INITIAL EVALUATION

Patient’s Name: M. A. S.
Age: 27 years old
Sex: Male
Height: 177 cm
Weight: 95 kg
Address: Antipolo City
Civil Status: Married
Citizenship: Filipino
Occupation: Professional Basketball Player
Religion: Catholic
Referring Unit: Fatima University Medical Center - Antipolo / Orthopedic Dept.
Referring Doctor: Dr. D.J.P. / Orthopedic doctor
Rehab Doctor: Dr. K.C.B.
Date of Consultation: April 11, 2024
Date of Referral: April 11, 2024
Date of IE: April 13, 2024
Diagnosis: (R) Grade II Ankle Sprain

History of Present Illness:

Present condition started ~ 1 week prior to PTIE, when pt. was competing in a basketball game. Pt. attempted a jump
shot and landed awkwardly on his (R) foot, twisting his ankle inwardly. Pt. flopped to the ground and felt a sharp pain
(PS: 9/10) on his (R) ankle. Pt’s teammates and coaches rushed to him, and the game was discontinued for a
moment. Pt. attempted to stand but was unable to bear weight on the injured foot d/t extreme pain. Pt. was assisted c
w/c to get off the court and was evaluated by the medical staff. ST was performed (See Special Test) and pt. was
diagnosed c ankle sprain. Pt. received RICE (rest, ice, compression, elevation) as initial tx. Pt. was ordered to rest
and withdraw from the upcoming games. At home, pt. continued to apply ice q 2 waking hours during the first 48
hours. Pt. also took ibuprofen to manage the pain and swelling.

~ 4 days prior to PTIE, pt. went to Fatima University Medical Center - Antipolo, and was assessed by Dr. D.J.P.
Physical examination revealed grade 3 tenderness and ecchymosis over the (R) anterolateral ankle, swelling around
(R) ankle, and weakness of muscles around the (R) ankle. Dr. D.J.P. ordered an MRI scan of the (R) ankle (See
ancillary procedures) to see the extent and specificity of the injury. After 2 days, pt. went back to the hospital to see
the results which revealed partial ATFL and CFL tear, which confirmed pt’s diagnosis of (R) grade II ankle sprain. Pt.
was prescribed c air splint orthosis on (R) foot for immobilization and (B) axillary crutches. Pt. was then referred for
physical therapy treatment.

At present, pt experiences no to minimal pain at rest (PS: 2/10) and is aggravated during movement and WBAT (PS:
7/10) on the (R) foot. Pt. has restricted ambulation and requires axillary crutches c WBAT. Pt’s (R) foot has presence
of swelling and ecchymosis. Pt. has difficulty walking long distances and is unable to go back to training and
competing in basketball.
Ancillary/Laboratory Procedure:
Laboratory Procedure Date Findings Significance

Lateral X-ray of April 11, 2024 (+) soft tissue To r/o fractures
NWB (R) leg and swelling on lateral
ankle side of the foot
(+) slight anterior
displacement of talus
(-) fracture
(-) osteophytes

Present Medications:
Drug Name Dosage Frequency Indication

Ibuprofen 700 mg tid Pain reliever

PMHx:
(+) Mild (R) ankle sprains in September 2023 and January 2024, treated with RICE
(-) Hospitalization
(-) HTN
(-) DM
(-) Heart Condition
(-) Pulmo Condition

FMHx:
Maternal Paternal

HTN (+) (-)

DM (-) (-)

CVA (-) (+)

Heart Condition (-) (-)

PSEHx:
➢ Pt. has a type A personality, pt prefers to go out and socialize with friends; competitive and ambitious. Pt.
goes to the gym 4x a week
➢ Pt prefers to eat green vegetables, rice and meat.
➢ Pt is a non-cigarette smoker and doesn’t drink alcoholic beverages.

Home Situation/set up:

➢ Pt. lives in a two-storey house c his 2 children and his wife. Pt’s wife takes care of the chores and food. After
work, pt. usually play c his children, help his wife to do chores as well.
 ➢ Pt’s bedroom is located on the 2nd floor and is ~15 ft away from the main door
➢ Pt’s bed is ~5ft away from the bedroom door
➢ Pt’s bed is ~3ft away from the bathroom
➢ Pt’s bedroom is ~5ft away from the stairs
➢ Stairs is ~4ft away from the kitchen
➢ Stairs is ~4ft away from the living room
➢ Stairs is ~10ft away from the main door
➢ Main door is ~10ft away from the main gate

Work Situation/set up:

➢ Pt works as a professional basketball player, training 3 days/wk for 3 hrs.
➢ Pt drives a car to the team’s gym for 5km/30 mins. to attend training and games.
➢ Pt’s sport requires a lot of running and jumping.

SUBJECTIVE:

Chief Complaints (c/c): “Di ako makalakad nang maayos at makapag-basketball kasi ang sakit ng right foot ko
when I put my weight on it.”
PT Translation: Pt. c/o intermittent, localized, dull-aching pain (PS 7/10) on lateral aspect of (R) ankle, elicited by
WB and application of pressure, leading to moderate difficulty in ADLs concerning amb and inability to play
basketball.

Patient’s Goal: “Gusto ko lang maka-recover tong foot ko para makalaro na ulit.”
PT Translation: Pt. wants to recover from his injury and return to playing competitive basketball.

OBJECTIVE:

Vital Signs
A P

BP 120/80 120/70

RR 15 bpm 18 bpm

PR 82 bpm 86 bpm

TEMP 36.2° 36.4°

Findings: All vital signs are WNL.
Significance: Serves as baseline measurement for precautionary measures and is to be monitored during further
assessment and facilitation of interventions.

Ocular Inspection
➢ amb c (B) axillary crutches
➢ Mesomorph
 ➢ A/C/C x3
➢ (+) Postural deviation (see postural analysis)
➢ (+) Ankle tape on R foot
➢ (+) Swelling on lateral side of R foot
➢ (+) Bruising on lateral side of R foot
➢ (-) Gait deviation (unable to test)
➢ (-) Wound
➢ (-) Scar
➢ (-) Deformity

Palpation
➢ Hyperthermic on lateral side of R foot
➢ (+) grade 3 tenderness on lateral side of R foot
➢ (+) muscle guarding on R foot
➢ (+) Pitting edema
➢ (-) Tightness
➢ (-) Contracture

I. ROM
All joints of (B) UE/LE are WNL, actively and passively done in pain free with normal end feel, except for the
following:

Motion (N) values AROM PROM Difference End Feel

AROM PROM

(R) Ankle 0-20 0-10 0-10 10 10 Empty

Dorsiflexion

(R) Ankle 0-50 0-40 0-40 10 10 Empty

Plantarflexion

(R) Ankle 0-15 0-10 0-10 5 5 Empty

Eversion

(R) Ankle 0-35 0-20 0-20 15 15 Empty

Inversion
Findings: The pt. Have decreased AROM and PROM due to pain.
Significance: The pt. will have difficulty in ambulation and weight bearing activities.

II. MMT
All major muscle groups on (B) UE & LE are grossly graded 5/5 except for the following:
Muscle Group Grade
 (R) Ankle Dorsiflexors 2-/5

(R) Ankle Plantarflexors 2-/5

(R) Ankle Evertors 2-/5

(R) Ankle Invertors 2-/5

Findings: The Pt. present weakness of ankle dorsiflexors, plantar flexors, evertors, and inverters d/t pain.
Significance: The Pt. will have difficulty in amb. and may affect ADLs such as playing basketball, ascending and
descending stairs, and doing exercises.

III. Special Test

Tests Findings Significance

Anterior Drawer Test (+) pain on lateral side of R foot R/I ATFL injury

Talar Tilt Test (+) pain on lateral side of R foot R/I ATFL and CFL injury

L foot: Swelling on R foot

Trial 1 - 25 cm
Trial 2 - 26 cm
Trial 3 - 26 cm
R foot:
Trial 1 - 30 cm
Trial 2 - 30 cm
Trial 3 - 30 cm

IV. Anthropometric Measurements

Figure eight measurement
Side L R Difference

Trial 1 25cm 30cm 5cm

Trial 2 26cm 30cm 4cm

Trial 3 26cm 30cm 4cm

Findings:
Significance:

V. Postural Analysis
The pt. was assessed in standing position in anterior, lateral, and posterior views c assistive device (Axillary
crutches). All landmarks of the UE & LE were found to be WNL except for the ff:
 Anterior view Lateral view Posterior view

Shoulder (R)Shoulder is slightly (B)Shoulder is slightly (R)Shoulder is slightly

higher forward higher

Hip ®Hip is slightly lower ®Hip is slightly flexed ®Hip is slightly lower

®Knee ®Knee is higher ®Knee is slightly flexed ®Knee is higher

®Ankle In-toeing Plantarflexed In-toeing

Findings: Pt’s. affected extremities shows uneven secondary to pain.
Significance: Pt. will be having a hard time walking without crutches specially weight bearing in the affected side.

VI. Functional Testing

STARTING POSITION ACTION RESULT FINDINGS:

Standing on one leg ® Lift medial aspect of foot 0 out of 15: nonfunctional Pt was unable to do the
of the ground task due to pain on lateral
side of R foot
Significance: Pt. will present difficulty in ADL such as walking, running, and ascending/descending stairs.

GAIT ANA —- antalgic gait

decreased lahat sa right or negative

MOVEMENT ANA
locate pain saang movement

Outcome Measures
Foot and Ankle Outcome Score (FAOS)
Findings: The pt. score for FAOS Symptoms is 32/100, for FAOS Pain is 19/100, for FAOS ADL is 26/100,
For FAOS Sports/Recreation is 10/100, and 13/100 for FAOS QoL.
Significance: For baseline assessment that describes the condition of the pt. within the past week. Lower
score denoting severe problems.

Ankle Joint Functional Assessment Tool (AJFAT)

Findings: The pt. score is 11 out of 48
Significance: The findings indicates pain, stiffness, instability, and weakness of injured ankle compared
with the non-injured ankle in performing ADLs such as walking, running, and descending and
ascending the stairs.

ASSESSMENT

PT Diagnosis:
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with
Connective Tissue Dysfunction

PT Impression:
Pt. Was medically dx c (R) grade 2 ankle sprain. Based on examination, pt. has decreased AROM on (R) ankle in AP
d/t pain. Decreased muscle strength on (R) Ankle plantarflexors, dorsiflexors, evertors, and inverters are noted. Pt.
complains of difficulty to bear weight d/t pain on (R) ankle, swelling is also evident. Based on the outcome measures
used, pt. is experiencing severe pain on (R) ankle that leads to inability to participate in basketball training and
inability to perform ADLs that require weight bearing such as walking, running, and descending and ascending stairs.
Pt. will undergo PT treatment everyday for 1 month.

Prognosis/Rehabilitation Potential:
Pt. has good prognosis as to functional recovery because of the following reasons:

Positive
1. Pt. is financially stable
2. No muscle contracture has developed
3. No associated injury
4. No chronic ankle instability
5. Pt is young and has an active lifestyle
6. Pt has no Hx of ankle sprain
7. Pt. was treated immediately

Problem List:
1. Pain on ® ankle PAIN SCALE
2. Muscle weakness on (R) ankle
3. LOM on (R) Ankle
4. Postural Deviation
5. Gait dev
6. ADLs limitation

Short Term Goals: 2-3weeekssss 6-7 sessions per week

➢ Pt. will have ↓ pain on (R) ankle 7/10 ↔ 2/10 p 6 PT sessions
➢ Pt. will have ↑ ROM on (R) Ankle in AP by 5°-10° p 6 PT sessions
➢ Pt. will have ↓ Postural Deviation p 6 PT sessions
➢ Pt. will have improvements on posture p 6 PT sessions
➢ Pt. will have improvements on Gait p 6 PT sessions

Long Term Goals:

Rehabilitative:
➢ Within 4 weeks of PT sessions, pt will have grade 4 muscle strength on all affected ® ankle muscles
➢ Within 4 weeks of PT sessions, pt. Will have complete ROM in (R) Ankle
Preventive
➢ Within 4 weeks of PT sessions, pt. will be educated about the prevention of chronic ankle instability and use
of ankle supports during basketball games and training.
Participative
➢ Within 4 weeks of PT sessions, pt. will be able to participate in basketball trainings
➢ Within 5 weeks of PT sessions, pt. will be able to participate in competitive basketball games without pain
and difficulty
➢ Within 4 weeks of PT sessions, pt. Will be able to do ADLs without difficulty

PLAN
Prescribed PTMx:
➢ Ice Pack on ® ankle for 20 mins or until numbness
➢ Underwater Pulsed US
➢ Stationary Cycling for 5 mins low intensity
➢ Seated Static Isometric Contraction on Ankle towards Inversion and Eversion on ® ankle for 15sh x 10 reps
x 2 sets
➢ Seated Toe Taps on ® Leg 10 reps x 2 sets
➢ Seated Soleus Raise on ® Leg 10 reps x 2 sets
➢ Grade II Joint Mobilization on ® ankle for inital tx for 1 to 2 mins
➢ ALPHABET TRACING
➢ TOE CIRCLES
➢ STAR EXCURSION
➢ ATHLETIC TAPING OR KINESIOTAPE FOR SWELLING
➢ PROGRESSION—GRADE 1 FOR PAIN RELIEF
PROGRESSION
➢ Cross Friction Massage on ® ankle for 7mins x every other day
➢ STRENGTHENING -RESISTANCE
➢ PROPRIOCEPTION EXERCISE
- wobble board
- standing on one leg

Home Instructions:
➢ Avoid actions involving moving the foot inward example of this is indian sit position
➢ Engage in self stretching and strengthening exercises that focuses on your foot and ankle
➢ Perform activities that will boost your mood and self confidence like mindfulness meditation for at least 5
mins per day

Home Exercise Programs:

➢ ankle pump
➢ mobility exercisessss
➢ alphabet writing
➢ Daily Wrapping/Taping of the affected ankle for protection and support
➢ self strengthening exercises
➢ Self Stretches for 15sh x 10 reps x 2 sets
- Achilles Tendon
- Ankle Dorsiflexors
- Ankle Plantarflexors
- Ankle Evertors
- Ankle Invertors

______________________
Alexie Andrea Laciste

______________________
Antione Corpuz

______________________
Amos Joachim Castorillo

_____________________
Madeline Christiana Villamon

____________________
Mohana Nuada

_____________________
John Michael Tiu

_____________________
Louis Cuenco