Avoid Tunnel Vision

Many times, I will see a client who complains of knee pain.  During my initial assessment, I will check the knee strength and range of motion.  I will perform special tests to detect deficits with the ACL, PCL, Collateral Ligaments, Menisci, etc.  I will compare the "good" knee to the "bad" one with the prior tests and measures.  That would be considered a "FAIR" assessment.  But to provide a "GOOD" assessment, I must perform a 'peripheral joint scan' checking at least one joint above and one joint below the "problem" area to truly pinpoint the problem.  The knee pain could be caused by some biomechanical problem at the ankle such as over pronation due to tight gastrocnemius, tight soleus or restricted subtalar joint.  It could also be caused by weak hip musculature, particularly the posterior gluteus medius.  You may not pick up on these other areas as being potential causes until 2 or 3 sessions have gone by.  But the point is, do not have tunnel vision.  If your client attends 2 weeks of sessions, and there has been no change in the symptoms, that is your cue to look elsewhere as a possible cause.  Check one joint above and one joint below the knee.  You can usually detect signs of deficiency in these other joints while simply observing your client's posture, gait and stepping activities.  So always pay close attention to your client's movements, especially as they transition from one exercise or position to the next.  You will be surprised at what you see, as it may be the cause of their main complaint.

Popular Causes of Knee Pain

Knee pain is a very popular issue for Personal Trainers and Physical Therapists.  Although the pain is localized to your client/patient's knee, you must observe the peripheral joints as possible causes.  One of the first joints you need to assess is the ankle/foot.  Many times, your client may be flat-footed on one or both sides.  Pronation or "flat-footed" many times creates a "down and in" movement of that entire lower extremity.  "Down and In" refers to an internal rotation motion of that leg.  This internal rotation leads to a shortening/tightening of the Ilio-Tibial Band/Tensor Fascia Latae (ITB/TFL).  This then leads to more internal rotation and "down and in" and it becomes a viscious cycle. 

Tightness of the ITB/TFL may create an increase in lateral pull of the patella or knee cap.  Instead of the patella tracking superiorly upon knee extensor contraction (quadriceps), it tracks supero-laterally.  In time, this may cause knee pain.  Most of my "knee clients" are taught how to perform proper calf (gastrocnemius/soleus) stretches to help minimize the "down and in."  They are also educated on ITB/TFL stretches if I observe the patella tracking laterally.  Unfortunately, these stretches alone will not correct the "down and in" motion.  You must ensure proper carry over by immediately practicing the activity in which the "comparable sign" (your client's chief complaint) was observed.  During the practice, make sure that the "down and in" motion is minimized.  For example, many times this motion will be obvious during step downs.  Instead of the knee tracking over mid to lateral foot, the foot arch drops (pronates) and the knee track medially over or past the big toe.  This step-down (using the affected leg to lower the body) may create your client's symptoms of knee pain.  Teach the stretches, and have your client perform the step down during that same session, making sure the knee tracks properly over the foot.  Many times, if you correct the movement pattern, the involved muscles will begin to work properly and efficiently.  Oh yeah, and don't forget to check the VMO contraction which assists with medial pull of the patella during contraction.  The VMO is the tear drop shaped muscle on the inside aspect of your thigh just medial and superior to the knee cap.  This muscle helps minimize lateral patella migration.  So, stretch the calves and ITB/TFL and strengthen the VMO.  Then perform the required activity and make corrections.  Remember "Perfect practice makes perfect!"

On a side note, for those trainers with clients who want to train barefoot, keep the above information in mind.  Training barefoot may have its benefits.  However, if your client demonstrates any of the pronation and "down and in" movement patterns with shoes on, their form will very likely worsen without foot/ankle support (training barefoot).  If they are unable to correct this inefficient pattern when barefoot, you may want to scrap barefoot training for now.  This is especially true if they already require orthotics in their footwear to reduce pronation.  Make sure the benefits outweigh the risks of barefoot training.

Client Assessment Part 4

C.H.A.R.T.S.

"R" Stands for Range Of Motion (ROM)

During your client assessment, you will want to evaluate the range of motion, particularly of the area related to the chief complaint.  You are looking for the 3 R's (Range or quantity, Resistance or quality/willingness to move, and Reactivity to the movement).  Be  especially attentive to the "Comparable Sign." The comparable sign is the client's chief complaint or symptom.  If you have your client perform an action that causes pain, however it is not the same pain that he is usually complaining about, then it is not the comparable sign.  Reproducing the symptoms/comparable sign will help you figure out the source of the problem. 

First have your client perform the movement actively.  If he feels symptoms, then you take him through the movement passively.  Lastly, test that movement resistively to assess strength.  With each of these, you are always looking for the 3 R's.  If there is pain prior to applying resistant, your client is highly reactive. Pain with resistance means he is moderately reactive.  While pain after resistance means low reactivity. 

A normal result of active range of motion is as follows:

-smooth motion at all speeds

-full ROM

-Pain free

-Normal strength

Abnormal result of active range of motion is:

-client resists movement

-painful area in the movement

-pain at end range

-compensations are observed

-you hear joint noises/crackling

Limited active range of motion may be a sign of the following:

-weakness

-tightness

-nerve issues

-internal derangement (you can use special tests to figure this out)

-pain

-tight joint capsule

What does Passive Testing tell you (you take your client through the movement)?

-Normal and pain free means no lesion

-Normal and painful may mean a minor sprain

-Hypomobile and painfree may mean a muscle contracture or joint adhesion

-Hypomobile and painful means acute sprain with guarding

-Hypermobile and painfree means a complete rupture of the tendon

-Hypermobile and painful may mean a partial tear

What does Resistive Testing tell you?

-Strong and no pain: no lesion

-Strong and painful: minor lesion

-Weak and painless: nerve damage or complete rupture

-Weak and painful: partial rupture

When performing Resistive Testing, remember the following:

-Isolate one motion for the test

-Test one joint at a time

-Test the motion at its mid range

-Increase your applied resistance slowly (do not crank on it)

-Hold the resistance 5 seconds

The above information should help a great deal in figuring out the cause of your client's condition. 

Client Assessment Part 3

C.H.A.R.T.S.

"A" is for Asymmetries

After taking an extensive history and finding out what your client's chief complaint is, you will want to begin gathering objective measures as a baseline status.  The first observation should be your client's posture. 

From the back, look for the following:

1. Foot position: are the toes pointing in or out, or is the foot flat?

2. Check out muscle mass: Is one calf bulkier than the other?

3. Position on the knees: Are they pointed in towards eachother or is it bowlegged?

4. Check for scoliosis: Does the spine have an 'S' curve?

5.  What about shoulder position: Is one shoulder elevated?

From a lateral view:

1.  Is the knee flexed or hyperextended?

2.  Is there an arch in the lower back?

3.  Is there a rounded upper back, rounded shoulders or a forward head posture?

With this section, you rely heavily on your observation skills and vision to determine asymmetries.  Noting these asymmetries will help a great deal in customizing an exercise plan with goals for your client. Setting up a plumb line to assist in your facility may help. 

Next we will discuss Range of Motion ('R' in C.H.A.R.T.S.)

Client Assessment Part 2

C.H.A.R.T.S.

"H"  Stands for History

During the assessment, it is important to gather information regarding patient history in order to determine the "health state" (behaviors/activities) as well as the "injury/disease state."  Knowing where your client was, helps to determine their goals as well as the extent of their injury.  During the patient history, you will want to gather the following information:

1.  General demographics: age, gender

2.  Growth/development: hand/foot dominance

3.  Present problem/complaint

4.  Past medical/surgical history

5.  Present medications: pain meds, muscle relaxants, anti-inflammatories

6.  Family history

7.  Vocational/Recreational info: Is their occupation a contributory factor? Ergonomics?

Following this section of the assessment, you will plan an in depth physical examination.  This is where you ask yourself:

1.  What are possible hypotheses for the cause of your client's problem? 

2.  How aggressive can you be with their training?  

Next entry will be "A" for Assymetries.

Another Acronym To Help Organize a Detailed Assessment

C.H.A.R.T.S.

When first meeting a client/patient or upon re-assessing that client to assess progress, a good guidance system to help accurately collect information is to base the assessment on the acronym C.H.A.R.T.S.  In the next few blog entries, I will break down each section.  Today, I will discuss "C".

"C" stands for Chief Complaint.  This is the subjective section of the client/patient interview/assessment.  Here you are finding out why that person is seeking your assistance.  It is also during this interview that you will decide whether there are other possible causes of the client's issues, especially any life-threatening pathologies that may contraindicate your services.  If the client has a complaint of pain, you will use the O-P-Q-R-S-T question format (previous blog entry) to analyze that.  Again, it is during the interview process that you want to rule out any other serious pathology that the client may have.  Some things the client may tell you that would lead you to believe there is a more serious issue are the following:

1.  Unexplained weight loss - Was he/she trying to lose weight?

2. Malaise/decrease in energy level

3. Fever/chills

4. Weakness/numbness

5. Fainting (loss of consciousness) or syncope (no loss of consciousness)

6. Pain at night

7. Pain at rest that is not affected by position change

8. Bowel or bladder problems

Also check out the previous blog entry on "Red Flags"

Lastly, you will want to assess that client's response to working with you. 
1. Did he/she have an unusual response?
2. Was there any symptom magnification?
3. Did the symptoms improve but then return for no reason?
4. Was their pain unaffected by your session/treatment?
5. Was the pain worsened by the session/treatment (considering you were not being too aggressive)?

 

All of the above information should help guide you in obtaining an in-depth description of your client's or patient's problem and will later help you in developing goals and customizing a program.  Next entry will focus on "H" for History of the condition.

Detailed Pain Assessment

When a new client begins working with you, he or she may come to you experiencing pain in one or more areas.  During your initial assessment, an easy way to formulate a detailed pain assessment is as simple as remembering O-P-Q-R-S-T.  If you know your alphabet, you can do this assessment.

"O" stands for onset of symptoms - when did the symptoms start? Is it an acute, subacute or chronic condition? Was it a slow or sudden onset?
"P" stands for properties of symptoms - What makes your symptoms better or worse?
"Q" stands for quality of symptoms - Type of pain...dull ache, sharp stabbing, shooting, etc...
"R" stands for radiating - Is it local or diffuse?
"S" stands for score - How does the pain rate on a scale from 0-10 where 0 is nothing and 10 is "get me to the emergency room!"
"T" stands for timing of symptoms - Is it constant or intermittent?

Answering these questions during an initial assessment and on subsequent sessions will provide you with a guidance system on whether your client is improving or not.  It will also help you to advise your client on what activities may be beneficial and which are detrimental.