Patient Problems

#4
Rebecca Stevens

A 21 year old white female sprained her ankle (third degree) and had it casted. It is now out of
the cast but she has restricted ankle ROM plus she has decreased strength. Please write her an
ankle home exercise program to increase her strength and ROM. Begin with some easy
exercises and progress to more advanced ones.

Patient Problems
#4
Rebecca Stevens
MEDICAL HISTORY:
R wrist carpal tunnel
DIAGNOSIS:
L ankle 3 sprain
SUBJECTIVE:
Home situation: Lives in apartment building, on the 1st floor. There are 3 steps to door with one
railing. She has one roommate. She sleeps on a low futon and uses a shower seat.
Occupation: Senior in college, IT major. She works as a cashier at Giant Eagle. While in the
cast, she worked reduced hours but had to sit on a stool, which was killer on my back.
Functional Activities: computer work at small desk, standing in 8 hour shifts, hiking and biking
Patient Goals: Return to standing at work and hiking and biking without pain.
OBJECTIVE:
Pain: current 4/10
GONIOMETRY
Hip
Hip /
Hip ABD
Hip ADD
Hip IR
Hip ER
Knee
Knee /
Ankle df
Ankle pf
Ankle INV
Ankle EV
MMT
Hip
Hip /
Hip ABD
Hip ADD
Hip IR

AROM
Left
90
25
40
20
50
50
50
0
10
25
16
8

Left
5
4+
5
5
5

Right
5
5
5
5
5

PROM
Right
90
25
40
20
50
50
120
0
20
40
30
20

MMT
Knee
Knee /
Ankle df
Ankle pf
Ankle INV

Left
96
41
44
20
52
50
122
0
13
28
18
12
Left
4
4
3+
3+
3

Right
95
42
44
21
51
51
123
0
22
41
30
20

Right
5
5
5
5
5

Treatment: 2-3x/wk, 6 weeks. MH, CP, E-stim, US, HEP, strengthening and ROM. BAPS
outpatient, not for HEP.

Patient Problems
#4
Rebecca Stevens
ASSESSMENT:
Condition: Subacute
Rehab Potential: Good
STG: return to work; Reduce pain 0-1/10; Ambulate 3 stairs reciprocally
hamstring, and ankle extensors/flexors to 5/5
AROM:
L Ankle DF 10 20
L Ankle PF 25 40
L Ankle INV 16 30
L Ankle EV 8 20
LTG:

strength and ROM for return to work and leisure activities

PLAN OF CARE:
Education: HEP, stairs
Referral:
Discharge Plan: Continued strengthening for pain and prevention of future sprains, use of home
modalities (MH, CP)