DOI: 12/2/2015. Patient is a year old male safety associate who has an acute onset of right knee pain while pushing a cart weighing an 80-90 pound load. He felt a sudden “pop” medially with swelling.
Per the medical report dated 12/14/15, the patient reported that swelling has improved but he has episodes of sharp pain in the right medial knee with weightbearing or pivoting. He was given a prescription for ibuprofen.
Per PT note dated 01/21/16, the IW reported that his pain is rated as 1/10 at its best and 8/10 at its worst. He states he is feeling about 82.5% of full function.
On examination, there is tenderness to the distal patella. Active range of motion is +2-118 degrees. Strength testing shows 4+/5 with hip flexion, 4-/5 with gluteus medius and 4/5 with quadriceps and hamstrings. Moderate hamstring tightness is noted. He ambulates with some decreased quadriceps control. IW was diagnosed with right knee partial patella tendon tear. It was noted that the IW has been seen for 7 visits and presents with improvement in his overall range of motion and strength. …show more content…
He continues to benefit from skilled PT to address these limitations and return him to full function. Plan is for PT 2 times a week for 4-6 weeks.
Based on the latest medical report dated 01/25/16, the patient was last seen 12/15. Overall, he is feeling much better. He flared up pain at the inferior pole of the patella after climbing a lot of stairs recently, but this has subsided. He is minimizing any functional limitations. He would like to continue with PT. He has no further episodes of sharp pain in the right medial knee with weightbearing or