Athletic Training Soap Note
Prepared by: [Your Name]
I. Subjective
| The athlete reports pain in the left ankle after a sprain during a basketball game two days ago. Pain worsens with weight-bearing activities. |
| 6/10 on the pain scale, sharp pain with movement, dull ache when at rest. |
| Previous ankle sprains in the right ankle. No history of fractures or surgeries. |
| Difficulty walking, especially when going upstairs, limited ability to perform sport-specific movements. |
II. Objective
| Swelling is observed on the left ankle's lateral side with bruising around the lateral malleolus. |
| Tenderness over ATFL and CFL; no open wounds or deformity. |
| |
| Weakness in dorsiflexion (3/5) and plantarflexion (4/5). |
| Positive anterior drawer test indicating instability of the ATFL. |
III. Assessment
| Grade 2 sprain of the left ankle, specifically affecting the anterior talofibular ligament (ATFL) with mild instability and swelling. |
| Recovery is estimated at 2-4 weeks. With proper care, the athlete should return to sport without limitations. |
IV. Plan
Immediate Treatment:
R.I.C.E (Rest, Ice, Compression, Elevation) for 48 hours.
Anti-inflammatory medications (NSAIDs) as needed for pain and swelling.
Taping or bracing to support the ankle during mobility.
Rehabilitation:
Begin range-of-motion exercises after swelling decreases (within 2-3 days).
Strengthening exercises targeting the ankle’s stabilizing muscles (starting with isometric exercises).
Proprioceptive exercises such as balance drills on a wobbleboard.
Follow-up: Reassess in 5-7 days to evaluate progress and modify treatment as necessary. Consider referral to physical therapy if needed.
Return-to-Sport: Pending full recovery of strength, range of motion, and functional stability. Reassess after 2 weeks.
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