SOAPIER

Subjective

• 38 yo M (Callum Vance, DOB: 12/08/1985, IHI: 8003608166690503) presents with 3/52 Hx of R lateral ankle pain and perceived instability following an inversion injury while playing amateur football on 02/05/2024. Reports residual swelling at end of day and sharp pain (NPRS 5/10) with rapid directional changes or descending stairs. Unable to return to training.
• PMHx: R ACL reconstruction (2016) with full return to sport. Nil other significant medical history.
• Ibuprofen (Nurofen®) 400 mg PO TID PRN, fish oil 1,000 mg PO daily.
• Works as a project manager (sedentary). Lives in a two-storey house with partner. Goals: return to amateur football training within 4/52.
• NKDA. Tape allergy (mild contact dermatitis to rigid zinc oxide tape).

Objective

• BP 122/78 mmHg, HR 64 bpm, SpO2 99 % on RA.
• Observation: Mild effusion over R anterolateral ankle joint line. Gait: NAD on level surfaces. Palpation: Tender over R ATFL and CFL; nil tenderness over syndesmosis, base of 5th metatarsal, or distal fibula. ROM: R ankle DF knee-to-wall 6 cm (L 11 cm), PF full and pain-free, inversion limited by pain at end-range. Strength: R ankle evertors 4/5 MMT with dull ache, DF/PF 5/5. Special tests: Anterior drawer test +ve (grade II laxity), Talar tilt +ve for pain, Squeeze test -ve. Single leg balance: R 8 s (eyes open) vs L > 30 s.
• XR R ankle (03/05/2024, Perth Radiological Clinic): No acute fracture or dislocation. Mild soft tissue swelling laterally. Ankle mortise intact.

Assessment

• R Grade II lateral ankle sprain (ATFL and CFL involvement), subacute stage.
• Resolving lateral ligamentous sprain demonstrating mechanical laxity, residual DF restriction, and significant proprioceptive and peroneal strength deficits limiting return to high-level cutting/pivoting sports.

Plan

• Commence structured HEP: 1) Knee-to-wall ankle DF mobilisations 3 x 15 reps BD; 2) Resisted TheraBand (green) ankle eversion 3 x 12 reps daily; 3) Single-leg balance on firm surface progressing to Airex pad 3 x 60 s daily. Cease ibuprofen; utilise ice 15 mins post-exercise PRN for swelling.
• Educated on ligament healing timeframes, importance of proprioceptive retraining to prevent chronic ankle instability, and load management. Advised to use hypoallergenic underwrap prior to any strapping.
• Referred to podiatry for assessment of worn football boots and potential semi-rigid ankle brace fitting for return to play.

Intervention

• Grade III AP talocrural joint mobilisations (3 x 60 s) to improve DF ROM. Soft tissue massage to R peroneals and gastrocnemius-soleus complex (10 mins). Supervised neuromuscular control drills (single-leg stance with contralateral leg reaches) and side-stepping with resistance band. Applied kinesiology tape (hypoallergenic) in a lateral stirrup and figure-of-6 configuration for proprioceptive feedback.

Evaluation

• Pt tolerated manual therapy and exercises well with nil adverse skin reaction to K-tape. Immediate post-treatment reassessment showed R knee-to-wall DF improved to 8.5 cm (from 6 cm) and reduced pain during single-leg loading (NPRS 2/10).
• Good initial progress toward short-term goal of restoring symmetrical DF ROM and baseline static single-leg balance.

Review

• Review in 1 week (31/05/2024 at 14:30 AWST) to reassess ROM, progress strengthening to eccentric loading, and introduce plyometric/hopping drills if effusion remains stable.