PHYSIOTHERAPY ASSESSMENT

SUBJECTIVE ASSESSMENT:
Demographic data:

a. Name:

b. Age:

c. Gender:

d. Weight:

e. Occupation:

f. Address:

g. Phone no:

CHIEF COMPLAINTS: Right lower leg and foot swollen and painful since

previous evening.

HISTORY

Presenting history of illness:

Past history of illness:

Present and past medical history: analgesics

Associative diseases: diabetes,

HTN,
 obesity

Family history: diabetic history

Personal history: smoker

Chronic alcoholic

Socio Economic history: normal

PAIN ASSESMENT:

1.Onset: Gradual

2. Duration:

3. site/location: ankle and foot

4. Mode: Constant

5. Type:

Dull and aching

Radiating

6.pain agrevating factors: any weight bearing acticities,adl’s

7.pain relieving factors: rest

8 Intensity of pain:

a. Visual analougus scale (vas)

|-----------------------------------------------------|

0 7 10
 OBJECTIVE ASSESMENT:
1. ON OBSERVATION:
- GENERAL BODY POSTURE
- BODY BUILT : normal (mesomorphic)
- ATTITUDE OF LIMB : slightly in knee flexion
- REDNESS
- SWELLING : around foot and ankle
- DEFORMITY : bowing out of plantar surface
- GAIT :

2. ON PALPATION

i. TEMPERATURE : warmth
ii. TENDERNESS : present (grade 3)
iii. OEDEMA : In right leg
iv. PULSE : bounding pedal pulse

ON EXAMINATION:

i. SENSORY EXAMINATION:

A. Superficial sensations

- Touch:
Fine touch
Crude touch
- Pain:
 - Temperature

B. Deep sensation:

- Proprioception
- Kinaesthesia
- vibration

C. Cortical sensation:

- 2point discrimination:
- Tactile localization
- Sterognosis
- Barognosis
- Graphestesia

ii. MOTAR EXAMINATION:

a. Muscle tone:
b. Manual muscle testing:

UPPER LIMB: 5

LOWER LIMB-

Hip:

Flexion : 3

Extension : 3

Abduction : 3

Adduction : 3
Knee:

Flexion :

Extension :

Ankle:

Dorsi Flexion

Plantar flexion

Inversion

Eversion

RANGE OF MOTION:

MUSCLE GIRTH:-

Girth measurements L R

Calf 41.2cm 42cm

Ankle 23.1cm 23.4cm

LIMB LENGTH DISCREPANCY (LLD)

TENDON REFLEXES
Knee reflex : 1

ankle reflex : 1

ACTIVITIES OF DAILY LIFE: unable to squat

INVESTIGATIONS:

- LAB DIAGNOSIS (Enzymatic levels) -

RADIOLOGICAL INVESTIGATIONS (x-ray, mri, ct- scan)

DIFFERENTIAL DIAGNOSIS:

SPECIAL TESTS:

PROVISIONAL DIAGNOSIS:

LIST OF PROBLEMS:

TREATMENT PLAN:

Aims ;
: to correct muscular imbalances by increasing strength &
decreasing contractures of specific muscles

Prevention of further jt destruction and foot deformity

 To provide rest and stabilisation of the area

PHYSIOTHERAPY INTERVENTIONS:

FOOT ASSESSMENT

1.Prior history of foot ulcer?

• Is there an ulcer now?In the past? : no

• Is there a previous amputation? : no

• Pt is at risk for developing another foot ulcer,potential for

amputation.. : yes

2.Appearance of the foot:

• Color : red

• Nails :

• Symmetry

• Swelling :

• Deformities

3.Assess the skin:

• Absence of hair
• Thin/shiny skin

• Calluses

• Ulcers

4.Assess Circulation:

• Pedal pulses : bounding

• Temperature fluctuations : increased

• Atrophy :

5.Assess Sensation

• Quick test - 2 mins

• Painless

• Predicts potential ulcer development

6.Inspect Patient’s Footwear:

Old and new shoes should be checked daily for-

• -nails/sharp objects
• -spots caused by open injuries