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Ankle Sprain Assessment Full

The document is a physiotherapy evaluation form for a 16-year-old female patient, Nandini Singh, who has been experiencing pain and swelling in her right ankle for three weeks following an inversion injury during a basketball game. The evaluation includes a detailed history of the injury, objective examination findings, a diagnosis of a Grade 2 right lateral ankle sprain, and a comprehensive treatment plan with short-term and long-term goals. The treatment plan outlines specific phases of rehabilitation, home exercises, and a follow-up plan to monitor progress.

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8 views3 pages

Ankle Sprain Assessment Full

The document is a physiotherapy evaluation form for a 16-year-old female patient, Nandini Singh, who has been experiencing pain and swelling in her right ankle for three weeks following an inversion injury during a basketball game. The evaluation includes a detailed history of the injury, objective examination findings, a diagnosis of a Grade 2 right lateral ankle sprain, and a comprehensive treatment plan with short-term and long-term goals. The treatment plan outlines specific phases of rehabilitation, home exercises, and a follow-up plan to monitor progress.

Uploaded by

vaniphysio13
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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PHYSIOTHERAPY EVALUATION FORM

Patient Information
Name Nandini Singh
Date 20-11-2024
Age 16
Gender Female
Occupation Student
Address Noida, UP

Chief Complaint
The patient presents with persistent pain and swelling in the right ankle for the past 3 weeks following an
inversion injury during a basketball game.

History of Chief Complaint


The patient was asymptomatic before the injury. During a basketball match, she suffered an inversion injury to
the right ankle while landing after a jump. Initial management included RICE (Rest, Ice, Compression,
Elevation) and intermittent use of a brace.

Medical and Social History


Medical History No past injuries, took pain relief
medication post-injury.
Social History Regularly engages in physical activity,
plays basketball at school level.

Symptoms History
Side Right
Site Ankle
Onset Sudden
Duration Persistent (3 weeks)

Pain Evaluation

- At Rest: 5/10
- With Activity: 8/10
- Aggravating Factors: Weight-bearing, physical activity, inversion movements, prolonged standing.
- Relieving Factors: Rest, ice therapy, elevation, bracing.

Objective Examination
Observation:

- Built: Mesomorphic
- Posture: Normal
- Oedema: Present, Grade 3
- Gait Pattern: Antalgic gait with shortened stance phase on the right side.

Palpation
- Tenderness: Present, Grade 3
- Swelling: Present
- Warmth: Present
- Crepitus/Abnormal Sounds: None

Motor Assessment

Range of Motion (ROM)


Could not be assessed due to pain.

Manual Muscle Testing (MMT)


Muscle Right Left
Knee Flexors Could not be assessed due to pain 5
Knee Extensors Could not be assessed due to pain 5
Ankle Muscles Could not be assessed due to pain Normal

Special Tests
- Anterior Drawer Test: Positive (suggesting ligament laxity)
- Talar Tilt Test: Positive (indicating lateral ankle instability)
- Squeeze Test: Negative (to rule out syndesmotic injury)
- External Rotation Stress Test: Negative (no high ankle sprain)

Diagnosis
Right Lateral Ankle Sprain (Grade 2)

Goals
Short-Term Goals (1-3 weeks):

1. Reduce pain and swelling (target VAS <3/10 at rest).


2. Restore ROM
3. Improve balance to achieve single-leg stance for 10 seconds on the affected side.

Long-Term Goals (4-12 weeks):

1. Achieve full ROM and functional strength.


2. Enhance balance and proprioception to prevent future injuries.
3. Return to sport without pain.

Treatment Plan
Week 1: Acute Phase
- Pain Management: Ice packs, electrical stimulation.
- Gentle ROM: Ankle circles, alphabet exercises.
- Isometric Strengthening: Knee isometrics.
- Progression Criteria: Advance to active ROM when pain <3/10.
Week 2-4: Subacute Phase
- Continued Modalities: Ice, compression, elevation.
- Active ROM Exercises: Ankle dorsiflexion, plantarflexion, inversion, eversion.
- Strengthening: Mini squats, wall squats.
- Balance Training: Weight shifting, stable surface single-leg stands.
- Progression Criteria: Increase difficulty when single-leg stance ≥10 sec.

Week 4-7: Rehabilitation Phase


- Advanced Strengthening: Calf raises, resistance band exercises.
- Dynamic Balance Training: Balance board, stability exercises.
- Proprioceptive Training: Wobble board, unstable surface drills.
- Sport-Specific Training: Agility drills (cone drills, lateral shuffles, drop jumps).
- Progression Criteria: Advance to agility training if balance test scores >90% compared to non-injured side.

Week 9-11: Return to Sport Phase


- Continued Strengthening: Progressive load training.
- Agility Training: Ladder drills, cutting drills.
- Injury Prevention Education: Warm-up routines, proper landing techniques.
- Follow-up Assessments: Re-evaluate every 2 weeks to adjust training load.

Home Program
1. Daily ROM Exercises: Gentle mobility drills in morning and evening.
2. Strengthening Routine: Light resistance band exercises at home.
3. Balance Drills: Single-leg stance, toe taps, heel raises.
4. Caregiver Involvement: Tracking progress, ensuring adherence.
5. Education: Proper footwear, taping techniques, and injury prevention strategies.

Follow-up Plan
Reassessment every 2 weeks to monitor progress in ROM, strength, balance, and functional mobility. Adjust
rehab exercises accordingly.

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