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Case Studies

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Shared by: qinmei liao
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posted:
10/21/2011
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Case Studies

Therapeutic Modalities

• For Each Case, provide the following:



• List patients problems

• Prioritize

• Set Goals

• Plan treatment

Case #1

• 21 yo, wrestler sustained a left quadriceps

contusion 4 days ago

• Subjective:

– c/o pain, weakness, and stiffness

– Reduction of symptoms following ice

• Objective

– Painful gait 5/10

– Mild localized swelling, no discoloration

– Point tender w/ no temp increase

– PROM 0 – 90; AROM 10 – 90

Case #2

• 25 yo, soccer player suffered an inversion sprain

24 hours ago; c/c inability to FWB w/o pain

• Subjective:

– Pain w/ WB and constant ache, Previous Hx

• Objective:

– Mild limp from lack of push-off during gait

– Mild swelling in lateral ankle and foot

– Point tender over ATF, mild warmth

– Full AROM; 4/10 pain w/ active movement

– Anterior Drawer Test – normal end feel, increased

pain

– MMT: 4/5 EV, 4/5 INV, 4/5 DF, 4+/5 PF

Case #3

• 43 yo patient w/ adhesive capsulitis in L shld for 5

months; improved since start of Ther Ex and Joint Mobs

• Subjective:

– Pain w/ daily activities, 60% function

– Diffuse, intermittent aching sensation in shld

• Objective:

– Pain 4/10

– No point tenderness

– L Shld AROM – ABD 0 – 80, FLX 0 – 100, ER 0 – 15, IR 0 – 20

– Reduced capsular glide (esp. ant and inferiorly)

– Scapular substitution pattern with active movement

Case #4

• 17 yo patient removed from 4 weeks of

long leg cast for Gr III MCL sprain.

Cleared to perform strengthening ex’s and

has no restrictions. Having difficulty

generating a strong quad contraction

• Subjective:

– Skiing injury, immediate dysfunction, unable to walk

– MRI – MCL rupture, small MM tear

– Immobilized at 25 of flexion for 4 weeks

– Hinged brace w/ ROM to tolerance

– WB as tolerated w/ crutches until normal gait

• Objective

– Joint line tenderness at MCL

– Pain rating 3/10

– Minimal effusion; slight thickening at suprapatellar pouch

– Quadriceps atrophy

– AROM 12 – 95

– PROM 5 - 105

Case #5

• Swimmer c/o recurrent shoulder pain,

increased over last 2 weeks. Vague,

aching sensation that somewhat resolves

with ice and rest. Heat application prior to

practice irritates the condition. c/c is pain

late in evening and night. Concerned

about upcoming Olympic Trials

• Subjective:

– Pain in R shoulder, especially during warm-up and

after practice

– Ice and exercise have decreased symptoms over the

past two weeks

• Objective:

– 8/10 at worst, 5/10 w/ activity

– Pain on palpation at posterior aspect of GH jt.

– Full AROM, PROM

– Generalized laxity at GH joint, greatest with anterior

stress

Case #6

• 73 yo retired carpenter had a TKR 15 days ago. Cleared

for rehab. Limit WB to 50% for 4 weeks. c/c is stiffness

• Subjective:

– DJD for 25 years

– Past medical Hx of hypertension, mild cv disease

– Ambulatory and PWB with crutches

• Objective:

– Incision closed and healing well

– Pain 2/10

– Moderate effusion

– Decreased patellar mobility

– Anesthetic area around incision

– AROM 18 – 93

– PROM 4 – 97

• Two weeks later continues to have a 15

active extension lag. Effusion has

decreased. How would you modify your

treatment plan.

Case #7

• 37 yo, mother of 3 is 6 wks s/p R ankle bimalleolar Fx with ORIF.

Short leg cast removed. Primary goal is independent ADL’s.

• Subjective:

– Tripped on stairs and fracture R ankle 6 wks ago

– FWB

– c/o stiffness, aching, and swelling

• Objective:

– Mild pain w/ gait, R foot turns out to accommodate for decreased ROM

– Incisions well healed; skin dry and flaky, no palpable warmth

– Pitting edema on dorsum of foot

– AROM 5 – 22 PF

– PROM 0 – 28 PF



• Insurance will cover 2 visits / week for 3 weeks

Case #8

• 19 yo, college gymnast with Grade I stable

spondylolisthesis has been cleared to

participate to tolerance. She decribes an

“achiness” in her low back before practice,

and “soreness” after practice.

• Subjective:

– Dx with spondy in HS, annual x-rays show no further

slippage

– Increased achiness with sitting for prolonged periods,

symptoms resolve with movement

– Denies radicular symptoms

• Objective:

– Palpable spasm in lumbar paraspinals

– AROM full; increased with extension

– PROM: hip flexion 0 – 110

– Symptoms increase with trunk extension



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