General Information

Patient’s Name: Lloyd Oliver Corpuz

Age/Sex: 32/M
Occupation: Music & Sound Editor
Dx: Grade 2 MCL Tear on (L) LE
HPI:
~16 yrs. PTIE (June 2003) Pt. was playing basketball with his friends. Pt was
performing his post-up move with his (L) LE as pivot but his pivot foot twisted.
Pt then suddenly felt an excruciating pain (PS 10/10) on his (L) knee and
was left lying on the floor. Pt. Describe it that most of his body was already
moving full force but he didn’t notice that his left leg was not moving. It may
be due to the shoe traction or the concrete floor. He also heard a popping
sound in his (L) knee and felt excruciating pain (PS 10/10). Pt was then
rushed to Las Piñas Medical Center for ~15mins and was administered by
Dr. Gonzales and was sent to undergo x-ray which resulted with (-) Fracture
and grade 2 MCL tear on his (L) LE and was referred for PT Mx at UERM
rehab. Unit under Dr. Santos. Pt. Only went for 2 tx sessions, because he
found out that his condition can heal on it’s own. Pt then went to a sport clinic
in Binondo, Manila to aspirate assuming that it will cure his (L) knee. The
aspiration decrease his knee pain (PS 10/10 to 6/10). Pt then took rest for
several days and carried on with his ADLs.

Past Medication
Indication Drug Name Dosage Frequency
Pain Mx Celecoxib 100mg Capsule QD/ 3 days

Present Medication
Indication Drug Name Dosage Frequency
Vit. B Deficiency Vit. B Complex 236ml per QD
serving
Digestion aid Probiotics 500mg QD
Pain Mx Ibuprofen 500mg PRN
PMHx
(+) Hospitalization (Lumbar strain, 2015)
(+) Previous Trauma
(-) HTN
(-) DM
(-) Cardiac Dse
(-) Pulmonary Dse
(-) Cancer

FMHx
Disease Maternal Paternal
HTN + -
DM - +
ARTHRITIS (OA) + -
CA - -
Cardiac Dse + -
Pulmonary Dse - -

PSEHx
1. Pt. is outgoing, workaholic, energetic & ambitious to be a Type A
personality
2. Alternative-cigarette (IQOS) smoker (6 sticks/day, since August 2017)
3. Former cigarette smoker (since 2007-2017, 15 pack/years)
4. Non-Alcoholic beverage drinker
5. Caffeine beverage drinker: 3 to 4 cups/ day
6. Diet:
1) Beef
2) Chicken
3) Pork
4) Rice
7. Home Orientation:
1) Pt. lives alone in a studio type condominium unit
2) Unit is on the 8th floor
3) The building is equipped with an elevator and stairs
4) Stairs have ~20 steps with two flights per floor
5) Pt. does not do any household chores
6) Pt. usually utilize a housekeeping service in maintaining the
cleanliness of the unit
7) Pt. relies on laundry cleaning services in cleaning his clothes.
8) Pt. usually goes home to his hometown in Las Piñas during the
weekends.
9) Pt. Usually eats out during lunch and dinner.
10) Distances
a) Basement Floor to Stairs/Elevator: ~6 steps
b) Elevator/Stairs to Main door : ~7 steps
c) Main door to Bathroom: ~3 steps
d) Main door to Kitchen: ~4 steps
e) Main door to Living room: ~6 steps
f) Main door to Bed: ~11 steps
11)The unit is equipped with tiles and airconditioning
1) Types of flooring
a. Living room: Faux wood
b. Kitchen: Granite
c. Bathroom: Ceramic
d. Bedroom: Faux wood
12) Bed is equipped with Uratex Foam

8. Work Orientation:
1) Pt. is a Music & Sound Editor at ABS-CBN who works 5x/wk (8hrs/day)
but usually goes undertime (6hrs/day)
2) Pt. walks ~300m for about 10mins to & from his condo to ABS-CBN
building
3) Pt. walks ~15 steps from ABS CBN main entrance up to the elevator
4) Pt.’s workplace is equipped with both stairs and elevator
5) Pt.’s office is located on the 11th floor of the building
6) Pt. mostly uses the elevator
 7) Pt. rides the elevator up to the 11th floor
8) Pt. walks ~10 steps from the elevator door to his work desk
9) Pt. walks ~20 steps from his work desk to the music studio
10) Pt.’s job usually involves desk job such as editing and music
composition and going to and from studios for recording sessions.
11) Pt. reported that his work chair has little to no back support
12) Pt. has both lunch and coffee breaks
13) Pt. also sidelines as a bass player and occasionally performs at
gigs with his bandmates
9. Hobbies
1) Pt. plays basketball 1x/wk
2) Pt. plays his guitar every morning for ~30mins
3) Pt. goes surfing occasionally 1-2x/month
4) Pt. goes Skateboarding 2x/wk
PIPs:
1) Pt. c/o pain on his (L) knee d/t his MCL tear
2) Pt. c/o pain oh his achilles
3) Pt. c/o his LBP
4) Pt. c/o pain on (L) knee when sitting or standing for too long
5) Pt. c/o his work chair that has a little to no back support

VS
BP 120/90 mmHg
HR 72bpm
RR 15cpm
T° 36.0°C

Findings: Vital signs are WNL

Significance: For baseline purposes and tx precaution
OI:
Amb s any assist
Endomorph
A/C/C
Oriented x3
(+) Postural deviation (See postural analysis)
(+) Gait deviation (See gait analysis)
(-) Bruising
(-) Erythema
(-) Swelling
(-) Atrophy
(-) Scars

PALPATION:
Hyperthermic on (L) Patellar area
Normotonic on B UE and LE
Gr.1 Tenderness on L Achilles area
(-) Tautbands
(-) Ms tightness
(-) ms spasm
(-) ms guarding
(-) inflammation
(-) edema
(-) crepitus
(-) nodules
ROM:
All major jt. Motions are WNL actively and passively done pain free c N end
feels except:
Jt. Motion A P N N-A N–P End feel
(L) Knee Flexion 0-100° 0-110° 0-130° 30° 20° Empty

(L)Knee Extension 100-0° 110-0° 130-0° 30° 20° Empty

Findings: LOM towards L Knee Flexion and Extension

Significance: 2° to pain

MMT:
All major M groups of L/R UE/LE are grossly graded 5/5 except

Ms Group Grade

(L) Knee Flexors 4/0-100°

(L) Knee Extensor 4/100-0

Note: break test was done

Findings: Ms weakness of (L) knee flexion and extension
Significance: 2° to pain

Special Tests

Test Findings Significance

Anterior Drawer Test No excessive anterior R/o ACL involvement
translation of tibia
McMurray Test (-) Pain upon extension R/o Meniscal Injury
of the knee involvment
Valgus Stress Test (+) Pain upon axial T/C MCL Tear
compression
Sensory Assessment:
Legend:

Sensation Procedure Findings

Light touch (STD PT strokes (B) UE & LE
used: cotton) skin c cotton & ask if the
sensation was felt
Pressure (STD PT press on (B) UE & LE
used: thumb) c thumb & ask if the
sensation was felt
Temperature (STD PT press on (B) UE & LE
used: test tubes: c hot & cold test tubes and
hot & cold) ask if the sensation was
felt
Pain (STD PT pin prick the pt on (B)
used: pin) LE c the use of sharp end
of pin & ask if the
sensation was felt
Pt was able to feel the
cotton
Pt was able to feel the
pressure from the
thumb
Pt was able to identify
the difference of hot &
cold sensation.
Pt was able to feel the
pin prick sensation
from the sharp end of
the pin

FUNCTIONAL ASSESSMENT:
POSTURAL ANALYSIS: Pt was assessed on levelled surface in standing
position and noted the ff.:
A/P view:
(L) Landmark (R)
Neutral Head Neutral
Levelled Shoulders Levelled
Neutral Trunk Neutral
Neutral Elbows Neutral
Neutral Hips Neutral
Neutral Knees Neutral
Out-toeing Feet Neutral
Lateral view:
Landmark Findings
Head Slightly flexed
Shoulders Slightly protracted
Trunk Increased lumbar lordosis
Elbows Neutral
Hips Slightly extended
® Knee Neutral
® Ankle Neutral
® Foot Pes planus

Findings: (+) Forward head posture, (+) Pes planus

Significance: Central obesity

Gait Analysis:
Pt.’s gait pattern was assessed on levelled surface and noted the ff:
(L) (R)

Hip Knee Ankle Hip Knee Ankle

Stance Phase

IC (N) (N) Decreased (N) (N) Decreased

DF DF
LR (N) (N) (N) (N) (N) (N)
Midstance (N) (N) (N) (N) (N) (N)
TS (N) (N) (N) (N) (N) (N)
Swing Phase

IS (N) (N) (N) (N) (N) (N)

MS (N) (N) (N) (N) (N) (N)
TS (N) (N) (N) (N) (N) (N)

Findings: Abnormal Gait 2°Pes Planus

Significance: May slow pt. down during amb and may need additional effort
in performing ADL’s associated c gait
DTR:
Legend:
0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hypereflexia
++++ clonus
Findings: Normoreflexive on B UE & LE
Significance: Intact reflex arch

NPIPS:

Existing Rationale
LOM towards knee flexion & If not treated properly it could lead to further
extension difficulty in performing AROM
Gr.1 Tenderness on L Can bring more discomfort and if not treated
Achilles area it could cause another problem to the pt.
↓ Ms strength on (L) knee Difficulty in playing his hobby: Basketball
towards flexion and
extension

Anticipated Rationale
Abnormal Gait 2°Pes Planus May slow pt. down during amb and may
need additional effort in performing ADL’s
associated c gait

PT Impression:

Pt. was medically diagnosed c Grade 2 MCL Tear on (L) LE c LOM, ↓

ms strength causing difficulty & discomfort in performing his ADL’s and
hobbies.
Severity: Chronic

Irritability:
 Pt. manifest discomfort when extending his (L) knee

Stage: Chronic, d/t Grade 2 MCL tear but can heal on it’s own

Nature: Trauma
Stability: Good

Pros Rationale Cons Rationale

Cooperative Pt has a good Med Hx Pt. has been
compliance & can hospitalized
tolerate all PT Mx last 2015
because of
Lumbar
strain
Financially Pt. can afford Physical Cooperative
stable therapy treatment if he
would want to

No sensory Pt has intact sensation

affectation that prevents further
problems such as
burns.
 Problems LTG Resting STG Resting
(4wks, 3 PT predictive (2 wks, 3 PT predictive
session/wk) criteria sessions/wk) criteria

LOM Regain N Pt. reports 10°↑ in ROM ↑ motion in

towards (L) ROM of (L) movements of (L) knee (L) knee
knee flexion knee on (L) knee towards flexion and
& extension pain free in flexion and extension
flexion and extension
extension
Gr.1 Perform Pt. reports Eliminate Increase in
Tenderness specific tasks no tenderness physical
on (L) of (L) knee s discomfort on (L) activity as
Achilles area any difficulty when doing Achilles area far as the pt.
and any tasks can tolerate
discomfort
↓ ms Maintain the Pt. is able to ↑ Ms. Pt. will
strength on Ms strength do activities Strength of report an ↑
(L) knee of (L) knee involving (L) (L) knee in strength
towards and perform knee flexion flexors and when
flexion and activities and extensors performing
extension involving extension from 4/5->5/5 activities
knee flexion that involves
and (L) knee
extension s flexion and
pain extension
 STAGE: Chronic TX DURATION/# OF SESSIONS: 4wks, 3 PT session/wk

FOCUS OF TX:

1. Improve ms strength
2. Restore ROM in (L) knee flexion & extension
3. Improve performance in ADLs
PPROBLEMS TO BE ADDRESSED:
1. Difficulty in extending his (L) knee
2. ↓ Muscle strength on his (L) knee
3. Abnormal Gait 2°Pes Planus
4. Pain
5. Weight
6. Posture
SUGGESTED Mx:
TX APPLIED:
1. Knee flexion c heel slide x6sh
x10sec rest x 10reps x2 set
2. Quad sets x6sh x10sec rest
x10 reps x 2sets
3. Straight leg raises x6sh
x10sec rest x10 reps x2 sets
4. Stair climbing

a. Gentle ROM excercises on his (L) knee x10 reps x2 sets

b. Quad sets x6sh x10sec rest x10reps x2 sets
c. Straight leg raises x6sh x10sec rest x10reps x2 sets
d. Proper gait education
CRITERIA FOR PROGRESSION:
 Pt will be able to perform all exercises with ease.
 ROM results will increase.
 ↑ ms strength
 Performance ADL has returned to original state

DATE OF RE-ASSESSMENT: