On Tueaday and Wednesday all of my patients except one had fractures or knee conditions such as ACL reconstructions, menisectomy's or TKR's. The other patient I had presented with a typical shoulder impingement, however the reason he had it was so interesting.
He has a condition called Arnold-chiari malformation. It is a condition that causes the brainstem to be elongated and displaced into the opening of the base of the skull and the spinal canal. It occurs in most people with hydrocephaly and spina bifida. It affects not only the brainstem, but also the cranial nerves and the cerebellum. Consequently, anything controlled by the brainstem, cranial nerves or cerebellum can be affected.
Althought he had had surgery 3 years ago to decompress these structures, he still presented with posture control, upper limb weakness and unsteady gait. It was due to his weakness of scapula muscles that he had a secondary impingement.
When I was reading his notes his conditioned was only mentioned twice; in his subjective assessment in the 'past surgery' section, and in his transfer summary from his previous therapist. I therefore didn't consider it a major part of his condition. It wasn't until he walked in that it dawned on that a big part of his therapy would revolve around his condition. I really learnt that co-morbidities should never be ruled out and can always affect your treatment and assessment.
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