Transcript of Sbaird 2014 ivr case part 1 v1
- 1. CLINICAL EXCELLENCE NETWORK CASE PRESENTATION Part 1
Evaluation NAME: Steve Baird DATE: 12/18/14 BODY REGION: Distal (R)
Tibia, ankle, foot
- 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Questions?