34-year-old pleasant female presents today for reevaluation regarding acute sprain/strain of the left ankle she sustained on December 17, 2014 while walking down the stairs of her home. The patient states that she misstepped and rolled her ankle. She presented to our facility on December 18, 2014 for an evaluation in which edema was noted over the lateral malleolus extending into the anterior aspect of the foot with ecchymosis noted. The patient was walking with antalgic gait and; therefore, x-rays were recommended to rule fracture. The patient had x-rays of her left ankle performed on December 18, 2014, which demonstrated mild soft tissue swelling about the ankle joint without acute ankle fracture. The patient returns today after having receiving the physical medicine and rehabilitation visits with an overall good improvement in pain symptomatology and swelling of her left ankle.
The patient describes her left ankle pain as a constant pressure, throbbing, and achy pain which is localized to the lateral and anterior aspect of her ankle. The patient is able to perform weightbearing; however, states that is difficult for her to stand for then 20 minutes or going up and down stairs. The patient currently places her pain levels at 5-6/10 on the VAS scale.
Acute sprain/strain of the left ankle, slowly progressing.
Goals of Treatment:
Short-term goals: (4 wks)
1. Continue to decrease pain from a constant 4-5/10 to a 2/10 by next followup.
2. Continue to increase mobility.
3. Increase instability of the ankle.
4. Maximize function.
Long-term goals: (8 wks)
1. Teach Home exercise program
2. Strengthening/stabilize the ankle.
1. Continue physical medicine and rehabilitation therapy directed at the left ankle.
2. Continue ultrasound of the ankle and anterior aspect of her foot in addition to electrical muscle stimulation and myofascial release.
3. Continue active rehabilitation and therapeutic exercises and activities.
4. The patient is to continue using left ankle brace to aid with stability.
5. Advised the patient to continue avoid weightbearing for more than 15 minutes at a time.
6. Consideration in the future for MRI of the left ankle if pain symptomatology persists.
7. The patient will follow up in four weeks or sooner for change or worsening in condition as needed.