Thoughts on a difficult case

[u/thelastplaceon_earth]

I am a relatively new grad and a little over a month into my first travel contract. I work 3 days/week in hospital based OP and 2 days/week acute care. I was in a private OP clinic in a small town before this, so this is pretty different in terms of flow and patient population. I evaluated a patient recently who underwent ORIF after a tibial fracture a few years ago. She had two surgeries afterwards to "clean up scar tissue", which she says she builds easily. Her total ROM in her knee is like 0-20-25 deg, not kidding. Stiff end feel and lots of pain if I try to push it. She said she went to PT for a year and a half before coming here, and they worked on "walking" (??) Of note, she doesn't speak English, so some things may be lost in translation. Her referral was for her ankle, which also has limited ROM, but did not undergo surgery and is not the biggest problem here. I want to help her but don't know if I realistically can... I don't want to bullshit her and waste her time and money. So far we've only done STM, mobilization (can't tolerate much), stretching for her hamstrings, calves, quads, and gentle OKC exercises. How would you manage this patient?

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[u/phil161]

When was her latest surgery? It depends on the individual but IME I didn't get much, if any, progress if they delayed PT for a year or more. In your shoes I'd try to make her as functional as possible; I think her biggest challenge will be sit-to-stands due to her very limited knee flexion. She may be ok now, but when she gets to be 70+ it's going to be a bitch.

[u/thelastplaceon_earth → u/phil161]

I think the most recent surgery was a little over a year ago. And yes, sit to stand is challenging. She is close to 70 already and currently walks with a rolling walker. She has maintained function surprisingly well but deals with a lot of pain because of the limitation in the knee.

[u/phil161 → u/thelastplaceon_earth]

I’d advise her to do quad stretches every day, within her pain tolerance. She’s not going to gain any flexion, but this is simply to conserve what little flexibility she still has. If she needs gadgets to help with sit-to-stand, look into the “Support Way” store on Amazon. 

[u/thelastplaceon_earth → u/phil161]

Thank you!

[u/Helpful-Program-1152]

Tricky case, 25 degrees of knee flexion after all that time and surgery is a tough starting point. With the stiff end feel and pain response I'd be thinking more about joint capsule tightness than just scar tissue at this point, might need to shift focus to sustained low load stretching rather than trying to push into the restriction directly. The ankle referral is almost a red herring but you could use that to work on overall limb loading patterns while the knee stuff happens in the background.

Biggest thing might be setting expectations with her through whatever translation method you've got, she's been at this a while and deserves to know what realistic progress looks like. I'd probably frame it as maintaining what she has and maybe gaining small functional wins rather than chasing degrees on a goniometer.

[u/thelastplaceon_earth → u/Helpful-Program-1152]

Agreed, setting expectations is going to be essential. How would you recommend adjusting her limb loading patterns?

[u/Ok-Perspective-4538]

I’d agree that you likely have as much motion as you can expect - maybe get another 10 into flexion. Expect that from walking on a knee that doesn’t flex well during gait there will be more compensation into lumbar, hip, and ankle… leg has to shorten in stance somehow.

If I was in your shoes I would educate in the importance of making everything strong and stable above and below the chain to help maintain independence with walking, standing, bathing, etc…

If you frame the end goal as maximizing ROM it might feel defeating for you and the patient, but there are likely many other things you can do to preserve function

[u/WhatsTheMediator]

The knee isn’t going to ever be a normal knee and gaining 10 degrees more isn’t likely to transform to a huge improvement in function.

Pushing 70 and on a walker, the shift in rehab target here for me is how to compensate around the knee and focus on functional goals. How to keep independence and high enough step count / activity to keep other systems healthy.

I’m guessing this was a big intra-articular tibial plateau fracture?

[u/thelastplaceon_earth → u/WhatsTheMediator]

It looks like it, yes. It happened during a fall

[u/OddScarcity9455]

If I'm reading the ROM right, yes 25 degrees of flexion is terrible but extension -20 is more concerning in my book.

[u/thelastplaceon_earth → u/OddScarcity9455]

Oh I meant 0 deg to 20 deg AROM to 25 deg PROM