Download SOAP Note S: 19 year old female collegiate gymnast was doing

SOAP Note
S: 19 year old female collegiate gymnast was doing giants on the pit bar and hands
slipped off mid swing. Landed into the pit below with more weight on the right leg, felt
knee buckle bad, and heard a pop. She had to be pulled out of the pit because of how
unstable her knee felt. She reports an initial pain of 9/10 when the fall happened there
was sharp pain. She has a history of hyperextending her knees. She has not done anything
for the injury, it just occurred
O: Major deformity of the knee, tibia and femur misaligned. Inflammation and heat over
area, severe muscle guarding. Athlete is not able to perform any range of motion or
manual muscles test. Neurovascular is intact but slightly diminished on affected leg;
pulse can be felt in the posterior distal tibia region and the dorsal pedal region.
A: Knee dislocation with possible multi-ligament injuries (ACL, PCL, MCL)
P: Athlete was immediately taken to the hospital for further tests and attempted reduction
of dislocation; referred by team physician on site. Further plans will be made when
diagnosis is final; most likely surgery will occur to repair damage done followed by
treatment to return to gymnastics.
Surgical Procedure
The surgical procedure for multi-ligament reconstruction is used to provide a functional
and stable joint. Typically the ACL and PCL are reconstructed in the standard way and
the MCL, depending on the severity, is seen to heal on its own with functional bracing1.
A combined PCL and ACL reconstruction surgery begins with the decision of what type
of graft to use. It is recommended an Achilles allograft is used for the PCL and a
hamstring autograft is used for the ACL1. The tissue is prepared and arthroscopic
instruments are placed in the correct position. To resect the hamstring graft the surgeon
will make an incision along the anterior tibia where the hamstring attaches. The tendons
are arranged into three or four strips, which will increase the strength of the graft, then
the surgeon stiches the strips together to hold them in place1.Arthroscopic instruments are
placed in the superior lateral portal, inferior lateral patellar portal, inferior medial patellar
portal, and the superior medial portal1. An accessory extracapsular extra-articular
posteromedial safety incision is used to protect the neurovascular structures1. Notch
preparation is performed and removal of any debris of the torn ligaments is removed. The
arm of the PCL/ACL guide is inserted to make the tibial tunnel for the PCL graft; the
tunnel is drilled to the posterior cortex of the tibia2. The surgeon will insert their finger
into the safety incision to confirm the placement of the guide wire and graft. The femoral
tunnel can be made from the inside out; the right size guide wire is drilled through the
aimer, through the bone, and out through a small skin incision2. The aimer is removed
and an acorn reamer is used to finish the tunnel for the PCL graft. It will be anchored
with a bioabsorbable interference screw and spiked ligament washer back-up fixation2.
The ACL tunnels can be made with a single-incision technique2. The tibial tunnel begins
externally and comes through the stump of the previous ACL footprint. The femoral
tunnel is positioned on the medial wall of the lateral condyle2. The ACL graft is then put
in position and anchored, by a bioabsorbable interference screw and spiked ligament
washer back-up fixation, on the femoral side followed by tensioning and fixation on the
tibial side2. Tension is placed on each of the grafts and the knee is put through a full
range of motion as well as all the corresponding special tests (i.e. anterior drawer,
lachmans, etc)1. The arthroscopic incisions as well as the hamstring incision from where
the graft was taken from are stitch closed and the patient is bandaged and braced to be
sent to recovery.
Goals
0-12 Weeks: Full Range of Motion, Full weight bearing and out of brace, Begin
proprioceptive and strengthening exercises
4-6 Months: Start walking normally and progress to running by month 6
7-12 Months: Return to Full Activity
Rehabilitation
Phase 1 (0-6 weeks): immobilized to begin, control inflammation and effusion, muscle
re-education, ROM 0-120°, full weight bearing3-12
Weeks 1-3
General Observation
Goals
-Immobilized in brace, non
weight bearing
-ROM 0-110° (Passive with
Active Ext)
-Adequate quad Contraction
-Partial weight bearing
-control inflammation and
effusion
-protect insertion sites
Range of Motion
-PROM: pull with band
-Patella Mobilization
-Ankle Pumps w/ resistance
-Light hamstring,
gastroc/soleous stretches
20 cycles
Strength
-Straight leg raises(flexion)
-Quad Sets
-Knee extension(activeassisted)
3x10
3x10
3x10
Modalities
-Cryotherapy(ice with
compression)
-E-stem(NMES: small
muscle contraction with
pain and edema control)
20 minutes; 3 times per day
Weeks 4-6
General Observation
Goals
Range of Motion
Strength
Aerobic Training
-brace when needed, partial
weight bearing, controlled
pain
-ROM 110-120° (Passive
with Active Ext)
-Muscle Control
-Full weight bearing
-PROM: pull with band,
possibly wall slides,
stationary bike
-Patella Mobilization
-Hamstring, gastroc/soleous
stretch
3x15
30 sec go through 3 times
10 pps/bps; 10 sec on 30 off
for 10 minutes
20 cycles
3x30”
-Leg raises (flexion,
ABD/ADD)
-Multi-direction isometrics
-Mini Squats
-small leg kicks(knee
extension)
Calf Raises
3x10
-Water Walking
-Upper Body
Conditioning(bicep/tricep
curls, lats, crunches/sit
ups/obliques)
15 minutes
3x15
3x10
3x10
3x20
3x20 per exercise
Modalities
-Cryotherapy(ice with
compression)
-E-stem(NMES: muscle
firing and holds)
20 minutes, 3 times per day
30 pps/bps; 10 sec on 30 off
for 10 minutes
Phase 2 (7-12 Weeks): Full weight bearing, use of mobile brace into Patellar sleeve,
ROM 120-135°, Begin CKC strengthening and use of Proprioceptive training, improve
muscle control3-12
Weeks 7-9
General Observation
Goals
Range of Motion
Strength
-Full weight bearing
-no effusion
-painless ROM 120°
-Normal Gait
-Increase Strength and
Endurance
-Normal ADLs
-Increased Muscle Control
-120-130° Wall slides,
stationary bike, manual
manipulation
-Patellar Mobilization
-Hamstring,
gastroc/soleous, quad,
ABD/ADD, ITB stretch
20 cycles
3x30”
-Straight leg raises(3-way)
-Knee ext( leg kicks off
table)
-Leg Press
-Wall sits
-Mini squats
-Calf raises
3x15
3x15
Balance
-double/single leg stance
3x30”
Aerobic Training
-Upper Body Conditioning
(bicep/tricep curls,
rows/TIY, abs on ball)
-Water Walking(inc speed)
3x25 each
-Cryotherapy(Ice with
compression)
-E-stem(NMES: muscle
movement, get full
contraction)
20 mins; 3 times per day
Modalities
3x10
5 repsx30”
3x20
3x20
10 minutes
70 pps/bps; 10 sec on 30 off
for 7 minutes
Weeks 9-12
General Observation
Goals
Range of Motion
Strength
-Full weight Bearing
-Painless ROM 130°
-Normal ADLs
-Increase Strength and
Endurance
-ROM 130-135°
-Walking on Treadmill 15
minutes without pain
-Joint Stability
-Flex/Ext(wall slide,
30 cycles
stationary bike, prone hang,
manual manipulation)
-Hamstring,
3x30”
Gastroc/Soleous, Quad, ITB
Stretches
-Straight Leg Raises (4way, weighted)
-Hamstring Curls
-Lunges
-Mini squats
-Heel Taps
-Lateral Step Ups
3x15 with 3#
Balance
-BAPS
-Balance on Airex(work to
single leg balance)
3x20”
3x45”
Aerobic Training
-Walk on Treadmill
-Upper Body
Conditioning(resistance
bands, Lat pulls, dead bugs,
toe touches)
15 minutes
3x30 each
Modalities
-Cryotherapy (Ice)
20 minutes; 3 times per day
3x10
3x10
3x20
3x15
3x10
Phase 3 (4-6 Months): Increase strength and endurance, Begin functionality exercises,
start jogging3-11
4-6 Months
General Observations
-Walk 20 mins without p!
-Perform all ADLs
-Full ROM all directions
-Pain Free
Range of Motion
-Stretch all lower extremity
muscles (need to work back
into the splits)
Strength
-Leg Raises (4-way)
-Leg Press/Ham Curls
-Heel Taps(Step-BOSU)
-Lunges (3 way floorBOSU)
-Squats(floor-BOSU)
-Wall Sits
-Bridges
-Monster walks (3-way)
3x25 with 7#
3x20
3x20
3x15
-Single Leg Dyna Disc
-Cup pick up
-Balance on BOSU and
catch a ball
-Walk across beam(multidirection with pivots)
3x1’
5 times through
3x20
-Eliptical-Treadmill
(jogging)
-Walking Backward
-Upper Body(pushups,
burpees, deadbugs/bird
dogs, row punch/TYI)
10 minutes
Cryotherapy
20 minutes twice a day
Balance
Aerobic
Modalities
3x15
5x45”
3x20
5 passes each direction
5 passes
5 minutes
3x25 each
Phase 4 (7-12 Months): Run (multi-directional)-sprinting, Maintain Strength and
Endurance, Fully Functional3-11
7-12 Months
General Observations
Range of Motion
Strength
-Jogging 10 mins
-Full Joint Stability
-Increasing Strength
-Stretch all lower
extremity(splits all three
ways)
10 minutes a day
-Weighted Ham curls/Leg
Press (multi-way)
-Lunges on Slide Board(3way)
-Monster walks with
weighted ball (3-way)
-BOSU Squats/Heel Taps
-Donkey Kicks/Fire
Hydrants
-Bridges with ball(Dblsingle leg)
-Single Leg Calf Raises
3x20
-Cup Pick up
-BOSU Balance catch
weighted ball
-Balance on Beam (multidirectional single leg work
up to turning)
7 times through
3x20
-Treadmill Running
-Upper Body (burpees, one
leg tramp toss, jumping
jacks)
15 minutes
3x30 each
-Box Jumps
-Slide Board
-Latters (Multi directional)
-T-Test
-Power Skips
-Agility Shuttle
-Sprint jump on spring
board onto mat
-Leaps and Jumps
5 passes
3x25
twice through each step
3 times through
5 passes
3 times timed
7 passes
3x20
4 passes each way
3x25
3x30
3x20
3x40
Balance
10 passes; 10 stuck turns
Aerobic
Functional
10 of each sequence and
jumps
-Basic Tumbling
work on basic passes and
ease back into required
Citations
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