Examples Using the SNAPPS Model in Clinical Setting with Student SNAPPS Steps Student Response
Instructor Response
1. SUMMARIZE the findings:
A 44-year-old female runner is reporting knee pain after training for a marathon. Her pain began 2 months ago and is located on the lateral aspect of her right knee. Running down hills and walking down stairs makes symptoms worse, while reduced activity makes symptoms better. Lower extremity muscle strength and range of motion are within functional limits and muscle stretch reflexes are normal. The following special tests are negative: McMurray for meniscus, Lockman for ACL tear, Varus testing for lateral collateral ligament damage. You’ve collected good information from the patient and performed a number of appropriate tests and measures that will help us understand what is causing the patient’s pain. I have some additional questions for you to help me understand your thinking: ● Is this patient’s pain acute or chronic? How do you know if the patient’s pain is acute or chronic? This will help us to determine prognosis, appropriate intervention, and to estimate how long it will take for symptoms to improve. ● What type of pain is the patient describing? The type of pain helps to determine what structures are causing the pain. For example, an achy pain typically describes an inflammatory process, a burning or tingling pain is more of a nerve injury, and a sharp pain could indicate bony misalignment.
○ Patient history and physical exam.
2. NARROWS the
It seems like the patient may be having signs and symptoms consistent with a partial lateral meniscus tear, maybe iliotibial band syndrome. I know runners may have this and a lateral collateral ligament strain. Lateral meniscus tear is usually caused by a twisting motion, which this patient didn’t describe as a mechanism of injury, so I am leaning away from this as a possibility. Iliotibial band syndrome is a common condition in runners with lateral knee pain. It would be consistent with an achy type of inflammatory response. Lateral collateral ligament strain is a possibility but upon palpation this ligament wasn’t tender, and I found a negative varus ligament test so I am thinking this is not the problem. Osteoarthritis is another condition to consider given the patient’s age and her past running history of 20 years. I have narrowed down the patient’s problem to either iliotibial band syndrome or osteoarthritis, but I don’t know much about either health condition. In reading more about osteoarthritis, it typically happens with people over 40 years of age, creates stiffness in the joint, particularly when getting up in the morning, and the joint can be warm and tender. A radiograph would help to identify the cartilage damage. Could osteoarthritis cause such pinpoint tenderness over the lateral femoral condyle? Would the patient experience pain just when running or going down hills? What other tests should I perform to confirm iliotibial band syndrome? Since this patient is entering the chronic phase of pain management, I would recommend soft tissue mobilization through foam rolling, hip abductor strengthening, and rest from running. I am going to search the literature for any clinical practice guidelines on iliotibial band syndrome so I can better understand this health condition and know when to suggest stretching versus orthotics versus strengthening.
This is a good starting place in narrowing down what is going on. Are there any other conditions that you might want to consider? The patient is getting older in age and so there could be one other health condition to consider. I agree that a meniscus tear is unlikely. I would ask the patient if she is getting any “catching or popping” when going down stairs to rule out a meniscus tear. What other tests and measures could you perform to confirm or disprove iliotibial band syndrome? What specific muscle strength testing do you want to perform? I also agree that a lateral collateral ligament strain is unlikely given the negative varus ligament test, a lack of acute trauma, and non-tenderness over the tendon during palpation. Osteoarthritis is something else to consider. What are the signs and symptoms of this condition? What additional questions do you want to ask the patient to rule in or rule out osteoarthritis? Osteoarthritis could begin as just symptoms when running since this is a high impact sport. You may want to ask the patient more about stiffness in the morning and any family history of osteoarthritis. You will also want to perform the Ober test bilaterally to determine iliotibial band tightness and isolate hip abduction strength to determine any asymmetries.
differential diagnosis.
3. ANALYZES the
differential diagnosis: ○ Comparing and contrasting the various possibilities.
4. PROBES the instructor:
○ Asks questions to clarify any areas of uncertainty.
5. PLANS patient management.
6. SELECTS case for self- directed learning.
Discuss evidence the learner has found related to iliotibial band syndrome and effectiveness of stretching versus orthotics versus strengthening. Review when these interventions may be appropriate and why.
Note . From Western Schools, 2020.
EliteLearning.com/Physical-Therapy
Book Code: PTCA2622B
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