Abstract
A 28-year-old male, Amazon delivery driver presenting with acute left ankle sprain was seen for 6 physical therapy sessions over 5 weeks in an outpatient clinic. Treatment was provided by a physical therapy student under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with goniometry, manual muscle tests, figure 8 girth measurement, numeric pain rating scale, ligamentous integrity tests, the Lower Extremity Functional Scale, and ability to complete work tasks. A plan of care was established to address edema; impairments in strength, range of motion, and pain; and limitations in functional capabilities. The main goals for the patient were to decrease their pain and return to work.
The interventions used were manual therapy, therapeutic exercises, task-specific exercises, gait training and patient-related instruction. At the conclusion of the episode of care, the patient achieved the following goals: increased range of motion, increased strength, decreased swelling, decreased pain, improved Lower Extremity Functional Scale score, and improved tolerance for work activities.
The patient was discharged to continue living at home with a recommendation to follow up with his physician to discuss his progress and continue to do his HEP independently as he continued to heal and return to his prior level of function. Additional physical therapy was requested to continue to build up the patient’s tolerance for work activities and work on strategies to prevent future injuries.