MSA Initial Physiotherapy Consult

SUBJECTIVE EXAMINATION MSA Sport Football, Athletics HOPC / MOI Patient reports a twisting injury to their left ankle whilst playing football 2 weeks ago. Initially, they felt a sharp pain and were unable to weight bear. They rested for 2 days and then attempted to return to sport, but pain and swelling returned. They have been managing the injury with rest, ice, and over-the-counter pain relief. Symptoms Patient reports sharp pain on the lateral aspect of their left ankle, which is aggravated by weight-bearing and running. They also report swelling and stiffness. They feel a loss of confidence in their ankle. Aggs * Weight-bearing * Running * Twisting movements Eases * Rest * Ice * Elevation 24/24hr Pain is worst in the morning with stiffness. Pain increases throughout the day with activity and is often worse in the evening. Imaging / MDT * No imaging has been performed. * Has not consulted any other health professionals. Patient Reported Contributing Factors * Increased training volume in the last month. * Playing on uneven ground. Medical Conditions / Dietary * No known medical conditions. * No dietary concerns. PHx * No previous injuries to this region. * Fractured right wrist 5 years ago. SHx Patient is a 17-year-old male, lives at home with his parents and siblings. He is a student and enjoys playing football and athletics. He is supported by his family and friends. Training Schedule * Monday: Football training * Tuesday: Athletics training * Wednesday: Rest * Thursday: Football training * Friday: Athletics training * Saturday: Football match * Sunday: Rest Upcoming Competitions / Goals * Football match next Saturday. * Aiming to compete in the regional athletics championships in 2 months. OBJECTIVE Observation * Swelling noted around the lateral malleolus. * Mild bruising present. * Patient is able to weight bear with a limp. Range of Motion * Ankle dorsiflexion: 10 degrees (painful) * Ankle plantarflexion: 35 degrees (painful) * Ankle inversion: 5 degrees (painful) * Ankle eversion: 15 degrees (painful) Functional Tests * Single leg hop test: Unable to perform due to pain. * Star excursion balance test: Reduced reach in the injured leg. Special Tests * Anterior drawer test: Positive (painful) * Talar tilt test: Positive (painful) Palpation * Tenderness over the anterior talofibular ligament (ATFL). * Tenderness over the lateral malleolus. IMPRESSION Left ankle sprain, likely ATFL injury. TREATMENT * Explained the nature of the injury and the healing process. * Discussed the importance of rest, ice, compression, and elevation (RICE). * Explained the role of physiotherapy in rehabilitation. * Manual therapy: Grade 1 and 2 joint mobilisations to the ankle. * Exercises: * Ankle alphabet (1 set of 10 reps) * Calf stretches (3 sets, 30-second hold) * Toe raises (3 sets of 10 reps) * Reassessment: Patient reported a reduction in pain during the session. PLAN Sport Modifications * Avoid running and jumping for the next week. * Modify football training to non-weight-bearing activities. Gym Modifications * Focus on upper body and core exercises. * Avoid any exercises that aggravate the ankle. Timeline to next review or any planned referrals Review in one week. Communication planned before next session – letters, emails, phone calls * Provide patient with a home exercise program via email. SHARED NOTES Patient has sustained an ankle sprain during a football match. The physiotherapist has assessed the injury and provided initial treatment. The patient needs to rest, ice, compress, and elevate the ankle. They will be reviewed in one week. Key findings and differential diagnosis Left ankle sprain, likely ATFL injury. Client needs to do to reduce symptoms or referrals that have been advised * Rest, ice, compression, and elevation (RICE). * Perform the home exercise program. Restrictions for sport and gym classes * Avoid running and jumping for one week. * Modify football training to non-weight-bearing activities. * Focus on upper body and core exercises in the gym.