CASE REPORT

1. DATABASE (October 18th, 2018)

1.1 Identity
 Name : Mr. P
 Sex : Male
 Age : 46 years old
 Address : Surabaya
 Occupation : Online driver
 Religion : Moslem
 Marital status : Married
 Ethnic : Javanese

1.2 Referred from: Physical medicine and rehabilitation out patient clinic Airlangga
University Hospital Drop foot et causa suspect peroneal nerve lesion + post screw tibia
sinistra with request : AFO

1.3 Chief complaint: pergelangan kaki kiri tidak dapat diangkat

1.4 History of present illness

The patient cannot lift his ankle since 2 months ago. Patient fell when he was in the
bathroom but he didn’t remember how it was. 3 days later he went to Airlangga University
hospital and had an x ray for his left knee. The doctor found a broken bone at his left lower
leg and he went through surgery 10 days later. He was hospitalized for 4 days. After the
surgery he cannot lift his left ankle until now. He was treated at the PM&R outpatient clinic
for a month and referred to Soetomo hospital for EMG-NCV examination and pro AFO.
Patient didn’t complain any pain but he complaint about stiffness at his left calf. He also
felt numbness at his left feet at the same time. He was ambulated independently using
crutches but he was still afraid to stepping on his left foot. The orthopedic at Airlangga
university tell him to slowly increase the stepping on his left foot.
1.5 History of Past Illnesses
 Diabetes Mellitus (+) controlled
 Post wiring surgery at right patella due to fracture of patellar bone (7 months)
 No history of Hypertension, cardiac disease, or tumor

1.6 History of Medication

 Metformin 3 x 500 mg

1.7 History of Activity

 The patient was an online driver since 4 years ago.
 He can’t work since he had last surgery.

II. PHYSICAL EXAMINATION (October 18th, 2018)

2.1 General Status

 Compos Mentis, Independent ambulation using crutches, three point gait, Right
Handed Dominant
 Vital signs : BP 110/70 mmHg, HR 76 x/minute, RR 18 x/minute
 Body weight : 75 kg, body height : 1,69 m, BMI : 26,25
 Head and Neck : no anemia, icterus, cyanosis, or dyspneu
 Thorax
o Cor : S1–S2 single sound, no murmur or gallops
o Pulmo : normal vesicular sound, no wheezing nor ronchi
 Abdomen : normal peristaltic sound, liver and spleen unpalpable
 Extremities : acral warm, edema at left lower extremities

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2.2 Musculoskeletal Status
Region Joint Movement Muscles Strength
Movement Range of Motion Muscles MMT
(active and passive)
Neck Flexion Full (0-450) Flexor 5
Extension Full (0-450) Extensor 5
Lateral flexion Full / Full (0-450) Lateral flexor 5/5
Rotation Full / Full (0-600) Rotator 5/ 5
Trunk Flexion Full (0-850) Flexor 5
Extension Full (0-300) Extensor 5
Lateral flexion Full / Full (0-350) Lateral flexor 5/ 5
Rotation Full / Full (0-450) Rotator 5/ 5
Shoulder Flexion Full / Full (0-1800) Flexor 5/ 5
Extension Full / Full (0-600) Extensor 5/ 5
Abduction Full / Full (0-1800) Abductor 5/ 5
Adduction Full / Full (0-450) Adductor 5/ 5
Internal Rotation Full / Full (0-900) Internal Rotator 5/ 5
External Rotation Full / Full (0-700) External Rotator 5/ 5

Elbow Flexion Full / Full (0-1350) Flexor 5/ 5

Extension Full / Full (135º-0) Extensor 5/ 5
Pronation Full / Full (0-900) Pronator 5/ 5
Supination Full / Full (0-900) Supinator 5/ 5
Wrist Flexion Full / Full (0-800) Flexor 5/ 5
Extension Full / Full (0-700) Extensor 5/ 5
Radial deviation Full / Full (0-200) Radial Deviator 5/ 5
Ulnardeviation Full / Full (0-350) UlnarDeviator 5/ 5
Fingers Flexion Full / Full Flexor 5/ 5
Extension Full / Full Extensor 5/ 5
Abduction Full / Full Abductor 5/ 5
Adduction Full / Full Adductor 5/ 5

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 Hip Flexion Full / Full (0-1250) Flexor 5/ 5
Extension Full / Full (0-300) Extensor 5/ 5
Abduction Full / Full (0-450) Abductor 5/ 5
Adduction Full / Full (0-200) Adductor 5/ 5
Internal Rotation Full / Full (0-450) Internal Rotator 5/ 5
External Rotation Full / Full (0-450) External Rotator 5/ 5
Knee Flexion Full / Full (0-1350) Flexor (pain) 5/ 5
Extension Full / Full (135º-0) Extensor 5/ 5
Ankle Dorsoflexion Full/A(00) P Full(0-200) Dorsoflexor 5/ 1
Plantarflexion Full / Full (0-500) Plantarflexor 5/ 5
Eversion Full / Full ( Evertor 5/ 2
Inversion Full / Full ( Invertor 5/ 4
Big toe Flexion Full / Full Flexor 5/ 5
Extension Full / A (0) P Full Extensor 5/ 1
Toes Flexion Full / Full Flexor 5/ 5
Extension Full / Full Extensor 5/ 1

Tibialis anterior muscle : 5 /1

Extensor digitorum longus : 5/ 1
Extensor halucis longus : 5/ 1
Peroneus longus and brevis : 5/ 1

2.3 Neurological Examination

 N. Cranialis I –XII : Normal
 Physiological Reflex : BPR +2/+2, KPR +2/+2, TPR +2/+2, APR +2/+2
 Pathological Reflex : Babinski -/-, HT -/-
 Sensory deficit : sensory deficit at dermatome area L4, L5 S 60%

2.4 Local Status of leg

 Inspection : wound scar is healing and dry, no pus at left knee
 Palpation : warm -/-, swelling dorsum pedis -/+, atrophy of calf muscle -/+
 Special Test : walk on heel able / not evaluated, walk on toe able / not evaluated.

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2.6 Functional Examination
 Count test : 18
 Chest expansion test : T2 : 4 cm / T4 : 3 cm / T6 : 3 cm
 Static and dynamic : sitting balance good
 Static and dynamic standing balance : good
 Frax major osteoporotic / Hip fracture : 2,7 / 0,2

2.7 Barthel Index

Feeding 10 Bladder 10
Bathing 5 Toilet use 10
Grooming 5 Transfer 15
Dressing 10 Mobility 15
Bowel 10 Stairs 5
Total : 95 (totally independent)

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2.8 Supporting Examination
X ray genu sinistra AP/ Lateral (August 20th, 2018)

1. Incomplete intra articular fracture of 1/3

proximal of left tibia with no sign of callus
formation.
2. No sign of osteomyelitis.

X ray genu sinistra AP/ Lateral (October 16th, 2018)

1. Screw insertion at 1/3 proximal left

tibia .
2. No sign of osteomyelitis.

III. DIAGNOSIS
3.1 Medical :
 Drop Foot Sinistra (M21.372) ec left peroneal nerve lesion (2 months) + post screw
insertion of tibia sinistra ( 2 months) + post wiring at right patellar bone ( 7 months) +
Diabetes Mellitus (E11) + overweight

3.2 Functional Diagnosis (based on ICIDH 1980)

 Impairment :
o Weakness of left miotome L4, L5
o Sensory deficit dermatome L4, L5 S 60%
o Atrophy of left calf muscle
o Post screw insertion of left tibia (2 months)
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 o Post wiring at right patella (7 months)
o Diabetes Mellitus (controlled)
o Decrease of count test
o Overweight
o Swelling at left foot
 Disability :
o Three point gait
o Difficult to walk and taking stairs
 Handicap :
o Unable to work as online driver

3.3 International Classification of Functioning, Disability, and Handicap (2001).

ICF
DESCRIPTION PATIENT’S CONDITION
CODE
Body Functions
B555 Endocrine function Diabetes melitus
B730 Muscle power function Weakness miotome L4, L5
B770 Gait pattern function Three point gait
Body Structures
S580 Structure of endocrine Diabetes melitus
S750 Structure of lower extremity Ankle
Activities and Participation
D450 Walking Cannot walk fast or far
Community life Unable to join community
D910
gathering
Economic life Unable to work as an online
D879
driver
Activities and Participation
E580 Health services, systems and JKN insurance
policies

IV. PROBLEM LIST :

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 Surgical : Post screw insertion of left tibia (2 months)
Medical : Diabetes Mellitus
Rehabilitation Medicine :
o R1 (Ambulation) : three point gait
o R2 (ADL) : difficulty in walking up and down stairs
o R3 (Communication) :-
o R4 (Psychological) : worried about his condition
o R5 (Social Economy) : low economy status
o R6 (Vocational) : cannot work as online driver
o R7 (Others) :
• Weakness ankle dorsoflexion, big toe extension sinistra
• Atrophy calf muscle sinistra
• Sensory deficit in dermatome area L4, L5 S 60%
• Post screw insertion of left tibia (2 months)
• Post wiring at right patella (7 months)
• Decrease of count test
• Diabetes mellitus (controlled)
• Overweight
• Swelling at left foot

V. GOALS
Short Term Goals :
- The patient understand about his condition
- Muscle strengthening
- AFO
- Increase count test
- Decrease left foot swelling

Long Term Goals :

- Endurance maintenance
- Controlling body weight
- Blood glucose maintenance
- Improvement of quality of life

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VI. PLANNING :
Surgical : -
Medical : continue medication for diabetes mellitus
Rehabilitation Medicine :
Ambulation : three point gait
PDx EMG-NCV
PTx  Modality :
o NMES faradic current on tibialis anterior, extensor
halluces longus, and peroneus longus sinistra muscle,
intensity visible muscle contraction, 30 minute as
patient tolerate, frequency 2x/week
 Therapeutic exercise
o AROM exercise AGB dextra sinistra
R1 o Except ankle, big toe, toes extension sinistra PROM
exercise
o Resensitisation sensory
o
 Orthesa : posterior leaf spring
PMx MMT, gait, sensory, weight bearing
PEx Health education/Home Exercise Program
 Explain the patient disease
 Continue exercise at home
 Use posterior leaf spring when walking
ADL : Difficulty in walking and stairs
PDx (-)
PTx Modify ADL
R2
PMx ADL
PEx Health education
 Explain the patient disease
R3 Communication : no problem
Psychological :worried about his condition
R4 PDx (-)
PTx Give psychological support

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 PMx Psychologic condition
PEx Explain to the patient and his family about the disease
give psychological support (from family, clinician, environment)
Social Economy : low economy
R5
PEx Find another source of income
Vocational : cannot work as online driver
R6
PEx Alternative possible occupation
Others
• Weakness ankle dorsoflexion, big toe extension S
• Atrophy calf muscle S
• Deficit sensory dermatome L4, L5 S
• Decrease of count test
• Diabetes mellitus
• Overweight
• Swelling at left foot
PDx Continue Diabetes medication
PTx  Modality :
o NMES faradic current on tibialis anterior, extensor
halluces longus, and peroneus longus sinistra muscle,
intensity visible muscle contraction, 30 minute as
R7
patient tolerate, frequency 2x/week
 Therapeutic exercise
o AROM exercise AGB dextra sinistra
o Except ankle, big toe, toes extension sinistra PROM
exercise
o Resensitisation sensory
 Orthesa : posterior leaf spring
PMx Clinical condition, MMT, sensory, ROM, gait, BMI
PEx Health education/Home Exercise Program
 Explain the patient disease
 Continue exercise at home
 Use posterior leaf spring when walking
 Decrease body weight

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  Ankle pumping and ankle elevation
 Partial weight bearing 50%, increase slowly until full weight
bearing at 12 weeks post screw insertion.

PROGRESS REPORT

1st follow up (after 4th therapy) : October 29th 2018

 Patient still cannot lift up his left ankle
 Patient felt numbness in left foot
S
 Intermittent swelling at left foot
 Posterior leaf spring was still being made on the OP
 General status : CM, independent ambulation using crutches, three point gait,
right handed
 Vital sign : BP : 120/60 mmHg, HR : 72x/min, RR : 18x/min
 Body weight : 75 kg, body height : 1,69 m, BMI : 26,25
O  Musculoskeletal status : ankle dorsiflexi 5/1, ankle eversion 5/2, ankle inversion
5/4, extension toe 5/1, extension big toe 5/1
 Neurological status : deficit sensory 50% at dermatome area L4
 Atrophy calf muscle S
 Count test: 18
 Drop Foot sinistra ec left peroneal nerve lesion (2 months) + post screw
A insertion of tibia sinistra ( 2 months) + post wiring at right patellar bone (7
months) + Diabetes Mellitus (controlled) + overweight
PDx : EMG-NCV (planning on November 12th, 2018)
PTx :
 Modality :
P
o NMES faradic current on muscle grup dorsiflexor
S, intensity visible muscle contraction, 30 minute,
frequency 2x/week

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  Therapeutic exercise
 PROM exercise ankle S
 Resensitisation sensory
 Endurance exercise:
F: 3x/week
I: THR = 60% HR max
T: 5 minutes warm up, 20 minutes core, 5 minute cooling down
T: static cycle
 Orthesa : Posterior leaf spring
PMx : Clinical condition, MMT, sensory, ROM, gait, weight bearing, BMI
PEx : Health Education and Home Exercise Program
 Explain patient about his condition
 Continue exercise at home
 Use posterior leaf spring when walking
 Decrease body weight
 Ankle pumping and ankle elevation
 Partial weight bearing 60%, increase slowly until full
weight bearing at 12 weeks post screw insertion

2nd follow up : November 8th 2018

 Patient still cannot lift up his left ankle
 Patient felt numbness in left foot slowly decrease
S
 Posterior leaf spring already finished
 Swelling at left foot still exist
 General status : CM, independent ambulation using single crutch, two point gait,
right handed
 Vital sign : BP 110/80 mmHg, HR : 71x/min, RR : 18x/min
O  Body weight : 75 kg, body height : 1,69 m, BMI : 26,25
 Musculoskeletal status : ankle dorsiflexi 5/1, ankle eversion 5/2, ankle inversion
5/4, extension toe 5/1, extension big toe 5/1
 Neurological status : deficit sensory 50% at dermatome area L4

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  Count test: 21

Drop Foot sinistra ec left peroneal nerve lesion (2,5 months) + post screw insertion of
A tibia sinistra (2,5 months) + post wiring at right patellar bone (7,5 months) + Diabetes
Mellitus (controlled) + overweight
PDx : -
PTx :
 Modality :
o NMES faradic current on muscle grup dorsiflexor S, intensity visible
muscle contraction, 30 minute, frequency 2x/week
 Therapeutic exercise
o AROM ankle plantar flexi S, PROM ankle dorsifleksi S
o Resensitisation sensory
o Endurance exercise:
F: 3x/week
P I: THR=60% HR max
T: 5 minutes warm up, 20 minutes core, 5 minute cooling down
T: static cycle
 Orthesa : Posterior leaf spring
PMx : Clinical condition, MMT, sensory, ROM, gait, BMI
PEx :
Health Education and Home Exercise Program
 Explain patient about his condition
 Continue exercise at home
 Partial weight bearing 70%, increase slowly until full weight bearing at 12 weeks
post screw insertion

3rd follow up : December 3rd 2018

 Patient still cannot lift up his left ankle
 Patient felt numbness in left foot
S
 No more swelling at his ankle
 Still wearing posterior leaf spring

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  General status : CM, independent ambulation using crutches, three point gait,
right handed
 Vital sign : BP : 120/60 mmHg, HR : 72x/min, RR : 18x/min
 Body weight : 75 kg, body height : 1,69 m, BMI : 26,25
O  Musculoskeletal status : ankle dorsiflexi 5/1, ankle eversion 5/2, ankle inversion
5/4, extension toe 5/1, extension big toe 5/1
 Neurological status : deficit sensory 50% at dermatome area L4, L5
 Atrophy calf muscle S
 Count test: 21
 Drop Foot sinistra ec left peroneal nerve lesion (2 months) + post screw
A insertion of tibia sinistra ( 3,5 months) + post wiring at right patellar bone (8,5
months) + Diabetes Mellitus (controlled) + overweight
PDx : Review the latest x ray genu sinistra
PTx :
 Modality :
o NMES faradic current on muscle grup dorsiflexor
S, intensity visible muscle contraction, 30 minute,
frequency 2x/week
 Therapeutic exercise
 PROM exercise ankle dorsiflexi, AROM ankle
plantarflexi S
 Resensitisation sensory
P
 Endurance exercise:
F: 3x/week
I: THR = 60% HR max
T: 5 minutes warm up, 20 minutes core, 5 minute cooling down
T: static cycle
 Orthesa : Posterior leaf spring
PMx : Clinical condition, MMT, sensory, ROM, gait, weight bearing, BMI
PEx : Health Education and Home Exercise Program
 Explain patient about his condition
 Continue exercise at home

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  Use posterior leaf spring when walking
 Decrease body weight
 Ankle pumping and ankle elevation
 Partial weight bearing 70% until the review of the latest x
ray genu

EMG (12/11/2018)
Evaluation on the left peroneal motor nerve showed no response (ankle) and no
response (B fib). All remaining nerves (as indicated in the following tables) were within normal
limits. F Wave indicate that the left peroneal F wave has no responses. All remaining F wave
latencies were within normal limits. Needle evaluation of the left extensor digitorum brevis
muscle showed increased insertional activity and white spread spontaneous activity. The left
interior tibialis muscle showed increased insertional activity, increase spontaneous activity,
diminished recruitment and very decreased interference pattern. The left extensor halluces
longus muscle showed increased insertional activity and increases spontaneous activity. The
left peroneus brevis muscle showed increased insertional activity, increased spontaneous
activity, increased motor unit duration, diminished recruitment, and very decrease interference
pattern. The left peroneus longus muscle showed moderately increased polyphasic potentials,
diminished recruitment, and decreased interference pattern. The left biceps femoris (short head)
muscles showed moderately increased polyphasic potential and decreased interference pattern.
Impression: The current electro diagnostic study showed axonal lesion of left common
peroneal nerve (distal to the branch of biceps femoris short head muscle, proximal to the branch
of tibialis anterior muscle) with sign of denervation at extensor digitorum brevis, extensor
halluces longus, peroneus brevis, and tibialis anterior muscles.

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