Initial Outpatient MSK Physiotherapy Assessment

HOPC

• Pt presents with R lateral ankle pain and swelling following an inversion injury while playing netball on 12/05/2024. Heard a 'pop', unable to continue playing. Managed initially with PEACE & LOVE protocol, compression bandage, and ibuprofen (Nurofen®) 400 mg PO TID PRN.
• Aggs: Weight-bearing (WB), descending stairs, uneven surfaces. Eases: Elevation, ice, rest.
• 24-hour pattern: Stiff and achey in AM (NRS 3/10) for ~20 mins; throbbing increases by evening (NRS 6/10) with prolonged standing at work. No night pain.

Radiology

• X-ray R ankle (13/05/2024, Perth Radiological Clinic): NAD for #; mild lateral soft tissue swelling noted. Ottawa ankle rules negative on reassessment.

Past Medical History

• Mild asthma, well-controlled with salbutamol (Ventolin®) 100 mcg INH PRN. Previous R ankle sprain 3 years ago, self-managed with no formal rehab.
• NKDA.

Social History

• Lives in a two-storey townhouse (14 internal stairs) with partner. Plays social netball twice weekly. Non-smoker, social EtOH (2–3 std drinks/wk).
• Nil significant family Hx of connective tissue or rheumatological disorders.
• Works FT (38 hrs/wk) as a retail store manager; requires prolonged standing and walking on concrete floors. Currently on light/seated duties for 1 wk.

Goals

• Short-term: FWB with normal gait pattern and pain-free descending stairs within 2 weeks.
• Long-term: Return to competitive netball training and games within 6–8 weeks.

Objective

• Observation & Palpation: Mild effusion over R lateral malleolus, bruising tracking distally to lateral foot. Antalgic gait, reduced stance phase on R. Tenderness on palpation over ATFL and CFL; nil tenderness over syndesmosis, base of 5th MT, or deltoid lig.
• Active Range of Motion (AROM): R ankle DF 5° (L 15°), PF 35° (L 50°), Inv 15° with pain (L 35°), Ev 20° (L 25°). Knee-to-wall (KTW): R 3 cm, L 11 cm.
• Manual Muscle Testing (MMT): R ankle DF 4/5, PF 4/5 (unable to perform single-leg calf raise), Inv 3+/5 (pain-limited), Ev 4-/5.
• Special Tests: Anterior drawer test +ve (Grade II laxity + pain reproduction). Talar tilt test mildly +ve. Squeeze test and external rotation stress test -ve.

Treatment

• Educated on ATFL/CFL healing timeframes, importance of progressive optimal loading, and avoiding prolonged immobilisation.
• AP talocrural joint mobs (Grade II–III, 3 x 60s) and soft tissue massage to peroneals and gastrocnemius-soleus complex. Applied rigid sports tape (stirrups and figure-6s) for lateral stability.
• Practised weight-shifts and bilateral calf raises in clinic with focus on symmetrical loading.
• HEP prescribed:
  • Active ankle alphabet: 1 set, 3x/day.
  • Towel-assisted DF stretches: 3 x 30s holds, 3x/day.
  • Isometric eversion against wall: 3 x 10 reps (5s hold), 2x/day.
  • Bilateral heel raises (60/40 L/R weight distribution): 3 x 12 reps, 1x/day.

Assessment

• R Grade II lateral ankle sprain (predominantly ATFL and CFL involvement).
• Differential diagnosis: Osteochondral defect of talar dome, subtle syndesmotic injury (low suspicion).
• Initial assessment; baseline established. Immediate post-treatment improvement in KTW to 5 cm and improved gait symmetry with taping.
• High standing demands at work and history of incomplete rehab from previous R ankle sprain may limit progress or predispose to chronic ankle instability (CAI).

Plan

• Continue daily HEP, wear supportive footwear, and maintain taping for work shifts over the next 48 hrs.
• Review in 5 days (22/05/2024 at 14:00 AWST).
• Reassess KTW and gait; progress talocrural mobilisations, initiate single-leg balance/proprioceptive training, and introduce theraband isotonic strengthening.
• Nil onward referrals required at this stage; will refer for MRI if mechanical symptoms develop or if progress plateaus at 4 weeks.
• Provide work capacity certificate outlining modified duties (seated breaks 15 mins every hour, no heavy lifting > 5 kg or ladder use) and send initial assessment summary to GP (Dr S. Patel).