Ahmad Hakimul Ashraf Bin Roslan Hakim 12DPY0010

Knee joint hinge joint Made up by 4 bones known

as femur, tibia, fibula, andpatella.

Bony Anatomy◦ Lower Leg

Tibia Fibula

◦ Upper Leg Femur

◦ Patella

Patella

Tibia & Fibula

Femur

Thigh Muscles◦ Anterior

Quadriceps Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris

◦ Posterior Hamstrings

Biceps Femoris Semitendinosus Semimembranosus

Lower Leg Muscles Anterior

Tibialis Anterior

Medial Tibialis Aanterior Extensor Digitorum Longus Extensor Hallucis Longus

Lateral Peroneals

Posterior Gastrocnemius Soleus Tibialis Posterior

Ligaments◦ Medial Collateral ◦ Lateral Collateral ◦ Anterior Cruciate ◦ Posterior Cruciate

Meniscus◦ Medial◦ Lateral

ACL reconstruction is a surgical tissue graft replacement of the ACL.

To restore its functions after an injury Torn ligament can’t simply be repaired by sewing

it together The torn ligament will be remove before the graft

inserted. The surgeon usually perform an arthroscopic

procedure but some of them prefer to open the knee.

Type of Graft

Grafting procedures

1. Deep Vein Thrombosis (DVT) Occurs when blood clots flow into deep vein of the leg. DVT may cause the leg to become swelling, warmth, and painful.

2. Infections Chance of getting is very low Antibiotic will be given before and after surgery to prevent

this complication.

3. Stiffness The excessive scaring inside the knee joint after surgery can

lead to the stiffness. ROM exercise after the surgery is improtant to prevent it.

Rehabilitation Program Physiotherapy play an important role in this program Begin immediately after surgery. Involves in crutches training, teaching the exercise

(isometric) and attempt the patient to lift their leg independently.

By one week almost all the patient will be able to lift their leg without assistance and by the second week they can walk without crutches.

They will need an immobilizer such as knee ranger depend on the surgery and the preference of the surgeon.

Post- surgical ProgramOne of the examples of rehabilitation program :

Phase 1 This period is called Early Rehabilitation • This phase focused more on decreasing the pain and

swelling following surgery.• The exercise in this phase focused more on improving the

ROM and promote muscle activities and strength.• Improve the blood circulation by using Ankle Pumps and

Ankle Circle exercise.• Example exercise is SQE and SLR.

Phase 2 More attention is placed on joint protection as the pain had mostly

disappeared. The patient should able to bend the knee 0 – 100 degrees Exercise balancing activities can be performed. Gait training using parallel bar and also the treadmill if patient

able.

Phase 3 Also know as controlled ambulation phase Exercises on this phase includes all the former exercise plus few

more depend on patient abilities. Teach more balance activities.

Phase 4 Also known as moderate protection phase. Being able to do full range of motion. Gradually increase the weight to give more resistance on

existing exercise

Phase 5 Known as light activity phase Emphasis on strengthening exs and concentration more on

balance and mobility.

Final phase Should be begin at 10 week after surgery. This phase continues until the desired activities level is

reach. If necessary ,using a functional brace during sport activities

and work situation.

After all this phase patient can return to their normal activities such as work, sport with a general guidelines to prevent the injury back.

Subjective Information

Name : Mdm.N Age : 52 years old Sex : Female Race : Malay Occupation : teacher MRN : 424424 D.O.A : D.O.AX : DR. Diagnosis : Rt. Facial palsy DR. MX :

1.Chief complaint • Pt c/o discomfort at Rt. Side of face• Pt c/o difficulty to close her Rt. Eyes and mouth since 2/7 ago

2.Current Hx :• pt. woke up at 5am in the morning to prepare for her work when she

realize he Rt. Side of face dropped and uneven• She then went to PSH with her husband on 10.4.14 @ 7.00am for further

medical attention3.Past Hx :• Pt. suffers massive headache on and off since 10 years ago• The pain became regular lately since 3/7ago • She went to local clinic at larkin for medical attention but no

improvement in her headache

Medical hx◦ Migrain since 10years ago

3.Social Hx : Nature of work : prolong walking and sitting Marital status : Married Smoking/alcohol : NIL Type of house : single storey terrace houce Transportation : car (auto)

4.Medication Hx : Pain killer

Pain Scale

On rest

Rt Lt Lt Rt

swelling, and pain noted at Lt. knee joint

6.Type of Pain : Dull aching pain at lt. knee jt.

7.Aggravating Factor : Pain increase when flex over 90 degree. Prolong standing and walking will increase the pain.

8.Ease factor : Supine ly. or relax / no movement on at the affected side.

9.24 Hours : Pain increase during exercise Other period, pt feel mild pain.

Objective Information

1.General Observation A mesomorph size Malay man come to physiotherapy department

independently Full weight bearing with brace at Lt. leg Pt came with normal facial expression Pt is very cooperative

2.Local Observation Patient has scar at his Lt infrapatella region swelling at Lt Knee joint

3.On Palpation Warmness noted at Lt Knee joint. Tenderness grade 1 on medial and laterak side of knee Jt. No muscle spasm noted Lt.thigh and calf muscle

4.Range of Motion

Decrease knee flexion ROM in Lt Knee joint due to surgical pain

Joint Movement Right Left

Active Passive Active Passive

Knee FlexionExtension

FROM0

FROM0

0-90 degree0

0-120 degree0

5.Muscle Bulk

swelling noted at 5cm from mid patellamuscle wasting at 10cm and 15cm from midpatella

Region Point Right Left(affected)

Differences

Supra patella

5cm from mid-patella

42.0cm 44.0cm >2.0cm

10cm from mid- patella

51.0cm 48.5cm <2.5cm

15cm from mid-patella

57.0cm 55.0cm <2.0cm

Region Point Right Left Differences

Infra patella

5cm from mid-patella

38.0cm 40.0cm >2.0cm

10cm from mid-patella

39.0cm 36.0cm <2.0cm

15cm from mid-patella

35.0cm 37.5cm >2.5cm

swelling noted at 5cm and 15cm from mid-patella of Lt. knee Jt.

date joint muscle grades

Rt. Lt.

16/10/2013 Knee Jt. quadriceps 5/5 4/5

hamstring 5/5 4/5 (within 90 degree ROM)

Indicates decrease in muscle power of left side knee jt. d/t muscle weakness

7.Problem Listing Pain at Left knee joint d/t post operative ACL reconstruction Swelling at Left knee joint d/t ACL reconstruction Decrease ROM at Left Knee joint d/t surgical pain Reduce muscle power d/t pain

Short Term Goals To Decrease pain To reduce swelling To Increase ROM within 1 week To Regain muscle power/strength within 1 wek

Long Term Goal To prevent secondary complication e.g. tightness, muscle

atrophy

Plan of Treatment Faradic current

◦ To prevent muscle weakness CPM

◦ To increase ROM to spesific degree

Strengthening exercise◦ to improve muscle power and ROM

Cryotherapy ◦ To reduce swelling and reduce pain

Intervention Inner range quad

Pt in supine., place towel under the knee, straighten the leg 30 reps 10 sec hold

• Sqe Pt in supine., lock the knee., 30 reps 10 sec hold• Slr• Pt in supine., lock the knee flex the hip., 30 reps 10 sec hold• Heel slide• Pt in supine., flex the knee until pain range., 30 reps 10 sec holdCycling

pt cycle at static cycle, 10 min• Cryo cuff• Pt in long sitt.,lt. knee jt., 20 minutes

Evaluation◦ Pt claimed reduce in pain at lt. knee jt.◦ Pt was able to perform all activities that had given

Review◦ Kiv muscle bulk on next ass.◦ Kiv rom on next ass.◦ Kiv muscle power on next ass.