Hip Discomfort Case Summary
SUBJECTIVE
Patient reports to PT. Reports his frequency of hip discomfort spikes are increasing, overall pain level is not changing, certainly not improving. Reports regular compliance of stretching. Trying to maintain his activity levels does not feel like he is making poor progress there.
OBJECTIVE
Hip range of motion is 70 degrees in the horizontal abduction, 110 degrees into flexion. No appreciable internal rotation. External rotation about 70 degrees. Right hip is 50 degrees of horizontal abduction, 100 degrees of flexion. No appreciable internal rotation and external rotation of 60 degrees. Patient walks stiffly the first two or three steps after getting out of a chair; otherwise, ambulates relatively small step size, but otherwise, independently, fluidly, and without …show more content…
Some slow progress in terms of range of motion. The patient feels he would be making more progress to the left hip as well except that he is relatively stiff after sitting for awhile waiting for physical therapy today due to some delays. Talked with him about how to further progress his hip range of motion. Patient appears to be making some general effort at reducing impairments at his hip by building flexibility and strength. Given the stubbornness of his symptoms, indications of degenerative change, and lack of subjective reports of progress despite apparent fair amount of compliance of his home exercise program, I would suspect at this point where he would eventually come to a place where some kind of further intervention is needed. Both patient and I favor starting as conservatively as possible. It is possible patient would benefit from an intra-articular hip injection. Both he and I agree that we should try to eliminate as many of his measurable impairments as possible first by building up levels of strength and flexibility at the hips first, seeing what his maximum better from this is and then potentially suggesting the
Patient reports to PT. Reports his frequency of hip discomfort spikes are increasing, overall pain level is not changing, certainly not improving. Reports regular compliance of stretching. Trying to maintain his activity levels does not feel like he is making poor progress there.
OBJECTIVE
Hip range of motion is 70 degrees in the horizontal abduction, 110 degrees into flexion. No appreciable internal rotation. External rotation about 70 degrees. Right hip is 50 degrees of horizontal abduction, 100 degrees of flexion. No appreciable internal rotation and external rotation of 60 degrees. Patient walks stiffly the first two or three steps after getting out of a chair; otherwise, ambulates relatively small step size, but otherwise, independently, fluidly, and without …show more content…
Some slow progress in terms of range of motion. The patient feels he would be making more progress to the left hip as well except that he is relatively stiff after sitting for awhile waiting for physical therapy today due to some delays. Talked with him about how to further progress his hip range of motion. Patient appears to be making some general effort at reducing impairments at his hip by building flexibility and strength. Given the stubbornness of his symptoms, indications of degenerative change, and lack of subjective reports of progress despite apparent fair amount of compliance of his home exercise program, I would suspect at this point where he would eventually come to a place where some kind of further intervention is needed. Both patient and I favor starting as conservatively as possible. It is possible patient would benefit from an intra-articular hip injection. Both he and I agree that we should try to eliminate as many of his measurable impairments as possible first by building up levels of strength and flexibility at the hips first, seeing what his maximum better from this is and then potentially suggesting the