OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE A Doctoral Project A Comprehensive Case Analysis Presented to the faculty of the Department of Physical Therapy California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHYSICAL THERAPY by Julie Hammond FALL 2017 © 2017 Julie Hammond ALL RIGHTS RESERVED ii OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE A Doctoral Project by Julie Hammond Approved by: _____________________________________, Committee Chair Edward Barakatt, PT, PhD _____________________________________, First Reader William Garcia, PT, DPT, OCS, FAAOMPT _____________________________________, Second Reader Rafael Escamilla, PhD, PT, CSCS ____________________________ Date iii Student: Julie Hammond I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project. __________________________________, Department Chair ____________ Michael McKeough, PT, EdD Date Department of Physical Therapy iv Abstract of OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE by Julie Hammond 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. v 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. _____________________________________, Committee Chair Edward Barakatt, PT, PhD _______________________ Date vi ACKNOWLEDGEMENTS I acknowledge California State University, Sacramento Physical Therapy Pro Bono clinic for allowing me to learn about and treat a patient with an orthopedic disorder. vii TABLE OF CONTENTS Page Acknowledgements .............................................................................................. vii List of Tables ........................................................................................................ ix Chapter 1. GENERAL BACKGROUND ........................................................................... 1 2. CASE BACKGROUND DATA ........................................................................3 3. EXAMINATION – TESTS AND MEASURES ...............................................6 4. EVALUATION................................................................................................11 5. PLAN OF CARE – GOALS AND INTERVENTIONS..................................13 6. OUTCOMES....................................................................................................20 7. DISCUSSION ..................................................................................................22 References ..............................................................................................................24 viii LIST OF TABLES Tables Page 1. Medication Table………………… .................. .……………………………….5 2. Examination Table……………………………….……………………………10 3. Evaluation and Plan of Care… ... ………….………………………………….13 4. Outcomes……………………………….……… .... ………………………….20 ix 1 Chapter 1 General Background Ankle fractures are common injuries of the lower extremities, occurring at an incidence rate of approximately 187 fractures per 100,000 people each year.1 Studies have shown that one third to one half of these fractures are due to sports-related injuries.1,2 Similar fracture rates were found overall between women and men, although women have higher rates in the 50 to 70 year age group.3 The large majority of ankle fractures are malleolar fractures: 60-70% occur as unimalleolar fractures, 15-20% as bimalleolar fractures, and 7-12% as trimalleolar fractures.1,3 In trimalleolar fractures, the medial malleolus of the tibia, the lateral malleolus of the fibula, and posterior aspect of the distal tibia (considered the posterior malleolus), are all fractured. Medical management of ankle fractures can entail conservative treatment without surgery, or the fracture may be surgically stabilized. Stable fractures in which the bones are not displaced are likely to improve with conservative care.4 Surgical treatment of unstable ankle fractures typically consists of an open reduction internal fixation of the fractured malleoli and/or a syndesmotic stabilization.4-6 After surgery, the orthopedic surgeon may opt to immobilize patients for up to 6-8 weeks by means of an external support with the aims of protecting the surgical wound, limiting postoperative pain, and minimizing the mechanical stress on the joint during the initial phases of healing.7 Studies that have investigated the possible risk factors for fractures in perimenopausal women found that cigarette smoking, a high body mass index, polypharmacy and a positive fracture history have been associated with an elevated risk 2 of ankle fractures.8,9 Long term work disability was also a notable risk factor with all fractures in perimenopausal women.9 The clinical impairments associated with operatively managed ankle fractures are pain, swelling, decreased strength, decreased joint range of motion (ROM), and impaired balance. These impairments can have a large effect on patients’ functional status by reducing their ability to perform activities of daily living. These limitations can lead to restrictions in patients’ participation in community events, social gatherings and sports. Rehabilitation efforts are aimed at managing pain, increasing ROM and strength, reducing edema, maximizing function, and teaching self-management skills. Ankle fractures can have long lasting effects on a patient’s physical, social, and psychological health.10 Some of these effects can be limited function, decline in leisure activities, fatigue, and persistent ankle symptoms.5,10 An unfavorable prognosis has been associated with multimalleolar fractures, higher levels of pain, reduced function, swelling, and decreased ROM.6,11-13 Broos and Bisschop found that 39% of patients with trimalleolar fractures and only 13% of subjects with unimalleolar fractures had unfavorable outcomes.13 Return to sports is a common rehabilitation goal for athletes sustaining ankle fractures. Colvin et al. found that at one year after surgery, 88% of recreational athletes had resumed participation in sports.14 Younger age, male gender, lack of a syndesmotic injury, and no systemic disease were positive predictors of returning to sport.14 The negative predictors that were found were older age, female gender, and several comorbidities.14 3 Chapter 2 Case Background Data Examination – History The patient was a 46-year-old, active female who self-referred to physical therapy (PT) due to weakness, stiffness and limited function of her right (R) ankle secondary to a trimalleolar fracture sustained during a skiing incident. The fracture was surgically stabilized approximately 3 months prior to her PT examination. The patient had three PT treatments at an outpatient facility for her present condition; she had discontinued care at the other outpatient PT facility. The patient had returned to her surgeon for follow up three weeks prior to her initial PT evaluation at which time radiographs revealed her bones were healed and she was permitted to weight bear as tolerated (WBAT). She had sprained her R ankle ten years ago resulting in a residual instability that did not interfere with her daily function or recreational activities. Her past medical history was unremarkable except for controlled asthma and occasional migraines, both of which her primary care physician was aware. She lived with a supportive partner in a two story house with multiple stairs. The patient’s chief complaints were weakness in R quadriceps and plantar flexor muscles, an occasional aching pain and stiffness in R medial and anterior ankle region, stiffness in the R foot, and an aching pain in R anterior knee. She reported past episodes of numbness and tingling in R lateral ankle/foot which resolved about 1 week prior to her examination. The patient’s aching pain was intermittent, ranging from 0-3/10 on the numerical pain rating scale (NPRS) and only present when ambulating without boot. Her 4 symptoms of weakness and stiffness were reported to be constant and variable. She reported increased swelling after periods of activity. The patient’s symptoms recently worsened with her increased activity since given WBAT orders.