INITIAL EVALUATION

Dx: (L) Foot drop 2 to common peroneal neuropathy

PT IE: 8/27/2013 (Jose R. Reyes Memorial Medical Center)
Castro Ariel, 52 M
San Andres Bukid, Manila
Physiatrist: Dr. Inciong
S> AC, a 52 y/o (-) Htn/DM/Asthma -handed was referred for PT eval & mx 2 to c/o weakness of (L) foot &
constant aching pain of wound on (L) sole marked 5.4 cm on VAS, that is worse on prolonged walking ~100 m,
marked 9.2 cm on VAS. HPI: Pt got his wound 5 yrs ago when a storm struck their house in Pangasinan, scattering
bamboo sticks on their lawn. Pt tried to fix their house the whole afternoon & rested during the night. 3 days later, he
felt pain on his (L) sole marked 9.2 on VAS & noticed that his (L) ankle & foot was a bit swollen. He discovered a
wound on his (L) sole & remembered stepping on a few sticks of bamboo 3 days ago but did not remember feeling
pain or anything on his foot. Pt washed his wound with soap & water & took a capsule of mefenamic acid & opened it,
applying the powder on his wound thinking that it would the pain. He was awakened that night d/t the unrelieved
pain on his wound; he took mefenamic acid orally & slept; the next morning, the pain to 3.5 marked on VAS. He
continued the same regimen for his wound & was unable to recall how long he took it & never went for MD consult. Pt
regularly cleans & applies the powder on his (L) wound & covers it with dry cotton & masking tape. In 2011, the pain
worsened to 9.2 on VAS, which prompted him to seek Rx at Region I Medical Center in Dagupan. He was given
tetanus shot & was prescribed c Meds for pain, but when he went home, his foot became swollen; pt felt that he was
given the wrong injection & never went back to the clinic again. He took the pain Meds a couple of times which the
pain but refrained from using it d/t financial reasons. In 2013, pts family moved to Manila & he was noticing that his
(L) foot was feeling numb esp when walking. He went to Jose R. Reyes Memorial Medical Center for a consult last
July & was prescribed by the dermatology dept c Tretinoin (0.05%) cream for his wound to be applied bid; underwent
biopsy during the same month but was unable to show results. Pt was referred for rehab in August 2 to Dx of foot
drop 2 to common peroneal neuropathy. Pt was prescribed c Vit. B complex to be taken bid. PMHx: Unable to recall
other trauma to the (L) LE. Lifestyle: Pt is a (-) smoker & an occasional alcoholic beverage drinker (2 bottles/wk) & is
currently unemployed. Pt chops wood 2x/wk which he uses for cooking. Pt often wears socks & slip-on footwear.
Home situation: Pt now lives c his wife & 12 children in a bungalow house in Manila. Bedroomfront door ~12m,
bedroombathroom ~8m. Pts goal: Pt wants wound to heal & foot to regain previous strength.
O> VS>
BP
PR
RR

a
120/80 mmHg
84 bpm
12 cpm

p
120/80 mmHg
86 bpm
12 cpm

OI> amb s assist. device

Ectomorph
Alert, coherent, cooperative
(+) atrophy of (L) calf
(+) swelling of (L) ankle
(+) wound on plantar aspect of (L) foot
(+) gait deviations (see GA)
(-) postural deviations
(-) redness on all 4s
(-) trophic skin changes on all 4s
Palpation > normothermic on all exposed areas
Hyperthermic on (L) ankle
(+) tightness of (L) plantarflexors & invertors
(-) tenderness around wound margins on (L) sole
(-) mm spasm/guarding on (L) LE
(-) crepitations on (L) LE
ROM > All major joints of (B) UE/LE are WNL, actively & passively done, pain free c (N) endfeels except for:
MOTION
AROM
PROM
Endfeel
(L) ankle dorsiflexion
0
20-0-20
Firm

(L) ankle plantarflexion

(L) ankle inversion
(L) ankle eversion

0
20-30
0

20-40
20-40
0-15

Firm
Firm
Firm

MMT> all major mms of (B) UE/LE are grossly graded 5/5 except:
(R) ankle plantarflexors = 4/5
(L) hip flexors = 4/5
(L) knee flexors = 4/5
(L) knee extensors = 4/5
(L) ankle invertors = 2/5
(L) ankle plantarflexors = 2/5
(L) ankle dorsiflexors = 0/5
(L) ankle evertors = 0/5
(L) big toe extensors = 0/5
Wound assessment> 2x2 cm wound on plantar aspect of (L) foot at the area of the midtarsals
Wound is covered c cotton fibers that stick on its surfaces
Depth N/A
Anthropometric measurements>
Figure-of-8 for ankle swelling:
Trials
(L) ankle
Trial 1
58 cm
Trial 2
57 cm
Trial 3
58 cm
Average
57 cm

(R) ankle
55 cm
55 cm
54 cm
54 cm

Muscle bulk measurement:

Landmark: 3.5 in from medial tibial plateaubulkiest part of leg
Landmarks
(L) leg
(R) leg
2 in
30 cm
32 cm
Bulkiest part of leg
31.5 cm
33.5 cm
2 in
27.5 cm
29.5 cm

Difference
3 cm
2 cm
4 cm
3 cm

Difference
2 cm
2.5 cm
2 cm

Special tests> (-) Tinels sign on (L) ankle

(-) SLR 1-4 tests on (L) LE
Pathologic reflex> (-) Babinski sign on (L)
DTRs> Normoreflexive on (L) Achilles tendon
Sensory testing> 100% deficit on (L) distal third of lateral leg, lateral malleolus & dorsum & plantar aspect of foot as
to light touch, pain, & pressure (using cotton, pin & PTs thumb, respectively)
PA> all landmarks are level in ant, post & lat views taken in standing, except:
(R) medial arch higher than (L)
GA>
Hip
Knee
Ankle

Stance phase
(L) hip flex during initial contact
(L) toes strike first during initial
contact
(L) foot slaps towards loading
response

Swing phase
(L) hip flexion throughout swing phase
(L) knee flexion throughout swing phase
(L) ankle PF throughout swing phase

FA> indep in all aspects of ADLs such as bed mobility & transfers
Indep in wearing footwear on (L)

A>
PT Dx: MD dx of (L) foot drop 2 to common peroneal neuropathy further defined by difficulty in prolonged walking
~100m 2 to mm weakness & chronic wound on (L) foot
Problem list:
1.
2.
3.
4.
5.

Muscle weakness on (L) LE

Wound on plantar aspect of (L) foot
Gait deviations
LOM on (L) ankle motions
(+) swelling on (L) ankle

LTG> Rehabilitative: Pt will amb on level surface ~100m c AFO on (L) s gait deviations & c healed wound on (L) p 20
PT sessions
Preventive: Pt will be knowledgeable on present condition & proper wound care to promote healing & prevent further
complications p 2 PT sessions
STG:
1.
2.
3.
4.
5.

Pt will demonstrate in mm strength of (L) hip flexors, knee extensors & flexors, ankle dorsiflexors &
plantarflexors & big toe extensors, & (R) ankle plantarflexors by 1 grade p 1 mo of PT sessions to be able to
amb c less difficulty
Pt will demonstrate partially healed wound on (L) plantar aspect of foot as manifested by absence of
infection p 1 wk of PT sessions to be able to amb c less pain
Pt will amb on level surface c proper gait patterns ~50m c AFO on (L) p 1 wk of PT sessions to be able to
amb c ease
Pt will demonstrate ROM on (L) ankle dorsiflexion, plantarflexion, inversion & eversion by 10 p 1 wk PT
sessions to be able to amb c less difficulty
Pt will demonstrate swelling on (L) ankle by ~2cm p 1 wk of PT sessions to be able to amb c ease

P> Pt will be seen as an OP for 3x/wk for 20 PT sessions c the ff mx:

1. UVR using cold quartz ~1in away on wound of (L) sole x 10 to promote healing
2. ES on (L) TAs, gastrocsoleus & peroneals x 10 mins to retard atrophy
3. GPS on (L) ankle dorsiflexors, plantarflexors, invertors & evertors x 30SH x 3 sets to tightness
4. FES on (L) invertors & plantarflexors x
5. PREs on (L) hip flexors, knee flexors & extensors, & (R) plantarflexors using gold theraband x 10 reps x
6SH x 2 sets
6.
7. Gait retraining c AFO on (L) x 3 rounds to promote proper gait pattern
HEP>
1.
2.

GPS on (L) ankle dorsiflexors, plantarflexors, invertors & evertors x 30SH x 3 sets to tightness
AAROMs

Pt. education>

1.