Physio Eval Note

Primary Concern: - Right knee pain following a sports injury History of Present Condition: - The patient presents with right knee pain following a soccer injury sustained two weeks ago. The pain began after a sudden twist during a match. - The patient has not undergone any prior therapy or surgery for this condition. - The pain has progressively worsened, with swelling and difficulty in weight-bearing activities. - The pain is sharp and localized to the anterior knee, rated 6/10 in severity. - Symptoms are aggravated by running and alleviated by rest and ice application. - The patient reports limited mobility and difficulty in performing daily activities. - The patient is a college athlete with a high activity level and no significant social history impacting the condition. - The goal is to return to competitive sports with improved knee function. Medical History: - No significant past medical conditions. - No previous surgeries. - No known allergies. - Currently taking ibuprofen for pain management. - Non-smoker, occasional alcohol use. - No relevant family medical history. Objective: - Swelling and tenderness observed in the right knee. - Positive Lachman test indicating possible ACL involvement. - Range of motion limited to 90 degrees flexion. - No vital signs abnormalities noted. - MRI results show partial ACL tear. Assessment: "John Doe is a 20-year-old male presenting to physical therapy following a right knee sports injury." - The therapist's professional opinion suggests a partial ACL tear with associated swelling and pain. - Prioritized problems include pain, swelling, and limited range of motion. - Progress towards goals is hindered by pain and swelling. - Referral to an orthopedic specialist is recommended. - Education on knee stabilization exercises provided. - Knee brace recommended for support during activities. - Anticipated goals include pain reduction and improved knee stability. "John Doe will benefit from skilled physical therapy to address aforementioned impairments and limitations to return to their activities of choice." Medical Diagnosis: - S83.511A (Sprain of anterior cruciate ligament of right knee, initial encounter) - M25.561 (Pain in right knee) Short term goals: - Reduce knee pain to 3/10 in two weeks. - Increase knee flexion to 120 degrees in four weeks. - Decrease swelling by 50% in two weeks. Long term goals: - Return to full sports participation in three months. - Achieve full range of motion in the right knee in three months. - Strengthen quadriceps and hamstrings to pre-injury levels in three months. Rehabilitation Potential: - High potential for recovery with adherence to therapy. - Motivated patient with strong athletic background. Interventions: - Manual therapy twice a week for four weeks. - Therapeutic exercises focusing on knee stabilization thrice a week. - Cryotherapy sessions post-exercise. Patient education provided: - Educated on the importance of adherence to home exercise program. - Discussed the role of knee brace in preventing further injury.