Case 2

A 20-years-old girl had a left ankle injury during semi-final badminton match. She stated she jumped
for the shot and landed on her foot causing her ankle to roll sharply. After examination, we
discovered that she had sprained 2 ligaments in her ankle with no signs of a fracture.

Deltoid partial tear grade ½

PRICE
**first 3 weeks x mvmt @ all for partial tear.
P- ankle brace min first 21 days, no ankle mvmt, no wb til 6W. can do gentle stretch w/ removed
brace.
X inversion/eversion (x possible cause pain). But now can dy???
Can test Arom (2w), no Prom.
No mmt cause pain.
Brace + US
X contrast bath for acute, begin in sub-acute.
Arom exe ok.
Crutch mm, crutch walking.

*most common: inversion (lateral) ankle sprain.

 Sprained:
o Anterior talofibular ligament (ATFL)
o Calcaneofibular ligament (CFL).
 Swelling & pain, use cryo + PRICE.
 Compression wraps/socks.
 US can reduce pain & stiffness.
 Stretching (improve ROM???) & strengthening exe
 Elastic bandage reduce edema better than splint. Figure of 8, from distal to prox.
 Reduced ROM d/t pain & swelling.
 Tenderness.
 Pain w/ WB & ambulation.
 Mild instability (unilateral +vity of clinical stress examination)
 Elevation: Ideally elevate ankle above the level of the heart

Demographic data:
Name: Ms Alice
Age: 20 y/o
Gender: Female
Occupation: Professional badminton player.
Dominant hand: Rt.
Dr’s Dx: Grade 2 ATFL and CFL sprain of L. ankle.
Dr ‘s Mx:
 Conservative mx:
o Painkillers (Ibuprofen 400mg)
o Refer to PT.
Date of Ax: 31st March 2020
C/C:
 Pt. c/o of pain on lat. side of L. ankle that worsens with movement.

Subjective assessment:
Present Hx:
Pt. suffered from a L. ankle injury 2 days ago on 29th March 2020 during a semi-final badminton
match. She stated that she had sprained her ankle when she jumped for a shot and landed on her
foot, which caused her ankle to roll inversely. She had consulted a doctor on 30 th March and had
radiographs of her L. ankle. The results showed that she had partial tear of ATFL and CFL with no
signs of fracture. Thus, Dr. diagnosed her with grade 2 ATFL and CFL sprain and had prescribed
ibuprofen and referred her for physiotherapy.
Past Hx:
 Nil.
Medical Hx:
 Ibuprofen (400mg) for pain relief.
Surgical Hx: Nil
Investigation:
 MRI ( 30th March 2020):
o Axial, coronal, and sagittal view of L. ankle.
o Partial tear of ATFL and CFL.
o No fractures.
Family Hx:
 Nil.
Personal Hx:
 Non-smoker, non-alcoholic.
 Lifestyle: Active.
 Badminton training 4 days per week.
Socioeconomic Hx:
 Single, living with parents.
 Financially stable. Both parents are working.
Environmental Hx:
 Double storey house.
 Seated toilets at home.
 Absence of handgrips in toilets.
Pain Hx:
 Site: Distal to lat. malleolus of L. ankle.
 Onset: Sudden.
 Characteristics: Throbbing pain.
 Radiating: Nil.
 Associated symptoms: Nil.
 Time: No specific timing, persistent pain throughout day and night.
 Exacerbating factors: moving the ankle especially in PF and Inv., walking.
 Relieving factors: ibuprofen, rest.
 Severity:
o On movement: 6/10
o At rest: 4/10

(Follow green crosses)

Objective assessment:
General observation:
 Body type: mesomorph.
 General condition of pt.: good.
 Deformities: Nil.
 Walking aids: cane.
Local observation:
 Swelling: present around lat. aspect of L. ankle.
 Bruising: Present on lat. side of L. ankle just below lat. malleolus.
 Scar: Nil.
 Skin texture: shiny.
Palpation:
 Tenderness: Grade 2 around lat. aspect of L. ankle.
 Mm spasm: Nil.
 Skin temperature: warmth on lat. aspect of L. ankle.
 Edema: Non-pitting edema at lat. aspect of L. ankle.
 Crepitus: Nil.
 Capillary refill of toes: normal.
 Dorsal pedal pulse: normal
 Posterior tibial pulse: normal.
Mm. girth measurement:
 Technique: Figure of 8 around ankle.
 Lt ankle: 45cm.
 Rt ankle: 44cm.
 Interpretation: Pt. has increased Lt. ankle mm. girth d/t swelling.
Postural assessment:
 Anterior view:
o Lt. ASIS slightly higher than Rt. side.
o Lt. knee slightly higher than Rt. side.
 Lateral view:
o NAD.
 Posterior view:
o Lt. PSIS slightly higher than Rt. side.
o Lt. knee slightly higher than Rt. side.
o Lt. foot is supinated.
Gait assessment:
 Type of gait: Antalgic.
o Reduced step length of Lt. foot.
o Reduced single limb support time for Lt. foot.
o Reduced PF of Lt. foot.
ROM:
Joints Action AROM(°) PROM(°) End feel
Knee Left Right Left Right Left Right
Flex. FROM FROM - - Firm Firm
Ext. FROM FROM - - Firm Firm
Ankle DF 90-85 FROM 90-86 - Empty Soft
PF 90-65 FROM 90-67 - Empty Hard
Inv. 0-10 FROM 0-12 - Empty Firm
Ev. 0-7 FROM 0-9 - Empty Hard

 Interpretation:
o Pt. has normal ROM in knees and Rt. ankle.
o Pt. has reduced ROM for Lt. ankle in all planes of movement.
MMT:
Location Muscles Grade (MRC Grading)
Left Right
Shoulder Flexors 5/5 5/5
Extensors 5/5 5/5
Abductors 5/5 5/5
Elbow Extensors 5/5 5/5
Wrist flexors 5/5 5/5
Knee Flexors 5/5 5/5
Extensors 5/5 5/5
Ankle Dorsiflexors KIV 5/5
Plantarflexors KIV 5/5
Invertors KIV 5/5
Evertors KIV 5/5

 Interpretation:
o Pt. has good UL muscle strength for crutch walking.
o Pt. has good muscle strength in knees and Rt. ankle.
o Unable to test mm. strength for Lt. ankle d/t pain.

Grip strength:
Lt. hand: 10.7kg
Rt. hand: 11.0kg
Interpretation: Pt. has good grip strength for both hands.

Sensory Test:
Sensations Lt. LL Rt. LL
Light touch Intact Intact
Pin prick Intact Intact
Temperature Intact Intact
  Interpretation: Pt. has normal sensations.

Balance Test:
Static Dynamic
Standing Feet apart: Good Nudge: Fair
Feet closed: Good Reaching: Fair
Tandem stand: Fair
Single limb stand (Lt): Poor
Single limb stand (Rt): Good
 Interpretation: Pt. has reduced standing balance.

ICF:
 Structural impairment:
o Pain and swelling on lat. aspect of Lt. ankle.
o Limited Lt. ankle ROM.
o Reduced standing balance.
o Abnormal standing posture and gait.
 Activity limitation:
o Unable to stand for prolonged periods.
o Unable to walk and climb stairs.
 Participation Restriction:
o Unable to participate in badminton training and competitions.
o Unable to perform outdoor activities independently.
 Personal factors:
o Age (+)
o Motivation (+)
o Athlete: competitive background (-)
 Environmental factors:
o Emotional support (+)
o Financial support (+)
o Seated toilets at home (+).
o Double storey house (-).
o Absence of handgrips in toilets (-).
Analysis
PT impression:
o Pain on lat. aspect of Lt. ankle d/t swelling and ligament sprain.
o Warmth and swelling on lat. aspect of Lt. ankle d/t inflammation and edema.
o Increased Lt. ankle mm. girth d/t swelling.
o Reduced Lt. ankle ROM d/t pain and swelling.
o Reduced standing balance d/t reduced ankle stability.
o Abnormal standing posture and gait d/t pain.

Goals:
 STG (< 2 months):
o Reduce pain and swelling from VAS 6/10 to 3/10 on activity and 4/10 to 2/10 on rest
within 1/52.
o Immobilization of L. ankle in brace for 3/52.
o NWB crutch training in 1/52.
o Achieve PWB in 4/52.
o Regain FROM of Lt. ankle within 5/52.
o Achieve FWB in 6/52.
 LTG:
o Improve posture and gait within 8/52.
o Regain full mm. strength of Lt. ankle within 8/52.
o Improve balance and proprioception within 9/52.
o Perform ADL independently without difficulties in 9/52.
o Return to badminton training in 10/52.
o Maintain aerobic endurance.
o Prevent recurrence of ankle sprain.
Plan of Tx:
 Pain and swelling management.
 NWB crutch training.
 AROM exercises for Lt. ankle.
 Isometric exercises for Lt. ankle
 Stretching exercises for Lt. ankle
 Pt. education
 HEP
Intervention:
1. Pain and swelling management:
a. PRICE protocol
i. Protection: Immobilize Lt. ankle in neutral position with an ankle brace.
ii. Rest: Instruct pt. to only move their ankle within pain-free range.
iii. Ice:
1. P: Long sitting
2. I: Wrap cold pack with towel and place over ankle for 20mins.
3. R: 3 times/day.
iv. Compression: With the ankle in neutral position, wrap the ankle with elastic
bandage from distal to proximal in figure of 8 pattern to reduce swelling.
 v. Elevation: Elevate Lt. ankle 25cm above level of heart using 3 pillows to
assist in edema drainage.
2. NWB crutch training:
a. Pt. was taught on how to get up from chair using crutches.
b. Pt. was taught 3-point gait for level walking, stair climbing and descending.
3. AROM exercises for Lt. ankle:
a. Alphabet exercise:
i. P: Long sitting
ii. I: Pt. instructed to move ankle within pain-free range by drawing alphabets
in the air.
iii. R: 4reps/day.
4. Isometric exercises for Lt. ankle:
a. P: Long sitting.
b. I: Pt. instructed to perform dorsiflexion with unaffected foot providing resistance. Pt.
was also instructed to perform plantarflexion, inversion, and eversion by placing
foot against a wall to act as resistance. Each contraction is to be held for 5s.
c. R: 10 reps, 3 sets/day.
5. Stretching exercises for Lt. ankle:
a. Towel stretch:
i. P: Long sitting
ii. I: Pt. instructed to use a towel to pull foot towards face and to maintain the
stretch for 30s within pain-free range.
iii. R: 5reps, 3sets/day.
6. Pt. education:
a. Advise pt. to keep the brace on at all times except during shower and performing
exercises.
b. Advise pt. to avoid WB on Lt. ankle for first 3/52.
c. Advise pt. to sleep with Lt. leg elevated above heart level.
d. Advise pt. to temporarily move her room to first floor.
7. HEP:
a. Pt. instructed to perform the exercises taught at home according to frequency and
repetitions given when pain and swelling has subsided.
Evaluation:
1. Pain at Lt. ankle reduced from 6/10 to 5/10 after cryotherapy.
2. Tenderness reduced to Grade 1 after cryotherapy.
3. Swelling at Lt. ankle had reduced slightly after cryotherapy.
4. Pt. is cooperative and able to complete the exercises taught with minimal fatigue.
Review:
 Pain severity
 ROM
 MMT
 Posture
 Balance