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