STARES WEEK 1

SITUATION
I had a new patient referred to outpatients for hip and knee pain, but the referral also said they were suffering from “sciatica” and “lumbago”. The patient had attended outpatients at Bentley for low back pain approximately ten years ago. This patient had a history of osteoarthritis (OA), currently being treated with analgesics. The doctor had asked for a regular exercise program on the referral.

TASK
I had to perform an initial assessment for this patient and determine the treatment I would perform, based on my assessment findings.

ACTION
I began the subjective assessment with the plan being to focus on the hip and knee pain, rather than the general umbrella diagnosis of “lumbago” and “sciatica”. The patient told me he had a sharp knee pain but minimal hip pain. He also had numbness in his lower back which could also go down the side of his leg. The knee pain was brought on with flexion or loading and the numbness in his back came on after approximately fifteen minutes of standing. Heat had been helping ease the pain in his knee.
Objectively his hip and knee range of movement was good. The movements caused slight stretching through his lower spine and legs. Muscle length tests showed his quads were shortened (with increased tension) and on palpation I found increased tension through the lateral structures of his thigh. Neural testing did not show anything abnormal. I observed his gait and noted his feet were turned out and his legs were externally rotated. There was also swelling on the medial side of his knee.
After gathering this information on my assessment I tried working out a diagnosis and treatment plan. This became difficult when I kept going back to the doctor’s referral letter that said “lumbago” and “sciatica”. My assessment did not find these problems, but rather it found knee pain and problems with the muscles around the knee. I tried working out how the “sciatica” or “lumbago” would be related to the knee pain and got very confused.
It was only when I disregarded the diagnosis from the doctor and decided to treat what I had found in my assessment that things started to make sense. Rather than looking at his back or sciatic nerve as a cause of the knee problem, I looked at my results from the gait analysis and muscle tests.

RESULTS
By looking at the assessment findings to work out the patient’s problem (rather than trying to fit my findings into a diagnosis from the doctor) I worked out what could be causing the knee pain. His externally rotated feet were putting pressure on the medial aspect of his knee, what was causing a problem at the insertion of pes anserinus. His medial thigh muscles were not working properly, causing an imbalance with the muscles on the lateral thigh. Due to this imbalance the muscles on the lateral thigh were very tight and over-working.
By developing this diagnosis I could then start working on a treatment plan.

EVALUATION
When I was focused on the diagnosis from the doctor’s referral I had tunnel vision. I did not properly analyze my results from my assessment as I was trying to make them fit to a specific problem. After opening up and looking at my results alone it was much easier to work out what was going on. My supervisor gave me the advice to treat what I see, rather than what the referral letter says.
I do feel I did some things well. The subjective questioning was difficult as the patient’s English was not very good, but I managed to get a complete history and most of the information I wanted. It took a long time but I was patient and it paid off. I also think I performed the objective tests fairly well, but then had difficulty making sense of my findings.

STRATEGIES
While the referral is important it should not be the only source of information I use. What the patient tells me is much more important in developing a diagnosis. From now on I should work with what my assessment finds and use clinical reasoning to ensure I do not get tunnel vision when working out what is wrong with a patient. It is too unreliable to only go by what is on the referral.