University of Cincinnati DPT - Systematic Clinical Reasoning Worksheet

Patient Profile (age, gender, occupation, hobbies, exercise habits, etc.):

Name: Ms. Elizabeth
Age: 46 years
Gender: F
Occupation: Server at Skyline
Hobbies: Patient likes to golf with her friends but has not been able to d/t L ankle
Exercise Habits: no current exercise or acitvity, used to golf 2-3 times per month with friends or go to driving
range

Chief Complaint (why are they coming to physical therapy):

Patient chief complaint is instbaility of L ankle, L ankle weakness, limitations with hobbies, and limitated ability to keep
up at work.

Part 1: ASSESSMENT OF THE BODY CHART: what areas/structures must be considered as possible sources
of the patient’s symptoms? Consider the following:

Joints & Muscles & Ligaments, MSK Pain NON-MSK

bony Tendons, Nerves and producing structures or
structures UNDER & IN other Soft structures conditions
UNDER THE the area of Tissues which may which must
AREA of symptoms UNDER & IN REFER into be examined
symptoms the area of the area of or ruled out
symptoms symptoms

Fracture of Fibularis ATFL Syndesmo Lumbar

foot Longus/ sis sprain spine
Brevis CFL referral
OCD Tendon
Strain Anterior Peripheral
Bone Talofibular nerve
Bruise Ligament referral

Initial Hypotheses

Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:

(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 hypothesis
requiring referral)

1. Chronic Ankle Istability 1. Fracture in foot 1. Referral From Lumbar Spine

2. Ankle pain secondary to 2. Lateral Ankle Sprain 2. Bone Bruise/OCD

osteophyte formation at
anterior distal tibia

Planning the Interview: What questions will you ask to clarify or gather information to support/refute each hypothesis?

Can you describe pain/symptoms? Are there specific surfaces that Do you have any previous history
(ie. deep, ache, unstable,
soreness)
What is the 24 hour symptom
behavior for this injury?
What limitations are you
experiencing in day to day life? At
work? With hobbies?
What is your goal(s) for PT?
Anything else you think I should
know?
cause an increase in symptoms
more than others?
What are easing and aggravating
factors or activities that either
alleviate your symptoms or
increase symptoms?
Do you have any other imaging to
the ankle?
Have you received treatment for
this before?
of injuries to the ankle?
Can you describe this latest
episode? How it started? How it
has changed?
How are ADL’s? Sitting? Climbing
Stairs? Descending Stairs?
Walking?
Ankle numbness or tingling?
Have you ever had PT?

Part 2: Revised and Reprioritized Hypotheses/Planning the Physical Exam

Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:

(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 hypothesis
requiring referral)

1. Chronic Ankle Instability 1. Fracture in foot 1. Referral From Lumbar Spine

2. Lateral Ankle Sprain 2. Ankle pain secondary to 2. Bone Bruise/OCD

osteophyte formation at anterior
distal tibia

Determine the patient’s SINSS - consider how that will influence your exam and treatment

Severity Irritability Nature Stage Stability

High High MSK Acute Getting better
Mod Mod Non-MSK Subacute Getting worse
Min Min Psychosocial concerns Chronic Staying the same

☐ ☐ ☐ ☐
- Highly limited exam due to - Moderately limited exam due - Minimally limited exam due to - Unlimited exam due to
anticipated tolerance to anticipated tolerance anticipated tolerance anticipated tolerance
- ROM 1st onset of sx - ROM to active limit - ROM to passive limit - ROM to sustained/ combined
- Very low vigor and extent - Low vigor and extent of - Moderate vigor and extent of - High vigor and extent of
of tests/measures tests/measures tests/measures tests/measures

Rationale: This patient is dealing with a chronic condition. She has been dealing with episodes like this since she was in
highschool and is now 46 years old. I do not want to aggravate her too much where she will not want to return to
therapy but I am willing to teeter on the edge of aggravating her symptoms in order to gain information that can help me
provide her resources to improve her condition. Additonally, her evaluation took place in the morning on her day off. I
felt comofrtable pushing her to get the information I need to best help her.

Part 3: Planning the Physical Exam

What movement/functional test is most related to their chief complaint?

Lunge for instability of L ankle and squat to assess dorsiflexion restriction of L ankle.
Physical Exam Plan for day #1: Prioritize based on the most likely or most concerning hypothesis and the patient’s
tolerance to the exam. List in order of importance.

Prioritized P/E tests and measures: Justification:

Squat/Lunge Squat and Lunge (bilaterally) allows for assessment of

whole body mechanics, stability of L ankle when WB in
single leg position with lunge, and assessment of
dorsiflexion ROM with squat.

Gastrocnemius and Soleus Length Test Want to see if muscle inflexibility limiting factor in squat
and dorsiflexion movements. Limited dorsiflexion can be
caused by a variety of factors including muscle tightness
 want to tease this out.

Palpation Want to assess for fracture, Ottowa Ankle and Foot Rules,
and rule out other pathologies.

Ankle PROM/AROM Want to assess gross ROM both active and passive.
Limitations in active can be due to phsyioogical blocks,
weakness, or muscle tightness which does not allow
movement. PROM can assess which limitations these may
be.

Passive Movement Assessment AP movement of talocrural joint, medial tilt, lateral tilt to
assess movement and compare bilaterally

Balance (SL) SL balance with eyes open to assess for balance strategy,
stability of ankle, imbalances, and proprioception.

MMT (DF, PF, IN, EV, and HIP ABD) Assess ankle for strength and see if contributing factor for
CAI and hip strength if + trendelenberg or trunk strategy
with SL balance

Exam items deferred to future visits (list in priority)

Prioritized P/E tests and measures: Justification:

SL balance with eyes closed Able to further test proprioception with loss of visual input

Lumbar Neurological Exam Want to ensure no contributions from lumbar spine seeing
as these are often related

Hip strength Want to look up the chain to see if weakness in upper

chain contributing to CAI

Y balance test Allows for objective measure of balance and reach 

requires control for increased measures

Part 4: Assessment

Is the patient an appropriate candidate for physical If refer, indicate reason to include what and why (imaging,
therapy intervention? lab, specialty, etc.):

☐Treat ☐Treat and Refer ☐ Refer

Most important baseline findings from the interview: Greater instability with greater fatigue, worsening
symptoms, inability to play in sport, limitations at work, previous history of ankle pathology, symptom
behaviors, and aggravating/easing factors.

Activity Limitation or Participation Restriction (list in order of importance)

1. Limitated in partiicpation at work and it is affecting her ability to work  main priority for this patient!!

2. Unable to participate in golf outings with friends due to fear of reinjury and feelings of instability.

3. Unable to mow lawn due to increasing symptoms and increased aggravation with ambulation on uneven
surfaces.

Most important baseline findings from the examination: Notable laxity with passive movement assessment
of L ankle talocrural PA/medial talar tilt/lateral talar tilt, decreased flexibility in L ankle with gastroc and
soleus, decreased strength with hip abduction bilaterally, decreased anterior tib strength, limited talocrural
AP motion of L ankle.

Impairment/movement test What limits (pain, stiffness, strength, What aggravating factor is this related
control, etc.) to?

1. Squat 1. Limited dorsiflexion due to TC 1. Stairs  Stiffness

stiffness and muscular
stiffness (gastroc and soleus)
2. Lunge 2. Instability

2. Inability to weight bear SL

3. SL Balance with control 3. Mowing Lawn  Instability
(Uneven Surfaces)

4. AP Talocrural Passive 3. Impaired

Movement Assessment Proprioception/Control 4. Soreness, Stiffness, Instability

4. Stiffness

Most Likely Hypothesis: Chronic Ankle Instability Alternate Hypotheses: Acute Lateral Ankle Sprain

What clinical evidence supports this?

What clinical evidence supports this?
- Location of symptoms - No traumatic MOI, no bruising, no swelling, no
- Symptoms related to instability pain
- History of previous episodes - Location of symptoms
- Restricted ROM - Symptoms related to instability
- Dorsiflexion ROM limited  muscle tightness - Soreness with WB
- Hip weakness - Restricted ROM
- Chronic history of ankle sprains without treatment

Part 5: Prognosis
What is the natural history of this disorder? How do you expect it to progress over time?
Chronic Ankle Instability is characterized by episodes of giving way or prolonged instability with activity. Patients with
this condition are typically presenting with a past history of lateral ankle sprains. Over time, if this goes untreated,
patients suffer with limitations and impairments in DF range of motion, ankle strength, hip strength, knee strength,
postural control, ankle proprioception, and timing of muscle activation. If left untreated, symptoms will continue and over
time continue to increase. Limitations with activity, exercise, and occupation are not uncommon.

Likelihood of recurrence: MILD / MODERATE / HIGH

How will you attempt to prevent recurrence of symptoms?

Provide patient education on a varriety of topics including bracing during beginnning phases of treatment to return to
golf, mowing lawn, and for work. Patient will be prescribed a independent HEP that provides a plethora of exercises and
managemnet techiniques in order to improve current condition, manage condition over time, and decrease symptom
reoccurance rates.

Contextual Factors: What contributing factors will influence this patient’s prognosis?

Personal Factors: How will you account/address these?

(Health/wellness, psychosocial, efficacy, age, gender, etc.)
1. Psychosocial  patient not participating in golf
because is afraid of reinjury or provoking
symptoms
2. Current exercise/activity level  none
3. Patient Age  older individual who works a
demanding job
. these.
Providign patient education on all of these factors to make
patient aware of factors that may affect her progress in
therapy. Will use taping and/or bracing with work, golf, and
mowing grass to see if increases stability of ankle and
confidence in her ankle (at least in early stages of
treatment). Encourage patient to return to exercise and
partiipate in activites that don’t provoke her symptoms.
Exercising on days she is off from work is great as to not
tire her foot before work and increase symptoms later in
the day when she is working. Including patient in her
prescription and intervention plan best way to address

Environmental Factors: How will you account/address these?

(Occupation, location, home/family, cultural, etc.)
1. Patient job as a server requires her to be on her
feet for prolonged amount of time.
2. Patient walks a lot when volunteering at local
animal shelter.
Patient education on effects of condition on work and
volunteering and the effects of activites required by work
and volunteering on her condition. Provide patient
resources and interventions to help aid in decreasing
symptoms with these environemental factors such as
wearing the brace during work or volutneering. Encourage
patient to volunteer but find an activity less demanding at
least for the time being until condition improves.

SMART GOALS: Specific, Measurable, Attainable, Realistic, and Time-Oriented

What is the patient’s goal? Patient would like to return to work with minimal impairments, golf with her
friends, and mowing the lawn without difficuly.

Short Term Goals Long Term Goals

1. Patient will return to golfing 9 holes with her 1. Patient will improve single leg stance time to > 30
friends in 2 weeks with brace to return to social seconds with quiet standing and no
interaction. compensations in 3 months to improve
proprioception and decrease feeling of instability.

2. Patient will increase hip abduction strength to 5/5

bilaterally in 5 weeks to increase LE stability with 2. Patient will increase ankle dorsiflexion to 15
Wb activities. degrees bilaterally in 2 months to improve squat,
lunge, stair ascending, and stair descending

Justification/ relationship to long term goals and chief
complaint:
Patient would like to return to golf. The use of a brace as
an assitive device allows her to return to this activity
sooner by providing her external support. Patient exhibits
weakness in hip abductors which has been known to
affect distal segments of the LE. Patient demosntrates
trendlenberg signs with SL balance.
mechanics.
Justification / relationship to the chief complaint and
patient’s goals:
Patient complains of feelings of instability. Improving
proprioception decreases insability. Patient lacks DF due
to multiple factors. Stretching and manual techniques can
improve DF and decrease limmitations with squat, stairs,
and lunges at ankle joint.

Part 6: Plan of Care

How many visits over what period of time do you expect to see this patient? Why?
I will initially see this patient for 2x/week for 2 weeks to determine a plan for what activities are helpful for her. At the
end of the first two weeks, we will reduce therapy to 1x/week for 4 weeks for weekly check ins and prescription of HEP.
After this point, depending on patient progress, will decrease visits to every other week. This is a chronic condition and
need to give this patient the tools to self-manage her condition. Can have booster sessions later on in treatment or
every few months for check ins.

What patient education will you provide (at a minimum include diagnosis, prognosis, plan [both what you will do and
what they will do]):

Diagnosis/Assessment: Patient education on purpose of therapy and goals in therapy. Patient has chronic ankle
instability secondary to previous history of ankle sprains. Contrbuting factors include occupation, exercise habits, and
previous history of ankle sprains without treatment.

Prognosis (what does their recovery look like?): Patient education on her condition and how it is chronic. Can
emphasize that previous inuries most likely contributed to current condition. Her symptoms can reside with treatment
and adherence with her HEP. Since this is a chronic condition will be spending the future working to build strength,
increase mobility, increase flexibility, and maintain status once recovered. Important to listen to her body and seek
treatment as needed.

Plan of Care:
- PT plan (what you add): I will continue to add strengthing exercises to the ankle, knee, and hip as deficits are
identified. Patient requires increased strength, mobility, proprioception, balance, and flexibility. Addition of
activities on various surfaces as patient condition improves is essential in order to attain patient goals for
therapy. Dependent on patient response to interventions.

- Patient plan (what they can do): Patient can return to exercise as she feels comfortable. Encourage patient to
return to golf and can use external supports to feel more comfortable. Provide patient with HEP she feels
confident is helping her in order to improve strenght, mobility, and proprioception. Dependent on patient
response to interventions.

Initial Day 1 Interventions Rationale Expected Response

Be Specific to include FITT principles. (What impairment or goal indicates (What movement test will you
(Manual therapy, exercise, education, this treatment is important?) reassess to prove that your treatment
modalities, assistive device, etc.) was effective?)

1. Active DF while leaning Anterior tibialis was weak and MMT of anterior tibialis in long sitting
against wall (3x15) requires strengthening to pull foot in a few weeks to assess progress.
through full range of dorsiflexion and Can ask patient response on day one
improve ambulation mechanics. to assess “muscle burn”.

2. DF Streches: Gastroc and Patient lacks normal ranges of DF Squat and assess depth of squat
Soleus at Edge of Step (3x20 required for walking on L ankle. relative to patient DF range.
each side for each exercise) Patient deficits evident in gasroc and
 soleus muscle length tests. Important
to improve DF for walking, squats,
lunges, stairs, and patient goals.

3. Self-Mobilization into DF with
Chair/Step (L side, 3x20) 
PROVIDED manually by PT during
examination prior to teaching patient.
Patient lacks DF and seems to
improve with Grade III oscillations into
dorsiflecion. Patient taught to self
mobilize using stair or kitchen table
chair at home
Compared side ot side passive motion
or have patient demonstrate squate
and how it feels.

Assume good patient adherence and no red flags are present. At the next visit, what treatment will you
consider if the patient is:

Better: Worse: The Same:

Continue with current HEP if patient
deems exercises as helpful.
Add new exercises to HEP and have
patient rotate between exercises daily
to switch up activities.
Progress current exercises to
increase difficulty if they are not
challenging enough.
Encourage patient return to sport 
can provide patient with bracing
and/or taping to return to driving
range or 9 holes of golf with friends
with a rented golf card to limit walking
over uneven surfaces for prolonged
time.
Determine which exercises are pain
provoking  have patient demostrate
to correct posture/form during
exercise and if still painful after
correction will discontinue.
Determine if worsening symptoms is
with therapy or with activities at work,
hobbies, or with exercise.
If worsening continue for > 2 weeks,
or at patient request, refer back to
orthopedics to rule out other
diagnoses.
Add new exercises to HEP and have
patient rotate between exercises daily
to switch up activities.
Progress current exercises to
increase difficulty if they are not
challenging enough.
Remove exercise patient does not feel
are helpful to her condition  she is
less likely to compelte exercises if she
does not find them useful
Ensure patient is actually completing
her current exercises as prescribed.

Part 7: Course of Physical Therapy Care

Describe the desired end-state or discharge from physical therapy care (what do they look like/what are
they able to do? Consider how that relates to the chief complaint, impairments, and goals.)

CAI is a chronic condition so patient will be discharged with an independent home exercise program. Patient
will be provided a lot of exercises to choose from for a maintenance program, strenthening program, and
acute incidence program if relapse occurs so patient can self-manage. Patient education huge part of
discharge from therapy. Patient should be provided tools to properly self-manage. At end stage, patient will
continue to strengthen ankle and hip, increase muscle flexibility, and improve proprioception by transitiong
from HEP to more tradiitional exericse program in order ot return to work with minimal limitations,
volunteering with no limitations, and golf with minimal limitations. Patient goals are to reutrn to work with
minimal limiations, improve tolerance to return to golf, and mow lawn without insecurities or increased
soreness. At end stage, patient will be able to golf 9 holes with no limitations and be able to start workign to
18 holes at discharge, mow the lawn in stages with no increase in symptoms, and work her usuala shifts with
minimal limitations if at all.
Describe a treatment plan that will achieve the desired end state/ discharge: Describe how and what you will
re-assess throughout the course of PT care. Explain how your management plan will progress and what
different impairments or areas/regions you will address at future follow-ups.

The tereatment plan that will achieve the desired discharge status includes strength of entire LE including
ankle, muscle felxbibility especially gastroc and soleus, proprioception, and balance. Each of these
components will be tested and retested throughout the patients course of care to assess progress. If the
patient is showing objective progress and subjectively noting progress will continue with current interventions
and progress as seen fit. If patient is not progressing for a specific component then will need to reassess
interventions that are assessing that component. Patient subjective updates will be taken at each visit to
assess progress. Measurements will be assessed every 1-2 weeks depending on visits to assess objective
measures. Future follow-ups will include updating progress both subjectively and objectively in addition to
prescribing and progressing exercises. Encouragement of self-management as time continues is important
because patient will be performing HEP completely independently at some point.

What changes to your management plan will you make if they are not progressing as expected? Why?

The changes in management plan are dependent on where in the patient’s intervention plan they are not
progressing. If patient is not progressing strength wise, may need to look at arthrogenic inhibition and work
on isolating those muscles more exactly or increase load. Changes in management of flexbility may require
consult if patient is not achieving ranges they require for ADL’s. Changes are dependent on patient reaction
to intervention plan.