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I.Problem Demographic InformationInitials – JF Year of Birth – 1960 (56 years old) Education Level - College level Present Condition/Chief ComplaintsPatient presents with pain “behind the knee, and to the side” that is brought on with too much exercise. Patient enjoys walking a 3 mile path, that includes hills, but whenever she participates in this activity, she has knee pain and the “area around the knee” swells up.PMH Patient reports she has hypothyroidism that is medically managed and has no effect on her exercise. Prescription information found in Rx section. PSH Patient reports no past surgical history.Medical Test Results (-) Radiograph of L Knee. Physician ordered an MRI that the patient has not yet scheduled. II.Subjective Current Condition/Chief ComplaintsPatient reports onset of L knee pain in August 2013. Prior to this onset patient reports no history of significant hip, knee or ankle injuries bilaterally. Pain started after going on a run late at night in which she increased the cadence of her run to get home before dark. She did not feel any pain or discomfort during the run, but woke up with swelling and pain described at the L posterolateral Knee. Patient was alarmed by the amount of swelling and went to the ER where she received medical treatment via a (-) radiograph. She takes OTC Ibuprofen for the pain prn. Patient has not had Physical Therapy (PT) treatment. Self-treatment has included rest, ice and ibuprofen. Patient reports that rest and ice have helped to decrease the pain, but it is not a long term relief as pain is continually exacerbated with running, and walking in the park up hills. Patient takes the same path every time she walks, in the same direction. Patient reports current walking shoes are “from last fall” as with the winter weather she has not been as active.Pain is described as “deep” and “aching” slightly superior and posterior to the fibular head. Currently the pain is 2/10, the best the pain gets is 0/10 (with rest) and the worst is 6/10 (after a run or long walk). Patient reports the pain is only made better with rest from exercise and with ice, and that the position (sit, stand, supine, prone) has had no noticeable effect on the pain. Patient reports the pain is made worse with exercise, which the patient objectively defined as walking/running on a 3 mile path with hills, squats and lunges. She avoids these activities to avoid the pain. The patient reports that she is very frustrated with the pain because it is limiting her from exercising the way she would like to. She does not require caregivers so her family has not been affected by this pain/injury. Current Functional Status/Activity LevelPatient reports her level of function in terms of home/work life (day to day functioning) has not changed. She has not noticed a change in her involvement in sports activity or community based activity. She has noticed a decreased in her recreational activity. Her prior level of function was walking/running the 3 mile trail (in the same direction) 4-5 times a week, and now she is not able to run without pain. The patient reports that she has used two different types of bracing to help with the pain. She described a brace similar to a J-Brace, that helped her knee pain but she did not like because it was “bulky, heavy and annoying.” She has also used an “IT Band Strap” that she said she puts right under her patella, and it helps “when she remembers to wear it.” She has not had to use crutches or a cane with this injury. I do not feel she requires any additional bracing/assistive/adaptive devices at this time as the patient is completely independent in all ADL/IADL. Social History Patient reports that she has no cultural/religious beliefs that would affect or be of concern throughout this episode of care. She also describes a great support system to help her with PT exercises and compliance including her husband, two sons and daughter. Employment Status Patient works full time, out of the house in an office setting as an accountant. Her career requires her to sit a lot, and she noted that she tries to get up every 45 minutes – 1 hour to walk down 4 flights of stairs and back. Patient reported that she knows at work she slouches a lot to work on the computer, and sometimes her neck muscles feel very tight/weak because of the position. Living EnvironmentPatient reports her home is a Ranch that has ~3 stairs to get in and out of the house. Inside the house, there are no stairs to the bedroom/bathroom, but she must utilize a full flight of stairs to get to the basement for laundry and recreational purposes. These are no problem and do not cause or exacerbate any of her symptoms. Patient reports she has a long driveway she likes to walk along to get her mail daily, and there are no hills so her symptoms do not occur. General Health Status The patient feels she is generally in “good health” because of her exercise habits (when pain free) and her lack of co-morbidities. She denies any major life changes in the last year. Social/Health Habits Patient reports she drinks alcohol socially – defined as 1-2 drinks per week. She is not a tobacco user. Patient reports exercising 4-5 days per week when pain free. Since the pain has begun she had to decrease the intensity of these walks. She avoids hills and walks slower. She has not ran in ~ 6-8 months. Family Health History Patient denies family history of Stroke, Diabetes, Psychological Conditions, OA/RA or Osteoporosis. Significant family history - Paternal Grandfather had Heart Disease, Dad had Hypertension, and Maternal Grandma had Cancer. Medical/Surgical History (Diagnostic)(-) Knee Radiograph taken August 2013 – day after onset of injury. MedicationsPatient has been prescribed Vitamin D supplements to take 2x/month. She was unsure of the dosage of these pills.Patient takes 112 mg Synthroid every day for hypothyroidism. This is regulated and controlled. Other Clinical Tests Patient recently underwent a Bone Density Scan which found her right hip had decreased density (but not significantly). Patient was prescribed Vitamin D supplements to control this. Patient Goals for PT“Be able to walk more days of the week, without being limited by pain” (Goal 5 days/week). “Decrease the swelling around my knee, that is noticeably different compared to the other side). “Be able to walk/run the 3 mile trail that I enjoy pain free and without swelling the next day by the end of therapy”Examination ObjectiveReview of SystemsSYSTEMS REVIEWMEASUREIMPAIREDNOT IMPAIREDCOMMENTSCARDIOVASCULAR/PULMONARY BLOOD PRESSURE102/70XPULSE RATE68XRESPIRATORY RATE14XEDEMAN/AX No findings grossly, except at L lateral knee joint INTEGUMENTARYPLIABILITY XPRESENCE OF SCAR X SKIN COLOR XSKIN INTEGRITY XMUSCULOSKELETALGAITXSlight weight shift to the R with ambulation ~ 10 feet, Stance time: L<R LOCOMOTION XUses arms to stand from sittingBALANCE XNo reported falls everMOTOR FUNCTION XCOMMUNICATION, AFFECT, COGNITIONCOGNITION XORIENTEDXOx3LEARNING BARRIERS, LEARNING STYLES, EDUCATIONAL NEEDSVISION? XCorrected with contacts. HEARING?XPatient is literate, via preferred learning method of reading. She noted that she likes handouts to take notes on, and for later reference. Patient would like more information regarding the best exercise program to improve her pain and injury as well as information regarding the expected time to heal and return to full exercise. ScreeningLower Quarter Screen DermatomesRLMyotomesRLL1Not ImpairedNot ImpairedL1Not ImpairedNot ImpairedL2Not ImpairedNot ImpairedL2Not ImpairedNot ImpairedL3Not ImpairedNot ImpairedL3Not ImpairedNot ImpairedL4Not ImpairedNot ImpairedL4Not ImpairedNot ImpairedL5Not ImpairedNot ImpairedL5Not ImpairedNot ImpairedS1Not ImpairedNot ImpairedS1Not ImpairedNot ImpairedReflexesRLPatellar/Quad Tendon2+2+Achilles Tendon2+2+*If deemed necessary from historyObservation ExaminationFindingsPosture – Anterior ViewSwelling L Lateral knee, superior to the patella. Bilateral Genu Varum. Posture – SideBilateral hyperextension of knees, L>R. Forward head posture. Slight anterior tilt. Posture – PosteriorIncreased Supination L footGaitSlight weight shift to the R with ambulation ~ 10 feet, Stance time: L<RFMS – SquatKeeps neutral spine to ~110*, feel familiar pain at ~30* knee flexion (where she typically stops)FMS – Picking Something Up Proper mechanics utilized (Bends at knees). Lumbar Lordosis. AreaRLTibial Tuberosity No findings. No findings.Medial Femoral CondyleNo findings.No findings.Medial Joint Line No findings.No findings.Lateral Femoral CondyleNo findings.Familiar pain at the lateral femoral condyle.Lateral Joint Line No findings.“Can feel some pain, but more higher”Fibular Head No findings.“A little pain, more just in the general area”Iliac CrestNo findings.No findings.ASISNo findings.No findings.Popliteal FossaNo findings.“Some pain, worse more in the front” Palpation ROMAROMRLNormsPain?/End FeelPROM**RLPain/Pain Relief?Knee Flexion 120*118*132-141*No findings. Soft End.120*118*Soft end with Knee Extension 2*4*0-10*No findings. Capsular End. 0*-2*No pain. Hip Flexion 140*140*120-125*“sore/tight” Firm End. 140*140*No soreness, still tight.Hip Extension15*17*9-19*No findings. Firm End.Hip ABD41*41*39-46*No findings. Firm End. Hip ADD20*22*12-31*No findings. Soft End (body)Hip IR30*25*32-47*No findings. Firm End. 28*No pain. Hip ER20*20*32-47*No findings. Firm End. *Indicates Degrees **PROM only measured if there is a limitation in AROM or Pain is produced with AROM MMT –Gross Hip and Knee Strength tested with Isometric Break Test in Mid-Range was Normal (5/5) except:L Hip Extension (4+/5)L Hip Abduction (4/5)R Hip Abduction (4/5) Girth MeasurementLocationRLAt Patella37 cm37 cm5 cm Above Patella40 cm41 cm10 cm Above Patella43 cm43 cm5 cm Below Patella33 cm34 cm10 cm Below Patella35 cm34 cmTestReasonRLStats3CommentsLachmann’sRule Out ligament laxity in the knee. (-)(-)63-99% Sensitive42-100% SpecificAnterior DrawerRule Out ligament laxity in the knee.(-)(-)22-95% Sensitive78-97% SpecificPosterior DrawerRule Out ligament laxity in the knee.(-)(-)25-90% Sensitive99% SpecificPosterior Sag SignRule Out ligament laxity in the knee.(-)(-)46-100% Sensitive100% SpecificThesslays – at 20*Rule Out Meniscus involvement. (-)(-)89-92% Sensitive96-97% SpecificValgusRule Out ligament laxity in the knee.(-)(-)89-96% SensitiveVarusRule Out ligament laxity in the knee.(-)(-)25% SensitiveApprehension TestRule Out Patellar Movement Dysfunction/Dyskinesia(-)(-)7-39% Sensitive70-92% Specific FABERDetermine if the Hip is involved in injury. (-)(+)41-89% Sensitive16-100% SpecificFemoral Grind (scour) TestRule Out Labral Tear at Hip. (-)(-)75-91% Sensitive43% Specific Trendelenburg SignDetermine reliability/ consistency in MMT findings. (-)(+)73% Sensitive77% SpecificConsistent with MMT findingsHip DerotationRule Out Trochanteric Bursitis.(-)(-)Ober’s Determine tightness of IT Band. Also a Flexibility Test. (-)(+)(+) with Straight Leg and with Knee Flexion. No pain, but does not fall below level of table. ThomasDetermine tightness of IT Band.Also a Flexibility Test. (-)(-)Noble’s Compression Determine friction/tightness at IT Band. (-)(+)“pressure and familiar feeling” under SPT finger Special Tests – (Examinations to Rule Out – Sensitive, THEN Examinations to Rule In – Specificity) Outcome Measure – LEFS = 84% (16% Disability) AssessmentHypothesized DiagnosesPrimary – Iliotibial Band (ITB) Friction SyndromeThe patient primarily reports pain with activities such as walking and running, that is not present if the patient is inactive. This has been going on for an extended period of time, so the patient is classified as Chronic. IT Band Friction Syndrome is an overuse syndrome that presents with lateral knee pain in people engaging in regular exercise.1 With palpation, the patient was most sore at the Lateral Femoral Condyle and at the Lateral Joint Line. This is consistent with ITB Friction Syndrome.1The patient presented with a posture including forward head, slight anterior tilt and knee hyperextension that was more pronounced on the involved side. From an anterior position, genu varum was noted bilaterally. When performing a Functional Movement Screen with a squat, the patient noted that the familiar pain began at ~ 30* knee flexion, which is also consistent with ITB Friction Syndrome.4Upon examination, the patient presented with full hip flexion AROM, but described the end range as “sore and tight.” Soreness was relieved with PROM, but tightness persisted with a firm end feel. The patient also had weak Hip Extensors and Abductors on the involved side. Special tests ruled out ligamentous and meniscal pathologies of the knee,(-) Lachmann’s, (-) Anterior Drawer, (-) Posterior Drawer, (-) Posterior Sag Sign, (-) Valgus, (-) Varus, (-) Thesally’s and confirmed the ITB Friction Syndrome diagnosis (with (+) Ober and (+) Nobel tests). The weakness in the Hip Extensor and Hip Abductor musculature relate to the patients functional deficits of pain with activities such as walking up hills or running. An inconsistency in my examination findings would be that I did not find a decreased activation or ability of the VMO muscle that typically contributes to ITB Friction Syndrome. Additional testing procedures that would have been helpful during the initial examination include a more thorough walking/gait analysis as well as a running analysis to see how the patients biomechanics change with different activities that cause the pain. I do not feel this patient required referral to additional health care providers at this time. The Step Down Test and Renne Test could also help confirm the diagnosis.4 Finally, I would perform a static balance assessment to determine how the patient performs ankle, knee and hip strategies because the patient likes to walks on hills. Secondary – Lateral Meniscal Pathology/Knee Ligamentous InstabilityThis diagnosis was chosen as a secondary diagnosis because of the pain the patient felt upon lateral joint line palpation.2 The unknown mechanism of injury, without note of trauma, twisting or pivoting did not support this diagnosis.2 The diagnosis was further ruled out because of a (-) Thessaly’s meniscal test. Additionally, the patient denied any feelings of snapping, popping or clicking around the joint. This diagnosis was chosen because the pain was localized to the lateral knee and lateral popliteal fossa area. Additionally, there was edema noted (1-2 cm differences when compared bilaterally) around the joint. I wanted to ensure that I did not miss an underlying cause for the pain and edema, so I performed 6 tests ((-) Lachmann’s, (-) Anterior Drawer, (-) Posterior Drawer, (-) Posterior Sag Sign, (-) Valgus, (-) Varus ) to rule out the surrounding ligaments. I performed these tests first because of the overall high level of sensitivity to rule out respective pathologies.3Tertiary – Hip Trochanteric Bursitis After ruling out the knee joint involvement (ligamentous/meniscal/patellofemoral injuries) I wanted to ensure I did not miss a pathology originating at the hip joint. To do this, I had to consider what pathologies occur at the hip joint, and which have chronic etiologies consistent with my patients signs and symptoms. Knowing the ITBand spans both the Hip and Knee Joint, I felt it was fair to consider Hip Trochanteric Bursitis as a 3rd diagnosis. To rule in Hip Joint involvement (opposed to SI) I used the FABER test, which was (+) for tightness while it did not produce pain. I wanted to rule out faulty structures in the hip joint such as the Labrum, so I performed the Scour/Grind Test which was (-). Finally, to rule out Trochanteric Bursitis I performed the Hip Derotation test which was (-). The corroboration of positive findings (Obers Sign, Noble Compression Test, Point Tender to palpation at the Lateral Femoral Condyle) as well as negative findings (Lachmann’s, Anterior Drawer, Posterior Drawer, Posterior Sag Sign, Valgus/Varus Tests, Thessalys, Patellar Apprehension) lead me to believe the pathology was involved with IT Band Friction Syndrome. Prognosis The patient has a good prognosis for rehabilitation because she is motivated to return to pain free exercise and activity, and she has a great support system in her husband and children. It is predicted that STG #1 (Patient will be able to increase frequency (walking 5 days a week without pain) of exercise) and STG #2 (Patient will have decreased swelling around the knee joint, so it is equal at, above and below the patella bilaterally) can be achieved within 4 weeks. It is predicted that LTG #1 (Patient will be able to walk/run 3 mile trail pain free and without episodes of swelling) will be accomplished by 12 weeks. Factors that could positively influence the patient’s prognosis include her high level of motivation, her steady emotional state and her activity level prior to activity. The only co-morbidity that could negatively affect the patient is if her hypothyroidism began to be uncontrolled. There are no unusual expected outcomes or anticipated goals with this patient. Patient would benefit from ~ 10 PT sessions over 3 months to develop and maintain a HEP, as well as continue to analyze gait and posture with walking and running to ensure the patient is strengthening muscles to improve the ITB Friction Syndrome without compensating other structures. This patient currently does not require referral to other Health Care Providers. Plan of Care Expected OutcomesPatient will be able to walk/run 3 mile trail pain free and without episodes of swelling by 12 weeks. Patient will increase score on LEFS to 100% (0% disability) by 12 weeks. Patient will be able to perform a full squat pain free to facilitate safe lifting of objects as well as safe gym mechanics by 12 weeks. Anticipated GoalsPatient will be able to increase frequency (walking 5 days a week without pain) of exercise by 4 weeks.Patient will have decreased swelling around the knee joint, so it is equal at, above and below the patella bilaterally by 4 weeks. Patient will be able to achieve full AROM Hip Flexion without tightness or soreness by 6 weeks. Patient will increase Hip Extensor and Abductor Strength to 5/5 to decrease the presence of Trendelenburg and to facilitate proper gait mechanics by 8 weeks. Intervention Plan ExerciseDescriptionRationaleProgressionPrescription (Frequency, Intensity, Duration, # Projected Visits +Re-Eval) PicturesPatient Education Teaching patient pain management strategies, education on ice, compression and elevation with swelling. Education on the working in pain free ROM with exercises. Giving patient strategies to manage pain and edema will help patient remain compliant and give her tools if swelling re-occurs. N/A Done on first visit.Re-visit occasionally for patient teach back and understanding. 1-2 Visits.N/AActivity Modification4Teach patient about walking in different directions on different days of the week. Educate on importance of changing footwear every 500 miles. The patient walks in the same direction every day which may be putting undo stress on the involved side. Switching directions may lessen the stresses placed on the joint. N/ADone on first visit.Re-visit occasionally for patient teach back and understanding. 1-2 Visits.N/AIT Band Stretch4Patient standing with uninvolved leg straight and involved leg behind uninvolved. Use arms for balance and support. Lean away from uninvolved side until there is a strong, but pain free stretch felt. (See picture) Stretching out the IT-Band helps to achieve flexibility in the hip joint/IT-Band so there is a foundation to strength train without pain. Increase time stretch is held as tolerated. Start: 3x15 seconds, 3x/dayFinish: 3x30 secondsBefore and after activity. Done at first 2-3 visits.Included in HEP.Re-Eval: Ober’s Test (IT-Band Tightness)49221147700Clam Shells4Patient in sidelying, with neutral pelvis. Knees bent, feet together. Have Patient raise top knee to ~45*, maintaining neutral pelvis. Slowly return to start position. (See picture) IT-Band Friction Syndrome is associated with weak gluteus medius hip strength. Closed chain approaches have been shown to have better results via EMG.4After patient has mastered raising the knee while keeping a neutral spine against gravity, progress to using a resistance band around the legs. Start: light greenProgress as fit. 3 sets of 10-12 reps3x/weekIntensity – gravity or resistance bandDone for 6 visits with increasing difficulty. Included in HEP>Re-eval: Hip Abduction muscle testing, Trendelenburg Test 6540520066000BridgingPatient in hook lying position. Places hands on the ground. Engages a Transverse Abdominis draw in. Lifts bottom up towards the ceiling, while keeping the upper body in a straight line (no sagging in the butt area). Hold position for 5 seconds, slowly returns to start. (See top picture)Exercise facilitates glut max recruitment. Helps to strengthen the hip joint and keep the IT-Band out of the impingement/friction zoneBridging with stability ball under feet (adds proprioception component with keeping the ball under feet) (See middle picture)Further progression to single leg lifts(See bottom picture) 10x5 sec holds3x/day3days/weekIntensity set by performing static (feet on ground) or dynamic (feet on stability ball). Included in HEP with mastery. Done for 10 PT sessions with increasing difficulty. Re-Eval: Hip Extension strength testing. Trendelenburg Test. 2584621442119001660788289300BAPS BoardPatient stands on the board, attempts to hold the position (utilizing proprioception and balance/ correction strategies) to maintain positioning. (See picture) Patient enjoys walking on trails in hills and will be walking over un-even surfaces. The BAPS board is a start to simulating the demands she may face. Utilize distraction while balancing on the board (ex: catching a ball with the UE) to stimulate the multi-tasking that will occur as she walks in the park. 3x30 seconds3x/session Intensity set by performance (including UE is more intense). Done visits 4-10. Not included in HEP for safety concerns. Re-Eval: Romberg Test ScoresTreatment RationaleAs a part of this Intervention Plan, I have decided to use the Clamshell exercise to facilitate Hip Abduction strengthening in a closed chain environment. After performing a search strategy through Cleveland State University’s Article Data base, I found the systematic review “Iliotibial Band Syndrome: Soft Tissue and Biomechanical Factors in Evaluation and Treatment.” 4 This article included many intervention exercises to strengthen the hip musculature to reduce the amount of impingement that occurs with IT Band Friction Syndrome.4 This article looked at various research studies that included interventions for IT-Band Syndrome, utilized an EMG to see how effective each exercise was in specific muscle recruitment. The article found that 60% or greater activation on an EMG as a percentage of maximal voluntary isometric contraction was the requirement to constitute a strengthening exercise.4 The article found that side lying hip abduction exercises (such as a clam shell) had an 81% gluteus medius requirement.4 This means that the exercise facilitates enough muscle fibers specific to the gluteus medius to strengthen the muscle. My patient was found to have generally weak Hip Abduction muscles, found via isometric break tests so I feel this exercise would help to increase the strength in those muscles. Strengthening the weak hip muscles (the patient’s body structure impairments) will help to stabilize the hip joint, decreasing the impingement on the IT-Band. This strengthening combined with patient education and activity modifications as discussed in the intervention plan would allow the patient to resume activity with less pain and swelling at the lateral femoral condyle. Outcome MeasureThe outcome measure I would, and did use, with this patient is the Lower Extremity Functional Scale. I utilized this outcome because it asks about many functional activities that a person does in day to day life, and it is able to show the level at which the patient is functioning, as well as the level of disability/impairment present. At subsequent visits, I would re-administer this outcome measure to see if the patients function was improving. LEFS was administered at the time of evaluation with a score of 84%. ReferencesPantano K. The Hip Joint: Part 1 General Pathologies. Presented at Cleveland State University. Cleveland, Ohio. Presented on Tuesday, March 22, 2016. Pantano K. The Knee Joint: Part 3 Meniscal Injury. Presented at Cleveland State University. Cleveland, Ohio. Presented on Tuesday, April 19, 2016. Wise CH. Orthopaedic Manual Physical Therapy: From Art to Evidence, 1st Edition, FA Davis, Philadelphia, PA., 2015. Baker R, Souza R, Fredericson M. Iliotibial band syndrome: soft tissue and biomechanical factors in evaluation and treatment. PM & R: Journal Of Injury, Function & Rehabilitation [serial online]. June 2011;3(6):550-561 12p. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 29, 2016. ................
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