Athletic Training Soap Note

Prepared by: [Your Name]

I. Subjective

Chief Complaint:	The athlete reports pain in the left ankle after a sprain during a basketball game two days ago. Pain worsens with weight-bearing activities.
Pain Level:	6/10 on the pain scale, sharp pain with movement, dull ache when at rest.
History:	Previous ankle sprains in the right ankle. No history of fractures or surgeries.
Functional Limitation:	Difficulty walking, especially when going upstairs, limited ability to perform sport-specific movements.

Inspection:	Swelling is observed on the left ankle's lateral side with bruising around the lateral malleolus.
Palpation:	Tenderness over ATFL and CFL; no open wounds or deformity.
Range of Motion:	Dorsiflexion: 10° (normal: 20°-30°) Plantarflexion: 25° (normal: 40°-50°)
Strength Testing:	Weakness in dorsiflexion (3/5) and plantarflexion (4/5).
Special Tests:	Positive anterior drawer test indicating instability of the ATFL.

Diagnosis:	Grade 2 sprain of the left ankle, specifically affecting the anterior talofibular ligament (ATFL) with mild instability and swelling.
Prognosis:	Recovery is estimated at 2-4 weeks. With proper care, the athlete should return to sport without limitations.

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.