1. 1. CLINICAL EXCELLENCE NETWORK CASE PRESENTATION Part 1 Evaluation NAME: Steve Baird DATE: 12/18/14 BODY REGION: Distal (R) Tibia, ankle, foot
2. 2. Patient Profile: 15 y/o (m) high school student, off-road vehicle riding, Exam date: 11/24/14; Referral Dx: s/p open (R) distal tibia fx; Followed by 3 surgeries taking place Dec. 2013 to Jan. 2014; ring external fixator placement, hard cast, followed by cam boot prescription; WB and activity restrictions ~ 10 months; Recently cleared for FWB without AD, but limited school physical education. Chief complaint: D/T prolonged activity and WB restrictions noted above, was referred for balance and proprioceptive therapy. C/O stiffness, ankle swelling, strength loss , sensory loss over dorsum and lateral edge of foot; Date of Injury: Off-road ATV accident on 12/22/13 Self Reported Scores / Outcome Tools: (FOTO) FOTO score = 55 Mean Score = 52 Fear = 19 Predicted change = 72 Predicted # visits = 12 Predicted length of episode (days) = 51 PATIENT PROFILE
3. 3. BODY DIAGRAM Primary complaint (s) in depth: P1: (Primary) [Distal (R) Tibia, C, V, D, 24 HR NPRS 5/10; Described as sharp pain with stiffness throughout distal tibia area and (R) ankle] P2: (Secondary symptom Dx by MD as resulting s/p surgical repair of P1 region of injury) [Dorsum/lateral side of (R) foot, C,c, S, 24 HR NPRS 4/10; Described as constant lack of sensation superficially over the dorsum and lateral side of (R) foot] Relationship between symptom areas: P1=P2 P1 P2
4. 4. PE Planning JOINTS under area of symptoms Structures which may REFER to area CONTRACTILE structures in the area OTHER structures Distal tibiofibular, talocrural, subtalar, calcaneocuboid, talonavicular, Lisfranc, Cuboid 4-5 metatarsal, metatasal phalangeals, interphalangeals Deep fibular nerve, tibial nerve, superficial fibular nerve, common fibular nerve, posterior tibial artery, medial and lateral plantar nerves, fibular artery, anterior tibial artery, poplietal artery, lumbar nerve roots, deltoid ligament, talofibular ligament tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis longus, fibularis brevis, gastrocnemius, soleus, flexor digitorum longus, flexor hallucis longus Small saphenous vein, posterior tibial vein, anterior tibial vein, achilles tendon, retinaculum I. What areas/structures must be considered a source of symptoms?
5. 5. Early Hypotheses Pre Interview List your primary hypothesis AND at least 5 competing hypotheses in prioritized order: Primary: s/s Post Open Tibial Fx Repair Secondary: Peripheral neuropathy Nerve compression Tarsal tunnel syndrome Infection
6. 6. Symptom Behavior Aggravating and Easing Factors: P1 Aggravating Factors: 1. Prolonged standing for < 45 min (NPRS 5/10), eases in 10 minutes 2. Other WB activities (walking, stairs) - variable to onset and intensity (NPRS 2-4/10), eases in 10 minutes 3. Squatting immediate onset (NPRS 3-4/10), eases in 10 minutes P1 Easing Factors: 1 3 Rest, elevation, ice P2 Aggravating Factors: Unknown P2 Easing Factors: None
7. 7. History Sleep and 24 hour pattern: No difficulty with sleeping. P1 symptom is WB related. Pt. just released for FWB, and after walking 7 laps around school track experienced NPRS 5/10. Duration of current symptoms: Since 12/22/13 (12 mo) Mechanism of injury / current history: Off-road ATV accident causing (R) open distal tibial fx. Progression since onset: Restricted WB and activity while wearing external fixator, then cam boot. Weakness noted, but getting better after removal of cam boot on 11/03/14, and FWB release. Significant prior history: None Previous treatment: No previous therapy
8. 8. Medical History / Co-Morbidities / Review of Symptoms (ROS): Red Flag Screen: Pt. denies any red flags besides numbness in ankle and foot. Yellow Flag Screen: Absent Special Questions: Diagnostic tests / Imaging: Recent X-rays show fully healed fx of (R) distal one-third tibia with excellent alignment. Medications: None PATIENT INTAKE
9. 9. Subjective Asterisks What will you use as your asterisk signs from the history? (Specify for P1, P2, etc) P1: Reduced NPRS from standing and squatting, increased time to onset, time to ease of pain P2: N/A
10. 10. Hypotheses List your primary and competing hypotheses in prioritized order: Primary: s/s Post Open Tibial Fx Repair Secondary: Peripheral neuropathy Nerve compression Tarsal tunnel syndrome What initial hypotheses have you ruled out during history? Musculoskeletal: None Non-musculoskeletal: Infection no indication of increased warmth, TTP, nor red flag systems
11. 11. Clinical Reasoning (S) What is the severity of the condition? Mod: He can function in daily activities with compensation, but recreational activities are still difficult d/t his stated weakness and lack of ROM in his ankle (I) What is the irritability of the condition? Min to Mod: How quickly the sx are aggravated depend on the activity, being able to walk the longest till onset, and only able to squat once (N) What is your primary nature statement of the problem? Musculoskeletal, neuromuscular (S) What is the stage of the disorder: Better; Remodeling (S) What is the current stability of the disorder ? Stable and reproducible with WB activities as noted Element of randomness during restful periods as he notes
12. 12. Planning the PE What will you include to rule in/out your top 3 hypotheses? Primary hypothesis of post (R) tibial fx: No rule out required Secondary hypothesis: 1: Sensory light touch for peripheral neuropathy or nerve root involvement 2: PROM in all ankle planes for nerve compression What items (if any) will you defer for day 1,2,3? Why? 1: Tinels test over the region of the deep peroneal (fibular) nerve for TTS (deferred d/t time constraint in planning for proper testing method and technique)
13. 13. Physical Exam Precautions and/or Contraindications: Slight sensory loss over dorsum and lateral edge of (R) foot Postural Observation: Moderate FHRS, slight antalgic stance on (R) Functional movement analysis (* sign): Bilateral squat: 74 , (P1) NPRS 4/10, observable (R) LE weakness Gait analysis: Limited DF during swing phase, (P1) NPRS 0/10 Step-ups: Knee /ankle instability during ascent/descent, (P1) NPRS 1/10 Quick screening/clearing of additional jt. structures: LB, Hip, Knee AROM & OP Neurological Examination (if indicated): (B) LE light touch sensory comparison slight sensory loss over L5/S1 dermatome; DTR intact ROM: Resting pain: P1: 0/10 P2: 1/10 0 (Ankle AROM) DF PF-9 WNL (Ankle PROM) INV EV 12 20 DF PF INV EV -7 WNL WNL WNL0 0 0
14. 14. Physical Exam Screening Exam: Ankle ROM Palpation : No TTP or numbness noted at distal tibia or ankle; foot numbness and sensation loss indicated by palpation Spinal Segmental and or Joint Restrictions: ROM/joint play of ankle and foot joints Hypomobility of talocrural , subtalar, and Lizfrancs joints Manual Muscle testing: Gross (R) LE (4- to 4+) Muscle Length: (R) SLR (+ for H.S. tightness) ; (R) Thomas Test (+ for iliopsoas and rectus femoris tightness) Motor control: Instability observed during (B) squat and step-up functional tests Special tests: Tinels test deferred
15. 15. Assessment & Plan Primary hypothesis following the PE as well as any competing hypotheses (include contributing and predisposing factors as well): Primary (P1): Sharp pain and stiffness s/p open tibial fx repair Reasoning: Remodeling and healing process; Secondary (P2): Peripheral neuropathy: Possible nerve damage during accident or surgery Nerve compression: D/T remodeling scarring, edema, bone fragment Tarsal tunnel syndrome: Deferred to rule out on Day 2 List your historical and physical exam asterisk items: Historical: Standing Walking Stairs Squatting Physical Exam: Step-ups Squatting
16. 16. Plan of Care Prognosis Pt. is good candidate for flexibility, strengthening, and proprioceptive training. Is expected to make full recovery with possible slight impairments remaining contingent on nerve function recovery. Timeframe for recovery? 10 weeks Frequency & Duration: 2x/week for 6 weeks (initial referral) What are your patient-specific goals for physical therapy? To be able to jog, run, and jump without pain or numbness If your patient is not making progress, at what point will you stop treatment & what will be your plan? Will reassess after 2-3 visits maximum for improvements in squatting and stair climbing function. If no progress, will modify program with focus geared where indicated. What will be your overall management strategy? Flexibility and strengthening of ankle musculature; proprioceptive activities for improved motor control; PROM and joint mobs to address hypomobility
17. 17. Questions?