Abstract
A 33-year-old female professor received four weeks of outpatient physical therapy care following an acute right sided lateral ankle sprain sustained while hiking. Care was provided by a student physical therapist under the direct supervision of a licensed physical therapist. The patient was assessed for impairments at initial evaluation and discharge with the numeric pain rating scale, ankle figure of 8 measurement, manual muscle testing, goniometry, single leg balance testing, and ligamentous integrity testing. The patient’s objective findings were classified as grade II and grade III severity. Her impairments resulted in activity limitations and participation restrictions that were measured with gait observation, the Foot and Ankle Ability Measure, and patient report. Primary goals were to reduce pain, decrease edema to bilateral symmetry, improve strength to normal, increase active range of motion to bilateral symmetry, return to normal gait mechanics, tolerate jogging up to 1 mile, and return to her recreational exercise classes. Primary interventions were based on symptom modulation with gradual progression of strengthening, stretching, balance training, and return to normal activity. Care was also based on recommendations by the American Physical Therapy Association’s Clinical Practice Guideline for ankle ligament sprains. At discharge the patient met most goals for impairments and functional limitations, but was restricted in ability to return to full participation in recreational exercise. Her return to activity was within the expected time frame for a lateral ankle sprain between grade II and grade III severity. She was discharged with a home exercise plan and patient education of symptom management with the expectation of all goals to be met with gradual return to exercise.