19.Hip 髋关节 – Tcm Foundation

Initial acc treatment
ACC details
ACC45 No:
Read code:
Date of Accident:

Subjective findings
Reason for visit:
Hip pain
Previous surgery or fractures:
Nil
Previous illnesses:
Nil
Medication and/or supplements:
not known
Subjective Findings:(patient’s description of injury)
When pulling the lawnmower cord, I sprained my back.
Lifting a heavy box above the head, whilst turning the head, twisted and sprained the neck.
Whiplash to the neck after being hit in the rear by another car
Whilst playing football, I was tripped by another player and fell sideways, straining the knee.
Onset and progression:
Felt sharp pain for one day after the injury, followed by an ongoing dull ache since then, experiencing intermittent sharp pain with certain movements.
Aggravated by:
Running
squat
Relieved by:
heat pack/rest
Yellow flags(psychological or emotional factors):
N/A
Red flags(potential serious complications):
N/A
Previous treatment:
physio for 1 session
Objective Findings:
Observation: no swelling, no bruising

Numerical Pain Rating Scale (NPRS): most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS) :
To be able to squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10

Range of movement:
Left
Internal rotation 35°
External rotation 40°
Flexion 120°
Extension 30°
Abduction 40°
Adduction 25°
Right
Internal rotation 35°
External rotation 40°
Flexion 120°
Extension 30°
Abduction 40°
Adduction 25°

palpation:
tender to touch around the local injured area.

Tongue: Dark Red Tongue with White Coating
Pulse: Wiry

Diagnosis:
read code(blood stasis and qi Stagnation)
Treatment Principle:
promote Qi and remove blood stasis to relieve the pain
The goal for treatment:
To be able to squat without pain
To be able to run without pain
To be able to stand for 1 hour without pain
Treatment Plan:
acupuncture and cupping 1-2times/week
Estimated time frame :
6 weeks/12 weeks
Today’s treatment:
Acupuncture 50 mins
Ashipoints,zulinqi,neiting,taibai,taichong,sanyinjiao,yangfu
cupping 10 mins- in the locally affected area
Post-treatment advice:
Avoid too much running
Keep warm

2nd visit acc treatment

Subjective
Results/Progress:
The patient reports that

The pain has slightly decreased compared to the last visit. However, it worsens with long hours of standing at work. The patient experiences intermittent sharp pain along with a constant dull ache, particularly noticeable without movement.

Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst

Patient-Specific Functional Scale (PSFS):
To be able to squat 6/10
To be able to run 6/10
To be able to stand for 1 hour 6/10

Objective
MSK exam
Observation: No swelling, no bruising

palpation:

tender to touch around the local injured area.

TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry

Today’s treatment
Acupuncture 50 mins
Ashipoints,zulinqi,neiting,taibai,taichong,sanyinjiao,yangfu
cupping 10 mins- in the locally affected area

Post-treatment advice
Avoid too much running
Keep warm

3rd visit acc treatment

Subjective
Results/Progress:
The patient reports that

The pain is more localised compared to the last visit. The patient still feels sore when running. There is a constant dull ache, but the intensity is not as much.

Numerical Pain Rating Scale (NPRS): Most of the time 4/10, 6/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to squat 7/10
To be able to run 7/10
To be able to stand for 1 hour 7/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:
Left
Internal rotation 40°
External rotation 45°
Flexion 125°
Extension 10-40°
Abduction 45°
Adduction 30°
Right
Internal rotation 40°
External rotation 45°
Flexion 125°
Extension 10-40°
Abduction 45°
Adduction 30°

TCM exam
Tongue: Dark Red Tongue with White Coating
Pulse: Wiry
Plan
Today’s treatment
Acupuncture 50 mins
Ashipoints,zulinqi,neiting,taibai,taichong,sanyinjiao,yangfu
cupping 10 mins- in the locally affected area

Post-treatment advice
Avoid too much running.
Keep warm

4th visit acc treatment
Subjective
Results/Progress:
The patient reports that

The pain returned one day after the last treatment, and there is still significant discomfort in the local area. However, the pain is now more localised, presenting as intermittent sensations of pain.

tender to touch around the local injured area.

Range of movement:

Left
Internal rotation 35°
External rotation 40°
Flexion 120°
Extension 30°
Abduction 40°
Adduction 25°
Right
Internal rotation 35°
External rotation 40°
Flexion 120°
Extension 30°
Abduction 40°
Adduction 25°

5th visit acc treatment

Subjective
Results/Progress:
The patient reports that

The pain is becoming more and more localized, and there is much improvement compared to the first visit. However, there is still pain when standing for long hours. The patient reports much more flexible movement.

Numerical Pain Rating Scale (NPRS): Most of the time 5/10, 7/10 at worst
Patient-Specific Functional Scale (PSFS):
To be able to squat 8/10
To be able to run 8/10
To be able to stand for 1 hour 8/10

Objective
MSK exam
Observation: No swelling, no bruising

tender to touch around the local injured area.

Range of movement:

Left
Internal rotation 40°
External rotation 45°
Flexion 125°
Extension 10-40°
Abduction 45°
Adduction 30°
Right
Internal rotation 40°
External rotation 45°
Flexion 125°
Extension 10-40°
Abduction 45°
Adduction 30°

Post-treatment advice
Avoid too much running.
Keep warm