OUTPATIENT PHYSICAL THERAPY FOR A PATIENT FOLLOWING

OPEN REDUCTION INTERNAL FIXATION DUE TO

BICONDYLAR TIBIAL PLATEAU FRACTURE

A Doctoral Project
A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

by

Rose Fair Linehan

SUMMER
2019
 © 2019

Rose Fair Linehan

ALL RIGHTS RESERVED

ii
 OUTPATIENT PHYSICAL THERAPY FOR A PATIENT FOLLOWING

OPEN REDUCTION INTERNAL FIXATION DUE TO

BICONDYLAR TIBIAL PLATEAU FRACTURE

A Doctoral Project

by

Rose Fair Linehan

Approved by:

_____________________________________, Committee Chair

Brian Moore, PT, DPT, NCS

_____________________________________, Second Reader

Toran MacLeod, PT, PhD

_____________________________________, Third Reader

William Garcia, PT, DPT, OCS, FAAOMPT

____________________________
Date

iii
Student: Rose Fair Linehan

I certify that this student has met the requirements for format contained in the University

format manual, and that this project is suitable for shelving in the Library and credit is to

be awarded for the project.

__________________________________, Department Chair ____________

Michael McKeough, PT, EdD Date

Department of Physical Therapy

iv
 Abstract

of

OUTPATIENT PHYSICAL THERAPY FOR A PATIENT FOLLOWING

OPEN REDUCTION INTERNAL FIXATION DUE TO

BICONDYLAR TIBIAL PLATEAU FRACTURE

by

Rose Fair Linehan

A 49-year old female patient underwent open reduction internal fixation due to a

bicondylar tibial plateau fracture. She was seen in outpatient physical therapy for 20

sessions over 10 weeks. Treatment was provided by a student physical therapist under the

supervision of a licensed physical therapist.

Initial evaluation was conducted 2 weeks post-operation where the patient

presented with swelling in the right knee and ankle, decreased knee and ankle range of

motion (ROM), decreased lower extremity muscle strength, and decreased functional

status. Per physician’s orders, the patient was non-weight bearing for 6 weeks following

surgery and ambulated using 2 axillary crutches. The patient was evaluated at the initial

encounter with goniometry, manual muscle testing, Numeric Pain Rating Scale, mid-

patellar girth measurements, palpation, observation, the Wells criteria, the Lower

Extremity Functional Scale, the Timed Up And Go test, and patient report of status. A

plan of care was established, and treatment was administered twice weekly for 10 weeks.

v
 The patient’s primary goals were to decrease pain, ambulate without an assistive

device, return to driving, and return to work. The interventions used were patient

education, postoperative bracing, progressive ROM techniques, neuromuscular electrical

stimulation, pneumatic cryotherapy, soft tissue mobilization, isometric exercises, open-

and closed-chain strengthening exercises, stretching, gait training, and balance activities.

At discharge, the patient showed improvements with ROM, strength, girth measurements,

fall risk, gait mechanics, functional independence, return to driving, and return to work.

The patient was discharged from outpatient physical therapy with a home exercise

program.

_____________________________________, Committee Chair

Brian Moore, PT, DPT, NCS

_______________________
Date

vi
 ACKNOWLEDGEMENTS

I acknowledge my dedicated professors at California State University,

Sacramento and my clinical instructor, Holly Harris, for fostering my learning. To all my

mentors who have enabled me to treat patients with skill and care, I thank you. I also

acknowledge my mother and father for their immense support because without it, I would

not be where I am today.

vii
 TABLE OF CONTENTS
Page

Acknowledgements .............................................................................................. vii

List of Tables ........................................................................................................ ix

Chapter

1. GENERAL BACKGROUND ........................................................................... 1

2. CASE BACKGROUND DATA ....................................................................... 4

3. EXAMINATION – TESTS AND MEASURES .............................................. 7

4. EVALUATION............................................................................................... 12

5. PLAN OF CARE – GOALS AND INTERVENTIONS................................. 14

6. OUTCOMES................................................................................................... 26

7. DISCUSSION ................................................................................................. 31

References ............................................................................................................. 33

viii
 LIST OF TABLES
Tables Page

1. Medications ………………… .......................... .……………………………….6

2. Examination Data……………………………….…. …………………………10

3. Evaluation and Plan of Care… .. ………….…………………………………. 14

4. Outcomes……………………………….……… ......... ………………………26

ix
 1

Chapter 1

GENERAL BACKGROUND

Bone fractures that result from a trauma such as a fall, are a common orthopedic

injury. In 2017, the prevalence of non-spinal fractures resulting from a fall was 63.1%.1

The majority of these fractures (82.7%) were sustained by females, with an overall

incidence of 1,030.3 per 100,000/year.1 The knee is the largest weight-bearing joint in the

body, with articulating surfaces between the medial/lateral condyles of the femur and the

tibial plateau of the tibia.2 Anatomically, the tibial plateau is comprised of cancellous

bone which is less dense than the distal cortical bone.2 Tibial plateau fractures (TPFs) are

often the result of a force that drives the distal femur into the cancellous bone of the tibia,

resulting in compression and damage.2

Tibial plateau fractures account for about 1% of all fractures.3 The overall

incidence is 10.3 per 100,000/year.3 These fractures occur from high- or low-energy

trauma.4 High-energy traumas such as severe falls or motor vehicle accidents result in

complex fracture patterns whereas low-energy traumas are often the result of advanced

age or osteoporosis (OP).2,4 The Schatzker classification system is used to assess the

extent of the fracture using computed tomography (CT) scans.5,6 Fracture severity

progressively increases from Schatzker type I to type VI.5 Types I, II, and III are

unicondylar lateral fractures, type IV is a unicondylar medial fracture, and types V and

VI are bicondylar fractures.5 Soft-tissue damage which is detected using magnetic

resonance imaging (MRI) can accompany even low-energy fractures.4 A study that
 2

assessed various Schatzker fractures including type I (3), type II (62), type IV (7), type V

(17), and type VI (14) found associated soft-tissue injuries in 99% of these subjects.7

Modifiable risk factors for sustaining a fracture include smoking, sedentary

lifestyle, poor nutrition, and OP.8-10 Osteoporosis, as well as poor lifestyle factors

mentioned, increase fracture risk by decreasing bone mineral density (BMD) causing

weak bones that are prone to fracture.8,10 Non-modifiable risk factors include age, sex,

menopause, and trauma. The highest frequency of TPFs occur between 40-60 years old.3

Complex TPFs are often set surgically through open reduction and internal

fixation (ORIF) which involves securing the bone fragments into place with metal plates

and screws.11 Most rehabilitation protocols for postoperative TPF recovery offer

guidelines for brace use, non-weightbearing (NWB) time, and partial weight bearing

(PWB) time.12 The most common NWB time was 4-6 weeks followed by 4-6 weeks of

PWB.12 Similar rates of rigid (47%) and hinged braces to restrict knee motion (58%)

were used for the initial 3-6 weeks following surgery.12 Early range of motion (ROM) at

the knee is encouraged with the goal of 0° of knee extension and 90° of knee flexion

within 5 to 7 days.13

Long-term concerns following ORIF include loss of joint motion, joint instability,

and osteoarthritis (OA) as these affect one’s return to function.2,4 An important factor that

is predictive of future function is knee stability based on postsurgical joint congruity.14

One study showed OA developed in 27% of subjects with valgus or varus malalignment

>5° (p=0.02) postoperatively.14 Positive prognostic factors for return to function are

tolerance of early passive knee joint mobilization and patient motivation.15,16 Negative
 3

prognostic factors include bicondylar fractures, extensive soft-tissue injury, deep surgical

site infection, tobacco use, and OP.14,15,17,18

 4

Chapter 2

CASE BACKGROUND DATA

Examination – History

The 49-year old female patient sustained a right (R) bicondylar TPF while

walking her dog downhill on a paved road. When she attempted to stop the leashed dog

from running towards a cat, she fell with her left leg forward and R leg hyperflexed

behind her. A CT scan in the emergency room allowed the fracture to be classified as

Schatzker type VI (bicondylar fracture with dissociation of the metaphysis from the

diaphysis and varying degrees of comminution).6 An MRI confirmed all soft tissue

structures around the knee were unaffected by the injury.

At the time of injury, she was placed in a rigid leg brace and provided axillary

crutches (AC). Nine days later, she underwent ORIF surgery and was placed in a hinged

brace locked into 0° of knee extension. A front-wheeled walker (FWW) and a wheelchair

(WC) were provided as the patient was NWB for 6 weeks postoperatively. She received

inpatient physical therapy the day after surgery and was discharged to her home the next

day. She had 1 appointment with her surgeon to assess healing approximately 10-12 days

postoperatively. No rehabilitative services were received between her hospital discharge

and her physical therapy evaluation on post-operative day 14. She presented to the

outpatient clinic using AC and wearing a hinged brace locked to 0° extension. Per

postoperative protocol, the brace was to be worn for 6 weeks and only removed for

bathing and physical therapy sessions. After this period, the patient was to wear the brace

only for community outings.

 5

Prior to her injury, the patient worked full-time as a Veterans service

representative performing clerical duties. She lived with her partner in a one-story house

that had 2 stairs into the front entrance with a left handrail. She was moderately active

prior to her injury with walking and housework. She drove a raised Ford F-250 with a

side step bar. During rehabilitation, the patient had frequent follow-up visits with her

surgeon to assess fracture healing and postsurgical joint congruity via radiographs which

confirmed proper fracture healing and appropriate joint congruity. Her goals were to

decrease pain, ambulate without an assistive device (AD), and return to driving and work.

At initial evaluation, the patient presented with high severity and high irritability

due to increased pain in R knee and R ankle regions. Using the Numeric Pain Rating

Scale (NPRS), the patient reported her baseline pain at the knee and ankle as a constant

5/10 with the worst pain of 10/10 experienced with prolonged sitting and stairs. Other

aggravating factors were prolonged standing, walking, and showering. Easing factors

were rest, ice, and use of an AD. She used AC for indoor ambulation and a FWW or WC

for community outings. Her prior medical history included tinnitus, migraines, back pain,

anemia, tubal ligation, and hepatitis C. She was a smoker with a 20 pack-year history.

Systems Review

The patient’s cardiopulmonary system was impaired based on blood pressure of

130/90 millimeters (mm) mercury. Pulses, resting heart rate (75 beats/minute), and

respiratory rate (18 breaths/minute) were unremarkable. The integumentary system was

impaired due to the healing surgical incision, but no ulcers, rashes, or lumps were

reported or observed. The urogenital and gastrointestinal systems were unimpaired based
 6

on patient report. The musculoskeletal (MSK) and neuromuscular systems were impaired

based on observation and patient report. Sensation and reflexes were intact. She answered

negatively for fatigue, malaise, dizziness, infections, nausea/vomiting, weight change,

and cognitive changes.

Examination - Medications
Table 1
Medications
MEDICATION DOSAGE REASON SIDE EFFECTS
Norco (contains 10 mg, 1 PO Used to relieve Constipation, drowsiness,
acetaminophen and every 6 hours moderate-to-severe lightheadedness, anxiety,
hydrocodone) pain; can also be used abnormally happy or sad
to relieve cough19 mood, dry throat, difficulty
(Class of drug: opiate urinating, rash, itching,
analgesics; antitussives) narrowing of the pupils,
slowed breathing,
hallucinations, sweating,
confusion, nausea, vomiting,
loss of appetite, decreased
sexual desire, chest tightness19
Tylenol (acetaminophen) 500 mg PO Used to relieve mild to Red, peeling or blistering skin,
PRN moderate pain from rash, hives, itching, swelling of
(Class of drug: headaches, muscle the face, throat, tongue, lips,
analgesics; antipyretics) aches, menstrual eyes, hands, feet, ankles, or
periods, colds and sore lower legs, hoarseness,
throats, toothaches, difficulty breathing or
backaches, and to swallowing19
reduce fever19

Abbreviations: PO, taken orally; PRN, as needed

 7

Chapter 3

EXAMINATION – TESTS AND MEASURES

The patient’s deficits were categorized and measured using the International

Classifications of Functioning, Disability, and Health (ICF) Model.20 Tests and measures

used to assess the patient’s body structure and function impairments were goniometry,

manual muscle testing (MMT), the NPRS, mid-patellar girth, palpation, and observation.

At the activity level, the measurements used were the Lower Extremity Functional Scale

(LEFS), the Timed Up And Go (TUG) test, and patient report. For participation, patient

report and items within the LEFS were used. The Wells criteria were used to screen for

deep vein thrombosis (DVT), and the TUG test prognosticated fall risk.

Goniometry is a common tool used to assess joint ROM. A minimal detectable

change with a 95% confidence interval (MDC95) of 10° for passive and active knee

flexion, 10° for passive knee extension, and 6° for active knee extension has been

established.21 The minimal detectable change (MDC) is the minimum amount a score

must change to ensure the change is not the result of measurement error.22 Goniometry

has excellent intrarater reliability for all active and passive knee motions with Intraclass

Correlation Coefficient (ICC) values ranging from 0.78-0.98.21 Goniometry also has

excellent intrarater reliability for active ankle dorsiflexion (DF) and plantarflexion (PF)

(ICC=0.89-0.91).23 The MDC95 values for active DF and PF are 3° and 5°, respectively.23

Manual muscle testing is the most commonly used technique to evaluate muscle

strength impairments.24 The grading system is based on a six-point ordinal scale, from 0

to 5, with 0/5 indicating no contraction and 5/5 indicating ability to maintain a joint
 8

position against maximal resistance applied by the examiner.24 A change of at least one

full grade is necessary to be confident a true change in strength has occurred.24

The NPRS is an 11-point numeric scale used to assess pain intensity.25 There are

no clinically feasible objective markers for pain, so the most reliable evidence of intensity

is based on patient report.26 The NPRS requires a patient to report a number from 0 to 10

that best describes his/her pain, where a 0 indicates no pain and a 10 indicates severe

pain.26 A study of subjects with chronic MSK pain established the MCID as a change of 2

points.26 The minimal clinically important difference (MCID) represents the smallest

amount of change in an outcome required for the patient to feel a difference.22

Mid-patellar girth measurements assess edema in a symptomatic joint and allows

for comparison to an asymptomatic joint on the contralateral side of the body. Knee

circumference measures have an MDC95 of 1.0 cm.21

The LEFS is a self-reported clinical test used to assess disability associated with

lower extremity (LE) MSK conditions.27 It is a 20-item questionnaire with each item

scored on a 5-point scale (0 to 4). Higher scores indicate higher levels of physical

function. An MDC with a 90% confidence interval (MDC90) of 9.9 points and an MCID

of 9 points has been established.28,29 The MDC value of 10 points was used for goal

setting as it was the higher of the two psychometric values and representative of greater

improvements. The LEFS has excellent test-retest reliability (ICC=0.94).30 The LEFS is

an activity-level measure, but its first 2 questions can assess participation restrictions.

Current clinical practice guidelines established by the American Physical Therapy

Association strongly recommend that physical therapists screen all post-operative

 9

patients for DVT.31 The clinical decision rule established by Wells et al.32 assesses

likelihood of DVT using 4 medical history findings and 5 physical exam findings. A

score classifies the patient’s probability as likely (score ≥ 2) or unlikely (score < 2) of

having a DVT. Comparing the Wells criteria to the gold standard of D-dimer testing, a

positive likelihood ratio (LR+) of 0.91 and a negative likelihood ratio (LR-) of 1.07 were

established.33 After major orthopedic surgery, the number of DVTs has been reported to

range from 40 to 60%.34 Given a conservative pre-test probability of 60%, a Wells

criteria score of ≥2 would result in a negligible shift in PTP to 62%, while a score of <2

would result in a negligible shift in PTP to 58%. In the absence of other clinically

feasible tests for DVT, this method was used.

The TUG test is a sensitive prognostic measure used to determine fall risk. It is a

timed test in which the participant is asked to stand from a chair, walk 3 meters, turn

around, and return to the chair to sit down as quickly yet safely as possible.35 The time

begins when the buttocks rise from the chair and ends when they touch back down.35 The

standard error of the TUG test for adults without a history of falls is 0.44 seconds.36 In a

study following surgery for hip fracture, a cutoff score of ≥24 seconds was found to have

a negative predictive value of 0.93 and a positive predictive value of 0.41 (CI 95%). This

means with a TUG score less than 24 seconds, there is a 93% probability of not falling in

the 6 months following the surgery, and with a score ≥24 seconds, there is a 41% chance

of experiencing a fall.37 The prevalence of 32% used in the study was based on the

subjects that experienced 1 to 4 fall(s) after discharge; this prevalence is more applicable

to the case study than the prevalence of 30% for community-dwelling elderly.37
 10

Table 2
Examination Data
BODY FUNCTION OR STRUCTURE
Measurement Test/Measure Used Test/Measure Results
Category
Knee ROM Goniometry Left Right
AROM flexion 0-140° NT per post-op
protocol (no
AROM for 3
weeks)
AROM 0-3° NT per post-op
MDC95: extension protocol (no
-AROM flexion: 10° AROM for 3
-AROM extension: 6° weeks)
-PROM flexion: 10° PROM flexion 0-140° 18-32°
-PROM extension: 10°
PROM extension 0-3° -18°
Ankle AROM Goniometry Dorsiflexion 0-10° -3°
AROM
MCD95: Plantarflexion 0-50° 3-45°
-AROM dorsiflexion: 3° AROM
-AROM plantarflexion: 5°
LE muscle MMT Quadriceps 5/5 2/5
strength Hamstrings 5/5 2/5
MDC: one full grade Gastrocnemius 4/5 * 2/5 *
Self-reported NPRS -Average: 5/10 pain
pain -Worst pain (prolonged sitting, ascend/descend stairs):
MCID: 2 points 10/10
Swelling Mid-patellar girth Left Right
measurements Mid-patella: 34 cm Mid-patella: 38 cm

MDC95: 1.0 cm
Edema and skin Palpation -tenderness with palpation of the surgical incisions,
integrity changes patella, popliteal space, medial/lateral tibial plateaus,
knee joint line, gastrocnemius, and ankle joint
Risk of LE DVT Wells criteria32 The patient was classified as likely to have a DVT
based on score of 2: 1 point for recent immobilization,
1 point for major surgery within 4 weeks, -2 points for
alternative diagnosis of post-operative swelling, 1 point
for localized tenderness along deep venous system, and
1 point for pitting edema.
FUNCTIONAL ACTIVITY
Measurement Test/Measure Used Test/Measure Results
Category
Self-reported LEFS Score: 11/80
functional status
MDC90=9.9 points (86% restricted based on LEFS score)
MCID90=9 points
Fall risk Timed Up and Go test Time: 24 seconds
 11

Note: Patient was NWB and used 2 AC to complete

test.

Unable to Observation and patient Patient arrived for evaluation with 2 AC and a hinged
ambulate report leg brace locked at 0° extension. The brace was to be
independently worn for 6 weeks postoperatively and removed only for
bathing and physical therapy sessions. Per
postoperative protocol, she was NWB for 6 weeks.
Unable to Patient report Patient reported difficulty with ascending/descending
ascend/descend the 2 stairs into her home, even when using left-sided
stairs handrail and AC
independently
Unable to get Patient report Patient reported her truck is lifted and before her
into Ford F-250 injury, she used a side step bar for entry/exit to the
truck and drive vehicle; patient reports her surgeon had not cleared her
independently to return to driving at the time of initial examination
Unable to Patient report Patient reported that she needs to use a shower stool to
shower without safely shower
equipment
PARTICIPATION RESTRICTIONS
Measurement Test/Measure Used Test/Measure Results
Category
Self-reported LEFS – Questions 1 and 2 Score: 0/8
functional status only
1) Do you or would you have any difficulty at all with
No MDC or MCID any of your usual work, housework, or school
established so 20% activities? 2) Do you or would you have any difficulty
improvement was used to at all with your usual hobbies, recreational, or sporting
establish improvement activities?

Unable to Patient report Patient reported that surgeon had not cleared her to
participate at return to work at the time of the examination
work as a
Veterans service
representative
Abbreviations: AC, axillary crutches; AROM, active range of motion; DVT, deep vein thrombosis; L,
left; LE, lower extremity; LEFS, Lower Extremity Functional Scale; MCID, minimal clinically important
difference; MDC, minimal detectable change; MMT, manual muscle testing; NPRS, Numeric Pain Rating
Scale; NT, not tested; NWB, non-weight bearing; PROM, passive range of motion; R, right; ROM, range
of motion; SF-36, Short Form 36; TUG, Timed Up And Go

*=assessed in supine position

 12

Chapter 4
EVALUATION

Evaluation Summary

The patient was a 49-year old woman who sustained a bicondylar TPF resulting in

ORIF surgery. Prior to the injury, she worked as a Veterans service representative. She

had a body mass index (BMI) of 22.7 and a 20 pack-year smoking history. The patient

presented with decreased ROM in the R knee and ankle, decreased R LE muscle strength,

increased swelling in the R knee, decreased functional status, and restrictions with

driving and working. She was NWB for 6 weeks after surgery and required assistive and

adaptive equipment for household ambulation, showering, and community outings. She

was also limited in part, due to post-operation instructions/restrictions, including a hinged

brace that limited knee mobility following surgery. Her goals were to decrease pain,

ambulate without an AD, and return to driving and work.

Diagnostic Impression

The patient presented with common signs and symptoms following ORIF surgery

involving the knee joint. Impairments of increased pain and knee joint girth, decreased

LE ROM and strength, and tenderness to palpation were noted at initial evaluation. These

impairments contributed to limitations with ambulation, driving, stairs, showering, and

overall LE function. She was classified as 86% disabled based on the LEFS. These

activity limitations affected her ability to work. Based on Wells criteria, she was likely to

have a DVT (see Table 2) with a pre-test probability set at 60%. A LR+ of 0.91 produced

a negligible shift which resulted in a PTP of 62%.

 13

Prognostic Statement

The patient’s positive prognostic factors for return to function were appropriate

postsurgical joint congruity and patient motivation.14,15 Despite a family history of OP,

she had normal BMD with no signs of OP. Her negative prognostic factors were

bicondylar fracture and tobacco use.14,15,17,18 The patient was at risk for future falls based

on her TUG score. With a cut-off score of 24 seconds, there was a 41% chance that the

patient would experience a fall in the 6 months following surgery. Considering the

positive and negative prognostic factors, the patient was likely to have moderate

improvement with return to prior level of function (PLOF) following physical therapy.

She was expected to regain independence with ambulation, driving, and working but

would likely require minor lifestyle modifications including use of handrail with stairs

when appropriate and use of a hinged brace for support during prolonged sitting.

G-Codes

Initial Evaluation: LEFS score of 11/80

• Current: G8990-CM (80-99% restricted based on LEFS score)

• Goal: G8991-CK (40-59%)

Re-evaluation at Week 5: LEFS score of 37/80

• Current: G8990-CK (40-59% restricted based on LEFS score)

• Goal: G8991-CI (1-19%)

Discharge Plan

The patient was to be discharged from the outpatient clinic after 10 weeks of treatment

with a home exercise program (HEP) and support provided by her partner. She would

have access to ADs to use as needed including AC, FWW, and WC.
 14

Chapter 5

PLAN OF CARE – GOALS AND INTERVENTIONS

Table 3
Evaluation and Plan of Care
PLAN OF CARE
Short Term Goals Long Term Goals Planned Interventions
(Anticipated Goals) (Expected Interventions are Direct or Procedural
Outcomes) unless they are marked:
5 weeks (C) = Coordination of care intervention
10 weeks (E) = Educational intervention

Warm-up:
• Week 5: NuStep, 5 mins w/ no
resistance
• Week 6: stationary bike oscillating
back and forth with pedals but not
completing full revolutions, 6 mins w/
no resistance
• Week 7: stationary bike with full
revolutions, 5 min w/ no resistance
• Weeks 8-10: stationary bike for 10
mins, resistance to 2
PROBLEM
BODY FUNCTION OR STRUCTURE IMPAIRMENTS
Decreased R 1) Patient will 1) Patient will 1) (C) Student physical therapist reviewed
knee ROM achieve 80° of achieve 125° of surgeon’s protocol to ensure the ROM
AROM knee flexion. AROM knee restrictions and hinged brace
flexion. recommendations are understood and
2) Patient will followed. Patient was to remain NWB and
achieve 90° of 2) Patient will wear a hinged brace locked at 0° extension
PROM knee flexion. achieve 125° of for 6 weeks postoperatively. The brace was
PROM knee to be removed only for bathing and
3) Patient will flexion. physical therapy sessions. After 6 weeks
achieve 0° of AROM postoperatively (Week 4 of rehabilitation),
knee extension. 3) Patient will the patient was to wear the brace only for
achieve 3° of community outings.
4) Patient will AROM knee
achieve 2° of PROM extension. 2) PROM into knee flexion and extension
MDC95: knee extension. provided by PT and/or SPT; patient
-AROM 4) Patient will position varied:
flexion: 10° achieve 3° of • Supine and prone during first 2 weeks
-AROM PROM knee • EOT (w/ PROM 75°) by Week 4
extension: 6° extension. • Patient in supine (90° hip flexion) by
-PROM Week 8
flexion: 10°
-PROM 3) Extension hang with towel under ankle
extension: 10°
• Week 1-3: Supine, no weight, 2 mins.
• Week 4: Supine, 2#, 2 mins.
 15

• Week 5: Prone, 3#, 3 mins.

• Week 6: Prone, 3#, 3 mins x 2 sets

4) Seated heel slides on white board (2

sets, 10 reps, 2 sec. hold)

5) Supine hamstring stretch (30 sec, 2x)

performed passively either by PT/SPT or
by patient using stretch strap

6) Week 5: Calf stretch standing on wedge

(30 sec hold, 3 reps)
• Pt was at 50% PWB status.

7) AAROM flexion with stretch strap

around R foot to mobilize knee into flexion
(5 sec holds at end range, 10x)

8) Soft tissue mobilization to quadriceps

and peri-patellar area to relieve stiffness at
the knee joint

Decreased R 1) Patient will 1) Patient will 1) (E) Patient education on importance of

ankle AROM achieve 2° of active achieve 10° for mobilizing ankle with 30 ankle pumps and
and passive DF. active and passive ankle ABC’s every hour to increase ROM
DF. and decrease swelling
2) Patient will
MCD95: achieve 50° of active 2) Patient will 2) Calf massage in prone
-AROM DF: 3° and passive PF. maintain 50° of
-AROM PF: 5° active and passive 3) Passive physiologic ankle mobilization
DF. into DF (30 sec hold, 3x)

4) Calf stretch standing on wedge (30 sec

hold, 3 reps)

Decreased 1) Patient will 1) Patient will 1) (E) Patient education on recruiting

right LE increase R quad achieve 4/5 quad quadriceps effectively in HEP with tapping
muscle strength from 2/5 to strength. techniques to encourage maximum
strength 3/5. voluntary contraction
2) Patient should
2) Patient will be be able to perform 2) Quad sets
able to perform 50 5 sit-to-stands • Weeks 1-2: quad sets with towel under
MDC: 1 full SLRs with no quad from a chair knee and NMES (4 min.) plus quad
grade lag. without UE sets with no towel under knee (6 sec
support. hold, 5 reps)
o 35-50 Hz for edema reduction and
3) Patient will be for tetanic contraction (strength);
able to step over a 200-300 µsec; symmetric biphasic
6” object without waveform; 4 minutes consisted of
falling. 10 sec on, 50 sec off; bilateral
bipolar pad placement
• Week 3: prone quad sets (6 sec, 10x)
 16

4) Patient will be • Week 6: TKE with light band (12

able to perform reps, 3 sec holds)
100 SLR with no • Week 7: short arc quad, 3# ankle
quad lag. weight (2 sets, 10 reps)

3) Week 5: Prone gluteus maximus

extension (1 set, 10 reps)

4) SLR
• Weeks 1-3: Quad sets & SLR
(brace on) with no lag
• Week 4-10: Quad sets (see
above), worked up to 100 SLR
without brace and no lag,
performed at home with 50 SLR
being average for several weeks
and 100 SLR being the average
for the last 2 weeks of treatment

5) Supine leg press with “Shuttle” machine

performed with double leg (DL) and single
leg (SL) – all were 2 sets, 10 reps
• Week 7: 50# DL, 25# SL
• Week 8: 62# DL, 37# SL
• Week 10: 75# DL, 50# SL

6) Week 9-10: TRX® squats (2 sets, 10

reps)

Increased pain 1) Patient will 1) Patient will 1) Pneumatic cryotherapy per “Game
in R knee decrease baseline decrease baseline Ready” to the R knee in supine with leg
pain intensity from pain intensity elevated x 10 minutes to conclude each
MCID: 2 5/10 to 3/10. from 3/10 to 1/10. session
points
2) Patient will report 2) Patient will 2) General desensitization of knee region
8/10 for worst pain. report 6/10 for over pillow case (Week 1-4)
worst pain.
Increased R 1) Mid-patellar girth 1) Mid-patellar 1) Pneumatic cryotherapy per “Game
knee girth will reduce from 38 girth will reduce Ready” to the R knee in supine with leg
to 36 cm. from 36 to 34 cm elevated x 10 minutes to conclude each
MDC95: 1.0 cm to achieve session
2) Patient will bilateral
independently symmetry with
demonstrate without mid-patellar girth.
cueing all home
edema management
techniques

Impaired skin 1) Patient will 1) Scars along 1) (E) Patient education on importance of
integrity due to demonstrate 100% both incisions will skin care per surgeon’s discharge
surgical recall of skin care be mobile in all instructions with emphasis on keeping
directions. peri-incisions clean, moist, and protected.
 17

incision and instructions per

edema verbal report 2) (E) Patient education on mobilization of
developing scar tissues for prevention of
2) Full closure of adhesions and improved ROM. Scar
both surgical mobilization recommended 2x per day
incisions will be starting at week 4
achieved with intact
skin sufficient to 3) (E) (C) Patient education provided on
provide mechanical benefits of smoking cessation to improve
barrier. healing time and decrease risk of
osteoporosis and/or fracture; surgeon also
discussed smoking cessation with patient
during follow-up visits so SPT would
reinforce surgeon’s advice after certain
subjective reports

4) Week 6-9: Scar mobilization along

incision lines, 5 min/session

Risk of LE 1) Patient will 1) Patient will 1) (E) Educated patient on importance of

DVT perform 30 ankle perform ankle monitoring calf swelling and redness
pumps and ankle pumps and ankle between physical therapy sessions; SPT
ABCs every hour to ABCs as needed monitored swelling and redness at each
decrease risk of during the day visit
DVT. and continue to
monitor swelling 2) (C) Patient wore compression stocking
2) Patient will and redness over as often as possible for 3 weeks after
demonstrate 100% the rehabilitation operation as per surgeon’s protocol
recall per verbal program.
report of daily self- 3) 30 ankle pumps and ankle ABC’s every
assessment for hour
calf/ankle regions to
ensure no excessive 4) PC for calf swelling at end of each
swelling and redness. treatment session

3) Patient will wear 5) (E) (C) Patient education provided on

compression stocking benefits of smoking cessation to decrease
as often as possible risk of DVT; surgeon also discussed
for 3 weeks. smoking cessation with patient so SPT
reinforced this advice

ACTIVITY LIMITATIONS
Decreased 1) Patient will 1) Patient will Various components of the LEFS were
functional increase LEFS score increase LEFS addressed in the plan of care such as
status (LEFS) from 11/80 to 21/80 score to 31/80 for walking, stairs, standing, sitting, and
for improved improved squatting. See interventions addressing
functional status. functional status. activity limitations.

Increased fall 1) Patient will 1) Patient will 1) SLS started on Week 7 when patient
risk demonstrate safe use stand on one leg achieved full WB status with 2 sets of 30
(TUG) of AC during for 30 seconds on sec.; pt initially used 2 hands on support
flat ground surface during SLS but found it difficult to
 18

ambulation for without touching perform for entire 30-sec. period due to
decreased fall risk. support bar with instability and hesitancy to fully WB; over
hands and without time, she progressed to holding SLS for
2) Patient will touching entire 30-sec period with 2 fingers per
demonstrate safe use contralateral foot hand on support surface.
of AC during stair down.
ascending/descending 2) SLS on blue foam started on Week 9
for decreased fall 2) Patient will (30 sec., 2x)
risk. stand on one leg
on blue foam for
3) Patient will re- 30 seconds with
perform TUG at only 2 fingers on
Week 6 with 75% each hand
WB status using AC touching support
and score <24 sec. bar and without
for decreased post- touching
surgical fall risk. contralateral foot
down.
Unable to 1) Patient will 1) Patient should 1) (E) Patient education about progression
ambulate demonstrate be able to from assistive devices based on surgeon’s
independently adherence to weight ambulate without protocol including safe use of front-
bearing precautions AD in 10 weeks wheeled walker and AC including stair
per surgical protocol with heel-to-toe ascent/descent (i.e. railing use and
for 6 weeks post- gait pattern during appropriate sequencing of crutch and
surgery. weight unaffected lower extremity)
acceptance.
2) Weight bearing: NWB for 6 weeks post-
surgically which included 2 weeks at home
and during 4 weeks of physical therapy
treatment
• Week 4: 25% WB status (per
surgeon’s protocol) was done using
two scales and weight shifts of +30#
to R side [10 sec on, 10 sec off]
• Week 5: 50% WB status with weight
shift on scales of +60# [10 sec on, 10
sec off]
• Week 6: 75% WB status with weight
shift on scales of +90# [10 sec on, 10
sec off]
• Week 7: 100% WB status; entered
clinic using 1 crutch but used 0
crutches during session and upon exit
from clinic
o Patient advised to use crutch during
community outings, especially in a
crowded setting, for safety

3) Gait training:
• Week 4: with crutches and 25% WB
emphasizing heel strike and knee
extension during initial contact
 19

• Week 5: with crutches and 50% WB

emphasizing heel strike and knee
extension during initial contact
• Week 6: walking over short red cones
(5”) for 20 steps total
• Week 7 onward: patient walked
around the clinic (1-2 laps) focusing
on proper gait mechanics with PT and
SPT observing

4) (E) Patient education on practicing

proper gait mechanics with crutches at
home to ensure heel strike and knee
extension (HEP) to become more confident
and promote restoration of normal gait
mechanics

Unable to 1) Patient will be 1) Patient will be 1) Performed step-ups onto 3” platform;

ascend/descend able to ascend and able to ascend and progressed to stepping up and over 3”
stairs descend one 6” step descend four 6” platform, and then progressed to 4” and 6”
independently while facing forward stairs using 1 platform/stair
for 5 repetitions. handrail.
2) Performed side step-ups on 3” platform;
progressed from toe tap down, to foot flat,
to heel tap down, and then progressed to 4”
and 6” platform/stair

3) Week 7 onward: Step-to stair

ascending/descending using 1 handrail;
progressed to reciprocal stepping using 1
handrail

Unable to get No change expected 1) Patient will be 1) (E) Patient education about safe
into Ford F- in 5 weeks able to get into techniques for getting into and out of
250 truck and and out of Ford F- raised truck such as using side step bar and
drive 250 truck safely grab bar and ensuring safety by having her
independently using side step partner nearby when first attempting this
bar and grab bar. transfer at home

2) Patient able to 2) Week 10: patient drove truck to clinic

drive 15 minutes and time was spent observing her get into
independently to and out of truck using safe technique that
do errands and to was effective for her to accomplish the
return to work. task; performed twice and her technique
was observed and approved by PT and
SPT team

Unable to No change expected 1) Patient will be 1) (E) Patient education on importance of

shower without in 5 weeks able to shower for assistive devices such as shower stool for
use of AD at least 10 mins. first 6 weeks due to NWB status
without use of
 20

shower stool or Plan of care addressed this goal through

other ADs. intervention at the BSF level.

PARTICIPATION RESTRICTIONS
Decreased self- No change expected 1) Patient will Plan of care addressed participation goals
reported in 5 weeks achieve combined through interventions at the BSF and
participation total of 5 points activity levels.
status on the first two
questions of the
LEFS (8 points
total) to show
improvements
with “work,
housework, or
school activities”
and/or
improvements in
“usual hobbies,
recreational, or
sporting
activities”.

Unable to No change expected 1) Patient will Plan of care addressed participation goals
participate at in 5 weeks return to work as through interventions at the BSF and
work as a a service activity levels.
Veterans representative.
service
representative 2) Patient will be
able to complete
all work-related
tasks without any
major restrictions
to participation.

Abbreviations: AAROM, active assisted range of motion; AD, assistive device(s); AROM, active range of
motion; BSF, body structure and function; EOT, edge of table; IADL, instrumental activities of daily
living; LEFS, Lower Extremity Functional Scale; NMES, neuromuscular electrical stimulation; NT, not
tested; NWB, non-weight bearing; PC, pneumatic cryotherapy; PROM, passive range of motion; PT,
physical therapist; SBA, standby assist; SLR, straight leg raises; SLS, single-leg stance; SPT, student
physical therapist; TKE, terminal knee extension; TRX, total resistance exercises (brand name for
particular piece of exercise equipment); TUG, timed up and go; WB, weight bearing
 21

Plan of Care – Interventions

See Table 3.

Overall Approach

The overall treatment approach addressed all levels of the ICF model with a focus

on task-specific training for functional activities and an impairment-based approach to

address pain, decreased ROM, and strength deficits. A postoperative protocol provided

by the surgeon guided the plan of care. Various interventions were used to return the

patient to her PLOF including education, progressive ROM techniques, neuromuscular

electrical stimulation (NMES), pneumatic cryotherapy (PC), soft tissue mobilization

(STM), isometric exercises, open- and closed-chain muscle strengthening, stretching, gait

training, balance activities, and functional training such as stairs and truck entry/exit. The

patient attended physical therapy sessions twice per week for 10 weeks. Modalities like

NMES and PC were used to manage pain and swelling while addressing LE strength

deficits. Progressive resistance exercises were incorporated after initial healing period

(week 7) and allowed strengthening within new ROM at each session. Joint mobilization,

STM, and stretching were used to mobilize scar tissue, reduce tissue adhesions, and

improve pain-free ROM, respectively. Training of functional tasks were emphasized for

return to ambulation, stairs, and driving. The overall treatment plan focused on improving

LE function to allow for return to work.

 22

PECOT question

For a 49-year old female after ORIF surgery involving the knee joint (P), is

immediate weight-bearing and passive joint ROM (E) more effective than non-weight-

bearing and immobilization of the joint for 6 weeks (C) to avoid knee instability and

malalignment for return to function (O) in 10 weeks (T)?

While investigating this question, it became clear that there is limited evidence

involving postoperative rehabilitation protocols for ORIF following TPFs. Arnold and

colleagues published a systematic review in 2017 (CEBM level 1a) providing a general

consensus on postoperative management of TPFs.12,29 After reviewing 124 studies, the

authors concluded that prescribed NWB time was most frequently 4-6 weeks (39%),

followed by 7-9 weeks (24%), 10-12 weeks (21%), and 0-3 weeks (16%).12 The main

concern with early WB is fracture collapse, which is why protocols are solely based on

the surgeon’s judgment.38 Factors that can influence the surgeon’s decisions include

BMI, age, bone quality, cognitive impairment, patient compliance, fracture complexity,

and operative results.38 For example, patients with complex fractures and imperfect

operative results would likely be provided a NWB postoperative protocol.

Haak et al. (CEBM level 2b) investigated whether immediate WB following

locking plate osteosynthesis of proximal tibial fractures is associated with radiographic

changes indicative of malalignment.29,38 Subjects were divided into two groups: NWB for

6-8 postoperative weeks (n=20) and immediate postoperative WB (n=12). A major

limitation of the article was no explicit report was provided with regards to the amount of

time subjects spent in WB. The 32 subjects (17 females, 15 males) had a mean age of 48
 23

years. The results of the study showed no significant between-group difference in

depression of tibial articular surface (ranged from 0-5 mm), width of the TPF (+0-1mm),

articular congruence, and varus/valgus angulations. The implication of the results is that

surgeons may be able to permit immediate postoperative WB which may decrease the

risk of DVT and stiffness and encourage earlier return to function.

Solomon et al. (CEBM level 1c) investigated whether early partial WB leads to

displacement of fracture fragments.29,39 Seven subjects with Schatzker type II split

depression fractures of the lateral TP (central depression >1cm) underwent ORIF through

an anterolateral approach. All subjects were instructed to partially WB up to 20 kilograms

(kg) postoperatively using AC for 6 weeks then progress to full WB over the next 6

weeks. Using radiostereometric analysis to assess migration of fracture fragments,

minimal fracture displacement under load was found at 2 weeks (range -0.73 to 0.02 mm)

and 1 year (-0.12 and 0.15 mm). Partial WB for 6 weeks following ORIF using

subchondral screws and a buttress plate successfully maintained the reduction up to 1

year. These results suggest PWB may be appropriate immediately following TPF repair

as it does not contribute to structural damage nor negatively impact fracture healing.

With regards to timing of postoperative joint ROM, the systematic review by

Arnold and colleagues reported early passive mobilization of the knee joint appears to

commence, if at all, immediately after surgery (36% of studies), day one after surgery

(16%), or day two after surgery (20%).12 Knee flexion ROM is associated with return to

function, as the following knee flexion ROM values are required for everyday tasks such

as, walking: 50-70° during preswing and initial swing; ascending stairs: 80-105°;
 24

descending stairs: 77-107°; and sitting in a chair: 93°.40 Importantly, Arnold and

colleagues reported a mean passive knee flexion ROM of 122° at last follow-up.12 This

follow-up time was not defined, but the mean follow-up for the systematic review was

reported as 34.9 months (range: 12-264).

A retrospective study (CEBM level 2b) used hospital records to compare the

effects of immediate versus delayed passive knee joint mobilization following ORIF for

varying degrees of TPF.16,29 The study had 39 subjects that underwent ORIF surgery

(mean age: 41.6 years old), and of those subjects, the 26 that could tolerate immediate

passive knee mobilization were provided passive knee mobilization by a licensed

physical therapist. The remaining 13 subjects, who were not able to tolerate passive knee

mobilization on the first postoperative day, underwent immobilization for 4 weeks (i.e.

no active or passive mobilization of the knee joint). Both groups also performed isotonic

ankle and isometric quadriceps exercises beginning on the first postoperative day, and all

subjects wore a hinged knee brace for at least 6 weeks. At 4 weeks postoperatively,

results showed knee flexion was significantly greater in the early mobilization group

(EMG) (87.5˚ ± 7.8˚) compared to the immobilization group (IG) (55.1˚ ± 9.1˚).16 The

EMG also had greater ROM at 12 weeks (104° versus 117°) compared to the IG. The

presence of meniscus and ligament lesions negatively affected patient tolerance of early

movement (p=0.002). In fact, 77% of the IG and only 12% of the EMG had soft tissue

damage in addition to the fracture.

Based on the studies reviewed, it appears that PWB and passive knee joint

mobilization in the immediate postoperative phase may not contribute to instability and
 25

malalignment. This could encourage earlier return to function following ORIF at the

knee. Weight-bearing up to 20 kg during the first 6 weeks can allow for successful

maintenance of the surgical reduction up to one year.39 The patient in this case was a

compliant 49-year old female with a Schatzker type VI fracture who was at risk for falls

and DVT. Her age, fracture type, and surgical procedure (ORIF with subchondral screws

and buttress locking plate) aligned her with the subjects in all appraised studies. Her

postoperative protocol required 6 weeks of NWB followed by 4 weeks of PWB involving

25% increases in weight-bearing (30 pounds) each week.

Based on the research, the patient may have benefitted from early passive knee

joint mobilization and immediate PWB. Despite her fracture complexity, she had good

operative results, a normal BMI, and no signs of OP, which are factors considered in a

surgeon’s postoperative protocol. Early mobilization would have been feasible due to her

lack of concomitant soft tissue damage. Additionally, early mobilization may have

decreased her risk of DVT established by the Wells criteria and reinforced by her 20

pack-year smoking history. Early passive knee joint mobilization could have been

provided by inpatient physical therapists and subsequently by home health physical

therapists to improve progressive knee ROM. Weight-bearing up to 20 kg could have

encouraged early knee joint mobilization without jeopardizing postoperative joint

alignment. In conclusion, passive joint mobilization and PWB in the immediate

postoperative phase has the potential to be more effective than NWB for return to

function in 10 weeks without contributing to knee instability and malalignment.

 26

Chapter 6
OUTCOMES
Table 4
Outcomes
OUTCOMES
BODY FUNCTION OR STRUCTURE IMPAIRMENTS
Outcome Initial Follow-up (DC) Change Goal Met?
Measure (Y/N)
Knee ROM AROM flexion
Y
L: 0-140° R: NT L: 0-140° R: 0-126° 0° n/a
AROM extension
L: 0-3° R: NT L: 0-3° R: 3-0° 0° n/a Y

PROM flexion
L: 0-140° R: 18-32° L: 0-140° R: 0-125° 0° +93° Y

PROM extension
L: 0-3° R: -18° L: 0-3° R: 3-0° 0° +21° Y
Ankle AROM Dorsiflexion
L: 0-10° R: -3° L: 0-10° R: 0-5° 0° +8°
N
Plantarflexion
L: 0-50° R: 3-45° L: 0-50° R: 0-50° 0° +8°
Y
LE muscle Quadriceps
strength L: 5/5 R: 2/5 L: 5/5 R: 3+/5 none 1.5 grades N
Hamstrings
L: 5/5 R: 2/5 L: 5/5 R: 4/5 none 2 grades Y
Gastrocnemius
L: 4/5 R: 2/5 L: 4/5 R: 4/5 none 2 grades Y
Patient unable to Patient able to perform 5 n/a
perform sit-to-stand sit-to-stands from a chair
and stand-to-sit from a without UE support. Y
chair without UE
support.
Patient unable to Patient able to perform n/a
perform SLR without 50 SLR with no quad Y
brace due to quad lag. lag.
Self-reported Baseline pain: 5/10 Baseline pain: 2/10 3 points Y
bodily pain Worst pain: 10/10 Worst pain: 6/10 4 points Y
(NPRS)
Swelling Mid-patellar girth (L): Mid-patellar girth (L): L: 0 cm ---
34 cm 34 cm R: 3.5 cm Y
Mid-patellar girth (R): Mid-patellar girth (R):
38 cm 34.5 cm
 27

Edema and -tenderness with -no tenderness to n/a

skin integrity palpation of the palpation reported at Y
changes surgical incisions, surgical incisions,
patella, popliteal space, patella, popliteal space,
medial/lateral tibial medial/lateral tibial
plateaus, knee joint plateaus, knee joint line,
line, gastrocnemius, gastrocnemius, and ankle
and ankle joint joint
-scar still forming -scars along both
along both incisions incisions are mobile in Y
all directions.
Risk of LE Likely to have DVT Not likely to have DVT n/a
DVT (Score: 2) (Score: 1) Y

1 point for recent 1 point for pitting edema

immobilization, 1 point
for major surgery
within 4 weeks, -2
points for alternative
diagnosis of post-
operative swelling, 1
point for localized
tenderness along deep
venous system, and 1
point for pitting edema.

ACTIVITY LIMITATIONS
Outcome Initial Follow-up (DC) Change Goal Met?
Measure (Y/N)
LEFS Score: 11/80 (86% Score: 65/80 (19% Increase of 54 points Y
restricted) restricted) for decrease of 67%
in restriction
TUG 24 seconds [fall risk] 15 seconds [no fall risk] 9 seconds
Y
Performed with 2 AC Performed with 2 AC at
at Week 1 (NWB) Week 6 (75% WB)
Unable to Patient arrived for Use of hinged leg brace No AD needed to
ambulate evaluation with 2 AC was discontinued at the ambulate
independently and a hinged brace end of week 4. At week
locked in 0° extension; 7, patient was 100% WB Y
per protocol, she was and using 0 crutches; no
NWB status for 6 ADs were used from
weeks post-operatively week 7 onward.
Unable to Patient reported that Patient able to n/a
ascend/descend she has difficulty ascend/descend four 6”
stairs ascending/descending stairs (with slight hip
Y
independently the 2 stairs into her hike) without using
home, even when using handrail by Week 8.
handrail and crutches
Unable to get Patient reported Patient able to safely Able to enter/exit
into Ford F- inability to enter and perform 2 ground-to- truck and drive Y
250 truck and exit from lifted truck truck transfers in parking independently
 28

drive using side step bar; her lot of physical therapy

independently surgeon had not cleared clinic with proper
her to return to driving technique.
at the time of the
examination
Unable to Patient reported that Patient able to stand in No AD needed to
shower without she needs to use a shower without AD to shower
assistive shower stool to bathe bathe independently Y
device safely

PARTICIPATION RESTRICTIONS
Outcome Initial Follow-up (DC) Change Goal Met?
Measure (Y/N)
Self-reported Score: 0/8 [questions 1 Score: 6/8 +6 points
participation and 2 only] Y
status (75% improvement
“Do you or would you in score)
have any difficulty at
all with: a) any of your
usual work, housework,
or school activities? b)
your usual hobbies,
recreational, or sporting
activities”
Unable to Patient reported that Patient returned to full- n/a
participate at surgeon had not cleared time work with ability to Y
work as a her to return to work at perform most clerical
Veterans the time of the duties by Week 9
service examination
representative
Abbreviations: AD, assistive device; AC, axillary crutches; AROM, active range of motion; DF,
dorsiflexion; DVT, deep vein thrombosis; L, left; LE, lower extremity; LEFS, Lower Extremity Functional
Scale; MCID, minimal clinically important difference; MDC, minimal detectable change; NPRS, Numeric
Pain Rating Scale; NT, not tested; NWB, non-weight bearing; PF, plantarflexion; R, right; ROM, range of
motion; TUG, Timed Up And Go; WB, weight bearing
 29

Discharge Statement:

The patient was seen at an outpatient clinic twice weekly for 20 visits. During the

episode of care, the patient improved passive and active knee ROM and passive and

active ankle ROM. A true change in strength was achieved in the R hamstrings and

gastrocnemius muscle groups. Her pain intensity at rest decreased from 5/10 at baseline

to 2/10 at baseline; her worst pain (brought on with prolonged sitting and stairs)

decreased from 10/10 to 6/10. Both changes in pain intensity met the MCID of the NPRS.

Improvements in ROM and strength may have been facilitated by a decrease of 3.5 cm in

mid-patellar girth which also met the MDC. Her surgical incisions healed well and

allowed mobility in all directions. She progressed from likely to have a DVT to not likely

to have a DVT based on the Wells criteria. Her TUG score decreased to 15 seconds,

resulting in a decreased risk of falls based on a 24 second cut-off score. Her LEFS score

decreased from 11/80 (86% restricted) to 65/80 (19% restricted). She discontinued use of

the AC and hinged brace and improved gait mechanics by demonstrating heel-to-toe gait

pattern during weight acceptance and increased knee extension during stance phase. The

patient also regained the ability to ascend/descend stairs and the ability to enter/exit her

vehicle. The patient’s primary goal of returning to work was achieved by week 9 due in

part to improvements at the BSF and activity levels, specifically increased knee and ankle

ROM, increased strength, independent ambulation, and return to driving. From the initial

encounter to the discharge date, the patient made marked improvements in all outcome
 30

measures and exceeded all available MDCs or MCIDs. Upon discharge, she felt confident

in her ability to work, drive, attend community outings, and return to her PLOF.

DC G-Code with modifier:

• Discharge: G8992-CI (1-19% restricted based on LEFS score)

 31

Chapter 7
DISCUSSION

The patient presented to the outpatient clinic with signs and symptoms common

after ORIF surgery. She attended physical therapy sessions twice per week for 10 weeks.

Based on impairments of pain, ROM, and swelling, initial treatment addressed symptoms

with bracing, PC, and AD training. Patient education was used to encourage safety and

adherence to the postoperative protocol. Passive ROM exercises were used to

progressively increase knee ROM. Isometric exercises and NMES were performed early

on for quadriceps activation. Once initial tissue healing was complete, STM, progressive

muscle strengthening, and stretching were incorporated. Strengthening exercises were

performed in patient’s available ROM at each treatment session. Task-specific training

was a primary focus which included ambulation, balance, and stairs.

The patient responded well to the interventions, but she did have complaints such

as itching from the hinged brace, pain fluctuations, temporary discomfort in R hip and

lower back, tingling sensation in R knee and R ankle during PWB transition, painless

clicking in knee joint, and discomfort with prolonged sitting after returning to work. With

gait and stair training, she worked with her student physical therapist to relearn heel-to-

toe pattern during ambulation and minimize R hip hike during stair descent. The overall

treatment plan addressed all levels of the ICF model with a focus on the patient returning

to work. The patient remained motivated throughout treatment to return to her PLOF.

While I feel the interventions were appropriate, there are several things that I

would have changed. First, the patient should have received rehabilitative services
 32

between her hospital discharge and her first visit to the outpatient physical therapy clinic.

The patient was likely to be tolerant of early passive knee mobilization based on lack of

soft tissue damage, according to Arslan and colleagues.16 Early passive mobilization may

have contributed to greater improvements in knee flexion ROM during rehabilitation and

lowered her risk of DVT. Second, I would have allowed the patient to partially weight-

bear up to 20 kg using AC during the immediate postoperative period. She was

compliant, had good operative results, had a normal BMI, and showed no signs of OP.

Therefore, I think early mobilization and PWB would have benefitted the patient and

encouraged earlier return to function. Third, I would have administered the Fear

Avoidance Behavior Questionnaire and Short Form-36 to assess potential yellow flags

and participation restrictions.

Overall this patient’s clinical presentation was typical for a post-ORIF case. The

atypical factors were lack of concomitant soft tissue damage, 20 pack-year history,

likelihood of DVT, and 2-week immobilization following surgery. The Wells criteria and

TUG test were appropriate for this patient case. The interventions used were based on the

postoperative protocol provided by the surgeon which could have potentially been

modified to include earlier PWB and passive joint mobilization. Any changes to the

protocol would only have been implemented following a thorough discussion with the

surgeon. All interventions used in this case can be broadly applied. Better evidence is

becoming available every day, and clinicians must find and appraise it for the benefit of

their patients. For this case, the combination of interventions utilized contributed to

improvement in status at all levels of the ICF model for this patient.
 33

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