REPORT OF THE CLINICAL STATUS

STASE TRAVEL MEDICINE

I MADE GEDE DWI SUPUTRA

1902631017

PHYSIOTHERAPY PROFESSIONAL EDUCATION PROGRAM

MEDICAL SCHOOL
UDAYANA UNIVERSITY
2019
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

ANKLE SPRAIN
DEFINITION
Ankle sprain is one of acute injury that often happened in athletes. Ankle joint is very
easy to injury because of less able to resist the power, pressure from rotation, medial and
lateral. Unlike the other injuries caused by low-level pressure repeatedly in the long term.
Acute ankle injury due to the suppression of movement to turn suddenly, which is included in
level II sprain injury. Sprain levels, consist of: 1) mild sprain, frequently happened in the
talofibula anterior ligaments, caused fracture in some particular bone, 2) moderate sprain,
happened in talofibula anterior and calcaneo fibula ligament can exacerbates the damage to
ligament structure, 3) severe degree sprain, the ligament covering both posterior talofibula
ligament caused break up complex tendons or fracture. The treatment is determined by the
degree sprain, how long the treatment is done before doing certain exercises. Not appropriate
treatment cause ankle in chronic unstable and back to get injury. To avoid sprain injury better
to do prevention there are, warming-up, stretching, strengthening exercise in ligament, muscle
and tendon that cross the joint, ankle exercises, than do ankle taping when practice as well as
competition.
Everal intrinsic and extrinsic risk factors predispose an athlete to chronic ankle
instability. The most common risk factor is previous history of sprain. A previous sprain may
compromise the strength and integrity of the stabilisers and interrupt sensory nerve fibres.
Sex, height, weight, limb dominance, postural sway and foot anatomy are intrinsic. Extrinsic
risk factors may include taping, bracing, shoe type, competition duration and intensity of
activity. Lateral ankle sprains have traditionally been described as an excessive inversion and
plantar flexion mechanism that results in damage to the lateral ankle ligaments. Current
analysis techniques, including those of real time injury mechanisms, and findings in
laboratory studies, have shown the mechanism to be inversion and internal rotation of the
foot. The injury is defined by damage to the lateral ankle ligaments. Due to the multi-planar
nature of the injury, inversion and internal rotation, damage to the lateral musculature and
connective tissue of the lower leg and foot may also occur.

ASSESSMENT
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

I. Patient Identity
a. Name : JM
b. Age : 21 years old
c. Origin : Kanada
d. Occupational : Student
e. Hoby : Football
II. Subjective Examination
a. Main Complaint

Pain in the right ankle

b.
5 days ago the patient fell while playing football. Leg inversion and plantar
flexion position when falling. The patient hears a click on the ankle shortly
before falling. The patient gets first aid with ethyl chloride spray. The
patient still feels pain until now, the pain is felt while still or moving.
 
History of Present Illness

c. Past Medical History and Comorbidities

The patient had experienced the same incident one year ago. The incident
d. occurred while playing football.
No one experience this

Family History

e.
He has insurance, he is a student, and now he is holiday

Social & Economy History

III. Objective Examination

a. Vital Sign
Absolut Additional *
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

HR : 76x/Min Oxygen Saturation : 99%

RR : 20x/Min Awareness : compos mentis
BP : 120/80 mmHg
Temperature : 36,50Celcius

b. Per-Competention Examination
Physical Examination
Examination Result
Static Inspection - The patient comes with a bandage on the right leg
- Swelling on the lateral side of the right ankle
when the patient opens the bandage
Dinamic - The patient feels pain in the ankle when walking
Inspection - The patient feels pain when moving the right
ankle
Palpation Tenderness, swelling and redness on the side of the right
ankle.
Auskultation Is not done

Basic Motion Function Examination

Examination Result
Active Motion Result Possible
ROM Pain
Area to Do
Plantar
400 + Can be move
Flexion
Dorso
100 + Limited to move
Flexion
Inversion 150 + Limited to move
Eversion 200 + Can be move

Passive Motion Result Possible

ROM Pain
Area to Do
Plantar
400 + Can be move
Flexion
Dorso
200 + Can be move
Flexion
Inversion 300 + Can be move
Eversion 200 + Can be move

Isometric Motion ROM Pain Result Possible

 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

Area to Do
Plantar
200 + Limited
Flexion
Dorso
100 + Limited
Flexion
Inversion 150 + Limited
Eversion 100 + Limited

Spesific Test
Spesific Test Result
Anterior draw test Pain, Ligament laxity
Posterior draw Pain, Ligament laxity
test
Talar tilt test Pain, Ligament laxity
External rotation Pain in recreated in the area over the interosseous
stress test membrane
Lateral & Medial The patient feels pain when the ankle is moved laterally
Stability Ankle

Differential Diagnosis
Differential Spesific Test Result
Diagnosis
Impingement Single leg squat Pain during single leg squat
Tarsal Tunnel
Tinel’s Sign Distal radiation of parathesias
Syndrome
Peroneal
Provocative test Pain, or subluxation
Tendinopathy
Posterior Tibial A single leg Patients can't do a single heel rise
Tendon heel rise with the affected foot
Dysfunction

Measurement
Measurement Measurement Result
Instrument
Pain VAS Move pain : 4/10
Silent pain : 3/10
Tenderness : 4/10
Swelling Midline Right ankle 33 cm different from the left
ankle 3 cm
Muscle Manual - Plantar flexion : 4
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

Strength Muscle Testing - Dorso flexion : 4

(MMT) - Inversion : 4
- Eversion : 4

IV. Examination Support

Checking Type Impression Information
X-Ray - is not done
CT-Scan - is not done
MRI - is not done
Laboratorium - is not done
Dll* - is not done

Algorithm

Pain in the right ankle Ha : functional activity limitation because Ankle

Sprain Grade I
yes
5 days ago the patient fell while playing football. Leg
Anamnesis inversion and plantar flexion position when falling.
The patient hears a click on the ankle shortly before
yes falling. The patient gets first aid with ethyl chloride
spray. The patient still feels pain until now, the pain is
felt while still or moving.
Vital Sign
Static : The patient comes with a bandage
- HR: 76x/mnt
on the right leg and Swelling on the lateral
- BP: 120/80 mmHg
side of the right ankle when the patient
- SPO2: 99%
opens the bandage
- RR: 20x/mnt
yes - T: 36,50C
Dinamic : The patient feels pain in the
- GCS: Kompos
ankle when walking and The patient feels
Mentis
pain when moving the right ankle
Physical
Assessment Inspection
Tenderness, swelling and redness on the
yes Palpation side of the right ankle.

Basic
Functional The range of motion Active and passive
Test movement has been deacrease, and felt pain of
all movement test and the limitations of motion
yes VAS :
Move pain : 4/10
Anterior draw test (+) Silent pain : 3/10
Spesific Test Posterior draw test (+) Tenderness: 4/10
&Measuremen Talar tilt test (+)
t External rotation stress test (+)
Lateral & Medial Stability
Ankle (+)
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

Swelling : Right ankle

33 cm different from the
yes
left ankle 3 cm

Diagnose
MMT
- Plantar flexion : 4
- Dorso flexion : 4
Overstretch of Antero Fibular Ligament Grade I - Inversion : 4
- Eversion : 4
DIAGNOSIS
ICF Coding
I. Impairment (Body Structure & Body Function Impairment)

Body Structure :
- s75021.2.0.1 Ankle koint and joint of foot and toes
II. Activity
- Limitation
s75023.2.0.1 Ligaments and fasciae of ankle and foot
- d4104.1 Standing
s8104.1.0.1 Skin of lower extremity
III. - d4500.2
Participation Walking short distance
of Restriction
Body- Function
d4552.3:Running
-- d4553.3
d9201.3 Sports
b28016.2Jumping
Pain in joints
IV. -
Contextuald9204.3
Factor Hobbies
- b7100.2 Mobility of a single joint
- b7150.2 Stability of a single joint
- b830.1 Other function of the skin
- b840.2 Sensation related to the
- Patient skin
can communicate well with Physiotherapists
- Patient can submit complaints properly
- Patient desire to recover quickly is very high.

a. Personal Factor

b. Environmental Factor

Fasilitator :
- E310 Support and relationship immediate family
- E355 Health Professionals
Barrier :
The patient still can’t move his ankles because he still feels pain

Physiotherapy Diagnostic

Impaired functional activity due to ankle pain and hypermobility e.c right ankle
sprain
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

PROGNOSIS
I. Quo ad vitam
Bonam
II. Quo ad sanam
Bonam
III. Quo ad cosmeticam

Bonam

IV. Quo ad Funtionam

Bonam

PLANNING
I. Short Term
- Reduce pain
II. Long Term
- Reduce swelling
- Increase ROM
- Can return to the activities of daily living well.
- Improve joint stability, ankle movements, mobility (walking, running,
jumping).
- Practice motor coordination skills while performing mobility exercises
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

Clinical Reasoning

Pain in the right ankle

Spesifik Test

Sprain Ankle

Mild Sprain Moderate Sprain Severe Degree Sprain

Pain Swilling Limitation of Motion

TENS RICE Exercise Therapy

Reduced Pain Reduce Swilling Increase ROM

Can return to the activities of daily living well

 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

INTERVENTION
I. Intervention Table
Intervention Method Dose
Modality TENS TENS stimulations were applied
First, the skin of the ankle for 30 min at a frequency of 100 
region was cleaned using Hz, duration of 0.2 ms, and
cotton smeared with 70% intensity of 15 mA.
alcohol to decrease the skin
resistance. Next, two
electrodes were placed on
lateral side of the right ankle
Exercise Isometric exercise For each exercise hold 5 seconds
Therapy Resistance applied by do 10 repetitions; repeat three
immovable object like wall or times a day.
floor in contra lateral foot.
Isometric exercise consists of
plantar flexion, dorso flexion,
inversion, eversion.
Proprioception ankle sprain - Initially perform these
exercises exercises once a day and
Proprioception exercises are then increase to twice a day
important to prevent re- when you are confident.
injuring the ankle. Ensure the - Repeat 5 times for each leg
area you are working in is
safe and free from obstacles
that you could knock into. Do
not start exercises until pain-
free walking. If you
experience any pain whilst
performing the exercise, stop
immediately. Standing on one
leg eyes open with arms out :
- Clear an area without
obstacles.
- Stand one leg on a flat
surface with bare feet
and arms out to the
side.
- Balance for as long as
possible.
- Record how long you
balanced for without
putting the other leg
down.

II. Education
 KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS UDAYANA
FAKULTAS KEDOKTERAN
PROGRAM STUDI FISIOTERAPI
Jalan PB. Sudirman, Denpasar 80232 Bali, Telp. (0361) 222510, Fax. (0361) 246656, E-mail : psfisioterapi@unud.ac.id

Education
- Patient education regarding gradual increase in activity level, guided by
symptoms
- Provide information about possible preventive measures (tape or brace)
- PRICE

- Encourage the patient to continue practicing at home

III. Home Program

Program
- Patient performs active movements with the toes and ankle within pain free
limits to improve local circulation
- Practise foot and ankle functions : Range of Motion, Active Stability
- RICE

EVALUATION
Less of pain with VAS Additions of ROM :
Move Pain : 3/10 Dorso – Plantar Flextion : 15°-0°-40°
Silent Pain: 2/10 Inversion – Eversion : 15°-0°-20°
Tenderness: 3/10 Swelling : 31 cm after treatment

MMT
Plantar flexion : 4
Dorso flexion : 4
Inversion : 4
Eversion : 4