Chief Complaint/Functional Limitations: Patient with complaint on left foot pain secondary to swelling. Patient with complains of pain with changes in position, with foot down for prolonged periods and with movement of ankle and knee.
Past Medical History: None reported with exception of left fracture elbow and low back injury in 8th grade.
Pain Scale: 3/10 now; 6/10 worst
Tests: X-rays taken 5/11/99 and 5/20/99
Medications: Vicoden, Lovenox, Celexa (anti-depressant).
Prior Activity Level/Functional Status: Full and painfree activities of daily living, work, and leisure activities.
Range of Motion/Flexibility/Active:
Strength: Right lower extremity 5/5. Left hip flexion 4/5, knee extension 4-/5, flexion 4-/5, ankle not tested secondary to recent surgery.
|Ball of foot||25.5cm||28.7cm|
Palpation: not tested due to recent surgery.
Special Test/Neuro: Patient able to perform straight leg raise lower left extremity.
Treatment/Initial Visit: Evaluation; home exercise program of ankle pumps, ankle ROM, heel slides and use of ice; ice and elevation; tubigrip size F.
ASSESSMENT: Patient is a 29 year old male status post left tibia fracture with rod and screw implementation on 5/11/99. Patient presents to the clinic with pain, edema, decrease ROM, decrease strength, and decrease functional mobility secondary to recent surgery.
PLAN: home exercise program, edema control, ROM, strengthening, gait training, wound management.
Frequency/Duration: 2 times per week for 5 weeks.
|STG (#2 weeks)||Patient will be independent with ROM home exercise program
Patient will be independent with icing and elevation
Decrease edema left lower extremity by at least 2cm
|LTG (#4 weeks)||Patient will be able to ambulate 200' with crutches
Patient will be able to tolerate gently strengthening
Increase ankle ROM left by at least 50%
Physical Therapist: Amy R.