Ankle Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 25y/o female with gradually worsening ankle pain over several years. 3-7/10. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: none, no proximal tenderness
Hindfoot Alignment (R/L): neutral / neutral
Effusion (R/L): none / none
Dorsiflexion (R/L): 30 / 30
Plantar flexion (R/L): 50 / 50
Anterior Drawer in plantar flexion (R/L): 0+ / 0+
Anterior Drawer in dorsi flexion (R/L): 0+ / 0+
Lateral Talar tilt (R/L): 0+ / 0+
Medial Talar tilt (R/L): 0+ / 0+
subjective normal distal sensation
5/5 EHL, TA, PF
2+ dorsalis pedis
Xray: The osseous structures are intact without fracture, dislocation or evidence of arthritis.
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
NSAIDS
Information sheet given
Follow-up 6-8 weeks