This document discusses what happens during a physiotherapy appointment. It begins with choosing a physiotherapist based on their qualifications and experience. A typical initial consultation involves taking a medical history, physical examination, treatment plan, and communication with referrers. Key interventions discussed include exercises, manual therapy, bracing, and strengthening programs. Specific conditions like osteoarthritis, ligament injuries, and meniscal tears are examined in terms of appropriate physiotherapy management.

1. What
Happens
at
the
Physiotherapist
Cameron
Bulluss
Titled
Musculoskeletal
Physiotherapist

2. Choosing
a
Physiotherapist
• Extra
qualifica?ons,
?tles
or
specialisa?on
– Musculoskeletal
– Sports
• Relevant
experience
• Physical
Capacity
of
Physiotherapist
• Communica?on
policy
• Equipment
and
space
• Clinical
approach
– Exercise
and
hands-­‐on
versus
electrotherapy

3. This
talk
• Which
condi?ons
you
should
send
to
physiotherapy
• What
happens
when
you
send
someone

4. When
to
bypass
a
Physio
Ini?ally
• Suspected
fracture
• Tumor
• Major
ligamentous
disrup?on
eg
ACL
(concurrent)
• Neurovascular
signs
and
symptoms
• The
hot
knee
• Possible
slipped
capital
femoral
epiphysis
• Symptoms
dispropor?onate
to
mechanism
• Acute
locked
knee
–
either
loose
body
or
bucket
handle
meniscal
tear
• Extensor
mechanism
disrup?on

5. When
to
send
to
physio
first
• Osteoarthri?s
• Spor?ng/Occupa?onal
Injuries
– Most
Ligament
injuries
– Most
Meniscal
injuries
– Tendinopathies
– Patellofemoral
pain
– Trac?on
apoposysi?s

6. Typical
Ini+al
Consulta+on
(30-­‐60
minutes)
• History
including
medical
history,
meds
etc
• Physical
examina?on
and
measurement
• Explana?on
of
problem,
consent
• Outcome
measures
• Goal
seSng
and
planning
• Interven?on
• Communica?on
with
referrers

7. Knee
Managment
• Exercise
is
main
interven?on
• Also
– Manual
therapy
– Muscle
s?mula?on
– Strapping
– Bracing

8. Interven?ons
Should
Not
Include
• Electrotherapy,
hot
packs
or
icepacks
as
main
interven?on
• Alterna?ve
medicine

9. Osteoarthr?ts

10. Osteoarthri?s
• The
most
common
musculoskeletal
disorder
• The
leading
cause
of
pain
an
disability
in
the
community
• Prevalence
expected
to
double
by
2020
• Will
usually
improve
with
physio
interven?on
(70
-­‐
80%)

11. Age
and
Gender
(MJA
March
2004)

13. OA
effects
the
en?re
synovial
joint
• Ar?cular
Car?lage
• Bone
• Synovium
• Periar?cular
So[
Tissues
• Muscles
• Nerves

14. Subchondral
Bone
• Much
of
the
pain
comes
from
the
subchondral
bone
(Hunter
2009
Radiological
Clinics
North
America
2009
(539
-­‐531)

15. OA
knee
pa?ent
presents
with
• Pain
and
func?onal
loss
• Deformity
• Loss
of
movement
• Muscle
atrophy
• Loss
of
propriocep?on/balance

16. Outcome
Measures
–
Koos
Knee
Survey

17. • If
we
can
improve
– Loss
of
movement
– Muscle
atrophy
– Loss
of
propriocep?on/balance
– BMI
– Load
– Pain
will
reduce
and
func.on
will
improve
70
-­‐
80
%
of
the
.me
– Slow
progression
of
the
disease

18. This
can
only
be
achieved
with
exercise
• Non
impact
–
walking
o[en
not
ideal
• Whole
body
• Cardio
• Balance
• Open
chain
• Minimum
12
week
program

19. Strengthening
• Load
Sharing
Occurs
Between
Joints
and
Muscles
• Muscle
weakness
is
likely
to
be
present
in
knees
with
symptoma<c
Osteoarthri<s.
•
It
is
also
likely
to
be
a
risk
factor
for
the
development
and
progression
of
knee
osteoarthri<s.
(Ann
Intern
Med.
1997)
• Muscle
weakness
is
probably
more
important
in
the
pathogenesis
of
OA
than
wear
and
tear
(Br
J
Sports
Med
2004)

20. Keys
to
Management
Weight
Reduc?on
• For
every
2
units
of
BMI
increase
there
is
a
36%
increase
in
the
risk
of
developing
knee
OA
• For
every
2
units
of
BMI
increase
there
is
a
36%
increase
in
the
risk
of
developing
knee
OA
• BMI>30
there
is
a
20
fold
increased
risk
of
knee
OA
• Body
fat
%
perhaps
more
important
than
BMI
• Inflammatory
proteins
such
as
cytokinenes
may
contribute
to
sensi?sa?on
of
nerve
endings,
• Connec?ve
?ssue
degenera?on

21. Reducing
Load
with
shoes
Brooks
Addic+on

22. Clinical
Guidelines
-­‐
AAOS
Recommenda+on
1
We
suggest
pa?ents
with
symptoma?c
OA
of
the
knee
......incorporate
ac?vity
modifica?ons
(e.g.
walking
instead
of
running;
alterna?ve
ac?vi?es)
into
their
lifestyle.

23. Clinical
Guidelines
-­‐
AAOS
Recommenda+on
3
We
recommend
pa?ents
with
symptoma?c
OA
of
the
knee,
who
are
overweight
(as
defined
by
a
BMI>25),
should
be
encouraged
to
lose
weight
(a
minimum
of
five
percent
(5%)
of
body
weight)

24. Clinical
Guidelines
-­‐
AAOS
Recommenda+on
6
We
suggest
quadriceps
strengthening
for
pa?ents
with
symptoma?c
OA
of
the
knee.

25. Ligament
Injuries

26. Anterior
Cruciate
Ligament
Tears
• Common
• 50%
of
pa?ents
will
have
OA
changes
at
10
years
• Whether
reconstruc?on
is
needed
or
not
Physio
is
useful

27. Acute
Care
• RICE
• Gentle
exercises
to
restore
knee
func?on
• With
isolated
ACL
knee
will
gradually
segle
(6
–
8
weeks)
and
can
feel
normal)
• Pre-­‐opera?ve
Physio
is
crucial
to
– Restore
range
of
mo?on
– Restore
quadriceps
func?on
– And
will
result
in
lower
post
surgical
morbidity

28. Post-­‐opera?ve
Physiotherapy
ACL
Tear
• 6
-­‐12
months
• Approximately
150
rehab
sessions
to
restore
range,
strength
and
neuromuscular
control
of
which
approximately
20
should
be
fully
supervised
• 20
–
30
different
exercises
used
• Must
have
a
gym

29. ACL
PREVENTION
PROGRAMS
• Preven?on
very
important
• Sophis?cated
exercise
programming
– 6
–
12
different
exercises
– Knee
control
when
landing,
and
changing
direc?on

30. Anterior
Cruciate
Ligament
Injury
Preven+on
–
PEP
program
(Santa
Monica
Orthopaedic
and
Sports
Medicine
Research
Founda+on)
• 1041
female
subjects,
RCT
• Results:
During
the
2000
season,
there
was
an
83%
decrease
in
anterior
cruciate
ligament
injury
in
the
enrolled
subjects
compared
to
the
control
group.

31. Collateral
Ligament
Tears
• Medial
Collateral
ligament
is
most
common
• These
do
not
require
reconstruc?on
in
most
cases
and
will
heal
well
with
a
conserva?ve
approach
in
4
–
16
weeks
• Demonstrate
knee
ranger
brace

32. Acute
Meniscal
Tears
Adolescent
• Place
on
crutches
NWB
and
refer
for
immediate
orthopaedic
opinion
• These
are
repairable
in
some
situa?ons
if
seen
early
Adult
• Unless
acute
locked
knee
(indica?ng
bucket
handle
tear)
,
refer
to
Physio
with
concurrent
orthopaedic
referral

33. Degenera?ve
Meniscal
Tears
• Older
pa?ent
(>
45
yo)
• Slow
onset
of
symptoms
• Trial
6
weeks
of
Physio
first
– Strengthening
– BMI/adiposity
op?misa?on
• Menisectomy
followed
by
6-­‐8
weeks
of
exercises
if
conserva?ve
care
fails

34. Patellofemoral
Pain
• Variety
of
causes
• Generally
Physiotherapy
referral
will
suffice
and
treatment
typically
consists
of
– Quadriceps
strengthening
– Stretching
exercises
– Patella
tape
– Biomechanical
correc?on
– Hip
strengthening
– Correc?on
of
spor?ng
technique
– Load
management