Presenting Complaints:
A 32-year-old male presented with complaints of severe pain, swelling, and instability in the right ankle after a recent ankle sprain. He reported that the injury occurred while playing basketball when he landed awkwardly on the outer side of his right foot.
History of Presenting Complaints:
The patient described experiencing an audible “pop” at the time of injury, followed by immediate pain and swelling. He had difficulty bearing weight on the affected ankle and reported recurrent episodes of giving way while walking.
Chief Complaints:
Severe pain and swelling in the right ankle.
Instability and a feeling of “giving way” during weight-bearing activities.
Past Medical and Surgical History:
The patient had no significant medical history or previous surgical interventions.
Family History:
There was no family history of similar ankle injuries or ligament problems.
Socioeconomic Status:
The patient had a stable job and a moderate socioeconomic status.
Present and Pre-morbid Functional Status:
Before the injury, the patient had an active lifestyle and regularly participated in sports and physical activities. He had no significant limitations in his daily activities.
General Health Status:
The patient was generally in good health with no chronic medical conditions.
Vitals:
Vital signs were within normal limits.
Aggravating Factors:
Activities such as walking on uneven surfaces, running, and pivoting movements aggravated the pain and instability in the right ankle.
Easing Factors:
Rest, elevation, and icing provided temporary relief from pain and swelling.
Examination:
Physical examination revealed tenderness and swelling over the lateral (outer) aspect of the right ankle. The patient demonstrated limited range of motion due to pain. There was also noticeable laxity in the lateral aspect of the ankle joint during manual stress testing.
Sleep and 24-hour Pattern:
The patient reported disturbed sleep due to pain and discomfort in the affected ankle. Pain was particularly intense when attempting to change positions during sleep.
Duration of Current Symptoms:
The patient’s symptoms had been present for the past two weeks since the time of injury.
Mechanism of Injury/Current Symptoms:
The injury occurred when the patient landed on the outer side of his right foot during a basketball game. This mechanism of injury caused excessive inversion (rolling inward) of the ankle, leading to strain on the lateral ligaments, including the calcaneofibular ligament.
Progression Since the Current Episode:
The patient reported that while the swelling had decreased slightly, the pain and instability remained persistent and had not improved significantly.
Significant Prior History:
The patient had no significant prior history of ankle injuries or ligament problems.
Previous Treatment:
The patient had self-administered rest, ice, compression, and elevation (RICE) and had taken over-the-counter pain medications to manage his symptoms.
Diagnostic Test/Imaging:
An X-ray was performed to rule out any fractures, and an MRI scan was ordered to assess the extent of ligamentous injury.
Differential Diagnosis:
Calcaneofibular ligament sprain
Anterior talofibular ligament sprain
Peroneal tendon injury
Fracture of the lateral malleolus
Postural Observation:
The patient exhibited a slight lateral shift in weight-bearing due to discomfort in the right ankle.
Precaution and Contraindications:
The patient was advised to avoid activities that could further strain the injured ligament, such as running, jumping, and sudden changes in direction.
Functional Movement Analysis (Sign):
The patient exhibited difficulty in maintaining balance during single-leg stance on the affected side.
Quick Screening Tests/Clearing of Additional Joint Structures:
Screening tests were performed to rule out involvement of other joint structures, such as the subtalar joint and peroneal tendons. These tests showed no significant abnormalities.
Range of Motion (ROM):
The patient had limited dorsiflexion and inversion due to pain and swelling.
Special Tests:
Talar Tilt Test: Positive for increased laxity on inversion stress.
Anterior Drawer Test: Negative for anterior translation of the talus.
Lateral Hop Test: Positive for decreased stability during hopping on the affected leg.
Assessment:
The patient was diagnosed with a grade 2 sprain of the calcaneofibular ligament based on clinical examination and imaging findings.
Problem List/Complaints:
Severe pain and swelling in the right ankle.
Instability and a feeling of “giving way” during weight-bearing activities.
Limited range of motion and functional impairment.
Treatment:
Pain Management: Prescribed non-steroidal anti-inflammatory drugs (NSAIDs) to alleviate pain and reduce inflammation.
Immobilization: Provided the patient with a removable ankle brace for support and protection.
Physical Therapy: Recommended a structured rehabilitation program focused on ankle strengthening, proprioception training, and range of motion exercises.
Modalities: Utilized ice and electrotherapy modalities to manage pain and swelling.
Activity Modification: Advised the patient to avoid activities that could exacerbate the injury.
Prognosis:
With appropriate treatment and adherence to the rehabilitation program, the patient’s symptoms were expected to improve over the next 6-8 weeks.
Goals:
Reduce pain and swelling.
Restore ankle stability and range of motion.
Improve proprioception and balance.
Interventions:
RICE protocol.
Ankle brace for immobilization and support.
Physical therapy including manual therapy, exercises, and modalities.
Gradual return to weight-bearing activities and sports under medical guidance.
Patient Education:
Importance of adhering to the treatment plan.
Proper usage of ankle brace.
Home exercises for strengthening and mobility.
Signs of worsening symptoms requiring medical attention.
Patient/Family Education:
Assisting the patient in adhering to the treatment plan.
Recognizing the need for medical attention in case of worsening symptoms.
Providing emotional support during the recovery process.
Discharge Plan:
The patient will continue with the RICE protocol and wear the ankle brace as directed. He will attend regular physical therapy sessions and perform home exercises. Follow-up appointments will be scheduled to monitor progress and adjust the treatment plan as needed. Gradual return to sports activities will be guided by the treating physician and physical therapist.