Week 1.3 Entry

Today WE had our first truly undiagnosed patient which made us work a lot harder in our assessment. She was referred to us by a doctor who suggested some early degenerative changes which only presented as ant-med knee pain. We quickly determined that the pain was a lot more diffuse and covering more than the area stated (which was another occasion where the referral letter should not be taken as gospel and our own assessment should guide our diagnosis). The widespread nature of the pain required us to perform all possible tests of the knee (PHTY211 revision stat!). It was obvious that the patient had a lot on her plate in terms of work and children and was very keen to start on the road to rescovery. The patient was very responsive and helpful with all questioning and assessing, possibly even too helpful. The Hawthorn effect may have been in play to a small extent when we attempted to relieve her pain with a medial glide of the patella during a squat….she knew we expected a decrease in pain. Maybe something to keep an eye on for next time. Our supervisor suggested the use of a squat as a quick test first up and then reassess at the end of the session. This enabled us to witness clearly how the patient compensated and just how restricted she was.

All special tests were negative except for assessment of the patella which reduced pain when it was glided medially which indicated some form of patella alignment dysfunction and this guided our treatment. When I performed the special tests I had not planned the progression of the tests very well which lead to repeated movement of the patient throughout the session. Not a major issue but can be frustrating and time consuming for the patient especially with the amount of tests possible on the knee. Despite this I was happy with not only the fact that I remembered the majority of the tests but did them correctly. I felt that we explained clearly to the patient what all the tests were for and that it’s all part of a standard assessment and there was no cause for concern. Next time we see this patient we have already done the majority of the tests and we can streamline the assessment further and progress her exercises and determine her improvements.

Due to the unknown nature of the pain we were left to hunt for answers a bit more which had us thinking through all the information and trying to piece it together. With some guidance from our supervisor we managed to point ourselves in the right direction and eliminate many possible causes. As we progressed through my confidence grew in what we were doing. Next time I would set out clearly the plan for the session and make it a lot smoother and think about what all the information means in the overall scheme of things.

We will need to determine a greater amount of exercise options and make sure they are kept interesting since we heavily rely on the patient to effectively carry out their HEP. Overall we progressed through the session very well and despite the unusual nature of the pain experience we were happy with our eventual diagnosis and look forward to next time to further analyse our clinical reasoning. To enable her to function more effectively for the short term we taped her patella medially to relieve pain and show her that our treatment plan was in the right direction to resolve her problem.

Patella-femoral pain syndrome is very common and the treatment is fairly standard so a look into a more diverse range of exercises and treatments would be worthwhile.