Abstract
A retired 65-year-old female patient who sustained a left lateral tibial plateau fracture was seen for physical therapy treatment for 14 sessions for outpatient physical therapy. Under the supervision of a licensed physical therapist, treatment was provided by a student physical therapist. The patient arrived at the clinic with a front-wheel walker and presented with decreased stride length of the right lower extremity, decreased knee flexion of the left lower extremity, and decreased confidence with balance. The Five Times Sit-to-Stand, Berg Balance Scale, Dynamic Gait Index, Knee Injury and Osteoarthritis Outcome Score, and Lower Extremity Functional Scale were used to evaluate the patient and form a plan of care. Problems identified included decreased strength, decreased active range of motion, increased pain, gait deviations, impaired stair climbing ability, and decreased recreational/athletic ability. The goals set for the patient included increasing left lower extremity strength in knee flexion, knee extension, hip abduction, and hip external rotation to a 5/5 manual muscle testing grade. The goal for the patient’s range of motion was 120º for knee flexion and 0º for knee extension. The goal regarding pain was for the patient to decrease pain levels to 0/10. The goal for the patient’s gait was to have an even stride length bilaterally. Lastly, the goal for the patient by the end of treatment was to improve stair climbing ability and return to recreational and athletic activity. The patient’s treatment consisted of land-based and aquatic strengthening, range of motion, balance, functional mobility, aerobic, and plyometric exercises. The patient was discharged to live independently at home and had met or exceeded all goals.