ASSESSMENT

Diagnostic hypotheses: Never healed ACL/MCL/medial meniscus injury due to self d/c 3 years ago, Knee OA, OCD, PFPS

Examination identified physical impairment list: Left knee flexion and extension 4+ (slight diffuse discomfort with ext.), left knee IR
4+, quad atrophy

Examination identified functional limitations: Squat with feelings of instability/valgus collapse, step up with valgus collapse,
running/walking lacking full extension

Prognosis/Rehabilitation potential: Excellent prognosis due to the young age and motivation to get better to return to
activity/fitness.

Intervention performed today:

(be specific with in clinic treatment, home exercise program and activity advice. Be sure to include dose, frequency or any other
pertinent factors)
Clinical Tx: A-P passive manuals good stretch at 50%, step-up with unstable left knee-> valgus with left leg going up first (3x), squat
with unstable left knee falling into valgus collapse as well going down x3, assessed gait lacking full extension up and back 2x (10 ft
each way),
HEP: demonstrated in 1st clinical visit but made for HEP, TKE supine 2 sets of 8 each due to the good stretch feeling with passive
motion (warm-up), TKE in standing PT guided pressure, given theraband for HEP to facilitate how hard to push back 3 sets of 12,
Squats to a chair height -> used gaitbelt to cue pushing out to avoid valgus collapse 3x5, step-ups focusing on lateral weight shifts
having the knee go over the toes or out to the side to avoid the medial valgus collapse 2x14 (to facilitate the 10-12 steps usually for a
flight on campus).

Reassessment of Primary History and Physical Examination Findings Following Intervention (SE* & OE*):
SE* - Feeling of instability/pain
OE*- Knee Extension MMT

PLAN OF CARE AND GOALS

Plan of care: Pt will come to therapy 2x for 2 weeks, then 1x week for 4-6 weeks. Then possible booster visits 1 to 3 months out.

Patient education: Just talking with the patient about the impairments, why we are seeing it due to the non-healed tissues, how this
will progress, how to take care of their body, how to properly do their exercises and HEP and when too much and too little.

Coordination/Communication: Keep an open communication with me, if things are getting better we can taper down visits, but if not
we can get you back in to see what’s going on and possible need for referral

Patient goal: Get knee to feel stronger and more stable to get back to regular exercise/fitness

Short term goal:

1. Patient will get full knee extension to 0 degrees in order to ambulate properly while walking to class in 3 weeks.
2. Patient will do 6 step-ups without feeling of instability or discomfort in 3 weeks in order to walk up stairs to get to class.

Long term goal:

1. Patient will be able to do 10-12 step-ups without feeling of instability or discomfort in 6 weeks in order to walk up stairs to
get to class/at home.
-------------------------------------------------------------------------------------------------------------------------------------------------------
FOLLOW-UP NOTE

1) Items to reassess – include subjective and objective measures:

a. SE * Feelings of instability and pain
b. OE* Knee Extension
c. Also want to reassess, gait, squat, and step-up/downs
2) Plan for continued treatment if symptoms continue to improve:
a. Work on progressing into deeper squat, increased load with squat, increase reps, and size of step, start
to progress to jogging -> running,
3) Plan for continued treatment if symptoms stayed the same:
a. Try to increase what was said before to try and see if the symptoms are provoked and see if the pt is
doing the exercises correctly.
4) Plan for continued treatment if symptoms are worse:
a. Move into more supine for TKE’s, lower step height for step-ups, and decrease depth for the squat, and
maybe move more into manuals as well.
5) Trigger for additional tests/measures/imaging/referral:
a. If the instability continues to be a problem after 12 weeks of therapy, refer to an orthopedic physician
for possible imaging of the knee ligaments/structure
b. If something acutely presents before then