A CASE REPORT OF NERVE DAMAGE AND KNEE EXTENSOR WEAKNESS AS A RESULT OF A TKA

Robert Whittaker, SPTUniversity 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”• 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

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• 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

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• 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• 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) vastus lateralis, 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 Points13

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 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 & S1 diminished• Posterior (R) knee pain (5/10)• *Vastus lateralis, lateral gastrocnemius head, and distal biceps femoris were tender to

palpation – guarding/trigger points?• *Laxity in lateral knee• Excessive BMI• Scars

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• 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.

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• 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 – 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• 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 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: 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• 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 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 ADLs10

• Low SEM (but not the lowest)• 73% of subjects score above MDC• Large ES and ESSEM (4-5x SEM – indicative of sensitivity)• Smaller ceiling effect compared to other functional

assessments• Missing data? – bad translation

Instrument Pre Test (SD) Post Test (SD) SEM (%mean) MDC (%>MDC*) ICCOKS 32.5 (7.1) 26.1 (9.3) 2.2 (7.2) 6.1 (60) 0.91WOMAC pain 43.5 (20.5) 20.4 (18.7) 6.8 (15.2 18.8 (61) 0.91WOMAC stiffness 47.4 (23.4) 23.5 (21.7) 9.8 (28.3) 27.1 (51) 0.84WOMAC function 39.8 (21.4) 20.2 (18.7) 4.8 (18.5) 13.3 (61) 0.96KOS symptoms 17.7 (6.1) 23.4 (5.1) 1.9 (19) 5.3 (60) 0.86KOS function 20 (6.7) 28.5 (7) 1.9 (18.9) 5.3 (51) 0.93KOS total 53.5 (15.2) 74 (15.9) 4.1 (8.6) 11.4 (73) 0.93SF-12 PC 32.7 (7.9) 42.1 (9.4) 3.5 (10.5) 9.7 (55) 0.81SF-12 MC 55.2 (10.7) 53.1 (9.3) 2.9 (6.6) 8.0 (56) 0.9

ValuesPatient Values• Motivation/

determination• Done right quick• Hesitant• Open to new

experiences, revisiting old ones

• Punctual• Social support• Cost

Personal• Ambitious• Thorough/complete all

tasks• Reliable/pleasing

everyone• Living up to

expectations• Respect honest• Fair• Slowing down• Humor• Understanding

Quickly• Black & white

PT – Professional• Goal oriented• Efficient• Equal tx/professional

behavior• Being right or

confident (knowing all)• Teachable• Organized• Responsible• Passion• Full effort• Flexibility• Realistic

Little treatment time as possible

Johari WindowArena• Has general idea of diagnosis, both

familiar with functional limitations• Exercise program & parameters

written instructions

Blind Spot• PT knows much more on anatomy

of knee, differential dx, expected prognosis, how modalities/exercise affects

• Share the knowledge!

Façade• Pt. may not be sharing all possible

information as there is so much history, pt. may assume we ask all that is required

• Home life, kids, environment?• Ask all appropriate history

questions!

Unknown• What is truly going on and what

potential is there for rehabilitation• Refer to another specialist who can

shed light on situation

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• 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 Practice20

• Functional exercises/outpatient rehabilitation better results compared to traditional/home therapy

• Benefits did not persist to 12 months• Short term rehabilitation focusing on functional exercises!

Meta-Analysis 3-4 mo (95%CI) 12 mo (95%CI)Function (ES) 0.33 (0.7 – 0.58) -0.07 (-0.28 – 0.14)

Walking (ES) 0.27 (-0.13 – 0.67) 0.03 (-0.24 – 0.31)

ROM (WM) 2.9° (0.61° – 5.2°) 0.96° (-1.1° – 3°)

QoL (ES/WM) 1.7 (-1 – 4.3) 0.03 (-0.2 – 0.25)

Strength N/A N/A

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

Date Cost10/22/13 $50

10/25/13 $50

11/1/13 $50

11/15/13 $50

12/4/13 $50

Total $250

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• 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?

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