Right Knee Pain

Case Description: Pt is a 74 y/o female who arrived to physical therapy with right knee pain. She had a left tibial fracture 5 months prior due to a fall. With this, she was non-weight bearing through her left lower extremity and hopped on her right lower extremity with a 4WW to get around. She now has difficulty with prolonged standing and weight bearing, walking, and she avoids negotiating stairs. Her goals are to be able to walk longer distances and find ways to become more physically active. 

Objective Measures: The patient was seen for physical therapy 16 visits over a course of 2 months. 

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
Numeric pain rating scale	4/10 at worst1/10 at best	0/10 at worst
LEFS	38/80	45/80
Knee range of motion	R: -5 deg L: -3 deg	R: -1 deg L: 0 deg
Hip Strength (* painful)	Ext Rotation: R:4/5* L:4-/5Int Rotation:R: 5/5 L: 4+/5Abduction: R: 3+/5 L: 4-/5 Extension: R: 3+/5 L: 4-/5	Ext Rotation: R: 4+/5 L: 4+/5Int Rotation: R: 5/5 L: 5/5Abduction: R: 4/5 L: 4+/5Extension: R: 5/5 L: 5/5
Daily activity performance	Difficulty with prolonged standing/weight bearing stair negotiation, ambulation	No difficulty or pain with previously listed and pt got membership at Evergreen commons to begin a regular physical activity regime

Summary: Patient was discharged from physical therapy due to reports of 80% improvement since the start of therapy and no longer experiencing any pain in the right  knee. She is able to perform her daily tasks without any difficulty. She is able to walk longer distances and has been challenging herself to utilize stairs more. She signed up for Evergreen Commons to begin a regular physical activity regime which was one of her goals at the start of therapy. She was educated on the use of her home exercise program to maintain gains in strength and range of motion.