Lower Quarter Cases - Hip Case (PDF)

**LOWER QUARTER CASES** **HIP CASE** History & Review of Systems 1. Reason for seeking PT a. Issue/Concern: Pain in the left hip b. Onset: On and off for 2 years but recently worsened c. Location/Body region: deep in the buttock or hip joint area and achy d. Modif...

**LOWER QUARTER CASES** **HIP CASE** History & Review of Systems 1. Reason for seeking PT a. Issue/Concern: Pain in the left hip b. Onset: On and off for 2 years but recently worsened c. Location/Body region: deep in the buttock or hip joint area and achy d. Modifying factors: increases with sitting \>20 minutes, especially on soft surfaces such as the couch; also increases after running \>15 minutes; pain decreases with getting out of sitting or avoiding running; occasional snapping or popping when transitioning from sit to stand. At rest, 2/10 pain, at worst 7/10 2. Personal Information e. Age: 30 f. Sex: female g. Pronouns: she, her, hers h. Height: 5'6" i. Weight: 132 lbs j. BMI: 20 k. Occupation: office worker 3. Living Environment: l. Type of home: 2 story home, bedroom on 2^nd^ floor m. Support: lives with toddler and spouse; family and friends live nearby 4. Abbreviated Review of Systems -- Checklist n. Negative for all questions 5. Medical/Surgical history: o. One singleton vaginal delivery (3 years ago) 6. Current medications p. Prescription: Mirena IUD q. Over the counter (OTC): seasonal allergy meds, NSAIDs PRN 7. Current Health Behaviors r. Physical Activity: typically walks for exercise, but recently began running; participated in high school and college gymnastics 8. Self-report measures s. LEFS: 40% (lower score indicates higher disability) 9. Safety and well-being t. No concerns reported 10. Goals discussed with patient, client, or care partner u. Goals related to physical therapy: Abolish pain with sitting for work and leisure and progress to pain-free running 1. **What structures in the area of the symptoms could be the source of pain?** (Bone/muscle/ligament/bursa/capsule) ***HINT: Check out content in the "Source of Signs or Symptoms" column on the hip diagnostic grids*** - **muscle, ischial bursa, iliopsoas tendon, and hip joint capsule are likely candidates based on the patient\'s symptom pattern.** 2. **What structures or regions could refer pain to the area of symptoms?** - **lumbar spine (L4-S1 nerve roots), SI joint, and gluteal muscles,** 3. **Based on the location of symptoms and modifying factors, what is your working movement system diagnosis?** - **Femoral Anterior Glide with Medial Rotation** 4. **Open the power point titled "Hip Flexion Tests" located on the page with the description of Guided Activities LQ. Then, observe AG's movement pattern for hip flexion with the knee flexed. Describe what you see.** - **excessive rom** - **Limited rom** 5. **Using the diagnostic grids, identify 2 factors from the "Symptoms or History" column and 2 key tests from the "Key Tests & Signs for MS Diagnosis" column that distinguish Femoral Anterior Glide with Medial Rotation from Femoral Anterior Glide with Lateral Rotation. Fill in the table below.** +-----------------------+-----------------------+-----------------------+ | | Ant Glide w/ LATERAL | Ant Glide w/MEDIAL | | | Rotation | Rotation | +=======================+=======================+=======================+ | *Symptom location* | Anterior, lateral | Anterior or deep | | | groin | buttock | +-----------------------+-----------------------+-----------------------+ | *Reported movements | excessive hip | hip flexion and | | that increase | external rotation | internal rotation | | symptoms* | | | +-----------------------+-----------------------+-----------------------+ | *Activities/Populatio | hip external rotation | prolonged sitting or | | n* | | running activities | | | ,ballet, dancers, | | | | athletes | | +-----------------------+-----------------------+-----------------------+ | *Alignment:* | Excessive hip | Hip internal rotation | | | external rotation, | with anterior pelvic | | | pelvic asymmetry, and | tilt | | | anterior pelvic tilt | | +-----------------------+-----------------------+-----------------------+ | *BKFO (bent knee fall | Excessive lateral | Limited or excessive | | out)* | movement | internal rotation | +-----------------------+-----------------------+-----------------------+ | *Gait* | Increased external | Increased internal | | | rotation during | rotation during the | | | terminal stance | swing phase with knee | | | | valgus | +-----------------------+-----------------------+-----------------------+ | *ROM* | *Excessive external | Excessive internal | | | rotation with limited | rotation with limited | | | internal rotation* | external rotation | +-----------------------+-----------------------+-----------------------+ | *MMT* | -Weakness in hip | -Weakness in the | | | internal rotators | external rotators | | | (gluteus med and | (gluteus max) and | | | mini) | posterior hip muscles | | | | | | | -overuse of the | \- overuse of the | | | external rotators | internal rotators | | | (piriformis) | (adductors, TFL) | +-----------------------+-----------------------+-----------------------+ 6. **What is a movement or alignment impairment at the knee that would contribute to femoral anterior glide?** a. knee valgus 7. **What is a movement or alignment impairment at the foot/ankle that would contribute to hip medial rotation**? b. **Excessive pronation causing the tibia to internally rotate.** **KNEE CASE** History & Review of Systems 1. Reason for seeking PT a. Issue/Concern: Referred by her primary care physician for the evaluation and treatment of right knee pain, most likely patellofemoral syndrome b. Onset: 3 months ago c. Location/Body region: "sharp" and located "below the knee cap" d. Modifying factors: increases with jumping during basketball practice and going up or down stairs. Pain is relieved by rest and ice. At rest, 1/10 pain, at worst 5/10 2. Personal Information e. Age: 17 f. Sex: female g. Pronouns: she, her hers h. Height: 5'8" i. Weight: 145 lbs j. BMI: 22 k. Occupation: junior in high school 3. Living Environment: l. Type of home: 2 story home, bedroom on 2^nd^ floor m. Support: lives with her parents 4. Abbreviated Review of Systems -- Checklist n. Negative for all questions 5. Medical/Surgical history: o. None reported 6. Current medications p. Prescription: birth control q. Over the counter (OTC): Ibuprofen PRN 7. Current Health Behaviors r. Physical Activity: plays basketball in the winter months and softball in the spring 8. Self-report measures s. LEFS: 70% (lower score indicates higher disability) 9. Safety and well-being t. No concerns reported 10. Goals discussed with patient, client, or care partner u. Goals related to physical therapy: She would like to be able to climb stairs and engage in all of her sports activities without pain. 1. **Based on this information, what are your top 2 working movement system diagnoses? Provide rationale for each.** a. Knee Extension Syndrome AND Knee Hyperextension Syndrome TEST & MEASURES: (for right side only) Posture/ Alignment: Mild swayback in standing Palpation Tibiofemoral Joint**:** positive for pain along the joint line in hooklying position Movement Standing: **Hip and knee flexion (partial squat):** negative for symptoms; mild valgus noted **Heel tap:** positive for pain; can only resolve by using smaller size stool Prone: Passive Joint Mobility Muscle Performance Muscle Length 1. **At this point in the exam, what is your current top working movement system diagnosis and why?** a. Knee Extension Syndrome 2. **You only have 10 minutes left in your session. What are 2-3 additional key clinical tests or functional activities that you would like to perform to help you confirm your suspected final movement system diagnosis? Please list tests and associated test results you would expect: (be sure to refer to the Knee Grids):** b. Single-Leg Squat Test: knee valgus c. Step-Down Test: Knee valgus d. Resisted Knee Extension Test: anterior knee pain 3. **What are other impairments related to the alignment or movement at the hip and/or ankle-foot that could contribute to your patient's movement system diagnosis? Briefly explain your answer(s):** e. **Hip muscles weakness** 4. **Based on your movement system diagnosis and this patient's specific needs/goals, what would be the major focus of your intervention?** f. Strengthening the hip Muscles, Reduce Quadriceps Overuse, Hip flexor and ITB stretches, Neuromuscular Re-education. 5. **What would be the most important cues you would use to modify the functional tasks of squatting and jumping that she has to perform during her sports?** g. Keep your knees in line with your toes, **Sit your hips back** **FOOT/ANKLE CASE** **History & Review of Systems** 1. a. b. c. d. 2. **Personal Information** e. **Age: 47** f. **Sex: female** g. **Pronouns: she, her hers** h. **Occupation: Hostess at a restaurant** 3. **Abbreviated Review of Systems -- Checklist** i. **Negative for all questions** 4. **Medical/Surgical history:** j. **None reported** 5. **Current medications** k. **Over the counter (OTC): Ibuprofen PRN** 6. **Safety and well-being** l. **No concerns reported** 7. **Goals discussed with patient, client, or care partner** m. **Goals for physical therapy: Be able to return to full time work without foot pain** **TEST & MEASURES:** **Posture/Alignment (Standing): Calcaneus neutral, medial longitudinal arch low.** **Movement:** **Gait:** **Arch: lowers heel strike to midstance and remains low through push off.** **Dorsiflexion: 0° at heel off** **Right and left similar pattern, but worse on the right.** **Range of Motion:** **Active talocrural dorsiflexion with knee extended R= 0^o^, L=5^o^** **Active talocrural dorsiflexion with knee flexed R=10°, L=10°** **Source of Symptoms** **Palpation: Pain is localized at the medial plantar calcaneus.** **Equipment** **Footwear: Patient wearing her work shoes which are well worn dress shoes.** 1. **What structures in the area of the symptoms could be the source of pain?**(Bone/muscle/ligament/bursa/capsule) a. plantar fascia**, the** flexor digitorum brevis**, and possibly the** calcaneus **itself.** 2. b. **Excessive Pronation with Associated Plantar Fascia Dysfunction.** 3. c. **Location of Symptoms, Calcaneal Eversion During Gait, Reduced dorsiflexion ROM, Low medial longitudinal arch** 4. d. **Achilles Tendinopathy was ruled out because the patient lacks posterior heel pain or tenderness along the Achilles tendon, and her pain is primarily associated with pronation rather than activities that place stress on the Achilles tendon** 5. e. Knee valgus f. Inc Hip Internal Rotation g. Inc Hip Adduction/hip drop 6. h. Excessive Foot Pronation, Prolonged Weightbearing, Footwear, Dec Dorsiflexion ROM 7. - **Walking barefoot** - **Morning stiffness (pain after rest)** - **Standing and walking during work shifts.** - **Supportive footwear** - **Rest** - **Ibuprofen** - **reduced stiffness in the afternoon** 8. i. Walking Barefoot , Standing and Walking During Work 9. **Treatment Plan: What are two top priority exercise you would provide?** j. Calf Stretch, Intrinsic Foot Muscle Strengthening) **10) Write one short term goal:** Within 2 weeks **patient will demonstrate a 25% reduction in morning heel pain (from 7/10 to 5/10) with the use of stretching exercises and supportive footwear** **11) Write one long term Goal: Within 8 weeks, the patient will return to full-time work with no more than 2/10 pain during standing or walking, by consistently performing exercises to improve foot mechanics and wearing supportive footwear**