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Clinical Reasoning Exercise

Clinical reasoning is the process by which the Musculoskeletal Physiotherapist assesses the client's dysfunction. Titled Australasian Musculoskeletal Physiotherapists are trained in the superior clinical reasoning skills required for independent self-directed reasoning. The cognitive and meta-cognitive skills required for clinical reasoning may lead to expertise if applied clinically for at least 10 years. This process not only allows the clinician to recognize their limitations, moreover it empowers the clinician to know how to plug any gaps in their knowledge by either researching a particular topic and/or attending post-graduate training courses (self directed learning). These skills are founded under the umbrella of life long learning (the 3 L's).

The following is an illustration of the process of clinical reasoning using the Maitland approach. Other examples of using clinical reasoning are found in the 'mind maps' section of this site, as well as the 'neurophysiology of treatment of low back pain using mechanical traction' and the presentation on viewing the 'muscles as an organ of the immune system'.

I: Body Chart





Relationships : - # Pain A alone;
#Pain A with i# Pain B
- # Pain B + # Pain D , and C
- can have # Pain D and E without # Pain A
- can have P+N / numbness without # Pain B

From the body chart what is your 'working hypothesis'?

Do you think there is more than one structure involved? Why?

Are there symptoms suggesting referred somatic or radicular pain? What are they?


II : Past History

nil history of Pain A prior to 6/12 ago

past history of Pain B over past 5 years

- onset after lifting a heavy load (~body weight) in a bent over position

- initial injury took 2-3 weeks to subside

- gradually worsening

increased frequency of Pain B (~ 2-3 times per year)

increased intensity of Pain B

takes longer to get better again ( ~ 4-6 weeks vs a few days)

takes less effort/strain for pain B to come on again

quality of pain B has changed from a 'dull ache' to a 'deep ache & throbbing'

past history of Pain C similiar to Pain B

- onset 5 years ago during the incidence of Pain B

- also gradually worsening , however the recurrences are not as frequent as Pain B


Pain D started at a similar time to pain A but is more frequent (almost constant tightness)

Pain E started some 2 years ago - insidious onset / little changed

history of recurrent sprained ankle on left.

unsure of onset of Pins and Needles / Numbness

previous physiotherapy treatment consisted of electrotherapy and massage and some exercises that helped

What information does the past history reveal w.r.t

- the relationships of the pain?
- your 'working hypothesis'?

III : Current History

Pain A commenced 6/12 ago

  • insidious onset that gradually worsened over the past few months
  • started in the bottom of the heel and became greater in area and intensity.
  • mostly constant pain since 2 months
  • had been working a lot in the cold open air at the time of onset
  • 3 week rest from running made little change
  • 12 treatments from a Physiotherapist consisted of massage, ice and a stretching regime - has helped a little but did not last. Recommenced back exercises as Pain B had also been getting worse. Exercises consisted of 'modified' pushups and bring knee to chest whilst lying on back

What information does the current history reveal to help your 'working hypothesis'?

- central pain generating mechanisms? (neurophysiology)

-peripheral pain generating mechanisms? (neurophysiology and anatomical)

History of abuse, overuse, misuse?

Aggravating factors

  • standing on a ladder for 30 minutes -> Pain A 3/10; Pain B 3/10
  • can continue standing on ladder (risk of Pain C and D)
  • standing and moving on ladder for 60 minutes -> Pain A 5/10; Pain B 2/10
  • running 10km, the first few km?s are quite painful (~3/10) then it settles down to ~1/10, unless on uneven ground.

Easing factors

  • After standing on the ladder for 60 minutes must stop activity, whereby Pain A decreases after approx. 30 minutes to 2-3/10. Pain B remains at 2-3/10.
  • Stretching the 'Hamstring muscles' relieves Pain E somewhat.
  • Extension exercises help Pain B, little effect on Pain A during day but good a.m.
  • Brief (~ 5 minutes) icing of the heel helps Pain A when severe
  • NSAIDS help Pain A a little with morning pain and stiffness
  • Repeated or heavy (~10kg overhead) lifting may cause pain B

V : 24 hour behaviour


  • the morning after running 10 km, when getting out of bed-> Pain A 7/10 ; stiff in region of pain B. Occasional Pain E.
  • takes Pain A some 30 - 45 minutes to loosen up using a hot shower and stretches.


  • both Pain A and Pain B can be worse if having spent a lot of the day climbing ladders;
  • frequently Pain D is worse at the end of the day, as are the pins & needles
  • running on even ground in the evening helps Pain B and Pain A after a period of time


  • pain A constant dull ache but better than during the day
  • pain B wakes him occasionally. Unsure whether he wakes due to movement or due to positioning. Takes some 10-15 minutes to sleep again. Prefers to sleep on right side with the left knee up towards chest
  • occasional calf cramps at night
  • no pins and needles at night

What is the "irritability"? why?

What is the "Severity" ? Why?

What is the "Stage" of the disorder ? Why?

What is the "stability" of the disorder? Why?

Is there evidence for inflammation?

  • neurogenic?
  • non neurogenic?
  • adverse neural tension?

How will you measure technique and treatment success?

Special Questions
Weight loss OK; Steroids OK; Corda Equina OK; Cord OK; Xrays NAD; Operations OK; Other jnts; OK Diabeties OK

VI: Physical Examination

Achilles : very tender to palpation, some rubifaction, some swelling, medial and lateral calf tightness

  • : heel raise -> pain A 2/10, dev.inv.

Ankle : lateral instability

  • : small big toe

Detailed information regarding the neuromodulation of pain as it relates to musculoskeletal physiotherapy

more clinical reasoning for the cervical spine-upper quadrant

Updated : 14 November 2012


Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected