Abstract
A 64-year-old female patient with a right grade II posterior tibial tendon dysfunction was seen for student physical therapy treatment for 6 sessions in a 9-week period at an outpatient physical therapy clinic under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with the Numeric Pain Rating Scale, goniometry, manual muscle testing, standing heel-rise test, single-leg stance test, ligamentous integrity testing, Foot and Ankle Ability Measure, and patient report. A plan of care was established to address pain, decreased ankle dorsiflexion range of motion, decreased strength in ankle plantarflexion, inversion, and eversion, decreased balance, functional limitations in daily activities, and her return to recreational activities. Main goals for the patient were to decrease pain, improve range of motion, increase strength, improve balance, tolerate walking down a flight of stairs, and return her to usual recreational activities such as hiking and playing pickleball. Main interventions used include manual therapy, modalities, balance training, therapeutic exercise, therapeutic activity, education, and an independent home exercise plan. The patient responded well to physical therapy interventions, and demonstrated moderate improvements in pain, right ankle range of motion, right ankle strength, balance, and physical function in regard to activities of daily living and her return to recreation. The patient was discharged to her home with a comprehensive home exercise plan, and patient education of symptom management and a gradual return to recreation.