Atypical cases for physiotherapy.

As a primary contact healthcare professional, I see clients who knock on my door without a doctor’s referral.
For example, someone with lateral foot pain may walk into the clinic seeking physiotherapy treatment for it, but it could turn out to be a 5th metatarsal fracture that requires immediate medical attention (cast, perhaps even a surgery if indicated). These conditions that require immediate medical attention (also known to us as red flags) must be screened for, identified and rushed off to the doctor as soon as possible.

This knowledge and skill is important as it will determine how early the client can seek appropriate treatment. Any delay in correct diagnosis may result in poorer or failed healing, which has tremendous consequences to a person’s quality of life.

Over the last 1 year of working in private practice, I have met with a few interesting cases, more than I expected. These episodes will serve as important reminders to myself ( and hopefully, you as a reader too) to keep vigilant and be updated with the latest medical research. I will recall these clinical encounters without disclosing their names for their privacy.

50 year old man with recent episodes of knees buckling while walking with previous history of tennis elbows and rotator cuff repairs

I was treating this young girl who was trying to return to competitive basketball after her 5th metatarsal fracture was fixed about 1 year ago. She casually mentioned that her dad was having problems with his knees recently, and he used to be a very active person who lifts and plays basketball very often.

Assuming it was osteoarthritis-related, I provided simple advice of strengthening and stretching exercises for the knee, knowing that the evidence is strong for physiotherapy prescribed general knee conditioning exercises for osteoarthritis in the knee. Most people do well with a “easy-to-follow” knee conditioning exercises if their osteoarthritis is mild-moderate and I was encouraged that the fact that this man is not new to exercise and he most likely will benefit from an independent home program.

Few weeks later, I learnt that he had consulted an orthopaedic specialist after experiencing sudden buckling of his knees while walking in the community on 2 occasions. It affected him so much that he stopped going out as he was afraid of this happening again. An MRI scan showed that he had meniscal degenerative tears in the knees with all ligaments intact. His spinal MRI scans were clear. This time he was referred for physiotherapy and he came with his family. It was interesting that the orthopaedic doctor would request a spinal MRI for a lower limb problem. This raised my suspicion that this may not be a simple meniscal problem that I will be dealing with…

During the interview, I learnt that he has been inactive for more than 1 year, especially after his bilateral tennis elbow and rotator cuff tears, undergone Platelet-rich-plasma injections to his elbows and rotator cuff repairs a couple of years ago. He recalls that his elbows and his shoulders are still ‘weak’ and the procedures didn’t really help him. He never had painful elbows (that’s the primary complain of tennis elbow). He used to train hard and does alot of resistance training and coaches his daughter in basketball. They are all disappointed that he is not able to return to his former self again. Doing normal activities of daily living is difficult, pouring water out of the kettle is difficult.

This episode of knee buckling happened suddenly while he was walking in the mall and he fell because of that. He just felt like his knees went soft and his thighs ache. There is no pain. Otherwise, he is in good health, he has tremendous family support (the whole family attends physiotherapy, every, single, session).

On physical assessment, he looks like he was still training as his muscle tone throughout the whole body is still evident. Knee looks fine, healthy, full range, no laxity in the ligaments and no signs of injury/inflammation. However, his strength was a big problem: there was poor quadriceps strength, not matching to someone of his age and muscle tone. He had significantly poor active range of the shoulders. He was unable to flex or abduct beyong 80 degress. Significantly weak deltoids, pectoralis, biceps, triceps, wrist extensors, flexors… Something is not right…

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Assessment of his spine and bedside neurological tests does not reveal any problems and I was confident that it wasn’t a spine-related neuropathy. I was happy to strike the spine out of the picture.

Here we have a middle-aged man, with sudden weakness in the lower limbs, especially the quadriceps, and also with upper limb weakness of unknown origin. He is apparently in good health and was a very active person in the past. Is he depressed and anxious about his weakness, thus causing him to lose confidence in his abilities and therefore suffering from physical deconditioning? Although his family believes that this is the problem, I highly doubt so, as the weakness I have found is way more than what can happen to a middle-aged man who is confined to his home who works from home. This man isn’t confined to the bed, yet!

I next looked at his gait of the treadmill. There is slight wide-base gait with early knee locking on heelstrike, but he was afraid of walking especially when I asked if we can go faster. After just 3-4 minutes, he reports of aching in the quadriceps and calves and he really needed to rest. From the treadmill, he had significant difficulty descending.  We next tried the recumbent cycle and after 5 minutes, he was fatigued and he was not able to stand up from the cycle. This was not right…

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As this was the first assessment and insufficient evidence has been found in his investigations to prove anything, I explained that we could work on his muscle strength by application of NMES (neuromuscular electrical stimulation) to hypertrophy weak quadriceps muscles. During the application, I found that the intensity that I had to apply to create sufficent amount of muscle contraction was also more than twice what I use for most of my clients. From here, I suspect it’s a peripheral nerve issue. From my past experience, people with Charcot’s foot have the same problem, they were able to tolerate 3 times the intensity that most people can tolerate because they have peripheral nerve dysfunction. In my mind, I was thinking of all the possibilities of peripheral neuropathy that is widespread, or neuro-degenerative diseases. This is clearly not within my area of expertise…

After we did NMES, I followed-up with some strengthening exercises that he could perform at home independently and safely. It seems like his endurance is not good, after a while, his muscles fatigue and he requires more rest that most of us do… I was patient and informed him to take as long as he needs to recover, which was about 2 minutes per set of exercise.

At the moment, I was happy that he gets to start strengthening but I was not happy that I don’t have a definite diagnosis. Without it, predicting how well he will do in the future with strengthening exercises would be quite difficult. I immediately wrote back to the doctor of the assessment findings and flagged that it could be something else…

Fast forward 1 month later and after a couple of sessions of physiotherapy, there is still no functional improvement despite patient reporting of improvements in strength: walking endurance is still poor, there were no buckling episodes because he was always staying home and avoiding going outdoors. This time, there was more calf tightness. His referring orthopaedic doctor referred him to a neurologist. His resulting investigations (including muscle EMG) suggests that it is likely neurodegenerative disease. Oh no… Prepare for the worse… (remember the ice bucket challenge?)

This family was strong and resilient. They were not happy with just one opinion and on orthopaedic’s advice, they went to NNI (National Neuroscience Institute) for a second opinion. 3 long months on the waiting list.

The final verdict was… Myasthenia Gravis!

His daughter informed me that her dad was doing better with medication, his quality of life improved and he was able to go out more often with his family, and he’s still working out! Attending physiotherapy sessions is not the only time he steps out of the house now! His daughter’s wish is that one day, her dad can return to the court to coach her basketball…

Young healthy 30 year old gentleman with sudden onset of severe knee pain and swelling after cycling 

About July 2015, an ex-classmate in school called me up to ask about knee problems. I learnt that her husband developed severe knee pain and swelling after a session of long distance cycling. As he had severe difficulty moving his knee, he was unable to walk properly and had to use a cane to walk. Although it was a rest day for me on a Wednesday, I offered to see him at short notice.

When they turned up at the clinic, he was limping into the clinic with a cane of one hand. I offered to assist him into the room but he raised his hand to shake my hand, forcing to crack a smile despite his knee problem, while standing. I shook his hand and quickly helped him to lie on the bed. I thought that conducting the interview lying down would be best for him. My friend (his wife) said that he was shouting in pain at home, and this really is him trying to bear with the pain…

What I learnt from him is that, a few days ago, he went for his weekly long distance cycle with his mates, nothing out of the ordinary, and it was uneventful. One day later, the knee started to swell and became painful. At the same time, he also had some fever and he felt generally unwell…

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After interviewing him, I next started to assess his knee. The affected knee was very swollen, red and warm (what we call, an ‘angry looking’ knee). Light movements in the knee was significantly painful. He was unable to walk on it, bend it and he has a fever… coould it be Rheumatoid Arthritis? Very unlikely…

If you can remember, about this time last year, there were rumours in Facebook and friends relaying whatsapp messages about consuming raw freshwater fish and developing life-threatening infection (Group B Streptococcus). I happened to come across one message just one day before I saw this man.

I casually asked him if he had received any of such messages or came across in social media.

He hasn’t heard anything about it, but he recently eaten raw fish with porridge in the hawker centre about one week ago!

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I immediately jumped and informed him that he needs to see a doctor, immediately. If he really has this condition, any delay may be fatal.

I made a call to book him with a doctor immediately and he was seen within an hour.

At the end of the day, his wife informed me that the diagnosis was correct. Fluid extracted from the knee was filled with pus and sent for testing. An operation was done to further clean up the knee, otherwise it may cause joint degeneration with all that infection and even spread of infection. He was lucky that the infection only involved one knee and did not affect other major areas. There were cases of people having limbs amputated and undergoing brain surgery. He was very lucky. After a few days staying in the hospital with antibiotic treatment under the care of an Infectious Disease specialist, he was ready for discharge.

Fast forward 2 weeks later, he was back for post-operative physiotherapy. He was still limping as his knee was stiff and weak, not because it was painful and infected. He was very diligent with his rehabilitation and extremely grateful for the help rendered.

Within 3 months, he was able to resume road cycling and even took his IPPT during reservist!


41 year old lady with acupuncture-related ankle infection

tom dick harry

Z was referred to me with a diagnosis of ankle tendinitis: Tibialis posterior (TP), flexor Digitorum longus (FDL), flexor Hallucis longus (FHL) (mnemonics Tom, Dick & Harry as we learnt in school last time) with delayed healing after an acupuncture-related infection about 4 months ago. She was in an Aircast and wheeled in on a wheelchair.

When she was seen on the first session, she had moderate stiffness and pain in both knees and the Right hip. It was so bad that she could not raise her leg when supine, and she was also wheelchair-bound. She was depending on anti-inflammatory medication, which usually give her ‘almost magical’ relief of her pain and stiffness, so she’s taking 2 to 3 doses a week as required. She claimed that when the effect resolves after 2 to 3 days, the pain and stiffness returns and she has to take her medication again.

Her affected ankle was placed in a removable cast and she was instructed to keep it in cast for a further 3 weeks, so she was mainly moving about in a wheelchair or just limping around. Good thing was that her ankle was pain-free.
When I assessed her knees, they were swollen, warm and stiff on moving. Bending (flexion) was limited to just about 100 degrees. Her ITB were tender on palpation and tight on assessment. On the whole, it appears that there is active synovitis, probably related to mal-adaptive use and deconditioning of lower limb muscles causing cartilage irritation resulting in synovial inflammation. Probably immobilizing of her Right foot contributed to Right hip stiffness from change in walking habit?

At this point, she was very fearful of doing too much as she had a previous encounter of a ‘flare up’ after physiotherapy elsewhere, and she was informed that if her inflammation doesn’t get better, her doctor will have to operate on her. This was a very fearful patient who only dares to put weight on the Right foot in an Aircast, despite having no foot pain.
Treatment was directed to the most disabling areas: the knees and hip. Within 2 weeks, she could do a leg raise in bed, her knee flexion was improved but the frequency of pain and stiffness in the knees were not better.

She also offered that she has a chronically stiff neck and if I can do anything to help her. I was very surprised that her neck was moving so little for a person of her age, so I immediately checked her lower back because I immediately suspected a fused spine. True enough, it was also very stiff! She began to give me some history of her neck problems and stiffness in the shoulders, previous treatments (regular TCM, stretching, massage and yoga) and how she was managing for the last 20 years.

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The first thing that popped into my mind was ‘Ankylosing Spondylitis’, an auto-immune arthritis disorder that primarily affects the sacroiliac joints and gradually affects the entire spine, with the end result a completely fused spine. It being an auto-immune problem, it is highly associated with the presence of this gene “HLA-B27”, with about 95% of people diagnosed with spondyloarthritis testing positive for this gene. However, not everyone with a positive “HLA-B27” test has spondyloarthritis, only about 1 in 15 go on to develop this condition (National Ankylosing Spondylitis Society).

What is spondyloarthritis?

I previously blogged about this condition briefly.

This condition was something I was familiar with as I used to run a physiotherapy service in Autoimmune and Rheumatology Centre (ARC) in SGH treating people with this condition. On further questioning, she seemed to tick the boxes for spondyloarthritis (SpA). Ankylosing spondylitis is just one of the disorders that belong to this group of autoimmune arthritis disorder. The other conditions that fall under this group are:


However, Ankylosing Spondylitis is less likely as her lumbar and sacroiliac joints are not stiff and painful. The symptoms that got me highly suspicious of SpA are:

– history of iritis (inflammation of the iris in the eye)
– bilateral heel pain (plantar fascia or achilles entheses)
– neck, back stiffness and reduced mobility
– peripheral joints synovitis: hip, both knees
– significant relief of joint pain with anti-inflammatory drugs
– movement and exercise helps reduce stiffness and pain

She happens to know about Ankylosing Spondylitis because her ex-husband has that condition but it is under control now. And she confidently said that she tested negative when her eye specialist ordered a HLA-B27 test after she had 7 episodes of iritis in one year.
I informed her that small percentage of people testing negative for HLA-B27 can also develop SpA. After the session, I immediately flagged to her referring doctor and 2 weeks later, her blood test results are positive and she was referred to a rheumatologist, who subsequently confirmed that she has “HLA-B27 positive peripheral Spondyloarthritis”.


After starting medication, her neck mobility improved slightly, her knee pain also got better. She was really happy that she finally got a right diagnosis and she need not undergo ANY surgery as of now. With the reassurance of her rheumatologist, she was also informed that within one month, her condition will be greatly improved.

When she came in to see me last week, she was very grateful for the referral to the rheumatologist. She also mentioned that, on looking back, she now has an answer to all her symptoms tracing back to her 20s, with unexplained neck and multi-joint disabling stiffness. It all makes sense now.

Duration of delay in diagnosis in Z: Almost 20 years.

How can the HLA-B27 test be negative initially but positive now?

This is probably a good article to read about false-negative result in HLA-B27 tests. It seems like it is possible for someone to show different test results on subsequent testing.


Why was a spine MRI not able to diagnosis SpA?

Z hMRI_SpAad MRIs done to the neck and lower back, and both did not report the presence of pathology, except for degenerative discs (normal findings in people of this age group). However, when I looked at the images, I was suprised that I was able to observe ‘bridging’ and ‘shiny corners’ in the vertebral bodies.

I concluded that:

“if you’re not looking for it, you won’t see it.”


(left) an example of MRI and x-ray of a person with Ankylosing Spondylitis (fairly late disease)

How important is it to diagnose SpA early?

We know that on an average, people generally have delayed diagnosis by up to 6 years. That’s 6 years of suffering in silence, not knowing what is wrong and being prescribed with sub-standard medication to manage this often painful and limiting condition.

With early treatment, one can live with less pain, less fatigue, probably slower fusion in joints.

When treatment is late, the joints may already be fused and treatment is not going to be effective in improving mobility. A rheumatologist is still the best person to diagnose this condition in the early stage, before joint fusion happens. Physiotherapy is very important to prescribe the right exercises and intensity.

Typical symptoms of AS include (National Ankylosing Spondylitis Society):

  • Slow or gradual onset of back pain and stiffness over weeks or months, rather than hours or days
  • Early-morning stiffness and pain, wearing off or reducing during the day with exercise
  • Persistence for more than 3 months (as opposed to coming on in short attacks)
  • Feeling better after exercise and worse after rest
  • Weight loss, especially in the early stages
  • Fatigue or tiredness
  • Feeling feverish and experiencing night sweats

Where can I find help for SpA?

If you know of someone who have been suffering from similar symptoms without positive response to medical/physiotherapy treatment, perhaps I can help. With appropriate medication and physiotherapy, one can live with SpA with good quality of life, continue to exercise like run, swim, cycle regularly and live an almost normal life.

Visit the National Ankylosing Spondylitis Association website for more information!

Or Singapore Ankylosing Spondylitis club for more information and activities.

Thank you for reading!


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