BAB III

CASE REPORT

I. DATABASE (August 27th, 2020)

1.1 Identity
- Name : Mrs. S
- Sex : Female
- Age : 70 years old
- Address : Surabaya
- Occupation : Sembako Seller at Marketplace
- Religion : Moslem
- Marital status : Widow
- Ethnic : Javanesse

1.2 Referred from : Orthopaedic outpatient clinic with OA Genu

Billateral Grade II

1.3 Chief complaint : Nyeri pada lutut kiri

1.4 History of Present Illness

Patient felt pain at her left knee since 5 years ago, the
pain got worsen since 1 month ago especially on the side of
patellar site. Pain is dull and localized. There was no radiating
pain, no numbness, and no tingling sensation. The pain got
worsen when she walked for long distance (>100m) and stand
for a long time (± 30 minutes) (WBS : 5-6) and relieved when
she took a rest with lying position (WBS : 3-4). She denied any
pain on other joint.
The patient also complained about stiffness on the left
knee when waking up in the morning for about 5 minutes, The
stiffness was relieved if she moved her knee. Sometimes there
was crackling sound on her left knee especially if she did
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 sholat in rukuk and sujud position. Unstable sensation during
walking was denied.
She can do activities of daily living independently, but
due to her pain, she found difficulties to using stairs and
sholat. She still went upstairs at the mosque every morning.
She did sholat in sitting position due to her pain.

1.5 History of Past Illnesses

- History of Hypertension since 5 years ago. She didn’t routinely
controlled. Sometimes she had Amlodipin 5mg once a day.
- History of Diabetes Mellitus, hyperuricemia, malignancy and
trauma at knee were denied

1.6 History of Medication

She got medication from Orthopedic OPC :
- Vit. B complex 1x1
- Meloxicam 2x1
- Alpentin 1x100mg

1.7 History of Familly Illness

Her mother also had the same complaint.

1.8 History of Social Economy and Activity

The patient lived with her granddaughter. She had 3
daughters, and all of her daughters lived separately from her.
She lived at one story house. She had squatting toilet but she
modified it to sitting toilet to avoid pain at her left knee.
She was a sembako seller at Marketplace, she often
walking around when she worked, but she didn’t work these
past 5 months because of the pandemic. She is a housewife
now. Sometimes she still washes the clothes and dishes by

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 herself using small chair, despite of having housemaid. She
went to mosque every morning and did sholat on the 2 nd floor
of the mosque.
She rarely did any exercise. She hoped that the pain
would disappear and she could walk without pain again. She
used BPJS as insurance to cover her treatment expenses.

II. PHYSICAL EXAMINATION (August 27th 2020)

II.1 General Status
 Compos Mentis, independent ambulation, normoposture,
antalgic gait, right handed
 Vital signs : BP 150/100 mmHg, HR 72 x/minute, RR 18
x/minute, SpO2 99%
 Body weight: 56,5 kg, body height: 144 cm, BMI: 27,2 kg/m2
(Obese grade I)
 Head and Neck : no anemia, no icterus, no cyanosis, no
dyspneu
 Chest
- Inspection : ictus cordis invisible
- Palpation : Ictus cordis palpated at ICS V MCL sinistral
- Percution:
 Upper heart margin at ICS II parasternal line sinistral
 Lower heart margin at ICS IV parasternal line dextra
 Lower left heart margin at ICS IV MCL sinistra
- Auscultation: heart sound S1-S2 single, regular, no murmur,
no gallops normal vesicular breath sound, no wheezing nor
ronchi
 Abdomen : soefl, normal bowel sound, liver and spleen
unpalpable
 Extremities : warm acral, edema at her left knee.

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 Figure 3.1 Posture photos

II.2 Musculoskeletal Status

Region Movement Range of Motion MMT
Neck Flexion Full (0-450) 5
Extension Full (0-450) 5
Lateral flexion Full / Full (0-450) 5/5
Rotation Full / Full (0-600) 5/5
Trunk Flexion Full (0-800) 5
Extension Full (0-300) 5
Lateral flexion Full / Full (0-350) 5/5
Rotation Full / Full (0-450) 5/5
Shoulder Flexion Full / Full (0-1800) 5/5
Extension Full / Full (0-600) 5/5
Abduction Full / Full (0-1800) 5/5
Adduction Full / Full (0-450) 5/5
Internal Rotation Full / Full (0-900) 5/5
External Full / Full (0-700) 5/5
Rotation
Elbow Flexion Full / Full (0-1350) 5/5
Extension Full / Full (135º-0) 5/5
Pronation Full / Full (0-900) 5/5
Supination Full / Full (0-900) 5/5

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 Wrist Flexion Full / Full (0-800) 5/5
Extension Full / Full (0-700) 5/5
Radial deviation Full / Full (0-200) 5/5
Ulnar deviation Full / Full (0-300) 5/5
Fingers Flexion:
MCP Full / Full (0-900) 5/5
PIP Full / Full (0-1000) 5/5
DIP Full / Full (0-900) 5/5
Extension:
MCP Full / Full (0-450) 5/5
Abduction Full / Full (0-200) 5/5
Adduction Full / Full (20-00) 5/5
Thumb Flexion:
MCP Full / Full (0-500) 5/5
IP Full / Full (0-900) 5/5
Extension:
MCP Full / Full (50-00) 5/5
IP Full / Full (90-00) 5/5
Abduction Full / Full (0-900) 5/5
Adduction Full / Full (0-500) 5/5
Opposition Full / Full (50-00) 5/5
Hip Flexion Full / Full (0-1250) 5/5
Extension Full / Full (0-300) 5/5
Abduction Full / Full (0-450) 5/5
Adduction Full / Full (0-200) 5/5
Internal Rotation Full / Full (0-450) 5/5
External Full / Full (0-450) 5/5
Rotation
Knee Flexion - Full / Full (Pain) 5/5
Extension Full / Full 5/5
Ankle Dorsoflexion Full / Full (0-200) 5/5
Plantarflexion Full / Full (0-500) 5/5
Eversion Full / Full (0-150) 5/5
Inversion Full / Full (0-350) 5/5
Toes Flexion Full / Full (0-300) 5/5
Extension Full / Full (0-800) 5/5
Big Toe Flexion Full / Full (0-250) 5/5
Extension Full / Full (0-800) 5/5

II.3 Neurological Examination

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 N. Cranialis I –XII : Normal
 Physiological Reflex : BPR +2/+2, KPR +2/+2, TPR +2/+2,
APR +2/+2
 Pathological Reflex : Babinski neg/neg, Hoffman neg/neg,
Tromner neg/neg
 Spasticity : negative/negative
 Sensory deficit : negative

II.4 Local Status of the Knee Region

 Inspection : redness neg/neg, swelling neg/pos, deformity
neg/neg
 Palpation : warmth neg/pos, crepitation neg/pos, tender point at
lateral genu sinistra, atrophy vastus medialis oblique (VMO)
sinistra
 Circumference
- MTP : 38 cm / 40 cm
- Thigh circumference (10 cm above MTP) : 43 cm / 42 cm
- Calf circumference (10 cm below MTP) : 33 cm / 33 cm
 Q-angle
- Non Weight Bearing : 10o (valgus) / 10o (valgus)
- Weight Bearing : 10o (valgus) / 10o (valgus)
 TLL (True Leg Length) : 70cm/70 cm
 ALL ( Apparent Leg Length) : 65cm/65 cm

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 Figure 3.2 Local
State of Knee

II.5 Special Test

 Patellar Grinding Test : pos / pos
 Anterior Drawer Test : neg / neg
 Posterior Drawer Test : neg / neg
 Valgus Stress Test : neg / neg
 Varus Stress Test : neg / neg
 Lachman Test : neg / neg
 McMurray Test : neg / neg
 Compression Test : neg / neg
 Distraction Test : neg / neg

II.6 Functional Examination

 Count test : 15
 Chest expansion test : 2,5 cm / 2,5 cm / 2,5 cm

 Static and dynamic sitting balance : good

 Static and dynamic standing balance : good
 Balance :
- Romberg : good
- Tandem walking : good

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  Frax Score (without BMD)
- Major osteoporotic : 3,6
- Hip Fracture : 1,1
 KOOS Score : 57,7
 TUG Test : 13,45 seconds (risk for falling)

II.7 Barthel Index

Feeding 10 (N: 10) Bladder 10 (N: 10)
Bathing 5 (N: 5) Toilet use 10 (N: 10)
Grooming 5 (N: 5) Transfer 15 (N: 15)
Dressing 10 (N: 10) Mobility 15 (N: 15)
Bowel 10 (N: 10) Stairs 5 (N: 10)
Total : 95 (slight dependent)

II.8 Geriatric Giant

1. Immobility : none 7. Impaction : none
2. Instability : none 8. Isolation : none
3. Incontinence : none 9. Inanition : none
4. Intelectual impairment: none 10. Impecunity : none
5. Infection : none 11. Insomnia : none
6. Impairment of hearing & 12. Immune deficiency : none
vision : patient use glasses 13. Impotence :-
when reading

II.9 Supporting Examination

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  X-Ray Genu AP + Lateral Sinistra (August 19th 2020)

Figure 3.3 X-ray

Genu AP, Lateral Sinistra
- Alignment baik
- Trabekulasi tulang normal
- Osteophyte di condyles medial os femur et tibia
- Osteophyte di basis et apex patela
- Tak tampak erosi / destruksi tulang
- Tak tampak fracture / dislokasi
- Tak tampak soft tissue mass / swelling
Conclusion:

■ Osteoarthritis femurotibial joint gr I

■ Osteoarthritis femuropatelar joint gr I

III.DIAGNOSIS
3.1 Medical Diagnosis

Knee Pain Sinistra ec Osteoarthritis Genu Grade II-III +

Hypertension Stage II (Uncontrolled) + Obese Grade I

3.2 Functional Diagnosis (Based on 2001 ICF)

Body Function

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 ● b280 Sensation of Pain (Pain at left knee, WBS = 5-6)
● b420 Blood pressure function (Hypertension stage II
uncontrolled)
● b530 Weight maintenance function (Obesity grade I)
● b710 Mobility of joint function (Crepitation, Positive Patellar
grinding test)
● b735 Muscle Tone Function (Atrophy VMO)

Body Structure
● s410 Structure of cardiovascular system (Hypertension stage II
uncontrolled)
● s750 Structure of Lower Extremity (Osteoarthritis Genu
Sinistra)

Activity Limitation
● d450 Walking (Pain if walking long distance >100m)
● d530 Toileting (Have to sit on the floor when using squatting
toilet)

Participation Restriction
● d930 Religion & Spirituality (discomfort when doing Shalat
because of pain)

Enviromental Factors
● e155 Design, Construction, and Building Products and
Technology of Building for Private Use (Squatting toilet)
● e580 Health Services, Systems, and Policies (covered by
BPJS)

3.3 Rehabilitation Problem

 Left knee pain

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 Atrophy of VMO
 Swelling and warmth at left knee
 Decrease of count test and chest expansion
 Hypertension stage II uncontrolled
 Obese grade I

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 ICF Framework

Functional Diagnosis
Knee Pain Sinistra ec Osteoarthritis Genu Grade II-III + Hypertension Stage II (Uncontrolled) +
Obese Grade I

Body Function Body Structure Participation

Activity Limitation
b280 Sensation of Pain s410 Structure of Restriction
b420 Blood pressure function cardiovascular system d450 Walking d930 Religion and
d530 Toileting Spirituality
b530 Weight maintenance s750 Structure of lower
function extremity
b710 Mobility of joint
function
b735 Muscle Tone Function

Enviromental Factors Personal factor

e155 Design, Construction, and Building - Woman
Products and Technology of Biulding for - Age
Private Use - HT
e580 Health Services, Systems, and - Obese
Policies

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IV. GOALS

Short Term Goals :

 Reduce pain at knee Sinistra
 Reduce inflammation at knee Sinistra
 Maintain the strength and ROM of both knees
 The patient understand about her condition so she can be more cooperative and
has better compliance to do knee joint conservation
 Comorbid control

Long Term Goals :

 Reduce body weight
 Pain free mobilization
 Improvement of quality of life

V. PROGNOSIS
- Ad Vitam : Ad Bonam
- Ad Sanationam : Ad Bonam
- Ad Functionam : Ad Bonam

VII. PLANNING

Medical :

 Planning diagnosis and therapy :

Rehabilitation Problem Planning

Obesity grade I Consult to Nutritionist

Hypertension Stage II Consult to Cardiologist
Left knee pain Continue medication from Orthopedy outpatient
clinic
Left knee pain LASER 2 J/cm2 at tender point Genu Sinistra

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 100% continous
Decrease of count test and Breathing exercise active with chest expansion
chest expansion
Decrease of count test and Endurance exercise:
chest expansion F: 3-5x/week
I: 40-60% Heart Rate Reserve
I: 5 minutes warming up, 15 minutes
conditioning, 5 minutes cooling down
T: Static Cycle
Maintain Joint Flexibility AROM exercise genu D/S

Atrophy VMO Isometric quadriceps and hamstring sinistra

strengthening exercise (2-3x/week, repetition
10-15x, 2-4 set/time, intensity as patient’s
tolerance)
[PRECAUTION VALSAVA MANUVER]
Swelling and warmth at Icing compress at left knee when she felt pain,
left knee frequency 4-6x/day, duration 15-20 minutes
Left knee pain Orthosis : Knee sleeve (patient refused)

 Planning monitoring : clinical findings, vital sign, WBS, ROM, MMT, atrophy,
endurance, BMI
 Planning Education : Health Education and Home Exercise Programme
o Explain the patient’s condition
o Continue the exercise at home
o Reduce body weight
o Icing compress at left knee when she felt pain, frequency 4-6x/day, duration
15-20 minutes
o Knee joint conservation :
 Use sitting toilet
 Avoid squatting
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  Hold on to surrounding when transferring or changing position
 Modify the activities that require sitting on the floor or sitting on a low
bench
 Avoid using stairs, practice proper use of stair if still necessary (step by
step, climbing stairs by using the healthier knee side first, descending
stairs by using worse knee side first)
Surgical : -

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 PROGRESS REPORT

September, 26th 2020

 The pain on left knee decrease, WBS : 3-4
 Still felt pain when squatting and standing for a long time, the pain is reduce
S when walking.
 Still felt difficulty at going upstairs because of pain. Did Shalat with sitting
on a chair.
 General status: CM, independent ambulation, normo posture, right handed
 Vital sign: BP: 135/80 mmHg, HR: 76x/min, RR: 18x/min
 Body weight : 55 kg, body height : 1,44 m, BMI : 26,5 kg/m2 (obese grade I)
 Musculoskeletal status of knee:
 Flexion : ROM = Full/ Full ; MMT 5/5
 Extension : ROM = Full / Full ; MMT 5/5
 Local status of knee: Swelling -, Warmth -, Crepitation -/+, tender point at
lateral left knee, atrophy VMO Sinistra (+).
O
o Q-Angle : Non WB : 10o (valgus) / 10o (valgus), WB : 10o (valgus) / 10o
(valgus)
o Thigh circumference : 43 cm / 42 cm
o Knee circumference : 38 cm / 38 cm
o Calf circumference : 33 cm / 33 cm
 Special test : Patellar grinding test : +/+
 TUG Test : 10,17 (normal)
 KOOS Score : 68,3
Knee Pain Sinistra ec Osteoarthritis Genu Grade II-III + Hypertension Stage
A
II (Controlled) + Obese Grade I

P PDx : -
PTx :
Modality :

LASER 2J/cm2 at tender point Genu Sinistra 100% continous

Therapeutic exercise :
 AROM exercise lower extremity Dextra and Sinistra

36
  Isotonic quadriceps and hamstring strengthening exercise
(2-3x/week, 50% 1 RM, repetition 8-12x for 2-4 sets, Q Bench)
 Breathing exercise active with chest expansion
 Endurance exercise :
o Frequency : 3-5x/week
o Intensity : 40-60% Heart Rate Reserve
o Timing : 5 minutes warming up, 15 minutes conditioning, 5
minutes cooling down
o Type : Static cycle
PMo : clinical findings, vital sign, WBS, ROM, MMT, atrophy, endurance,
BMI
PEd : Health Education and Home Exercise Programme
Explain the patient’s condition
o Continue the exercise at home
o Reduce body weight
o Icing compress at left knee when she felt pain, frequency 4-6x/day,
duration 15-20 minutes
o Knee joint conservation

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 October, 17th 2020
 The pain on left knee decrease, WBS : 2
 The pain decrease when squatting and standing for a long time, doesn’t feel pain
anymore when walking.
The pain decrease when going upstairs. Did Shalat with sitting on a chair.
 General status: CM, independent ambulation, normo posture, right handed
 Vital sign: BP: 130/90 mmHg, HR: 76x/min, RR: 18x/min
 Body weight : 54,5 kg, body height : 1,44 m, BMI : 26,3 kg/m2 (obese grade I)
 Musculoskeletal status of knee:
 Flexion : ROM = Full/ Full ; MMT 5/5
 Extension : ROM = Full / Full ; MMT 5/5
 Local status of knee: Swelling -, Warmth -, Crepitation -/+, tender point at lateral
left knee, atrophy VMO Sinistra (+).
o Q-Angle : Non WB : 10o (valgus) / 10o (valgus), WB : 10o (valgus) / 10o (valgus)
o Thigh circumference : 43 cm / 42 cm
o Knee circumference : 38 cm / 38 cm
o Calf circumference : 33 cm / 33 cm
 Special test : Patellar grinding test : +/+
 TUG Test : 9,46 (normal)
 KOOS Score : 76,2
Knee Pain Sinistra ec Osteoarthritis Genu Grade II-III + Hypertension Stage II
(Controlled) + Obese Grade I

PDx : -
PTx :
Modality :

LASER 2J/cm2 at tender point Genu Sinistra 100% continous

Therapeutic exercise :
 AROM exercise lower extremity Dextra and Sinistra
 Isotonic quadriceps strengthening exercise (2-3x/week, 60% 1 RM,
repetition 8-12x for 2-4 sets, Q Bench)
 Breathing exercise active with chest expansion

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  Endurance exercise :
o Frequency : 3-5x/week
o Intensity : 40-60% Heart Rate Reserve
o Timing : 5 minutes warming up, 15 minutes conditioning, 5 minutes
cooling down
o Type : Static cycle
PMo : clinical findings, vital sign, WBS, ROM, MMT, atrophy, endurance, BMI
PEd : Health Education and Home Exercise Programme
Explain the patient’s condition
o Continue the exercise at home
o Reduce body weight
o Icing compress at left knee when she felt pain, frequency 4-6x/day,
duration 15-20 minutes
o Knee joint conservation

6
Knee Pain
5

3
WBS

0
Au gu st 2 7 t h 2 0 2 0 S ep t em b er 2 6 t h 2 0 2 0 Oc t o b er 1 7 t h 2 0 2 0

39
 KOOS
90
80
70
60
50
40
30
20
10
0
Au gu st 2 7 t h 2 0 2 0 S ep t em b er 2 6 t h 2 0 2 0 Oc t o b er 1 7 t h 2 0 2 0

Tes TUG
14

12

10

0
Au gu st 2 7 t h 2 0 2 0 S ep t em b er 2 6 t h 2 0 2 0 Oc t o b er 1 7 t h 2 0 2 0

WEIGHT
57

56.5

56

55.5

55

54.5

54

53.5
Au gu st 2 7 t h 2 0 2 0 S ep t em b er 2 6 t h 2 0 2 0 Oc t o b er 1 7 t h 2 0 2 0

HOME VISIT :

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Figure 3.3 Home Visit

41
 SUMMARY

Reported Mrs. S, 70 years old, referred from orthopedic outpatient clinic

with OA genu Billateral grade II. Patient complained about pain at her left knee.
Pain is dull and localized. There was no radiating pain, no numbness, and no
tingling sensation. The pain got worsen when she walked for long distance
(>100m) and stand for a long time (± 30 minutes) (WBS : 5-6) and relieved when
she took a rest with lying position (WBS : 3-4). She also complained about
stiffness on the left knee when waking up in the morning for about 5 minutes. The
stiffness was relieved if she moved her knee. Sometimes there was crackling
sound on her left knee especially if she did sholat in rukuk and sujud position.
Unstable sensation during walking was denied. Now she had difficulty in using
stais and sholat. She did sholat in sitting position.
From physical examination there were antalgic gait, knee crepitation,
tender point at lateral side and positive patelar grinding test at left knee. From X
ray examination, we found osteoartritis femorotibial and femuropatellar joint
Sinistra grade I.
The patient was diagnosed with Knee Pain Sinistra ec Osteoarthritis Genu
Grade II-III + Hypertension Stage II (Uncontrolled) + Obese Grade I. Our
planning therapy were LASER 4J/cm2 at Genu Sinistra, AROM exercise lower
extremity Dextra and Sinistra, Quadriceps strengthening sinistra, Breathing
exercise active with chest expansion and Endurance exercise.
Our planning monitoring were clinical findings, vital sign, WBS, ROM,
MMT, atrophy, endurance, BMI. We educated the patient by Explain the patient’s
condition, reducing body weight, Continue the exercise at home, Icing compress
at left knee with frequency 4-6x/day and duration for 15-20 minutes, and Knee
joint conservation.
After serial rehabilitation, there were pain and inflammation reduction so
the patient felt more comfortable in performing her daily activities. The pain scale
(WBS) was decreased and KOOS Score has improved.

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