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11/30/2015: INITIAL EVALUATION

SUBJECTIVE:
Patient reported today complaining of right ankle pain. She said it happened 2 weeks ago when
she stepped into a hole and inverted her ankle. She states that jumping and landing on her right
foot is painful. Pain level is 0/10 at rest, 0/10 with ADLs and 8/10 during dance, with pain
described as "shooting." Ice does not help. She occasionally hears a popping with dorsiflexion
and eversion of the right foot. She has a history of a greenstick fracture but does not remember
what bone or which foot.
OBJECTIVE:
------------------- Observation --------------------------------No observable deformity, edema or ecchymosis. Resting, standing and sitting postures appear
normal. Gait appears normal.
------------------- Palpation --------------------------------Mild pain with palpation of the ATF ligament of the right ankle.
------------------- Neurological --------------------------------Patient denies having any neurological symptoms.
------------------- Range of Motion ---------------------------Active:
Dorsiflexion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Plantarflexion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Inversion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Eversion:
R - WNL, mild pain, and equal bilaterally
L - WNL, pain free, and equal bilaterally
Toe Flexion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Toe Extension:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Passive:
Dorsiflexion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Plantarflexion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Inversion:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Eversion:
R - WNL, mild pain, and equal bilaterally
L - WNL, painfree, and equal bilaterally
Toe Flexion:

R - WNL, painfree, and equal bilaterally


L - WNL, painfree, and equal bilaterally
Toe Extension:
R - WNL, painfree, and equal bilaterally
L - WNL, painfree, and equal bilaterally
------------------- Manual Muscle Testing ----------------------Gastocnemius: 5/5
Soleus: 5/5
Anterior Tibialis: 5/5
Posterior Tibialis: 5/5
Peroneals: 5/5 with mild pain noted
------------------- Special Tests ----------------------------------(-) Compression (Squeeze) Test
(-) Percussion (Bump) Test
(+) Anterior Drawer Test- positive for mild pain
(-) Kleiger's Test
(-) Talar Tilt - Inversion
(-) Talar Tilt - Eversion
(-) Tinel's Sign
(-) Glides/Stress
(-) Tarsal Glides
ASSESSMENT:
Patient is most likely experiencing a mild ATF sprain of the right ankle. It may also be
accompanied by a mild sprain of the peroneals as well.
Differential diagnosis:
-ATF Sprain
-Peroneal Strain
-AITF Sprain
PLAN:
Patient has been advised to modify dance activities as needed. She has also been instructed to
ice as needed and to follow up in a few days to discuss a strengthening program. Her right ankle
was taped in order to see if she liked it and was comfortable with the taping. We also talked
about lending her an ankle brace. We will be creating a general strengthening program for her
and implementing it after this week's performance.
------------------- Treatment -------------------------------Modalities--1) Ankle Taping
Goals:
1) Reduce pain by 50% within 3-4 days.
2) Restore ADL function to 100% within 1 week.
3) Reduce pain by 75% within 3 weeks.
4) Return to full, painfree, IUCD activities within 4 weeks.
She noted understanding of all items discussed, voiced agreeance with the treatment plan
discussed, and presented no further questions or concerns.
Morgan Grubb, Student Athletic Trainer