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108009401 408
10800970€ ã¿6

1
 :
I. Brief history-----------------------------------------------------P.3
 Basic data
 History
 Past medical history
 Vital sign
 Laboratory
 Operation
 Special examination
 Medication

II. Subjective - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.5

III. Objective - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.7

 Observation
 3 minutes step test
 Incentive spirometer (coach)

IV. Assessment - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.8

 Problem list
 Short-term goal
 Long-term goal

V. Plan - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.9
 Short-term
 Long-term

VI. Home program - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.11

Reference - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - P.11

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Brief history
The 33-year-old man, Wr. Lee, was sent to the TCH ED because of car accident and X-ray
impressed right patella open fracture with quadriceps tendon rupture s/p repair on
110/08/0€. 110/08/0€~110/08/0† was transferred to ordinary ward and discharged on 110/08/06.
10 days after discharging, he went back to the TCH because of wound infection. He performed a
wound management operation on 110/08/16. He kept on observation in ordinary ward from
110/08/16 to 110/08/۠. Under the generally stable condition, the patient was discharged on
110/08/€6, and started to do physical therapy on 110/09/€0.

1. Basic data
 Name: $ O Ÿ
 Age: 33-year-old
 Gender: male
 Body height: 178 cm
 Body weight: 77 kg
 BWI: €4.3 kg/cm€ (>€4 kg/cm€, overweight)
 Occupation: Radiological technologist

€. History
 Onset
 110/08/0€ Sent to the TCH ED because of car accident and X-ray impressed right
patella open fracture with quadriceps tendon rupture s/p repair.
 110/08/0€~110/08/0† Subsequent care in ordinary ward.
 110/08/06 Discharged.
 110/08/16 Postoperative wound infection and performed a wound management
operation.
 110/08/16~110/08/€† Keep on observation in ordinary ward.
 110/08/€6 Discharged.
 110/09/€0 Start to do physical therapy, 1.† hrs/day, 3 days/wk.
 Admission date: 110/08/0€ and 110/08/16
 Operation date: 110/08/0€ and 110/08/16
 Discharge date: 110/08/06 and 110/08/€6
 PT intervention date: 110/09/€0
 Admission diagnosis (110/08/0€): Right patella open fracture, Quadriceps tendon rupture
3. Past medical history: Denied

4. Special examination

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  X-ray of right knee (110/08/0€)
 Right patella open fracture

Subjective
110/10/€0
Patient: Wr. Lee/ 33 years old/ Wale
 Onset: 110/08/0€ Wr. Lee was hit by a left-turning truck on the way from get off work
by motorcycle. After rolling 30-40 meters, he felt pain in his right knee and was sent to
the Emergency Department by an ambulance for surgery.
 Operation: 110/08/0€ quadriceps tendon repair and patella open fracture operation
 Occupation: Radiological technologist (occupational sickness leave)
 Education: WS
 Living environment: 3F of the apartment with elevator
 Exercise habit: Aerobic exercise and weight training in the gym €~3 days per week
 Health habit: smoking (1PPD)
 Wajor caregiver: Wife
 Family Hx.: Grandmother DW and father HT
 Wedical Hx.: Nil
 Chronic illness: Nil

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  Chief complaint: Right knee ROW limitation (flexion, extension)
 Expectation: restore fully knee flexion ROW and IADL without crutches in 3 months

Objective
 Observation (110/10/€0)
 Dominant side: R’t
 Involved side: R’t
 Right knee joint swelling and have four OP scars
 Right quadriceps femoris muscle atrophy
 Gait analysis:
 Trunk: Sway during whole gait cycle.
 Pelvis: Right pelvis hikes in swing phase.
 Knee: Limitation of right knee flexion in swing phase.
 During whole gait cycle, the duration of the stand phase are different. (left > right)
 Palpation (110/10/€0)
 Right patella high temperature (compare with left side)
 Scar adhesion and knee joint edema, no tenderness
 Pain
 VAS: €
 Type: dull pain
 Frequency: Reproduce by specific activities (up/downstairs )

Pain:

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  Swelling grade (110/10/€7): Grade +€
Grade Description
Grade +1 Up to €mm of depression, rebounding immediately
Grade +€ 3-4 mm of depression, rebounding in 1†sec or less
Grade +3 †-6 mm of depression, rebounding in 60sec
Grade +4 8mm of depression, rebounding in €-3min
Data source: OSWOSIS

 Circumference test (110/10/€7)

R’t L’t
+9 4€.† 43.€
+6 41 41.7
+3 41.† 39.3
+0 41.† 37
-3 37.6 34
-6 36 34.3
-9 37 36

 Vancouver Scar Scale (110/10/€7)

Score
Vascularity 3
Pigmentation €
Pliability €
Height €
Total 9

 ROW (110/10/€7)
AROW PROW End-feel
Joint Wotion R’t L’t R’t L’t R’t L’t
Flexion 0-10†° 0-110° 0-110° 0-11†° Soft Soft
Hip Extension 0-€0° 0-€0° 0-€3° 0-€†° Firm Firm
Abduction 0-†0° 0-†0° 0-††° 0-†0° Firm Firm
ER 0-38° 0-40° 0-40° 0-4†° Firm Firm

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 IR 0-30° 0-40° 0-33° 0-43° Firm Firm
Flexion 0-†0° 0-140° 0-††° 0-143° Hard Soft
Knee
Extension WNL WNL WNL WNL Firm Firm
PF 0-4†° 0-4†° 0-†0° 0-†0° Firm Firm
Ankle DF 0-€0° 0-€€° 0-€†° 0-€†° Firm Firm
Eversion 0-1†° 0-1†° 0-€†° 0-€†° Hard Hard
Inversion 0-30° 0-30° 0-33° 0-3†° Firm Firm

 WWT (110/10/€7)
Grade
Joint Wuscle Compensation
R’t L’t
Flexors † † Nil
Extensors † † Nil
Hip Abductors 4 4 Nil
External rotators † † Nil
Internal rotators † † Nil
Flexors 4 † Nil
Knee
Extensors NA NA NA
Dorsiflexors † † Nil
Ankle Plantar flexors † † Nil
Eversors † † Nil
Inversors † † Nil

Assessment
1. Problem list
 Right knee swelling (Grade +€)
 Right knee ROW limitation (0-†0°)
 Right quadriceps femoris muscle atrophy (WWT: 4)
 During whole gait cycle, the duration of the stand phase are different due to poor stability
of single leg stand on right side. (left > right)
€. Short-term goal (1 month)
 Decrease swelling of knee
 Grade +€ - resolved
 Increase knee flexion ROW
 Knee flexion: 0-†0° - 0-110°
 Waintain quadriceps femoris muscle strength

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  WWT: 4
 Correct abnormal gait cycle
 Symmetric stand phase between the right and left side
 Doing ADL without crutch.
3. Long-term goal (3 months)
 Improve quadriceps femoris muscle strength
 WWT: 4 - †
 Do ADL without limitation
 Climbing three-flights of stairs with no pain
 Squat with BW*8 (can back to the gym)

Plan
1. Short-term plan
 Decrease swelling of knee
 Instrument Assisted Soft Tissue Wobilization (IASTW)
 Technique: Using fasciotomy from distal to proximal part of the swelling place.
 Dosage: 10～1† mins/session, 3 sessions/week
 Compression knee sleeve to promote circulation
 Ankle pumping
 Dosage: 10～1† mins/session, 3 sessions/week
 Increase knee flexion ROW
 Joint mobilization
 Patella: Longitudinal and transverse glides in supine
 Tibia on femur: PA glide in supine
 Stretching exercise
 Hamstring, calf and quadriceps femoris
 Waintain quadriceps femoris muscle strength
 NWES
 Technique: Placed over the vastus medialis near knee and on the proximal thigh
over the Vastus lateralis.
 Parameters:
 Frequency: 40 Hz
 Pulse width: 300 µs
 On time: 10s
 Off time: 30s
 Intensity: WLT

8
  Dosage: 1† rep/set, 3 set/day, 3 day/week
 Short arc lift exercise
 Technique: Place a rolled-up towel under the knee that is about 6 inches thick,
then hold the knee fully straight for † seconds
 Dosage: †~8 rep/set, 3 set/session, 3 session/week
 Isometric quadriceps sets
 Technique: Place the leg straight on the bed with a towel under the knee
(popliteal fossa), then contract the quadriceps to press the towel making the
knee flat and straight for † seconds
 Dosage: €0 rep/set, 3 set/session, 3 session/week
 Squat (up to 70 degree)
 Dosage: † rep/set, 3 set/session, 3 session/week
 Leg press (loading: €0RW)
 Dosage: €0 rep/set, 3 set/session, 3 session/week
 Correct abnormal gait cycle
 Single leg stand (ground - foam) of right leg
 Dosage: €0 secs/set, 3 set/session, 3 session/week
 Doing ADL without crutch.
Static balance training
 Single leg stand
 Dosage: €0 secs/set, 3 set/session, every single day
Dynamic balance training
 Single leg stand with resistance
 Dosage: €0 secs/set, € set/session, every single day
 Reaching
 Dosage: † rep/set, € set/session, every single day
 Front/back weight shifting
 Dosage: 10 rep/set, € set/session, every single day
€. Long-term plan
 Improve quadriceps femoris muscle strength
 Pistol squat (body weight)
 Dosage: † rep/set, 3 set/session, 3 session/week
 Aquatic exercise that stimulates freestyle and breaststroke leg kick with large fins
(14th week)
 Dosage: 30 min/day, 3 day/week
 Seated leg press (16th week)
 Technique: The weight may be increased by about † pounds every 7 to 10 days
thereafter, as long as you can perform €0 repetitions per set for 3 sets, and as

9
 long as the weight used does not exceed body weight when using both legs,
or
½ body weight when using the one leg. In this exercise, avoid letting the knees
snap or drop suddenly into extension when reaching the fully straightened
position.
 Dosage: €0 rep/set, 3 set/session, for †~7 days
 Do ADL without limitation
 Step-up-down exercise
 Technique: Beginning the development of single leg strength and walk up stairs.
Start with 3 sets of † repetitions (7.6 cm in height), if pain free, add one
repetition per set, until can do 3 sets of 10 repetitions (about two weeks). If
pain free, progress to a step of 1†.€×€€.8 cm.
 Do not continue to raise the height if there is pain at the knee cap.
 Dosage: † rep/set, 3 set/session, 3 session/day
 Squat with BW*8 (can back to the gym)
 Technique: Slowly squatting down until femur parallel to the ground, holding
3 secs, and rapidly standing up.
 Dosage: 8 rep/set, † set/day, † days/week

Home programs
1. Decrease swelling of knee
 Hot pack
 Dosage: moderate heat (40-41˚C), 1† min/set, € set/day, 7 day/week

 Facilitated by elevation affected limb

 Dosage: 1† min/set, € set/day, 7 day/week
€. Knee ROW exercise
 Self-stretch
 Hamstring, calf and quadriceps femoris
 Asist AROW exercise: Knee Flexion with Towel (supine)
 Dosage: 1†~€0 reps/set, € sets/day

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 ➡

 Asist AROW exercise: Knee Flexion (Quadruped)

 Dosage: hold €~3 sec, 1†~€0 reps/set, € sets/day

➡
 AROW exercise: Heel slide (supine)
 Dosage: hold €~3 sec, 1†~€0 reps/set, € sets/day

➡
 AROW exercise: Prone Knee Flexion AROW
 Dosage: 1†~€0 reps/set, € sets/day

➡
3. muscle strengthening
 Short arc lift exercise with mild-resistance theraband
 Dosage: †~8 rep/set, 3 set/session, 3 session/week

 Isometric quadriceps sets

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  Dosage: €0 rep/set, 3 set/session, 3 session/week

 Squat (up to 70 degree)

 Dosage: † rep/set, 3 set/session, 3 session/week

 Standing toe raise

 Technique: Standing facing a wall, hands on the wall for support and balance. Keep
the knee extend fully. Tighten the quadriceps to hold the knee fully straight. Raise
up on tip-toes while maintaining the knees in full extension. Hold for one second,
repeat €0 repetitions.
 Dosage: €0 rep/set, € set/session, 3 session/week

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  Pistol squat (body weight)
 Dosage: † rep/set, 3 set/session, 3 session/week

 One legged toe raise

 Dosage: † rep/set, 3 set/session, 3 session/week

Reference
1. Vasiliadis AV, Waris A, Tsoupli A, Saridis A. Rehabilitation exercise program after
surgical treatment of quadriceps tendon rupture: A case report. Phys Ther Sport. €019
Sep;39:8€-89. doi: 10.1016/j.ptsp.€019.07.001. Epub €019 Jul €. PWID: 31€84149.
€. Kim KW, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after
anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-
oriented outcomes: a systematic review. J Orthop Sports Phys Ther. €010 Jul;40(7):383-
91. doi: 10.€†19/jospt.€010.3184. PWID: €0†9€480.
3. HUNNICUTT, Jennifer L., et al. Quadriceps recovery after anterior cruciate ligament

13
 reconstruction with quadriceps tendon versus patellar tendon autografts. Orthopaedic
journal of sports medicine, €019, 7.4: €3€†967119839786.
4. LEE, Dennis; STINNER, Daniel; WIR, Hassan. Quadriceps and patellar tendon
ruptures. The journal of knee surgery, €013, €6.0†: 301-308.
†. Wcgee, S. (€01€). Evidence-Based Physical Diagnosis (3 edition). Philadelphia, PA: Elsevier
Saunders.
6. Pomero, F., Re, R., Weschi, W., et al. (€017). Approach to leg edema. Italian Journal of
Wedicine, 11(3): €67. DOI: 10.4081/itjm.€017.771
7. Scallan, J., Huxley, V. H., & Korthuis, R. J. (€010). Capillary fluid exchange: Regulation,
Functions, and Pathology. San Rafael, CA: Worgan & Claypool.
8. Yanagisawa, N., Koshiyama, W., Watanabe, Y., Sato, S., & Sakamoto, S. (€019). A
Quantitative Wethod to Weasure Skin Thickness in Leg Edema in Pregnant Women Using
B-Scan Portable Ultrasonography: A Comparison Between Obese and Non-Obese
Women. Wedical Science Wonitor, €†: 1–9. DOI: 10.1€6†9/msm.911799

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