Ankle Assessment
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Please convert the below information into Physiotherapy soap note and also add Opportunities for Improvement
Type of assessment
Initial Evaluation
Follow Up Note
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Ankle Assessment
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Side (global selection)
Left
Right
Bilateral
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Standing Inspection
Findings
Swelling/oedema around malleoli
Ecchymosis/bruising
Foot posture: Overpronation
Foot posture: Oversupination
Hindfoot valgus
Hindfoot varus
Medial arch collapse
Lateral border loading
Heel alignment asymmetry
Callus pattern (plantar)
Skin changes/scars
Standing notes
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Functional Tests
General
Single-leg heel raise (endurance/reps)
Calf raise pain
Single-leg balance deficit
Hop test pain
Stair descent pain
Squat Assessment
Bodyweight squat
Overhead squat
Single-leg squat
Functional notes
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Muscle Power (MMT)
MMT – Dorsiflexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
MMT – Plantarflexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
MMT – Inversion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
MMT – Eversion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Strength notes
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Range of Motion
ROM – Dorsiflexion
Full range of motion – 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
ROM – Plantarflexion
Full range of motion – 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
ROM – Inversion
Full range of motion – 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
ROM – Eversion
Full range of motion – 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
ROM measurements (deg)
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Palpation
Structures
ATFL (Anterior talofibular ligament)
CFL (Calcaneofibular ligament)
Deltoid ligament (medial)
Syndesmosis (AITFL/PITFL)
Achilles tendon
Tibialis posterior tendon
Peroneal tendons
Plantar fascia origin
Medial malleolus
Lateral malleolus
Base of 5th metatarsal
Navicular
Calcaneus
Palpation notes
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Gait (ankle-related)
Findings
Overpronation
Oversupination
Reduced ankle rocker
Toe-out gait
Toe-in gait
Foot slap
Antalgic gait
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Special Tests
Anterior drawer (ankle) – ATFL
Negative
Positive
More details...
Talar tilt – inversion (CFL)
Negative
Positive
More details...
Talar tilt – eversion (Deltoid)
Negative
Positive
More details...
External rotation stress (Kleiger)
Negative
Positive
More details...
Squeeze test
Negative
Positive
More details...
Dorsiflexion-compression test
Negative
Positive
More details...
Thompson test (Achilles rupture)
Negative
Positive
More details...
Windlass test (plantar fascia)
Negative
Positive
More details...
Navicular drop
Negative
Positive
More details...
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