[Ankle Sprain Template]

S: Date & Time of Injury: ______

[ + -- ] Previous history of ankle injury (If previous Hx, when ______)

[ + -- ] Able to bear weight immediately after the injury.

[ + -- ] Rapid onset of swelling after injury.

[ + -- ] Audible sound or a sensation of popping, snapping, or cracking.

Type of Injury (circle one): Inversion, Eversion, Dorsiflexion, Plantar Flexion, Unknown

# 1: Bilat. Posterior Ankles

# 2: Bilat Anterior Ankles

Indications for X-rays before Stress Tests:
(1) Immediate significant swelling. (2) Obvious deformity.
(3) Inability to bear weight. (4) Pain mainly over bone.

O: [ + -- ] Anterior Drawer Sign (tests ant. Talofibular ligament, ant. Capsule, and calcaneofibular band).

[ + -- ] Inversion (Talar Tilt) Test (tests calcaneofibular ligament).

[ + -- ] Eversion Test

# 3: Lat. Right Ankle

# 4: Lat. Left Ankle

[ + -- ] Transverse Test (tests inferior tibiofibular ligament and interosseous membrean or with a fracture).

[ + -- ] Fibular Compression (“Squeeze”) Test

[ + -- ] Thompson’s (Squeeze Calf) Test

Pulses: [ + -- ] Tibialis posterior; [ + -- ] Dorsalis pedis.

Sensory Test: [ + -- ] Sural n.; [ + -- ] Peroneal n.

Skin: [ + -- ] Ecchymosis; [ + -- ] Swelling (mild - moderate - severe)

[ + -- ] Weight Bearing: [+ -- ] limp

Tenderness:

ROM:

# 5: Xray R. Ant. Ankle

# 6: Xray L. Ant. Ankle

DTR’s:

Ottawa Rules for Ankle X-rays (for Guidance Only)
1. An Ankle Series is only necessary if there pain near the malleoli and any of these findings:
a. Inability to bear weight both immediately and in emergency department (four steps)
OR
b. Bone tenderness at the posterior edge or tip of either malleolus.
2. A Foot X-ray Series is only necessary if there is pain in the midfoot and any of these findings:
a. Inability to bear weight both immediately and in emergency department (four steps).
b. Bone tenderness at the navicular or the base of the 5th metatarsal.

A: ( Right – Left ) Ankle Sprain [Class: I II III ]

Other Dx’s:

P: ¨ Rest: ¨Crutches; ¨Other: ______

¨ Ice: Apply 20-25 minutes, taken off for an hour, and re-applied x 24-48o

Alpine Medical Group
of the Roaring Fork Valley / Provider: ______Date: _____-____-_____Patient: ______DOB: ___ -___ - ___ Age:____

BasaltClinic

1450 E. Valley Rd, Ste 101

Basalt, CO 81621

970-927-6101 FAX 970-927-6144 / Aspen Clinic
225 N. Mill St. #116
Aspen, CO 81611
970-920-7024 FAX 970-920-6746

¨ Compression: ¨Ace Wrap (Caution dangers of too tight wrap)

¨  Elevation

¨  NSAID’s: ¨Motrin _____mg 1-pill ____x daily #_____/___; ¨Naprosyn ______mg 1-pill ______x daily #_____/___.

¨Posterior Splint

¨Referral: ¨Physical Therapy for: ______; ¨Orthopedic Referral for: ______.

¨Return to Clinic: ______days for reevaluation.

Alpine Medical Group
of the Roaring Fork Valley / Provider: ______Date: _____-____-_____Patient: ______DOB: ___ -___ - ___ Age:____

BasaltClinic

1450 E. Valley Rd, Ste 101

Basalt, CO 81621

970-927-6101 FAX 970-927-6144 / Aspen Clinic
225 N. Mill St. #116
Aspen, CO 81611
970-920-7024 FAX 970-920-6746

¨Other:

Alpine Medical Group
of the Roaring Fork Valley / Provider: ______Date: _____-____-_____Patient: ______DOB: ___ -___ - ___ Age:____

BasaltClinic

1450 E. Valley Rd, Ste 101

Basalt, CO 81621

970-927-6101 FAX 970-927-6144 / Aspen Clinic
225 N. Mill St. #116
Aspen, CO 81611
970-920-7024 FAX 970-920-6746