PHYSICAL THERAPY INITIAL EVALUATION

June 5, 2017

Subjective> F.P. is a 52 y/o (-) HTN, (-) DM, (-) Asthma __ handed male was referred
for PT evaluation and management 2 to c/o constant localized uncomfortable deep
pain on (R) ankle, graded 2/10 on a subjective pain scale (0= no pain, 10= worst
possible pain), aggravated by prolonged position ~ __ mins., 1 st step in the morning,
fatigue to up to PS 4/10 and is relieved by walking and doing ankle movements
down to PS 2/10. HPI: Present condition started last May 12, 20117, when pt.
suddenly stumbled upon a sidewalk while crossing the street. Pt. said that hi foot
faced inward and his weight was all shifted to that area as he felt extreme pain PS
10/10 on (R) ankle. He continued his day as he got to work but went home early and
just slept the pain away. The next day, pt. felt extreme pain PS 10/10 as he stepped
his (R) leg first thing in the morning, this prompted him to go to the doctor by
afternoon on the same day. Pt. went to Commonwealth Hospital and was checked by
Dr. Heradura, he was asked to undergo X-ray (See ancillary procedures) and was
diagnosed c (R) ankle sprain on the same day and was then referred to PT
department of same hospital. Pt. had his first PT session by May 17, 2017 and only
continued up to his 4th session which included: HMP c TENS, PREs on (R) ankle and
LE bike ergometer. Pt.s friend recommended to have pt. checked at PHC which pt.
did and had a consultation c Dr. Agbayani last June 3, 2017. Pt. was then referred to
PHC-PMRD to undergo physical therapy. At present, pt. is ambulatory and c/o
tolerable but uncomfortable pain on (R) ankle and will be receiving PT 2x/week.
PMHx: Pt. had previous hospitalizations d/t vehicular accident 30 years ago, had
metal implantation on his (R) leg (tibia), underwent lymph node surgery a~ 20
years and had upper respiratory infection (B) ~ 20 years ago. Pt. denies having any
cardiac disease. Lifestyle and Work Situation: Pt. is a non-smoker and
alcoholic beverage drinker ~ 2 bottles a month. Pt. works in a government agency,
which requires him to do paper and computer works ~ 8 hours a day and 5x a week.
Home and Environmental Situation: Pt. lives in a bungalow type of house c his
wife, 2 kids, and mother who assists him in doing some of his ADLs. Pt. usually
drives to work for ~ 80 mins a day. Goal:
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Objective: VS: BP a: 110/70 during : ________ p: __________

HR a:_______ during : ________ p: __________
RR a:_______ during : ________ p: __________
O2Sat a:_______ during : ________ p: __________
Temp: Afebrile to touch
OI:
Independent amb s AD
 Mesomorph
Alert, coherent, cooperative
(+) Postural Deviations (See postural analysis)
(+) Gait Deviation (See Gait Analysis)
(-) Pain in distress
(-) Swelling on (R) ankle
(-) Atrophy on (R) gastrocsoleus mm.
Palpation
Normothermic on (B) UE and LE
Normotonic on (B) UE and LE
(+) mm. guarding towards (R) ankle inversion, dorsiflexion and plantarflexion
(+) Grade 1 tenderness behind, medial anqd on (R) lateral malleolus
(+) Mm. tightness on (R) peroneals and gastrocsoleus mm.
(-) Crepitus on (R) ankle
(-) Tautbands on (R) leg and ankle
(-) Nodules on (R) leg and ankle
(-) Trigger points on (R) leg and ankle
(-) Edema on (R) LE
Sensory Assessment: To follow
ROM> All major joints of (B) UE and LE are WNL, passively assessed, painfree and c
N endfeels except:
Motion AROM PROM Endfeel
(R) ankle 60-44 60-30 Mushy Mm.
dorsiflexion tightness
(R)ankle 60-74 60-80 Pathologic Firm
plantarflexion

MMT> All major mm. groups of (B) UE and LE were grossly graded 5/5 except:
(R) ankle dorsiflexors = 4/5; (R) ankle plantarflexors = 4/5

Anthropometric measurement> Landmark: Medial Tibial Plataeu

(R) in cm (L) in cm Difference in cm
4 in. above 42.5 40 0
2 inches above 37 37.5 1
Medial Tibial 38 37.5 2
Plateau
LLD:
(R) LE in cm (L) LE in cm
Trial 1 86 88
Trial 2 86 89
Trial 3 88 89
Average 86.7 88.7

Figure of eight: (ankle)

(R) ankle in cm (L) ankle in cm
Trial 1 62 62
Trial 2 62 63
Trial 3 62 64
Special Test:
(+) Squeeze test on (R) ankle
(-) talat tilt teston (B) ankle
(-) Posterior drawer on (R) ankle but has pain
(+) ER test on (R) c pain in eversion > inversion
(-) Sigmunds test on (B) ankle
(-) Peroneus tendon subluxation on (B) LE
Lunge Test: 4 inches on (B) feet
Postural Analysis> All postural landmarks are aligned and level, viewed APL in
standing except:
Anterior/Posterior:
(R) shoulder higher than the left
(R) iliac crest lower than (L)
(L) PSIS lower than (R)
(R) Popliteal crease lower than (L)
Too many toes sign on (L) LE
Slightly pronated (R) foot
Lateral:
(+) Forward head posture
Slight (B) shoulder protracted
Decreased lumbar lordosis
Gait Analysis> Independent amb s AD on oval c the ff. gait deviations noted:
STANCE PHASE (L) LE (R) LE
Initial Contact N Decreased DF
Loading Response N Pronate Foot
Midstance Extended knee, increased Decreased WB, Lurching
WB to the (L)
Terminal Stance N N
Preswing N N
SWING PHASE (L) LE (R) LE
Initial Swing N N
Midswing N N
Terminal Swing N N
Decreased cadence (82 steps/min)
Wide BOS
Functional Analysis> Independent in all aspects of ADLs as to self-care, transfers,
bed mobility and locomotion except:
Modified assist on walking on uneven terrain
Minimal difficulty in single leg stance of (R) LE as tolerated ~ 10 secs then
tends to lean on something for support
Assessment> PTDx: MD dx of (R) ankle sprain c PT impression of Mild high ankle
sprain on (R) as further defined by pattern of pain, LOM on (R) ankle and (+) ER test
on (R) leg
Rehabilitation Potential: Good, because pt.s condition is reversible and pt. is still
young c no other comorbidities.
Intervention Scenario: Restore through strengthening of weak mm. groups,
stretching tight structures and mobilization of joints to improve movement.
Problem List:
1. Pain on (R) ankle
2. Weak (R) ankle dorsiflexors and plantarflexors
3. LOM on (R) ankle platarflexion and dorsiflexion
4. Minimal difficulty on single leg stance on (R)
5. Modified independence on walking on uneven surfaces
6. Postural deviations
7. Gait Deviations
Long Tern Goal> Rehabilitative: Pt. will be able to do all ADLs independently s pain
and difficulty p 1 month of PT sessions.
Preventive: Pt. will understand condition and will be cooperative in treatment
sessions and adhere to HEP, observe proper body mechanics and posture, to
tolerate pain and fatigue p 2 PT sessions to achieve faster recovery and prevent
secondary complications.
Short Term Goals:
1. Pt. will dec pain on (R) ankle from 2/10 to 0/10 p 6 PT sessions.
2. Pt. will exhibit improved posture as manifested by increased lumbar lordosis,
decreased forward head posture and ER of (L) LE p 8 PT sessions.
3. Pt. will increase mm. strength of (B) ankle dorsiflexors and plantarflexors by 1
grade p 1 month of PT sessions.
4. Pt. will increase ROM by 5-10 increments in (B) AROMs and PROMs p 1 month
PT sessions.
5. Pt. will experience no difficulty in walking on uneven terrains and single leg
stance as tolerated >30 secs. p 1 month of PT session
6. Pt. will have improved gait patter as manifested by no lurching towards the
(L) side during midstance and increased DF of (R) foot during initial contact p
1 month of PT sessions.
Plan> PT. will be seen and treated 2x/week for 1 month as an OP c the ff. prescribed
PT Mx:
1. HMP c Tens on (R) ankle x 20
2. FES on (R) evertors x 10 c use of green theraband x 6SH x 1 reps x 1 set
3. AROMEs of ankle x 10 reps x 1 set x AP
4. Grade 2 joint mobilization on (R) talocrural joint x posterior glide of talus x
6SH x 30 osc x 3 reps x 1 set
5. Proprioception exercise using BAPS board forward, backward, clockwise and
counterclockwise directions x 10 reps x 1 set
HEP:
1. AROMEs of ankle x 10 reps x 1 set x AP twice a day
2. Towel cramping exercise towards eversion dorsiflexion and plantarflexion x 3
sets c 1 small bottle of water on other end of towel
3. Heel and toe raises x 10 reps x 1 set
4. Draw of alphabet using (R) ankle for proprioception
Pt. Education:
1. Proper body posture and mechanics