Sports Injury Medical Report

Sports Injury Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Female

Contact Information:

123-456-7890

Injury Incident Details

  • Date of Injury: 09/25/2055

  • Time of Injury: 2:15 PM

  • Location of Incident: Riverside Stadium, Main Field

  • Mechanism of Injury:
    During a high-speed sprint, the patient attempted to pivot sharply to avoid a defender. This sudden change of direction caused his right knee to twist awkwardly, followed by an immediate collapse to the ground. The patient reported hearing a “pop” in the knee at the time of injury.

Chief Complaints

  • Primary Symptoms Experienced:

    • Severe pain localized to the right knee.

    • Immediate swelling around the knee joint.

    • Inability to bear weight or walk without assistance.

    • Limited range of motion with difficulty bending or straightening the knee.

Initial Physical Assessment

  • Injured Body Part: Right knee

  • Type of Injury Suspected: Anterior cruciate ligament (ACL) tear

  • Severity of Injury: Severe

  • Functional Limitations:

    • Complete inability to bear weight on the right leg.

    • Difficulty moving the knee without extreme pain.

  • Objective Findings:

    • Visible Swelling: Present; significant swelling in the right knee joint.

    • Bruising/Discoloration: Mild discoloration observed laterally around the knee.

    • Range of Motion: Severely limited; unable to fully extend or flex the knee beyond 30 degrees.

    • Palpable Tenderness: Marked tenderness on the anterior knee and medial joint line.

    • Deformity or Misalignment: No visible deformity noted, though the knee is visibly swollen and feels unstable during movement.

Imaging & Diagnostic Results

  • Diagnostic Imaging Performed:
    MRI of the right knee confirmed a complete rupture of the anterior cruciate ligament (ACL), with associated mild meniscal damage on the medial side. No fractures were identified.

Medical Diagnosis

  • Primary Diagnosis: Complete ACL tear in the right knee

  • Secondary Conditions: Mild meniscal tear, medial joint line

Treatment & Management Plan

  1. Immediate Treatment Administered:

    • Application of ice to the knee to reduce swelling.

    • Compression with an elastic bandage.

    • Knee immobilizer applied to restrict movement.

    • Prescription of ibuprofen 400mg for pain relief, to be taken every 6 hours as needed.

    • Non-weight-bearing instructions were given, and crutches were provided.

  2. Rehabilitation & Recovery Protocol:

    • Physical Therapy Referral: Yes; intensive physiotherapy to begin after 3 weeks of post-operative recovery. Initial exercises will focus on restoring range of motion, followed by strength training and stability exercises.

    • Medications Prescribed:

      • Ibuprofen 400mg for pain, 3 times daily.

      • Naproxen 250mg for inflammation, 2 times daily.

    • Rest and Recovery:

      • Strict non-weight-bearing on the right leg for the first two weeks, followed by gradual weight-bearing with crutches.

      • Post-surgery recovery is expected to last 6-9 months before returning to full athletic activity.

    • Activity Limitations:

      • No running, jumping, or high-impact activities for the first 6 months.

      • Avoid prolonged standing or walking during the initial recovery phase.

    • Projected Timeline for Return to Play: Estimated 9-12 months post-surgery, depending on the progression of rehabilitation and functional recovery.

Follow-Up Care

  • Scheduled Follow-Up Appointments:
    Next appointment with the orthopedic surgeon on 10/10/2024 for post-surgical evaluation.

  • Additional Diagnostic Testing (if needed):
    Follow-up MRI in 3 months to assess the progress of healing.

Physician's Signature:

Dr. Sarah Mitchell

Report Templates @ Template.net