Subjective:

10/1/2017: CDT Smith reports today with bilateral ankle pain. This began insidiously about one
week ago after warming up during Monday morning ROTC physical training. He describes pain
to the anterior ankle mortise that occurs after sustained running. He describes the pain as
sharp and pin-pricky. His pain in stronger in his left ankle. Reports VAS currently as 1/10 when
non-weight-bearing. At the worst, it has been a 6/10 VAS and occurred with prolonged running.
Aggravating factors include: sprinting, sustained running. Alleviating factors are reported as:
slowing down and walking. Self-treatment thus far has included: NONE. He reports having
approached ROTC staff about possibly having shin splints last week, though he is feeling better
this week after stretching more.

He played golf in high school, and only started a running regimen last summer. He ran
approximately two miles a week. His current pair of shows were a Christmas present that he
didnt start using until the beginning of the summer. He reports having a flat-foot strike while
running, and was coached by a senior cadet to start running on his toes. Since then he feels his
running has gotten worse, and that he feels like he is fatiguing faster than normal. He feels that
he is losing his ability to dorsiflex the longer he runs.

He also has concerns about the rubbing of his boots on the back of his heels, and that he will
attempt to wash the boots and wear then while they dry to break them in.

He denies any numbness or tingling. He denies any current medical concerns, current
medication or substance use, medical history, surgical history, and any family history. States no
known allergies.

Objective:

Observation:
No observable deformity, discoloration, or swelling. Resting, standing, and sitting postures
appear normal. Functional observation shows instability at ankles, knees, and trunk when
standing on one leg, standing on his toes, squatting, and lunging.

Palpation:
CDT was mildly tender to palpation of anterior ankle mortise. Dorsal muscle tendons were
stressed to confirm pain discrimination.

AROM:
Dorsiflexion L: WNL, R: WNL
Plantarflexion L: WNL w/pain, R: WNL
Inversion L: WNL, R: WNL
Eversion L: WNL, R: WNL
Hallux Flexion L: WNL, R: WNL
Hallux Extension L: WNL, R: WNL
Toes 2-5 Flexion L: WNL, R: WNL
Toes 2-5 Extension L: WNL, R: WNL
Knee Flexion L: WNL, R: WNL
Knee Extension L: WNL, R: WNL

PROM:
Dorsiflexion L: WNL, R: WNL
Plantarflexion L: WNL w/pain, R: WNL
Inversion L: WNL w/pain, R: WNL
Eversion L: WNL, R: WNL
Hallux Flexion L: WNL, R: WNL
Hallux Extension L: WNL, R: WNL
Toes 2-5 Flexion L: WNL, R: WNL
Toes 2-5 Extension L: WNL, R: WNL
Knee Flexion L: WNL, R: WNL
Knee Extension L: WNL, R: WNL

Manual Muscle Testing:

Dorsiflexion L: 5/5 w/pain, R: 5/5
Plantarflexion L: 5/5 w/pain, R: 5/5
Inversion L: 5/5, R: 5/5
Eversion L: 5/5, R: 5/5
Hallux Flexion L: 5/5, R: 5/5
Hallux Extension L: 5/5, R: 5/5
Toes 2-5 Flexion L: 5/5, R: 5/5
Toes 2-5 Extension L: 5/5, R: 5/5
Knee Flexion L: 5/5, R: 5/5
Knee Extension L: 5/5, R: 5/5

Special Tests:
(-) Bump Test
(-) Anterior Drawer
(-) Compression Test
(-) Kliegers Test

Neurological:
Neuro-screen: Negative
Dermatomes and myotomes intact normal sensation to light touch, two-point discrimination
intact.
Assessment:

Possible weakness of ankle support musculature causing excess motion at the ankle mortise.
Functional observation of the ankle showed a lack of joint control when balanced on one foot
or when standing on his toes. Because he has recently altered his running form to running on
his toes, excess tightness in his calves may be prohibiting proper dorsiflexion while running
which further impairs his gait.

Plan:

He was advised against running on his toes and will be coached on proper running form. He will
begin a stretching program for his lower leg musculature, as well as a strengthening regimen for
all ankle, knee, and trunk support musculature.

Goals:
Reduce pain by 25% within 1-2 weeks
Increase functional stability by 50% within 3 weeks
Reduce pain by 75% within 4 weeks
Return to full, pain-free Army ROTC activities within 6-8 weeks

Christopher Thompson, ATS

Referral Considerations:
If the patient does not show improvement after two weeks of rehabilitation, referral may be
considered to rule out any conditions that are not obvious through standard musculoskeletal
examination and testing. Onset of pain at the beginning of exercise may also indicate that his
condition is resulting in further damage to the ankle mortise. If the patient is unable to bear any
weight, he should be restricted from lower-body exercise and given a boot/crutches until he
can be seen by a physician.

Medications:
Prescribed medications are not indicated for his injury. However, it is expected that strenuous
and/or prolonged lower-body exercise may cause discomfort that lingers through the day.
NSAIDs are acceptable for inflammation-related pain, so long as he does not take more than
1,500 mg within a 24-hour period. Non-NSAIDs will also relieve any minor discomfort, but lack
the benefits of reducing the inflammatory process within or surrounding the joint.

Patient Outcomes:
The patient did not have an active lifestyle in high school, and reports being overweight until a
growth spurt around his junior year. The rigors of ROTC physical training often result in
overtraining injuries to those who do not take the time to acclimate to it before the start of the
semester. He was counseled about opportunities outside of his treatment that will assist him in
developing a strong baseline of physical fitness to reduce re-injury or further injuries later.
Four-week Rehab Flowsheet

Week 1 Comments
Slantboard stretch 5 Knees straight and bent
4-way ankle theraband 2x12 bilateral Orange band
Heel raises 2x25 bilateral
Doming 2x15
Hallux Abduction 2x15
Single Leg Balance 3x30 bilateral
Single-leg Quarter Squats 2x12 bilateral Focus on knee alignment
Planks 3x30

The focus of week one is an overall coverage of the lower body support musculature. Because
of the patients lack of exercise experience, it is likely that he will require more guidance and
proper cueing. Knee and trunk stability will be included from the start, but ankle support will be
the central effort until pain symptoms begin to resolve.

Week 2 Comments
Slantboard stretch 5 Knees straight and bent
4-way ankle theraband 2x12 bilateral Orange band
Single-leg heel raise 2x15 bilateral
Doming 2x15
Hallux Abduction 2x15
Single-leg Balance 3x30 bilateral
Single-leg Half Squats 2x12 bilateral Focus on knee alignment
Planks 3x35

Week two increases the exercise challenge mildly. No changes to be made for exercises where
form is scrutinized. Any initial DOMS can be treated with passive/active stretching, ice, and/or
foam rolling.

Week 3 Comments
Slantboard stretch 5 Knees straight and bent
4-way ankle theraband 2x12 bilateral Blue band
Single-leg heel raise 2x20 bilateral
Marble pick-ups x3 While sitting
Hallux Abduction 2x15
Single-leg Balance 3x30 bilateral On Airex Pad
Squats 3x20 Focus on knee alignment
Clamshells 2x15
Planks 3x40
Week three again increases exercise challenge, while including more knee stabilization exercise
to prevent the knees from internally rotating during squatting motions. Exercise progression
will now include functional activities that challenge all intrinsic foot muscles.

Week 4 Comments
Slantboard stretch 5 Knees straight and bent
Manual Tibialis Anterior Stretch 3x45
4-way ankle theraband 2x12 bilateral Blue band
Single-leg heel raise 2x25 bilateral
Marble pick-ups x3
Hallux Abduction 2x15
Single-leg Balance 3x30 bilateral On Airex Pad with ball toss
Squats 3x25 Focus on knee alignment
Clamshells 2x20
Planks 3x45

By week four the patient is expected to tolerate end-range plantarflexion without significant
pain, if any. Anterior compartment stretches can be manually done or with bodyweight.
Emphasis on proprioception as well as functionality will be stressed from week four onward.

Rehab Enhancement Strategies:

Rehab compliance from the patients perspective can be achieved through a variety of
strategies. Reduction in pain and improvement in function are tangible improvements that
signal to the patient that the treatment is working. Although research does not strongly support
the typical pain relief modalities employed in the clinic, offering those options can assist with
the patient feeling that the unpleasantness of his injury is being taken seriously. A patient
feeling like they are an active participant in their rehabilitation is a force multiplier: outcomes
continue to improve, and there is a stronger adherence to the home exercise plan.
Developing a strong quantitative baseline of any pain or impairments is another opportunity to
improve compliancy. With each re-evaluation, improvements are reported to the patient. If the
patient feels they arent getting better, that quantifiable data can be a strong advocate for the
current treatment.
Lastly, explaining the why to a patient is an effective way to build trust, report, and self-
confidence. Not many patients have a strong understanding of musculoskeletal injuries and the
healing process, which can cause skepticism towards treatments and modalities. A stronger
understanding of what the clinician is trying to do can build an appreciation for the process and
lead to better decisions outside the clinic.