Weekend 6: Case Presentation

[Erik Kreil]

Please see file attached below for weekend 6 case presentation.

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[jeffpeckins]

1. Based on the subjective information presented above what are your top three differential diagnoses? (Ranking order)
– CRPS
– Central sensitization
– MCL/PCL injury

2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
– CRPS: swelling, changes in skin temp and color, hypersensitivity, decreased sensation that is not at one specific dermatomal level.

3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?
– Skin texture changes?, hair growth?, sensitivity to light touch?
– I would ask yellow-flag questions to get an idea of she has any S&S of these. This also might be a good way to begin any education that you believe the patient needs.

4. Rank by % her origin of Pain: central, nociceptive, neuropathic.
– Central: 40%
– Nociceptive: 20%
– Neuropathic: 40%

5. Rank which of these you would want to provide during IE: Education, Manual, Exercise. Why?
– #1: Education – I would explain to her that there is something more going on beyond anatomically-driven knee pain. I’d say that it seems as though her whole body is in a sensitized state, and that it is interpreting thinks that aren’t normally painful as pain.
– #2: Low intensity exercise – She has probably been very guarded since the MVA and since she has been in so much pain, and I think low-intensity activities would help facilitate decreased fear of movement.
– #3: Manual therapy – I would not make this a priority during treatment, at least until her widespread and vague pain symptoms begin to normalize to something that makes more sense anatomically.

6. How would you educate the patient regarding our findings and her upcoming surgery? If this means a suggestion of no surgery, how would you address the doc?
– I would briefly explain to the patient that there doesn’t seem to be one pathological structure at fault for her pain symptoms, and therefore don’t think surgery should be considered at this time.
– This would be a time when I would try to get in touch with the physician, especially if surgery is already scheduled or in the closing stages of being finalized. I would tell the physician that you found that the patient is displaying pain complaints that are much more widespread than just her knee, as well as S&S of non-MSK issues.

[Cameron Holshouser]

1. Based on the subjective information presented above what are your top three differential
diagnoses? (Ranking order)

– Lumbar radiculopathy (L3/4)
– Complex regional pain syndrome
– knee ligamentous injury (PCL) – dashboard injury

2. Based on the objective information presented above what is your top clinical diagnosis and
why? Does it follow a clinical pattern?

– L4/5 Lumbar radiculopathy (discogenic, annular tear?, extension bias?)

o Subjective
– Young
– None specific knee pain
– Recent MVA
– Pain referral pattern (knee, hip, back, ankle, foot)
– Changes with WB
– Worsens with LE extension in seated (slump)
– Valsalva with urinating ?

o Objective
– Myotomal, dermatomal changes
– Lumbar motion recreates same pain in LE
– + Slump for same pain
– + CPA radicular and local pain
– + POE

3. Is there any information you would have asked during the subjective examination or
collected during the objective examination?

– what surgery is she schedule for?
– What other imaging has she had if they are planning on surgery?
– Injections / anti-inflammatory medications?
– Tibiofemoral joint mobility / laxity
– Functional LE tests
– Color of LE
– Distal pulse / capillary refill
– Calf/knee/ankle swelling measurements
– Lateral shift posture?
– Seated flexion overpressure
– Quadrants for spine
– Valsalva
– Prone torsion test
– SLR
– Saddle paresthesia,
– t/s mobility

4. Rank by % her origin of Pain: central, nociceptive, neuropathic.
– Nociceptive 60%
– Neuropathic: 25%
– Central: 15%

5. Rank which of these you would want to provide during IE: Education, Manual, Exercise.
Why?

1. Education
2. Manual
3. Exercise

I would only provide education with this patient. First to go over exam findings and your plan of care. Second, provide education on positions to avoid and positions of comfort. Based on her irritability, I would want to see how she tolerates the exam before providing exercise or manual.

6. How would you educate the patient regarding our findings and her upcoming surgery? If this
means a suggestion of no surgery, how would you address the doc?

– Depends what surgery and where
– I would communicate your subjective and objective asterisks
– See what his thoughts were and why
– I don’t think I would tell the patient that she shouldn’t have the surgery. I would like to see the MD’s take on the situation first. I would communicate with the patient on where you think her symptoms are coming from and why, what you can do to help, and will try to communicate with the MD prior to her next appointment.

[Matt Fung]

Hey Erik, very interesting case.

1. Based on the subjective information presented above what are your top three differential diagnoses? (ranking order)
• CRPS
• Lumbar radiculopathy
• PCL/MCL injury

2. Based on the objective information presented above what is your top clinical diagnosis and why? Does it follow a clinical pattern?
• Lumbar radiculopathy (myotomal weakness, dermatomal sensory loss, +slump, +POE, +radicular sx w/ shear testing, familiar pain w/ L/S AROM)

3. Is there any information you would have asked during the subjective examination or collected during the objective examination?
• What type of surgery is she planning on undergoing?
• Any other imaging performed for knee symptoms?
• Has she been out of work since accident? Or during recent flare up?
• Functional LE tests (DL/SL squat, SLS)
• Edema measurements?
• Color of LE

4. Rank by % her origin of pain: central, nociceptive, neuropathic
• Nociceptive: 60%
• Neuropathic: 30%
• Central: 10%

5. Rank which of these you would want to provide during IE: Education, manual, exercise. Why?
1. Education
2. Exercise
3. Manual
• I would educate the patient on objective findings and POC. I would echo the doctor’s recommendations to discontinue running or aggravating factors identified during the examination and promote positions of relief.
• I would promote low intensity aerobic exercise if she can tolerate i.e. biking
• I would also hold on manual therapy for IE based on her current irritability level and her subjective reports of “9/10 unbearable pain” and “10/10 unable to carry on any activates” and wait to see how she responds to education and exercise.

6. How would you educate the patient regarding our findings and her upcoming surgery? If this means a suggestion of no surgery, how would you address the Doc?
• First I would determine which surgery she is ready to undergo. I would not directly recommend against surgery but I would promote attempting a conservative PT route first before jumping into surgery. In regards to communicating with the doctor I would make them aware of the subjective and objective findings and see what their findings were and his/her indications for surgery. Additionally I would express our potential role can be in the rehabilitation process for this particular patient.

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