a case report of nerve damage and knee extensor weakness as a result of a tka
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A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA. Robert Whittaker, SPT University of North Dakota. Patient Presentation. 49 y.o . female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down”

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a case report of nerve damage and knee extensor weakness as a result of a tka

A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA

Robert Whittaker, SPT

University of North Dakota

patient presentation
Patient Presentation
  • 49 y.o. female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down”
  • Patient evaluated on 10/20/13 for posterior knee pain & discharged on 12/9/13 for a total of 5 visits.
    • Patient private pay & had 20 independent visits to clinic gym
  • Pt. instructed on home NMES use & to use clinic’s gym to recumbent bike, leg press/extension/curls with emphasis on eccentric contraction for duration of rehab.
  • Pt. progressed from lacking 50° of AROM (L) knee extension to lacking ~35° with some improvement in pain.
    • Referred to physician for genetic testing for nerve disease & nerve conduction test of femoral nerve (HNPP?). Pt. stated she was looking into getting a knee brace.
patient care
Patient Care
  • Accept
    • Familiar with TKAs and protocols, treatment appropriate for pt. to regain strength
    • Skills to improve quadriceps weakness, seen multiple TKAs in clinicals
  • Direct
    • Goals, extent of condition, patients availability, handling techniques
  • Indirect
    • Private pay, travel in winter, can do HEP, pain, past therapy, PMH, life
  • Refer
    • Refer back to MD eventually from little progress
  • Patient is full time homemaker (military wife?)
  • C/O constant (L) posterior knee pain 5/10
  • Patient has to lift her leg into car and leg gives out often
  • Pain and weakness in left leg cause her to ambulate with SPC
  • (R) knee pain secondary to DJD and hasn’t walked well for years
  • Pt. wore an AFO to ambulate after TKA but no longer wears
  • Also has neck & low back pain due to bulging discs
  • Indicated she has diabetes, thyroid trouble, arthritis, sleeping problems, frequent headaches, & degenerative joint disease for many years
  • Many imaging studies (none available)
history cont d
History Cont’d
  • Medications: Aspirin (81mg), Inderal (120mg), Janumet XR-50/100xz), Lipitor (20mg), Lisinopril (40mg), Omeprazole (20mg), Synthroid (50mcg), Topamax (100mg), Zyrtec (10mg)
  • Allergy Meds: Penicillin, Ampicillin, Bactrim, Celocin, Feldene, Zomig
  • Family history: Her father had a myocardial infarction (MI) as well as COPD. Her mother has prediabetes. Both her parents have high blood pressure.
past medical history
Past Medical History
  • Cholecystectomy (1991)
  • (L) Carpal Tunnel release (1998), (R) release (1999)
  • 2008
    • Cortisone Shots (March & July)
    • Arthroscopy & meniscectomy (June)
    • Arthroscopy, chondroplasty, partial meniscectomy (Dec)
  • 2009
    • Orthovisc and cortisone shots (Jan-Sep)
    • TKA (Oct) with fibular nerve palsey knee manipulation (Dec)
    • PT – ionto, e-stim, strength (Nov – May 2010)
  • 2010
    • EMG Nerve Study on Fibular/Femoral Nerve (June)
    • LLE Inching study fibular nerve (Oct)
  • 2011
    • Fibular nerve release, knee manipulation (may)
    • More PT (14 sessions for IT band and fibular nerve pain) (Oct)
  • 2012
    • More PT (12 sessions for fibular nerve and posterior knee pain) (Feb)
    • EMG nerve study (Nov)
  • 2013
    • Epidural steroid injection (Jan)
examination systems review
Examination – Systems Review
  • Initial Eval (10/20)
    • Weight 190lbs, 61.5” (BMI 36)
    • Mature scaring on anterior knee from TKA, posterolateral knee from fibular nerve release, small scars on wrists from carpal tunnel releases
    • AROM: (L) knee ext -50° sitting. (L) ankle AROM appears to be WFL
    • PROM: 110° (L) knee flexion, 0° (L) knee.
    • Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension
  • 11/15
    • AROM: -35° left knee ext
  • Discharge (12/14)
    • AROM: -38° left knee ext. PROM (L) ankle DF 7°
    • Strength: Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV.
    • Palpation: (L) vastuslateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation
    • RHR 60 BPM, BP 124/76, SaO2 98%.
    • Dermatomes L1-L3 feel same (B), L4-S2 diminished sensation to touch on (L) compared to (R)
    • Reflexes: (R) L3 & S1 normal, (L) L3 & S1 diminished
    • Special Test: (+) varus stress test
rigor assessment 8
Rigor – Assessment8
  • Varus Stress Test18
    • 20-30° Flexion: LCL, posterolateral capsule, arcuate-poplitus complex, ITB, biceps femoris tendon
    • Extension: fibular or lateral collateral ligament, arcuate-popliteus complex, biceps femoris tendon, PCL, ACL, lateral gastrocnemius muscle, ITB
  • Article: investigated reliability of multiple knee clinical tests in CE, EUA, and by comparing to arthroscopic techniques
    • 6 (+) in CE, 10 (+) EUA (p=0.0277, Wilcoxon)
    • Limited to collateral ligament tear: 4 subjects, 1 instability found in CE and 3 EUA
      • Sensitivity = 25%, Specificity not reported
icf model cont d
ICF Model Cont’d
  • Health Condition
    • (L) Dysfunctional Quadriceps, (L) fibular nerve dysfunction, (R) knee DJD
  • Body Structures/Function (impairments)
    • ROM: (L) knee ext -50° sitting. PROM: 110° (L) knee flexion, 0° (L) knee. (L) ankle AROM appears to be WFL. *(L) ankle DF PROM 7°
    • Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension. *Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV.
    • *Dermatomes L1-L3 feel same (B), but L4-S2 diminished sensation to touch on (L) compared to right
    • *Reflexes: (R) L3 & S1 normal, (L) L3 & S1diminished
    • Posterior (R) knee pain (5/10)
    • *Vastuslateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation – guarding/trigger points?
    • *Laxity in lateral knee
    • Excessive BMI
    • Scars
icf model cont d1
ICF Model Cont’d
  • Activities
    • Ambulates independently with SPC
    • Can transfer into/out of car with difficulty
  • Participation
    • No mention of being able to not participate in what she desires
    • If health condition not addressed may possibly lead to further deterioration in QOL  need for assistive equipment, TKA revision/other knee, amputation from diabetes?
  • Contextual
    • Personal Factors (internal)
      • motivated to get better, pessimistic, pain in other knee/neck/back
    • Environmental Factor (external)
      • Husband/family?, home, weather
  • Initial Evaluation
    • The patient presents with (L) knee weakness with decreased PROM/AROM with increased pain with motion. The patient’s functional mobility is decreased and will be instructed on a gym program and how to operate a home NMES unit to improve quadriceps activation and knee functionality.
  • Reevaluation
    • The patient has not gained quadriceps strength like expected. Patient has laxity with varus stress test and is being referred back to MD.
diagnosis 5
  • Pattern 5F: impaired peripheral nerve integrity and muscle performance associate with peripheral nerve injury
  • She was diagnosed with left weakness and dysfunctions S/P a left TKA with DJD in her right knee.
  • ICD-9-CM Codes
    • 728.87 - muscle weakness-general
    • 719.4 - joint pain-lower leg
prognosis poc
Prognosis & POC
  • STG
    • To be independent with HEP
    • To have EMG/NCV results by next visit
  • LTG
    • Independent with gym exercise program in 4 weeks
    • To improve knee extension to be -20° in 4-6 weeks
  • Patient Goals
    • Walk without use of assistive device
    • Be completely pain free
  • POC
    • Patient will be seen once/week for 6 weeks and be independent in a gym exercise program ASAP due to being Private Pay
  • Prognosis5
    • Patient will demonstrate optimal peripheral nerve integrity and muscle performance over the course of 4-8 months
    • Expected range of visits 12-56
rigor intervention 14
Rigor – Intervention14
  • Article: Review of 4 recent RCTs since 2009
    • Initiation: 2 days post-op, sooner the better!
    • Volume: 30 minutes to 4 hours per day
    • Intensity: The higher the better, methods to make pt. comfortable!
    • Adjust to supervised PT: combined modalities may possibly increase improvements
  • Home unit available to decrease costs of PT
  • Home exercises and free gym access while a patient.
patient education
Patient Education
  • Content: Demonstrated, 1 on 1, pamphlet (NMES), flow sheet, written instructions
  • Pt. instructed on NMES by demonstrating to pt. how to set it up, having the pt. repeat it, and providing written instructions & the pamphlet. Pt’s. concerned addressed at additional visits.
  • Pt. instructed on setting up recumbent bike & using clinic’s equipment with appropriate settings with demonstration & return demo (pt. able to ask available PT if confusion arises)
    • Pt. needed additional help 1 time with knee flexion machine.
  • General anatomy/physiology of condition
  • POC and to maintain the lowest cost
  • Barriers
    • Pt. wears glasses
    • Somewhat quiet (pessimistic?)
patient education1
Patient Education
  • Learning type: did not address patients type (maybe reflective observation?)
    • SPT learning style: Accommodator
  • Cognitive Domain (facts) – recall exercise prescription from flow sheet, where to place electrodes (parameters on HEP), setting up equipment, comparing past PT, establish why exercises were prescribed, plan
  • Affective (attitude) – listening to instruction, participating/informed consent, going through HEP independently, resolve confusing equipment
  • Psychomotor (skills) – observing our demonstration, return demonstrating, practice HEP independently after learning and perfecting it
  • Documentation: use of NMES on location setting and duration and time/day, exercises with times on pt. flow sheet
    • No weight/duration in computer documentation for resistance
strengths limitations to pt education
Strengths & Limitations to Pt. Education
  • Strengths: available to help if confused with equipment, provided instructions to HEP with demo/return demo
  • Weaknesses: Small hand writing (make more legible!), was all of pt’s. concerns addressed?, no written instructions for D/C?
evaluating clinical change
Evaluating Clinical Change
  • Goals
    • STG: Pt. to be independent with HEP at next visit (C, EF)
      • Following PT intervention, the pt. will be independent with a HEP and familiar with clinic gym equipment as pt. is private pay and would like to minimize cost.
    • LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks (A, C, EF)
      • Following PT intervention, the pt. will improve (R) knee extension AROM in sitting to -20° to be able to transfer into a car more efficiently.
  • Functional Assessment
    • Not performed but would have wanted to use The Knee Outcome Survey Activities of Daily Living
      • Estimated evaluation score – 27/70 = 38.6%
      • Estimated discharge score – 28/70 = 40%
knee outcome survey adls 1
Knee Outcome Survey ADLs1
  • 2 Parts to Questionnaire – 14 total questions (also 11 question sport questionnaire)
    • Symptoms (6 Questions) – Pain, stiffness, swelling, giving way/buckling/shifting of knee, weakness, limping
      • No symptoms (5), symptoms but: does not effect activity (4), slightly affects (3), moderately affects (2), severely effects (1), unable (0)
    • Function – walk, ascending stairs, descending stairs, stand, kneel on front of your knee, squat, sit with knee bent, rise from chair
      • Activity not difficult (5), minimally difficult (4), somewhat difficult (3), fairly difficult (2), very difficult (1), unable to do (0)
knee outcome survey adls 10
Knee Outcome Survey ADLs10
  • Low SEM (but not the lowest)
  • 73% of subjects score above MDC
  • Large ESand ESSEM (4-5x SEM – indicative of sensitivity)
  • Smaller ceiling effect compared to other functional assessments
  • Missing data? – bad translation

Little treatment time as possible

force field analysis improved rom
Force Field Analysis – Improved ROM
  • Driving Forces
    • Motivated to be normal
    • Doesn’t want to use SPC
    • Free gym use
    • Not a busy schedule/free time?
    • Improve function for family?
    • Therapy instructions/help
  • Restraining Forces
    • Weakness
    • Pain
    • $$$
    • Weather (winter)
    • Slow progress  Doubt
    • Comorbidities (diabetes, back/neck pain bulge)
    • Anatomical/Physiological knowledge
  • LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks – not met
ethical issues
Ethical Issues
  • Private pay – distress
    • Solutions – expensive vs. least expensive
    • Least expensive as pt. does not have the financial resources for extensive PT
  • Pain through exercise– issue
    • Solutions – modalities vs. informed consent vs. referral
    • Informed consent as pt. would have to pay additional for modalities, eventual referral
  • Code of ethics 1, 2, 3, 5, 6
    • Respect, trustworthy, accountable for judgment, legal/professional obligation, enhance expertise
  • RIPS
evidence based practice 20
Evidence Based Practice20
  • Functional exercises/outpatient rehabilitation better resultscompared to traditional/home therapy
  • Benefits did not persist to 12 months
  • Short term rehabilitation focusing on functional exercises!
c ost benefit analysis
Cost/benefit analysis
  • Patient Private Pay Out of Pocket
    • PTC charges $25/unit (code 00050)
    • Gym free to use during business hours for current patients - $20/mo 1 month after D/C
  • Potential Costs?
    • Commuting
    • TKA revision/other knee?
    • Conduction/genetic testing
    • MD visits
  • Role in society – pt. homemaker and has been living with this condition, overall unchanged
  • Fair service – I believe I would have been satisfied as I’ve seen 2 units cost ~$100 instead
  • So far the patient has gained about 15° of knee extension since initial visit and feels she has improved since starting.
  • She has been discharged for now until she gets further testing done on her femoral nerve function to see if she has potential for more rehabilitation.
  • She mentioned she is talking with her physician about doing just a bicompartmental partial knee replacement in her right knee to help with pain, but is very hesitant in doing so after her current TKA dysfunction.
  • Patient working with MD to get genetic testing for HNPP
  • May return to therapy if potential for further gains
  • Looking into brace to provide knee stability preventing joint stress
  • Examination
    • Did a full evaluation right away
    • Provided functional assessment to evaluate how the patient perceives change
    • Mapped out dermatones – diabetic education?
    • Gathered postop reports
    • Biofeedback?
  • POC
    • Provided more functional exercises & adjust NMES volume
    • Use pain modalities – Pro bono?
  • Knee outcome survey activities of daily living scale (ADLS). http://www.ptbyart.com/media/file/341881/Knee%20Outcome%20Survey2%20RETYPED.pdf. Accessed March 19, 2014.
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