CASE

PRESENTATION
PRESENTED BY: PRISHITA

REG NO: 11809251

 DISUSE ATROPHY AND
DECONDITIONING POST THR
Date of assesment: 16 october 2021
◦ SUBJECTIVE ASSESSMENT
◦ Name: XYZ
◦ Age: 76 years
◦ Gender: Male
◦ Address: 48,new model town , phagwara
◦ Occupation: Buisness man (owns car repair workshop)
◦ Marital status: Married
◦ Socio-economic status: Middle class family
◦ Dominance: Right handedness
◦ Referral: Self referral
 Presenting Complaints: Patients complains of pain
during Walking, standing , sitting on the left side of the
leg since one year

Difficulty in walking , standing, sitting, doing ADLs

Patient also complains of locking on left side of leg

while walking.

◦ History of Present Illness: Patient was apparently

well before October 2020. He visited bank with his
son, where he lost his consciousness and fell down on
the ground and after that he was not able to stand. He
was taken to orthopedician on the same day. Doctor
suggested to go for an Xray . After that he concluded
that it was femoral head and neck fracture on the left
side of the leg and he was suggested to go for THR.
Patient underwent THR on the same day and was
well after that. Slowly and gradually he starts to feels
pain and locking on left side of leg and then he came
to our clinic for the treatment.
 ◦ Mechanism of Injury: fall on the ground
◦ Past Medical History: hypertension from last 20
years, no DM , no CVD
PAIN EVALUATION
◦ Surgical History:THR on left leg one year ago
and cholecystectomy done 15 years back. ◦ Location: left leg (femoral head and neck area)
◦ Personal History: N/A ◦ Side: Left side
◦ Drug History: Amlodipine 10 mg for BP(once a ◦ Radiation: Non radiation of pain
day in morning), Calvitan D (twice a day) from ◦ Duration: Pain occurs during and after
last one year. walking,sitting , standing ,prolonged standing.
◦ Gynaecological History : N/A ◦ Aggravating factors: walking, standing , sitting.
◦ Physiotherapeutic History: Underwent ◦ Relieving Factors: NSAIDS, rest.
physiotherapy treatment one year back (TENS,
NMES, strengthening exercises) ◦ Pain - Episodic
◦ Any prior hospitalization: Ganga orthocare, ◦ Quality of Pain: Dull ache.
Jalandhar( underwent THR) ◦ Intensity Of Pain: According to patient (5/10)
VAS scale during walking
0/10 while at rest.
 OBSERVATION
GENERAL OBSERVATION LOCAL OBSERVATION
◦ Attitude of limb: left leg slightly in flexion
◦Built: Mesomorphic position with Partial weight bearing.
◦Posture: Anterior view: Rounded and dropped ◦ Swelling : no swelling seen on quadriceps and
shoulder. hamstrings areas.
Posterior view: Kyphotic (gibbus formation at ◦ Muscle wasting: quadriceps , abductors ,
thoracic region)
adductors , hamstrings wasting on left side of
Lateral view: stopped posture, mild flexion at the leg as compare to right side.
knees, left foot in mild inversion.
◦ Color & texture of skin: Dry skin
◦ Gait: Trendlenberg gait
◦ Assistive Device: Elbow crutches
◦ Willingness To Participate: Active participant.
ON PALPATION
◦ Swelling: Not present on quadriceps ,
hamstrings and lower leg (left and right side)
◦ Tenderness : Not present on quadriceps ,
hamstrings and lower leg (left and right side)
◦ Warmth of skin: normal at room
temperature on both the lower extremities.
◦ Texture of skin: Dry skin
 ON EXAMINATION Motor examination
◦ Vitals examination: Blood pressure:
90/135mmhg , Heart rate: 79 beats/min , Tone: Normal(acc to modified ashworth scale)
Respiratory rate: 19 breaths/min, oxygen ROM: Active ROM
saturation: 97%.
JOINT LEFT SIDE RIGHT SIDE
◦ SENSORY EXAMINATION: lower extremity Hip flexion 0-90⁰ 0-110⁰
Hip extension 0-5⁰ 0-15⁰
Sensation Right side Left SIDE
Hip abduction 0-28⁰ 0-35⁰
PAIN INTACT INTACT

TEMPERTURE INTACT INTACT Hip adduction 28-0⁰ 35-0⁰

TOUCH INTACT INTACT Hip Internal rotation 0-32⁰ (pain in IR) 0-40⁰

VIBRATION INTACT INTACT Hip external rotation 0-35⁰ 0-40⁰

TWO POINT INTACT INTACT

DISCRIMINATION Knee flexion 0-125⁰ 0-130⁰

Knee extension 125-0⁰ 130-0⁰

KINESTHESIA INTACT INTACT

PROPRIOCEPTION INTACT INTACT Dorsiflexion 0-20⁰ 0-20⁰

Plantarflexion 0-30⁰ 0-30⁰
 PASSIVE ROM MANUAL MUSCLE TESTING

JOINT MUSCLE RIGHT SIDE LEFT SIDE

JOINT Left side Right SIDE END FEEL GROUP
Hip flexion 0-100⁰ 0-110⁰ Firm end HIP FLEXORS Grade 4+ Grade 2+
feel
Hip extension 0-12⁰ 0-15⁰ Firm end EXTENSORS Grade 4+ Grade 2+
feel
Hip abduction 0-35⁰ 0-35⁰ Firm end
ABDUCTORS Grade 4+ Grade 2+
feel
Hip adduction 35-0⁰ 35-0⁰ Firm end
feel ADDUCTORS Grade 4+ Grade 2+
Hip internal 0-35⁰ (pain in IR) 0-40⁰ Firm end
rotation feel INTERNAL Grade 4+ Grade 2+
ROTATORS
Hip external 0-38⁰ 0-40⁰ Firm end
rotation feel EXTERNAL Grade 4+ Grade 2+
Knee flexion 0-130⁰ 0-130⁰ Soft end feel ROTATORS
KNEE FLEXORS Grade 4+ Grade 3+
Knee extension 130-0⁰ 130-0⁰ Soft end feel

EXTENSORS Grade 4+ Grade 3+

Dorsiflexion 0-20⁰ 0-20⁰ Firm end
feel
ANKLE DORSIFLEXO Grade 5 Grade 4
Planatrflexion 0-30⁰ 0-30⁰ Firm end
feel
RS
PLANTARFLE Grade 5 Grade 4
XORS
 ITEMS SCORE

Measurements Sitting to standing

Standing unsupported
3/4
4/4

◦ LLD – True: left side : 35 inches(89 cm) Sitting unsupported 4/4

Right side : 38 inches(97 cm) Standing to sitting  3/4

◦ Apparent: left side: 38 inches(97 cm) Transfers 2/4

Right side: 40 inches (101 cm) Standing with eyes closed 3/4

◦ Limb Girth: Standing with feet 3/4

MUSCLE/JOINT RIGHT LEFT together 
MID THIGH GIRTH 40 cm 25 cm Reaching forward with 3/4
outstretched arm
CALF GIRTH 30 cm 29 cm Retrieving object from 3/4
floor
Turning to look behind  3/4
◦ SPECIAL TEST: N/A
Turning 360 degrees 4/4
◦ Balance: checked using BERG BALANCE
SCALE Placing alternate foot on 4/4
stool
SCORE: 44/56
Standing with one foot in 3/4
front
Standing on one foot 2/4
Investigations: X RAY

◦Implant used: Acetabular shell 60 mm with a

6.5 mm x 30 mm cancellous screw, with ceramic
femoral head 36 mm, 0-degree polyethylene with
127-degree neck angle hip stem.
(written from the report)

◦PHYSIOTHERAPY DIAGNOSIS: DISUSE

ATROPHY AND DECONDITIONING POST
THR
 ICF MODEL
HEALTH CONDITION
DISUSE ATROPHY AND DECONDITIONING POST
THR

BODY
STRUCTURES BODY ACTIVITIES
FUNCTIONS Sitting
Standing PARTICIPATION
Pain at joint
Hip joint mobility of hip joint Kneeling
Muscles of thigh Power of muscles of Climbing
single limb Running Working out
Muscles of anterior
Gait pattern Kicking Recreational activities
leg
Riding bike Social participation
Muscles of posterior Muscle endurance of
leg single limb Prolonged standing

PERSONAL
ENVIRONMEN
FACTORS
TAL FACTOR
MALE, 76 years
Supportive friends
very social
and family
no smoking, no
Transportation
alcohol.
Work requires a
Enjoys
lot of moving
recreational
around
activities
 GOALS OF TREATMENT
Short term goals Long term goals

◦ To decrease the pain ◦ Improve gait and its components

◦ To improve strengthen of the limbs ◦ Improve Balance and risk of falls
◦ To improve the ROM ◦ Improvement of Full ROM of leg and new hip
◦ To make him independently walk without any ◦ Improve proprioception and endurance
assistive device. ◦ Improve muscle strength
◦ To make patient walk and do ADLs
indepentdently
 TREATMENT PLAN
◦ Hamstrings curls with half kg weight cuff(10 x 3
◦ NMES on quadriceps , hamstrings muscles (surge reps) ; progression with light –moderate resistance
faradic current) band)
Intensity: as per patient tolerence(3 minutes x 3 ◦ Pelvic bridge exercise with 10 sec hold (10 x 3
times with 1 minutes of break) reps)
◦ STRENTHENING EXERCISES ◦ Heel raise and toe raise with weight cuff(15 X 3
◦ Straight leg raise with half kg weight cuff(10 x 3 reps)
reps) ; progression with light –moderate resistance ◦ Cycling for 10 minutes
band)
BALANCE and PROPRIOCPETION
◦ Side leg raise with half kg weight cuff(10 x 3 TRAINING
reps) ; progression with light –moderate resistance
band) ◦ Standing on bosu and wobble board.
◦ Ball pressing exercise between knees in supine ◦ Progression to one leg stand with assistance.
(10 x 3 reps) ◦ Weight shifting using chair in front in standing
position (10 reps on each side)
 FUNCTIONAL MOBILITY
◦ Gait training using ladder
◦ Tandem standing and tandem walking
◦ Stair training using stepper(step ups 15 X 3
reps )
◦ Hurdle walking
◦ Cone agility exercises in standing position
◦ Single leg ball throw on wobble board