| 218 | | Plan Date: 03-11-2026 | | Physical Assessment Summary: Self Care/ADLs:
Types of Food: Good appetite
Mobility & Transition:
Locomotion: IND with ambualtion but lacks coordination, bilateral foot pronation, tight hip IR
Complicating/Personal Factors Affecting the Plan of Care:
Mechanism of injury/ Illness: Congenital
Multiple Treatment Areas: Weakness, limited balance, lack of coordination, limited activity tolerance, pain that limits movement
Patient age: 10 years 9 months
Time since onset of injury/illness: Congenital
Medical History Review:
High Complexity: The patient has a history of present problem with a history of 3 or more factors and/or comorbidities that impact the plan of care.
Assessment:
Child assessed using a Standardized Assessment
Clinical Observations: tightness in bilateral hip IR, limited balance, lack of coordination, bilateral foot pronation, pain with minimal activity, decreased activity with all activity, mild scoliosis
The patient is a 10-year, 9-month-old male referred to physical therapy secondary to a systemic condition affecting the musculoskeletal system (not isolated to the feet) and mild scoliosis. Parent reports the primary goal of therapy is for the patient to improve strength and reduce pain in order to better participate in sports and engage in family activities. Upon evaluation, the patient demonstrates significant deficits in gross motor performance, including generalized weakness, tightness in the bilateral hips (right greater than left), decreased balance without falls, impaired coordination, atypical gait mechanics, bilateral foot pronation, decreased activity tolerance, and reduced kinesthetic/proprioceptive awareness. These impairments negatively impact the patient’s ability to perform age-appropriate motor skills and participate fully in daily routines, recreational activities, and peer interactions. Standardized testing using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition revealed significantly below-average motor performance. The patient scored 8.0 –8.2 year age equivalence in bilateral coordination, with balance and agility skills below the 4-year age equivalence, and strength scores equivalent to approximately 5.8–5.9 years, all indicating severe delays in both simple and complex motor skills compared to age-matched peers. These findings demonstrate substantial deficits in motor planning, postural control, and functional strength. Due to these impairments, the patient is currently limited in participation in higher-level gross motor tasks, sports, and sustained physical activity, and is at increased risk for further functional decline, musculoskeletal compensation patterns, and potential progression of postural deviations if deficits are not addressed. Skilled physical therapy is medically necessary to address the patient’s neuromuscular and musculoskeletal impairments through targeted therapeutic interventions including strengthening, balance training, coordination activities, gait training, and flexibility exercises. Therapy will focus on improving overall strength, joint mobility/AROM, postural control, proprioceptive awareness, and functional mobility in order to support age-appropriate motor development, reduce pain, improve activity tolerance, and enable participation in sports and family activities while minimizing the risk of long-term disability. Patient would greatly benefit from skilled PT interventions in order to address established delays and facilitate functional independence and performance. Home programming alone is not sufficient to make the needed progress, direct one to one services are required for progress to be achieved. Results of the evaluation were reported and explained to parent(s), along w/ the diagnosis, prognosis, including the frequency, time and duration of treatment and contents of the plan of care. Family will be provided w/ a verbal report of progress noted along w/ any homework for the family as part of a home program (if applicable) at the end of every session. Parent(s) verbalized understanding of treatment plan and agreed to the initiation of skilled therapy. | | Physical Rehabilitation Potential: Good. with consistent Physical Therapy and parental support | | Physical Treatment Plan: | | Physical Long Term Goals: | | Category | Goal Description | | In 6 months, Patient will demonstrate improved medial arch muscle activation, control and decreased foot pronation during standing and ambulation, to sustain neutral foot alignment for greater than 30 mintues during functional activities (walking, squatting, and step-downs) across 4 out of 5 trials to improve lower-extremity biomechanics and reduce stress on joints. | | In 6 months, Patient will improve cardiovascular endurance by participating in continuous physical activity across 30 minutes without rest break and without increased pain or excessive fatigue to support participation in recreational activities. | | In 6 months, Patient will improve lower-extremity coordination during dynamic motor tasks (e.g., sport activity drills, jumping, and agility) for 20 feet with proper sequencing and minimal loss of balance in 4out of 5 trials to support participation in recreational activities. |
| | Physical Short Term Goals: | | Category | Goal Description | | In 3 months, Patient will decreased symptoms to less than 2/10 pain level across 5 days per week while performing daily activities and therapeutic exercise. | | In 3 months, Patient will sustain single-leg stance for 10 seconds on each lower extremity (right and left side) with no more than 1 loss of balance across 3 out of 4 trials, to promote kinesthetic sense, spacial awareness, reflexes with functional movement. | | In 3 months, Patient will improved strength of lower extremity by 1/2 grade from baseline to improve postural stability during functional activities. | | In 3 months, Patient will improve hip internal rotation ROM by 5+ degrees bilaterally to promote improved lower-extremity alignment during functional mobility and gait |
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