ankle/foot

onset

hours days weeks months years
sudden gradual

side

left right bilateral

new?

new issue previously known issue

symptoms

+ pain – + stiffness – + swelling – + erythema –

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

status

improving unchanged resolved gradually worsening significant worsening

context

+ trauma – + repetitive movement –

location

ankle whole joint medial lateral anterior posterior achilles
foot calcaneus dorsum medial lateral

worse with

weight bearing walking all movements

improves with

rest tylenol NSAIDs ice

HPI

side

left right bilateral

inspection

normal
normal gait antalgic gait

palpation

A temperature N
tenderness
medial malleolus lateral malleolus achilles calcaneus peroneal tendons
ATFL plantar fascia sesamoid
MTP 1 2 3 4 5

ROM

normal
pain with inversion eversion supination pronation

muscle testing

normal

special tests

Ottawa

negative ankle/foot
Tenderness:
+ Posterior medial malleolus – + Posterior lateral malleolus –
+ base 5th metatarsal – + navicular –

exam

Assessment

Plan

RICE

medication

tylenol topical NSAIDs PO NSAIDs opioids

physiotherapy

self referral MFP physio

- private coverage

yes no

other therapy

orthotics

off work

yes (1-2 weeks) no

imaging

not indicated x-ray MRI

referral

orthopedics sports med

follow-up

2-4 weeks PRN only

RTC

instructions given

O/

A/

P/