SOAP physiotherapy session

14/05/2024 10:30

Home visit

Subjective

• c/o R lateral hip pain and stiffness, requesting physio r/v.
• 6/52 duration. Constant dull ache (4/10 VAS), sharp (7/10 VAS) on weight-bearing after prolonged sitting. Insidious onset after increasing walking distance.
• Agg: lying on R side, climbing stairs, single-leg stance (putting on trousers). Ease: rest, heat pack, ibuprofen 400 mg PO TID (moderate relief).
• Progression: Gradually worsening over past 2/52; now waking pt at night.
• Previous episodes: Similar milder episode 2 yrs ago, resolved after 4/52 of rest and GP-prescribed NSAIDs.
• Impact on daily activities: Unable to walk dog for > 15 mins; difficulty sleeping on R side; struggling with stairs at home.
• Associated symptoms: Nil paraesthesia, nil weakness, nil Lx spine pain. Cauda equina red flags negative.

Past Medical History

• Mild bilateral knee OA, HTN. Nil previous hip surgery.
• Retired teacher, lives in 2-storey house with spouse, usually walks 5 km daily, non-smoker.
• Mother had R THR aged 72 for OA.
• Nil relevant occupational or travel exposures.
• Up to date with routine immunisations including annual influenza and COVID-19 boosters.
• Other: Takes amlodipine 5 mg PO OD. NKDA.

Objective

• BP 128/78 mmHg, HR 72 bpm, SpO2 98 % on RA.
• Trendelenburg gait +ve on R. Palpation: marked tenderness over R greater trochanter. R hip AROM: flexion 100°, abduction 25° (painful), internal rotation 15° (painful at end-range), external rotation 40°. MMT: R hip abductors 3+/5 (pain-inhibited), extensors 4/5, L hip 5/5 throughout. +ve FABER and +ve FADIR for lateral hip pain. Single-leg stance on R reproduces pain at 5 s. Lx spine screen clear, distal neurovascular exam intact.
• Pelvis X-ray (02/05/2024): mild bilateral hip joint space narrowing, calcific tendinopathy adjacent to R greater trochanter.

Treatment

• Soft tissue massage to R TFL, gluteus medius, and ITB in L side-lying. Grade II PA joint mobilisations to R hip in supine.
• Acupuncture to R GB30, GB31, and GB34 for 20 mins, needles stimulated 2 times (at 10 mins and 15 mins), De Qi achieved.
• Practised isometric hip abduction in supine with pillow between knees. HEP: Isometric gluteal contractions (5 x 10 s holds, 3 times daily), supine bridge with theraband around knees (3 x 10 reps, OD). Advised to avoid crossing legs and sleeping on R side (use pillow between knees in L side-lying).

Assessment

• R Greater Trochanteric Pain Syndrome (GTPS) / gluteus medius tendinopathy.
• R hip OA flare, referred Lx spine pain, trochanteric bursitis.

Plan

• Nil further imaging required at this stage.
• F/u home visit in 1/52 to review HEP compliance, progress to eccentric loading, and repeat acupuncture.
• Load management education provided; advised to discuss switching from ibuprofen to topical diclofenac 1 % gel with GP given HTN history.