Ankle/Foot R L
Injury_______________________________________________________________________________________________________
___________________________________________________________________________________________ (Date)________
Noninjury_____ How long has the problem been active _________
Sharp (when) _______________ Dull/Ache (when) ______________ Constant (at rest) __________
Pain Level (sitting)____/10 (activity)____/10
Maximum point of pain_____ Medial. Lateral. Dorsal. Plantar.
What makes it worse: ______________________ Better: _____________________
Been seen for this in the past: ______________________ What tests or treatment_____________________
Gait: Antalgic?
Inspection: Ecchymosis Effusion Erythema or warmth Edema/Swelling
Lower Examination: Normal ______________________ Valgus ankle turn in – flat foot Varus ankle out - high arch
Bilateral Ankle Alignment ________________
Palpation: _________________________________________________________________________________________
Tenderness ATFL anterior tibiotalar ligament (lax plantar flexion) _______ CFL calcaneofibular lig. (dorsflx, inversion) ______
PTFL posterior talofibular lig. (post fibula) _________ Achiles_________ Metatarsals________ Squeeze test (syndesmosis injury) high
sprain ________ Calcaneus __________ 5th metarsal _______ Cuboid ______
Range of Motion: Dorsiflexion ____ Plantarflexion _______ Passive: Dorsiflexion _______ Plantar Flexion _______
Inversion ________Resisted _____ Eversion______ Resisted Supination________ Pronation ____________ External
Rotation______
Stability: Anterior Drawer____________ Talar Tilt supine ft 90 supinate _______________
Morton’s Neuroma walking on a marble (squeeze top of metatarsal) _________
Paresthesia ______
Pulses: Dorsalis pedis ____ Posterior tibial _____
X-ray: Fracture___________
ASO Brace Pneumatic walking boot Compression Stretches Even Up Post-op
