My Physical Therapist found time to write the following referral note, prior to my visit with the Surgeon's assistant tomorrow:-
Pt. has been seen for a total of 17 physical therapy visits since initial
evaluation on 2/7/2008.
Subjective Findings
Pt.
reports some improvement post surgically. He states that his overall
alignment has improved and general functional mobility has increased, however
intermittent spasms and hip pain continues.
No lower extremity
radicular symptoms are reported. No sleep disturbances are reported.
No medications being taken.
Chief complaint relates to morning
stiffness and transitional pain from sit to stand.
Objective Findings
Inspection: Standing
posture reveals moderate left lateral shift. Lumbar lordosis is
normal.
AROM L/S: Flexion: Minimal loss with complaints of
bilateral hip pain L>R upon initiation of movement.
Extension: Minimal loss with no complaints of pain.
Reflexes: +1 bilateral lower extremities.
Sensation:
Unremarkable throughout bilateral lower extremities.
Strength: No
myotomal weakness noted.
Palpation: Moderate
tenderness noted over posterior iliac crest L>R. No tenderness over
surgical site.
Stability:
Unremarkable.
Assessment
Pt.
has made fair progress with therapy. He has been extremely compliant with
his program and I am pleased with the progress made throughout the L/S
region. I am not pleased with the continued hip and gluteal region pain
noted upon initiation of position changes. Soft tissue mobilization and
exercises have been able to reduce the symptoms, however some symptoms
persist.
Although insurance benefits have expired I recommend
continued therapy 1x/week for advanced stabilization program and soft tissue
mobilization.
Plan
Pt. to return to M.D.
for follow up visit on 4/25/2008.
