Everything is going well over here in the motherland (aka UK)...other than the banter of being labeled a ‘convict’ by my workmates!
I have been improving my skills and enjoying every day of it. A couple of recent experiences have led me to reflect on my own practice (La Trobe Uni, who knew they were onto something!).
The concept of 'Diagnosis' is often considered ‘simple’ concept central in physiotherapy and sports medicine .
I remember at undergraduate level always asking questions such as “what would you do for this condition” or “how would you treat that” and being totally focused on how to ‘fix’ each problem.
Now proper clinical reasoning regarding management is integral. However, if you don’t know what you are managing... this is near impossible.
A short story to express exactly what I am talking about.
Back in the great land of Oz I saw a footballer who had come to see me for his ‘hamstring’ strain he had sustained at training. With my mind already made up of a low grade distal hamstring injury the rapid clinical examination that ensued obviously confirmed this diagnosis. My management of hamstring injuries I thought was effective and I started my almost recipe like rehabilitation (another fault of my early practice). After 6-7 days of offload, strengthening, low speed running he was still complaining of mild pain; which didn’t fit with how I thought it should settle.
I continued however on my predictable rehabilitation timeline to no avail as the player still had pain 2 weeks later.
In a follow up appointment the player mentioned he had pain when bending his leg to descend stairs. This rang alarm bells as it definitely didn’t fit the neat and tidy diagnosis I was working from. I decided to investigate with a proper, thorough examination and realised the pain generating structure didn’t seem like his hamstring. All the signs pointed towards a distal ITB problem and things then all became clear. The signs and symptoms then all made sense to me and fit with the history and timeline of symptoms.
Luckily this player wasn’t angry with an incorrect diagnosis but just happy there was a reason for the stagnated presentation. With some appropriate manual therapy his pain improved within the session. The player then went on to have a corticosteroid injection (not recommending this management for all patients, this player pushed to get one) and it settled within 4-5 days, allowing him to play the following week.
Although this is only one example, to me it drives home the point of the importance of ‘beginning at the beginning’ and not jumping too far ahead. Too quickly physiotherapists assume they have seen a problem previously. This can result in a misdiagnosis following a rushed assessment.
Decision making regarding management is important...but if you aren’t clear on what you are dealing with, then there is minimal chance of positive patient outcomes.
Ask yourself this question with each and every patient –
Could I stand in front of the Coach & Medical Team and justify my assessment findings, diagnosis and management of the athlete?
If you couldn't, then you have to either:
investigate further
utilise colleagues knowledge or
inform the patient the diagnosis isn’t clear and further investigation is needed
I encourage young physiotherapists to constantly look to improve their assessment diagnostic skills. Whether this is university students practicing palpation on other students during practical sessions or in breaks; or new graduates using private clinic patients as repetitive practice for special tests, (you can even do this without telling them... you'll just look thorough). Practice a McMurray's test on every knee patient or rehearse a thorough palpatory process on anybody complaining of back pain even if they ‘just want a rub'.
Be comfortable with uncertainty... no one has all the answers when it comes to the human body.
Keep asking yourself each and every patient you see – what is the problem here? Is their potential for it to be anything else?
Brenton Egglestone is a founding director of Enhance Sports Performance & Rehabilitation. He graduated from La Trobe University with a Masters in Physiotherapy Practice. Brenton has been working in elite sport for the past 4 years.
His first role was with the North Melbourne Football Club in the AFL, followed by a move across the pond, working at the Norwich Canaries last season in the English Championship.Brenton is passionate about the Sports Physiotherapy profession, and is keen to pass on his skills and discuss his success and mistakes with upcoming therapists.