Sample Report: Physical Therapy Initial Evaluation
Chief Complaint: Pain in the right buttock, extending down the right lateral thigh and into the foot.
History of Present Illness: This patient reports that she has had pain in the right buttock that extends down into her right lower extremity, and has had this pain for approximately four to five years. This began after a hemorrhoidectomy. Subsequent to that she has had three other procedures to attempt to remove scar tissue. She states that her pain is aggravated by bowel movements and sitting for prolonged periods of time. The pain is relieved when she lies down and rests.
In the morning her pain is minimal to nonexistent, and she considers it a 0/10 on the pain scale. She states it is consistently 10/10 at the end of a working day. During the interview today, she states her pain is a 7/10 to 8/10 on the pain scale this afternoon. She describes the quality of her pain as aching and very deep, originating in her buttocks. The pain does go down her right leg along the lateral thigh and lateral calf and occasionally extends into her foot. The intensity of the pain does decrease as it goes more distally down her leg.
She describes multiple functional limitations from this chronic pain. She works as a legal secretary and has had to cut her workday from an eight-hour day to a six-hour day, five days a week. She states that she does best at tolerating a four-hour workday, but because of personnel shortages she has been forced to increase this to a six-hour day. Pain at the end of the day is intense, but she will go home and lie down for a while and then be able to continue with some activities at home in the evening. She also feels her recreational activities have been severely curtailed. Sitting for long periods in the automobile is very painful, so she has limited her traveling because of this. She also states that she is unable to go to movies or plan social activities in the evening because she knows the pain will be too severe.
Previous Therapy: This patient has received physical therapy for a few sessions in the past for treatment of low back pain. She was given some Mackenzie back exercises, as well as a lumbar roll for sitting.
Physical Examination
Pain Behaviors: The patient exhibited no overt pain behaviors, other than an abnormal sitting posture. She sits on her left hip with her right leg crossed over, stretching her right lateral hip muscles. She states that this is the only way she can feel comfortable. We discussed sitting postures at work, etc., and because she is a small woman in stature she has had difficulty getting a chair that fits her comfortably. She states it is difficult for her to sit back in her chair far enough to have any type of lumbar support, so she usually sits on the end of her chair with most weightbearing through the left buttock. During the interview she was asked to sit in the chair properly with her back supported in a normal amount of lordosis and stated that this felt quite comfortable.
Range of Motion: Range of motion of her extremities is within functional limits. Her back range of motion is also within functional limits, with some limitation in lumbar extension. This is limited by a feeling of tightness and does not reproduce any of her pain. Straight leg raising is limited on the right at approximately 75 degrees and on the left at 65 degrees by tight hamstrings.
Posture: Standing posture is good and well balanced. Sitting posture is described previously.
Strength: Overall, strength is 5/5 with manual muscle testing, with the exception of the gluteus medius on the right, which tests at a 4/5 and the left a 5/5.
Gait: The patient appears to have a gluteus medius limp when weightbearing on the right lower extremity. Trendelenburg was negative bilaterally. She is able to correct her gait pattern fairly well when she concentrates on not sagging over the right hip.
Special Tests: Piriformis stretch test did not reproduce the exact pain. However, she is tighter on her left side than her right. She is not tender to palpation on the piriformis on the right side. Iliac crest, ASIS, PSIS, greater trochanter, and gluteal folds appeared equal in height.
Impression: This patient has a long history of right buttock, right low back, and right lower extremity pain that worsens as her day progresses. She appears to be exacerbating this pain by the posture she has adapted over the years, as well as some weakness in the right hip musculature. She is a very motivated person, and she has continued to do all of her housework and other activities through the pain. She appears willing to try any suggestions and is anxious for education.
Treatment Plan: This patient will be in the day program for one week only. During that time our goals will be to educate her in an aerobic walking program, as well as to educate her in proper sitting posture, especially in the workplace. She will be given ideas on how to improve the fit of her current chair in the workplace, as well as some ideas on other office chairs that may fit her better and improve her sitting posture.