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Outpatient rehabilitation for a patient following a surgically stabilized trimalleolar fracture.
A 46 year old woman with a right surgically stabilized trimalleolar fracture was seen for physical therapy treatment for 13 sessions from 06/17/2016 to 09/16/2106 at an outpatient pro bono physical therapy clinic. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with manual muscle test, goniometric measurements, single leg balance test, Timed Up and Go test, and a self-report questionnaire (Foot and Ankle Ability Measure). Following the evaluation a plan of care was established. The main goals for the patient were to improve her strength, increase her range of motion, normalize her gait pattern, improve her static standing balance, and regain her functional independence. The main interventions used were therapeutic exercise, joint mobilization, soft tissue mobilization, over-ground gait training, and functional activity training. The patient improved her strength, increased her range of motion, improved her balance, normalized her gait pattern, regained her functional independence in all activities of daily living, and was able to resume participation in a few recreational activities. The patient was discharged from outpatient physical therapy with a home exercise program.