Physiotherapy Case Studies

Case 1: ACL Injury

Age: 24 Gender: Male

Sustained a twisting knee injury during a football game. Immediate swelling and difficulty weight-bearing. Reports a sensation of instability when pivoting.

1. What is the most sensitive clinical test for an ACL tear?

Lachman’s test is considered the most sensitive because it isolates anterior tibial translation with minimal hamstring interference.

2. What mechanism most commonly causes an ACL injury?

Most ACL injuries are non-contact and occur during pivoting or sudden deceleration, especially in sports.

3. Which structure is typically injured alongside the ACL?

The medial meniscus is frequently injured with ACL tears due to joint instability.

4. What is the primary goal of early ACL rehab?

The early rehab phase focuses on restoring ROM, reducing inflammation, and normalizing gait.

5. Which of the following is a late-phase ACL rehab goal?

Late-phase rehab focuses on return-to-play readiness through sport-specific and high-load training.

6. What muscle group is crucial to strengthen to support the ACL-deficient knee?

The hamstrings resist anterior tibial translation, providing functional support when the ACL is injured.

7. What outcome measure is commonly used in ACL rehabilitation?

The IKDC is a standardized, validated outcome tool used specifically in ACL injury rehab.

8. Which imaging modality is best for diagnosing ACL tears?

MRI provides high-detail soft tissue imaging and is the gold standard for diagnosing ACL tears.

9. What activity is typically contraindicated early post-ACL surgery?

Jogging or any high-impact activity is typically contraindicated in early ACL rehab to prevent graft overload.

10. What is a common long-term complication after ACL reconstruction?

ACL injury and surgery increase the long-term risk of knee osteoarthritis.

Case 2: Rotator Cuff Tear

Age: 58 Gender: Female

Gradual onset of shoulder pain over months, aggravated by overhead activities and sleeping on the affected side. Weakness when lifting arm away from body.

1. What muscle is most commonly torn in a rotator cuff injury?

The supraspinatus tendon is the most commonly involved in rotator cuff tears due to its position and vulnerability under the acromion.

2. What test best identifies a supraspinatus tear?

The Empty Can Test isolates the supraspinatus muscle and is highly indicative when positive.

3. What common complaint suggests a rotator cuff tear over impingement?

Weakness (especially active abduction) is more suggestive of a tear than impingement alone.

4. Which imaging is most definitive for diagnosing a rotator cuff tear?

MRI gives excellent soft tissue detail and is the gold standard for detecting rotator cuff tears.

5. What initial management is appropriate for a partial rotator cuff tear?

Most partial tears are initially treated conservatively with rehab focused on strengthening and reducing impingement.

6. Which muscle is primarily responsible for external rotation?

Infraspinatus and teres minor externally rotate the shoulder; infraspinatus is the primary mover.

7. What is the function of the rotator cuff?

The rotator cuff muscles dynamically stabilize the head of the humerus in the glenoid fossa.

8. What activity should be avoided early in rehab?

Overhead activities place strain on the healing tendon and should be avoided early post-injury.

9. What is the role of corticosteroid injections?

Corticosteroids help reduce inflammation in the subacromial space and can improve pain short-term.

10. What outcome measure is appropriate in shoulder rehab?

The Oxford Shoulder Score is validated and widely used for functional assessment post shoulder injury.

Case 3: Lumbar Disc Herniation

Age: 34 Gender: Male

Developed low back pain after lifting a heavy object. Pain radiates down the right posterior thigh and calf. Positive straight leg raise on examination.

1. What nerve root is most commonly affected in lumbar disc herniation?

The L5 and S1 nerve roots are most commonly affected in disc herniations at L4-L5 and L5-S1 levels.

2. What clinical test is used to detect lumbar radiculopathy?

The Straight Leg Raise test stretches the sciatic nerve and indicates nerve root irritation when positive.

3. What symptom is most typical of a lumbar disc herniation?

Herniated discs compress nerve roots, leading to sciatica — pain radiating down the leg.

4. Which initial management strategy is preferred for lumbar disc herniation?

Conservative management with exercise and education is first-line unless red flags are present.

5. Which movement should be initially avoided during rehab?

Repeated lumbar flexion can exacerbate posterior disc herniation symptoms early in rehab.

6. What red flag symptom necessitates urgent referral?

Saddle anesthesia, bowel/bladder dysfunction, and bilateral sciatica suggest cauda equina syndrome.

7. What imaging modality is preferred to confirm disc herniation?

MRI gives detailed imaging of discs, nerve roots, and soft tissues — the best for confirming herniation.

8. What muscle may show weakness with L5 radiculopathy?

L5 root compression can lead to weakness in great toe extension (extensor hallucis longus).

9. What advice should patients with acute herniation receive?

Gentle movement and remaining active within pain limits promote better recovery compared to bed rest.

10. What is the role of McKenzie therapy?

McKenzie therapy focuses on extension exercises to reduce disc bulge symptoms and centralize pain.

Case 4: Lateral Epicondylitis

Age: 42 Gender: Male

Gradual onset of pain over the lateral elbow following increased tennis playing. Pain worsens with gripping and resisted wrist extension.

1. What muscle is primarily involved in lateral epicondylitis?

ECRB is the primary tendon involved in tennis elbow due to its stress during gripping and wrist extension.

2. What test confirms lateral epicondylitis?

Cozen’s test reproduces pain with resisted wrist extension and is specific to lateral epicondylitis.

3. Which movement typically aggravates symptoms?

Pain is typically reproduced with resisted wrist extension and gripping tasks.

4. What is a typical treatment strategy?

Eccentric strengthening has shown effectiveness in managing tendon overuse injuries like lateral epicondylitis.

5. What tendon attaches at the lateral epicondyle?

The common extensor tendon, particularly ECRB, originates from the lateral epicondyle.

6. What differential should be ruled out?

Radial tunnel syndrome can mimic tennis elbow but involves more diffuse pain and nerve involvement.

7. What is a common functional complaint?

Patients often complain of pain when lifting objects like kettles or briefcases due to gripping.

8. What modality is least likely to be useful in chronic tennis elbow?

Diathermy has limited evidence in chronic tendon injuries compared to eccentric training and shockwave.

9. What is the prognosis of lateral epicondylitis?

Most cases improve with physiotherapy, load management, and time without surgery.

10. What brace can help reduce pain?

A counterforce strap helps reduce strain on the ECRB tendon during activities.

Case 5: Ankle Sprain

Age: 19 Gender: Female

Twisted right ankle during basketball. Experienced immediate swelling and difficulty bearing weight. Tenderness over lateral ligaments.

1. What ligament is most commonly injured in a lateral ankle sprain?

The ATFL is the weakest lateral ligament and is most commonly injured in inversion sprains.

2. Which test assesses the integrity of the ATFL?

The Anterior Drawer Test assesses anterior translation of the talus, indicating ATFL integrity.

3. What grading system is used to classify sprains?

Ankle sprains are typically graded I–III based on severity of ligament damage and functional loss.

4. What is the first priority in acute management?

Initial management follows the PRICE/MICE protocol to reduce swelling and protect tissue.

5. Which phase involves proprioceptive retraining?

Once swelling subsides, rehab should focus on restoring proprioception and dynamic stability.

6. What tool helps assess functional readiness for return to sport?

Functional hop tests assess dynamic stability, power, and confidence for sport return.

7. What is a red flag for a fracture?

Bony tenderness over 5th metatarsal base or navicular may indicate fracture (Ottawa Ankle Rules).

8. What type of brace supports recovery from sprain?

Ankle braces can limit inversion and support recovery while allowing early movement.

9. What muscle group should be strengthened in rehab?

The peroneal muscles (evertors) are key dynamic stabilizers of the ankle joint.

10. What outcome measure is used in ankle rehab?

FAAM is a validated tool to assess function after ankle injuries.

Case 6: Chronic Tendinopathy

Age: 45 Gender: Male

Runner with persistent Achilles tendon pain for over 3 months. Pain worsens with activity but improves after warm-up. Swelling and tenderness over mid-tendon.

1. What describes the underlying pathology of chronic tendinopathy?

Chronic tendinopathy involves collagen disorganization and neovascularization without inflammation.

2. Which loading technique is best supported for tendinopathy rehab?

Eccentric training promotes collagen alignment and tendon remodeling in chronic tendinopathy.

3. Which tendon is most commonly affected in runners?

The Achilles tendon is highly loaded during running and commonly affected in endurance athletes.

4. What symptom pattern is most characteristic?

Tendinopathy typically shows pain at start of activity, easing with warm-up, and worsening post-exercise.

5. What scan is most sensitive for tendon pathology?

Ultrasound is ideal for visualizing tendon thickness, neovascularity, and structural changes.

6. What should be avoided during early rehab?

High-impact activities should be restricted early to avoid tendon overload during healing.

7. Which outcome measure tracks progress in Achilles tendinopathy?

The VISA-A score (Victorian Institute of Sport Assessment-Achilles) is a validated outcome for Achilles tendinopathy.

8. What common mistake delays healing?

Tendons need controlled loading for remodeling — avoiding load entirely can delay healing.

9. What medication is generally avoided in tendinopathy?

Steroid injections may reduce short-term pain but worsen tendon health and increase risk of rupture.

10. What describes tendinosis vs tendinitis?

Tendinosis is a chronic degenerative process, whereas tendinitis refers to acute inflammation.

Case 7: Hip Labral Tear

Age: 29 Gender: Female

Gradual onset of groin pain, worsened by pivoting and prolonged sitting. Occasional clicking and locking of the hip. Positive FADIR test on examination.

1. What is the labrum of the hip?

The labrum is a ring of fibrocartilage that enhances hip joint stability by deepening the acetabulum.

2. Which test is commonly positive in labral tears?

FADIR (flexion, adduction, internal rotation) provokes pain in anterior labral pathology.

3. What is a common cause of labral tears?

FAI leads to abnormal contact between femur and acetabulum, increasing labral stress.

4. What imaging confirms labral pathology?

MR arthrography enhances labrum visualization and is gold standard for labral tear detection.

5. What is the role of physiotherapy?

Physiotherapy targets movement control, muscle balance, and load tolerance to reduce impingement and pain.

6. Which movement aggravates a labral tear?

Combined hip flexion, adduction, and internal rotation compresses the anterior labrum.

7. What long-term complication may arise if untreated?

Continued joint damage from untreated labral tears can accelerate hip cartilage degeneration.

8. What strengthening target is most important?

Stabilizing the hip requires glute medius, minimus, and rotators for load distribution and joint control.

9. What is a sign of intra-articular pathology?

Mechanical symptoms such as clicking or locking suggest intra-articular involvement like labral tear.

10. What does FAI stand for?

FAI describes abnormal contact between femoral head-neck junction and acetabular rim, often leading to labral damage.

Case 8: TFCC Wrist Tear

Age: 32 Gender: Male

Ulnar-sided wrist pain after a fall onto an outstretched hand. Pain worsens with gripping, pronation/supination, and weight bearing on the hand. Tenderness near the ulnar styloid.

1. What does TFCC stand for?

The Triangular Fibrocartilage Complex stabilizes the distal radioulnar joint and cushions the ulnar side of the wrist.

2. Where is pain typically located in TFCC injury?

TFCC tears typically present with ulnar-sided wrist pain and may be tender to palpation at the ulnar styloid.

3. Which mechanism commonly causes TFCC tears?

FOOSH injuries cause compressive and torsional stress on the TFCC, leading to tears.

4. What test is specific for TFCC pathology?

The Ulnar Fovea Sign involves palpation between the ulnar styloid and FCU tendon, eliciting tenderness in TFCC tears.

5. What diagnostic imaging is best for TFCC tears?

MRI arthrography provides detailed images of intra-articular structures like the TFCC.

6. What movement often aggravates TFCC injuries?

Ulnar deviation and combined pronation/supination compress the TFCC and reproduce pain.

7. What structure is adjacent to the TFCC?

The TFCC lies between the distal ulna and carpal bones, cushioning and stabilizing the ulnar side of the wrist.

8. What is the initial management of TFCC injury?

Conservative treatment involves rest, wrist support, and gradual rehab to offload the TFCC.

9. What is a common complication of untreated TFCC tears?

TFCC injuries can result in joint instability, reduced grip strength, and persistent dysfunction.

10. What exercise is helpful during rehab?

Controlled isometric loading helps stimulate tendon recovery while maintaining wrist stability.

Case 9: Frozen Shoulder

Age: 55 Gender: Female

Progressive shoulder stiffness and pain with no clear trauma. Difficulty with overhead tasks and dressing. Limited active and passive ROM. Diabetic history present.

1. What is the medical term for frozen shoulder?

Adhesive capsulitis is the correct term for frozen shoulder, involving capsular thickening and contracture.

2. Which movement is typically most restricted?

External rotation is usually the most limited due to capsular tightness in adhesive capsulitis.

3. Which phase of frozen shoulder is most painful?

The freezing phase is marked by progressive pain and inflammation leading to restriction.

4. What population is most at risk?

Adhesive capsulitis is more common in women aged 40–60, especially with diabetes.

5. What best describes capsular pattern in frozen shoulder?

The classic capsular pattern is greatest loss in external rotation, followed by abduction and internal rotation.

6. What is a key finding on physical exam?

Both active and passive movements are limited due to capsular contracture, distinguishing it from other conditions.

7. Which imaging helps exclude other diagnoses?

Imaging is often normal but helps rule out structural pathology such as rotator cuff tears or arthritis.

8. What is the primary treatment during frozen phase?

Treatment focuses on maintaining available ROM and minimizing pain during the mid-phase.

9. What pharmacological adjunct may assist?

Intra-articular corticosteroid injections may reduce inflammation and improve short-term ROM.

10. What is the natural course of frozen shoulder?

Frozen shoulder often resolves over 1–2 years through three stages: freezing, frozen, and thawing.

Case 10: Osteoarthritis

Age: 67 Gender: Male

Chronic knee pain worsened by walking and stair climbing. Morning stiffness under 30 minutes. Joint crepitus noted. X-ray shows joint space narrowing and osteophytes.

1. What is the primary pathophysiology of osteoarthritis?

OA involves gradual articular cartilage loss and subchondral bone changes.

2. Which joint is most commonly affected in knee osteoarthritis?

The medial compartment of the knee is most commonly affected due to weight-bearing stress.

3. Which of the following is a hallmark X-ray finding in OA?

Classic radiographic signs of OA include joint space narrowing, osteophytes, subchondral sclerosis, and cysts.

4. Which symptom best differentiates OA from inflammatory arthritis?

OA typically causes stiffness lasting less than 30 minutes, unlike inflammatory arthritis.

5. What type of exercise is recommended in OA?

Strengthening and low-impact aerobic exercises improve joint function and reduce pain in OA.

6. What is crepitus?

Crepitus is a clinical sign of cartilage wear and roughened joint surfaces in OA.

7. Which outcome measure assesses knee OA function?

KOOS is validated for assessing knee pain, symptoms, ADLs, sports, and QOL in OA.

8. What non-pharmacological advice is appropriate?

Exercise and weight loss are the cornerstone of conservative OA management.

9. What pharmacological options are recommended first-line?

Simple analgesics and topical NSAIDs are first-line; systemic NSAIDs may follow if needed.

10. What is an indication for joint replacement surgery?

Joint arthroplasty is reserved for end-stage OA with major functional impairment.

Case 11: Hip Bursitis

Age: 60 Gender: Female

Lateral hip pain worsened by lying on the affected side. Tender over the greater trochanter. No groin pain. No limitation in joint movement. Pain with resisted hip abduction.

1. Which bursa is typically inflamed in this condition?

Trochanteric bursitis is the most common form of lateral hip pain.

2. What clinical feature differentiates bursitis from intra-articular hip pathology?

Hip bursitis typically presents with preserved joint ROM but tenderness over the greater trochanter.

3. Which test reproduces pain in trochanteric bursitis?

Resisting abduction while side-lying compresses the trochanteric bursa and reproduces pain.

4. What movement pattern may contribute to bursitis?

Repetitive loading with poor hip control in adduction/IR increases bursal irritation.

5. What muscle group is key in management?

Strengthening gluteus medius and minimus improves pelvic control and reduces bursal load.

6. What is NOT typical of trochanteric bursitis?

Locking and instability are signs of intra-articular or ligamentous pathology, not bursitis.

7. What lifestyle factor is a common risk factor?

Prolonged sitting, poor posture, or repetitive movements can increase bursal compression.

8. What is the role of corticosteroid injection?

Local steroid injections may reduce inflammation in the bursa and improve symptoms temporarily.

9. Which outcome measure tracks functional progress in hip rehab?

The Oxford Hip Score is widely used for assessing pain and function in hip-related disorders.

10. What sleeping position may reduce pain?

Using a pillow between knees and avoiding pressure on the painful side can relieve symptoms overnight.