JR SOTAP "trial"

Subjective: Mechanism of Injury: Patient reports a twisting injury to their left ankle while playing football. The injury occurred when they landed awkwardly after jumping for a header. Injury Timeline: The injury occurred 3 days ago. Initially, there was immediate pain and swelling. The patient rested for the first 24 hours, but the pain has persisted. They attempted to walk on it the following day, which aggravated the pain. Symptoms: Patient reports sharp pain on the lateral side of the left ankle, with associated swelling and bruising. They also report pain with weight-bearing and difficulty with walking and running. There is also a feeling of instability. Severity, Irritability, Nature (SIN): Severity: 7/10 at worst, Irritability: High, Nature: Mechanical Visual Analogue Scale (VAS): 7/10 Activities-specific Balance Confidence Scale (ABC): Not assessed at this visit. Aggravating Factors: Walking, running, and any weight-bearing activities. The pain increases with prolonged standing. Easing Factors: Rest, ice, and elevation provide some relief. Past Musculoskeletal History: No previous ankle injuries. General Health History: No relevant medical history. Taking no medications. Sports, Hobbies, ADLs, Family, Vocation: Patient is a keen footballer and plays regularly. They work as a software engineer and have a desk job. Thoughts, Concerns, Questions, Fears: Patient is concerned about the severity of the injury and the impact on their ability to play football. Stated Diagnosis: Patient suspects a sprain. Objective: Observation: Swelling and bruising are noted on the lateral aspect of the left ankle. Patient is guarding the ankle and walks with a limp. Functional Testing: Single leg stance on the left leg is significantly impaired, unable to maintain balance for more than a few seconds. Hopping is painful and limited. Active Range of Motion (AROM): Dorsiflexion limited to 0 degrees due to pain and plantarflexion limited to 20 degrees due to pain. Inversion and eversion are also limited and painful. Passive Range of Motion (PROM): Dorsiflexion limited to 5 degrees due to pain and plantarflexion limited to 25 degrees due to pain. Inversion and eversion are also limited and painful. Strength Testing: Resisted plantarflexion and eversion are painful and weak (4/5). Resisted dorsiflexion and inversion are painful and weak (3/5). Special or Diagnostic Tests: Not performed at this visit. Neurological Testing - Strength: Not assessed at this visit. Neurological Testing - Sensation: Not assessed at this visit. Neurological Testing - Neurodynamic: Not assessed at this visit. Neurological Testing - Reflexes: Not assessed at this visit. Treatment: "Informed verbal consent gained & warnings given (IVCG & WG) applied to any form of treatment." Soft Tissue Release (STR): Applied to the surrounding musculature, including the peroneals and calf muscles. Joint Mobilisations (OMT): Grade 1-2 mobilisations to the talocrural joint. Dry Needling / Acupuncture (DN): Not performed at this visit. Home Exercise Program (HEP): Patient instructed on RICE protocol (Rest, Ice, Compression, Elevation) and gentle ankle range of motion exercises. Gym Program (GP): Not applicable at this stage. Exercise Prescription Details: Gentle ankle range of motion exercises: 10 repetitions, 3 times per day. Education Provided: Patient educated on the nature of the injury, prognosis, and importance of rest and activity modification. Advised on the use of ice and compression. Referrals Made: Advised to follow up with GP if symptoms do not improve. Analysis: Summary of Diagnosis, Prognosis, and Key Findings: Suspected Grade 2 lateral ankle sprain. Prognosis is good with appropriate management. Key findings include pain, swelling, limited range of motion, and functional limitations. Plan: Next Booking: Review in 1 week. Treatments Discussed: Continue RICE protocol, continue with gentle range of motion exercises, and progress to weight-bearing as tolerated. Planned Exercise Progressions: Progress to weight-bearing exercises and proprioceptive exercises as pain subsides. Jobs Promised to be Organised: Provide patient with a handout on ankle sprain management.