case study format for physiotherapy

AMA 11th Edition Citation Style Guide: Sample Case Study Papers in Physical Therapy

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• Sample Case Study Papers in Physical Therapy

Marymount Library Physical Therapy Collection Repository

Physical Therapy students can access the Marymount Physical Therapy Collection Repository sample papers.

Below are two Physical Therapy Case report sample papers that exemplify best practices in writing in AMA style:

• Kinesiophobia and Joint Hypermobility Syndrome - Why Fear of Movement Should Matter to Movement Experts
• Patient Function Versus Time as a Driver for Rehab Progression Following Total Shoulder Arthroplasty
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Standards of Practice: Case Study Template

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Physical Therapy Case Files®: Orthopedics

Author(s): Jason Brumitt; Erin Jobst

• 32 Achilles Tendinosis
• 3 Acute Shoulder Instability
• 6 Adhesive Capsulitis and Diagnosis
• 7 Adhesive Capsulitis and Treatment
• 8 Chronic Cervical Spine Pain
• 12 Degenerative Spondylolisthesis
• 34 Fibromyalgia
• 21 Hip Femoral Acetabular Impingement (FAI)
• 20 Hip Osteoarthritis (OA)
• 22 Iliotibial Band Syndrome
• 25 Knee Anterior Cruciate Ligament (ACL) Sprain: Diagnosis
• 26 Knee Anterior Cruciate Ligament (ACL) Sprain: Nonoperative Management
• 27 Knee Medial Collateral Ligament (MCL) Sprain
• 29 Knee Meniscus Sprain
• 28 Knee Posterior Collateral Ligament (PCL) Sprain
• 11 Lateral Epicondylalgia
• 14 Low Back Pain: Manipulation
• 17 Lumbar Spine: Herniated Disc-Mechanical Diagnosis and Therapy (McKenzie) Approach
• 15 Lumbar Spine: Herniated Disc-Muscle Energy Technique (MET) Approach
• 18 Lumbar Spine: Herniated Disc-Ola Grimsby Approach
• 16 Lumbar Spine: Herniated Disc-Traction Approach
• 31 Medial Tibial Stress Syndrome
• 24 Patellar Tendinopathy
• 23 Patellofemoral Pain Syndrome
• 33 Plantar Fasciitis
• 9 Postsurgical Rehabilitation Status/Post Neck Dissection for Cancer
• 5 Rotator Cuff Repair: Rehabilitation Weeks 1-4
• 2 Shoulder Labral Tear
• 19 Slipped Capital Femoral Epiphysis (SCFE)
• 13 Spondylolisthesis in Young Athlete
• 1 Subacromial Impingement
• 4 Surgical Stabilization for Shoulder Instability: Return-to-Sport Rehabilitation
• 10 Thoracic Spinal Cord Tumor
• 30 Tibial Stress Fracture

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Case Studies

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Case Studies

Please find here a selection of cases we have assessed and treated. We hope this gives you a little more detail and understanding of what we do and how we do it.

Rib pain, Covid 19 / Coronavirus

Rib pain is common following coughing fits. The huge amount of coughing some experience with Covid 19 can lead to rib joint dysfunctions and persistent pain. This patient was in her 40’s and had previously been fit and well, a regular Pilates class attendee and an occasional jogger. Covid 19 knocked her flat. For several weeks she was bedridden, coughing constantly and feeling dreadful. Slowly over 4 weeks, the symptoms reduced and…

Covid 19 Corona Recovery

Each of us will recover at different paces and involve different strategies. If you have spent time in bed or hospital you will be much weaker and less fit than you were. You typically start to lose fitness after a few days of no activity so this has to be taken into consideration. You will find everyday jobs tiring as you didn’t before. Simple things like stairs or just short walks will…

Finger fracture

A rugby player fractured his ring finger whilst making a tackle. The fracture was re-aligned at Accident and Emergency and was splinted for a few weeks. When the splint was removed, he had stiffness and swelling in the finger and was unable to use his hand. He was a self-employed plumber and therefore needed to have a good strong grip. On the assessment of his hand,  it was established that the fracture…

Distal radius fracture (wrist fracture)

A 40-year-old gentleman fell off a ladder backwards onto his right wrist and fractured his distal radius. He is right-handed and works as a carpenter. After a period of immobilisation in a cast, his wrist and hand were very stiff and weak. He was unable to do his job and was concerned as he was self-employed. He presented with very limited movement in his fingers, thumb and wrist and with persistent sub-acute…

Boutonniere deformity of ring finger

This patient was in his late 20’s and presented with a right ring finger stuck in a flexed posture. He had a rugby injury 6 months ago when his finger was caught in someone’s jersey. At the time he thought it was just a sprain so he did not seek medical advice. However, over time he was unable to straighten the finger and it developed a deformity of flexion at the PIPJ…

Thumb arthritis

A 65-year-old lady presented with chronic pain at the base of her right thumb which she described as a constant dull ache and loss of power in her hand. She loves gardening and cooking, however, the pain in her thumb was increasingly interfering with her ability to use her hands. She has tried a variety of pain medication which has not had much effect. She saw her GP and after investigations (x-ray),…

Coronavirus, Ribs and Breathing

Ribs and Breathing If you are recovering from illness or struggling with breathlessness, or even fear, anxiety or panic, learning some simple breathing techniques can really help. It is essential to keep good lung function and breathing patterns to ventilate all the lung to reduce infection by mobilising and clearing the whole of the lung of fluids. Your lungs sit within the protective cage of your ribs, with the diaphragm – the…

Foot Stress Fracture in a Runner

Running involves a lot of aches and pains and it is hard to work out what to be worried about and what not to be. However, the dreaded ache at rest, in a bony area, such as the foot is when alarm bells go off. This club runner, ‘Jess’, had been running well for a few months with nothing more than a bit of soreness on the inside of her left shin…

Shoulder surgery, a personal view

I am Mark Buckingham, one of the Physiotherapists at WPB, and on the 1st April 2019, I had surgery on my left shoulder. The shoulder had been troublesome for over a year, with pain on lifting and overhead work such as gym, throwing or hedge cutting. There was no incident or trauma, just a build-up. Like all of us, I initially ignored it, but then it became more painful, especially after gym…

Golfer’s back pain screening

A 55-year-old gentleman presented for a golf-specific screening to help his assess for any movement issues that could be addressed to help reduce the risk of injury. He explained to me that he played off a handicap of 15 and has experienced some ongoing lower back pain on the left-hand side. He was a right-handed golfer. The pain was intermittent and would come and go but he was more aware of it…

Persistent low back pain

A 48-year-old gentleman presented to our clinic with a long history of low back pain. The pain started after lifting incident at work three years previously. Initially, he had very severe pain in his back and some pain into his right leg and he had to take time off work. He underwent a course of chiropractic and physiotherapy care, local to him, which made some small improvements however his pain remained and…

Low energy / RED-S

Elite middle distance runner – low energy availability and symptoms of RED-S by Cara Sloss Presentation: Female, 22 years, 1.65m, 47kg National level athlete – competing distances 1500m – 5km Moved to university in the past year Training load increased from 55miles – 70miles per week also started strength and conditioning twice a week. Has a supportive coach and this mileage increase was done gradually. Living in a shared house, previously living…

Nutrition through injury

Example based on a female, 46 years, 1.70m, 62kg Club level runner, regularly competing in road, cross country and fell races (up to marathon distance) Trains with a club 2x per week and have weekly mileage of around 50 miles per week Has always thought she has a good knowledge of nutrition and fuelling for her longer races Has a chronic ankle injury which she now requires surgery on which will mean…

Marathon Nutrition

Disclaimer: Case study examples are highly specific to the individual, goals set may not be right for anyone else, even if the presentation sounds similar to you. Individualised nutrition assessment is key! Athlete preparing for Marathon by Cara Sloss Presentation: Male, 49yrs, 86kg, 1.86m Has ‘good for age’ place in London Marathon Works in an office and commutes 1hr each way to work Lives at home with his wife and pre-school children…

Osteoporosis & Fracture

A 55- year old lady injured the middle of her back (thoracic spine) when she had lifted a heavy suitcase down from the garage roof to the floor. At the time she felt a severe and very sharp pain in the middle of her thoracic spine. A few days later she came in for a physio assessment. She described “deep vice like constant pain” in the middle of the spine radiating around…

Bad back and sciatica

This patient was late 30’s with a desk job but tried his best to keep fit with trips to the gym a couple of times a week. This was hard because of the kids and the increasing demands on his time. He knew that his back was tightening up for several months and simple things like putting his socks on were harder as he just didn’t bend well. The issue came just after…

Hernia in a footballer

This patient played Sunday league football and due to a limited training regime was perhaps not as conditioned as he might have been for the enthusiasm he brought to the game. It was during a sprint to try and stop the ball from going for a corner that he felt a pull in his lower tummy on the right. It was not more than a pull and he was able to finish the…

Runner’s Achilles Tendon

The main symptoms were Achilles pain in the morning, struggling to get to the bathroom which took about 30 minutes to settle down and loosen up. It could be sore after being on it for a period of time, However, it was running which was the biggest issue. Very stiff and sore to get going and took a good mile to free up. The patient was limping and was feeling aches in the…

Calf muscle tear

The issue for this patient was not the dramatic sniper shot but a rather dull gradual build-up of tightness in the inside of the left calf muscle. This was related to playing badminton specifically but it had been troubling him whilst walking the dog as well over a few weeks. There was no specific sharp pain but a gradual weakness and ache in the calf as well as a feeling of not…

Gymnast’s Hamstring

The history is of a 12-year-old female gymnast presented with a 4-week history of a painful right posterior thigh. The pain started on the run-up to a vault, towards the end of a 2-hour training session. The patient did not describe immediate pain but rather, once aggravated, she suffered a fairly rapid onset of a deep ache and sharp pain that was made worse the more running/jumping she did. Her symptoms eased after…

Keyboard Wrist Pain

History: The patient had been suffering for several years of hand, wrist and forearm pain on both sides and also some left sided shoulder pain. He is a 40-year-old professional console gamer and writer, both activities involve spending long hours either gaming or typing for various contracts. His pain had been so debilitating he had had to stop taking on new contracts for several months and decided to seek help after accepting…

Chronic Pain – Case Study

In this case study, a 23-year-old male developed Chronic Regional Pain Syndrome (CRPS) after an accident at work. (it can be called Complex regional Pain Syndrome as well.) It started as a  relatively simple strain of numerous tendons in the hand. As is typical with manual workers it is hard for them to take time off to rest the injury. Whilst most issues recover given time, some can develop into a chronic…

Heel Pain – Case Study

My client was a forty two year old lady who had a long history of Plantar Fasciopathy (Plantar Fasciitis as it is often referred to) and was referred to the clinic by her GP. The Plantar facia consists of layers of tough connective tissue that spans the underside of the foot from the toes to the heel and blends with the tendons on the underside of the foot. It contributes to supporting…

Cycling – Fractured hip

This is a case study of a 50-year-old male who was knocked off his bike and fractured his acetabulum (the socket part of the hip). He was training for a triathlon when a car clipped his rear wheel and sent him up in the air. He landed on the pavement with the outside of the hip taking the full force of the impact. An x-ray revealed that the Femoral head (ball) had…

Headache or Migraine

Postural related headache or migraine in the forehead/frontal lobe of the head. A 22 year old female presented with a two month history of Migraines that come on mid-afternoon and then stay with her until she goes to sleep that same night. She had been to see her GP and was prescribed Topamax which is used to help prevent migraines in sufferers. She found this useful, but the dose that was required…

Chest and throat pain

A patient came to see me complaining of chest pain when cycling. He is a 38 year old I.T. Consultant who is a very keen cyclist, particularly time trials. His usual very high level of fitness had been diminished over the previous 6 months and he described a feeling of chronic fatigue.

Total Knee Replacement

A 54-year-old recently retired fire fighter attended for treatment, assessment and advice regarding his long standing knee pain. In the past he had undergone multiple knee joint injections and arthroscopic (Key hole) surgery to repair torn menisci (cartilage) in both knees.

Tennis Elbow – Case Study

This is a case history of a 49 year old lady with a classical tennis elbow. This is a typical presentation at the practice and shows how it is important not to just look at the painful spot. There are often a number of additional problems that have to be dealt with to get a good result. Subjective Pain on the outside of the right elbow with referral to top of shoulder…

Shoulder – Case Study

A 43 year old police officer presented in the clinic with a one week history of right shoulder pain. It is important to undertake a thorough assessment involving questions and physical tests to determine the best way to treat a problem. The patient explained that his pain started when he woke up one morning.  He had also noticed, “a strange feeling” in his middle two fingers that came and went with no…

Neck Pain / Whip-lash

This patient was involved in a road traffic incident in June 2012. The car hit her from behind and she was in the driver’s seat with her seat belt on. As she went to get out of the car, she pushed the door open and noticed a pain in her right shoulder. That night she had pain on undressing and could not put her hand up behind her back. Then after two…

Low Back Pain – a nasty one

This is the case study of a 38- year old fit and healthy gentleman, who presented with an acute onset of severe lower back pain, an extremely common injury that will affect approximately 90% of us at one stage or another in our lives. What follows is a basic account of my management, which demonstrates the importance of a thorough assessment and a close working relationship with local Specialist Surgeons to enable…

Knee injury after skiing

A 47-year-old lady fell whilst skiing, experiencing severe knee pain and swelling and was initially taken to a hospital.  Her knee was x-rayed and she was advised that she had not broken any bones.   On her return, she was seen by an Orthopaedic Consultant and she had an MRI scan to get a more detailed assessment of her injury.  She was found to have ruptured her anterior cruciate ligament (ACL) with a smaller injury to her medial…

History Two months ago this patient slipped whilst at work on a plastic bag. He landed on his left side and twisted his hip at the same time. This was very painful and a lot of bruising came out over the next few days. He could not put any weight on the leg, so he went to have an X-ray at A&E. They reported no fracture around the hip or pelvis. But…

Hip Pain – lateral tendon

Pain on the side of the hip (lateral hip pain) Gluteus medius/minimus tendinopathy A 47-year-old woman presented with right side hip pain (on the outside of the hip). She got the pain with running, walking up hills, lying on the side of pain and crossing her Legs. She stated she had the pain for the last two months. She also stated that she started work in the gym four months ago with…

Back, rib & shoulder pain

This case study involves a 28 year old lady (Ms P) who had a 7 year history of right sided pain half way up her back and under the right shoulder blade.  The pain was not becoming worse or improving but she recently realised that she was fed up with it and wanted to see if anything could be done. She described 2 pains: Pain 1 was a diffuse ache, present most…

Treating Arthritic Joints

Arthritic Joints – “a bit of wear and tear” Pain from stiff and degenerative, “worn” joints, can be quite debilitating and interfere massively with your activities of daily living.

Ankle Sprain

An England under 21 Basketball player sprained his left ankle in March 2012, after landing on an opponent’s foot after a jump shot. His ankle went over and it was very painful.

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Case studies in orthopaedics

CHAPTER SEVEN Case studies in orthopaedics Anne-Marie Hassenkamp, Diane Thomson, Sophia Mavraommatis, Kaye Walls Case study 1: Rotator Cuff Repair 166 Case study 2: Decompression/Discectomy 168 Case study 3: Fractured Neck of Femur 170 Case study 4: Total Knee Arthroplasty/Replacement 172 Case study 5: Anterior Cruciate Ligament Reconstruction 175 Case study 6: Fractured Tibia and Fibula 177 Case study 7: Achilles Tendon Repair 178 Case study 8: Idiopathic Scoliosis 180 Case study 9: Legg–Calvé–Perthes Disease 182 Case study 10: Surgical Intervention for Cerebral Palsy 185 Introduction Orthopaedics is a wide area of practice for physiotherapists and one which we encounter in most settings be it in a hospital (e.g. elective surgery, trauma or disease) or a community setting (e.g. post-operative, injury, secondary issues and long-term musculoskeletal problems). Due to the wide spectrum of orthopaedics the therapist is likely to encounter patients of all ages, from all backgrounds and with various health beliefs. Each one of these factors can have a huge influence on therapy management. Excellent communication and team working skills are essential. The orthopaedic physiotherapist is an integral member of the multidisciplinary team (MDT) and works closely with surgeons. The clinical reasoning and problem-solving approaches used are directed by the medical intervention. Clearly, a good knowledge of what is a normal change and what is a pathological one is of paramount importance. Higgs & Titchen (2000) remind us that knowledge is an essential element for reasoning and decision making, and how both of these are considered central to clinical practice. The therapist working in these settings has to have excellent anatomical, physiological and pathological background knowledge within a framework of an understanding of the psychosocial influences on rehabilitation goals. Atkinson (2005) advises the adoption of the long published movement continuum ( Cott et al 1995 ) as a good framework for orthopaedic reasoning. The changes from the person’s preferred movement capacity (PMC) to their current one (CMC) is the orthopaedic physiotherapist’s frame of reference. The process of getting from one to the other engages the therapist in educational as well as treatment situations which need the collaboration of the patient. Orthopaedic therapy goals therefore have to be patient-centred and collaborative rather than following a prescribed protocol. This makes orthopaedic physiotherapy an ideal training ground in reasoning for the starting professional. The hypothetico-deductive reasoning model ( Elstein et al 1978 ) adopted by junior physiotherapists is particularly well suited to this surgically directed arena as it stems from research in medical reasoning and hence mirrors that of the surgeon in charge of the patient. Pattern recognition ( Higgs & Jones 2000 ) – a sign of the more expert professional – allows for a quick integration into the clinical puzzle of many different pieces virtually simultaneously. Orthopaedic practice is an ideal setting for physiotherapists to become more aware of and more secure in their cognitive skills as well as honing them to expert level. CASE STUDY 1 Rotator cuff repair Subjective assessment PC 50-year-old female admitted for an arthroscopic left rotator cuff repair. The indications for surgery are: large rotator cuff tear demonstrated by MRI pain interfering with work as unable to use arm effectively above 90° night pain waking her 2–3 times per night failed course of conservative treatment including cortisone injection (twice) and physiotherapy over last 4/12 HPC Intermittent shoulder pain for about 18/12 Aggravated by reaching, particularly if sustained or repeated Patient felt excruciating pain while hanging curtains but worked through the pain for the rest of the day Was unable to sleep that night due to severe pain Attended A&E where X-ray showed no abnormality She was referred for physiotherapy which has now been ongoing for several months to no effect GP had given cortisone injections on two occasions which didn’t help Patient was then referred to an orthopaedic surgeon who organized an MRI and diagnosed a full thickness rotator cuff repair. She was listed for surgery SH Self-employed curtain maker. Has employed help for the time she will be off work Lives with husband Smoker Objective assessment Observation Increased thoracic kyphosis in relaxed standing/sitting but is able to actively correct this to a reasonable level Mild forward head posture and protracted shoulders which she can control Cervical and thoracic movements appear fine Pre-operative treatment aims Teach bed exercises for circulation Teach deep breathing exercises to maintain good chest expansion Explain post-operative management and introduce post-operative precautions. This is done with her husband present and it is explained that he will need to help with the exercises post operation Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (for 0–6 week period) Monitor respiratory and circulatory status during immediate post-operative period Protect healing of soft tissues. Maximum protection phase Prevent negative effects of immobilization Monitor and assist in pain control Re-establish scapula stability Encourage good posture Arrange out patient/community physiotherapy as appropriate 1st day post-surgery Breathing exercises are checked looking for basal expansion and clearance of any sputum Patient is mobilised out of bed as soon as able wearing a blow-up abduction pillow She is taught: scapular setting exercises in side lying and sitting, scapula protraction/retraction for proprioception. Full range of neck movements passive external rotation to full range minus 20° for 3/52 in lying. Passive elevation to shoulder level for 3/52. Passive movements are preferably done by a family member or carer. This person will need to be taught this before patient is discharged that at 3/52 both elevation and external rotation can be encouraged into full passive range both in lying and in sitting. Aim for full passive range soon after 6/52 post operation ( Gibson 2007 ) good postural alignment using a mirror in sitting and standing After 6/52 Start weaning from the immobilisation device and use her arm for light use at waist level Increasing ROM in all directions including behind the back Isometric internal and external rotation in neutral can be started to strengthen the cuff Progression to resisted and anti-gravity exercises will be as stability and pain permit Correct postural positioning is important throughout Pain will be monitored and addressed by her GP if necessary Questions 1. What are the rotator cuff muscles and what is their function? 2. The rotator cuff is said to be part of a force couple. What does this mean? 3. The causative mechanisms for rotator cuff disease are divided into intrinsic and extrinsic factors. What are these? 4. Why are we concerned about the scapula position for this patient? 5. Why does this patient need good postural advice? 6. What are the complications of rotator cuff repair and what can be done to minimise the impact of these? 7. What will be included in the discharge planning for this patient? 8. What is the expected long-term outcome for this shoulder? CASE STUDY 2 Decompression/discectomy Subjective assessment PC 36-year-old male architect presents with a prolapsed intervertebral disc (PIVD) and is booked for a spinal decompression (L4/5) the next morning. The aims of surgery are to: decrease pain decompress the spinal nerve improve dural mobility to prevent adverse neural tension prevent or reduce neurological damage HPC History of recurrent back pain (but no leg pain) for many months with an insidious onset 7/52 ago, moved house and a few days later developed severe low back pain radiating into his right buttock and then, a few days later, into his right leg all the way down to his foot He was convinced that rest would alleviate this very sharp pain When this didn’t help, he was offered conservative treatment which also did not improve matters From thinking that he had a back strain he now started to worry that something quite serious was happening He also developed numbness on the outside of his lower leg A review with his consultant resulted in him being booked for surgery Objective assessment Investigations MRI – showed clear protrusion of L4/5 intervertebral disk onto the spinal nerve root and due to the worsening nature of his signs and symptoms it has been decided to decompress his lumbar spine Observation Patient has marked contralateral shift (away from his painful side) Can only sit for a very brief time Marked decrease in straight leg raise on the affected side Abnormal gait pattern of a shortened stride length on the affected side Pre-operative treatment aims Teach him bed exercises for circulation, breathing exercises and log rolling in bed Explain post-operative management and precautions Provide written information of post-operative management Fit him with a temporary lumbar corset Post-operative treatment Read operation report and check for any special instruction by surgeon Check wound if appropriate Reduce anxiety Identify and prevent any post-operative complications Monitor and restore respiratory function Check for any neurological abnormalities Get patient mobilised in his corset once muscular control of quadriceps and gluteus maximus has been demonstrated Educate patient regarding life after discharge: a. Recognition and prevention of complications b. Ergonomic advice c. Self-managed home exercise programme especially core stability and neural stretches ( Shacklock 2005 ) d. Advice on home activities including sitting, driving, working Enhance patient’s self-efficacy in his body Discharge criteria Usually discharged after 2–4 days depending on surgical procedure, wound state, neurological and muscular control Able to get dressed independently Able to use the toilet independently Sit for a minimum of 10 minutes Able to manage stairs Questions 1. What is a slipped disc? 2. What are the classic clinical features of a prolapsed intervertebral disc? 3. What is the differential diagnosis of prolapsed discs? 4. What red flag elicited in an examination of low back pain will need immediate action by a doctor? 5. Why is postural education and exercise important for this patient? 6. What psycho-social problems might influence this patient’s treatment outcome? CASE STUDY 3 Fractured neck of femur Subjective assessment PC 65-year-old very slightly built woman admitted via A&E with fractured neck of femur on the right Once the diagnosis has been confirmed by X-ray she is considered for total hip replacement (THR) The indications for surgery are: reduction of fracture reduction of pain increase of function HPC Patient fell on uneven paving stones in the street and immediately realised that she had ‘broken something’ Was in severe pain, unable to weight bear and had to be admitted to hospital by ambulance SH Lives alone, has a daughter in another city Completely independent and is a retired archivist Objective assessment Observation Her right leg appeared shortened and in external rotation in the A&E department X-ray Confirms fractured neck of femur – Garden classification stage III Pre-operative physiotherapy aims Introduce yourself to patient Find out about her anxieties Explain post-operative regime while still in bed Explain post-operative regime once she has been allowed to mobilise Breathing exercises Explain role of MDT Post-operative physiotherapy aims (rehabilitation starts on 1st day post surgery) Read operation report in notes and look for specific post-operative instructions by surgeon Reduce patient’s anxiety Check for post-operative complications Respiratory check and care as appropriate Start with vascular function maintenance (foot and ankle pumps) Introduce joint movement and muscle tone around the hip especially abduction and flexion, quadriceps and gluteus strength Bed mobility (especially bridging for toilet purposes) Keep abduction wedge when patient lies supine or lies on operated side Education about ‘do’s and don’ts (focussing on joint preservation and weight bearing) Confer with MDT (especially social worker) regarding possible hurdles to discharge (remember, she lives alone) Start mobilising with two crutches (usually by day 2–3 but check with medical colleagues) Reduce walking aid support to one stick (usually by day 4) Discharge usually by day 5 by which time she will need to be able to get in and out of bed on her own, sit to stand without help and manage to walk up and down a flight of stairs Overall aim: to enhance patient’s self-efficacy in her body Questions 1. What is the Garden classification of fractured neck of femur and how does it influence surgical management? 2. Is it typical for a fall to result in such severe injury in an elderly person? 3. What are possible post-operative complications? 4. What actions should the patient avoid until 6 weeks post operatively? 5. How would you start and then progress muscle re-education? 6. What could you do to assist this patient with her possible anxiety? CASE STUDY 4 Total knee arthroplasty/replacement Subjective assessment PC 71-year-old female admitted for an elective right total knee arthroplasty/replacement (TKR). The indications for surgery are: patello-femoral and tibia-femoral osteoarthritis demonstrated on X-ray pain interfering with and day-to-day activities including walking loss of right knee extension night pain failed course of conservative management and physiotherapy HPC Intermittent right knee pain and stiffness for at least 10 years but managed her pain with analgesia and rest Past 2 years pain has become more constant, her standing and walking tolerance has decreased and she is experiencing night pain The patient had one course of physiotherapy which included exercises, manual therapy and hydrotherapy. Therapy improved right knee extension but had no effect on pain Patient was referred by GP to an orthopaedic consultant where X-ray showed patello-femoral and tibial-femoral osteoarthritis The patient was offered an elective TKR PMH Nil of note SH Lives in a house with her husband who is fit and well No downstairs toilet and she does all the cooking and cleaning The patient is originally from Italy and still works in the family restaurant Objective assessment Gait/observation Antalgic gait, predominately weight bearing on her left lower limb Uses a stick on the right side There is a slight right knee varus deformity and a palpable patello-femoral joint crepitus There is no evidence of joint effusion or swelling Functional level Transfers independently in standing, sitting and supine positions Step-to pattern up and down stairs leading with left lower limb ROM Right knee ROM between 10° and 100° flexion All other peripheral upper and lower limb joints have normal range of movement Pre-operative treatment aims Teach bed exercises for circulation Teach deep-breathing exercises Explain post-operative management and introduce post-operative precautions Record right knee range of movement in the medical notes Teach patient to use appropriate walking aids correctly, including stairs Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Discuss with the MDT the patient’s health status and pain relief Assess bed exercises for circulation Assess deep breathing exercises to maintain good chest expansion Control post-operative knee joint swelling Commence knee joint passive and active range of movement according to the surgeons protocol Mobilize the patient according to the surgeons protocol for TKR Post-operative treatment aims (day 3 to discharge date) Discuss with patient and MDT the discharge goals Assess post-operative knee joint swelling Safe progression of all transfers between supine, sitting and standing Gait education with the appropriate use of walking aids Safe progression of stair mobility Progress active range of knee movement to 0–90° Assess the need of post-discharge physiotherapy? Education of the patient to include: a. Prevention of complications b. Self-managed home exercise programme c. Advice on home activity and gradual return to full independence Continuous passive motion machines, slings and springs and sliding boards are often used to increase the range of movement of the operative knee The discharge date is agreed when the patient can mobilise independently with or without walking aids, can mobilise on stairs independently and has achieved 90° degrees knee flexion Questions 1. What are the short-term and long-term goals for this patient and how can the therapist plan the post-discharge rehabilitation programme? 2. What is osteoarthritis? 3. What are the clinical features of osteoarthritis? 4. What can be considered conservative management for knee joint osteoarthritis? 5. Give examples of different types of total knee prosthesis 6. What are the post-operative complications of total knee replacement? CASE STUDY 5 Anterior cruciate ligament reconstruction Subjective assessment PC 35-year-old male is admitted to the ward for an elective left knee anterior cruciate ligament reconstruction (ACLR). The indications of surgery are: left anterior cruciate ligament (ACL) rupture patient is self-employed and he is not responding to conservative management HPC Patient injured his left knee 10/52 ago playing rugby when he fell forwards and sideways while the left foot remained fixed on the ground He felt immediate pain and was unable to continue with the game Pain and swelling increased over the next 2 hours X-rays taken in A&E were negative for fractures He was prescribed anti-inflammatories, referred to physiotherapy, given elbow crutches and advice on ice, rest and elevation A clinic appointment to see an orthopaedic consultant was arranged The patient had a physiotherapy assessment within 5/7 post injury and therapy focused on reduction of swelling and gentle mobility exercises 1/52 post injury the knee swelling had not reduced and the patient was still unable to weight bear on his left lower limb Soft tissue injury was difficult to assess and an urgent MRI scan was arranged which showed rupture of the left ACL and a medial collateral ligament tear The orthopaedic surgeon discussed conservative and surgical options and the patient consented to surgery as one of his main concerns was the physical requirements of his job and that he was self-employed SH Self-employed carpenter Married with two young children Plays rugby twice a week with friends and he is otherwise fit and well Objective assessment Observation Patient partially weight bearing with elbow crutches Slight muscle wasting of the left quadriceps muscles compared to the right lower limb Tenderness, heat and some swelling of the left knee joint but the patellofemoral joint is visible and palpable ROM The patient has lost 5° of knee extension and has 100° flexion Restricted by pain and swelling Knee extension is most painful movement Special tests Anterior drawer test in 70° knee flexion = positive (anterior tibial displacement) approximately 2 cm) was not conclusive due to pain and swelling Valgus stress instability was not conclusive due to pain and swelling Active Lachmans’ test was not assessed due to pain and swelling All other peripheral joints were documented as normal Pre-operative treatment aims Discuss aims and surgery procedure Explain that post-operative pain and swelling is a common presentation Discuss immediate post-operative plan Discuss and give written information of the post-operative protocol and rehabilitation programme Teach immediate post-operative knee joint exercises including patellofemoral mobilisations to maintain range of movement Teach safe mobilisation with elbow crutches Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Minimise swelling with advice on rest, ice and elevation Advise patient on the importance of adequate pain relief Mobilise partially or fully weight bearing according to surgeon’s protocol. Encourage normal gait pattern and safe mobility on stairs. Mobilise with cricket bat splint or brace depending on surgeon’s protocol Commence active range of movement as instructed by surgeon’s protocol. Common protocols aim to achieve 0–90° of active range of movement by week 2 post surgery Encourage resting position in knee joint extension Plan discharge goals Discharge goals Reiterate ACL post-operative rehabilitation protocol and graft protection Discuss the importance of a graduated rehabilitation regime and good muscle control Discuss return to work according to surgeons protocol Review home exercise programme Review safe mobilisation on elbow crutches Re-assure the patient that immediate post-surgical pain and swelling will gradually reduce Arrange post-discharge out-patient physiotherapy appointment Questions 1. What is the role of the cruciate ligaments in knee joint stability? 2. Describe common ACL mechanisms of injury. 3. Why is reconstruction using grafts preferable to repair of torn tissue? What type of grafts can be used in ACL reconstruction? 4. Considering your patient’s profession what might be a better choice of graft for his ACL reconstruction? 5. The patient has post-operative pain and swelling and this is increasing his anxiety about his return to work. How can the therapist re-assure him and address this anxiety? 6. What is the clinical reasoning behind open and closed kinetic chain exercises in ACL reconstruction? CASE STUDY 6 Fractured tibia and fibula Subjective assessment PC 36-year-old male admitted via A&E for surgery after a motorbike accident a few hours earlier which resulted in several open transverse and crush fractures of his right tibia and fibula He also has deep friction burns on his left side from sliding on the road surface HPC Patient suffered massive blood loss due to the open nature of his fractures He was referred for immediate surgery Pedal pulses were weak but present and it was therefore decided to use an internal fixator to pin his leg After the surgery he was transferred to the high-dependency unit where his medical condition resulting from the blood loss can be monitored SH Self-employed motorcycle courier and a trained motorbike mechanic Lives with his partner and their three young children Patient and partner juggle their work schedule so that both look after their children without outside help Post-operative aims Read the operation report and check for any special post-operative instructions Check chest and start with breathing exercises Re-assure patient and advise him on process of rehabilitation Pain relief Check wounds (do not forget the left side with the burns) and distal pulses Advise patient on vascular exercises (e.g. foot and ankle pumps) for his left leg. No muscle contractions of his right lower leg yet as this may put strain on the bone ends As the patient will be non-weight bearing when he mobilises he will need to work his upper body and non-operated leg to achieve the endurance needed for this high effort walking pattern Questions 1. How are fractures classified? 2. What is an internal fixation? 3. What are the possible disadvantages of an ORIF? 4. What are the classic healing times for fractures? 5. What are the complications of fractures in general? 6. What model of rehabilitation and clinical reasoning might be useful for Mike? CASE STUDY 7 Achilles tendon repair Subjective assessment PC 41-year-old male has undergone an Achilles tendon (TA) repair 1/7 ago. You have been asked to ensure that he is safe to go home today on crutches HPC He ruptured his TA (the first time) 5/12 ago Treatment consisted of full leg plaster for 3/12 followed by out-patient physiotherapy 3/7 ago he was walking on level ground when it re-ruptured Previous diagnosis had been Achilles tendinopathy SH Lawyer working in city and travels in by underground Single and lives alone in first floor flat He plays squash at club level. Until 2 years before he had also been playing rugby at club level. From then till his TA ruptured first time he was refereeing rugby at least one game each weekend Objective assessment Observation Strong, fit looking man despite the long period of recent inactivity, with a below knee cast, the foot position being full plantar flexion Able to easily lift cast in all directions, has full mobility Circulation appeared normal Post-operative instructions Below knee cast with ankle in full plantar flexion 4/52, non-weight bearing Cast changed to reposition the foot into neutral, i.e. the ankle is at right angles, for a further 2/52, and a walking cast applied for weight bearing Cast removed 6/52 post surgery and out-patient physiotherapy to commence ( Dandy & Edwards 2003 ) Post-operative treatment aims To be clear with post-operation instructions To ensure safety with crutch walking on the flat and on stairs To support the patient psychologically Elbow crutches were supplied and fitted. Instructions for use were discussed and he was taken to the staircase for stair practice. No problems were encountered – balance, transfers and on ascending/descending the stairs. Throughout the session he revealed what an extremely difficult time he was having adapting to this long period of inactivity. This was discussed and the patient decided with help, that regular visits to the gym to work on upper body and contralateral leg (the unaffected leg) strength would give him some means of having control on this situation. He was deemed safe to go home and was discharged Questions 1. What is a tendinopathy? 2. How is a TA rupture diagnosed? 3. What muscles make up the TA and what is their function? 4. What are the stages of healing and how do they apply to this tendon? 5. Describe the progressive changes you think occur in the normal gait pattern when using crutches. 6. What are the complications of poor crutch walking? 7. What exercise therapy will likely to be incorporated into his rehabilitation once his plaster has been removed? CASE STUDY 8 Idiopathic scoliosis Subjective assessment PC 15-year-old girl admitted with idiopathic scoliosis. Scoliosis is thought to be progressing (Cobb angle 40°, Risser four) Booked in for a single stage anterior fusion in 2/7 The aim of the surgery is: to stabilise the spine to prevent further deterioration to correct the deformity HPC Change in patient’s spine was noticed by her mother 6/12 ago GP referred to consultant Pre-admission 8/52 ago – stayed overnight, met the MDT Postural advice with emphasis on symmetrical weight bearing was given Investigations including new spinal X-rays and chest X-ray, blood tests, ECG and sleep studies were carried out SH Sitting GCSE exams at the end of year and very worried about having time off school Used to play netball but lately finds it too difficult but would like to be able to play again Not involved in other sport as she feels awkward Objective assessment Observation Right rib ‘hump’ (thoracic right convex) with right shoulder protracted and a prominence of the right hip, i.e. the trunk has shifted to the left Curves well hidden under loose clothing Leg length Indicates a shortening of right leg Neurological signs Nil Single leg stance Difficult on both sides due to asymmetrical weight distribution Gait Normal Pre-operative treatment aims Respiratory assessment – record lung function in medical notes to ascertain pre-operative values Explain post-operative management and introduce post-operative precautions Provide any written information sheets about post-operative care and discuss Post-operative treatment aims Identify and prevent post-operative complications Restore respiratory function Restore active muscle control Safe, functional rehabilitation and progression of mobility Education of the patient to include: a. ergonomic advice

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