The clinical assessment: history, physical examination ... · The clinical assessment: history, physical examination, load assessment, demand Rod Whiteley, PhD Physiotherapist

The clinical assessment: history, physical examination, load

assessment, demandRod Whiteley, PhD

Physiotherapist

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Pathology

Pain

Function

“My knee hurts” – what could this be?

• Patellar (Quads) tendonopathy

• PFPS, patellar instability

• Fat pad/bursitis

• ITBFS

• Physeal (tibia, patella, femur)

• Intra-articular (meniscal, loose body)

“My knee hurts”

• Where does it hurt?

• How did this start?

• What have you tried for this?

• Does your knee click/clunk? Does this hurt?

• Does your knee “lock up”? Does this hurt

• Does your knee “give way”?

• Focal, in the tendon

• Loading history (abrupt ↑ or ↓)

• What helps, what aggravates?

• ITBFS, Plica, crepitus, meniscal, patellar subluxation

• “Stiffening” after immob’n v mechanical

• “It goes out” v Quads inhibition

Where does it hurt?

Focal pain, in the tendon

PFJ

• Localised tenderness unusual

• Stairs/Squat/Sit-Stand usually bad

• Worse in flexion

• Dislikes heels

• Rarely swollen

Fat Pad

• Locally tender

• Standing/walking usually bad

• Likes standing in Flexion

• Heels can relieve pain

• Fat pad usually swollen

Activity

• “Warms up” (tendon) versus “Gets worse” (PFP, other inflammatory)

Onset

Tendon

• Jumping, direction change

PFP

• Running, stairs, loading in knee flexion

Acute:Chronic Workload Ratio

Ch

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load

(%

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110 4.7 4.1 3.6 3.4 3.2 3.3 3.5

100 4.3 3.7 3.4 3.3 3.3 3.6 4

90 3.9 3.5 3.3 3.3 3.6 4.2 4.9

80 3.5 3.3 3.3 3.7 4.3 5.3 6.6

70 3.3 3.3 3.7 4.6 5.8 7.5 9.5

60 3.3 3.8 4.9 6.6 8.8 11.6 14.9

50 4 5.5 7.9 11 14.9 19.6 24.1

40 6.6 10.1 14.9 20.9 28.2 36.7 46.5

30 14.9 23.2 33.7 46.5 61.4 78.6 98

60 70 80 90 100 110 120

Acute workload (% of normal average)

In season

• Past history of injury predicts injury because of training load changes

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Acute and Chronic Workloads

Acute Chronic

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Acute and Chronic Workloads

Acute Chronic

“Let’s have a look at your knee”

• Swelling – tendon v fat pad v intra-articular (v extra-articular)

• Adolescents – Osgood-Schlatter’s/S-L-J, SCFE, Perthe’s

• “Any kid with a limp needs their hip checked”

EffusionTendon

• Localised tendon swelling (US)

• Nothing intra-articular

PFP

• Tendon normal

• Intra-articular oedema

• (Pre-patellar bursitis)

Palpation

TendonopathyNot tendonopathy

Palpation Painful 40 84

Palpation Not Painful 1 193

Sensitivity | Specificity 0.98 0.70+LR 3.22-LR 0.04

Physical exam

• Reproduce the focal pain while loading the tendon – focal v diffuse

• Decline squat – jump landing 2 to 1 legs – repeated landings

Setter

Outside

Outside

Opposite

Middle

(Libero)

0%

5%

10%

15%

20%

25%

30%

10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% >90%

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Jump heights (as a percentage of maximum jump height)

Distribution of jump heights over one professional volleyball club season based on player position

Setter Middle Outside OppositeChris Skazalski (@cskazalski)

Loading and tendonopathy eg Jumps

• Current load

• Desired/required load

(Patellar) tendonopathy

• Get the diagnosis right

• Understand the loading parameters for this sport, this athlete

• Load is king

• Tenonopathy v PFPS, OA (etc)

• Understand how this happened & what to do about it to return the athlete safely

• No short-cuts

0

0,2

0,4

0,6

0,8

1

1,2

1,4

0

20

40

60

80

100

120

Whole squad jump load

4 week average 1 week average 1 wk / 4 wk

0

20

40

60

80

100

120

Daily Average Jumps Whole Squad

Chris Skazalski (@cskazalski)

Jumps every dayJumps every week7 day rolling average28 day rolling average7 Day : 28 Day (A:CWR)

Kjaer

• Extracellular matrix in skeletal muscle

Purdam – tendon loading

• Rate of loading of the tendon versus peak loading

• Symptoms the following day (delay in symptoms – look at collagen proliferation v degeneration curve) 24-72 hour response; “how it feels today reflects the response to the previous day’s loading”

• VISA questionnaires

• Reassess with decline squat. Hops, but watch for the same time of the day (not first thing in the morning)

• Pain and function – pain can stay the same if function is increasing

• 3 day load cycles

Rate of loading for same peak loads

• (Bodyweight per sec)

• Seated calf, standing calf, controlled push < half of

• Dynamic push, jumping, max hop, acceleration

Cook Purdam loading stages

• 1 4 daily sessions of heavy iso

• 2 Strength followed by isometrics followed by strength

• 3 strength FastElasticFunction iso strength fast iso optional

• 4 iso strength fast iso strength fast recuperateMon Tue Wed Thu Fri Sat Sun

1 4X daily iso

2 Str Iso Str Iso Str Iso Option

3 Str FEF Iso Str FEF Iso Option

4 Iso Str FEF Iso Str FEF Recup

TeamTraining

Game

Stress Shielding

• Preferential loading of parts of the tendon

Lyman et al AJSM 2004

Lyman et al AJSM 2004

1

3 4

2

5

Almekinders et al Strain patterns in the patellar tendonand the implications for patellar tendinopathy Knee Surg, Sports Traumatol, Arthrosc (2002) 10 :2–5