Now this case is definitely not what you think, although I'm sure with all those implants, Lee Majors and the Bionic Woman had some crazy isokinetic rehab as was the rage back then.
Subjective: 74 yo female with history of OA and RA. Severe arthritic changes in every joint. She had 3 THA on the left, 4 THA on the right, 3 TKA bilaterally, and 3 shoulder replacements bilaterally. She c/o severe left ankle pain with all WB ADLs. The onset was 2-3 years prior to being evaluated and had been worsening. Sx were intermittent and only felt in WB. She stated from the onset she did not expect a fix for her chronic complaints and only wanted to be able to walk, use her stairs, and be able to keep up with her house. She had prior PT with no effect, but they were just doing regular exercise (bike, SLR, quad sets, etc).
Objective:
Ankle ROM
- Left severe limits in all planes, hard end feels, pain at end ranges
- Right mod limits in all planes, firm end feels, no pain
Knee ROM
- Left and Right mod limits in flexion and extension, hard end feels, no pain
Hip ROM
- Left and Right severe limits in all planes, hard end feels, no pain
Strength was WFL for break tests since her ROM was limited in every joint, no increased pain with resistance around the left ankle
Assessment: Where to start? It was an overwhelming presentation from a neuromusculoskeletal standpoint. The key to her presentation was that she had a great attitude and was very focused on what she wanted out of PT. She did not expect any kind of quick fix or miracle for conditions that had been present for most of her life.
Treatment:
Visit 1: We started with IASTM very lightly around her left talocrural joint anteriorly, subtalar joint medially and laterally, and gastroc/soleus. HEP was light AROM in pf and df hourly.
Visit 2: She reported feeling about 50% reduction in pain with WB ADLs. The fellow who was co-treating, myself, and the patient were all very pleasantly surprised! We added very light mobilization with movement posterior gliding of the talus in light mini lunge and mini squat for this visit and continued with the IASTM from the previous.
Visit 3: She reported nearly a full reduction of pain with just morning stiffness. She was able to walk up and down starts without any ankle pain, but still had her usual aches which did not bother her in the least. No new treatments were added, but we continued the IASTM and MWM.
Visits 4 and 5: The patient had a slight setback of mild pain between visit 3-4 with some WB ADLs but she conceded she may have done too much at home. For visit 5 she was still feeling very good and had no more functional limitations other than those she expected and gotten used to. We reviewed her HEP and made sure she remained active with her stretches. She was happily discharged and very grateful.
Discussion:
After hearing just how many surgeries and seeing her physical presentation, I really did not know where to begin, much less think I may be able to help her. Where there really only mild issues in the tissues as well as some simple joint restrictions? Or did we give her the confidence after loosening up the area to move repeatedly and desensitize the CNS? My bet is both. We followed up with her a month later and she was still doing very well. Isn't it great that we can still be surprised at the outcomes of PT after practicing for over a decade? That's why I love this profession!
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