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.
SUBJECTIVE EXAMINATION
MSA Sport
[athlete's primary and secondary sport] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
HOPC / MOI
[chronological account of how the athlete developed the injury or soreness, including location, mechanism of injury, initial and subsequent management] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
Symptoms
[description of how the athlete reports their symptoms, including sensation, functional loss, impact on performance, initial presentation, and progression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph or bullet format as required.)
Aggs
[activities that aggravate symptoms, with detail on type of movement, symptom quality and intensity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
Eases
[strategies or activities that reduce symptoms or provide relief] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
24/24hr
[description of symptom behaviour across the day – morning, daytime, night-time] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Imaging / MDT
[summary of any radiology or imaging findings, and health professionals already consulted] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
Patient Reported Contributing Factors
[reported or suspected contributors such as training load, volume, intensity, equipment, or competition schedule] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
Medical Conditions / Dietary
[medical conditions or dietary concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Menstrual Health
[menstrual cycle details including timing, symptoms, or changes] (Only include if explicitly discussed with a female athlete, else omit section entirely. Use bullet points.)
PHx
[previous injuries to this region or elsewhere, including relevant medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
SHx
[lifestyle, living situation, support network, other sports or hobbies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph or bullet format.)
Training Schedule
[weekly breakdown of training activities including sports, HPP, ASP] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points for each day of the week.)
Upcoming Competitions / Goals
[details of future events including level of competition and dates] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
OBJECTIVE
[document findings from physical examination including postural observation, palpation, joint ROM, strength, and functional tests grouped under sub-headings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use sub-headings such as Observation, Range of Motion, Functional Tests, Special Tests, and Palpation. Use bullet points. Describe pain reproduction, movement quality, stiffness, or specific deficits where observed.)
IMPRESSION
[provisional diagnosis discussed with the athlete] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
TREATMENT
[education provided during session, including explanations of pain mechanisms, injury cause, management expectations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
[manual therapy interventions including technique, duration, reps, region treated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
[exercises prescribed during session including sets, reps, duration, and positioning] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List each exercise on a new line.)
[reassessments done during session and outcomes observed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
PLAN
Sport Modifications
[instructions regarding participation, restrictions, or modifications to sport training] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
Gym Modifications
[instructions regarding ASP/HPP or other gym sessions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
[timeline to next review or any planned referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentence.)
[communication planned before next session – letters, emails, phone calls] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
SHARED NOTES
[summarise for parent, athlete, and coach the assessment and injury diagnosis in layman's terms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.)
[summarise key findings and differential diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[summarise exactly what the client needs to do to reduce symptoms or referrals that have been advised] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use bullet points.)
[summarise restrictions for sport and gym classes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Keep brief.)
(Never come up with your own athlete details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
