S: The patient is a 19 y/o swimmer who was at conditioning at Memorial Stadium where the

team was playing football. He was going up for a jump to catch the ball and when he came
down he inverted his left ankle and immediately felt pain. Athlete was not sure if he came
down on someone elses foot. He was seen by one of the football athletic trainers in the
building where he was given ice. When he came back to the pool athletic training room he was
evaluated. The pt. sprained his right ankle this previously in the season.
O: Upon observation there was moderate swelling over the lateral malleolus, but no
discoloration or deformity. Upon palpation there was tenderness posterior to the malleolus
over the Calcaneofibular ligament.
AROM: Reduced dorsiflexion, plantarflexion, and inversion due to pain.
PROM: Limited dorsiflexion due to pain
RROM: Not performed due to pain
(+) inversion talar tilt (-) anterior drawer, squeeze test, bump test, and eversion talar tilt test
A: Pt. has a 2
nd
degree Calcaneofibular sprain to the left ankle
STG: Reduce pain and swelling LTG: Return to fall symptom free participation
P: Start pain management and to reduce swelling. Athlete will pull practices until pain
decreases. No running or L leg involvement in weight room until pain decreases. Will start
progressive rehab plan.
-Alice Jose, ATS
10.3.13
3:00pm