Ankle Case Study by KDLynn Fox
A 17-year-old female high school volleyball player presents to physical therapy in May of 2021 with complaints of left ankle pain and instability for approximately 2 years. The patient reported that she first injured her ankle when playing volleyball in June of 2019 and the imaging reports discovered she ruptured her medial talofibular ligament and partially ruptured her calcaneofibular ligament.
Image: Textbook Illustration of the talofibular and calcaneofibular ligament
The patient then wore a boot for 7 weeks prior to starting physical therapy. Patient reported the inability to walk for long distances, squat, and participate in volleyball games for the entirety of the game without having increased pain.
This patient continued with physical therapy for 38 visits from May to November of 2021 with a plan of care as follows: therapeutic exercises for ankle strengthening and stability, ultrasound for tissue healing/regeneration/swelling, and manual hands on approach from a licensed physical therapist to increase her left ankle mobility and range of motion.
Image: Ankle Walker Boot
After 38 visits, the patients’ orthopedic doctor recommended the patient for inner left ankle reconstruction surgery to tighten the tissue and create more support and stability of ankle joint due to patient being a young athlete.
After the surgery in November 2021, the patient continued with skilled physical therapy. Following the surgeons protocol, the patient wore an ankle boot for 3 weeks and then transitioned into a lace up brace for another 3 weeks.
In physical therapy, the patient continued to do therapeutic strengthening exercises and stretches in clinic and at home as taught by her therapist to improve mobility and muscle strength.
After 12 sessions, patient was able to return to impact exercises and exercises that simulate volleyball while continuing to wear a brace.
After 10 more visits, the patient was able to complete all exercises without a brace and start progressing to sports-related and plyometric exercises such as jumping, hopping, and running.
After 36 session post-surgical operation the patient was discharged due to meeting all goals set by the physical therapist. At this time the patient is able to sports-related activities with no reports of pain and no signs of instability in her ankle.