Physiotherapy New Patient Evaluation Note

Current Condition/Complaint

• 28 yo male presenting with acute R lateral ankle pain and swelling (NHI: ZXC4829, ACC45: KQ892341).
• DOI: 18/05/2026 at 14:30.
• Inversion injury to R ankle after landing awkwardly on an opponent's foot during recreational basketball. Heard a "pop" at the time of injury; unable to continue playing.
• Self-managed initially with ice and compression bandage.
• Seen by GP (Dr. S. Patel) on 19/05/2026; referred for physiotherapy.
• Constant dull ache at lateral aspect of R ankle (VAS 3/10 at rest), increasing to sharp pain (VAS 7/10) on weight-bearing.
• Aggravated by weight-bearing, walking > 5 mins, and stairs. Relieved by rest, elevation, ice, and ibuprofen.
• Swelling has decreased slightly over the past 48 hours; bruising now tracking distally along lateral border of foot.
• Hx of mild R ankle sprain 4 years ago; self-managed with rest, resolved in 2 weeks without residual instability.
• Currently off work; difficulty ambulating around flat, unable to drive (manual vehicle).
• Nil paraesthesia, numbness, or proximal lower limb pain. Red flags NAD.

Investigations

• R ankle X-ray (19/05/2026, Auckland Radiology Group): No acute fracture seen. Soft tissue swelling over lateral malleolus. Mortise intact.

Medical History

• Mild asthma, well-controlled.
• Appendicectomy (2015).
• NKDA.
• Ibuprofen (Nurofen®) 400 mg PO TID PRN, paracetamol (Panadol®) 1,000 mg PO QID PRN, salbutamol (Ventolin®) 100 mcg INH PRN.
• Nil relevant FH.

Social History

• Lives in 1st-floor flat (12 steps to access) with partner. Non-smoker, social EtOH (2-3 std drinks/week).
• Full-time electrician; requires prolonged standing, squatting, ladder climbing, and walking on uneven surfaces.
• Plays social basketball 2x/week, gym 3x/week (weights).
• Keen to return to work and sport; frustrated by current immobility.

Patient Goals

• Short-term: Walk pain-free without crutches within 2 weeks; return to light duties at work within 2 weeks.
• Long-term: Return to full pre-injury basketball training within 8 weeks.

Objective

• Observation: Antalgic gait, FWB with significant decreased stance phase on R. Moderate effusion over R anterolateral ankle and ecchymosis inferior to lateral malleolus.
• Palpation: TTP over ATFL and CFL. Nil bony tenderness over lateral/medial malleoli, navicular, base of 5th MT, or proximal fibula (Ottawa Ankle Rules negative).
• Range of Motion & Special Tests:
  • R Ankle AROM: DF -5° (pain), PF 25° (pain at EOR), Inv 10° (pain), Ev 15° (stiff). (L Ankle AROM: DF 15°, PF 50°, Inv 35°, Ev 20°).
  • Knee to wall (KTW): R = unable to achieve 0 cm; L = 11 cm.
  • Resisted isometrics: Ev 4-/5 (pain), Inv 4/5 (pain), DF 4+/5, PF 4+/5 (seated).
  • Anterior Drawer Test: Positive (Grade II laxity + pain).
  • Talar Tilt Test: Mild pain, firm end-feel.
  • Squeeze Test & External Rotation Stress Test: Negative.

Diagnosis/Impression

• R Grade II lateral ankle sprain (ATFL and mild CFL involvement).
• Differential: Osteochondral defect of talar dome, peroneal tendon strain.

Treatment

• Education provided regarding injury pathology, healing timeframes, load management, and POLICE protocol.
• Soft tissue massage (effleurage) to R calf and peroneals to reduce tone and assist oedema drainage; rigid strapping tape applied (stirrups and figure-6s) for lateral stability.
• Practised gait re-education with normal heel-to-toe pattern within pain limits.
• HEP provided:
  • Active ankle dorsiflexion/plantarflexion pumps: 20 reps, 3 sets, 4x/day.
  • Towel curls (intrinsic foot activation): 15 reps, 2 sets, 2x/day.
  • Sub-maximal isometric eversion/inversion against wall: 5 sec holds, 10 reps, 3x/day.

Assessment

• Presentation consistent with acute Grade II R ATFL/CFL sprain without bony injury. Good prognosis for full recovery given high baseline fitness and absence of syndesmotic involvement.
• Problem list:
  1. Acute pain and lateral ankle oedema.
  2. Decreased R ankle AROM (specifically DF and Inv).
  3. Impaired gait mechanics and functional weight-bearing tolerance.
  4. Decreased lateral ankle stability and strength.
• Initial evaluation; baseline established.
• High physical job demands (electrician) require solid functional stability prior to full return to work.

Plan

• Physiotherapy 2x/week for 4 weeks, tapering to 1x/week for 4 weeks. Interventions to progress from ROM and swelling management to proprioception, progressive strengthening (peroneals/gastroc-soleus), and plyometrics/sport-specific drills.
• Expect full AROM and normal gait by week 2; return to full duties by week 4; return to sport by week 8.
• Provide ACC medical certificate recommendation to GP for 1 week off work, followed by 2 weeks of selected light duties (no ladders or uneven ground).