Patient Problems

#5
Rebecca Stevens

A 16 year old female volleyball player has a diagnosis of chondromalacia. The doctor has
advised her to have outpatient physical therapy. She is to be seen once a week for six weeks.
You are to try a conservative program of exercise. If there is no success, the surgeon will go
ahead and do a patellar scraping. Please write a home exercise program for the patient.

Patient Problems
#5
Rebecca Stevens
MEDICAL HISTORY:
R wrist sprain 8/2012
DIAGNOSIS:
R knee chondramalacia
SUBJECTIVE:
Home situation: Lives with parents and sister, 12 stairs to 2nd floor, bath and bedroom on 2nd
floor, 2 sets 24 stairs at school, takes stairs one at a time, planning on using permit and
getting license soon.
Occupation: High school student, sophomore
Functional Activities: Volleyball, softball, basketball, stairs, running, jumping
Patient Goals: Return to sports ASAP, wants to drive without pain
OBJECTIVE:
Pain: current 4/10, last 24 hours 6/10 during volleyball
GONIOMETRY

AROM
Left
100
30
40
20
50
50
130
0
20
40

Hip
Hip /
Hip ABD
Hip ADD
Hip IR
Hip ER
Knee
Knee /
Ankle df
Ankle pf

MMT
Hip
Hip /
Hip ABD
Hip ADD
Hip IR
Hip ER
Knee
Knee /
Ankle df
Ankle pf

Left
5
5
5
5
5
5
5
5
5
5

Right
4
4+
4+
5
5
5
3+
4
5
5

PROM
Right
90
25
40
20
50
50
120
0
20
40

Left
105
40
44
21
51
50
135
0
23
42

Right
95
42
44
21
51
51
123
2 hyper/
22
41

Patient Problems
#5
Rebecca Stevens
Treatment: Conservative as per script, 1x/wk, 6 weeks; MP, CP, e-stim, stretch, strength,
isometric, HEP
ASSESSMENT:
Condition: Subacute
Rehab Potential: Good
STG:

return to sports; Reduce pain 0-1/10; Ambulate 24 stairs reciprocally

quad, hamstring, gluteus medius strength to 5/5
AROM:

R Hip 90 100
R Hip / 25 30
R Knee 120 130

LTG:

patellar scraping prevention; long term sports function

PLAN OF CARE:
Education: HEP, stairs, taping for sports activity
Referral:
Discharge Plan: Continued strength for knee pain; Use of home modalities (MH, CP); taping for
sports activity