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Case Rounds November 29, 2010

Case Rounds November 29, 2010. Chris Kuchta, PT,SCS,CSCS Director of Aquatics PRO Physical Therapy Wilmington, DE Chris.Kuchta@propt.com. Initial Evaluation. 17 y/o male high school soccer player No prior injury; negative medical history Referred to PT by primary MD

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Case Rounds November 29, 2010

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  1. Case Rounds November 29, 2010 Chris Kuchta, PT,SCS,CSCS Director of Aquatics PRO Physical Therapy Wilmington, DE Chris.Kuchta@propt.com

  2. Initial Evaluation • 17 y/o male high school soccer player • No prior injury; negative medical history • Referred to PT by primary MD • ‘R hip pain, eval & tx’ • Injury occurred approximately 2 weeks prior • Sprinting to ball, clipped toe of another player and subsequently tripped and fell to ground • Had immediate pain and took himself out of the game • Walked off the field • Currently 0/10 pain at rest, 10/10 attempting sports activities

  3. Initial Evaluation • The basics • When – Approximately 2 weeks ago • Where – Pt. generally rubs his right flank, and is unable to point to a specific cause of his pain with one finger • How – Unfortunately he does not remember if the injury occurred while sprinting or falling/landing • What else would you like to know about the patient?

  4. Initial Evaluation • Activities that worsen sx: • Coughing and sneezing • Twisting and turning, such as rolling over in bed and getting out of car • Any attempts at sports activity • Improve sx: • Advil • Relative rest

  5. Initial Evaluation • X-Rays negative • No bruising or abrasions noticed • Hasn’t been limping • No “red flags”

  6. Question # 1 • Blood in the urine after trauma usually indicates • A. Kidney stones • B. Urinary tract infection • C. Injury to the urogential system • D. None of the above

  7. Initial Evaluation • What sport-specific questions are pertinent to this case?

  8. Initial Evaluation • What position does he play? • Is he in-season? • If so, how much of the season is left? • Is he only playing for his high school? • What is his dominant (kicking) leg? • Is he responsible for throw-ins? • Is he currently playing another sport?

  9. Question # 2 • Based on the patient’s chief complaint of R flank pain, what structures may refer to this area? A. Ribs 4-7 B. Shaft of the femur C. 11-12th Thoracic nerve root D. Pubic symphysis

  10. Initial Evaluation • Lower T-spine and upper L-spine nerve roots can refer to hip and/or flank region • Note that a standard pelvic X-Ray may not show those levels

  11. Initial Evaluation • What is your hypothesis and why? • What objective tests would you like to perform and why?

  12. Objective Data Hip Outcome Score • ADL 62%, Sports 12% • Scale 0-100, lower scores indicate more disability • Global rating ADL 80%, Sports 0% • Corresponds with subjective report • Observations • No limp • No ecchymosis or swelling hip or flank

  13. PROM R L Trunk AROM Lumbopelvic screen (-) Fwd flexion – tip of 3rd finger 18cm from floor Extension – full, mild deviation to the right R lat flexion 40cm L lat flexion 51cm w 4/10 ‘pulling’ flank pain Max open of R and max closing L both 4/10 pain Objective Data

  14. Strength R L Objective Data Kendall’s DLLT Lost PPT with pain @ 75

  15. Special Tests • Thomas test + • Slightly more rectus tightness R vs L • 2/10 pain testing R • Obers test revealed bilat ITB tightness • 2/10 pain testing R • Faber, Scour, segmental spring testing of T10-L5 all negative, dermatomes intact

  16. Question # 3 • Patient is tender 1cm proximal to ASIS on the R. What muscle could this be? A. Rectus Abdominus B. Sartorius C. Oblique Externus Abdominus D. Quadratus Lumborum

  17. Objective Data • Palpation: • R rectus abdominus negative • Diffusely TTP R oblique vs L, distal third mm mass 4/10 pain • How can we try to isolate? • L S/L over pillows, ask pt to perform a side ‘crunch’ (i.e. Activate against gravity) • Result – 3/10 pulling pain in the start position, 8/10 upon attempting to ‘crunch’- test stopped

  18. Assessment • Why did he have pain with max opening/closing? • Why was coughing/sneeing, resisted R hip abd provocative? • What is your PT diagnosis???

  19. Assessment • PT diagnosis R external oblique strain

  20. Plan of Care • What are the patient’s impairments?

  21. Plan of Care • What are your goals?

  22. Plan of Care • What should be in the plan of care? • How can we effectively implement a plan of care when the patient has up to 10/10 pain?

  23. Plan of Care • Welcome to the world of Aquatic Physical Therapy!

  24. Question # 4 • What water temperature will be appropriate for whole body immersion to facilitate muscle relaxation and pain relief for aquatic therapy? • A. 115 degrees F • B. 68 degrees F • C. 92 degrees F • D. 34 degrees F

  25. Plan of Care • Benefits • Warm water (92 degrees F) • Facilitates flexibility/mobility • Decreases pain sensitivity/mm spasm • Bouyancy • Based on level of immersion, can drastically decrease axial compression/stresses • Eliminate gravitational load from extremities – facilitate mobility and sport-specific movements • Resistance in all directions • Can easily implement dynamic movements early in POC, safely challenge problem areas later on

  26. Plan of Care • Initial aquatic activities in straight planes, progressive challenge to core • Use buoyancy and surface tension to effectively restore mobility and flexibility of the involved area • Add rotational/multiplanar motions to tolerance • Sport-specific motions

  27. Acute Aquatic Management

  28. Plan of Care

  29. Plan of Care

  30. Plan of Care

  31. Plan of Care • After first pool treatment : “dude, there’s no way I could do that out there (on land)”

  32. Question # 5 • What other differential dx might you suspect if pain persisted or worsened during treatment (buoyancy did not help)? • “sports hernia” • T-11 pars interarticularis fx • Osteitis pubis • All of the above

  33. Reassessment At IE At re-check

  34. Reassessment • We decide to keep him in the pool • Pool program revamped to include more challenge to external obliques and incorporate sport-specific movements.

  35. Plan of Care

  36. Plan of Care

  37. Plan of Care

  38. Plan of Care • Functional testing • Performed in pool first

  39. Consider his injury and sport in choosing functional progression Plan of Care

  40. Plan of Care • Pt’s only complaint was 1-2/10 pulling type pain R flank with corner abdominal series, specifically reverse curl-up with R rotation. • After 8 aquatic treatments, we now decide he is ready for formal re-evaluation on land.

  41. Formal Re-Evaluation Test Deficit • No c/o pain during testing • DLLT to 40 degrees, 1/10 R oblique pain • Based on aquatic progression and objective findings, we decide to transition to land

  42. Plan of Care • As of 11/23, pt continues to progress well and is on his way to accomplishing PT and his own goals of full participation in indoor soccer. Any other questions? Thank you

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