INITIAL EVALUATION

Dx: (L) Foot drop 2° to common peroneal neuropathyPT IE: 8/27/2013 (Jose R. Reyes Memorial Medical Center)Castro Ariel, 52 MSan Andres Bukid, ManilaPhysiatrist: Dr. Inciong

S> AC, a 52 y/o (-) Htn/DM/Asthma ®-handed ♂ was referred for PT eval & mx 2° to c/o weakness of (L) foot & constant aching pain of wound on (L) sole marked 5.4 cm on VAS, that is worse on prolonged walking ~100 m, marked 9.2 cm on VAS. HPI: Pt got his wound 5 yrs ago when a storm struck their house in Pangasinan, scattering bamboo sticks on their lawn. Pt tried to fix their house the whole afternoon & rested during the night. 3 days later, he felt pain on his (L) sole marked 9.2 on VAS & noticed that his (L) ankle & foot was a bit swollen. He discovered a wound on his (L) sole & remembered stepping on a few sticks of bamboo 3 days ago but did not remember feeling pain or anything on his foot. Pt washed his wound with soap & water & took a capsule of mefenamic acid & opened it, applying the powder on his wound thinking that it would ↓ the pain. He was awakened that night d/t the unrelieved pain on his wound; he took mefenamic acid orally & slept; the next morning, the pain ↓ to 3.5 marked on VAS. He continued the same regimen for his wound & was unable to recall how long he took it & never went for MD consult. Pt regularly cleans & applies the powder on his (L) wound & covers it with dry cotton & masking tape. In 2011, the pain worsened to 9.2 on VAS, which prompted him to seek Rx at Region I Medical Center in Dagupan. He was given tetanus shot & was prescribed c Meds for pain, but when he went home, his foot became swollen; pt felt that he was given the wrong injection & never went back to the clinic again. He took the pain Meds a couple of times which ↓ the pain but refrained from using it d/t financial reasons. In 2013, pt’s family moved to Manila & he was noticing that his (L) foot was feeling numb esp when walking. He went to Jose R. Reyes Memorial Medical Center for a consult last July & was prescribed by the dermatology dept c Tretinoin (0.05%) cream for his wound to be applied bid; underwent biopsy during the same month but was unable to show results. Pt was referred for rehab in August 2° to Dx of foot drop 2° to common peroneal neuropathy. Pt was prescribed c Vit. B complex to be taken bid. PMHx: Unable to recall other trauma to the (L) LE. Lifestyle: Pt is a (-) smoker & an occasional alcoholic beverage drinker (2 bottles/wk) & is currently unemployed. Pt chops wood 2x/wk which he uses for cooking. Pt often wears socks & slip-on footwear. Home situation: Pt now lives c his wife & 12 children in a bungalow house in Manila. Bedroom↔front door ~12m, bedroom↔bathroom ~8m. Pt’s goal: Pt wants wound to heal & foot to regain previous strength.

O> VS>a p

BP 120/80 mmHg 120/80 mmHgPR 84 bpm 86 bpmRR 12 cpm 12 cpm

OI> amb s assist. device Ectomorph Alert, coherent, cooperative (+) atrophy of (L) calf (+) swelling of (L) ankle (+) wound on plantar aspect of (L) foot (+) gait deviations (see GA) (-) postural deviations (-) redness on all 4’s (-) trophic skin changes on all 4’s

Palpation > normothermic on all exposed areas Hyperthermic on (L) ankle (+) tightness of (L) plantarflexors & invertors (-) tenderness around wound margins on (L) sole (-) mm spasm/guarding on (L) LE (-) crepitations on (L) LE

ROM > All major joints of (B) UE/LE are WNL, actively & passively done, pain free c (N) endfeels except for:MOTION AROM PROM Endfeel(L) ankle dorsiflexion(L) ankle plantarflexion(L) ankle inversion

0°0°20-30°

20-0-20°20-40°20-40°

FirmFirmFirm

(L) ankle eversion 0° 0-15° Firm

MMT> all major mms of (B) UE/LE are grossly graded 5/5 except: (R) ankle plantarflexors = 4/5 (L) hip flexors = 4/5 (L) knee flexors = 4/5 (L) knee extensors = 4/5 (L) ankle invertors = 2/5 (L) ankle plantarflexors = 2/5 (L) ankle dorsiflexors = 0/5 (L) ankle evertors = 0/5 (L) big toe extensors = 0/5

Wound assessment> 2x2 cm wound on plantar aspect of (L) foot at the area of the midtarsals Wound is covered c cotton fibers that stick on its surfaces Depth N/A

Anthropometric measurements>

Figure-of-8 for ankle swelling:Trials (L) ankle (R) ankle DifferenceTrial 1 58 cm 55 cm 3 cmTrial 2 57 cm 55 cm 2 cmTrial 3 58 cm 54 cm 4 cmAverage 57 cm 54 cm 3 cm

Muscle bulk measurement:Landmark: 3.5 in from medial tibial plateaubulkiest part of leg

Landmarks (L) leg (R) leg Difference2 in ↑ 30 cm 32 cm 2 cmBulkiest part of leg 31.5 cm 33.5 cm 2.5 cm2 in ↓ 27.5 cm 29.5 cm 2 cm

Special tests> (-) Tinel’s sign on (L) ankle (-) SLR 1-4 tests on (L) LE

Pathologic reflex> (-) Babinski sign on (L)

DTRs> Normoreflexive on (L) Achilles tendon

Sensory testing> 100% deficit on (L) distal third of lateral leg, lateral malleolus & dorsum & plantar aspect of foot as to light touch, pain, & pressure (using cotton, pin & PT’s thumb, respectively)

PA> all landmarks are level in ant, post & lat views taken in standing, except: (R) medial arch higher than (L)

GA>Stance phase Swing phase

Hip ↓ (L) hip flex during initial contact ↑ (L) hip flexion throughout swing phaseKnee ↑ (L) knee flexion throughout swing phaseAnkle (L) toes strike first during initial

contact(L) foot slaps towards loading response

(L) ankle PF throughout swing phase

FA> indep in all aspects of ADLs such as bed mobility & transfers Indep in wearing footwear on (L)

A>

PT Dx: MD dx of (L) foot drop 2° to common peroneal neuropathy further defined by difficulty in prolonged walking ~100m 2° to mm weakness & chronic wound on (L) foot

Problem list:

1. Muscle weakness on (L) LE2. Wound on plantar aspect of (L) foot3. Gait deviations4. LOM on (L) ankle motions5. (+) swelling on (L) ankle

LTG> Rehabilitative: Pt will amb on level surface ~100m c AFO on (L) s gait deviations & c healed wound on (L) p 20 PT sessionsPreventive: Pt will be knowledgeable on present condition & proper wound care to promote healing & prevent further complications p 2 PT sessions

STG:1. Pt will demonstrate ↑ in mm strength of (L) hip flexors, knee extensors & flexors, ankle dorsiflexors &

plantarflexors & big toe extensors, & (R) ankle plantarflexors by 1 grade p 1 mo of PT sessions to be able to amb c less difficulty

2. Pt will demonstrate partially healed wound on (L) plantar aspect of foot as manifested by absence of infection p 1 wk of PT sessions to be able to amb c less pain

3. Pt will amb on level surface c proper gait patterns ~50m c AFO on (L) p 1 wk of PT sessions to be able to amb c ease

4. Pt will demonstrate ↑ ROM on (L) ankle dorsiflexion, plantarflexion, inversion & eversion by 10° p 1 wk PT sessions to be able to amb c less difficulty

5. Pt will demonstrate ↓ swelling on (L) ankle by ~2cm p 1 wk of PT sessions to be able to amb c ease

P> Pt will be seen as an OP for 3x/wk for 20 PT sessions c the ff mx:1. UVR using cold quartz ~1in away on wound of (L) sole x 10’ to promote healing2. ES on (L) TAs, gastrocsoleus & peroneals x 10 mins to retard atrophy3. GPS on (L) ankle dorsiflexors, plantarflexors, invertors & evertors x 30SH x 3 sets to ↓ tightness4. FES on (L) invertors & plantarflexors x5. PRE’s on (L) hip flexors, knee flexors & extensors, & (R) plantarflexors using gold theraband x 10 reps x

6SH x 2 sets6.7. Gait retraining c AFO on (L) x 3 rounds to promote proper gait pattern

HEP> 1. GPS on (L) ankle dorsiflexors, plantarflexors, invertors & evertors x 30SH x 3 sets to ↓ tightness2. AAROMs

Pt. education>

1.