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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

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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.


Clinical decision making

Clinical Decision Making


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


History

History

  • 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)


Pain drawing

Pain Drawing


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


Trigger points 13

Trigger Points13


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

ICF Model


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


Evaluation

Evaluation

  • 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

Diagnosis5

  • 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


Values

Values

Little treatment time as possible


Johari window

Johari Window


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


Outcome

Outcome

  • 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


Reflection

Reflection

  • 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?


References

References

  • 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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  • BaxL, Staes F, Verhagen A. Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials. Sports Med. 2005;35(3):191-212.

  • Cameron MH. Physical agents in rehabilitation: From research to practice. Elsevier/Saunders; 2012.

  • Clarke JV, Wilson WT, Wearing SC, Picard F, Riches PE, Deakin AH. Standardising the clinical assessment of coronal knee laxity. ProcInstMechEng H. 2012;226(9):699-708.

  • Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International knee documentation committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS), knee outcome survey activities of daily living scale (KOS-ADL), lysholm knee scoring scale, oxford knee score (OKS), western ontario and McMaster universities osteoarthritis index (WOMAC), activity rating scale (ARS), and tegner activity score (TAS). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S208-28. doi: 10.1002/acr.20632; 10.1002/acr.20632.

  • DelportH, Labey L, De Corte R, Innocenti B, Vander Sloten J, Bellemans J. Collateral ligament strains during knee joint laxity evaluation before and after TKA. ClinBiomech (Bristol, Avon). 2013;28(7):777-782. doi: 10.1016/j.clinbiomech.2013.06.006; 10.1016/j.clinbiomech.2013.06.006.

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References1

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