STARES #2: Assessment

Situation
My patient, Miss R, was a seventeen year old female with a three month history of severe, intermittent right sided hip pain. She reported that if felt like a stiffness and stinging pain and was associated with clicking and occasionally felt as if it would give way. There were no pins and needles or numbness associated with her hip pain. The pain developed gradually and no history of trauma or precipitating events could be attributed to the onset of the increased intensity. Relevant past medical history included being treated by a physiotherapist for incontinence in 2005 at the age of twelve. Miss R noted that her pain was aggravated by moving from a long sitting or crossed legged sitting position into standing with a sudden onset of pain that took around ten minutes to ease.

Task
My task was to perform an objective examination of this patient following my subjective assessment to identify the source of her symptoms and possible factors contributing to her pain.

Action
I initially looked at the patient’s active range of motion at her hip joint in supine, palpated along the joint line anteriorly and around the greater trochanter to assess for any obvious tenderness on palpation. Whilst still in supine I began performing muscle strength assessment for each direction of movement at the hip. I then performed the hip quadrant and FABERs tests in an attempt to reproduce my patient’s pain. Following this I assessed the muscle length of key muscles acting on the hip including Thomas test, Ober’s and hamstrings (90/90). I then got Miss R to move into prone lying to finish assessing range of motion and strength. Key findings from this assessment were tenderness on palpation around the right anterior hip joint; pain at end of range hip flexion and external rotation, positive FABERs on the right, and reproduction of her worst pain in this position, and reduced muscle length of rectus femoris on the right side. Miss R had full range of movement into all directions and normal muscle strength bilaterally.

Result
The result of this examination was that I was able to reproduce the patient’s pain and identify potential contributing factors; however, I failed to include some key aspects involved in this process. As a result of this I did not have a clear understanding of all factors relating to her pain and had my supervisor not been there to guide me, I would have provided a sub-optimal treatment for this patient.

Evaluation
Although I did include most parts of an objective examination in my assessment of this patient, on reflection there were some obvious areas that required improvement. First and foremost I did not disrobe the patient to expose the area I was assessing. This meant that I was unable to specific when palpating as key landmarks and prominences were not visible. I also did not initially perform quick tests such as looking at gait or her moving from sitting to standing prior to the rest of my assessment. Another area I did not assess was muscle function of key stabilising muscles around the hip. This was even more essential in assessment of this patient due to her history of incontinence secondary to poor pelvic floor and proximal muscle function. Finally I was not confident with the hip special tests and therefore did not include them in my initial assessment. I had intended to revise this area and assess it in my nest session with the patient however it would have been preferable if I knew them well enough to include them in my initial assessment.

Strategies
Following this very average objective assessment I immediately revised key aspects of a physical examination of the hip and went through the hip assessment preform that we had used in our lower limb musculoskeletal unit. I made sure that I was familiar with all aspects of the assessment including optimal positioning and special tests and then practiced the assessment again on another student. As well as this I reviewed anatomy of the hip and hip joint as I did not feel confident in knowing which muscles and ligaments I was palpating where which is essential knowledge to have to perform a thorough assessment. As well as this I wrote up an impairment list and possible treatment options for Miss R and discussed this in depth with my supervisor. I have since done another hip assessment on a patient and felt far more confident in my clinical skills following the revision I did which was prompted by seeing Miss R.