So Smart

She had spent 3 weeks in short-term rehabilitation after a stroke. She was one of the lucky ones: the medics arrived to her home quickly, and she arrived at the hospital in time to receive appropriate/beneficial therapies. She now presents without noticeable residual deficits. I evaluated her yesterday, 2 days after returning home from rehab.

Gertrude and her son (who lives in the same home with her) informed me that she is walking around the home well, but she is having difficulty with moving to standing. Otherwise, she is reportedly at her baseline with regards to her mobility in the home.

“Are there any ailments, aches or pains that I should be aware of before we get started with the formal assessment?” I asked.

“Just this left ankle, sweetie. It has been bothering me since October, but there isn’t anything that they can do about it.”

“Who is ‘they’?”

“The doctors. First I went to the Dr. Jones, because I had seen him before for another problem in my other leg. He did an x-ray and it didn’t show a thing. Then he did an MRI; that didn’t show a thing. Then he referred me the ‘ankle-guy’ in the group; he thought he saw something on the first x-ray that Dr Jones missed, so he gave me an injection in my ankle. He thinks I have tendinitis.”

“Did it [the shot] help?”

“Maybe a little, but not for long.”

“Okay, I will take a look at the left ankle in a couple of minutes, but first, I would like to – and forgive me; I am usually not so forward on the first date – but could I walk with you to your bedroom?”

She chuckled and agreed. After walking approximately 10 feet (with bilateral foot drop and a rolling walker), her left lateral ankle pain was provoked (per subjective report) but there was no significant change in her gait. The pain reportedly persisted until she was able to unload the ankle, sitting at the edge of her bed. While looking around her room, I noticed that her CPAP machine was at her recliner a few feet away, not at her bedside.

“Are you sleeping in bed, or in your recliner?” I inquired.

“Since I came home a couple of days ago, I have been sleeping in the recliner, because I don’t want to have to deal with the tendinitis.”

“What position are you in when you are lying in bed?”

“On my back…but I can’t stay there for long.”

“Are you having any pain now, while you are sitting here at the edge of the bed?”


“What if you place your hands on the back of your hips like this [I demonstrate] and lean backwards.”

[she moves into seated lumbar extension]

“It hurts a little.”

“Your back?”

“No, my ankle”

“What happens if you separate your knees and reach down, with your hands, toward your feet?”

[she reaches toward the floor, moving into seated flexion]

“It goes away.”

After 5 repeated extensions, her symptoms were significantly worsened. With a single repetition of seated lumbar flexion, her symptoms were again abolished. She raised her eyebrows and her eyes widened.

“You are so smart. How did you know it was my back? I have been to two doctors since October and just spent the last 3 weeks complaining to PTs in rehab and none of them could figure this out.”

I didn’t have the heart to tell her that I learned how to complete a lower quarter screen in my first semester of PT-school.

“Perhaps I was the first person who paid attention.”


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