Page 13 - Journal of Special Operations Medicine - Spring 2015

Figure 6 Anteroposterior (A) radiographs of the left tibia physical therapist in late 2013 to inquire about the de­
and fibula demonstrating malunion and hardware failure. vice and program eligibility, given that he had bilateral
The subsequent image (B) shows revision with ringed external deficits. There had only been one previous SF NCO
fixator application. within 5th SFG(A) to receive the IDEO and complete
(A) the RTR clinical pathway, but he only had a unilateral
(B)
impairment.
He was subsequently referred to the RTR clinical path­
way at the CFI and was the first patient from the 5th
SFG(A) to be considered for bilateral IDEOs, which is
a custom­made, energy­storing, ankle­foot orthosis. At
that time, he was overweight and moderately to severely
deconditioned. Physical therapy at each Special Forces
Group is embedded in the unit’s Tactical Human Op­
timization Rapid Rehabilitation and Reconditioning
(THOR ) program, and as such, there is ready access
3
to professional strength and conditioning coaching staff
and sports dietetics and sports psychology. Therefore,
5
Figure 7 Anteroposterior radiographs of the left (A) and he was assessed by the coaching staff and placed on an
right (B) ankles following tibiotalar arthrodesis. accelerated program to prepare for the rigors of the
IDEO program.
(A) (B)
On his initial evaluation on arrival to the CFI, just over
7 years from his injury, he was found to have full motor
strength testing in the iliopsoas, tensor fascia lata, quad­
riceps, and hamstrings bilaterally but zero degrees of
both dorsiflexion and plantarflexion in the right and left
ankles as a result of his ankle fusions. Prior to initiating
therapy (week 0), the patient’s speed and agility were as­
sessed using four standardized timed activities: the four
square step test; a 20m shuttle run; self­selected walk­
ing velocity; and timed stair ascent (stair climb). The
patient’s performance of these activities over the course
of the 8­week interval is shown in Table 1. Of the four
activities, the largest degree of improvement was seen in
multiple conservative measures, he underwent tibiotalar the shuttle run (Table 2). Five weeks after arrival (week
arthrodesis of the left ankle in 2008 and the right ankle 5), he was fit with custom­made carbon fiber lower ex­
in 2009 due to chronic ankle pain (Figure 7) at an out­ tremity orthoses, and on the following week, he began
side medical facility that was within geographic proxim­
ity to his unit, allowing for rehabilitative care following Table 1 Performance in Standardized Activities
both surgeries to be conducted at the 5th SFG(A) physi­ Assessments
cal therapy clinic.
SSWV
Visit Week FSST(s) Shuttle(s) (m/s) Stair Climb(s)
Despite the aforementioned interventions to stabilize
his complex injuries and the achievement of bony union 0 7.8 10.2 1.4 3.6
in bilateral lower extremities, the patient continued to 5 7.5 9.6 1.4 3.7
complain of significant functional deficits related to 8 5.6 6.9 1.8 3.2
chronic pain and loss of ankle range of motion that pre­
cluded running and activities requiring agility. Despite Table 2 Percentage Change in Standardized Activities
this limited capacity, he continued on active duty as a
senior Operations sergeant for 7 years. Assessment % Change
FSST 29
The patient inquired about the Intrepid Dynamic Exo­ Shuttle 32
skeletal Orthosis (IDEO) and the Return to Run (RTR) SSWV 18
clinical pathway at the Center for the Intrepid (CFI) at
Brooke Army Medical Center and reported to the group Stair Climb 18

Case Report: Return to Duty After Severe Bilateral Lower Extremity Trauma 3