HOAC II

Basis CTS

GENERAL INFORMATION:
Pt’s Name: R.S
Age/Sex: 48
Occupation: Physical Therapist at East Ave. Medical Center
Dx: R Knee Osteoarthritis

HPI:
Patient’s condition started 7 years PTIE when the pt jumped from roof of the first floor. the next morning after waking
up he felt pain (PS 7/10) on his R knee and it was swollen. pt consulted her wife about his condition that the pt needs
a "manghihilot" to lessen the pain and swollen knee. 3 days after it was healed. that night the pt eats "papaitan" and
drink beer c friends. the next morning upon waking up the pt felt pain (PS 8/10) on his r knee, again it was swollen.
the pt decided to do the same treatment thinking that it will lessen the pain and swelling. 3 days after pain and
swelling is still there. one of pt's friend saw the pt condition and suggested a medicine arcoxia thinking that the
swelling is due to arthritis and the pt decided to take the arcoxia that night, pain and swelling was lessen the next
morning. For 1 year pt takes arcoxia everytime he felt the same pain and swelling on his R knee.

~6 years PTIE the pt go to the other country and becomes ofw, for 5 years the pt stated that he did not feel anything
abnormal on his R knee.

~1 year PTIE the pt decided to stop working abroad and continue his welding services in the philippines. The pt goes
back to his old lifestyle causing him pain and swelling again. The patient ignores the pain because arcoxia lessen the
pain and swelling. Until 2 months the pt felt dull aching pain (PS 5/10) on his R knee due to 1 hour standing while
doing welding. Because of tolerable pain the pt take alaxan and rest to lessen pain. The pt also stated that he’ll feel
pain (PS 4/10) whenever he walks to cock fight arena for 15mins and take a rest for 5mins while massaging his R
knee. pt ignores the pain because resting and massaging his R knee alleviates the pain. (PS 1/10)

~1 month PTIE pt felt stiffnes on his R knee for 20 mins p waking up in the morning (PS 7/10) he took pain reliever
alaxan and massage the painful area, pain was partially relieved to (PS 1/10).

~ 4 Days PTIE The pt’s wife was worried about the pt's condition so she convince the pt to consult doctor. From then
the pt decided to consult MD since he is also worried about his worsening and decided to have a healtier lifestyle.
MD requested Laboratory and Ancillary procedure (R Knee X Ray (+) Definite osteophyte formation (+) slight Joint
space narrowing), (Joint Fluid Examination: 3.5mL volume, Clarity: Transparent , Color: Clear, WBC: 200 per mcL
Polymorphonucluear leukocytes: 25%, Culture: negative), (ESR (-) Inflammation ,19 mm/hr) and dianosed the pt c
Gr. 1 R knee OA. MD referred the pt to PT REHAB for further evaluation and management.

PMHx
(+) HTN controlled since 2011
(+) Obesity 31.09 BMI
(+) Trauma 7 years ago
(-) Fracture
(-) RA
(-) DM
(-) Osteoporosis
(-) CA
FMHx

MATERNAL PATERNAL

HTN + -

OA + -

RA - -

DM - -

Osteoporosis - -

CA - -

PSEHx
Pt is emotionally expressive and less stressed and considered to be a Type B personality.
Sedentary lifestyle
Cigarette smoker for 3pack years
Alcoholic beverage drinker (occasionally) 2 bottles of beer
Hobby is watching and playing cockfight
Diet:
- Vegetables and Meat
Lives with Wife, 1 son and 1 daughter
Always at home because of work
Does not do house hold chores and always at the working station

 Home Situation
Patients live in a bungalow type of house. All rooms are well-lit, well-ventilated c tiled-flooring and s obstructions.
Uses Bedroom 1 and always at the living room when have free time from work.
In reference to the main door, the measurements are the ff:
- Living room: ~3 steps
- Bathroom: ~20 steps
- Kitchen: ~20 steps
- Dining Room: ~20 steps
- Bedroom 1: ~5 steps
- Bedroom 2: ~10 steps

 Work Situation
- Has been working as welder for 20 yrs
- Works at home
- Main door to the working station is 6 footsteps

PIP:
1. Pt c/o dull aching pain that affects his work such as standing for 1 hour.
2. Pt c/o dull aching pain while walking for 15 minutes that affects his social life
3. Pt c/o dull aching pain and stiffness p waking up that affects his mood and time
4. Pt c/o pain and swelling after eating fatty foods which affects his enjoyment
 Outcome Measures Evaluation tool
WOMAC  Paper
 Table
 Pen

VS:
a p

HR 82 bpm 86 bpm

RR 18 cpm 20 cpm

BP 120/80 120/80

Temp. 36.8 deg. C 36.9 deg. C

Findings: All VS are WNL. Pt. was able to proceed to tx.
Significance: For baseline purposes and to be able to monitor the pt.’s reaction to the given tx.

OI
Ambulatory without assists
Oriented x 3
Endomorph
Alert, Coherent, and Cooperative
(+) Postural Deviation (See postural A.)
(+) Gait deviation (See gait A.)
(-) Swelling
(-) Deformities
(-) mm atrophy

PALPATION
Normothermic on (B) UE and LE
Normotonic on (B) UE/LE
(+) painful crepitus on R knee flexion and extension
(-) tenderness
(-) subluxation
(-) dislocation
(-) Joint effusion
(-) Inflammation

ROM:
All major joints of (B) UE and LE, including the neck and trunk were actively and passively assessed and
were found to be WNL, pain free and c normal end feels except:
motion AROM PROM Normal Difference End-feel

R knee flexion 0-120deg. 0-135deg. 0-135 15deg Empty

R knee 125deg.-0 135deg.-0 135deg.-0 10deg. Empty

extension
Findings: Pt has LOM of knee flexors and extensors
Significance: LOM secondary to pain;

MMT
All major muscle groups of (B) UE/LE were assessed using break test and were found to be graded 5/5 except

Muscle grade

R Knee flexors 5/120deg

R knee extensors 5/ 120 knee flexion – 10 deg knee extension

Findings: LOM of R Knee Flexion and Extension

Significance: LOM secondary to pain

Superficial sensory A:
All sensations cold, hot, pain, and pressure were tested on R and L anterior thigh and knee and was found to be all
100% intact.

Findings: All sensations tested are normal.

Significance: For baseline purposes: Modalities may be used on Pt.

ANTHROPOMETRIC MEASUREMENT
True Leg Length
Pt. was assessed in supine position.

Landmarks L R difference

ASIS to medial malleolus 92.5cm 91cm 1.5cm

Apparent Leg Length

Pt. was assessed in supine position

Landmarks L R difference

Umbilicus to medial 95.5cm 94cm 1.5cm

malleolus
Findings: The measurements taken were taken using a standard tape measure without physical barriers (i.e.
clothing) in both thighs and legs and are WNL.
Significance: No significant findings were noted. The Pt does not have leg length discrepancy which is a probable
cause of the condition.

Body Mass Index (BMI)

BMI = wt / ht^2
= 92 kg / 1.71
=31.5
Findings: Pt is obese.
Significance: Pt’s weight contributes to the severity of the condition. Pt may need to lose weight
Postural A:
Pt was assessed in uncorrected standing, viewed APL
Anterior Posterior Lateral

· Iliac crests level · PSIS higher than ASIS

· ASIS level
· Patellae facing anteriorly, level
· B LE in neutral rotation
· Tibial tubercle level
· Medial malleoli level
· Lateral malleoli level
· (-) Genu valgum/varum
· Iliac crests level · Slightly inc lumbar lordosis
· PSIS level · (B) knees slightly flexed
· Popliteal folds level
· B LE in neutral rotation
· Calcanei level
· (-) Genu valgum/varum

Findings: There is a postural deviation of the R LE

Significance: Postural deviation d/t pain and stiffness

Gait A:
Pt was assessed while amb on a level surface s any use of ADs using pt’s desired speed. All gait components are
within normal assessment except:

R L
Stance Initial Contact (↓) Initial Contact (↑)
Phase Loading Response (↓) Loading Response (↑)
Midstance (↓) Midstance (↑)
Terminal Stance(↓) Terminal Stance(↑)
Preswing Preswing
Swing Initial Swing (+) Initial Swing (-)
Phase Midswing (+) Midswing (-)
Terminal Swing (+) Terminal Swing(-)
Findings: Patient present c shorter stance phase of the R LE from loading response to terminal stance, shorter swing
phase of the L LE from initial swing to terminal swing.
Significance: Patient presents antalgic gait

ADL A:
Ambulation Pt is able to walk independently s ADs however presents c mod difficulty d/t
pain manifested by increased time of completion for the stance and swing
phase of the ® and (L) LE. Pt does not report knee locking or “giving way”.

Transitions:: Sit to stand Pt presents c modified independence as manifested by shifting his weight
slightly on his (L) LE then propping her hands on her knees when standing in
order to use her UE to push up, assisting her LE in propelling himself up.

Welding Pt presents modified independence as manifested by not being able to

tolerate 1 hour of standing while welding d/t pain. Pt rest for 5 mins and
massage the R knee to relieve the pain.
Significance: Pt’s modified independence may be attributed to pain and feelings of stiffness

WOMAC
WOMAC Osteoarthritis Index:

RESPONSE POINTS

None 0

Slight 1

Moderate 2

Severe 3

Extreme 4

PAIN

Walking 2

Stair climbing 0

Nocturnal 0

Rest 0

Weight bearing 1

STIFFNESS

Morning stiffness 2

Stiffness occurring later in the 1

day

PHYSICAL FUNCTION

Descending stairs 0

Ascending stairs 0
 Rising from sitting 2

Standing 2

Bending to floor 1

Walking on flat 1

Getting in or out of car 0

Going shopping 2

Putting on socks 1

Rising from bed 2

Taking off socks 1

Lying in bed 0

Sitting 0

Getting in/out of bath 1

Getting on/off toilet 2

Heavy domestic duties 3

Light domestic duties 2

TOTAL SCORE:
● Pain: 3/20
● Stiffness: 3/8
● Physical Function: 20/68
Findings: Pt has a low score
Significance: Serves as a baseline for progression of pt’s condition as well as to monitor pt’s subjective response, as
to her daily function, to the treatment being provided.
NPIPs:
Existing Rationale
LOM of the R Knee towards flexion and Extension d/t pain the pt cannot function properly in walking
(Antalgic Gait)
Obesity Greatly affects the stress in WB

Anticipated Rationale
Balance He might developed moderate balance problem if left
untreated
Deformities If the pt does not avoid deforming positions

PT Impression:
Pt wasmedically diagnosed to have Knee Osteoarthritis further defined by crepitus, LOM and decreased
strength, morning stiffness usually <30 mins and pain d/t walking and standingfor a long period of time.

Severity: Mild
Irritability:
 Pt manifest pain when there is prolonged time in standing and walking, also when eating fatty foods.

Pros Rationale Cons Rationale

Cooperative Pt has a good compliance

& can tolerate all PT Mx

Financial stability Pt has a good financial

background

Problems LTG Resting predictive STG Resting predictive

(10 PT session) criteria (5 PT session) criteria
Pain on the R Knee Diminished pain of Pt will address no Decrease pain on R Pt will report
(7/10) the R knee pain on the R Knee Knee (PS 3/10) decrease of pain on
R LE during
ambulation
LOM on the R Knee Prevent further loss Pt will be able to Increase ROM on Pt will demonstrate
towards Flexion and of ROM perform normal ROM the R Knee towards inc. rom towards
extension flexion and flexion and extension
extension
WOMAC score of Womac score of 0 Patient will get 0 on Womac score 0f Patient will have
26/96 all the questions 10/96 improved answers
on questionnaire
 FOCUS OF TX:

1. Minimize pain & improve health condition to have better quality of life.
2. Correct the Gait deviation
PROBLEMS TO BE ADDRESSED: TX APPLIED:
1. Pain on R knee upon walking and WB PS 7/10 1. HMP and TENS on the R Knee
2. LOM towards R knee extension and flexion 2. Joint mobilization Techniques
3. Antalgic Gait 3. Resistance Exercise
4. WOMAC Score of 26/96 4. Endurance Training – Walking
5. WB exercises

SUGGESTED Mx:

1. HMP on R knee x 20 minutes to decrease pain and muscle relaxation

2. AROMEs of R knees towards flexion and extension x 10 reps x 3 sets to maintain muscle and joint integrity
3. Joint mobilization Grade III distraction x 6 secs stretch x 3 mins to increase joint play
4. Resistance Exercise using Thera band towards flexion and extension at the pain free range x 10 reps x3 sets to inc.
muscle strength of the quadriceps and hamstring muscles.
5. Wall half squats x 10 reps x 1 set to improve activation of quadriceps and hamstring muscles.
6. sit – walk – sit x 20 mins to improve muscle endurance and neuromuscular control/strength
7. TENS on R knee x20 minutes to decrease pain

CRITERIA FOR PROGRESSION:

 Sit- walk – sit while catching the ball x 10 reps x 3 rounds to improve neuromuscular control/ strength
 Wobble board exercises to improve balance
 Resistance Exercise using Ankle weight x 10 reps x 3 sets to increase muscle strength
 Wall half squats c ball squeeze in between knees x 6 SH x 10 reps x 1 set to improve activation of VMOs and
help maintain good patellar tracking
 LE Ergo x 15 mins to improve cardiovascular endurance
DATE OF RE-ASSESSMENT: July 15, 2019

References:
Physical Rehabilitation – Sullivan
Therapeutic Exercise – Kisner
Physiopedia.com
nhlbi.nih.gov
Orthoinfo.org
Orthopedia.com

Prepared By:
Cañeza, Mary Joy M.
Sarmiento, Micahella Yvette C.

Southeast Asian College, 4th yr PT Student ’19-‘20