patient case study
TRANSCRIPT
Patient Case Study
PATIENT MBY JOANNE PAULINO
Introduction 48 y.o. male Maintenance worker Active in sports including basketball and weightlifting Cigarette smoker for thirty-five years
One pack per day Non-Compliant
e.g. Ignoring WB, ambulation parameters and ROM restrictions, using machines at gym w/extra weight, raising resistance on Sci-fit to 10
Significant Medical History Essential hypertension Claustrophobic Allergic to pork products and shellfish Right brachial plexopathy:
On September 9th, 2016 patient was diagnosed with Right Brachial Plexopathy due to incorrect use of axillary crutches throughout all his R sided surgeries and PWB status (included Neurological consult on September 9, 2016).
Significant Surgical History Right anterior cruciate ligament repair (7/14/2014)
With trochlea chondroplasty Removal of screw, washer and suture knot of left proximal tibia
Revision of right ACL reconstruction (6/10/2015) With removal of deep hardware
Right medial collateral ligament repair (8/17/2016) Right knee arthroscopy w/debridement of the lateral wall and roof of
intercondylar notch Right posterior oblique ligament reconstruction and MCLR
Left ACLR (and three other surgeries only mentioned in surgeon’s notes w/out dates)
Prescribed Medications Cephalexin, 500mg Ondansetron HCl, 4mg Oxycodone-Acetaminophen, 10-325mg
Mental Status Oriented x 3
Pain 4/10
Physical Therapy Diagnosis Right knee pain s/p right knee medial collateral ligament repair
MobilityInitial Evaluation
9/12/16 Walked up to 25 blocks 2 weeks prior Difficulty w/stairs Antalgic gait w/poor compliance to PWB
w/B crutches Stairs negotiated step to step w/rail and
crutches
Re-evaluation 10/15/16
Ambulates w/out assistive device Mild right circumduction Mild decreased right stance time Stairs negotiated reciprocally w/out
railing
Outcome measuresInitial Evaluation
9/12/16 LEFI score: 32/80
CL 60-79% impaired
Re-evaluation 10/15/16
LEFI score: 36/80 CK 40-59% impaired
ROMInitial Evaluation
9/12/16 L knee= -5-135 R knee ext= 10-90
Re-evaluation 10/15/16
R knee ext= 0 R knee flex (prone):
AROM=100 PROM=122
MMTInitial Evaluation
9/12/16 LLE=5/5 RLE:
Hip flex=4/5 Hip abd=4/5 Knee ext=3/5 Knee flex=3/4 DF=4/5 PF=3/5
Re-evaluation 10/15/16
LLE= RLE:
Hip flex=4+/5 Hip abd= 4/5 Knee ext=4/5 Knee flex=3+/5 DF=5/5 PF= 5/5 (25 heel raises)
Evidence-Based Practice
The patient must be educated as to the importance of optimal home-stretching frequency and duration in addition to mechanical stretch received in the rehabilitation setting.
-Joseph (2012)
Evidence-Based Practice Proximal stabilization is of particular importance…and should be
incorporated from the early postoperative phase until return to sport. The hips, pelvis, lumbar spine, and abdominal musculature are areas of primary focus.
-Mangine et al (2008)
It is important to continuously reinforce proper lumbo-pelvic positioning while avoiding faulty patterns. Abdominal and oblique muscle exercises advancement is paramount.
-Mangine et al (2008)
Interventions PNF contract/relax stretching SciFit Joint mobilizations Scar mobilizations Cryotherapy
Interventions-Static MatCurrent Progress
Donkey kicks Fire hydrant SLR w/bridge Bridging w/legs on physioball
Interventions-Static Standing
Current Single leg stance w/3 sec hold-with
progression SLS w/FW taps (superman)-on plain
floor, then foam Mini wall squats w/add with ball and 3
sec hold
Progress Knee circle w/block (for ankle) TKE w/tband SL squat Plié squat Squat on bosu ball
Interventions-Static Dynamic
Current Step ups/downs w/3” step Mini band walks
Possible progressions Lunge-progress w/ball, on step, and in
reverse Lateral lunge High kicks
Conclusion Due to the patient’s instability, evidenced by his inability to
perform certain standing exercises w/out pain, dynamic exercises are not recommended at this stage.
Furthermore, his consistent non-compliance places him at risk if he were to decide to progress dynamic exercises on his own. The possibility will always exist that he will do things his way and thereby hurt himself again.
Finally, taking into account the many surgeries he has had, four per knee, it is possible that the scarring is presenting issues barring him from progress, and ultimately, complete return to previous levels of function.
Bibliography Joseph, M. F. (2012). Clinical evaluation and rehabilitation
prescription for knee motion loss. Physical Therapy in Sport, 13(2), 57-66. doi:http://dx.doi.org/10.1016/j.ptsp.2011.10.002
Mangine, R. E., Minning, S. J., Eifert-Mangine, M., Colosimo, A. J., & Donlin, M. (2008). Management of the Patient with an ACL/MCL Injured Knee. North American Journal of Sports Physical Therapy : NAJSPT, 3(4), 204–211.