Specialty: Physiotherapist
**SUBJECTIVE**
**HPC:**
Left Knee, 6/52
Patient reports a sudden onset of sharp pain in the left knee 6 weeks ago while playing recreational football. The pain started immediately after a twisting injury to the knee when attempting to change direction. Initially, the pain was severe (8/10), accompanied by swelling and difficulty weight-bearing. She sought advice from her GP who advised RICE and rest. She has not seen any other practitioners. The pain is now a dull ache (4/10 at rest, 7/10 with activity) and is localised to the medial aspect of the knee. She experiences occasional clicking and a feeling of instability.
**Aggs:** Walking up and down stairs, prolonged standing, pivoting movements, deep squatting.
**Eases:** Rest, applying ice, elevation, taking paracetamol.
**24/24:** Experiences morning stiffness lasting approximately 30 minutes. Night pain is occasional, particularly if she has been active during the day, making it difficult to find a comfortable sleeping position.
**Past Injury Hx:** Right ankle sprain 5 years ago, fully recovered after 3 weeks of physiotherapy. No other significant musculoskeletal injuries.
**Social Hx:**
Employment and occupation: Works as an administrative assistant, 35 hours per week, mostly sedentary with occasional walking. No significant physical demands.
Exercise routine: Previously played recreational football twice a week and attended a gym for strength training three times a week. Has been unable to participate in these activities since the injury. Access to gym membership is current.
Social history: Lives with partner. Enjoys gardening and reading. Non-smoker, occasional social alcohol use.
**Past Medical Hx:**
Medical conditions: No known medical conditions.
Allergies: Penicillin (causes rash).
Family medical history: Father has a history of osteoarthritis in the knees.
**Red Flags:** Denies unexpected weight loss, night sweats, neurological symptoms (dizziness, diplopia, dysarthria, drop attacks, dysphagia, numbness, nystagmus, nausea). Denies drug use or general feelings of malaise.
**Psychosocial Factors:** Reports mild frustration due to inability to participate in usual sporting activities. No significant work, financial, or family stressors. Sleep quality has been slightly impacted by intermittent night pain.
**Imaging:** MRI of the left knee performed 3 weeks ago showed a medial meniscal tear and mild bone bruising. No ligamentous rupture.
**Medications:**
1. Paracetamol 500mg, as needed for pain (up to 4 times a day).
**Expectations & Goals:** Patient wants to understand the injury better, reduce pain, regain full knee function, and return to playing football without pain or instability. Short-term goal: Walk for 30 minutes without pain. Long-term goal: Return to football in 3-4 months.
**OBJECTIVE**
**Observation:** Mild swelling noted around the medial joint line of the left knee. No visible bruising or redness. Genu valgum noted bilaterally. Slight antalgic gait observed, favouring the left leg.
**AROM:**
Left Knee Flexion: 120 degrees (pain at end range)
Left Knee Extension: 0 degrees (full extension)
Right Knee Flexion: 140 degrees (full)
Right Knee Extension: 0 degrees (full)
**PROM:**
Left Knee Flexion: 130 degrees (pain at end range, soft end-feel)
Left Knee Extension: 0 degrees (firm end-feel)
Left Hip IR at 90deg Fxn: 35deg
Left GHJ IR at 90deg Abdn: 70deg
**Functional Ax:**
Single leg squat on left: Painful and unstable, unable to perform with good control.
Squat: Pain at approximately 90 degrees flexion.
Gait: Mild antalgic pattern, decreased stance phase on the left.
**Special Tests:**
McMurray's Test (Left Knee): Positive for pain and click on medial rotation with extension.
Lachman's Test (Left Knee): Negative.
Anterior Drawer Test (Left Knee): Negative.
Patellar Grind Test (Left Knee): Negative.
**Muscle Tests:**
Left Quadriceps Strength: 4/5 (manual muscle test)
Right Quadriceps Strength: 5/5
Left Hamstring Strength: 4/5
Right Hamstring Strength: 5/5
Left Calf Raise (single leg): 5 repetitions (pain 7/10), compared to Right: >20 repetitions.
**Palpation:** Tenderness and mild crepitus noted along the medial joint line of the left knee. No significant warmth.
**PAMs:** Left Ankle AP: Hypomobile.
**Neurological Exam:** Sensation intact to light touch in L2-S2 dermatomes. 5/5 power in L2-S2 myotomes. Reflexes (patellar, Achilles) 2+ bilaterally. Negative Slump test.
"Potential benefits, risks, and alternatives of the below proposed treatment have been discussed with the patient and/or parent/guardian. The patient and/or parent/guardian is aware of the above and consents to treatment."
**TREATMENT**
**Manual Therapy:**
Mobilisation: Gr III PA L) Tibia on Femur 2x30secs // increased knee flexion by 5 degrees.
Soft Tissue Massage: L) quadriceps and hamstrings, 5 minutes each side // decreased subjective tightness.
**Dry Needling:** Dry Needling: 0.25x25mm x3 L) Vastus Medialis (trigger points) GrII for 10/60.
**Advice & Education:** Provided detailed explanation of medial meniscal tear, including healing process and importance of relative rest. Discussed activity modification strategies and proper biomechanics during daily tasks to offload the knee. Advised on pain management techniques and gradual return to activity principles.
**Exercise Therapy:**
3x15 Wall sits (pain-free range)
3x10 Glute bridge with resistance band
3x12 Clamshells
**Exercise Program:** Provided a home exercise program including: Quadriceps isometric holds (3x10s, 10 reps), hamstring curls (3x10), gluteal strengthening (clamshells 3x15, glute bridges 3x15), calf raises (seated 3x15). Frequency: Daily. Dosage: As tolerated, without increasing pain above 3/10.
**ASSESSMENT**
6-week post-injury left medial meniscal tear, presenting with pain, swelling, and reduced function. Patient demonstrates good understanding of condition and is motivated for rehabilitation. Contributing factors include biomechanical inefficiencies (valgum) and reduced lower limb strength and control.
**PLAN**
- Next session plan: Progress home exercise program, introduce balance and proprioception exercises, continue manual therapy to improve joint mobility, and assess gait mechanics in more detail. Reassess pain levels and functional capacity.
- Goals: Short-term: Pain-free walking for 45 minutes. Long-term: Return to football in 3 months with no pain or instability.
**SUBJECTIVE**
**HPC:**
[Site of injury and time since injury] (Always list site of injury first, i.e. Left knee, followed by time lapsed since date of injury, i.e. 9/52 or 2/12. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
[History of current complaint] (History of current complaint including area of pain, type of pain, severity of pain, mechanism of injury, date of injury and clinical course since. What has the patient done so far in terms of other treatments, professions or exercise. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Aggs:** [Aggravating factors] (Things that cause or increase symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Eases:** [Easing factors] (Things that reduce severity or duration of symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**24/24:** [24-hour symptom behaviour] (Symptom behaviour over a 24 hour period including morning pain, night pain or difficulty getting to sleep. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Past Injury Hx:** [Past injuries] (Describe past injuries or conditions including timelines, what treatments they had and whether the injury fully recovered. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Social Hx:**
[Employment and occupation] (Summarise employment status, occupation, hours worked, physical/mental intensity of job, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
[Exercise routine] (Detailed exercise routine including frequency, duration, type, intensity, recent changes, access to gym. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
[Social history] (Mention relevant social history like lifestyle factors, hobbies, interests, family situation, living arrangements, support network, tobacco/alcohol use, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Past Medical Hx:**
[Medical conditions] (List existing and past medical conditions, e.g. osteoporosis, stroke, high blood pressure, surgeries etc. Include very small description and how they are managing each condition, e.g. Amlodipine 5mg QD. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
[Allergies] (Mention any allergies. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
[Family medical history] (Mention family medical history of disease. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Red Flags:** [Red flag symptoms] (Symptoms related to cancer i.e. unexpected weight-loss, night pain or sweats. Neurological signs i.e. dizziness, diplopia, dysarthria, drop attacks, dysphagia, numbness, nystagmus, nausea. Drug use. Feelings of malaise. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Psychosocial Factors:** [Psychosocial factors] (Family stressors, work stressors, financial stressors, lack of sleep, low mood, mental health conditions, external stressors. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Imaging:** [Imaging and tests] (List any imaging assessments or tests, i.e. blood tests, bone mineral density scans, and their findings that have been undertaken for this patient's presenting complaint/injury. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Medications:** [Medications list] (Make a numbered list for medications, with each medication mentioned on a new line along with details such as dosing. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Expectations & Goals:** [Patient expectations and goals] (Reasons for seeing physiotherapist and expectations of this consult, short-term goals, long-term goals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**OBJECTIVE**
**Observation:** [Observations] (Mention anything that involves observing the patient including bruising, redness, swelling or any asymmetries. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**AROM:** [Active range of movement] (Include joint being moved. Active range of movement tests of a specific joint, direction of movement and sides being assessed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**PROM:** [Passive range of movement] (Include joint being moved. Passive range of movement tests of a specific joint, direction of movement and sides being assessed. Include passive combined movements, for example, Hip ER at 90deg Fxn = 45deg or GHJ IR at 90deg Abdn = 30deg. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Functional Ax:** [Functional assessment] (Anything that involves functional movements such as gait, running, hopping, squatting. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Special Tests:** [Special tests] (Special tests specific to a joint or structure e.g. ligament tests, meniscus tests, quadrant movements for lumbar spine, hip or shoulder. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Muscle Tests:** [Muscle strength and endurance] (Include specific movement then L vs R. Any objective strength or endurance measures using technology such as a dynamometer or a work capacity test such as maximum reps. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Palpation:** [Palpation findings] (Anything that is found from touching the patient such as tight or painful structures. L vs R if indicated. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**PAMs:** [Passive accessory movements] (If indicated for spinal or back pain, or other joints if specified. Specify level and side being assessed, and findings such as pain and stiffness, for example, PA Right L4/5 sharp pain and hypomobile or Left Ankle AP hypomobile or Left lateral glide at C4/5. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Neurological Exam:** [Neurological examination] (Any tests relating to neurological structures such as dermatomes sensation, myotome power, reflex tests, straight leg raise, slump or nerve tension tests. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
"Potential benefits, risks, and alternatives of the below proposed treatment have been discussed with the patient and/or parent/guardian. The patient and/or parent/guardian is aware of the above and consents to treatment."
**TREATMENT**
**Manual Therapy:** [Manual therapy provided] (List all hands on treatment provided throughout session, for example, Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage L) medial calf, etc. Include reassessment findings after // i.e., // increased cervical rotation, // no pain on single leg calf raise etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Dry Needling:** [Dry needling treatment] (Size of needles, area inserted, number of needles, duration of treatment i.e. Dry Needling: 0.3x30mm x2 L2/3 Right Lumbar Erector Spinae (cau + med) GrIII for 15/60. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Advice & Education:** [Advice and education provided] (Describe all advice & educational treatment that was provided throughout session, e.g. pain science education. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Exercise Therapy:** [Exercise therapy provided] (List all active therapy treatment provided throughout the session, for example, 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**Exercise Program:** [Exercise program] (Include sets, reps, frequency and any other dosages. Exercise program provided. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
**ASSESSMENT**
[Clinical assessment] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**PLAN**
- [Next session plan] (Next physiotherapy session and plan for session. Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
- [Goals] (Short and long-term goals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
