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.