STARES 3

SITUATION

In my final week at AMR physiotherapy I was acting as an independent practitioner, seeing my own patients individually. A particular patient I saw, referred to physiotherapy by his school, was a 5 year old boy complaining of knee and hip pain when running and walking. Informally observing his posture and gait, the following was noted; bilateral pronation of the feet, internally rotated hips bilaterally, valgus knees and wide stance. By questioning the mother and son it was evident that the pain was worst with running and had been gradually worsening over the past month. The boy felt his left was sorer than the right and that it was mainly his knees that hurt. On formal examination it was evident his feet were over pronated with complete loss of arch, though he was able to actively achieve one, his knees were in valgus; left greater than right, he had adopted an abnormal gait pattern and there was no evidence of a leg length discrepancy. The mother had been in correspondence with the school in regards to the complaints of pain and teacher had observed the flat foot posture and recommended physiotherapy as an appropriate place to seek advice for treatment. The mother had also done research into flat foot posture in children and had become quite anxious about potential surgical treatments and outcomes.

TASK

My task in this situation was to ascertain the source of the pain by acquiring information from the teacher's referral as well as the young boy and his mother and perform a thorough examination. I was also required to establish the activity limitations and goals to make future treatment as functional and meaningful as possible.

ACTION

On subjective examination, I initially spoke directly to the child, building rapport by asking about school etc. From this I gradually became more specific, asking about what he was experiencing when he ran and exploring his thoughts. From the information I gathered from the boy, I then proceeded to confer these details with his mother and her perspective of his pain. This provided me with valuable information about where the pain was, what aggravated the pain, what had already been done and what the mother felt would help. Using the information I had retrieved, I began my objective assessment. This included postural and gait analysis, as well as specific tests of the knee, hip, ankles and feet. My supervisor assisted me in this element of the assessment, and he performed additional tests he had acquired over his physiotherapy career.

After the examination, we concluded that the main source was the altered foot posture, overly pronating affecting knee and hip alignment. I then instructed the boy through active supination by trying not to squash an egg that he had to keep safe under his foot. This was a game that I showed the mother to continue at home as often as possible.

On speaking with the mother I noticed her anxiety towards the pain her son was experiencing and possible surgical interventions that had been suggested on the internet. I reassured her that considering she had noticed it so early, children can change and adapt rapidly, so with correct input we would be able to make significant improvements. This alleviated some of her anxiety and she left feeling confident that she was on the right path to resolve the issue.

RESULT

As a result of this session, we had a clear understanding of the issue at hand and had a rough plan of our future treatment approach. I had also reassured the mother to reduce her anxiety, which also reduced anxiety in the child.

EVALUATION

In this session I was able to effectively build rapport with the mother and child through effective communication and a good approach. This rapport then translated into the assessment, and the boy was willing and trusting to allow me to do the assessments I needed to do.

My objective examination was less fluid, as I was unsure of which assessments were applicable. I also found it difficult to keep an open mind to any other underlying impairments, as the pronation and altered posture was so obvious.

In this situation I had a few treatment ideas that I had acquired from Notre Dame practical lessons, so was able to instruct the boy on how to perform these and give a few suggestions of running at the beach and wearing thongs as other strategies to encourage altered foot posture.

STRATEGIES

A strategy I found useful was starting the session with general conversation about school and friends to build rapport with the child. It is important that the child feels comfortable with you, especially when you will be asking the child to de-robe and be performing assessments on them. In future I will have a better knowledge of this impairment as I have now seen it presented clinically, so will be able to perform the objective examination in a more efficient and effective manner. Another strategy crucial to a good clinician is keeping an open mind, to discover all underlying impairments and get a whole picture of the patient in front of you rather than putting all presentations to text book as everyone is an individual.