Description: Shortly after commencing this course of
study, I injured my right knee, which necessitated surgery and physiotherapy
thereafter. The attending PT was a
veteran of 21 years’ practice, from whom I learnt a great deal in an unofficial
capacity. During the first session, I
discussed with her my desire to regain my old range of motion and return to
high-performance sport.
Between the
first session and the next, I worked diligently to strengthen my knee and
regain the ability to squat to full knee and hip flexion, which I demonstrated
to her at our next meeting. This elicted
a reaction of mild shock from her, followed by strong caution to avoid training
to such ranges of motion if at all avoidable.
As this was a subject that interested me deeply, I asked her to
elaborate further on her professional opinion and asked her to comment on the
state of current research. Her opinion
was that I was likely to aggravate the knee injury by squatting to such depth. She did admit that she was not up to date on the
state of current research when I asked her to comment on the work of Gray Cook (Cook, et al., 2010), with which she was
unfamiliar.
Feelings: Considering her experience and
seniority in practice, not to mention specialisation in the field of
orthopaedics, I was surprised that the PT was unable to comment further on the
research and had to fall back on professional opinion. It did raise questions for me as to how
thoroughly any one person could feasibly know a given field of practice, the degree of effort it took to stay up to
date with research and how far one could progress in practice on the basis of
fundamental science alone.
Evaluation: Complex as the field of orthopaedics
is, I could not in all fairness expect any one PT – even one as experienced as
her – to be intimately up to date with research for every given aspect of
practice. Furthermore, from
conversations with her, I gathered her patient base rarely if ever fell into
the athletic or highly active category and so had never needed to access such
extreme ranges of motion in loaded knee flexion. Considering
that advice and exercise prescription to avoid squatting past 90˚ of
flexion had sufficed to successfully treat the bulk of her knee patients over
the course of two decades, it would be understandable for her to never have had
a need to further investigate the literature on this topic.
This directing of CPD according to both need and interest was by
no means confined to this one PT, either – the trauma ward PTs I later worked
with were well-versed in acute care and rehabilitation for more frail or
seriously impacted patients, less so in exercise kinesiology for healthier sub-acute
or athletic populations.
Analysis: Having done some research of my own on
the topic at hand, I have concluded that her opinion did indeed have some
evidential basis. Tibiofemoral
and patellofemoral forces reach their peak values during maximal flexion in a
loaded knee. However, whether or not
this is actually injurious is less clear-cut, as, although the menisci
and articular cartilage are certainly under their greatest stress in this
position, no guidelines as to threshold of injury to these structures when
placed under such conditions exist.
Furthermore, knee structures have been found to be highly
constrained at angles of knee flexion
greater than 120˚, actually improving knee stability and tolerance to load at
this range of movement, consequently reducing ACL* and PCL** loading.
In my case, considering the original injury was to the tibial
plateau, the PT was probably right to recommend avoiding squatting deeper than
90
of flexion. On the other hand, considering the
degenerative changes to ligamentous tissue accompanying osteoarthritic joints,
it is possible that there were yet benefits to deep squatting, and so I remain
ambivalent on the issue.
of flexion. On the other hand, considering the
degenerative changes to ligamentous tissue accompanying osteoarthritic joints,
it is possible that there were yet benefits to deep squatting, and so I remain
ambivalent on the issue.
Conclusion
It is humanly impossible to be intimately familiar with the latest
knowledge for every aspect of a given field.
Yet, to choose to specialise in a given field is to hold oneself to a higher
standard of expertise than the average general practitioner, and so submit to
regular and intensive CPD activities to develop and maintain the relevancy of
one’s knowledge and skills in a given area of practice.
*Anterior cruciate ligament
**Posterior cruciate ligament
.
Works Cited
Cook, G. et al., 2010. Movement. Aptos: On
Target Publications.
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