Previous Physiotherapy

For Medical Students

What It Tests

Asking about physiotherapy tests whether non-operative treatment has genuinely been tried, which is the question most often answered loosely.

A patient who attended twice and stopped has not had physiotherapy in the sense the decision requires.

It also tests what the symptom responded to, which is diagnostic information as well as treatment history.

How It Is Performed

Ask whether they have had physiotherapy, then ask how many sessions and over how long.

Ask what it involved: exercises, manual treatment, acupuncture, machines, or advice.

Ask whether they were given exercises to do at home, and then ask whether they did them, and how often. This is the question that changes the answer most.

Ask whether anything helped, anything made it worse, and why they stopped.

Ask whether they were discharged, stopped attending, or ran out of appointments, since these are different.

What a Positive Means

A symptom that improved with a loading programme and relapsed on stopping has been diagnosed as well as treated, and the treatment is to resume it.

A symptom unchanged by a properly delivered programme is more likely to be structural, which strengthens a surgical argument.

A programme the patient did not do tells you nothing about the symptom, and the honest next step is to do it rather than to escalate.

A symptom made worse by exercise, particularly loading exercise, raises an inflammatory or a bone cause rather than a mechanical one. 4.2.14 covers the inflammatory pattern.

MRCS Level

What a Positive Means

The reasoning expected is that non-operative treatment is a trial with a result, and the result only counts if the treatment happened.

For patellofemoral pain, a progressive hip and quadriceps programme is the primary treatment and most patients improve, so a failure to improve should first prompt a check of whether the programme was followed. 4.15.9 covers the presentation.

For tendinopathy, progressive loading is the treatment and it takes months, so a six week course is not a failed trial. 4.16.3 covers one version.

For a degenerate knee, exercise improves pain and function and does not change the radiographs, which is worth saying to a patient who expects the second.

For instability, quadriceps rehabilitation changes function substantially and does not change laxity, which is the same distinction. 4.2.2 covers instability.

How Good It Is

This history performs well when asked properly and badly when asked as a yes or no.

The compliance question is the single most informative one and the one most often omitted, because it feels like an accusation and is not.

Duration matters: many of these programmes need months and are abandoned at weeks.

A documented, completed, supervised programme that failed is strong evidence and should be sought rather than assumed.

FRCS Level

How Good It Is

At decision level this history determines whether the non-operative route has been exhausted, which most elective decisions depend on.

A patient who has completed a supervised programme without benefit has a stronger case for surgery, and the history is the only record of it.

A patient who has not is being offered an operation in place of a treatment, which is a worse offer even when it is what they want.

The exception is a mechanical block or a structural injury with a repair window, where waiting for rehabilitation costs the repair. 4.2.5 covers locking.

Saying that the programme has to happen first, with a specific duration and a review date, is a clinical decision and should be recorded as one. 4.1.8 covers the record.

Where It Misleads

The commonest error is accepting failed physiotherapy at face value, which converts an untried treatment into a justification for surgery.

The second is prescribing more of the same when the first programme was wrong rather than insufficient. A patellofemoral problem treated with knee exercises alone and no hip work has not had the right programme.

The third is treating a patient's reluctance as non-compliance when it is a reasonable response to pain during the exercises, which is a reason to change the programme.

And in an elite athlete, physiotherapy has usually been extensive and the history is genuinely a record of failed treatment. 4.23.2 covers elite athletes.

Fellowship Level

Where It Misleads

In referred practice the question is usually whether a further programme is worth trying before a further operation, and the history decides it.

A patient who has had many courses of physiotherapy with no clear programme and no progression has not had a trial, however many sessions are recorded.

A patient who has had a structured, progressed, documented programme delivered by someone familiar with the condition, and has not improved, has had a trial.

The distinction is in the progression rather than the number of sessions, and it is frequently not recorded anywhere. 4.2.34 covers rehabilitation in more detail.

In a multiply operated knee a further programme is often the better option, and framing it as treatment rather than as delay is part of the consultation.

No figure here supports these claims, under decision 023.