Lower Limb Evaluation Format

LOWER LIMB FRACTURE ASSESSTMENT FORM

Demographic Data:

Name :
Age:
Gender:
IP Number:
Occupation:
Address:

History relevant to present condition:

Mode of injury:
orthopedics management:
surgical management:

Investigation:

Lab reports
Radiology

Co-Morbidities:

Diabetes mellitus
Hypertension
Osteoporosis

Observation:

General body appearance

Limb is positioned in BB splint with traction-Yes/No
Position of comfort adapted by patient when not in traction (if any):
Extent of cast/external fixator/ Surgical Incision
Swelling
Drain(if any)

Palpation:

Edema/Swelling
Capillary refill
Muscle spasm/guarding (if relevant)
Pulse

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 Lower Limb Evaluation Format

Testing:

Sensory Examination:

*In area below the fracture (Present/Absent)

Pain Examination:

pain in area other than the fracture area (if relevant)

Screening of other limbs

Motor Examination:

Muscle Girth:

Right Left
Thigh
Leg
Arm
Forearm
Hand

Range of motion:

ROM of Joint proximal and distal to the Active range

fracture site

Muscle strength:

-Manual Muscle Testing of joints proximal and distal to fracture site.

Functional Movement analysis :

- Lying to side lying / sitting

- Sit to stand
- Walking
- Stair climbing

Functional Evaluation:

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 Lower Limb Evaluation Format

FIM
Bed mobility
Transfer-bed –chair-bed
Sit-stand
Balance

Expected Function (Prognosis)

Proximal and distal joint mobility/strength

Self dependency during bed mobility/transfer/sit to stand/gait

Plan of Care: Pre-operative/Post-Operative

SMART GOALS

Treatment Plan:

*Treatment based on recent evidence /guidelines

Progress Note:

Functional range with assistance/without assistance

Active Lower limb function

Discharge Goals:

No swelling in ankle/knee
Functional range of joints proximal and distal to fracture
Minimal dependency while transfer
Ambulation upto 50 mts with assistive device
Can climb atleast 5 steps with crutch/canes

Home –exercise Program:

Exercise diagram No. of sets Repetition Do’s Don’t

Follow-Up:

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 Lower Limb Evaluation Format

Clinical Reasoning
Clinical relevance /
Special
contributing factors / Important Information
attention
Hypothesis / Reasoning
Healing / degenerative
Age changes /osteoporosis/
balance / strength / mobility
Reason for surgery
Surgical History – Incision /
HT/IHD/DM/ osteoporosis /
type of implant
previous trauma
Surgical Relevant medical conditions
history and Presenting complaints (list)
Previous Functional status
co- Relevant Past history ( Body
Activity Status
morbidities Function status/ Activity
Status) / contributing factors
Assisted devices used for
that may influence the
supports, transfers and
exercise planning)
mobility
To get information on the
Lab To correlate with the present level infection, inflammation
investigation condition of the patient and to test the level of
calcium precursors
To identify the type ,extent of
Radiology Severity of the injury
fracture
BMI
General – ( whole body To understand obesity /
appearance) overweight contributing to
OA, Joint loading
Healing
Surgical Incision, Swelling,
(stages-inflammatory/
Presence of drain tubes
Observation remodelling etc.,)
Scar (grading)
Position of comfort adapted To understand which position
by patient when not in relieves pain and also it
traction (if any): would help in educating them
regarding the position of limb

Extent of cast/external To understand the mobility

fixator/ Surgical Incision and stability of proximal and
distal joint
Edema/Swelling
Palpation Sign of inflammation/Pain

Capillary refill
To understand peripheral
perfusion(normal/decrease)

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 Lower Limb Evaluation Format

Sensory To understand if there is any

Examination
nerve involment
pain If pain
intensity is
more then
other motor
examination
should not be
performed.
Discuss with
To identify flags, relate to
nurse in
surgical history,healing,
charge
medication
regarding
pain
medication
and patient
need to be
followed up
after pain
reduction.
Girth measurement
(differentiate between
Tests for
swelling / wasting) Relate with observation
effusion /
- Limb Oedema (identify
Clinical
possible causes Test – Homan’s sign
reasoning
(decreased mobility ,
DVT, etc.,)
Active Range of Motion of Perform on
Movement pattern, quantity,
joints proximal and distal to plinth not on
muscle activity, kinematics,
fracture site. bed in supine
protective mechanism)
and sitting to
Identify
evaluate the
- Lag
muscle
- Muscle inhibition
activity
- Muscle power
(torque)
Strength of muscles proximal
Strength (MMT)
and distal to fracture site.
Perform test
to rule out
To observe the activity of
Isometric Resisted Test tightness of
muscle
capsule or
muscles
Functional Movement - Lying to side lying /
analysis sitting
- Sit to stand
( relate with normal pattern, - Walking
identify the possible - Stair climbing
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 Lower Limb Evaluation Format

structure)

Total assist/
max/mod/min assist /
Independent
Movement pattern at
Functional Status knee ( available flexion)

Distance walked

(observe for discomfort

during function and gait)

balance -sitting and standing

PT Plan of care

Pre- op / Prehabilitation

Mode Reasoning
Exercise counselling To Gain confidence

Upper limb exercise Assistance in mobility / crutches

Bed mobility exercise To prevent DVT, Pressure sores

Activation for Quads/ hams/ Hip

Exercises to affected side( knee/ Hip and Abd/Extensors / Calf muscles
ankle) ( aid in re-education during inhibition post-
surgery)

training for Quads/ hams/ Hip Abd/Extensors

Exercises to Un affected side (knee/ Hip / Calf muscles
and ankle) ( aid in re-education during inhibition post-
surgery)
Functional education and training
Mobility

Post operative

Treatment Reasoning / Progression Progress note

Gain confidence Exercise education
Decrease Pain Understand the underlying Pain rating (VAS /

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 Lower Limb Evaluation Format

causes of pain NPRS), quality and

- Cryotherapy - Inflammatory compliance at each visit.
- CPM - Chronic
- Positioning - Structural
- Muscle activation ( active - Muscle guarding
exercise / isometric - Effusion
exercises) - Cryotherapy ( once in
every 6 hours till 6th post
Support /bracing ( to avoid op day)
knee contractures/ FFD as
patient tends to keep in resting
position because of pain)
Oedema control - Compression - Active exercises with
- Elevation elevation
- ST mobilization (If - Activity modification
required) (elevation in between
with active exercises)
Restore ROM Increase Range of motion Increasing each visit (10-
15 days)
Active extension without lag
AROM –
Note: ROM returning to prior Identify active structure
level. function (Activation/
If they had contracture, they Inhibition)
are more likely to have in post
op

- Quadriceps sets
- Straight leg raise (SLR)
- Supine heel slides,
- Short arc Extension
- Sit to stand
- Supine leg press (on
pillows )

Slowly progress to
- Resisted exercises (
minimal weights / 30%
EST RM) in available
range
- Controlled flexion and
extension in high Sitting (
support if required)
- Static cycle

Modalities
- Electrical Stimulation

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 Lower Limb Evaluation Format
Safe transfers and ambulation
with assistive device
Prevention of Tightness and
Contracture
Skin / Incisional scar
Joint - PF joint / Capsule
Gait training / Mobility
Home exercise program (HEP)
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- COLD PACK
- CPM
Distance ( 50 meters)
Observe and train use of knee
flexion during gait
Positioning / brace ( 0 degrees
while sleeping / resting in bed
Active exercises during sitting
Stretching exercises
ST mobilization / scar
mobilization
Based to type of implant
decide on weight bearing
NWB-TTWB-PWB-
Weight bearing as tolerated
(WBAT) – ( walker / crutches/
canes)
Increase incrementally at
each visit ( 10- 25%)
Add functional training
for lower limb ( sit to
stand, stepping, stair
climbing, over obstacles)
Progress to stretching
exercises and ST
mobilization if tightness
of structures are identified
Progress to
- Normal gait without
assistive device
- Stair climbing
- Gait obstacles
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 Lower Limb Evaluation Format

Progress Notes

Components 0- 2 weeks 3-6 weeks 6-12 weeks

- Emphasis on - Emphasis on - Emphasis on
Exercise
Importance of Exercise Importance of precautions and
education
- Provide education on strength, balance and preventive
“hurt (vs) harm function measures
- Cryotherapy
- Positioning of Knee
and related joints Pain must decrease
- Muscle activation during rest at this stage. - Pain must
(active exercise / decrease at this
isometric exercises) Pain during movement stage.
- Support /bracing ( to must be identified and
avoid knee patient must be given - Identify pain
contractures/ FFD as exercise education. due to fatigue,
Pain patient tends to keep in educate patient
resting position Eg. Pain at the end of appropriately
because of pain) flexion may be due to
Pain must decrease stretch in anterior - Identify
gradually after 24 – 48 structures / Qaud structures
hours, indicate if there is (identify and treat the causing pain
increase. cause) (possibly due to
Observe for pain pattern tight structure )
during movements.
Educate about pain, during
exercise
- Compression
- ST mobilization Usually minimal
- Elevation
Oedema - Active exercises of or no swelling at
- ST mobilization (If
knee with elevation. this stage.
required)
- Ultra sound
(US) – Flexion
- CPM –Knee (0-100)
contracture/ scar
(progress to 125)
Modalities - Moist heat
- TENS if necessary - ES
(Pain and - Contrast bath
- Cryotherapy (once in - Cryotherapy after
oedema - Whirl pool bath
every 6 hours till 6th exercises
management) or pool ( after 6
post op day)
weeks and
- Electrical Stimulation
incision is
(ES)
completely
healed)

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 Lower Limb Evaluation Format

AROM –
Identify active structures
limiting ROM and function AROM – expected
(Activation/ Inhibition) 0 – 110 active / passive
IF inhibited start with
Increasing each visit
facilitation techniques ( If not achieved continue
(10-15 days) toward
EST / Isometric exercise) exercise as 2 weeks
125 degrees flexion,
and 0 degrees
Stretching Knee /Hip - Active
extension.
Use techniques based on Exercises
examination & reasoning Resisted exercises
- Functional
- Passive structure - 1 RM evaluation
movements (re-
tightness (use static (Functional – leg
education)
stretching) press)
- Lateral and
- Active structure - Theraband standing
multidirectional
shortening (use PNF total knee extension
movements
techniques ) (TKE)
- Strengthening
- High sitting
exercise (1RM
Achieve 0 degrees active exercises (knee
60% to 80%)
extension without lag extension and
- Quadriceps, hip
(100 degrees flexion, and 0 flexion) with weights
and core
degrees extension – - Hip ( weights at
strengthening
increase to 110 degrees at thigh)
nd - emphasis on use
Restore the end of 2 week) - Stand to sit / bed
of the affected
ROM - Quadriceps sets transfer training
side during
- Straight leg raise (SLR) Proprioception and
function such as
- Patellar glides Neuromuscular re-
rising from
(mobilization) education
sitting
- Supine heel slides, - Gait / movement/
- Stand to sit
- Short arc Extension balance /weight
(independent)
- Sit to stand squats transfers)
- Proprioception
- Supine leg press (on - Standing balance
training
pillows ) training – even and
- Progress
- Resisted exercises uneven surface
Functional
(minimal weights / (wobble board)
training for
30% RM) in available - Progress to single
lower limb
range leg standing ( with
without support
- Controlled flexion and short duration
and increased in
extension in high progress
the repetition
Sitting ( support if incrementally)
and distance
required) - Add functional
(sit to stand,
- Static cycle / pedo training for lower
stepping, stair
cycle limb (with support if
climbing, over
required) (sit to
obstacles)
Note: ROM returning to stand, stepping, stair
prior level. climbing, over
If they had contracture, obstacles)
they are more likely to
have in post op

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 Lower Limb Evaluation Format

- Increase distance
incrementally at each
visit ( 10%) – Full
With assistive device - Normal gait
Weight bearing with
- Distance at patients without assistive
no of minimal
comfort device
support
NWB,TTWB,PWB,We
ight bearing as - Stairs with
- Attain normal
tolerated (WBAT) – reciprocal gait
Safe transfers kinematics and
(walker / crutches/ for without
and weight bearing
canes) increase support
ambulation
incrementally day by - Independent
- Temporal and
day (based on transfers to and
Spatial parameters of
evaluation) from the bed/
gait normalization
- Observe and train use ground
and training
of knee flexion during - Independent
gait function
- Stairs with assistance
(rail support)

Positioning / brace ( 0
degrees while sleeping /
resting in bed
Tightness Progress to stretching
Active exercises during ST mobilization
and exercises and ST
sitting Stretching ( static)
Contracture mobilization if tight
Stretching exercises

ST mobilization / scar
mobilization
Home
HEP written based on HEP written based on HEP written based
exercise
patient goals with special patient goals with on patient goals
program
precautions special precautions with dos and don’ts
(HEP)
- PROM to be
achieved with
minimal force - Lifting more
- Watch incision for
- Avoid rapid forced than 10 kgs
signs of separation
during Gait and during
and/or infection.
Precautions functional functional
- Keep incision strain at
movements ( sit to activities
a minimum, watch
stand etc.,) - Body weight
blanching during
- Incision/ infection (maintenance)
flexion to monitor this.
issues / scar
- Avoid running and
jumping

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 Lower Limb Evaluation Format

- Continuing
improvement in
ROM
- No extension lag
- Improvement in
- Achievement of
quadriceps function,
- Improvement in ROM, ROM
Progression gait and activity
muscle function and
criteria tolerance
gait over the first 2 - No extensor lag
- Single crutch or a
weeks.
cane
- Walking short
distances without
anassistive device.
- Non-antalgic gait
pattern

Knee range – 110

Functional range – 100
degrees achieved
degrees achieved
Gait – 100 meters with
Gait – 50 meters with - Achievement of
minimum support or 50
Discharge minimal support / No ROM 0-125
meters without support
summary support HEP – adherence
Stair climbing minimum
Stair climbing minimum 4
10 steps up and down
steps up and down with
support
HEP – adherence

If goals are NOT achieved and patient is maximally dependent for ADL
Note then refer to Physical Medicine and Rehabilitation centre (PMRC) -JSSH
for further evaluation and rehabilitation.
If Patient is moderately dependent for ADL refer to Physiotherapy OPD
If patient is not stable with co-morbidities and not willing to stay
inPMR/visit OPD,refer Home care physiotherapy

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