making processes associated with
clinical practice (Edwards I, 2004). The way
how we think it will be important to make good
decisions and actions. Metacognitive practices
increase students’ abilities to transfer or adapt
their learning to new contexts and tasks. They
do this by gaining a level of awareness above
the subject matter, thinking about the tasks
and contexts of different learning situations
and themselves as learners in these different
contexts (Chick, 2016). Nevertheless, we know
that it is not a question of an easy matter of
practising, since we have not been educated in
the habit of carrying out an exercise that leads
us to introspection.
With these premises since the 2012-2013 we
have incorporated as elements of learning and
assessment a reflective diary, a blog of the
subject and the use of Twitter as social
network.
REFLECTIVE DIARY
With the base of the teaching guide, different
aspects were incorporated as the experience
was progressing and reading about other
experiences was made (Martiáñez Ramírez,
2012).
As the name suggests, it is a chronological
account of what happened every day in the
practicum. From the beginning we emphasize
that the diary is voluntary, although evaluable.
It contains views, concerns, desires,
discoveries, feelings, learnings,
disappointments, surprises, ambitions,
expectations, events, thoughts, reflections,
suggestions, explanations, etc., experienced
by the student. Reflection-on-action is what
gives added value to the experience. It is
intended that the cognitive effort to
remember, process, analyze and explain in
writing is a way to learn.
It is important to emphasize the consideration
that the concept of Practicum has for us.
According to Guijarro Martínez (2015) we
prefer the term clinical education in so far as
“can contribute to [the student] development
not only in doing, but also in knowing, being
and living “. Reasoning, critical thinking,
decision making, values, attitudes, ethical
behaviors and professional socialization are
involved in practice and this is considered from
this broader view than simply know how
(Guijarro Martínez, 2015).
TASK
The first day students are received and
teachers explain to them, among other things,
the tasks to be carried out during their stay in
the hospital. In the case of the diary they are
told that it has to be written on a daily basis to
achieve the objectives. They are provided with
information on the potential contents. They
have had previous and different experiences
with a reflective diary. Therefore, they are
provided with additional written information
to get what we expected.
The proposed model of reflective diary is
deliberately versatile and open. However, it
always contains the reflection of the students
beyond a mere description of facts. If not, we
indicated that the diary demands a richer and
more complex cognitive effort than the simple
description. It is noted that there is an added
value in this reflection that makes it necessary
and, above all, useful in their present and
future learning.
ACTIVITIES
15
Around reflection in action and reflection
deferred to the end of the day, the students
carry out different activities. They search
images, rating scales, variants on ways to
assess and treat patients, include database
search strategies, incorporate links to websites
and/or videos, attach annexes with these and
other contents, etc.
In our experience the weekly reflective diary
usually contains 6 to 12 pages. It is sent at the
end of the week by email to the teacher.
He/she receives two or three diaries and once
read, share relevant reflections with the
student in writing. The teacher corrects,
suggests, guides or compliments. The door is
open to discuss all this personally, making the
process something continuous.
The reflective diary is, as we said, an
assessment tool. Since the 2015-2016
academic year, in an attempt to be objective, a
rubric based on Martiañez Ramirez et al (2015)
is used.
 In short, reflection is used to what we have
been arguing. It encourages to propose
alternatives, rethink what has been done, said
or thought, to question processes, to justify, to
drive change, to change attitudes and values.
All this means work, and time. Students have
to work at home for a stronger learning and a
16 development of criticism. It will be useful for a
life-long-learning.
BLOG
Student blogging empowers students to take
charge of their learning, gives their learning
purpose while helping with reading, writing,
digital citizenship, artistic, critical thinking,
social skills, self-expression and creativity
(Huffaker, 2005). It could also increase
students and teachers´ motivation and
relationship, as well as academic achievement
(Read, 2006). In our opinion blogging is perfect
to use metacognitive strategies.
Our blog “Practicasfisio”
(https://practicasfisio.wordpress.com) has
been used as a teaching tool since 2014-2015
academic year.
TASK
Students are explained the steps to publish
their posts on the blog. They must publish two
posts in six weeks. They can choose the topic
that has to do with something related to the
practice. Guidelines are given and they can
read some posts in health blogs as examples.
Most of students did not use before this tool.
ACTIVITIES
We want the students to make the writing
process, adding the advantages of Internet
such as easy sharing, abundant information
and resources and unlimited communication.
The writing process consists of:
Prewriting: Plan the writing. It is a time to
think, brainstorm ideas and organize the topic.
Students have questions to consider: what do I
want to say? How do I want to say it? Who will
read my writing? What else do I need to know
to begin? Who can I talk to about my ideas?
Drafting: Write your first draft. It is a time to
write it down. Create a rough copy of the
writing. Students have question to consider:
Are my thoughts organized? Which ideas do I
want to develop? In what order do I want to say
them? Who can read this?
Revising: It is a time to improve the writing.
Change your write to make it better. Questions
to consider: Should I add or take out parts?
Have I used the best ideas and words? Are my
details clear?
Edit: check your writing. Questions to
consider: Are my spelling, capitalization and
punctuation correct? Could I use any image to
complete the text? Could I use some useful
links to add information?
Publish: share the writing on the Internet.
We emphasise the first part of the writing
process where the student must reflect.
We have published sixty posts with 7,825 visits
till the date but very few comments.
TWITTER
Our interest to incorporate new teaching tools
led us to put in the social network Twitter in
the practicum at the beginning of 2014. We did
not know prior experience in clinical settings of
Physical Therapy or other health discipline.
Social networks can be used as a learning tool
by providing information and means for
integration and communication (Moreno -
Badajós, 2016).
The study of Arroyo Sagasta (2012) addresses
the presence of Twitter in a particular high
education academic environment, face-to-
face education and very different to a clinical
setting, but it was our initial reference. Its
description of the use of social network for
teachers is done from a primarily qualitative
approach and contains a list of applications
that includes informative tweets, mentions
and communications to students. The author
also makes a proposal for other uses: academic
information, enrichment of the educational
experience, extension of contents and
“twitoria” or tutorial via Twitter. Finally,
Arroyo also proposes some dynamic
integration of Twitter in the classroom. 17
With that background we began by creating an
account named @practicasfisio. The teachers
had started the use of personal and collective
accounts nearly two years before. Surely that
previous usages led to learn utilities and
potential applications and the knowledge of
reference accounts in the field of Physical
Therapy. As Twitter inherent philosophy, we
intend to make public the contents whose
usefulness or uselessness can be decided by
anyone. This means that tweets should be
respectful to people and the information
should not contain personal or health
information related to any person. Our uses
largely coincide with those targeted by Arroyo
Sagasta, with some particularities proper to
the nature of the Practicum.
After two years and a half using Twitter the
teachers appreciate it positively. However,
against our prejudices, this network was not
used on a daily basis by most students. Most of
them do not participate regularly in Twitter
 after the practicum (at least with the profiles
with which they did in the Practicum II).
TASK
It is proposed, in the context of the practicum,
participate with messages of different types.
Students write spontaneous comments with
18 information on topics related to what
happened or they have seen. They may include
links to other written content, images, videos.
Teachers´ participation is considered more
important because of novelty and lack of
experience in use by many students.
ACTIVITIES
Depending on the content we can classified
the tweets in different types. In the
Information tweets the teachers use the
account, since the start of each rotation, with
indications about tasks, linking to content
about reflective diary or use of blogs in
healthcare, among other things. Other uses
are information about the way of publishing
posts in the blog of the subject, dates or
notifications for submission of tasks, changes
of teachers or teachers’ absences, exam dates,
etc. Other informations are about professional
organizations, announcements, offers,
courses/conferences that may be of interest
for the student or for his/her imminent
immersion in the profession.
In the framework of the Extension of contents
Tweets there are links to documents, articles,
videos, websites, highlighting references to
professional blogs as a source of information
and/or debate.
Questioning tweets contain questions about
different dimensions of practice (methods,
techniques, illnesses, etc.). Some of them
encourage enquiry about ethical codes and
legal aspects of professional practice. These
are responded via Twitter or students are told
if the answer will be in the diary or verbally.
Students are invited to participate with tweets
about the contents of the practicum, to re-
tweet, to share information, to open
discussions or to answer different questions
that appear in the practicum.
As in the case of diary and blog, a specific
rubric evaluates various aspects of student
performance.
CONCLUSIONS
The incorporation of teaching tools described
in this chapter has, as their ultimate goal, to
promote more lasting and deeper learning
and habits that facilitate livelong learning. For
the authors this is an ongoing process,
unfinished and subject to constant revision.
The opinion of students is a determining factor.
We asked them and their assessment is
encouraging. However, we think it is necessary
to promote continuous efforts to improve the
competences of future physical therapists.

REFERENCE LIST

1. Universia España. (Junio de 2016). http://eees.universia.es/. Recuperado el 16 de Junio de 2016, de

http://eees.universia.es/preguntas-frecuentes/conceptos-basicos/#4 19

2. Labatut Portilho, E. (2004). Aprendizaje universitario: un enfoque metacognitivo. Madrid:

Universidad Complutense de Madrid.

3. Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. (Abril de 2004). Clinical reasoning
strategies in physical therapy. Physical Therapy, 312-30.

5. Chick, N. (2016). https://cft.vanderbilt.edu/. From https://cft.vanderbilt.edu/guides-sub-

pages/metacognition/

4. Martiañez Ramirez, N. (2012). El diario reflexivo académico como recurso de aprendizaje en las
prácticas clínicas: una experiencia en el grado de Fisioterapia de la Universidad Europea de Madrid. IX
Jornadas Internacionales de Innovación Universitaria. Villaviciosa de Odón.

5. Guijarro Martínez, M. (2015). La educación clínica del estudiante de fisioterapia desde la experiencia
de los tutores y tutoras clínicas. Estudio fenomenológico descriptivo. Bilbao: Deusto.

6. Martiáñez Ramírez, N., Rubio Alonso, M., Terrón López, M., & Gallego, T. (2015). Diseño de una
rúbrica para evaluar las competencias del Prácticum del Grado en Fisioterapia. Percepción de su
utilidad por los estudiantes. Fisioterapia, 83-95.
 PART 2: REFLECTIVE CLINICAL CASES

Chapter 2: A 52 yo. man who broke his arm 9 month ago and referred pain in all movement,
Alcalá MA. and Uria A.

Chapter 3: A 32 year old woman with sore thightness in the upper posterior surface of the
20 right leg, Bertrand I. and Rannou M-A.

Chapter 4: A persistent shoulder pain and rigidity in a 51 y.o woman, Guido R. and Javier M.

Chapter 5: A 45 yo. garbage collector with chronic back symptoms , Javier M. and Guido R.

Chapter 6: A 23-year-old female preparing for army with lower back pain for 4 weeks , Kriik
G. and Ponce l.

Chapter 7: A 40 yo. man with a painful shoulder syndrome, Pérez G. and Kriik G.

Chapter 8: A 16 yo. female student that suffered a 2nd grade right ankle spring, Ponce del-
hoyo L. and Perez-Raymundo G.

Chapter 9: A 57 yo. housewife with a right hemi patellectomy and tenectomy of the patella
tendon after a patella fracture and a transidesmal fracture of the right fibula bone, Rannou
MA. and Bertrand I.

Chapter 10: A 8-year-old boy with fractures of both legs after a fall from the eighth floor of
an apartment, Tiberi A. and Violati D.

Chapter 11: A too early meniscal diagnosis, Uria A. and Alcalá MA.

Chapter 12: Pain causing a scapular diskinesis in a 25 yo student, Violati D. and Tiberi A.
21
 A 52 YO. MAN WHO BROKE HIS ARM 9
MONTH AGO AND REFERRED PAIN IN
ALL MOVEMENT
22 INTRO
A 52 yo. man who had a sedentary life and one
day fell down from a stone 9 month ago and
broke his arm and since that he referred pain in
all movement and his previous treatment
doesn’t work but he is stressed and tired about
this because he wants be better as soon as
possible.
SUBJECTIVE EXAMINATION
When I first met P.N was two month ago, he
had a lot of pain on his distal part of the left arm.
He doesn’t had all the range of motion and he
told me that sometimes he doesn’t feel his
third, fourth and fifth fingers.
He works as a lawyer and he is the boss of the
association, so his life is a little bit sedentary,
he doesn’t like practice any sport but he love to
go to the theatre, cinema and going out for
dinner with his wife. We can say he likes doing
relaxing things, because in his work he had a
lot responsibility and he is stressed. He told me
he is very active: because he usually have a lot
of things to do at the same time, being difficult
ALCALÀ M.D. AND URIA, A.
for him to relax himself, not only like stop
doing something but also he can’t calm his
body.
The accident affect his daily life activity due
the impossibility to use the hand he couldn’t do
all that things that he usually do and he was a
little bit overwhelmed and tired about this
situation.
He went to another physiotherapist before I
met him but the results weren’t the expected.
He was treated by this therapist 20 sessions
but he wasn’t happy and his problem
continued and also gets a little bit worst.
He use his hand and arm like he doesn’t have it,
also because his predominant arm is the right
arm but he couldn’t continue with this pain.
STUDENT REFLEXION AFTER S/E
With this presentation of P.N I think that he
has neurogenic and muscular damage.
The main problem is the fracture that he
suffered at the radio and the consequences are
the affectation of muscles and nerve. He has a
long period development of the pathology so I
know that the fracture is solved but I have to
work on all the tissue that are affected to mend
the neurogenic problem. After S/E I think that
the median nerve is affected so I will check at the
elbow and the wrist.
For the flexors and extensors muscles I have to
recuperate all the range of motions and then I
can work out to improve the debility that he has.
My patient start the treatment very stressed
because he wants to be better but he saw that
the last treatment doesn’t work but now I can see
how he is more animate and positive.
The last treatment was about massage on the
arms to relax the muscles and use ultrasound and
laser therapy, but it doesn’t work.
QUESTIONS TO IMPROVE REFLEXION
Q1: How did you know that radio´s fracture was
already cured, just because of the time that had
passed since the fracture took place or you had
photographical evidence? And do you know if he
used any orthotics after the fx and for how long?
A1: I know it because I saw the MRI so I have the
photographical evidence and I’m sure about the
consolidation of the fracture. No, he didn’t use
any orthotics after the fracture.
Q2: Didn’t you think about the possibility of the
ulnar nerve being damaged too because of the
alteration in the sensibility of the fourth and fifth
fingers?
A2: No, because the ulnar nerve’s test was
negative and because in the electromyography
we saw the damage of the median nerve.
23
TEACHER ADVICE
Choosing high evidence-based tests will add to
your reasoning better ingredients to make a good
decision. Regarding to the neurodynamics issues,
we need to discriminate among tests assessing
roots, nerve trunks and main nerves.
So far, ULNT3 hasn´t demonstrate high sensibility
and specify. So, adding your inexperience, we need
to take with precautions
PHYSICAL EXAMINATION
First of all my patient has a diagnosis before I met
him, so in part he knows what he has, but nobody
stopped one moment and tell him the exact
information about which parts of his harm and
hand were damaged and the different part of the
treatment.
Firstly I spend time to explain him exactly which
are the tissue he had affected than I started with
the P/E and with the medical diagnosis I build my
hypothesis and I started from the elbow and I
 saw that he has all the range of motion and no
pain, so I passed to the wrist.
In the clinical history of my patient I had all the
information about ROM, BM, damage and all
about the problem but I think that I had to
explore all and plan my own treatment
because the one he has received doesn’t work.
24
On the wrist I tested the range of motion and
muscular balance.
With neurodynamic technique I tested the
ulnar, median and radial nerve to see if the
debility and the strange sensation he had were
because of the damage of someone of this.
STUDENT REFLEXION AFTER P/E
The anterior diagnosis showed me which part I
had to test but I decide made my own P/E to
start another time from the 0.
I had no contraindications for P/E so I tested
without any problem and I saw that he had a
restricted range of motion in all movement of
the wrist and some alteration of the sensibility
on the hand. But the most important thing that
I saw is that the necessity of my patients is to
knows because I do one thing and no other
because he was saturated and tired that
people tell him what to do but not encourage
him and not explain him nothing.
QUESTIONS TO IMPROVE REFLEXION
Q1: You´ve said you had all the information
about ROM and BM… but it´s no clear which
joints are you talking about when referring to
ROM or which muscles BM are you testing.
A1: I referred to wrist’s joint and all the
extensors and flexors muscles.
Q2: You´ve said you started physical
examination from the elbow. Why didn´t you
start at a higher level, for example, from the
shoulder?
A2: Because of his mobility and his pain I
supposed that the shoulder shouldn’t suffer
any injuries, so I decided started from the
elbow.
Q3: Did you assess any reflexes or sensations
apart from making neurodynamic techniques?
A3: Yes, I assess the sensation with different
type of touch on his arm and hand but the only
think he feels is tingle sometimes on his hand
so I decide to make neurodynamic techniques
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
My goals are:
- Improve the range of motion of the
wrist
- Improve straightness of flexors and
extensors muscle
- Eliminate the pain
- Recuperate the sensibility
 - Change the treatment from the
anterior
- Increase the motivation of my patient
and improve self-confidence
Now I had to search a new treatment because
the anterior doesn’t work.
I know that my patient needs something more
than a simple massage and I think that the
ultrasound and laser didn’t have any benefice
in this case. After that I had to animate my
patients and explain him that now we going to
use new treatment and that he has to be
patients and trust on me but I know that at this
point maybe it can be difficult.
First of all I focus my attention on the wrist and
the movement of this because he had a big
restriction of all movement and at the same I
work on the median nerve and the sensibility.
DAY_1
I told him to take some posture of the wrist in
which he doesn’t feel pain and I make the same
thing for the elbow to see when the pain
appear.
After that I saw that the elbow had no
restrictions and no pain so I focus on the wrist.
I make mobilization fixing the radio than fixing
the ulna. After that I did the mobilizations of all
the bone of the hand. I make all this movement
in the passive form and evaluating after all the
mobilizations if the pain decrease or increase
and I saw that the pain decrease.
After that I started forced the end of the
movement to start improving the range of
motion.
To terminate the session I started stimulate
the sensibility on the hand with different type 25
of touch and with complete extension and
flexion of the fingers on the active form.
STUDENT REFLEXION AFTER D1
TREATMENT
At the end of the session my patient referred
that the pain decrease and a sort of liberation
on the wrist. I saw that something change, he
was more animate than when he arrived at the
session.
This process was different from the previous
and at the beginning the patient was a little bit
insecure but I could see how it works and also
him could see that from the first session we
had some results so I will continue with this
treatment.
QUESTIONS TO IMPROVE REFLEXION
Q1: What happened with the sensibility? Did it
improved?
A1: At the moment I didn’t know because I had
to wait the next sessions and see what happen
in those days and text it in the next session.
 DAY_2
Firstly I test the movement and the general
state of the wrist to saw if he had maintained
the resulted we reached in the anterior session
and it was ok.
After that I do the same treatment because I
26 saw that it works, also I started work with
resisted movement at the same time he was
with the electro stimulation and I saw that he
can do it perfectly even if with a little bit pain
at the moment of mayor tension of the
muscles.
At the end I relaxing the flexors and said him to
make the same exercise at home with a little
bottle of water.
DAYS 3-4
In the next session my patient referred less
pain and more agility on the movement so I
decide to continue with this treatment.
Also the sensibility was better because in those
days he doesn’t feel nothing strange about his
fingers.
Now I started work on the strength of the
muscles with resisted movement firstly than
we use the electro stimulation of the flexors
muscle with a dumbbell of 0.5 kg.
Finally I work releasing muscles in general to
avoid the overload.
On the next session I saw that the treatment
work out so I continued with this and increase
slowly the kg of the dumbbell.
I think that the prognosis is good because my
patient was satisfied with this new treatment
and was more animate and participate.
After that I can say that the part of the
treatment that works better was the
mobilization of the ulna and radio in all
direction because after that was the moment
in which I started to see important change in
the evolution of the problem

FINAL STUDENT REFLEXION

I think that at the moment in which I met my patient I had apparently all the information I need for my
clinical reasoning. I had the information from the medical diagnosis, from the anterior treatment but it
wasn’t enough because there was something that doesn’t work, so thanks to my examination I
discovered the main point of the problem. All this means that even if you apparently had all the
information you always had to search more and more to have a complete clinical reasoning that is the
main point for a successful treatment.
REFERENCE LIST

1. S. Jimenez del Barrio, M. Fortun Agud, N. Pascual Lanuza. E. Bueno Garcia, E. Estebanez de Miguel
and J.M. Tricas Moreno (2013). “Reliability of upper limb neurodynamic test for range of movement
and symptoms localization variable”. Cuestiones de Fisioterapia 281-289.

27
 A 32 YEAR OLD WOMAN WITH SORE THIGHTNESS IN
THE UPPER POSTERIOR SURFACE OF THE RIGHT LEG
INTRO
A 32 years old woman attends a physical
therapist due to sore tightness in the posterior
28
surface of the right leg; ischiotibial level. High-
level runner, the pain began and gradually
worsened 8 month after being operated from
the appendix.
SUBJECTIVE EXAMINATION
A 32-year-old patient entered the
consultation and started explaining her
condition. For a few month now, she started to
feel pain in the upper posterior surface of the
right leg while jogging; right underneath the
ischium. At first she could cope with the pain
but as time went by it worsened to a point
where it forced her to stop jogging. She would
feel the pain during the terminal swing and
beginning of the propulsion phase of the
human running locomotion cycle and would
increase when running up steep hills. The pain
would also appear while she blow-dried her
hair in a bending over position and occasionally,
complained of lumbar pain.
Continuing to gather useful
information about her case, she mentioned
that she underwent surgery to remove the
BERTRAND I. AND RANNOU M-A.
appendix a year and a half ago and that she still
doesn’t feel 100 percent “good”. She feels
tightness and bloated all the time in the area
and has digestive discomfort since then.
She is a very health, energetic,
sympathetic, open minded, athletic young
woman who has no relevant family
antecedents, doesn’t smoke and sporadically
drinks alcohol in social events. She would run
an average of 10 kilometers a day and was
getting ready for an important race that
needed a lot of training. She works long hours
behind a desk and seems to be very unsatisfied
with her job. She loves outdoors activities and
never misses an opportunity to join a group to
participate in the event.
STUDENT REFLEXION AFTER S/E
About my initial hypotheses about the
sources and pathobiological processes was
that she could have a tendonitis of the
proximal insertion of the hamstring muscle
due to overuse and maybe some active trigger
points in the gluteus area.
 She didn’t present any warning for
examination contraindications.
My first impression with her was quite
optimistic. Her positive and energetic attitude
was quite freshening; making it easier to
create a physiotherapist- patient bond of trust.
Even thought I knew that her condition was
also affecting her psychologically, since it
limited her ability to perform the activity she
loves most well, she always managed to keep
a positive and open-minded attitude about it;
listening and cooperating with us during the
treatments and completing her “home work
assignments”.
QUESTIONS TO IMPROVE
REFLEXION
Q1: How does she feel about her pathology?
A1: Haven’t asked her but I think she is
annoyed about the fact that she can’t run as
long and as well as she did before and anxious
to get better.
Q2: So far, what is the level of severity and
irritability of her clinical presentation?
A2: The level of severity of her pathology is
minimum but the irritability is quite high since
it’s affecting her daily life activities.
Q3: So far, what is your thinking about the
appendix-release issue in her actual clinical
presentation?
A3: It is explained further.
TEACHER ADVICE
Irritability means about the property of patient´s
29
current presentation reacting to any stimulus,
and it is not directly related with the amount of
affected activities or participation. It´s used to
be more related with the severity of the
presentation. In our management it is usually
linked with the quantity of mechanical stimulus
needed to cause patient´s symptoms and their
length. This quality will suggest the extension
and the level of depth of our exploration
procedures.
PHYSICAL EXAMINATION
Although she seemed like a joyful,
optimistic and stressless person during the
sessions, I wanted to know how she was in a
work-like environment; to see her stress levels
and if it had an impact on her. It turned out that
during her working hours she’s quite stressed
out because of the bad ambience there is at
work and admitted that she eats fast sugars to
quench her anxiety.
I started the physical examination by
palpating the right proximal insertion of the
ischiotibial’s but she felt very little pain
 compared to the one she used to while running.
Like I mentioned earlier the pain appeared
during the terminal swing and beginning of the
propulsion phase of the human running
locomotion cycle and would increase when
running up steep hills. The pain also appeared
while performing a resisted isometric
30 contraction of the hip in extension and of the
knee flexion; to test the ischiotibial and gluteus
muscle.
Body chart representing her pain.
She also had active trigger points in
her right gluteus muscles and a blocked STUDENT REFLEXION AFTER P/E
sacroiliac joint because of the hypertensions of About my initial hypotheses I met
the buttocks muscles. Her pelvis was in a slight consistent findings about the implications of
anterversion position and her body slightly trigger points in the gluteus muscle but not
leaned forward. Sometimes she complains of about the tendonitis of the proximal insertion
lower back pain. of the right hamstrings.

I decided to then explore her iliopsoas, It is clear that she has musculoskeletal
witched showed to be rather painful (both of dysfunction for, as mentioned in the physical
them). And the scar left by the appendix’s examination part, she has reduced muscle
surgery was ridged, fibrotic, adhered to strength and a slight anteversion of her pelvis
connective tissues below and painful on with a semi blocked sacroiliac joint; but I keep
palpation. asking myself why? How is it that in less than a
year, gradually, has she been feeling pain in
Muscle group Grad (0-5)
the posterior part of her leg when she’s been
Ischiotibial muscles 4 running all her life since the age of 17? Its not
like she’s not physically prepared; she is very
Hip abductors 3+
athletic and physically strong.
Iliopsoas 3+
The pain came gradually, little by little
Muscles’ Power since the surgery. I think that the surgery and
the scar left behind are partly the reason and
origin of all the simtomatology of why she is
complaining of isquion pain.
Due to the aggression her body
underwent with surgery, I think she adapted
analgesic positions wile running in order to
reduce the abdominal tension and pain
acquiring an erroneous body position;
triggering an imbalance between muscle
groups forcing some to work more than others.
QUESTIONS TO IMPROVE
REFLEXION
Q1: Was anything done with respect to her
digestive tract symptomatology?
A1: Yes, due to her digestive discomfort of
tightness and bloatedness, she was
recommended to take probiotics for a month
and to drink a lot of water in order to rebalance
her intestinal flora. (It was very useful) .
TEACHER ADVICE
Facing a high irritable presentation as you
suggest, involves to take some extra precautions
during the physical examination. In your case,
probably this means to explore carefully the
myofascial trigger points, and do not stress the
common ischiotibialis tendon to the extent you
couldn´t continue with the P/E routine.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS,
OUTCOMES AND PLAN
I think the pain she’s is feeling on the posterior
surface of the right leg is caused by an overload
of the isquitibials muscles due to the pelvis
anteversion, gluteus weakness and lumbar
31
pain; all of which is caused by an incorrect body
position.
Since she is a young athletic woman her
prognosis is good. She is willing, eager to get
better and does everything possible in order to
achieve this goal. However she is very
impatient, and so whenever we achieve to
reduce the pain, she forces her leg more and
relapses.
DAY_1 + 2
The first day she came to get treated, I applied
analgesic electrotherapy for 20 minutes on the
upper posterior surface of the right leg to
reduce the pain.
Afterwards I did massage therapy on the
iquioteibials muscles to relax the muscle as
much as I could to see if in doing so, the pain
would reduce.
I explained to her what I thought what going on
and the biomechanical of her lesion. I asked
her the next time she goes for a jog that she
should take smaller strides to reduce the hip
 flex/ext amplitude and the force exerted by the
muscles.
I ended the session with passive stretch of the
isquioteibials muscles and the gluteus muscles.
STUDENT REFLEXION AFTER D1+D2
TREATMENT
32
The patient was able to do the movement of
bending over and touching the ground
(movement that she couldn’t do without pain)
with a 40% decrease of pain.
I’m glad I managed to reduce her pain although
I expect it wont last long since I didn’t treat any
other areas due to lack of time.
QUESTIONS TO IMPROVE
REFLEXION
Q1: About the pelvic anteversion: Why did you
chose to treat only the joints and not for
example, her abdominals?
A2: Interesting point, I didn’t think about it; but
it would of have been an additional effective
treatment. I will take it into consideration for
next time.
TEACHER ADVICE
A test-treatment will allow you to get invaluable
information about the condition of the
presentation. Using the results of the treatment
as another piece of evaluation could inform you
how to treat your patient properly
DAYS 3- 5
Natalie, as expected, commented that the few
days following the treatment she noticed
improvement but then it went back to the
original pain.
So for the next few sessions I mostly insisted
on working on reducing her pelvic anterversion
with manual therapy techniques and
increasing the sacroiliac joint mobility.
I would also work on her scar; reducing the
fibrotic, adhered tissues and making it more
flexible using “ventosas” and massage theray.
Treating her iliopsoas was also important to
relieve the tensions and reduce the back pain
she would complain from time to time. I
showed her how to stretch it and told her to
stretch it as least once a day.
For the isquiotibial, I gave her exercise to do at
home to strengthen it. Eccentric exercise. And
strengthening exercise for her gluteus
muscles.
STUDENT REFLEXION
The pain reduces progressively. It seems that
we are on the good path.
QUESTIONS TO IMPROVE
REFLEXION
Q1: How does she feel about her treatment?
A1: She was very grateful. She knows the
progress is slow and that she needs to be
patient. But as the sessions passed by, she
would notice positive changes and that little by
little the pain reduces.
TEACHER ADVICE
To strength the tendon elastic properties will be
a required goal in most tendon issues
presentations. On the other hand we could not
forget the muscles power training. There are
recent published evidence to relieve tendon pain
using isometric, contraction, which should
helped with your patient too (Rio et al. 2015)
33

FINAL STUDENT REFLEXION

Natalie was improving slowly but surely. I think that the fact that she was really motivated actually
helped a lot with the healing process. There were ups and downs during the duration of her
rehabilitations but we managed to resolve all the problems and move forward to try and achieve a
full recovery.

REFERENCE LIST

1. Daniel Cushman, Monica E. Rho et al (2015). “Conservative Treatment of Subacute Proximal

Hamsting Thendinopathy Using Eccentric Exercise Performed With a Treadmil.” Journal of
Orthopaedic and Sports Physical Therapy. 0;0(0):1-24

2. White, K. E. (2011). High hamstring tendinopathy in 3 female long distance runners. Journal of
Chiropractic Medicine, 10(2), 93–99. doi:10.1016/j.jcm.2010.10.005

3. Sherry, M. (2012). Examination and Treatment of Hamstring Related Injuries. Sports Health,
4(2), 107–114. doi:10.1177/1941738111430197

4. Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015).
Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British
journal of sports medicine, bjsports-2014.
 A PERSISTENT SHOULDER PAIN AND
RIGIDITY IN A 51 Y.O WOMAN
INTRO
34 The patient is a 51 woman that refers pain,
especially during the night and stifness in her
left shoulder since 9 months ago. She was
initially treated for a supraspinatus tendinitis,
with poor results.
She came to consultation, referring
symptom’s change and helplessness of not
being able to accomplish daily things.
SUBJECTIVE EXAMINATION
M. come to visit in November, talking about a
dull and continuus pain and stifness in her left
shoulder, that prevents her to carry on
movements of daily life, for example when she
combs her hair, and paints (a passion of her).
She works as an architecht on her own and she
is married, with a German man, for 25 years.
Unfortunately they have no children, due to an
histerectomy she underwent at 32 yo.
She’s a busy woman, who worked around the
world, especially in Germany where she was
living since 6 months ago.
Her husband continues to work there, and being
away from him, overwhelms her a lot.
GUIDO R. AND JAVIER SIMON M.
M. cames showing an antalgic posture that
strikes me: aproximation and internal rotation;
holding the affected arm with the other.
The symptoms have started nine months ago,
when she was working in Germany.
She doesn’t remember any direct trauma in the
a
arm. She kept in mind that one day rising in the
morning, she started having a not well localized
acute and annoying pain in her left shoulder,
especially during the night.
This lack of sleep caused her a lot of tiredness
and anxiety, with the consequence of not being
able to work and take care at house chores.
She thought that the intake of medication was
the only way to fight against the problem. She
started taking medications (NSAIDs) to slow
down the symptoms, but this forced her to be
dependent on medications.
After a months of acute pain, under the advice
of her husband, she decided to attend to a
physiotherapist.
She was treated for a supraspinatus tendinitis
for two months, with poor results.
The symptoms increased over time and a arm symptoms change could be a evolution of this
rigidity began to manifest, that prevents her first problem.
from moving it.
There is also a emotional component that
When I asked her if the pain, after treatment
compromise the evolution and the mood of the
and a few months later, was always the same or
patient.
if she noticed change, her response was :“At the
beginning the pain was severe and sharp, to the M. is feeling alone, because her husband is not
point of crying for the pain. After the treatment with her and the pain and rigidity prevents her to 35
I noticed a small change in the pain quality. It have a normal life and to perform her hobby.
wasn’t too acute and I was able to rest a bit
I don’t think the disease is related with a tissue
more.”
damage, instead with a progressive disease: her
After the failed treatment, due to family
problem could be a tendinitis sequel and
reasons, she had to come back to Spain, and
shouldn’t be related, considering her symptoms
even she presented symptoms, she did not
evolution, with soft tissues and bones damage
intend to attend to another physiotherapist.
surrounding the shoulder.
The months passed, the pain was still present,
and rigidity even more. She’s very disappointed with her anterior
Desperate for being unable to move her arm, treatment and think that her problem has not
rest and have a normal life, she decided to go to solution.
a physioterapist practice.
I need to attend emotional issues in her
At the present day, the patient is not motivated
presentation. I’ll return considering this point
and thinks that her problem has not solution.
after the physical examination.
M. has hypothyroidism and take daily medicine
for this problem. She has been smoking a packet
QUESTIONS TO IMPROVE REFLEXION
of cigarettes a day for 15 years, and she is an
Q1: Do you think that could be related with a
occasional drinker.
visceral problem, for example with a lung problem,
like she is a smoker, and a lung problem refers pain
STUDENT REFLEXION AFTER S/E
in the shoulder?
I think her symptoms are related with the
pathology diagnosis. A1: I’d have considered it in the physical
examination. She was asked to do several
The supraespinatus tendinitis could be a
consequence of her actual presentation and the
 exams for discard associated diseases and, in literature to follow routinely. Sometimes is
particular, the chest radiography was normal. interesting to give this list to the patient in the
waiting, before entering the assessment room and
I think that can’t be a reffered pain of a visceral
check with her later the specifics.
disease: M. doesn’t have related sympthoms
and she refers, in the following physical
examination that her pains is triggered and PHYSICAL EXAMINATION
increase with movements. Before the physical examination, talked to me
36
that she did, a shoulder radiograph and a chest
I will deepen this thought in the rest of the issue.
radiograph to discard other pathologies. In both
Q2. So far, which is your hypothesis about the cases, the radiographs were normals.
pathobiological issues and pain component?
I decide to ask her other questions about her life,
A2: My hypothesis is about a nociceptive and
before starting the physical examination,
somatic pain that starts with an inflammation
specially about her hobbies.
presentation. With the passage of time this
inflammatory pain become chronic and the M. tells me that she paints since she was 20 yo,
inflammatory symptoms make space for and it was a very strong passion for her.
stifness and a adhesion role.
She used to paint, 5/6 hours a day, with both
Q3. Which could be the role of hypothyroidism in
hands alternately. She’s ambidextrous.
her presentation?
I start the physical examination with the visual
A3: Oliva,Berardi, Misiti, Maffulli (2013) noticed
inspection. I detected the left shoulder higher
that thyroid diseases should be linked to
than the other one and in antepulsion, also the
idiopathic tendinopathies and as Sardella White
protracted left scapula. Muscle atrophy of the
and Garbe (2010) found the hypothyroidism
shoulder girdle was present too.
could be a risk factor for the joint.
I detects also upper trapezius hypertone.
Her first tendinitis could be related to her
hypothiroidism disease, that could be The colour of the skin in general and in particular

considered like a predisposing factor. in the shoulder area is normal.

Palpation produces pain of subscapularis (VAS

TEACHER ADVICE
Ruling out red flags in the S/E has to be a wise 6/10) and deltoid (VAS 5/10).

option. There are several list s of questions in the

The passive movements exploration of left
shoulder refers limitation in all movements with
a not well localized pain (VAS 6/10), in particular
in abduction and external rotation.
Subescapularis pain: blue Deltoid pain: red
Not well localized pain
In passive flexion the patient can’t move beyond
85 degrees. The external and internal rotation
are respectively of 30 degrees and 40 degrees; in
the abduction the patient presents 60 degrees.
The active movements exploration refers similar
limitations and pain: 70 degrees of flexion, 25
and 35 degrees respectively of external rotation
and internal rotation and 55 degrees of
abduction. (Table 1)
The patient isn’t able to perfom power testing
because she refers so much pain and releted
37
weakness.
Subsequently I perform a provocative test for
cervical radiculopathy, the Jackson’s test, and
the Adson’s test to discard a thoracic outlet
syndrome. Both tests were negatives.
I perform also any special tests that help me to
diagnose a possible disease, like the Apley
Scratch Test and the Shrug Sign as McFarland
and Kim (2006) shown.
The negative test performed is the O'Brien's
test (to exclude SLAP lesion).
After the P/E, the patient refers me to be very
afraid about the diagnosis and sad.
I recommend her to attend to a doctor ,with the
suggest to have a MRI, to better diagnose.
 ROM F IR ER ABD
problem have no solution, could be a problem
during the treatment and the disease prognostic.
Passive 85° 40° 30° 60°
Active 70° 35° 25° 55°
QUESTIONS TO IMPROVE REFLEXION

Table 1 (F:Flexion; IR:Internal rotation; ER: Q1: Has your patient any red flag or yellow flag
External rotation; ABD: Abduction) regarding the physical examination procedure?

A1: No, there weren’t red flags to perform the

38 STUDENT REFLEXION AFTER P/E
physical examination. The yellow flags are the
I discard the possibility of a visceral and referred
low motivation of the patient about the
pain. The patient doesn’t refer any related
treatment, the sadness for the absence of his
symptoms and the radiographs were normal.
husband and for not being able to perform her
An important aspect is that she’s ambidextrous. hobby and passion.
Repetitive movements with her left shoulder,
Q2: So far, which is your first hypothesis with the
associated with hypothyroidism, could be
data coming from C/O and P/E? Which is the data
related with her disease.
supporting this hypothesis?
Passive and active motion limitation makes me
A2: Her associated disease, the symptoms
think in structural changes in the periarticular
change, and particularly the descreased passive
structures. These changes could be the results
range of motion, makes me think in a joint
from a combination of an initial inflammation
pathology, started with inflammation and then
and immobilization (caused by the pain).
became chronic. I wait the MRI result that can

The positives findings show me that the patient help me to diagnose a specific disease.

range of motion is affected, and help me to

TEACHER ADVICE
exclude pathologies like cervical radiculopathy
There should be findings in these 2 first steps of
and SLAP lesion.
the clinical encounter that have to correlate

Another aspect to take into consideration is the among them. As S/E comes firsts, usually points

emotional role in the patient disease. After the out which areas have to be evaluate in the P/E,

physical examination I can say that there is an and what should expect to find there. If we don´t

emotional and no only a physical aspect that find these relationships, we need to keep going

afflict the patient. The patient’s think that the with new questions and proceedings until we´ll
reach a point to make a clinical decision. If there
are not present any severe signs or symptoms we
should continue this assessment into the next
session.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
MRI reveals a reduced capsular volume with
absent inflammation.
With this ulterior test and the P/E results I can
say that the patient is affected by adhesive
capsulitis in the “frozen phase”.
The symptoms show me that the patient
presents a degenerative and chronic disease
that started with an inflammatory stage.
The initial tenditinis, the repetitives movements
painting and working, with her hypotiroidism
problem, could be risk factors of the next
shoulder disease.
To have a good prognostic I must work the
emotional role of the patient, explain the
following treatment and reassuring her.
However, the prognostic should be positive, if
the patient follows the treatment with a positive
attitude.
The plan starts with a progressive treatment,
helping the patient to understand her disease
and treat it.
DAY_1
My aims for the treatment are principally
to release the pain and to increase the
shoulder range of motion.
I started with shoulder joint
mobilizations in all directions. During the
mobilization, the patient refers a lot of
39
pain, especially in the end-range
mobilization, in all movements, saying
that she wouldn’t continue with the
treatment.
After spending time to reassure the
patient, I continue the treatment with a
soft tissue massage to reduce the stress
and relax her.
The first day of treatment ends here.
I explain her that the prognostic could be
good only if her works actively with me,
and that I can understand the pain she
feel and can help her.
At the end, the patient promises that will
try to have a positive role during the
treatment.
However, the patient feels very tired and
negative and decides to go home.
 STUDENT REFLEXION AFTER D1
TREATMENT
The first day of treatment was a disaster. The
patient was very negative about the treatment.
Pain at end-range in all directions, typical of
adhesive capsulitis, prevented me to continue
the treatment in a good way.
40
I hope she will change her negative attitude.
I must insist with the treatment and teach her to
understand that the pain is part of the journey
toward recovery.
QUESTIONS TO IMPROVE REFLEXION
Q1: What do you think that you can do to
motivate your patient to keep adherence of her
treatment?
A1: To motivate my patient I can express my
empathy and explain her the program
treatment and the benefits of it. The patient
should have, also, the support of her family,
helping her to keep adherence to the treatment
and feeling motivated.
DAYS 2-4
The following days of treatment were different
compared with the first one, maybe because her
husband returned to Madrid, to support her
wife. The husband presence influenced the
treatment, helping M. to have an active role in
the treatment program and to be more
motivated. The emotional role of the patient is
very important, and the love and the support of
her family is an additional drive to carry out the
treatment.
M. was more positive and the treatment
continued normally.
I started with shoulder intensive joint
mobilizations, passive, active and resistive
kinesiotherapy. The patient felt pain, but she
was able to withstand it.
The treatment keep on with shortwave, for
about 10 min/session, to increase tissues
temperature and improve motion and elasticy.
After one week of treatment the ROM of the
shoulder improved of 15 and 10 degrees in
flexion and abduction, while in rotational
movementes the degrees remain unchanged.
Anyway the patient was more motivated, than
the first day of treatment. (Table 2)
In the following treatment sessions, I added
Codman’s Pendulum exercise for shoulder, to
improve ROM and decrease pain; closed and
open kinetic chain exercises, like lean the hand
against the wall or with a ball against the wall
doing diferents movements, to improve
articular stability, neuromuscular control and
coordination.
After 20 days of treatment the shoulder passive
ROM improved of 20 degress more in flexion
and abduction, 15 degrees in internal rotation
and 10 degrees in external rotation. The end-
range pain decreased in all movements. (Table
2)
STUDENT REFLEXION
The treatment’s results were good. I think this
treatment program is adequately and efectively
in the patient presentation.
Also, the emotional role of the patient changes
and she’s very happy for the treatment and the
results.
I am very motivated and satisfied about the
treatment results.
I think that if the treatment will continue in this
way, I will be able to improve more shoulder
motion and decreased pain definitively.
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think that is useful and a good idea to
recommend her to do some kind of exercises in her
home?
A1: Now that she begins to be motivated, I think
it’s the better time to recommend her some
home exercises, because she’s more prepared to
keep adherence to the treatment and to have a
active role in the recovery. Some exercises
could be: in a supine position getting the arm up
overhead while lying down, using the opposite
arm to holding it; getting the arm to externally
rotate while standing, opening and closenig a
door; Internal rotation could be performed using
a towel behind the back, relying on the right
shoulder to stretch the affected one.
41
Q2.Which part of your management do you think
has worked better and why?
A2: I think the part, which was worked better
was the treatment plan, especially from day 2. I
planned exercises that could be appropriate for
the patient presentation. The anamnesis and
the physical examination helped me to diagnose
the patient disease and to produce a treatment
plan that could be good for the patient. The
results revealed to me that the treatment plan
was good. The ROM increased, the pain
diminished, and the patient now is more
motivated and can move forward to a symptoms
improvement and a better recovery.
Table 2 (F:Flexion; IR:Internal rotation; ER:
External Rotation; ABD: Abduction)
P-ROM F IR ER ABD
After 1 week +15° / / +10°
After 20 days +20° +15° +10° +20°
Present-day 120° 55° 40° 90°
 FINAL STUDENT REFLEXION

This clinical case made a significant contribution in my professional and human growth. I learned to
have empathy with the patient. It’s important to help the person also in her emotional issues.

At the beginning was complicated to analyse the patient’s symptoms, but with the physical
examination and the tests I was able to diagnose the disease.

The emotional role of the patient had an important influence during the treatment.

42 I learned that the family and psychological support is very important for the patient, especially in patient
with a long-term disease.

The treatment results makes me think that I had plan a good treatment program for the patient,
although still have a long way to go before she can be considered completely cured.

REFERENCE LIST
1. Sardella White, S., & Garbe, J.R. (2010). Thyroid Disease: Understanding Hypothyroidism and
Hyperthyroidism. Boston: Harvard Medical School.
2. Oliva, F., Berardi, A.C., Misiti, S., & Maffulli, N. (2013). Thyroid hormones and tendon: current views
3. and future perspectives. Concise review. Muscles Ligaments Tendons J, 3(3), 201-203.
4. McFarland, E. G., & Kim, T. K. (2006). Examination of the shoulder: the complete guide. Thieme.
A 45 YO. GARBAGE COLLECTOR WITH
CHRONIC BACK SYMPTOMS
JAVIER SIMON M. AND GUIDO R.

INTRO I asked him what could be the consequences of

My reflective clinical case is about a 45 years
old male who has pain in the cervical region,
lumbar region and dizziness, didn’t suffer any
direct trauma, may be related to his job,
garbage collector. The symptoms could be
related with a slipped disc (medical diagnosis),
and may be with other aspect like mood.
SUBJECTIVE EXAMINATION
his symptoms and he told me that his job as
required gain weight because it was operator
43
of garbage. When he described his work he
commented that it was not at all satisfied.
He commented that did not perform any
hobby or sports, which can lead us to think that
their emotional level is low, because if work
does not satisfy you and no activity that does.

The first day the patient came to the The most relevant symptoms was neck pain,

consultation derivative of general medicine back pain, pain in the chest area and tingling in

with sick leave. superior limbs. Because these symptoms were

chronic, he told me that he had made some
My first impression of the patient was a sad
treatments before, as Pilates, and private
and worried person, as he sat in the waiting
physiotherapy, he improve a bit, but the
room without speaking to anyone.
symptoms did not quite disappear.

When he started to talk to me, commented

He hadn´t pharmacological treatment, nor had
that he was married and lived with his wife and
any personal history that might be related.
son.
Only had a family history of osteoporosis and
He had pain in the cervical and lumbar from
arthritis.
several months ago. The patient described the
pain as annoying, with tension and sometimes The patient described the pain in the morning

radiated. with a 9/10 on the VAS scale decreased

throughout the day up to 5/10.
One thing that struck me about his pain was
that it hurt in any position and any movement.

44
STUDENT REFLEXION AFTER S/E
About my initial hypotheses the symptoms are
related with the medical diagnosis, but I think
that are something emotional that has been
influenced in the perpetuation of it.
I don´t think that could be related with arthritis
or osteoporosis because in the medical test
aren´t any signs which has any relation with
patient´s symptoms.
At that time I did not consider the patient's
posture, but because of the knowledge
acquired in other subjects this year I could
associated to a string anteromedial (AM),
which is related to the emotions. This is the
representation of the body posture explained
by Godelieve Denys-Struyf, and this string
could be related with some symptoms of areas
of our patients. (1)
I decided to return to this sphere during and
after the physical examination (P/E).
QUESTIONS TO IMPROVE REFLEXION
Q1: What kind of chest pain he felt and during
which movements he felt it?
A1: This pain was produce by a antalgic posture,
in the physical examination I found that the
Pectoralis minor muscles was shorted and had
active Miofascial trigger points, and in the
visual examination the shoulder was in internal
rotation.
I know it, because he felt pain in the stretch and
palpation of these muscles.
Q2: Is there any red flag in the history you have
to rule out first?
A2: No there isn´t any red flags. I can consider
a yellow flag the emotional feels of patient and
the relation with the pathology.
Q3: So far, which is your guess about the
relationship between the main symptoms?
A3: In my opinion the symptoms are related
with medical diagnosis, because the pain
causes by the disk alteration, has provoke
some compensation that development other
symptoms of patient.
TEACHER ADVICE
Relationship among symptoms often provides
clues about irritability, severity, and spreading
pattern. Drawing a timeline introducing the
starting point for signs or symptoms and their
evolution, also help us to focus over one area
instead of others, as the source could be the
same for example.
Sometimes, the pain in the former presentation
hasn´t to be the most relevant nor the origin of
the syndrome.
PHYSICAL EXAMINATION
After know the medical diagnosis, how patient
felt his symptoms, I startet with physical
examination.
Firstly I did a static inspection, where I
observed a little vascular alteration under
pectoral fold.
So I asked him if he had any visceral alteration
because this could have a relation with the liver
or stomach.
His posture was important to analysed
because represented AM string, antalgic
flexion and right lateral deviation of the trunk,
internal rotation of shoulders, flexion of neck
and extension of head.
Secondly I did the functional inspection, and I
found an articular limitation of the left lateral
deviation 35º and extension 50º movements of
the trunk, and right rotation of neck 45º.
About muscle balance he didn´t have any
alteration, only the shorted Pectoralis minor
muscle. And active Trigger point of Trapezius,
paravertebral, lumbar quadrate muscles and
psoas.
45
Other test that I realized in lumbar region was
thumb-ascending test; Gillet test (2) and
elasticity test and I observed an anterior
torsion of the sacro. In dorsal region I realized
the Mitchell test (3) and I found a FRSd in some
vertebras.
I too realized Adson, Eden and Wright test to
kwon if patient had any vascular alteration,
and this test was negative. (2)
STUDENT REFLEXION AFTER P/E
Analyzing the information got from subjective
and physical examination, I think that
symptoms are related with that pathology,
because of hernia disc and protrusion, he
started to felt symptoms, and went changing
his posture. This could cause some
compensation that activate Trigger points,
and decrease the activity of some muscles.
But maybe the posture was the responsible of
the hernia disc, because bad posture of
vertebral bones, cause an alteration on disk
 pressure and this could the reason of patient
alterations.
In the physical examination I hadn´t performed
a neurodynamic test because I didn’t know
how to do it in this moment. After one year, I
have learned the importance and how to
realize this test to patient how present
46
symptoms like tingling.
So maybe I lost some important information,
to plan the treatment.
But in this clinical case, I keep thinking that
symptoms are very related with emotional
state of this patient.
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think that could be useful before
start or during the physiotherapy treatment, to
help the patient with a psychological support by
an expert?
A1: In my opinion is a good idea, because our
principal objective with all patient are a
biopsychosocial treatment, so sometimes this
must be multi-disciplinary treatment that in
this case.
But I found difficult to give patient advices
about pay attention to a psychologist or other
therapy to changes his mood.
Q2: So far, which is your first hypothesis with the
data coming from C/O and P/E? Which is the
data supporting this hypothesis?
My first hypothesis is hypertonicity because of
he presents Miofascial trigger point, in my
opinion, activated by a bad posture and stress.
The data supporting this hypothesis is the
presence of Miofascial trigger point in the
palpation that reproduces his symptoms and
the information that patient give me when he
felt pain (for example when he has to gain
weight or when he is sitting are related with a
nociceptive pain).
TEACHER ADVICE
Our findings during the P/E have to be
meaningful for the patient. A positive finding of
an unknown dysfunction or pain could lead us
into a wrong path if it´s not related with the
general presentation. Usually if it is found in first
place of the examination.
We have to check if this pain is “the kind of pain
that the patient used to feel” and is related with
his other main complains.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
After analysed the information getting in the
subjective examination and physical
examination my diagnosis is that patient disc
herniation, he has hypotonicity in the posterior
muscles of the trunk and shortening in
Pectoralis and Psoas.
The prognosis is positive but has some
negative factors like the pathology because it,
is irreversible without surgery treatment, the
chronicity of symptoms and the laboral activity.
Positive factors are that after others physical
treatment he has improves.
The plan that I design was to address the
following objectives:
 Firstly in a short-term the objective
was decreased pain in cervical and
lumbar region.
 Secondly to medium term was to
increase ROM at cervical region and
strengthen in posterior and anterior
muscles of thorax.
DAY_1
First day I started with an osteopathic
manipulation, for the dorsal region I used the
“Dog-technique” and for the sacro and lumbar
region I did the “lumbar roll”.
To decrease tension I did a technique to relax
diaphragm and other for the Pectoralis minor
muscles that was a muscular energy technique.
STUDENT REFLEXION AFTER D1
TREATMENT
After first day, patient presented the same
symptoms and the dizziness increased.
Maybe I should choose other technique that
weren´t trust technique.
So he had more pain the second day, so I 47
decided to do a more relaxed session applying
TENS and magnetic therapy.
So after this day I learned to give more
importance the mood of patient before choose
any technique.
QUESTIONS TO IMPROVE REFLEXION
Q1: Why did you chose osteopathic
manipulation?
A1: I did manipulative techniques in order to
get the neurophysiological changes produced
by these techniques. It is sought to give a
stimulus to restore the SN information about
the area and get so hypoalgesia short-term
changes in the structures that could be
affected (4).
DAYS 3-4
The third day my patient had lumbar and
cervical pain; he felts bad and told me that he
had have vomit. So I decided to do a relax
treatment with manual therapy, the fifth day I
did the same treatment.
 Sixth day the patient hadn´t tingling, the
dizziness had been decreased, cervical pain
had been improved but he kept feel lumbar
pain.
So, for this session my objective was treating
the lumbar pain. I used a technique to relax
diaphragm, I did a compression treatment for
48
Psoas Trigger points, contract-relax stretching
for psoas and a active work for the deep lumbar
muscles (Transverse muscle, pelvic floor and
Multifidus muscles).
STUDENT REFLEXION
I hadn´t the final information before the
patient end the treatment but while I was treat
it, he had some improves like dizziness and
headaches, but the outcomes after each day
aren´t very representative because each day
had different symptoms, I mean one day he
was better of the cervical pain and worse of the
lumbar pain, and the next day on the contrary,
so the evolution was very confused.
For me was difficult to interpreted which was
the problem of patient´s symptoms because
the evolution was very different and when he
improve one symptoms get worse other and
vice versa.
So I think that I have left loss some
information. Maybe I was in a wrong way or
this development had relation with my first
hypotheses of has a relation with the mood
my patient.
In spite of I recommended him to did some
active exercise to make more powerful the
back and deep muscles, because I think that is
very important to have a good motor control
of the lumbo-pelvic region, to decrease the
back symptoms.
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think the patient disease could be
related with neurological disorders in addition to
his emotional state?
I think that there could be some present
peripheral entrapment because I didn´t
neurodynamic test and he present numbness
in the arm, but he didn’t have any entrapment
of Braquial plexum because the Jackson,
Adson, Eden and Wright test, were negative.
Q2: Which part of your management do you
think has worked better and why?
In my opinion the best treatment for this
patient was the relax technique a motor
control (“rana al suelo” (5) adding a good
breathing movement to relax diaphragm) and
manual therapy. Because the active
participation of patient to get a good control
motor in the lumbopelvic region, and being
aware how he is relax while he gets control the
breath, helps him to get better results.
 And the manual therapy at the Trigger point good decision. Regarding to the neurodynamics
helps to decrease the symptoms and the issues, we need to discriminate among tests
muscles tensions. assessing roots, nerve trunks and main nerves.

TEACHER ADVICE We also have special test to investigate where

the entrapment is and its dimension, first step in
Choosing high evidence-based tests will add to
the management of these presentations.
your reasoning better ingredients to make a

49

FINAL STUDENT REFLEXION

To conduct further analysis of this case, after a year in which I have acquired new knowledge, has helped
me to realize that parts of the exploration had not taken into account and the importance of them such
as neurodynamics, spinal mobilization with postero-anterior pressures, the patient's posture that can
give us information of structures that are influencing their pathology. For example, in this case with an
AM chain, I could choose treatment techniques and address the same depending on the patient, such
as given the mood of the patient would have been better to make more moderate techniques: muscle
energy techniques rather than with impulse techniques.

And remember at all times the importance of the biopsychosocial treatment as in the recovery of the
patient and their adherence to treatment is influenced by many factors. And some time that is
necessary to do a multidisciplinary work.

This has helped me to make a more complete reasoning and relating and integrating more different
fields of physiotherapy I've been studying

REFERENCE LIST
1. Lucas, E., & Ángeles, M. (2009). Análisis biomecánico de las algias de raquis y su relación con la
percepción del dolor y la calidad de vida. REDUCA (Enfermería, Fisioterapia y Podología), 1(2).
2. Cleland, J. (2006). Netter, exploración clínica en ortopedia: un enfoque para fisioterapeutas basado
en la evidencia. Masson.
3. Ricard, F. (2007). Tratamiento osteopático de las algias del raquis torácico. Ed. Médica
 Panamericana.
4. Pickar, J. G. (2011). Efectos neurofisiológicos de la manipulación vertebral. Osteopatía científica,
6(1), 2-18.
5. Souchard, P. E. (2005). RPG. Principios de la reeducación postural global (Vol. 88). Editorial
Paidotribo

50
 A 23-YEAR-OLD FEMALE PREPARING
FOR ARMY WITH LOWER BACK PAIN
FOR 4 WEEKS
KRIIK G. AND PONCE L.

INTRO where she wasn’t able to put on shoes in the 51

locker room when leaving the gym. After this the
My client was a 23-year-old female student with
pain had been troubling her especially on the left
lower back pain, which had started 4 weeks
side of the back. Also a tendon had started
earlier due to heavy weight training.
snapping on her right hip.
SUBJECTIVE EXAMINATION
She had tried to relieve the pain by stretching
My client was a 23-year-old woman who was in
and trying to find a painless position. During the
the second year of her studies in the field of
day sitting worsened the pain, and sitting
physical therapy. She was living together with
through a lecture at the university was agonising.
her boyfriend who was studying in the military
Because of this she had started to attend the
academy, and it was her goal to join the army too.
lectures standing up. At home she had
Due to lower back pain resulting from extensive
exchanged the sofa for a fitness ball. The pain
training she came to the clinic. Her aim was to
was most severe in the evenings and after sitting
get back on track with training again soon,
down for a long period of time. Lying down eased
because the entrance test for military studies
the pain. She had found sleeping on the side with
was a few months away. She was 165 cm tall and
a pillow between her legs the best position for
weighed 52 kg. She hadn’t had former traumas
her.
associated with the pain.
During her free time she was involved in many
My client had started a comprehensive weight
kinds of activities: walking her dog, going to the
training program a few months earlier in order to
gym, swimming and at times also climbing. At
pass the entry tests for the army. A month ago
the gym she usually trained with free weights
she had started to experience lower back pain
together with her boyfriend. They trained at a
after training. Two weeks before coming to the
“men’s gym” without contemporary adjustable
clinic the pain had been intensified to an extent
gym equipment.
 At the gym the most pain inducing exercise was
deadlift, which she usually did with 20 kg weights
3 x 10 repetitions. She said that she knew she was
executing the movement wrong without
performing a squat deep enough. She
recognized that also in her everyday life she was
moving in unfavourable ways by having a habit of
52 not bending her knees while picking things up
from the floor. She suspected that she had been
engaging with a training program too hard for
her fitness level, because she was training at the
same tempo with her boyfriend.
STUDENT REFLEXION AFTER S/E
Based on the interview and her description of the
onset of the pain I suspected a disorder in
neuromuscular control in the core area. My
hypothesis was that she was training with
weights too heavy for her level of fitness and
technique, and while she was performing the
deadlift her back extensors failed to uphold her
posture, resulting in a flexion in the lumbar spine,
and creating an increased torque that caused
significant pressure to the intervertebral discs
and extreme tension to the surrounding tissues.
I sensed that there was pressure for her to get
back on track to the training routine, and thus I
expected a challenge in motivating her to
patiently commit to the therapeutic exercises.
QUESTIONS TO IMPROVE REFLEXION
Q1: So far, which is the level of severity and
irritability of her presentation? How is this going to
impact on your plan for P/E?
A1: At the time of her therapy session the
severity of the pain had been decreased to a level
where it presented moderately in certain
positions and movements. The pain affected her
movements, activities and behaviour and in
order to begin the healing process I felt it was
extremely important not to irritate it any further.
Thus I planned to be careful with the physical
examination in order to avoid provoking excess
pain.
Q2: Do you think she should rest and stop lifting
weights?
A2: Yes, in order to recover she should rest for a
sufficient amount of time, and afterwards
gradually get back to weight training.
Q3: Did you think about other forms of getting
prepared for the army?
A3: She should train by doing versatile exercises.
Because she already had a good selection of
other physical activities she was engaging in, I
especially wanted to give her an alteration for
weight training.
TEACHER ADVICE
The degree of irritability and severity will drive the
deepness of the P/E procedures. If we are not
cautious, a tough physical testing could ruined the In the forward flexion the lumbar spine rounded
remaining management if we provoke elevate or only at the end of the flexion, and up until that
severe symptoms in a highly irritable presentation, point it was almost completely straight. In the
that avoid proper and comfortable following modified Schober test lumbar spine lengthened
procedures. in forward flexion 6 cm while standing and 5 cm
while seated - which is within the reference
PHYSICAL EXAMINATION
values, but in the low end. Especially in the first
Day1: forward flexions she conducted there was a 53
visible functional scoliosis present. Her body also
I started the physical examination by assessing
flexed to the right side, over her right lower
my client’s posture and active movements.
extremity.
Her ankles were in line and in her feet she had
Lateral flexions were symmetrical and the spine
symmetrical and strong longitudinal arches.
flexed evenly. Lateral rotation to the right was
There was no pronation in the ankles. Knees
smaller than to the left. Single leg squat revealed
were slightly asymmetrical: the right ham was
larger weakness in the right gluteus medius than
slightly lower than the left one. Also the right
in the left one. On the right side in the anterior
gluteal fold was a little lower than the left one.
part of the hip a tendon was snapping as she
The iliac crests were horizontally aligned. Knees
flexed her hip. In the movement control test for
were directed to the back into a locked position
the core there was no lack of control present.
and the pelvis had drifted to the front and tilted
However, as a physical therapy student she did
anteriorly. In the lumbar spine she had a normal
know what this test was about and perhaps was
lordosis but the kyphosis in the thoracic spine
able to concentrate to not show positive signs.
had straightened.

In the Straight Leg Raise Test her left leg raised

Scapulae were symmetrically aligned, both by
smoothly over 90° but the hamstrings in the right
their distance from the spine and the height of
thigh started to strain at 90°. In the Thomas Test
their position. However the scapulohumeral
there was no tightness in the iliopsoas muscles
rhythm was slightly asymmetrical: the right
presented. According to palpation during a
scapula moved smoothly but the left one did the
single leg hip raise the transversus abdominis
same abruptly. In the cervical spine she had a
muscle activation was slightly stronger on the
normal lordosis.
left side than in the right side.
 As first aid for her condition I gave her advice medius weakness. During palpation m.
about a painless position. I also advised and quadratus lumborum was not painful. While
encouraged her to actively keep up a better conducting a stretch to the muscle, there was no
posture in which her lower back is not under tension present and the stretch was symmetrical
stress. on both sides. By palpation the lumbar spine was
more flexible than the thoracic spine. The tonus
Day 2:
in the back extensors was symmetrical in
54 There were aspects that needed closer transversal manipulation.
examination and due to lack of time were not
examined during the first session, so I decided to STUDENT REFLEXION AFTER P/E

make a few more tests to confirm the most My initial hypothesis during the first therapy
accurate diagnosis and management. session was that she had a disorder in
neuromuscular control in the core area. However
During the second therapy session there were no
when she didn’t present any positive signs
more signs of functional scoliosis present in
towards the lack of control, I had to change my
forward flexion. It is possible that the muscle
presumption. In our first session we had gone
tension present before had loosened and did not
through different factors in the core area, but did
pull the spine into an asymmetrical position.
not have time to profoundly examine the pelvic
Lateral flexions and rotations were symmetrical.
area. That is why I decided I needed to conduct
While squatting m. transversus abdominis
more tests in the second session. Between the
stayed active and the lining of the knees
sessions I had gone through numerous options
remained. In the single leg squat m. gluteus
which could be the cause for her pain, and
medius failed on both sides.
expected to come into a conclusion after better
In forward flexion the movement of SI-joints was examining her pelvic area and movements.
symmetrical. However the left side of the hip
Before the management phase I put a lot of
raised while raising the left knee, while the hip
thought into how to make therapy appealing to
stayed in place when raising the right knee.
her. I felt like I had to balance between exercises
There was no pain when compressing the SI-joint.
that were not too difficult for her in order to
In the Straight Leg Raise Test hamstring stretch maintain the right load and the therapeutic
was symmetrical and no tension presented. In aspect, but also challenging enough for her to
the Donatelli Drop Leg Test the leg dropped ~10 stay motivated.
cm on both sides which refers to m. gluteus
QUESTIONS TO IMPROVE REFLEXION
Q1. Which is the most important piece of data
supporting your hypothesis with this patient?
A1: The most important piece of data was the
muscle imbalance presented by her poor posture
and the evident weakness of her gluteus medius
muscles combined with the information about
the high intensity of her training and her
unstable technique.
Q2: Do you think she has a preference for the right
side of the body at the moment she performs the
movements and that it makes it stronger than the
left one on the lumbar rotation?
A2: Based on the observations and tests I believe
she has a habitual imbalance in her posture - and
during heavy weight training the weaknesses in
certain parts of her body have provoked an
increasingly unbeneficial posture. Her posture
includes dominant elements in both right and
left side of her body, but they are unsymmetrical.
Q3: What do you think you could do to avoid her
not showing the positive signs of the test you
asked her to perform?
A3: If she is very aware of the tests and her
performance, it could prove beneficial to ask her
to describe in detail if she feels weaknesses or if
one movement is harder than the other. Asking
her to talk could also make the movements more
natural and intuitive.
TEACHER ADVICE
No general advice could be provide to choose the
most relevant information in the P/E. It has to be a
personal decision that could be shared with the
expectations and feelings of the patient. Your
experience and knowledge will drive you to this
part of the decision-making after performed the
best evidence-based tests procedures. 55
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
My physical therapy diagnosis was that the client
suffered from an unbeneficial habitual posture
caused by muscle imbalance, and muscle
tightness and weaknesses in the pelvic region,
which in high intensity weight training provoked
pain into the lower back.
The objective for therapy for her was to correct
the posture and to learn proper movement
control and right movement trajectories in order
to be able to train with weights. After the first
physical therapy session the aim was to locate a
painless position, avoid pain provoking
movements and to start practicing the right kind
of posture.
After the second therapy session the objective
was to strengthen the deep postural muscles and
to learn a deep, relaxed way of breathing during
exercise. In order to reach a strong posture
gluteus medius muscles had to be strengthened.
 In the early stage of therapy the aim was to cross-
strengthen the core muscles in myofascial chains
both in the anterior and posterior side of her
body.
In the advanced stage of therapy the goal was to
enable weight training. The objective was to
comprehensively train the musculature starting
56
with simple technique exercises and moving
onto wider trajectories.
In order to develop a strong muscle control I gave
my client exercises to strengthen her postural
core muscles. In order to correct her posture I
taught her an optimal position for knees and hips,
and to stabilize her pelvic area I gave her
exercises for strengthening gluteus medius. In
order to keep her motivated I composed a
therapeutic training program for the advanced
stage so she could witness her own improvement
and not get bored with a lack of options.
1. EXERCISES FOR DEEP CORE MUSCLES
To strengthen the activation of postural core
muscles I instructed her following exercises:
- vertically pulling down and bouncing a
rubber band (m. transversus abdominis)
(10 sec activation + 10 sec rest)
- moving the body weight onto a foot
stepped forward, walking backwards
(mm. multifidi) (5 times on both sides)
- relaxed and deep breathing when
exercising (diaphragm)
These exercises she was to do with every training
session in order to learn to sustain core activation
when functioning.
2. EXERCISES TO STABILIZE PELVIC
REGION
In order to stabilize the pelvic region I gave her
exercises to strengthen the gluteus medius
muscles.
- lifting the hip while standing on a
stepping board (3 x 10 on both sides)
- lateral rotation of a flexed lower limb
while lying on the side (3 x 10 on both
sides)
- abduction of the foot while standing -
first without a resistance and later using
a rubber band (3 x 10 on both sides)
In order to keep the therapeutic training
interesting and appealing she was able to choose
an exercise for each session.
3. EARLY STAGE
In the early stage I prescriber her
- crossover crunches (3 x 10 on both sides)
- by turns lifting up one hand and the
opposite leg on all fours (3 x 10 on both
sides)
4. ADVANCED STAGE
I advised her to conduct the early stage exercises
as long as she had fully learned the movements
and the postural control was stable. When she
would have mastered them she could move on to
more challenging exercises. This way her training
was as progressive and motivating as possible. In
the advanced stage I gave her following
exercises:
- pulling down across to the front a pulley
while crunching the opposite knee up (3
x 10 on both sides)
- pulling down across to the back a pulley
while extending the opposite leg back (3
x 10 on both sides)
I advised her to start the advanced exercises with
small resistance and moving onto heavier
weights while paying strict attention to her
condition and movement control.
5. ALTERATIONS FOR DEADLIFT
Because deadlift was a movement she was fond
of, I wanted give her an alteration to make it
possible for her to safely train the muscle groups
that the movement incorporates. With the
alteration she would be able to train the same
muscles but in a safe and technically more simple
way. I instructed her:
- squat (3 x 15), and possibly later a
telemark-squat (3 x 10)
- rowing both bilaterally and rotating the
trunk
This progressive therapeutic exercise plan aimed
to return her into the training routine in a better
shape than before, and also to keep her
motivated and committed into. We agreed with
her that she will incorporate these exercises into
her routine and exercise independently, and
after 6 weeks, during a follow-up contact she had
been able to start training again with a better
technique and a clear knowledge about the
required movement control. 57
STUDENT REFLEXION AFTER
TREATMENT
Because my client was an active young woman
with a concrete goal in her weight training, I
didn’t want to solely give her exercises for the
early stage, because she might have found it
boring it could have resulted in her not sticking to
it. I wanted to build a bridge between her state at
that time and the stage she wanted to be in. I was
concerned whether I was able to give her all the
information and support she needed to
independently conduct the therapeutic exercise
process.
QUESTIONS TO IMPROVE REFLEXION
Q1: Which part of your management do you think
has worked better and why?
A1: Based on the feedback I received from my
client after her therapeutic practice period, the
core as well as m. gluteus medius strengthening
exercises have proven to be the most beneficial
for her. Once she was able to support a firm
posture she avoided provoking pain even in
 complicated movements. A strong core has TEACHER ADVICE
given her the possibility to enjoy life without
As we read previously patients’ needs to have a
pain.
general idea about the length of the treatment.

Q2: What about the recovering time? Did you have Information about this point could be found in

an idea about how many weeks the treatment clinical reports for individual patients. Despite is

would take long? not one best researched issues in physiotherapy,

there are some populations in which these findings
58 A2: I estimated it would take her 3 months to
are extremely urgent and relevant, for example in
reach the advanced level in practicing if having
the professional sports area where time
successfully undergone the therapy.
constraints costs lots of money to the clubs.

FINAL STUDENT REFLEXION

In order for her to properly learn the optimal movements I started the therapy plan with low-intensity
training (Kisner & Colby, 2012). Especially with patients with lower back pain it is important to render
activation in the deep postural muscles such as m. transversus abdominis and mm. multifidi. By
increasing the activation of m. transversus abdominis the risk of generating lower back pain decreases
(Miura et al. 2014). Because of this I included stabilizing exercises into every training session of her plan.

In her case it was also extremely important to strengthen m. gluteus medius, which is a stabilizing
muscle for the pelvic area. I chose exercises that have been proven to be the most effective in creating
muscle activation in m. gluteus medius. (Bolgla & Uhl, 2005. Gowda et al. 2014.)

In my opinion she comprehended the instructions well and also was committed and eager to execute
the plan of therapeutic exercises. I was glad to hear her positive feedback later and excited for her
recovery.

REFERENCE LIST

1. Bolgla, L. and Uhl, T. (2005). Electromyographic Analysis of Hip Rehabilitation Exercises in a Group
of Healthy Subjects. JOSPT Journal of Orthopaedic & Sports Physical Therapy.
2. Gowda, A., Mease, S., Donatelli, R., Zelicof, S. (2014). Gluteus medius strengthening andthe use of
the Donatelli Drop Leg Test in the athlete. JOSPT Journal of Orthopaedic &Sports Physical Therapy.
3. Kisner, C., and Colby, L. (2012). Therapeutic Exercise. Foundations and techniques..
4. Miura, T., Yamanaka, M., Ukishiro, K., Tohyama, H., Saito, H., Samukawa, M., Takumi Kobayashi,
T., Ino, T., Takeda, N. (2014). Individuals with chronic low back pain do not modulate the level of
transversus abdominis muscle contraction across different postures. JOSPT Journal of Orthopaedic
& Sports Physical Therapy.

59
 A 40 YO. MAN WITH A PAINFUL
SHOULDER SYNDROME
PÉREZ G. AND KRIIK G .

INTRO as soon as possible to return to his daily activities.

He is married and they have 2 girls with who
A 40 YO man, who handle Remotely Piloted
60
wants to play again without pain.
Aircraft Systems (RPAS), in Mexico, which has a
painful shoulder syndrome on both sides, as a He said that the pain on his shoulders started 2
consequence of many years working at the same years ago but he only felt kind of discomfort and
position by long working hours. he didn´t attended it, along of time he feels only
got worse and neurological symptoms on his
SUBJECTIVE EXAMINATION
arms on few times. He has token NSAID,
One day a 40 YO man, with 40 years old came to
muscular relaxants & hot water fomentations, 3
the clinical rehabilitation where I was doing my
weeks felt kind of better, but 2 months later the
practices. He was 1.78m tall and 89 kg of weight.
discomfort begun again harder and his wife
He handles a Remotely Piloted Aircraft System
carried him to the doctor because the pain
(RPAS) for a company in Mexico, almost always
increase each time more, presented swollen
Monday through Saturday 8 hours with an hour
shoulder and red zone, and sometimes cannot
of break, but he was handles the drone for 3 or 4
work but he only said ¨it will pass, I´m ok! ¨. They
hours with the same position without any break
went first with a public doctor, where he has the
to stretch or eat either. He describes his position
insurance and take a Rx to see the acromion
as a super video game player, stand up, arms
position, and it was good, but he said the
down, elbows 90°, and loading the control with
doctor´s diagnosis was ¨Painful Shoulder
2kg of weight.
Syndrome¨. Then, he went to the traumatology,

He is working on that place since he was 20 years and he said to him the same diagnosis.

old. He had taken a course for pilot the drone to Consequently, the doctor gives to him medical

begin work, and a long of time he has been prescriptions to decrease the inflammation and

updated until nowadays. He was born and grew pain, relax the muscles and the numbness

up in Mexico, he´s very sympathetic, funny, disappears, and furthermore sends him to begun

friendly, simple, positive and waiting to recover with physical therapy sessions.
His pain becomes chronically because he didn´t
attend at time and at the work give to him some
days to rest.
He smoke occasionally like 1 cigar each weekend
and was an occasional social drinker.
He presents pain on abduction, extension,
flexion (less pain with elbow flexed than with
elbow extended), internal and external rotation,
but in adduction he doesn´t present pain. At the
same time he has several limited range of motion.
He presents a lot pain when try to hung out his
clothes on the closet, brush his hair, take a
shower, dress and every activity that implicate
put his arms up.
He feels better when his wife put to him socks
with hot rice on his shoulder.
STUDENT REFLEXION AFTER S/E
About my hypothesis is a mechanical input injury,
with possible tissue damage. He has a lot of time
with the pain, so it comes to be a chronic disease,
it could be slower to recover than a acute pain.
He didn´t receive any therapy from a specialist,
only the home remedies that calm a little the
pain.
My first impression at all was a big contracture of
upper limb, back and neck.
First of all, I could do explorations to verify which
muscle is more damaged, and to neurological
test maybe as 1UNLT & 2UNLT to be sure that he
hasn´t any nerve entrapment.
He has a good prognosis because he is very
motivated and anxious to recover full ROM to
return to his normal life, he has a very positive
attitude and perseverant.
61
QUESTIONS TO IMPROVE REFLEXION
Q1: Which were the activities that ease his
symptoms?
A1: When he applies a thermal compresses, and
when he rested a day or two of work.
Q2. Which is your opinion about central
sensitization component in his pain presentation?
A2: I think the main component on his pain is the
muscle overload that causes a chronic
inflammation without care on time.
Q3: Does he have identical pain in both of his
shoulders? In his work, did he usually do the same
task with both hands?
A3: He doesn’t have the pain as a specific point
he feels pain around shoulder and neck.
Furthermore, he used to do the same with both
hands (take a motor control).
Q4: Is possible for him to work shorter periods or
take a break?
A4: He said that is not possible to make a break
because when begin to record is hard to pause it.
 TEACHER ADVICE
It´s important to cover, at least, the main issues in
the first visit to allow you to manage all the pieces
of the quiz. Missing key issues as red flags could
decrease the quality of your management and set
your patient in risk
62 PHYSICAL EXAMINATION
He brings radiographies and the acromion
doesn´t indicates a possible impingement. He
doesn´t have a specific point with pain on his
shoulders, so I decided realize test for the rotator
cuff muscles and examine his ROM and posture.
He presents head anteversion, winged shoulder
blades and a little left side descending.
The range of motion on left shoulder:
-Flex (L / R) 45°, 40°
-Left ABD (L / R) 40°, 35°
-Add (L / R) 30°, 32°
-Ext (L / R) 35°,30°
-ER(L / R) 40°,40°
-IR (L / R) 40°,40º
On Jobe`s test was positive both sides, Patte´s
test was positive (same on both sides), belly
press was positive, Gerber was positive (same on
both sides), Yergason was positive too (more
limited on his right side). I did Neer and
Hawkins`s tests too, Neer was positive on both
sides, but Hawkins was negative. Furthermore,
on the radiographies can observed that has not
any inflammation about bursa. And finally he
refers more pain at night.
STUDENT REFLEXION AFTER P/E
About the diagnosis of doctors, I found that he
has the muscles inflamed and whichever
movement that he did, he presented pain,
consequently very limited his range of motion.
Although, he said he begun to feels better with
de NSAID´s he want to be all right as soon as
possible. I found same kind on limited on
external and internal rotators (as subescapularis
and Infraespinatus), and on muscles as that have
function of flexion, extension, abduction, the
right side has more restriction, but in adduction
the rom wasn´t limited just at the end present
pain. I think he has more restriction on his right
shoulder because his dominant hand at business
is right side, so it overloads a little bit more the
muscles. Moreover, all the test he present
positive because he continues with inflammation
and overload muscles for his work , tension
position and those are contributing factors. He
present very good attitude and that have good
prognosis with NSAID and therapy he going to
recover but exactly I don´t know the time.
Moreover, he doesn´t presents an anatomical
deformation of acromion, just muscular so it
becomes better for his luck.
QUESTIONS TO IMPROVE REFLEXION
Q1: Did you advise a painless position for him?
A1: He has painless when he has his arms down.
Q2: Was he still working at the same time of
therapy? Do you think it´ll affect your work
strategy?
A2: He continues working fewer days and fewer
periods of time. I think it can make slowest
rehabilitation but not totally affect.
Q3: Which is your second hypothesis for the data
coming from P/E? Shoulder bursitis. Which is the
data supporting this hypothesis?
Shoulder bursitis is include the alterations of
muscles, tendons, nerves, tendon sheaths, joint
syndrome and neurovascular entrapment and
more pain at night. He has pain on all
movements and with the studies
radiographies and magnetic resonance can rule
out impingement and bursitis.
Approximately 10 % of the general adult
population experiences an episode of shoulder
pain in your life (Van der Heijden, 1996) shoulder
pain is the third leading cause of muscle skeletal
pain extends to shoulder and back (Cailliet, 1981)
.The risk that the pain persists beyond acute
phase seems to be related to lack of treatment,
and occupational personality factors (Van der
Heijden, 1999).
TEACHER ADVICE
Getting the most reliable tests for a typical
presentation is the key point to get a chance in
discovering a tissue dysfunction.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN 63
About the diagnosis of the doctors and my point
of view I met consistent findings about the
painful shoulder syndrome. I had doubt then with
shoulder bursitis, because the impingement
shoulder was rule out with the radiographies, but
on the radiographies has not appeared.
Furthermore he made MRI and only has
appeared inflammation of tendons. I think he
as was good because he doesn´t present any
neurological symptom last 3 months, and he is
more relax on his work and his wife is supporting
him, physical and psychologically.
The plan to reduce inflammation with help of the
doctor and some NSAID´s, and TENS,
thermotherapy, relax and therapeutic exercise.
DAY_1-2
Applied TENS on his shoulders and furthermore
thermotherapy with hot-wet compresses at the
same time to release the pain and relax the
muscles, then applied ultrasound on the area
with more pain. Then told to him that he should
relax for all day and don´t do any heavy work.
And on the afternoon he applied an NSAID on gel.
 STUDENT REFLEXION AFTER D1 on 3rd and 4th days added pendular of Codman
TREATMENT exercises, and laser low potency to improve the
The patient came with a doctor prescription. And, mobility and muscular potency, and decrease the
he feels better with thermotherapy, so it can pain.
helps to relax the muscle and psychologically too.
5th: add pendular Codman exercises, laser low
potency, massage and finally 2 repetitions on
QUESTIONS TO IMPROVE REFLEXION
finger ladder on flexion and abduction.
64 Q1: Did you give him instructions on how to relax
his muscle at home-other than NSAID?
STUDENT REFLEXION
A1: only the pendular exercises. The patient was happy because he feels his
shoulder been better and won ROM con 4
Q2: Did you have an estimate on how many
sessions. Moreover, his attitude was so positive
therapy sessions it would take to improve
on therapy and on house because obey all
Roberto´s state?
instructions. Furthermore, he and would gladly
A2: I think near of 15 sessions. therapy because he spoke with more people, so I
think that psychologically these attitudes are
TEACHER ADVICE
best for speedy recovery.
A “test-treatment” will allow you to get invaluable
information about the condition of the QUESTIONS TO IMPROVE REFLEXION
presentation. Using the results of the treatment as
Q1: Have been your management different if you
another piece of evaluation could inform you how
didn´t have the MRI images? Were they valuable
to treat your patient properly. If we use a huge
for your results?
number of techniques in this first session, we will
be less sure about which has worked better. A1: Yes, because if we had found any
abnormality as a rupture of rotator cuff, bursitis
DAYS 3-5
or even a tumor should be care with those things.
For days 3, 4 and 5 applied, TENS on his
Q2: Would he only continue his treatment at
shoulders and furthermore thermotherapy with
home?
hot-wet compress at the same time to release
A2: He continues with the therapy on the clinic,
the pain and relax the muscles, then applied
but I kept giving no therapy because I was
ultrasound on the area with more pain. Moreover
moved to another patient.
FINAL STUDENT REFLEXION

All the clinical case was with help of my coordinator of practices, although we add some therapies
methods. But here I would like to improve on the physical examination explore the neurological
examination, Daniel´s scale (muscle strength power).
With the treatment can be helpfully to his body but a placebo effect can be influent too. The
treatment in four sessions began to show results, but those results were for the good and positive
attitude for the patient, discipline at home, and he toke less hours on his job. The syndrome of
65
shoulder pain is not exactly pathology but we can rule out other possible symptoms and treat that
one. The best thing to do in all people is prevent a lesion give them some recommendations and
ergonomic positions, and take a few minutes to take a break and relax on the work, in addition when
we feels symptoms out of common we should go to the doctor or physiotherapist to check it and not
allowed to continue advancing the affection.

REFERENCE LIST

1. Cortes V., Acosta M., Armendárez M., Domínguez M. J. Romero P. (2009). Guía de Práctica
Clínica, Diagnostico y Tratamiento del Síndrome de hombro doloroso en primer nivel de atención;
Delegación Cuauhtémoc, México: CENETEC.
http://www.cenetec.salud.gob.mx/descargas/gpc/CatalogoMaestro/085_GPC_SxHombdoloros
o1NA/GPC_SHD_EVR.pdf
2. Hernández Díaz, A., Méndez, G., Orellana Molina, A., Martín Gil, J. L., & Berty Tejeda, J. (2009).
Láser de baja potencia en el tratamiento de las calcificaciones de hombro. Revista de la
Sociedad Española del Dolor, 16(4), 230-238.
3. SUÁREZ-SANABRIA, N. A. T. H. A. L. I. A., & OSORIO-PATIÑO, A. M. (2013). Shoulder's
biomechanics and physiological basis for the Codman exercise. CES Medicina, 27(2), 205-217.
 A 16 YO. FEMALE STUDENT THAT
SUFFERED A 2 ND GRADE RIGHT ANKLE
SPRING
PONCE DEL-HOYO L. AND PEREZ-RAYMUNDO G.

66 INTRO forward position so she wanted to score the last

point before the game finished.
A 16 yo. girl who was a football player suffered
an second grade ankle spring on the right She was running really fast and got the ball but
limb .There had passed 3 weeks since she suddenly one player of the other team kicked her
suffered the spring. She was immobilized during really hard on the lateral part of her ankle and she
these 3 weeks, now she has a lot of complications felt down and because of the velocity she was
with the functionality of her ankle. running she felt on the ground. The pain
appeared just when she tried to stand up again.
SUBJECTIVE EXAMINATION
“I could not support my weight on my leg. Firstly
When my patient arrived to the clinic where I was
I felt like if I had lost all my strength and then a
developing my clinical stance or practices, she
lot of pain started to came to my ankle. It was
was using crutches because she felt pain when
insupportable. “I would not have had cried, but I
she supported the foot down on the floor at the
could not resist, the pain was so hard” she said.
moment of walking. She said on the consultation
When everyone noted that what had happened
with the doctor (I was present during all the
to was not a simple drop, all the players went to
examination) that she had had an accident while
the place where she was layed dowm. They
she was playing football in her high school. She
started to call the trainer and when he arrived he
was part of the school’s team and she was
had already called an ambulance. He ask her
training for the competition than is done every
what had happened but because of her crying,
year between the different grades of the school.
she said that she could not say many details of
When the accident happened, the game was on
what had happened. The other player that had
the second period and her team was winning for
kicked her was how explained what had
2-0 points, so their team was feeling kind of
happened. Then she did not noticed exactly what
security against the other team. She had the
happened until the ambulance arrived, and she
was taken to the hospital. In the hospital she was
taken to the X-ray department and the
traumatology discarded a possible fracture. He
told her that she had had an ankle sprain and that
she was going to rest and take some medications.
The doctor put her splint on her ankle and said
that she was going to be immobilised during 4
weeks. She took the prescribed medications so
she did not feel so much pain on the next weeks.
The pain came back at the moment that the
splint was taken off. She was really surprised
because her leg was so much thinner than the
other one, and her foot too. She refered to had
pain at the moment she tried to put all her weigh
on his right foot. She also felt kind of restriction
of the movement.
STUDENT REFLEXION AFTER S/E
About my hypotheses of my patient´s injury is
that, well she already had a certain medical
diagnosis, a second grade right ankle spring. But
what I could observe while she was describing
her situation, was that she was really worry
about if she was going to recover properly or not.
She was scared because she had never seen her
foot that thin and weak. I also noticed that she
did not have enough proprioception because she
was always seen to her ankle and moving it with
her hand to be more comfortable (it due to avoid
wrong positions of hes foot and avoid pain). I
thought that what she needed was firstly to
decrease the pain. Then gain strength and
proprioception, because if not, she would get
injured again. She does not have any important
antecedent. She is a healthy girl, does exercise
constantly and take a good diet. So my first
impression was that she was going to have a
good prognostic if she follows all the therapy to
the letter.
67
QUESTIONS TO IMPROVE REFLEXION
Q1: Was there any deformity on her ankle?
A1: Yes, there was a relative deformity, because
it was with less muscular mass and with
inflammation
Q2: Which data of the history supports your
hypothesis about lack of proprioception?
That she was immobilized, so she did not stand
during three weeks and that makes the
baroreceptors get damaged. If it is not corrected
she is really exposed to have another spring.
Q3: Which are going to be your precautions for the
P/E?
Avoid pain is the principal precautions. The
ligaments are almost recovered, (because it was
a 2nd grade not 3rd) but she is still in pain.
TEACHER ADVICE
It´s important to remember that our physical
proceedings could damage the patient. As usually
passive examinations are testing tissue response,
if we do not dosage them properly they could harm
 that tissues. We need a proper evaluation of the
Movement Strength ROM
severity of the presentation at this point.
Dorsal Flexion 3 10°
But there are other tests for different dysfunctions
Plantar Flexion 4 20°
that could put our patient in danger too. In
example, missing the potential risk fall of a Eversion 3 10°

balance test, could provoke a harsh result. Inversion 3 10°

68 PHYSICAL EXAMINATION Passive movements were the same range of

movements but with a little of restriction to
When the doctor started the physical exploration
make the natural joint movement.
(I was just looking), the patient was kind of scare
because she said that had not had a really good He did not explore the gait because the patient
experiences with other medical processes. So felt with insecurity at the moment of stand in
she did not wanted to know that she was going both limbs.
to have a bar recovering.
Comparing with the other limb this was the
The doctor started exploring first by observation results:
of her ankle, not her posture, because she could
not stay standed up without pain. The doctor Movement Strength ROM
found that the skin around the ankle was rubbish Dorsal Flexion 5 20°
and warm comparing with the other ankle.
Plantar Flexion 5 40°
Then he palpated the area, and it was swollen
Eversion 5 20°
and inflammated.
Inversion 5 35°
She referred her pain in level 4 in EVA scale at the
moment of stand all her weight on her right foot. STUDENT REFLEXION AFTER P/E
I think that the Physical Exploration was kind of
After that he started to evaluate the range of
obvious, because the patient already had the
movements and strength in Daniel´s scale and
diagnosis made at the moment she had the
this are the results in active mobilization:
lesson, and it was corroborated with a
radiography, so it was just to check the actual
symptoms and problems she had on her ankle.
And when the doctor said the results of the test
of strength, I thought it was relative, because he
evaluated the movements but without causing
pain, so I think the patient could have done more
strength even if she had felt a little of pain.
The other ankle had so much more strength than
the affected one because she had had to walk
standing just on one foot, so she had to improve
the range of movement and power of the health
one to compensate the lack of the other ankle.
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think your patient is going to have a
fast recovering?
Yes, I think she has a really good attitude and
also positive factors to get back to play football
again as soon as possible.
Q2: So far, which is your first hypothesis with the
data coming from C/O and P/E? Which is the data
supporting this hypothesis?
My hypothesis is that is clear that she needed to
gain strength and more mobility to have a
normal gait again. The atrophy of her ankle
makes her loose stability and muscle mass. And
also the pain was the main negative factor that
made her feel distrust in supporting his weight
on her ankle.
TEACHER ADVICE
At the end of the physical examination we need to
take back a step and think for a while if data
coming from S/E and P/E fits in some way.
If do so, it´s the moment to make out a working list
with the most reliable hypothesis for current
patient´s presentation. At the top of this list will be 69
the syndromes with higher likelihood to be present,
and remains in the therapist ability to stablish
which of them will be the working diagnostic
hypothesis during the treatment session.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
Thinking in my hypothesis, I beat that what she
needs is really clear. Her ankle had suffered the
consequences of the immobilization, so we need
to recover it as soon as possible. She had had a
specific diagnosis before she came to the
physiotherapy treatment so, we just had to take
her back to her normal life. She had an
impairment to walk normally, not just for pain,
but also for insecurity and weakness.
The prognosis I gave her was good, I supposed
she would be ok in some weeks, of course only if
she follow all the instructions given during the
therapy. She is young and a sportive girl, so what
we have to do, also is to prevent her to have
another lesion on the future, and the best way of
 doing it is trying to recover her at 100% and
giving her some extra points to her ankle.
She had the same treatment during 2 weeks, and
on the 3er week there were some changes,
because she did not feel pain anymore. She went
to therapy 3 times per week.
70 WEEK 1 AND 2
The treatment was given for the doctor, but I
applied it to her. Firstly I used ultrasound to
decrease the inflammation and pain, because if
she were in pain, we could not make strength
training.
After that, I applied a hot pack for around all
around her ankle for 2o minutes to relax the
muscles before the stretching. Then, mobilized
passively all the range of movements and
stretched until the pain was of 7 in EVA scale. I
explained that the therapy would be painful, but
it was going to worth it.
When the muscles were relaxed, we began to
make the proprioceptive training. Being in front
of the mirror, I asked her to stand in one leg and
then in the other one. I used some advisements
to make the exercises harder and raise the
difficulty (like different surfaces with instability
or closing her eyes at the moment she did the
exercises).
About the strength training, I began with
theraband exercises to make the resistance at
one level that were not so much painful to her.
She had to make 10 repetitions with an isometric
contraction in eversion, inversion, dorsiflexion
and extension of the ankle. She had to keep the
contraction for 10 seconds and then rest for 5
seconds between each repetition.
Finally I used to give her a relax massage to avoid
she was in pain after the sessions.
STUDENT REFLEXION AFTER WEEK 1-2
TREATMENT
I think the patient had good results, because we
could get the pain relief. O Without pain we were
going to be able to gain a lot of strength and
proprioception to retraining the gait.
WEEK 3RD
During the 3er week, she was not more in pain,
so all the session consisted in taught her a home
program to strength all the right lower limb. I
also prescribed a harder proprioceptive training
and functional exercises to taker her back to
football game.
STUDENT REFLEXION
She had really good results. She recovered all the
range of movements, so with that factor to our
favor, I think the only things she needed were get
extra points to not get injured again.
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think that is useful for her to use an
ankle support?
A1: I think that it would not be necessary, but it
would give her extra support when she is playing.
Q2: Does she should continue doing strengthening
exercises?
A2: I told her than she was going to have to do
the exercises for a long time. Just to prevent
another lesson. She needs to have more strength
than usual in her ankle, because of the spring.
Q3: Will you treat her in the same way if you have
another opportunity again?
A3: Yes, absolutely. I think my management was
good enough. The clue was in the initial
subjective examination…
Q4: How different should the treatment be if you
had the opportunity to prescribe it instead of the
doctor?
A4: I think that there wouldn´t be a lot of changes,
maybe I would use the kinesio-tape to help the
peroneus muscle to do the strengthening
exercises, and if the patient does not complain I
could use ice instead hot. The cryo-kinetics
exercises would have been a really good option
too.
71
TEACHER ADVICE
For the majority of the physiotherapists I know, it
is not the ideal situation to work under the orders
of other therapists or doctors, having no
opportunity to take any decisions in the treatment
you perform. In these occasions, although you
have to follow their prescriptions, I think that rely
on you the capacity to dose it properly and make
the necessary adjustments on patient´s benefit.
And of course, they should listen to your feedbacks
or reports with your own thoughts and proposals,
also in that situations in which you think the
treatment they prescribed is not working
optimally.

FINAL STUDENT REFLEXION

In my conclusion, I can say that she had a good recovering. I hope she follows all my instructions for
the home program to avoid having a second lesion in the future. The treatment was successful
because she was treated properly since she had the injury till the therapy program finished. The ankle
spring is a very common lesson in sport people, but if it is treated properly, it doesn´t have to bring
future discomforts.
REFERENCE LIST

1) Stanley Hoppenfield, (2007) Exploración física de la columna vertebral y las extremidades.

(1) . Madrid. Manual Moderno
A 57 YO. HOUSEWIFE WITH A RIGHT
HEMI PATELLECTOMY AND
TENECTOMY OF THE PATELLA
TENDON AFTER A PATELLA FRACTURE
AND A TRANSIDESMAL FRACTURE OF
THE RIGHT FIBULA BONE
INTRO
A 57 yo. Housewife with a right hemi
patellectomy and tenectomy of the patella
tendon after a patella fracture in July of 2014,
and a transidesmal fracture of the right fibula
bone. She’s diagnosed with imperfect
osteogenesis and osteoporosis comes to start
her rehabilitation with me in November after
her last rehabilitation doctor’s appointment in
August of 2014.
SUBJECTIVE EXAMINATION
I met D. at the hospital where she had a
surgery for her physical rehabilitation. She
was a dedicated housewife, mother of an
adult daughter with whom she was very
close, having a lifestyle rather sedentary.
Many years ago, she was diagnosed with
RANNOU MA. AND BERTRAND I.
imperfect osteogenesis and since then, she
became extra careful and fearful about every
kind of physical activity. Then, she also was
diagnosed with osteoporosis and her daughter
with imperfect osteogenesis too.
She had antecedents: a right ankle fracture (a
fibula fracture), a right patella fracture and a
few others in the other limbs but she couldn't
remember exactly how many. So, she was
coming to begin her physical rehabilitation
after her second fibula fracture (transindesmal)
and her second patella fracture on the right side.
It happened during the summer in July, five
months before I met her, first she fell and broke
her patella and a week later she fell again and
broke her fibula. Although her ankle fracture
didn't need surgery as it wasn't displaced, her
patella was quite bashed up and it resulted in a
hemi patellectomy and a tenectomy of the
patella tendon which was in this occasion re-
taunted with staples.
The doctor prescription, of four months old in
August, said that the physical therapist had to
concentrate in the ankle joint but she hadn't
been re-examined since then. As I spoke with
her it became clear that the ankle wasn't her
major problem, she was disabled by it and felt
pain but the one she had in her knee was worst.
She explained to me that the pain, the
discomfort and a sensation of instability and
weakness in her knee lead her to fear everyday
life activities such as go up and down on stairs
or go for a walk all alone even if she had
crutches.
She added that because of it, she depended a
lot of her daughter, feeling guilty and worry
about it, wanting to have a quick rehabilitation
and saying that she would do everything to
succeed. At the same time, she insisted a lot on
the fact that I had to be very careful about her
disease even if I didn't do anything yet.
STUDENT REFLEXION AFTER S/E
My initial hypotheses about the sources and
patho-biological processes: a mechanic pain as
a result of damages on bone and tendon
tissues in remodelling phase in both joints.
I decided to override the doctor prescription
and dedicated time to the knee.
Except for her very fragile skeletal structure
which would oblige me to be extra careful, she
didn't present contraindications to the
examination but, facing her fear, I decided to
start assessing the joints mobility and muscles
strength in the lower limbs.
My first impression of the patient was a person
with mood swings: she often passed from a
motivate, trustful and joyful state of mind to
sadness, fear, pessimism and lack of confidence
in herself as in myself. She had a tendency to
want to lead and control the examination,
sometimes by fear of making it too much and
sometimes by laziness. It also appeared that
the bond she had with her daughter was very
powerful: the fact that she inherited her
mother disease made D. feel very guilty and
preoccupied and worry about being a weight
for her.
I understood that, in this case, the
psychological sphere will be something very
important to include in the treatment.
QUESTIONS TO IMPROVE REFLEXION
Q1: Could you find in the history any data
supporting that the patient should has an
alteration of the pain modulation component in
her pain presentation?
A1: I think that her state of mind and her
attitude could be a proof that the patient has a
central modulation of the pain, in her case, the
psychological area has a great impact on her she felt the more pain (Tables 2 and 3). The
pain. mobility of the patella was quite good and the
Q2: How do you think her fear of not wanting to cicatrisation process was going on. I made her
talk about her pathology could affect her? walk with and without her crutch but she was so
A2: I think that this fear acts as a brake for her focused that the walk didn’t appear very
recovery. If she doesn’t know what it is, she natural.
can’t behave correctly to improve her condition. Right ROM Associated End-feel
ankle symptoms
Plantar 145° No pain Elastic
flexion
TEACHER ADVICE
Dorsal 75° No pain Firm
Alteration of pain modulation system and central flexion
sensitization are two components of the pain Table 1. Arthrocinematics of the right ankle.

mechanisms with some overlapping and could be

present at the same time. But they have to be Right ROM Associated End-
knee symptoms feel
addressed in different ways. Usually, information Flexion 80° Pain at the Elastic
related with both mechanisms could be found (if end of the
movement
present) in the subjective examination. Extension 0-1° Decreased Elastic
muscle
power
PHYSICAL EXAMINATION Table 2. Arthrocinematics of the right knee.

In order to really understand what was Muscle group Grade (0-5)

Ischiotibial muscles 4
frightening her, I tried to make her talk about Quadriceps femoris 3+
her disease although I knew it. I was surprised Gluteus muscles 4
Iliopsoas 4+
when I discover she didn’t know much about it
Flexor of ankle (DF) 4
and wasn’t very interested in knowing more. Extensor of ankle 3+
(PF)
I didn’t push her further, thinking she
Table 3. Muscles’ Power.
eventually could tell me and I decided to start
my P/E. I started with the right ankle. She didn’t
At this point, she had enough so I let her go to
feel pain but was disturbed by a sensation of
her magnetic therapy session. Before she went
fragility and instability. I assessed her range of
out, she explained that although she was happy
motion and her muscles power (Tables 1 and 3).
to start her rehabilitation and expect a lot from
Then, I did the same with her right knee where
it, she didn’t expect very good results.
As she walked away, I finally saw how she was
really walking.
STUDENT REFLEXION AFTER P/E
About my initial hypotheses, my observations
seemed to confirm that the real issue wasn’t in
the ankle but in the knee where she suffered
the more damages to the tissues. The pain finds
its origin in her knee as the fact that she feels
pain when moving seems to show. Also, I found
interesting that she felt more pain when
moving actively than when I executed the
movement myself. The lack of power in her
muscles didn’t permit her to move the way she
should as well as her fear of the pain and the fall.
It appears that she also doesn’t know how to
use a crutch.
About the narrative process, at this point I
understood that she didn’t want to expend
herself on her disease or hear about it although
it had a big impact on her life and she had
tendency to use it as an excuse to escape the
physical examination.
It occurs to me that I’ll have to check again her
walk as it appears that she didn’t know how to
use correctly her crutch making her
movements more difficult. I started to think
that in fact, she didn’t even may need it
anymore and that may have been something
restraining her without her knowledge.
I decided to not push her and told her that we
will start the next session with some easy
exercises and that we will take care of her walk.
My main idea was to make her participate and
join her own rehabilitation by herself to then
progressively lead her on a good path. She
seemed very relieved as she went home to
know that the next session wasn’t going to be
long and painful.
QUESTIONS TO IMPROVE REFLEXION
Q1: So far, which is your first hypothesis with the
data coming from C/O and P/E? Which is the data
supporting this hypothesis?
A1: Noticing her pain manifests when she
moves and go away when she rests, (associated
with a decreased ROM and muscle strength),
my first hypothesis is a mechanical pain process
as a consequence of her surgeries, in order to
reduce her previous fractures. I would add that
her state of mind and her mood modulate this
pain as shown by her attitude during the
sessions through her obvious fear.
TEACHER ADVICE
There should be findings in these 2 first steps of
the clinical encounter that have to correlate
among them. As S/E comes firsts, usually points
out which areas have to be evaluate in the P/E,
and what should expect to find there. After
performing the suggested tests, the therapist
should could check if her first hypothesis were
true or not and could move on to additional tests
or questions if necessary.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
About my initial hypotheses, the exploration of
the patient left no doubt that the major
problem was indeed a post-surgery
consequence and a significate lack of strength
in the lower right limb.
About the narrative process, I wasn’t really sure
about the implication of the daughter and her
influence on her mother but I was certain that
anyways the pathology, her history and the
rehabilitation had a strong impact on her
participation and on her daily life sending her in
a vicious circle: the less she does the worst she
feels; and the worst she feels, the less she does.
So my main goal was to break this circle and
restore her confidence through the
rehabilitation to move forward.
DAY_1
We started with easy exercises: firstly big range
mobilizations on both joints to show her that it
could be done without pain; and then, small
inner range mobilizations to start gaining ROM.
I also applied a very small manual resistance
during short series of movements to start
improving her strength slowly. The main idea is
to show her what I expect from her and that she
is totally capable of doing it.
Then, I dedicate time to show her the best way
to use her crutch to improve her walk and to
avoid that she only depends on it. I noticed she
was capable to support her own weight and I
asked her to try to do little walks and move in
her home without it.
Finally I let her go to her electrotherapy and
magneto therapy session because she feels
better to end with it, saying that she took that
as a way to relax and rest before going home.
STUDENT REFLEXION AFTER D1
TREATMENT
She didn’t feel any pain during the treatment
even if she is very attentive at every move I
make and how far I go during the mobilizations
only to relax after a few series.
The next day, if the treatment runs, I will
continue with the exercises adding a little more
difficulties: longer series and more resistance;
and if she has improved with her crutch I plan to
try working on parallel bars with obstacles and
little stairs. The goal will be to work targeting
the function of her upper limb and push her to
be confident about going for a walk by herself
and coming back to her daily life with good
bases and no fear.
DAY_2
I started assessing her progresses since the last
session (she has a session everyday but I choose
to explain the progresses and treatments each
week to really show her improvements with
significates observations.), and she showed an
increased strength and a decreased pain.
Seeing those improvements, I kept the initial
treatment, only increasing a bit the difficulty
with the resistance exercise and longer series of
movements.
Then, we practiced on obstacles where she can
help herself with parallels bars and started to
go up and down a banister. With these two
exercises, we try to prepare her to go up and
down the stairs, working on her joints and her
muscles in a functional way which would
improve her symptoms.
STUDENT REFLEXION AFTER D2
TREATMENT
I see a really significate improvement with this
patient. But she doesn’t seem to realize how
better she was. She tries her best to be
enthusiastic about her treatment and I think
she manages it better when the exercises are
about doing things of her daily life like trying to
go through obstacles, working on her walk…
I try as much as I could to keep it entertaining
as she wished her recuperation was faster but it
sometimes is quite difficult to manage her
mood swings and to motivate her, it demands
patience and inventiveness to convince her to
work out every session but it’s an interesting
challenge.
DAY_3
As every session’s begun, I assessed her
progresses. She was doing pretty well with the
obstacles and the banister and her strength
improved well so I decided to start practicing
the stairs and to do muscular strenghting’s
exercise with weights.
The first exercise consisted on a flexo-
extension of her knee with a 3kg weight tied on
her ankle, her thigh being supported by a pillow
while she was laying on her back.
The second one consisted on a flexo-extension
of her knee, pushing against a ball while she
was sitting on the couch.
She then continued with obstacles and banister,
my intention was to slowly set up a routine,
with warm up, which she could easily follow so
if I added exercises she won’t be lost only
removing the “old” ones when the new ones
were totally acquired.
Finally, we started to go up and down little
stairs, her two hands firmly holding on the
handtrails. The first problem was to correct her
posture as she was coming down the stairs
aside and putting both feet on each stair.
D. seemed more confident every day but
started to complain about the length of the
treatment showing some signs of impatience.
The fact that I added some exercises didn’t
please her, she thought that the ones she was
doing before were enough and I had to explain
that the key of her progress was in the variety
of her treatment, increasing the difficulties.
She wasn’t convinced.
The next session, according to the results, I plan
to continue with the stairs, trying to improve
her going down so she gains in autonomy (her
own stairs only have a handrail and she can’t
come down without any help). We also work
out on the strength in her both legs: with auto
passive exercises and more weight. Finally, we
will experiment some proprioception both for
her knee and ankle.
STUDENT REFLEXION ABOUT D_3
It’s now really difficult to keep her motivated
for her therapy, she doesn’t realize her
progresses at all, and this is why I think the
stairs will be the solution to this problem.
Working and improving herself on the stairs
will show her, with something she knows well,
how much she improved.
We must continue to work with the weights for
her strength even if she doesn’t see the
differences but maybe if she realize that in
order to do the stairs exercise correctly she
must gain strength it will be easier.
The main problem with D. is her lack of trust,
in herself mostly and in me a little, this is why
one of my objective is to give her
consciousness of all the work she managed to
do so far, giving her exercises that put it in
light, like the stairs.
DAY_4
For this session, seeing the previous results, I
decided to remove the obstacles exercises to
work more on the stairs. But to start, she
warmed up with her strength exercises and
auto passive movements: we worked on every
movement of her hip, knee and ankle, with
weights and pulleys seeking to improve the
general strength of her leg, not only her
quadriceps muscles.
Once she finished with it, we came up and
down the stairs. Last time, we didn’t manage to
change the fact that she was coming down
aside, both feet on each stairs with the two
handrails. I thought that the problem wasn’t
mechanic as I saw her with the obstacles and
she hadn’t any problem to come down from
them. It started to appear that she feared the
stairs. She was physically capable of doing it
but wasn’t confident enough.
We started slowly, with only two stairs and the
two handrails. Showing her that it was easier to
come down to the next stair if she put half of
her foot on the side of the stair before going
with the other on the stair of after, it was only a
question of control of her quadriceps. Solving
this, she was then able to come down frontally.
Very excited by this improvement, she didn’t
even realize that she used only one handrail.
These results acted as a trigger and at the end,
she wasn’t using the handrails at all.
We then tried to do little proprioception. First,
she had to work on a mattress, walking on it
varying steps: on tiptoes, on heels, aside,
crossing legs…The goal was to provoke an
adaptation of her body to the changing was difficult for her to let her crutches aside
parameters. We then tried it on a rocker device: because she felt like she needed it. Slowly, she
she was standing on it, on her both feet and I decided to let them go, and admitted to me
throw her a ball in various directions to provoke later that it was in fact easier to walk without
an unbalance. them.
Despite her apprehension, she did it very well Q3: Do you think that, if you ignored the
and we managed to make it more difficult psychological aspect of the treatment, it would
asking her to stand on one feet only (she had a had the same result?
wall to lean on if needed). She didn’t managed A3: I think that if I hadn’t, the results would
to do it so we stayed with the more stable have been really different, it would have been
version, for this time. worst. I imagine she would have stop her
treatment, convinced that I wasn’t seeing her
STUDENT REFLEXION AFTERDAY_4 like a person but only like a joint.
This session was quite important because she
TEACHER ADVICE
finally realized that her therapy was working,
after that, it was really easier to work with her
Sometimes is hard to be sure about which part of
and to propose her other exercises.
the treatment has worked better, worse or not at
I think that in her case, the fear of hurting
all, also in multi-treatment modalities. It´s the
herself was the biggest brake and that all the
same with lots of research case reports, in which
time we took was necessary to come to this
patients are treat with and elevate number of
result.
techniques and no data about confounding effect
is found. At least, if patient objectives are lined
QUESTIONS TO IMPROVE REFLEXION
with outcomes, technique effects, and these are
Q1: Which was the role of the electrotherapy in
properly performed, we could have a plan to
your management?
revisit after changes are seen.
A1: The electrotherapy was TENS and was
prescribed to strength her quadriceps muscles.
The patient was quite enthusiastic about it as
she felt a relaxing effect afterwards and
insisted to have it at the end of the sessions.
Q2: Did she manage to walk correctly?
A2: She eventually walked in a better way but it
FINAL STUDENT REFLEXION

The final results confirmed my initials hypotheses and even if it was a long process, the patient and I
managed to see the improvements. The difficulty in this case wasn’t really the diagnosis but the
management of the patient. It took a lot of patience and courage for both of us to communicate and
to go through the therapy. The key of the treatment was in the psychological area of the patient,
once she admitted that she was improving, it became a lot easier. She didn’t stop her mood swing
but she accepted better the directions I was giving.
If I had to treat her again, I wouldn’t change my treatment. It worked but maybe I’d try to be firmer,
to take the lead of the treatment more quickly.

Right ROM Associated End-feel

ankle symptoms Right knee ROM Associated End-feel
Plantar 150° No pain Elastic symptoms
flexion Flexion 90° No pain Elastic
Dorsal 80° No pain Firm Extension -3° No Elastic
flexion Table 5. Final assessment of the knee ROM.
Table 4. Final assessment of the ankle ROM

REFERENCE LIST

1. RESERVES, I. and FORIN, D. (2015). Orphanet: Ostéogenèse imparfaite. [online] Orpha.net.

Available at: http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=FR&Expert=666 [Accessed
14 Jun. 2015].

2. Root, L. (1984). The treatment of osteogenesis imperfecta. The Orthopedic clinics of North
America, 15(4), 775-790.
 8 YEAR OLD BOY WITH FRACTURES OF
BOTH LEGS AFTER A FALL FROM THE
EIGHTH FLOOR OF AN APARTMENT.
TIBERI A. AND VIOLATI D.

82
INTRO The medical diagnosis was; in the left leg
closed diafisary fracture of tibia and perone,
M. is an 8 year old boy who fell off the 8th floor
treatment with a monolateral external fixator
on the 31st of October and fractured both his
for 3 and a half months. And in the right leg
legs.
open fracture of the external femoral condyle

SUBJECTIVE EXAMINATION and right meseta tibial of grade IV in the Salter

and Harris’ epifisiolisis scale. The treatment
M. is an 8 year old boy who studies in a German
consists of an open reduction of the epifisiolisis
school in Madrid. He says he doesn’t practice a
with screws, cast and orthesis for the first 6
particular sport. He went to the
weeks.
physiotherapist the 13th of April of 2015 and
says he also goes to another physiotherapist After a MRI, it appears he had a slight

once every 2 weeks. When we met first I asked pulmonary contusion and a minimum

how the accident happened; M. felt a little bit neumothorax.

uncomfortable, so I decided to change the

He doesn’t present neurologic or vascular
topic. After a week he confessed that on the
alterations, the pelvis is stable and the upper
31st of October 2015 (Halloween night), he was
body moves without pain. He has been on a
playing by himself outside in the balcony,
wheelchair for 5 months and after that, until
which was on the 8th floor, when he
today, he uses a crutch to walk. He told me he
approached the border line and fell, the fall
had never had any other problem before.
was diminished since he fell on a bunch of trees.
He told me that that very day he went through He does not feel any creep sensation, tingling,

surgery on both legs. burning or allodynia; his sensibility has

increased on the right knee around the patella.
He also mentions that his pain appears when
he tries to move more the leg, and he has an
itchy sensation around the scar on the right leg.
He also says he feels his legs weaker when he
has to walk long distances tires or taking the
stairs at school
STUDENT REFLEXION AFTER S/E
M. is a little boy therefore it is complicated to
get him focused for a long time, he doesn’t
enjoy talking about the accident and this
makes the anamnesis harder. I always try to
ask but without making him
uncomfortable and for that reason I was
missing information during the first week in
the anamnesis.
My initial hypothesis of the source and
pathobiological process: M. has suffered a
great trauma, mentally and physically.
Physically the medical diagnosis was a great
help and gave a clearer picture of what he has.
The fact he has a hypersensitivity or muscular
weakness could be related to
immobilization and due to the surgery he
received. I decided to evaluate only the hip and
the knee of both legs and the position he has
from a bipedestation.
About the narrative process, my first
impression was that M. is a Young boy and
luckily his improvement is faster. We have to
pay attention to his self-confidence and try to
remove some fears which can interfere in the
rehabilitation.
QUESTIONS TO IMPROVE REFLEXION
Q1: Andrea, as you described, M. also has an
epiphysiolysis. How do you think you can deal
with it?
A1: This is a point where I feel a bit doubtful,
since the doctors said he has a grade IV
epifisiolisis, after a few searches on this type of
fractures, I saw that the prognostic is negative
due to M.’s age and his growing cartilage is
feel
affected. My objectives would be to stimulate
the vascularization to that zone.
Q2: What do you mean with, “a fear can
interfere in the rehabilitation”?
I think that in a normal mental state where the
patient feels ‘depressed’ or better said, not-
motivated, due to the fear of falling for
example or doing things wrong, can harden
our work. If I push the line of work too much on
the
something he does not want to do (for
whichever reason), he could obtain rejection
from him but at the same time if I think this line
of work is appropriate but he is scared due to
any reason, it can slow down the recuperation
times.
Q3: Which is the impact for daily life activities
and participation?
 A3: During every day activities, as we were physiotherapists. But it doesn´t mean that a
talking, I understood that M. can do everything wise therapist hasn´t to take it in consideration
inside certain limits. It was him who told me he to approach these patient´s area. Disability
had difficulties to play with the other kids since issues have a major role in patient’s
he is the slowest and if he forces his legs they presentations and perspectives for the
start to hurt so he is scared and avoids playing. treatment outcomes. And our work over the
The only thing he does with no problems is dysfunction has a direct effect in disability.
84 being a goalkeeper during break. But generally Physiotherapists have to know how the impact
he moves with the crutches by himself with no is in this area and which parts of Daily Life
difficulties and can dress up by himself etc… Activities and Participation are being affected. It
Regarding his participation during the is usually more significate and realistic for a
treatment M. is easily distracted, it is hard for patient the possibility to play soccer again than
him to keep focused and he says he gets tired to achieve the cold “knee´s full active ROM”
and doesn’t want to do certain exercises. goal.

Q4: How was the role of his family members PHYSICAL EXAMINATION
during the anamnesis? Do they cooperate?
One week has passed since the first time I saw

A4: The first time I met M. he was with his M. I was at the end of the clinic’s corridor and I
grandmother; she came to me and told me in saw him walk towards me accompanied by his

detail about M.’s accident. When I started grandmother. After saying hello we went

talking to M. and got a bit closer he was very inside the consult. After a few minutes talking

shy and didn’t want to answer me, so his with his grandmother I started with the
grandmother had to answer for him. I had to physical exploration. I ask M. if he can put his

ask his grandmother if she could leave so I trousers, socks, shoes and shirt off, explaining

could be with M. by myself and get closer to him that in that way I could have a clearer look

him. Since that moment he started answering on his state. After a few jokes I asked m. if he

more questions. could put himself on a comfortable position

and look towards the front, I tried to pay
TEACHER ADVICE attention to every detail (feet position, shape
Following the WHO definitions of the of the tibias, height of the patellae, popliteal
International Classification of Function in 2001 hole, hip, back, and compared his muscular
(ICF), disability is not the field of tone). Generally he seems he goes towards a
pelvic anteversion, knee flexion on the right leg,
and a clear division of weight towards the left
leg. I also evaluated his scars and the scar of
the right leg, above the patella, and saw it was
a queloid type; the others didn’t seem to have
any abnormal alteration.
- Muscle Balance:
 Right leg: grade 3/5
 Leg left: Grade 4/5
- ROM the knee:
 Right leg: 85 ° of flex. And 15 ° ext.
 Left Leg: Full
- VAS:
 Right leg: by forcing the movements of
flexion and extension reaches an 8 (not
strive wanted more) and palpation of
scars: supra patellar and the one in the
popliteal hole.
 Left Leg: painless movements but
palpation of the tibia and fibula is
painful.
I had the occasion to ask him some more
questions, but this time focusing on his
feelings after the accident. I asked him if he
could play with his friends in school. He said he
played as a goalkeeper and that he could stop
more goals with his crutches, but he can’t play
in any other position than goalkeeper and he
didn’t like this situation.
STUDENT REFLEXION AFTER P/E
When I saw M. walk I focused on his way of
walking, I was impressed because it looked like
a neurologic walk, therefore I asked my tutor
for advice and he tranquilized me and told me
it wasn’t like that. My idea at first was to
educate his walking since it looked much
uncontrolled. After the first time I saw M. at his
home, I looked for the type of fractures he
presented and made myself an idea to what I
was dealing with. After this first P/E, I already
have an idea to what I have to work with him
for the moment, my objectives for now is to
reeducate the walk, obtain a complete knee
extension, work on the pelvic anteversion,
strengthen the muscles and mobilize the scars
to avoid adherences.
I told him he’d play football again and he’ll be
stronger than before. I know inside my mind
that I’m facing a complicated case, mostly due
to the psychological aspect rather than the
physical.
 QUESTIONS TO IMPROVE REFLEXION
Q1: In the type of trauma and the postures
described in the P/E, do you think that some test
to assess the integrity of the nervous system
could be useful?
A1: Your proposition is very interesting and in
86 fact I thought about the same thing during the
day after the exploration. Unfortunately I don’t
have a lot of time to do many things, I want to
focus on these types of explorations for 2
reasons:
 Because doctors said after MRI that M.
has no sort of neurologic affectation
in the nerve root
 I think that for a kid like him it was best
to do something “faster” and simpler
for the first day of exploration. Surely
the next time I will do some test to
discard possible neurologic
affectations.
Q2: Could proprioception be an accurate goal for
your patient?
A2: Inside my head I have an idea of what the
objectives are and which ones I think could be
the most important ones. I think it is very
important to work all at once with him. I will
focus on working every day on the mobility,
paying more attention to the extension since it
is the movement that allows us to have a
functional walk, to work on this. I will have to
work at the same time the muscles that can be
pushing the femur anteriorly as the psoas iliaco
or muscles that can produce this anteversion.
Give mobility and break scar adherences could
allow us obtain more elasticity in the tissues
and obtain more movement of the knee. As I
said earlier, always put strength work to
strenghthen and reeducate the walk. I totally
agree with the propioception work but it will be
a line of work that I will be integrating
gradually little by little according to the
progress made on the objectives described
earlier.
Q3: Which are the positive and negative issues
for the prognosis in this patient?
A3: Positive Issues: M´s is, surely, important in
the prognosis due to the fact that it allows us
to advance a quicker way, the socio-economic
support of the family which allows to have
physiotherapy sessions every day and 3 times
a week with 2 hour sessions. The absence of
other types of diseases. Negative issues: lack
of concentration and doesn’t want to really do
the exercises is a factor that makes us lose a lot
of time to make the patient listen and do what
he is asked to, fear creates a defense response
where the muscles try to block the leg and
difficult the exercises centered on the
increment of range of articular movement. The
type of fracture of the epifisiolisis and the age
in which he did it is another important factor
since there is affectation of on the growth for the epifisiolisis with screws, plaster and
cartilage and also it’s an age where there is ferula for the first 6 weeks.
more bone development.
Also, after a TAC we can see a light pulmonary

TEACHER ADVICE contusion. Minimum neumothorax.

One of the typical questions asked by the patient He doesn’t present vascular nor neurologic

after this point is “How much time does the affectation, the pelvis is stable and the upper

treatment need to be effective?” Therapist limb can be moved without pain.

haven´t a crystal ball in their kit. But we could
He has been on a wheel chair for 5 months and
guess an approximate period of time thinking in
until today. From my point of view M. presents:
the clinical pattern, the related published
evidence, the pathology and your own  Pelvic anteversion
experience treating this kind of presentation.  15° knee flexion on the right leg
Not every former point weights the same; but  Queloide-type scar on the right leg
you could put, in a two-plate scale, positive above the
against negative prognostic factors and provide  Muscular balance
an estimation. o Right leg: grade 4/5
o Left leg: grade 5/5
PATIENT MANAGEMENT
 ROM:

DIAGNOSIS, PROGNOSIS, OUTCOMES o Right leg: 85° of flex. and 15°

AND PLAN of ext.

o Left leg: complete
From a medical point of view the diagnosis is
 VAS: only pain when movement and
clear, M. presents fractures on both legs:
palpation

- Left leg – diafisary closed fracture of o Right leg: when forcing the

tibia and perone, treatment with an external movements of flexo-extention

monolateral fixator for 3 and a half months. he reaches an 8 (didn’t want to

force more)
- Right leg – open fracture of external
o Left leg: the movements don’t
femoral condyle and right meseta tibial of
hurt but the palpation of the
grade IV on the Salter and Harris epifisiolisis
tibia is painful
scale, treatment consists of an open reduction
 The prognosis of M. can be good under a
functional point of view, since he is very Young
his recuperation is faster but what upsets me is
the epifisiolisis that he has on the right leg. My
objectives are that M. regains his confidence
on himself and that he can have once again
strength, mobility and more functionality than
88 before.
DAY_1
Before starting with the treatment I did a quick
neurologic exploration to see if there could be
an entrapment on a nervous level. Both
mecanosensibility test as to the nervious
conduction test were negative. I asked M if he
could lie down on the massage table sitting. I
rapidly evaluated the ROM on both legs to
have a comparative mean at the end of the
treatment. I explained what I was going to do
and to tell me when it’ll hurt. I explained to him
to classify his pain on a scale from 0 – 10
calculating 10 as an unbearable pain and 0 is
when you don’t feel anything. I started the
test:
 ROM:
o Right leg : 85° of flex. and 15°
of ext.
o Left leg: complete
The end feel was firm and was accompanied by
a muscular spasm as a defense mechanism due
to the pain.
In this section I focused completely on the right
leg:
I asked him if he could lay down, the attention
of M during the treatment was very low, he laid
down in incorrect positions and when I tried to
move the leg he’d pus hit on the opposite side
to avoid me from moving it. I made a deal with
him: he could ask me whatever he wanted if he
allowed me to move his leg. I then started with
the treatment. M was laid down facing up and
the left leg was resting while I had the right leg
and worked with the scar with a few massages
from superficial to deep in order to break
adherences, always basing on the pain M had.
Then I did passive mobilizations specifically on
the patella to the femur and on a second place,
passive analytic mobilizations of the knee on
extension with an external rotation
component of the tibia and tractions and
relaxation of the knee. On second place I
started working on the flexion from a seated
position adding an internal rotation
component of the knee. I then did the muscle
treatment of the psoas iliaco from the right
side, M was on supin position and I was holding
his right leg increasing the hip flexion to better
go in and palpate the iliopsoas. To the
palpation of this muscle we could clearly feel
an increase of the tone.
At the end of the treatment I re-assessed the
mobility and the improvement was noticeable
since I could reach with the right leg more than
95º of flexion and nearly 5º of extension.
STUDENT REFLEXION AFTER D1
TREATMENT
As expected it is a child and clearly bored
standing still in one place and also try
maintaining the most attention possible with
games and history while continuing my
treatment. I think it's very difficult to focus on
making techniques while reassuring the
patient, this makes me wonder if what I'm
doing is really the right thing, I wish you could
be more relaxed and understand that what I'm
doing here with the I do it just for him.
QUESTIONS TO IMPROVE REFLEXION
Q1: What types of treatment did you use to
assess the iliopsoas muscle?
A1: I applied a pumping technique of such
muscle to avoid an irritation of the muscle,
which would cause an increase of the pain.
Q2: Which part of your management do you
think has worked better and why?
A2: I don’t think that there has been a part
during the treatment that has been more
effective. I think that the set of techniques
have attained this improvement. I believe my
attitude towards the patient has played a key
element in order to obtain his attention and
be able to work with him on a better way.
DAY_2
When I saw M I asked him how he felt after the
treatment and he told me he felt good and that
he didn’t feel pain during the day. I then tried
the same treatment from the first day, giving
me time to do a few miofascial liberation
techniques on the quadriceps with my hands
crossed on top of the muscle and realizing a
traction on the opposite side as if I wanted to
enlarge the muscle and adding movements
that could go directed to miofascial
restrictions. At the end of the treatment I
spoke with him and his grandmother who was
inside the consult and I told them that the
following week we would start going to the
gym, dividing the treatment on 20 minutes of
manual therapy, 20 minutes of gym and 40 of
swimming pool.
DAY_3
Same as DAY_1 and DAY 2.
DAY_4
It was the first day of gym. I started treating
the scars and mobilizing the patella and knee
on flexion and extension with the same leg as
the first day, I also focused on working on the
hamstring muscles manually doing deep
passes and stopping on miofascial conflict
 zones and on latent trigger points. Then I went
to the gym with him and we started a strength
program. M was lying down and we had the
opportunity on the clinic to do some motor
control exercises with the STABILIZE
apparatus. I started with a few motor control
exercises on isometric for the quadriceps, I
90 positioned the STABILIZER below the
popliteous hole and explained to M that
according to the orders I gave him he’d have to
contract only the muscle on top of the thigh
and buttocks and the muscles below the thigh
had to be relaxed, to make the exercise easier I
told him top put a hand on top of the quad and
another one on buttocks and hamstrings. At
first it was hard for him to differentiate the
contractions between the different muscle
compartments. I did the same exercises for the
hamstrings positioning the STABILIZER below
the heel and telling him to push with the heel
downwards. I also worked on a propioceptive
level and explained to him 2 exercises, the first
one consisted on standing up on top of 2 tilts
and did charge transference from a leg to the
other without pain and the second exercise
consisted of walking on a DYNA DISC which is
a disc made out of rubber, I explained to him
that he had to put more charge on the heel 
Little toe  thumb. We then went to some
parallel bars in order to work on the gait. After
20 minutes I went down with him to the
swimming pool where we focused on the
reeducation of the gait by playing with speed
and amplitude of the gait, controlling the trunk,
another exercise consisted on him supporting
his feet on the wall of the swimming pool while
I had to hold him from behind, positioning his
legs separated by a few cm’s (shoulder width)
from this position he had to bend the legs more
so he could then push hard (as if he wanted to
jump) the objective was to strengthen and
work on the active mobility. For last I told him
to go on a little stair that sunk M’s leg until half
of the inferior part of the thigh (above the
patella) and from then on he had to be on a
monopodal posture and hold the position for
20 seconds.
DAY_4,5,6 & 7
The treatment was always the same
DAY_8
3 weeks have passed and I did again the
physical exploration, the improvements were
huge.
The pelvic anteversion, managed to have a
nearly full extension from the 3º of flexion on
the right leg. The scars remained more or less
the same, the muscular balance improved
even though we could still see there was a
difference between the left and right leg, with
less strength on the range of movement:
o Right leg: 105° of flex. and 3° of ext.
o Left leg: complete up and down the stairs. On the swimming pool
the exercises were more or less the same but
- VAS: pain only to movement and
we increased the intensities.
palpation
AFTER A MONTH AND A HALF:
o Right leg: when forcing the
movements of flexo-extention he reaches an 8 M’s treatments are still on the same line of
but he reaches greater amplitudes (didn’t want work but increasing little by little the
to force more) difficulties and intensities. On the third
evaluation I did that day M presented:
o Left leg: the movements don’t hurt,
the palpation of the tibia is less painful - Minimum pelvic anteversion

I started as always mobilizing the scars, rotula - Scar on both legs were had more
and knee. That day I focused on working more flexibility and the queloid type of scar had
with the psoas because I think it was one of the diminished its width.
factors which was altering the gait, so I applied
- Muscular balance
the same treatment as described before and
then I did an analytic stretch of that muscle. On o Balance muscular of the right leg:
this section I also worked on a Global Postural grade V
Reeducation technique (RPG) with the posture
o Left leg: grade V
of the dancer to stretch the posterior muscle
chain, maintaining this position for 4 minutes - ROM:
without M feeling any pain but a slight
o Right leg: 130° of flex. and 0° of ext.
tenseness Garrido-Marín, A. et all. 2012. On
the gym I started doing a few propioception o Left leg: complete
exercises which were a bit harder, such as
- VAS: pain on the movement and at the
stability on standing position on the BOSU, on
palpation
the side of the half ball, he had to maintain for
20 seconds, then he had to put a leg on top of o Right leg: when forcing the
the BOSU and the other one in front of the movements of flexion around the 133º/135º he
ground, and from there flexion the leg which reaches an 8 (didn’t want to force more)
was more anteriorized by controlling the trunk.
o Left leg: palpation of the tibia is
At last we were working on the gait and going
painless
 M. I realized that with the passage of time was
always hearing me more, working with is not
a complete knee extension, increase of the
easy because you have to be always doing
muscle tone: gastrocnemius, soleus, popliteus,
something that catches your attention, but I
isquio-cruralis muscles, mostly on the right leg.
think with these types of jobs in addition to the
I chose to apply an RPG treatment due to the
clear improvements at the level physical, M.
fact that in the article (Garrido-Marín, A. et all.
has greatly improved its attitude also fear. This
7 November 2012) the effectivity or global
92 was the last day I saw M. due to the end of my
postural reeducation was studied versus the
clinical practice.
Propioceptive Neuromuscular Facilitation, to
increase the extensibility of the hamstring
STUDENT REFLEXION
muscles and it concluded that the treatment
Throughout my treatments with M. my
with RPG is better. Therefore I surfed the web
thoughts were always to look for functional
for books that talked more in depth about this
exercises while at the same time entertaining
treatment and which was the RPG posture
him since he used to get distracted easily.
most indicated for M´s presentation (Souchard,
During the hours of training I always looked for
P. E. 2005).
simple exercises to strengthen, improve the
propioception and functionality in order to TEACHER ADVICE
bring it to his daily life activities.
In spite of you´ve found one paper suggesting
the prevalence of RPG stretching against PNF¨s,
QUESTIONS TO IMPROVE REFLEXION
it´s no necessary true that this method is going
Q1: On the 8th day you said that you worked to work better with your patient. Despite the
with M. a RPG stretch, the “dancer”, what is internal and external quality of the journal
the reason that made you believe that this was publication, we should find those which were run
a suitable stretch for him? within a similar population compared with our

A1: During the treatment weeks, I had the patients. If her/his profile fits properly within the

possibility to know more of M. as the days profile of the volunteers in a research, probably

went by. There are many reasons: limitation of you could better guess how treatment will be
with your client.
FINAL STUDENT REFLEXION

I’ve reached the end of the treatment with M. The case firstly really scared due to the fact that I had
to put a lot of effort in every day to make him pay attention, there were days in which he came and
he was really tired therefore working with him was very hard, also the fear I had when it came to do
certain exercises with him blocked me a little. I think it has been a very stimulating case for me
because every day I felt obliged to make up different exercises which were directed towards my
goals at the same time. It has also been my first experience on working with the swimming pool so I
am very happy about that, it’s a good line of work and the possibility to be able to follow the case
gave me the security that what I was doing with him was the right thing because I could constantly
see the improvements. It has been a difficult case but it has made me think a lot and improve my
knowledge

REFERENCE LIST

1. Souchard, P. E. (2005). RPG. Principios de la reeducación postural global (Vol. 88). Editorial
Paidotribo.
2. Marín, A. G., Guzón, D. R., López, P. E., Serrano, M. F., & Imedio, A. S. (2013). Efectividad de la
reeducación postural global frente a la facilitación neuromuscular propioceptiva, para aumentar
la extensibilidad de los isquiotibiales en sujetos sanos. Estudio piloto. Cuestiones de fisioterapia:
revista universitaria de información e investigación en Fisioterapia, 42(2), 98-106.
 A TOO EARLY MENISCAL DIAGNOSIS
URIA A. AND ALCALA L.

INTRO The pain started one month ago during a paddle-

tennis match when he made a sudden extension
31 year old man who works as a labourer in kitchen
of his right leg, but he continued playing at the
construction who complains about a continuous
time and for the next two weeks until the pain was
94 pain above his right patella accompanied by a
so strong that he decided to stop. He usually went
sense of engagement of 1 month onset…
running with his dog three days a week, but he

SUBJECTIVE EXAMINATION interrupted this too. The pain hasn´t hold on since
he first noticed but has increased to the point that
A.K is a 31-year-old man who works as a labourer
it hurts even at work.
in kitchen construction. He has come to
physiotherapy consultation because of a He needs to expend a lot of time squatting at work

continuous pain above his right patella and he feels a continuous pain, which influences

accompanied by a sense of engagement during him in his mood and work performance. He is

certain movements, which started one month ago annoyed about not being able to do any of his

during a paddle- tennis. He has recently started hobbies (jogging and paddle- tennis).

feeling pain in the internal part of the left patella

The pain on both legs (specially the right leg)
as well as an overload sensation of his left
increases at the end of the day (when walking and
gastrocnemius.
standing for long periods of time, squatting, when

When I first met him, he walked into the standing from a squatting position and while

consulting room limping his right foot trying not going up and down stairs). He usually puts his

to stand on it. I noticed he was a restless person right leg at rest, extended and with ice at the top

when he started talking to me. He didn´t stop of the knee to reduce pain and he feels no pain at

wondering about the diagnosis before doing any night. But when he wakes up, he feels a bit of

physical examination. He was really scared about stiffness and discomfort on his right leg that stops

having a meniscal injury because his father was after heating the joint.

operated twice due to his work, which is the same

as his.
He had three-ankle sprain on his right leg when he
was 14 years old.
He has a good overall health; no respiratory or
circulatory or urologic dysfunction and he had
good results on his latest blood test. He has not
attended any doctor and has no radiographs of his
knee.
He is not taking any medication, just ibuprofen
occasionally when working but without effect.
STUDENT REFLEXION AFTER S/E
Because of his family history (his father had
undergo a meniscus operation because of his
work), my first thought has been that the same
thing was happening to the son. So I have decided
meniscus testing without thinking in other
options.
QUESTIONS TO IMPROVE REFLEXION
Q1: Didn’t you think that the pain of the left leg is
caused by an overload?
A1: It was my first thought, but I first wanted to
know what was happening with the right leg as it
was the main cause for the patient visiting the
consultation and his main concern.
Q2: What about the patellar tendon and the LCA
and LCP?
A2: Yes, you are totally right. Meniscus testing
was my first step because of his family history and
his constant fear about being operated as his
father. But during the clinical case and after the
physical examination, you will see how I am going
to change my mind.
Q3. Which is the prevalence for genetic
transmission in meniscus diseases? Do you think is
high enough to lead a P/E thinking in that
possibility?
A3: No, there is no scientific evidence about
genetic transmission in meniscus disease but I
focused on that possibility because of the
triggering mechanism of injury and the
continuous aggravating situations during his work
TEACHER ADVICE
Illness scripts are good tools for clinicians during the
decision-making process. They provide therapists
with the most relevant characteristics of a
prototype patient within a syndrome. Despite they
are not always the same (they evolve as the same
time as the clinician´s experience) and there is no
such a thing as a “prototype patient”, having these
schemas in your mind prompts you with more
chances to discover of the patient´s presentation
fits in that schema or not, avoiding unnecessary
procedures
 PHYSICAL EXAMINATION
96
I have started with the static examination where
nothing relevant has been detected except a bit of
knee hyperextension and a great base of support.
 The main symptom is the continuous pain
above the right patella.
 The second symptom is an engagement
sensation in both sides of the right joint line.
 The third symptom is the pain at the internal
side of the left patella.
 And the fourth symptom is the overload
sensation he feels at left gastrocnemius.
His associated symptoms are a right leg block
sensation and articular crunch sensation. All
symptoms are related. Because of the pain in the
right leg, left leg has made lots of compensations,
and has ended up with pain too.
During the dynamic examination, active
movements are good except medial rotation of
the knee and hip in both legs (especially in the
right leg). Pain has been found during right leg
extension starting from a squat position.
Accompanied by an engagement sensation of the
knee.
During palpation, temperature and muscular tone
are normal and there is neither articular spilling
nor edema. Pain has been produced at joint line
palpation of the right leg and an increase in tone
has been found in the calf of the left leg.
Muscular balance is 3/5 in the right quadriceps.
Trigger points have been detected at the left leg
in the internal and external gastrocnemius.
Tests: Thessaly test, McMurray test. Appley test
and the Sensitivity test of the joint line have been
performed.
All of them have been negative except the last
one, which has been painful during palpation.
Lachman test has also been performed but has
been found to be negative too. (Harrison, B. K.,
Abell, B. E., & Gibson, T. W. (2009), (Akseki, D.,
Özcan, Ö., Boya, H., & Pınar, H. (2004).
STUDENT REFLEXION AFTER P/E
As all meniscal tests have been negative except
for the joint line test. I have dismissed any
meniscal injury by the limited relevance of this
last test alone. As Lachman test is also negative,
LCA and LCP injuries have been dismissed too.
I now have to make a hypothesis with all the
information I have:
- Pain mechanism is nociceptive and mechanical
and tissue is at proliferative phase (1 month).
Trigger mechanism: was isolated playing paddle-
tennis but was aggravated after repetitive
impacts and squat positions at work time.
The source of symptoms is skeletal muscle
because it affects the patella and tendons and
muscles that surround it.
His main functional limitations are going up and
downstairs, maintaining a squat position and
standing up from a sit position.
The left leg is painful after walking for a long time
or after work.
Because of all this information, my reflection
about his problem after subjective and physical
examination is that he might be suffering a
patellofemoral pain syndrome. (Thomeé, R.,
Augustsson, J., & Karlsson, J. (1999).
QUESTIONS TO IMPROVE REFLEXION
Q1: Did you think that maybe the problem started
because of a joint wear?
A1: The truth is that I did not think of a joint wear
problem because the reason for the beginning of
the pain was clear and precise: making an abrupt
knee extension-playing paddle. I think that a joint
wear has usually no clear beginning nor an exact
reason for its appearance.
Q2: I think that he should make some Rx or RMN to
see if there is some micro fracture on the patella or
in the joint in general because he spends a lot of
time in squat position, or maybe some problem in
the cartilage. Don’t you think?
A2: Yes, maybe you are right. But the reason for
not doing it was because I didn´t see any neither
oedema nor inflammations signs to make me
suspect about micro fractures. As I didn´t find any
contraindications nor red flags I decided trying
some physiotherapy techniques to see if
symptoms were released and patient improved
before any other complementary images (which I
thought were not necessary for the moment).
Q3: Have you found any symptoms on the other
limb and how do link them to the right knee
presentation?
A3: Yes, I didn´t put enough information at first,
but I´ve just revised it and as I noted, the left leg
was painful during joint line palpation and had
some trigger points in the external an internal
gastrocnemius. I think there is a relation with the
symptoms in the right leg because of the lots of
compensation made when walking or working
 that has cause an overload in his left leg because
of trying to avoid pain in the right leg.
TEACHER ADVICE
The development of same symptoms on the other
limb in our patients could be related with different
hypothesis. It could be the spread of a general
98 illness; an overused provoked by the increased
activity of the other limb; it could be a central
sensitization; or simply activation of mirror neurons
mimicking the neural activity of the other limb. It´s
under our scope to identify the source and the
pattern of progression to avoid wrong targets
during the treatment.
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES AND
PLAN
My patient´s main goal is pain decreasing. So my
goal table includes:
- Pain releasing
- Strengthening right quadriceps
- Remove load and possible contractures of
the left gastrocnemius
- Flexibilize muscles within the right knee
- Increase or keep the articular movements
limited or diminished range.
- Restore self-confidence
As regard good prognosis factors, his interest in
recovering will facilitate the process, but his fear,
disruption of exercise and constant overload that
will occur in the joint during his work in the future
will not help the recovering process.
So the last of my goals is to motivate my patient
to achieve better and quicker results.
DAY_1
My plan starts by reducing pain and strengthening
the right quadriceps.
- I have first make a passive transversal
displacement of the right patella and ask my
patient to make active flexion of the knee from
a standing position, meanwhile I have
continued maintaining the displacement. I´ve
asked him to do three sets of 10 repetitions.
- Taping: medial displacement of the right
patella
Like this we have worked the quadriceps and the
movements, which caused him pain, avoiding
pain because of my passive displacement of the
patella.
I have decided to apply the taping because of the
good results acquired during the sessions.
DAYS 2-4
My patient has come up to the next consultation
with less pain so I have decided to do the same
exercise as in the first session.
Apart from this, I have decided to work out the
internal rotation of the right hip in prone position
with a 90º-knee flexion with passive movements
and to work out right hip extension with anterior-
posterior movements in standing position with
the Mulligan tape as the patient does an active
extension of the hip.
I have also recommended him to start his
exercises and to ride in static bike for 15 minutes,
3 days per week.
In the third session, the patient has come with
barely no pain, with a muscular balance of 4/5 in
the right quadriceps and with an increase in hip
ROM. So I have decided to continue with the last
program and giving him a massage in the left leg
to release the overload sensation of the calf.
STUDENT REFLEXION
I really think the prognosis is this case would be
great because there has been a great increase
there has been a big improvement in all signs and
symptoms in just 3 sessions and the patient is
heavily involved. But to get our treatment to be
effective, we will recommend the patient to come
to our clinic one day a week for the next two
weeks and to begin slowly with his hobbies
(running, paddle…).
QUESTIONS TO IMPROVE REFLEXION
Q1: Why didn´t you work on the strength of
quadriceps in the first sessions and you didn´t focus
on the range of motion firstly?
A1: My idea in the first session was to reduce pain
during the movements that usually caused pain to
my patient. I achieved it by making a transversal
passive displacement of the patella at the same
time that he actively did his painful gesture (which
was making a squat from a standing position). So
despite gaining strength in the quadriceps was
not my main point, it was indirectly achieved
because of the exercise itself.
Q2: Why did you work on the hip? And in this way?
A2: I decided working on the hip because, as I´ve
said in the physical examination, internal rotation
of the right hip was limited. I worked it in this way
because it was easier and had better results.
Q3: Did you do reassessment?
A3: I reassed my patient in the next session
because he came 2 days per week for just 1 hour
treatment so we didn´t have enough time to do
everything in the same day.
Q4: What did the result from DAY1 tell you about
your patient presentation?
A4: He was presenting an acute condition that
was aggravated because of repetitive painful
movements. As pain was alleviated while making
a transversal patella movement and reduced
during each session, I thought about a
patellofemoral dysfunction
 TEACHER ADVICE Contrasting DAY_1 results with the initial
assessment of DAY_2 also provides information
Results of DAY_1 treatment usually give us a
about the lasting period of the changes achieved,
valuable information about paths of relieving
irritability and dosage of techniques.
symptoms and dysfunctions, if you really control
the neurophysiological and biomechanical effect
you are dealing with.

100

FINAL STUDENT REFLEXION

I think this case has helped me to improve my clinical reasoning. In my opinion, I´ve wanted to put, too
fast, the name to the disease, to make a quick diagnosis. And that is the reason why I have not
progressed from the beginning.

I now try to stop and pay attention to every single information about the subjective and physical
examination before giving a name to the dysfunction, which I´ve learned, is not that important.

REFERENCE LIST

1. Thomeé, R., Augustsson, J., & Karlsson, J. (1999). Patellofemoral pain syndrome. Sports Medicine,
28(4), 245-262
2. Harrison, B. K., Abell, B. E., & Gibson, T. W. (2009). The thessaly test for detection of meniscal
tears: Validation of a new physical examination technique for primary care medicine. Clinical
Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine, 19(1), 9-12.
doi:10.1097/JSM.0b013e31818f1689 [doi]
3. Akseki, D., Özcan, Ö., Boya, H., & Pınar, H. (2004). A new weight-bearing meniscal test and a
comparison with McMurray’s test and joint line tenderness. Arthroscopy: The Journal of
Arthroscopic & Related Surgery, 20(9), 951-958
 PAIN CAUSING A SCAPULAR
DISKINESIS IN A 25 YO STUDENT
VIOLATI D. AND TIBERI A.

INTRO She went to emergency immediately where she

received the diagnosis of idiopathic subluxation.
25 years old woman, with an alteration of her
No reduction was performed and she was told to
101
right scapular girdle movement after a strange
apply ice and use a sling “on and off” depending
episode of pain and stiffness during the night.
on the pain.
SUBJECTIVE EXAMINATION
She spent 4 days following the directions. The
I just had finished to treat a patient at the clinic
pain decreased but it was still strong so she
where I’m doing my last practices of the physical
decided to go back to the hospital at the
therapy career, when a colleague call me to help
emergency area where the doctor said to her it
him with the exploration of a new patient. When
was a “cervical problem” and he diagnosed her a
I got at the “gym zone” the therapist told the
cervicobrachialgia. The treatment was diazepam,
patient to lift her arm to show me the problem
NSAID and superficial heat application. The
even before to introduce me. When I saw her
doctor also gave her an appointment for two
right scapula movement during the arm flexion I
weeks later with the orthopaedic doctor.
got shocked cause I hadn’t seen something like
this before. When she put her arm down we During the 2 weeks before the appointment the

introduced to each other and we started talking. pain decreased progressively. The orthopaedic
doctor told her she has capsulitis and chronic
She was a 25 years old publicity student, she
instability of her shoulder.
have been living in Madrid all her life.
She showed me all the medical reports and I
She attended to physical therapy because the
asked her for previous pathologies and she
orthopaedic told her. She told me that the onset
answered me it was the first time she has a
of the problem was day 15/03/2015; She had been
health problem.
woken up by a very intense pain in her shoulder
during the night and She felt it very stiff (while I asked her if she was in pain and she told me:

she was telling me that, she simulated the “The pain appears only when I lift my arm and it

position in which her arm was stacked). is localized in the upper part of my shoulder. I’m
not able to lift my arm like the other, I feel loss of
strength when I have to take or hold something
with my hand far from my body, like a glass of
water or opening the door. I don’t feel
comfortable when I lay down looking up because
I feel my bone (scapula) pressing the sofa or the
bed, but I feel a lot better then 4 weeks ago”.
She hasn’t been practicing any kind of exercise
during the last 3 years.
My first thinking, putting together the
information that I received and the first
impression seeing her moving, was about a
mechanical problem because of her “on-off” pain
related to the last degrees of shoulder
movement over the 90 degrees, provoked for the
clash between the humeral head and the
acromion that could compromise the tissues
between them. The all thing caused by her
scapula that wasn’t moving in the right way. The
quality of the movement that I observed made
me think about an alteration of the sequence of
the muscular activation during the movement.
STUDENT REFLEXION AFTER S/E
I think that I forgot a lot of questions that could
provide me a lot more information, because of a
lack of a mental structure to formulate them
orderly.
I also didn’t considerate too much the medical
diagnosis because I didn’t think that any of them
were the accurate one to describe the patient
condition.
I think my first hypothesis of a mechanical
problem was right but I didn’t think too much
about a possible first cause of this mechanical
problem. If she really suffered by a subluxation
maybe an alteration of the muscular activation
could be provoked by a neural tissue damage or
maybe the severe pain it self could cause it.
I also didn’t considerate the loss of strength that
the patient told me about, that could also be
related with neurogenic problem that I didn’t ask
questions for.
My brain didn’t have the flexibility to “play” more
with the information. I think it stopped working
from the beginning keeping mainly the image of
the patient moving. I needed to much time to get
to this conclusion and start to think again.
The patient looked not worried at all for her
condition and she was very quiet at all time and
disposed to follow directions to improve as soon
as possible.
QUESTIONS TO IMPROVE REFLEXION
Q1: I would like to know if you asked your patient
about typical symptoms of neurogenic alterations,
like tingling or “burning sensation”… or moments
of the day in which the symptoms increase, that
may help you to get a clearer idea.
A1: I didn’t ask for them and I think it was a big
mistake during the first interview. Fortunately I
didn’t perform the physical examination the day
of the subjective examination because the
patient was late for an appointment so that I had
the time to reflex on it. Of course before the
beginning of the physical exploration it was one
of the first questions I asked the patient.
Q2: Do you think the activation of a trigger point
could provoke the alteration in the muscular
activation sequence of her shoulder?
A2: Actually I didn’t recognise a clear active
trigger point pattern in the localization of patient
pain but of course I will check it out in the
physical examination.
Q3: Are there any other signs supporting the
neurogenic hypothesis?
A3: The only signs and symptoms that could
make me think about an alteration in nervous
system is the loss of strength. No other signs or
symptoms were reported or found.
Q4: Could you identify, so far, any contributing
factors for both hypotheses?
A4: The only contributing factor that I found is
the possible subluxation she suffered because it
could be the cause of both hypothesis. No other
CF or yellow flag were found thinking in the
maintenance of the condition
TEACHER ADVICE
Contributing factors could play a key role in our
patients’ presentation. Therapist tend not pay
much attention to them as they are not the cause
of the client´s problem. But they should be under
our scope, also when they are suggested by the
patients as a main issues for them. Sometimes is
103
really challenge to eliminate their influence, for
example anatomic and biomechanics CF. On the
other hand, yellow flags or ergonomic CF will be
targets and should be dealt within patient´s
management.
PHYSICAL EXAMINATION
The second time I saw the patient, first thing
she told me was that she was getting better and
her attitude was very positive from the very first
moment so I thought that would be very helpful
to get good results.
I asked her for neurogenic symptoms and I got a
“not at all” as answer. I also asked more about
her strength problem and she told me it was like
an uncomfortable situation in which she was
feeling her arm falling and tightness in her
medial part of the scapula.
I started with the physical examination from the
static observation taking the most relevant
information for me:
  Anterior view: the humeral head looked
in a slight anterior superior position
compared with the other one.
 Posterior view: the medial borders of
the scapula as well as the inferior angle
of the scapula was more "detached"
from the rib cage
 Side view: significant decrease of the
dorsal curve (kyphosis)
The passives movements had a complete range
of movement (ROM) and they didn’t provoke
any pain or other symptoms.
In a posterior view, during the lifting movement
of the right arm, the difference in the
movement of the right scapula compared with
the contralateral was pretty clear: the medial
border of the scapula started to separate from
the rib cage from the first degrees of movement
(20 ° -30 °); during the lifting, the scapula
present a big reduction of the ROM compared
with the contralateral. When the scapula
stopped to move appeared a significant
increasing in the activity of the upper trapezius,
lower trapezius and also the elevator scapula.
The conclusion was that the ROM of the
physiological movements of the shoulder (arm
lifting) was limited and the last degrees
provoked by pain at the end of the ROM.
When the patient was in pain I used the VAS to
obtain the intensity of pain: VAS= 3. In that
moment I also tried to charge the neural tissue
asking a neck side bending in both sides with
the results of no changing in pain and no
presence of other symptoms.
I also tried to passively help the scapula
movement during the active lifting of the arm
with the result of reaching the full ROM with no
pain detected but with the increased muscles
activation described before.
I also asked the patient to open a door to check
the movement during one of the action in which
she was complaining about the loss of strength;
she repeated again that the movement was
uncomfortable; I observed that, during the arm
lifting, her scapula was separating from the rib
cage while maintaining the arm lifted and it
increase when she was trying to open the door.
At the palpation I perceived an increased tone of
the rhomboideus and intermediate region of
trapezius muscles, but no trigger point that
could reproduce the patient symptoms were
found.
I performed the muscular balance of the
serratus anterior getting a 3-/5 (Daniel’s scale)
asking the patient an abduction of the scapula.
During the test the scapula behave as described
during the arm lifting and the patient was
recruiting other muscles to complete the action
so that the quality of the movement was very
poor.
STUDENT REFLEXION AFTER P/E separated from the rib cage in a static rest
position could be normal cause the patient
After the P/E I considered my first hypothesis of
dominant hand is the right one, that could
a mechanical problem right: in this case I think
provoke more protraction in the homolateral
the mechanical problem is the cause of patient
shoulder but it doesn’t explain why she started
pain. It appears only during the active
to have the sensation of her scapula pressing
movement and its nature bring me to think
the bed or the sofa in a supine position. It also
about a nociceptive mechanical pain because it
doesn’t give me information about the muscular 105
appears with movement/ mechanical
status: the serratus anterior muscle is not active
provocation (on-off) (Smart, Blake, Staines, A.,
in a resting position.
& Doody, 2011) and it was localized in a specific
site that “agreed” with my first hypothesis of a I think the loss of strength could be due to a
clash between the humeral head and the poor proximal stability (shoulder) that doesn’t
acromion. allow a good “basement” for the transmission of
the forces needed for the action.
Analysing the muscular activation sequence, I
think the fact that the medial border of the When I looked for myofascial trigger points I
scapula and the inferior angle separation from tried to remember which muscle could provoke
the rib cage, could be due to a problem in the the pain in the location in which the patient was
serratus anterior muscle. The serratus anterior is feeling it. I didn’t look for them in the serratus
one of the responsible, with the trapezius anterior cause I didn’t think in the possibility of
inferior and the trapezius superior, of the their implication in the loss of strength.
scapula movement during the raise of the arm
After all the previous consideration I started
and also to maintain the scapula in a good
thinking about why the serratus anterior wasn’t
relation with the rib cage during the movement.
activating in the right way so I started to think
I also think that the increased activity of the rest
about a conduction problem, but I couldn’t
of the muscles that permit the movement and
the activation of the levatur scapulae muscle are
intent of the body to reach the full movement
supplying the poor action of the serratus
anterior.

I think the fact that the medial border of the

scapula and the inferior angle were slightly
remember the innervation of the target muscle.
Pain: red (VAS:3)
Tightness: blue
QUESTIONS TO IMPROVE REFLEXION
Q1: I didn’t get your conclusion about what you
found in the static observation; I mean, what do
you think about the relation between her scapula
position and her feeling of her scapula pressing
when she lay down supine cause as you said the
serratus anterior isn’t active in a resting position?
A1: I don’t have an answer yet. It could be due to
the use of the sling that could affect the position
of the scapula girdle, or maybe a change of her
shoulder posture as a result of the pain felt.
Q2: Have you found any coordination evidence-
based test in the literature for this muscle?
A2: I performed the muscular balance with a
test described in (Kendall, 2007) another
effective test described in the literature is the
“Wall push-ups”, used to evaluate serratus
anterior muscle strength.
Another test I used in the P/E is the “scapular
assistance test” that evaluates scapular and
acromial involvement in subacromial impingent,
probably the main cause of the mechanical
nociceptive pain of the patient. The assistance
for scapular elevation is provided by manually
stabilizing the scapula and rotating the inferior
border of the scapula as the arm moves. This
procedure simulates the force-couple activity
(coordination) of the serratus anterior and lower
trapezius muscles, the elimination or
modification of the impingement symptoms
indicates that these muscles should be a major
focus in rehabilitation (Kibler & McMullen 2003).
TEACHER ADVICE
If we find during the S/E information suggesting
the possibility of a neurology/neurodynamic
problem, neurology exam has to be conducted on
Day_1, prior to neurodynamic tests. Also it has to
be ruled out any red flag related with these kind of
symptoms (i.e. Cauda equine or an Upper Motor
Neuron Syndrome)
PATIENT MANAGEMENT
DIAGNOSIS, PROGNOSIS, OUTCOMES
AND PLAN
The final diagnosis was a “Scapular dyskinesis”
with either flexion or abduction is rated as having
obvious abnormality (dysrhythmias and winging)
(McClure, Tate, Kareha, Irwin, & Zlupko, 2009).
In the literature is described that the 5% of
scapular diskinesis can be caused by Injury to the
long thoracic nerve that can alter muscular
function of the serratus anterior muscle, and
injury to the spinal accessory nerve can alter
function of the trapezius muscle but no evident
typical postures of these problems were found in
the P/E (Kibler & McMullen 2003).
Usually muscles can be also inhibited as a
nonspecific response to a painful condition that
in my opinion is the most possible hypothesis in
the case of the patient, serratus anterior and the
lower trapezius muscles are the most susceptible
to the effect of the inhibition (Kibler & McMullen
2003). Inhibition is seen as a decreased ability of
the muscles to exert torque and stabilize the
scapula as well as disorganization of the normal
muscle firing patterns of the muscles around the
shoulder (Kibler & McMullen 2003).
The superior or entire medial border may be
painful to palpation or with motion because of
similar tightness or scar in the levator scapulae or
lower trapezius insertions, or both (Kibler &
McMullen 2003), this could explain the tightness
that patient referred in the P/E.
DAY_1
I applied the scapular assistance test, applied in
several series/repetitions, as treatment to
stimulate the activity of the serratus anterior
muscle and also to make the patient conscious
that the full ROM can be reached without any
pain.
I also tried to activate the serratus anterior with
active exercises in a standing position and in a
supine position, asking for a protraction of the
scapula with the shoulder positioned in a 90
degrees flexion.
107
I re-evaluated the ROM and pain in shoulder
flexion and ABD with no significant changes in
the first one and a decreased pain with an EVA of
2/10
STUDENT REFLEXION AFTER D1
TREATMENT
My first session was planned thinking in all the
information received during the S/E and the P/E.
I thought the serratus anterior muscle was the
main problem so that I chose techniques to
reach a better activation of this muscle.
The treatment didn’t gave me big results maybe
cause it was the first session and it was a very
short one or maybe I needed more time to apply
the techniques for a longer period, or maybe
cause I simply needed more sessions to get
better outcomes.
The true is that I didn’t knew protocols or other
kinds of assessment for this problem so that
looked for articles that describe the condition
and I took out from them some ideas to plan a
better treatment in the following sessions.
After the research I found that in the first 3 weeks
of treatment the first point is avoid painful arm
movements and positions and establish scapular
motion by proximal facilitation so that my first
technique was good (Kibler & McMullen 2003).
Another point was to initiate scapular motion
exercises without arm elevation, using trunk
flexion and trunk medial rotation to facilitate
scapular protraction It could be a good idea due
to the fact that the patient couldn’t activate the
muscle with effectiveness and quality using arm
elevation exercises (Kibler & McMullen 2003)
QUESTIONS TO IMPROVE REFLEXION
Q1: Do you think that activate other scapula
stabilizers could be a good idea to improve the
quality in the shoulder movement?
A1: Yes, probably I could look for some exercises
to activate rhomboids and medium trapezius
muscles. I’m just a little worried about charging
to much the superior trapezius and the inferior
trapezius because as we have seen in the P/E
they probably are already working too much.
DAYS 2-3
The patient came with better sensations about
her strength and she felt she could move more
than before.
After the research I repeated the first exercise
performed in day 1 and I also included the
evaluation and treatment, with proprioceptive
neuromuscular facilitation stretching
techniques, of the latissimus dorsi muscle and
the pectoralis minor muscle (Kibler & McMullen
2003).
I also teach her exercises of scapula protraction
using body movements previously described.
STUDENT REFLEXION
After checking the muscles flexibility and tone
related with the limitation of scapula
movements (pectoralis minor, levator scapulae,
upper trapezius, latissimus dorsi, infraspinatus,
and teres minor muscles) (Kibler & McMullen
2003), I decide to treat the muscle that appears,
compared with the contralateral side, to present
more tone.
The result of the second session was good in
terms of active ROM (full ROM) and pain (VAS:
1) so that I decided to follow this line for the
third session in which the patient came with
better sensations but still poor movement
quality of movement but maintaining the ROM
and pain improving, so that I wanted to see if
the treatment could also be useful to provoke a
change in the quality of the scapular
movement.
What I didn’t do was retest after each technique
applied so that I only know that all them
together get to patient improvement but I don’t
know if each technique alone could lead to technique, probably the scapular assistance test
better outcomes. used as technique is the one that worked more
cause is the only exercise I used in the first 2
QUESTIONS TO IMPROVE REFLEXION sessions getting a better ROM and less pain.

Q1: why don’t you try to activate muscles like the

latissimus dorsi to see if they can help you to
achieve a better scapula position in an unstable
position, amid range of flexion for example?
A1: It could be a good idea to see if they can help
me to reach a better quality of scapula
movement and position in different degrees of
movement. I’ll try it!
Q2: Which part of your management do you think
has worked better and why?
A2: I’m not pretty sure about it yet because as I
said in the reflexion, I didn’t retest after each
TEACHER ADVICE
Physiotherapy literature is full of trials measuring
the “initial effects” of lots of techniques. To be 109
“immediately effective” doesn´t mean that the
technique is “long-lasting” or worth it at all. Or at
least if it is going to be accurate in each case. But
re-evaluating patient´s main outcomes before
and after the session, will enlighten your thinking
and support next decisions in the management.
It could also be a way to give feedback to your
patient about his/her progression.

FINAL STUDENT REFLEXION

My diagnosis was a scapular dyskinesis with obvious abnormality (dysrhythmias and winging) during
shoulder flexion and ABD (McClure, Tate, Kareha, Irwin, & Zlupko, 2009). Causing a nociceptive
mechanical pain in the patient during the 2 movements (Smart, Blake, Staines, A., & Doody, 2011). I
found support that a painful condition is the most possible hypothesis in causing serratus anterior
inhibition (Kibler & McMullen 2003) that is in my opinion the most affected muscle in fact a poor
muscular balance during the test described in the P/E was found (Kendall, 2007); so first goal to reach
was “waking up” that muscle to improve the movement quality.

At this point of the treatment I didn’t find anything in the literature that could clarify me the natural
process of this condition, and I also didn’t find any other paper that could help me to be more consistent
during the treatment planning. I think that so far I’m missing the key treatment (exercise or manual
treatment…) to improve the patient quality of movement so that I’ll keep looking for it in the literature
and during the treatment sessions.
REFERENCE LIST

1. Smart, K. M., Blake, C., Staines, A., & Doody, C. (2011). The Discriminative validity of
“nociceptive,”“peripheral neuropathic,” and “central sensitization” as mechanisms-based
classifications of musculoskeletal pain. The Clinical journal of pain, 27(8), 655-663.
2. Kendall, F. P. (2007). Kendall’s Músculos Pruebas Funcionales Postura y Dolor, Editorial Marbán.
3. Kibler, W. B., & McMullen, J. (2003). Scapular dyskinesis and its relation to shoulder pain. The Journal
of the American Academy of Orthopaedic Surgeons, 11(2), 142-151.
4. McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying
scapular dyskinesis, part 1: reliability. Journal of athletic training, 44(2), 160.
111
 113

Second Edition, 2016©

CC BY-NC-ND 4.0