Ahmad Hakimul Ashraf Bin Roslan Hakim

12DPY0010

Knee joint

hinge joint
Made up by 4 bones known
as femur, tibia, fibula, and
patella.

Bony Anatomy
Lower Leg
Tibia
Fibula
Upper Leg
Femur
Patella

Femur
Tibia &
Fibula

Patell
a

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 cant 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 Program

One 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.

to

After all this phase patient can return to their normal

activities such as work, sport with a general guidelines
prevent the injury back.

Subjective Information

Name
Age
Sex
Race
Occupation
MRN
D.O.A
D.O.AX
DR. Diagnosis
DR. MX

:
:
:
:
:
:
:
:
:
:

Mdm.N
52 years old
Female
Malay
teacher
424424

Rt. Facial palsy

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 attention
3.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
Marital status
Smoking/alcohol
Type of house
Transportation

4.Medication Hx :

Pain killer

:
:
:
:
:

prolong walking and sitting

Married
NIL
single storey terrace houce
car (auto)

Pain Scale

On rest

Rt

swelling, and pain

noted at Lt. knee
joint

Lt Lt

Rt

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
Joint

Movement

Right
Active

Knee

Flexion
Extension

FROM
0

Passive
FROM
0

Left
Active
0-90
degree
0

Passive
0-120
degree
0

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

5.Muscle Bulk
Region

Supra patella

Point

Right

Left
(affected)

Differences

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

swelling noted at 5cm from mid patella

muscle wasting at 10cm and 15cm from midpatella

Region

Infra patella

Point

Right

Left

Differences

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.

16/10/2013

Knee Jt.

Lt.

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
To
To
To

Decrease pain
reduce swelling
Increase ROM within 1 week
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 hold
Cycling
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.