Therapist Name: Ashley Palmer, SPT

Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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Patient Name: Andrea Culpepper DOB: 08-06-2005

Date of Service: 02/24/2023

PT Diagnosis (ICD-10):
M21.222 flexion deformity of left elbow
S53.442A, ulnar collateral ligament sprain of left elbow
R22.32 localized swelling

Medical Diagnosis (ICD-10): M24.321, right elbow dislocation

BACKGROUND INFORMATION:
Referral Source: Orthopedic surgeon
Referring Diagnosis: Right elbow dislocation
Other Referral Information: 12 visits of PT authorized

SUBJECTIVE:
History of current complaint: Patient presents to physical therapy after suffering a fall
on their elbow while playing football 6 weeks ago. They state that their elbow was
“straight” when they fell on it. After the fall, the patient states they felt pain in their
elbow, but kept playing the game. The pain in their elbow then got worse after someone
had stepped on their elbow shortly after the fall during the same game. They state their
elbow was stuck in a position “outside of their upper arm”, but then “popped back into
place” once they grabbed their arm and pulled it back towards the right side of their body
after being stepped on. They rate their pain a 4/10 with movement and a 1/10 at rest and
described it as “aching” at the inside of their elbow and their upper arm above their
elbow. The patient states their athletic trainer instructed them to go to the ER right away.
They report having swelling at their elbow with a bruise that was purple after the injury
but is now yellow. The patient had an MRI and an ultrasound ordered by their physician.
Current Functional status/activity/participation level: The patient reports their current
functional status limited due to limited motion at their elbow causing them to have to sit
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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out of their sport. They are also unable to do homework due to pain at their L elbow and
are only able to carry their backpack on their R shoulder. They are also having trouble
brushing their teeth, washing their face at home, and eating with their L arm. The patient
is R hand dominant.
Prior level of function: Before the injury during their football game, they were able to
participate in their sport and perform their daily activities at home and school without
pain in their L elbow.
Medical/Surgical history; general health status (Review of Systems): The patient
reports having an ORIF for their broken femur a couple of years ago. No other known
medical history.
Current medications: The patient states taking no medications currently.
Allergies: The patient states being allergic to codeine, penicillin, Augmentin, and
adhesives.
Employment status: The patient is unemployed but is a high school student who plays
football and softball.
Home/Work/Other Environment: The patient lives at home with her two parents and
three siblings and participates in playing football and softball.
Family health history: The patient states having no known family health history.
Social/Cultural history: The patient reports no cultural or religious beliefs that might
affect their care. English is their primary language. The patient states no recreational drug
use or alcohol use.
Patient goals: The patient would like to return to their sport, do their homework on their
computer without pain, and perform their ADLs pain-free.

OBJECTIVE EXAMINATION:
Systems Review: (Use laminated Systems Review form)
HR: 67 bpm RR: 14 bpm BP: 121/80 taken on R arm in seated
Edema: 27 cm on L elbow 1 inch above antecubital region
20 cm on R elbow 1 inch above antecubital region
Other significant findings: light-yellow colored bruising near medial and lateral
epicondyle
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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Tests and Measures:

General Anthropometric Observations/Posture: Patient presents with slight rounded
shoulders when sitting and standing. Patients L shoulder is elevated due to sling on the L
UE when standing and sitting.

Inspection/Observation: Patient shows obvious signs of swelling and bruising near both
epicondyles and proximal and distal to the antecubital region of their L elbow.

Neurological/Sensory: No neurological or sensation deficits found.

ROM:
L elbow flexion/extension 41°-69° with empty end feel
R elbow flexion/extension WNL, will be measured next visit due to time constraint
L forearm supination 0-32° with empty end feel
L forearm pronation 0-40° with empty end feel
R elbow pronation/supination WNL, will be measured next visit due to time constraint

Muscle Length/Flexibility: Muscle length tests of the biceps and triceps will be taken
next visit due to time constraint.

Strength/MMT:
L wrist flexion 5/5
L wrist extension 5/5
L elbow extension 2-/5
L elbow flexion 1+/5
L forearm supination 2/5
L forearm pronation 2/5
R UE will be tested next visit due to time constraints.
Grip Strength: R 32 kg
L 16 kg
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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Palpation: Patient presents with tenderness and hypertonicity at the biceps brachii muscle
of the L UE. The patient is tender to the touch at their medial epicondyle, antecubital
region and posterior elbow with pain when palpated. The patient has no significant
findings when palpating the L wrist/hand. The patients L upper trapezius muscle was
tender and hypertonic when palpated.

Joint play assessment: Will be assessed next visit due to time constraints.

Special Tests:
Valgus stress test + for UCL instability of L UE

Gait: The patient lacks reciprocal arm swing when walking due to L UE being
immobilized in a sling.

Functional Mobility: The patient lacks functional mobility of their L UE for ADLs due to
limited flexion and extension ROM. The patient has normal functional mobility of their R
UE.

Balance: The patient can maintain sufficient balance when standing, walking, and sitting.

Standardized Outcome Assessments: The patient scored a 70.5/100 on the Quick DASH
questionnaire indicating significant impairment of the L UE.

Other: N/A
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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INTERVENTIONS (must include statement of informed consent (review of POC

and consent to treat) and patient participation in goal setting):
Verbal consent was given from patient to begin treatment.
Elbow flexion isometrics 10 sec x10
Elbow extension isometrics 10 sec x10
Elbow pronation isometrics 10 sec x10
Elbow supination isometrics 10 sec x10
AAROM flexion 15 x3
AAROM extension 15 x3
Exercises were provided with demonstration and verbal cueing to ensure proper muscle
activation. HEP was given.

ASSESSMENT (EVALUATION):
PROBLEMS LIST (Include impairments, activity limitations, and participation
restrictions):
Body structure/function (impairments): Patient has limited ROM of flex/ext and
supination/pronation of the L elbow and forearm. Patient has pain and swelling of L
elbow with bruising. Patient also presents with ulnar collateral ligament instability of the
L elbow.
Activity Limitations/Participation Restrictions: Patient is unable to do homework and
carry their backpack like they were able to before the injury due to pain and limited
ROM. They are also unable to complete most ADLs (e.g., brush their teeth, wash their
face and eat) without pain or difficulty. Patient is required to sit out of their sport
currently due to difficulty with throwing, catching, etc. because of their pain and lack of
full elbow range of motion. Patient is eager to reduce their pain and regain their
functional mobility back in order to complete ADLs and return to their sport.
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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Summary-Clinical Impressions (Tie the impairments to activity limitations and

participation restrictions and justify the need for skilled physical therapy):

Based on the patient’s presentation to physical therapy and subjective information

regarding the fall/injury during a football game 6 weeks ago, the patient has limited
mobility of their L elbow that is followed by pain and swelling. The patient is unable to
fully extend or fully flex their elbow as well as pronate and supinate their forearm
limiting their strength of the L UE as well. Due to her impairments, the patient has
limited ability to complete their ADLs and task at school like she was able to before the
injury. The patient is also unable to play their sport due to this injury. The patient
presents with ligamentous instability of the ulnar collateral ligament of the L elbow and
has pain and irritation while a valgus force is applied. The patient is tender to the touch at
the biceps brachii muscle and around the medial and posterior aspect of the elbow. The
patient’s strength is limited of their L UE (16 kg) compared to the R UE (32 kg) when
grip strength was tested. This patient would benefit from skilled physical therapy to
regain their functional mobility and strength and reduce their pain of the L UE.

PT Diagnosis: Patient has decreased L elbow flexion/extension and pronation and

supination ROM with pain. They have decreased strength of their L UE compared to the
R UE along with ligamentous instability of their UCL ligament in the L elbow. Patient
also has noticeable swelling and bruising following their injury.

Rehab Potential/Prognosis: Patient has an excellent rehabilitation potential due to their

motivation to return to their ADLs and return to their sport with an excellent prognosis
due to their young age.
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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GOALS:
Short-term (to be achieved in 6 weeks):
1. Patient will have at worst a 2/10 pain with movement of the L UE to decrease
difficulty of completing schoolwork and ADLs and will have 0/10 pain at rest
with no noticeable signs of swelling.
2. Patient will have increased functional mobility of the L elbow with a range of 20-
110° for flexion/extension and a range of 0-60° for pronation and supination of
the L forearm.
3. Patient will have an increased grip strength of 22 kg of the L UE.
4. Patient will score a 45/100 on the Quick DASH questionnaire.
5. Patients HEP will include progressed exercises and additional exercises to mimic
ADLs and throwing/catching to improve their participation in their sport.

Long-term (to be achieved in 12 weeks):

1. Patient will have 0/10 pain with movement and at rest of the L UE with no
difficulty of completing schoolwork and ADLs.
2. Patient will have full functional mobility of the L elbow with a flex/ext range of
0-145° and will have 0-80° for pronation and 0-90° for supination of the L
forearm.
3. Patient will have an increased grip strength of 30 kg of the L UE.
4. Patient will score a 0/100 on the Quick DASH questionnaire.
5. Patients HEP will be finalized with advanced exercises of the UE and will return
to sport.

PLAN OF CARE: Patient has given consent and agreed to be seen for physical therapy
for 2x/week for 12 weeks. Treatment will include strengthening of the flexors/extensors
of the elbow and forearm and stability exercises of their L elbow and L shoulder to
improve ligamentous stability and function of the L UE for ADLs and sport. Treatment
may include cold modalities to decrease swelling.

Ashley Palmer, SPT

 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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Evidenced-Based Practice

AMA Citation Reiter AJ, Schott HR, Castile RM, et al. Early joint use
following elbow dislocation limits range-of-motion loss and
tissue pathology in posttraumatic joint contracture. J Bone
Joint Surg Am. 2023;105(3):223-230.
doi:10.2106/JBJS.22.00064

Link to article (or doi) https://pubmed.ncbi.nlm.nih.gov/36723466/

Implications for your I implemented AAROM exercises early in rehabilitation to
clinical decision-making minimize immobility effects and regain functional mobility
of the UE following an elbow dislocation rather than PROM
techniques to avoid heterotopic ossificans. The study
supports early active mobilization post-trauma.
 Therapist Name: Ashley Palmer, SPT
Lab (AM/PM): AM
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): Group B
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