Patient Presentation:
A 20 year female presented to the P.T clinic complaining of right thigh weakness and walking difficulty.
History:
Patient presented two and a half years following patellar dislocation with complaints of weakness and atrophy of his right quadriceps since the initial injury. At the time of the injury, he received non-surgical care including physical therapy for a complete year following injury with no improvement. Subsequently, he underwent a medial patellofemoral ligament reconstruction. Post-operatively, he was initially fitted in a Bledsoe brace which he eventually stopped using. He also underwent another course of physical therapy with partial benefit. Surgical intervention did not improve patient's right quadriceps weakness and atrophy. He denied numbness, tingling or pain but did report intermittent right lower extremity buckling.
Physical Exam:
Examination revealed right quadriceps atrophy with knee effusion. There was no tenderness to palpation along the right quadriceps, joint line, and patella or patellar tendon. There was limited active range of motion secondary to weakness. Passive range of motion 0 to 90 degrees limited by pain. Manual muscle testing right lower extremity 5/5, except for right knee extension 1/5 and right hip abduction 4-/5. Lower extremity reflexes were 2+ and symmetric bilaterally. No ligamentous laxity was appreciated upon provocative tests. Spine and hip exam were unremarkable. There was right knee buckling during ambulation.
Radiographic findings:
EMG:
The motor nerve conduction study revealed prolonged distal latency for the right femoral nerve with normal amplitude. The sensory nerve conduction study revealed decrease amplitude, with normal peak latency for the right saphenous nerve.
The needle electromyography demonstrated that the right vastus lateralis, rectus femoris, and vastus medialis (Femoral N. L2, L3, L4) demonstrated decreased insertional activity, minimal to no recruitment, with vastus lateralis being most affected. There was electrodiagnostic evidence of a right demyelinating and axonal femoral neuropathy with the lesion at or distal to the right inguinal ligament.
Please provide the objective assessment, a justified diagnosis and Physiotherapy treatm