Abstract
A 28-year-old male patient who was 8 weeks postoperatively for an open reduction internal fixation due to a left bimalleolar fracture was seen for 10 biweekly visits in 5 weeks for outpatient student physical therapy under the supervision of a licensed physical therapist. The patient’s chief complaints included pain, difficulty with activities of daily living, and inability to work or swim. The patient was evaluated at the initial encounter with goniometry, manual muscle testing, numeric pain rating scale, figure 8 girth measurement, Wells criteria, timed up and go, foot and ankle ability measure, lower extremity functional scale, observation, and patient report. The plan of care was established to address ankle range of motion and strength deficits, pain, swelling, incision healing, fall risk, functional status, ambulation ability, and participation in work as a delivery driver and recreational swimming. The patient’s personal goals were to decrease pain, ambulate at prior level, shower without an assistive device, and return to work and swimming. The main interventions used were manual therapy, therapeutic exercise, gait training, and education. The patient met almost all clinical goals addressing body structure or function, impairments, activity limitations, and participation restrictions. Specifically, goals were achieved with regards to ankle range of motion, strength, pain, swelling, incision healing, fall risk, functional status, walking, and participation in work and recreational swimming. At follow-up, the patient was scheduled to continue physical therapy care in order to continue to improve functional status and progress further towards personal goals.