SUBJECTIVE ASSESSMENT DEMOGRAPHIC DATA Name: Miss Chua Age: 21 Gender: Female Ethnic group: Chinese Date of assessment: 5/12 Date of admission: 25/11 Doctor's diagnosis: left patellar dislocation Doctor's management: operative (left knee MPFL reconstruction) Relevant investigation: none Chief complaint: - Needs particularly more effort to climb up the stairs with left side - Difficulty in bending the left knee from a fully straight position and bearing weight. This is observed in her decreased confidence in descending the stairs - Feeling of “locking” sensation in her knee while walking - Slight pain and discomfort in stair climbing Patient's aim: - Wishes to climb up the stairs “normally” with lesser effort d/t the environment of her campus - To bear weight upon bending her left knee - To reduce “locking” sensation of her knees in walking Current history: Patient has a history of repeated patellar dislocation of around 4-5 times in the left leg since15 years old. She was sent to Columbia hospital by ambulance after it was dislocated 3 months ago in September while playing badminton. MPFL reconstruction was done soon after and she was then hospitalised for one day before going for rehabilitation at the same hospital, but no progress was seen for knee flexion ROM and lower limb strength even after 2 months. Rehabilitation was then transferred to Tung Shin Hospital for 1 and a half months with significant improvement in knee ROM and strength. Patient has now weaned off from wearing knee brace and is now more confident in walking and using the stairs without crutches Past medical history: none Social history: Occupation: student Marital status: single smoking/ alcohol: none House environment: she lives in an apartment with no stairs Dominant side: Right Premorbid status: independent - ambulation and active in sports Postmorbid status: independent - ambulation OBJECTIVE ASSESSMENT General observation: an alert mesomorphic young adult female walked independently into the department with a stiff gait and reduced arm swing and arms held slightly lateral to midline LOCAL OBSERVATION Specific area: Swelling: none Redness: none Bony deformity: none Scar: 5 healed surgical incisions on the left knee with no keloid formation Skin integrity: normal Wound: none Palpation of specific area: Tenderness: none Oedema: none Redness: none Temperature (left knee): Normal Spasms: none Swelling Mid-patella Right (cm) Left (cm) 41 40.8 Interpretation: no swelling and joint effusion in the left knee as difference with right side is minimal Range of motion (Knee): Moveme nt Left AROM Left PROM Right AROM Right PROM Normal range (AAOS) Flexion 4 - 128 4 - 132 0 - 135 0 - 135 0 - 135° Extensio 128 - 20 n 132 - 6 135 - 0 135 - 0 135 - 0° Interpretation: - There is a reduction in terminal knee extension (quadriceps lag) of 14 degrees in the left leg when compared with left PROM values. This shows that there is reduced muscle strength in the left quadriceps - AROM left knee flexion is short of 4 degrees compared to its PROM values which indicates slight reduction in hamstring strength - PROM for knee extension in the left is short of 6 degrees when compared with normal values which indicates slight tightness of hamstrings in the left leg MMT: Muscle group Left Right Knee extensors 4+/5 5/5 Knee flexors 4+/5 5/5 Hip flexors 5/5 5/5 Interpretation: there is reduction in strength in the left knee extensors and flexors. Normal strength in left hip flexors with reduced strength in knee extensor indicates weakness of other parts of the quadriceps’s muscle besides the rectus femoris (such as the vastus medialis, vastus lateralis, vastus intermedius and vastus medialis oblique). Functional Reach test (Average distance): 33cm Interpretation: Patient has normal dynamic balance Gait analysis: Examination (Left) Stance phase Examination (Right) Stiffness of the left knee More weight shifting to d/t reduction in flexion the right knee upon bearing weight. Swing phase Normal Normal Interpretation: - During the stance phase, there is stiffness of the left knee d/t reduction in flexion upon bearing weight. This may be due to weakness of quadriceps and hamstrings and reduced proprioception in the left knee, hence there is more weight shifting towards the right side with both arms held slightly laterally away from the body for balance. - There is reduced arm swing with arms held slightly lateral to midline for balance 90/90 hamstring test: Result (degrees) Normal range for females (degrees) (Yıldırım et al., 2018) Active knee extension angle (Right) 24.8 >23.4 Passive knee extension angle (Right) 20 >19.2 Active knee extension angle (Left) 18 >19.2 Passive knee extension angle (Left) 19 >23.4 Interpretation: Patient has slight hamstring tightness in the left leg as findings are below the standard values as indicated above End feel: Movement End feel (Left) End feel (Right) Knee extension Firm capsular with slight muscular stretch Firm capsular Knee flexion Soft Soft Interpretation: end feel for both knee extension and flexion are normal which indicates no restriction in passive movement besides muscle tightness THIGH GIRTH Left (cm) Right (cm) Difference (cm) 5 cm above patella upper border 38.5 40.2 1.7 10 cm above patella upper border 39.7 42 1.5 Interpretation: there is reduction in muscle girth in the left thigh region. This shows reduction in the muscle mass of the knee extensors and flexors CALF GIRTH Left (cm) Right (cm) 5 cm below patella lower border 35 39 10 cm below patella lower border 36 38 Interpretation: there is reduction in muscle girth in the left calf region. This shows reduction in the muscle mass of ankle dorsiflexors and plantar flexors, particularly the gastrocnemius ANALYSIS PROBLEM LISTING 1. Reduced strength of the quadriceps 2. Reduced strength of the knee flexors 3. Difficulty extending knee in climbing stairs and flexing the same knee in descending stairs 4. Reduced knee flexion of left knee in stance phase of gait 5. Difficulty and reduced confidence in bearing weight in the left knee 6. Decreased proprioception of left leg 7. Slight hamstring tightness 8. Reduced terminal knee extension by 14 degrees 9. Reduced muscle girth of the thigh circumference left knee extensors and flexors strength of left knee extensors 10. Slight pain in stair-climbing ANALYSIS 1. Difficulty extending left knee in stair climbing with slight discomfort d/t reduced quadriceps strength and hamstring tightness - Reduced quadriceps strength d/t reduced physical activity from slight weakness and pain 2. Difficulty flexing the left knee in descending stairs d/t reduced weight bearing of left knee and fear of fall - Reduced weight bearing of left knee in descending stairs d/t reduced quadricep strength in eccentric contraction and knee flexor weakness, as well as reduced left knee proprioception - Decreased quadriceps and hamstring strength d/t reduced physical activity from slight weakness and pain 3. Reduced knee flexion in stance phase of gait d/t reduced weight bearing of left knee - Reduced weight bearing of left knee d/t reduced quadricep strength in eccentric contraction and knee flexor weakness, as well as reduced left knee proprioception - Decreased quadriceps and hamstring strength d/t reduced physical activity from slight weakness and pain 4. Reduced terminal knee extension by 14 degrees d/t reduced strength of quadriceps and hamstring tightness - Reduced strength of quadriceps d/t reduced physical activity from slight weakness and pain ICF MODEL SHORT TERM GOALS 1. To be able to ascend the stairs by increasing the strength of knee extensors by next week. This is according to the patient’s desire to get around more easily in her campus environment with the start of a new semester. 2. To be able to descend the stairs more easily and safely by increasing balance and weight bearing in her left knee. This is done by increasing strength of left quadriceps and knee flexors and its proprioception 3. To improve gait by increasing left knee flexion in the stance phase. This is done by increasing its weight bearing capacity by increasing left quadriceps and hamstring strength and proprioception 4. Reduce quadricep lag by increasing strength of quadriceps LONG TERM GOALS - To increase walking and stair climbing speed - To increase muscle girth of knee flexors and extensors - To increase dynamic balance and proprioception - To improve ADLs PLAN OF TREATMENT 1. Pain management 2. Strengthening exercises for lower limb, especially on the left quadriceps and knee flexors - According to a meta-analysis by Wang et al. (2023), strength training has been shown to reduce time taken for TUG amd increase 6MWT distance 3. Weight bearing exercises for left knee 4. Balance exercises for lower limb, especially in the left lower limb - According to a meta-analysis by Lu et al. (2019) on balance and proprioceptive exercises on knee joint rehabilitation following knee arthroplasty, it is found that balance, knee joint function and quality of life are improved with these types of exercises 5. Gait training with visual feedback - According to a randomised controlled trial by Zhang et al. (2022), improvement in knee function and motor control in postoperative patients is observed following application of visual feedback training with traditional rehabilitation. 6. treadmill training 7. Stair-climbing training INTERVENTION 1. Ultrasound pulsed for 5 mins, 3MHz, 20% duty cycle for pain management (Munajat et al., 2019) - According to a randomised controlled trial by Alfredo, Junior and Casarotto (2020) on the efficacy of continuous and pulsed ultrasound combined with exercises for knee osteoarthritis, there is significant decrease in pain (p<0.05) in ADLs, mobility and functionality 2. IRQ (10 reps with 10 seconds hold) as a strengthening exercise for quadriceps, especially the VMO 3. Seated knee extension (10 reps with 10 secs hold) as a strengthening exercise for quadriceps 4. Hamstring curls (10 reps with 10 secs hold) as a strengthening exercise for knee flexors 5. Lunges on both legs for strengthening of quadriceps and hamstrings and balance - 10 reps 2 sets with 10 seconds hold for left leg - 10 reps with 10 seconds hold for right leg 6. Balance board to improve balance, proprioception, and strength of lower limb - Anterior and posterior (10 reps with 10 seconds hold) - Side-to-side (10 reps with 10 seconds hold) 7. Step up step down (10 reps with left leg up, right leg step down) as strengthening and weight bearing exercise for left knee - Progression: lateral step up and down with weight bearing on left leg (10 reps, 2 sets) 8. Stair climbing with alternate foot on each step (5 rounds) - Left leg up first, right leg down 9. Gait training with mirror in front for biofeedback - Walking backwards (3 rounds) - According to a study by Shen et al. (2019), walking backwards as a rehabilitation technique has been shown to improve knee proprioception after ACL reconstruction - Walking lunges (3 rounds) as weight bearing and balance exercise 10. Treadmill with incline and decline at 4 mph for 5 mins each EVALUATION - Patient complained that it was difficult to bend and lower the left knee during the lateral step-down exercise - There was slight shaking and swaying in her left knee upon descending the stairs REVIEW - To check strength of ankle plantar flexors and dorsiflexors as observed in its reduced muscle girth. This may also contribute to the lack of balance in her left leg - KIV to check knee hyperextension d/t reduced quadricep strength - KIV to check knee functionality with squats REFERENCES 1. Yıldırım, M.Ş., Tuna, F., Demirbağ Kabayel, D. and Süt, N. (2018). The Cutoff Values for the Diagnosis of Hamstring Shortness and Related Factors. Balkan Medical Journal, 35(5), pp.388–393. doi:https://doi.org/10.4274/balkanmedj.2017.1517. 2. Alfredo, P.P., Junior, W.S. and Casarotto, R.A. (2020). Efficacy of continuous and pulsed therapeutic ultrasound combined with exercises for knee osteoarthritis: a randomized controlled trial. Clinical Rehabilitation, 34(4), pp.480–490. doi:https://doi.org/10.1177/0269215520903786. 3. Lu, Y. and Xu, X. (2019). Effect of proprioceptive and balance training on rehabilitation of knee joint after total knee arthroplasty: a meta-analysis . Chinese Journal of Tissue Engineering Research, 23(16), pp.2601–2607. doi:https://doi.org/10.3969/j.issn.2095-4344.1217. 4. Wang, J., Zhu, R., Xu, X., Liu, S., Li, Z., Guo, C., Tao, X., Liang, Q., Charles, R. and Lei, F. (2023). Effects of strength training on functional ambulation following knee replacement: a systematic review, meta-analysis, and metaregression. Scientific Reports, 13(1). doi:https://doi.org/10.1038/s41598-02337924-1. 5. Zhang, T., Qui, B., Liu, H.J., Xu, J., Xu, D.X., Wang, Z.Y. and Niu, W. (2022). Effects of visual feedback during balance training on knee function and balance ability in postoperative patients after knee fracture: a randomized controlled trial. Journal of Rehabilitation Medicine. doi:https://doi.org/10.2340/jrm.v54.2209. 6. Shen, M., Che, S., Ye, D., Li, Y., Lin, F. and Zhang, Y. (2019). Effects of backward walking on knee proprioception after ACL reconstruction. Physiotherapy Theory and Practice, pp.1–8. doi:https://doi.org/10.1080/09593985.2019.1681040. 7. Munajat, M., Mohd Nordin, N.A., Mohamad Yahya, N.H. and Zulkifly, A.H. (2019). Effects of low-intensity pulsed ultrasound on recovery of physical impairments, functional performance and quality of life after total knee arthroplasty. Medicine, 98(36), p.e17045. doi:https://doi.org/10.1097/md.0000000000017045.
