51-year old construction worker with devastating leg injury from motorcycle accident; 1.5 years post injury and 10 left leg surgeries to salvage a crushed leg with Grade III left tibia and fibula fractures. John now wears a left leg compression stocking 24/7 and AFO brace for a drop foot for nearly all his waking hours; he continues to take Oxycodone and Oxycontin for pain, and attends physical therapy.
Independent for self-care, with need to now sit for all lower body dress and bathe activities and inability to assume unilateral weight bearing on the left leg; limited stand and walk, lift and carry in conjunction with homemaking for this single man who lives in a 2-story home.
Unable to return to work as a construction worker
Left leg Findings
- Constant leg pain that varies from 4/10-10/10
- Grossly disfigured left calf and foot drop
- Near 100% ankle motion restrictions in all planes of motion
- Minimal active toe mobility
- Altered sensation over the graft site and foot
- Decreased weight bearing on the left leg
- Stand tolerance of 10-15 minutes with primary weight bear on the right leg
- Use of cane for brief ambulation with antalgic gait and need to take intermittent rest breaks
- Primary weight bearing on the right leg to kneel and squat, with increased pain and pressure on left foot
- Need to keep the left leg elevated when seat
- Use of cane and rail support for stairs
- Abilities to do occasional low and medium level lifts of up to 40 pounds and difficulty for repeated lifts of 30 pounds
- Inability to do bilateral or right hand carries because of need for cane support and brief abilities to carry at left side of up to 20 pounds
- [Additional pulling on latissimus dorsi scar, which is site of donor transplanted muscle, in conjunction with all bend, lift and carry]
John has severe ongoing left ankle mobility restrictions with a drop foot and very limited weight bearing abilities that restrict his abilities to stand, walk, lift and carry, negotiate steps; perform daily home and recreation activities, or resume the Heavy work demands of a construction worker. While able to do occasional lifts and carries associated with Light-Medium work, he cannot do these on a repeated or sustained basis, nor stand for duration of the day as required to work associated with these physical demands. John’s current work capacities are at the Sedentary level. Re-evaluation is recommended upon John’s completion of therapy to see if he is able to increase his weight bearing capacities.