Patient Information & Context

Name

First Name

Date of birth

Sex—ManWoman

Date of injury

Type of lesion—Grade I sprainGrade II sprainGrade III sprainChronic instabilityPostoperativeOther

Balance date

Weeks since injury

Sport practiced

Sporting levelHobbyAmateurSemi-proElite

Affected side—LeftLaw

Therapist

Context/Objective

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Pain – Numerical Rating Scale (NRS 0–10)

Pain at rest

0

0 = no pain10 = maximum

Pain on exertion / during tests

0

0 = no pain10 = maximum

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Ankle Force - Handheld Dynamometer (HHD)

Force

📋Clinical markers: 3 trials, best value retained. LSI = (affected side ÷ healthy side) × 100. Symmetry goal: LSI ≥ 90 %.

Muscle group	E1 acquired	E2 is next	E3 happened	Max Sain	E1 reached	E2 reached	E3 reached	Max reached	LSI %
Sprinklers				—				—	—
Inverters				—				—	—

Protocol: Seated or supine patient, stabilized segment, 3–5 sec maximal isometric contraction, 3 trials per side.

Patient-Reported Outcome Measures (PROMs)

PROMs

📋Ankle-GO Standard Scale: FAAM ADL: 95 = 2 points. FAAM Sport: 95 = 2 points. ALR-RSI: 76 = 3 points.

Item	Value	Points	Thresholds
FAAM ADL (%)		—	95 = 2
FAAM Sport (%)		—	95 = 2
ALR-RSI (%)		—	76 = 3

Single Leg Stance Test

Stability

📋Scale >3 errors = 0 pts | 1-3 errors = 1 pt | 0 errors = 2 pts | +1 pt if no subjective insecurity.

Parameter	Value	Points	Note
Number of errors		—	>3 = 0 | 1–3 = 1 | 0 = 2
Subjective insecurity absent	NoYes	—	Yes
Total SLST		—	/ 3

Star Excursion Balance Test (SEBT)

Dynamic equilibrium

📋List of 3 directions: Anterior (ANT), Postero-medial (PM), Postero-lateral (PL). Comparison L/R with normalization by limb length.

Direction	Left (cm)	Right (cm)	Gauche normalisé (%)	Normalized right (%)
Anterior (ANT)			—	—
Postero-medial (PM)			—	—
Postero-lateral (PL)			—	—

Member length (cm)

Left composite

—

%

Straight composite

—

%

Score summary	Value	Points	Note
Affected side composite (%)	—	—	95 = 4
Normalized ANT > 60 % (affected side)	—	—	+1 if yes
PM normalized > 90 % (side reached)	—	—	+1 if yes
Subjective insecurity absent	NoYes	—	+1 if yes
Total SEBT		—	/ 7

Side achieved for the score LeftRight

SEBT Notes

Laid-back hopping test

Plyometrics

📋Scale >13 s = 0 pts | 10–13 s = 2 pts | <10 s = 4 pts | +1 pt if no subjective insecurity. Total /5.

Parameter	Value	Points	Note
Time (seconds)		—	>13 = 0 | 10–13 = 2 | <10 = 4
Subjective insecurity absent	NoYes	—	Yes
Total Side Hop		—	/ 5

Figure-of-8 Test

Agility

📋Scale >18 s = 0 pts | 13–18 s = 1 pt | <13 s = 2 pts | +1 pt for no subjective insecurity. Total /3.

Parameter	Value	Points	Note
Time (seconds)		—	18 or older = 0 | 13-17 = 1 | Under 13 = 2
Subjective insecurity absent	NoYes	—	Yes
Total Figure-8		—	/ 3

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Heel Raise Test

Endurance of the triceps surae

📋Clinical markers: Note full repetitions, range of motion, and quality. Goal: LSI ≥ 90 % with good execution quality.

Parameter	Healthy side	Affected side	LSI %
Complete repetitions			—
Quality / comments			—

Additional Clinical Criteria

Edema—AbsentLightweightModerateImportant

Yielding—NoRareRepeated

Knee dorsiflexion at wall (cm)

Single leg heel raise (reps.)

Ligament tenderness—NoYes

Apprehension jump / COD—NoLightMarked

Tested surface

Shoes / Barefoot

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Summary - Ankle-GO Score

Criteria	Scoring scale	Points earned	Maximum
FAAM ADL	0 to 2 pts	—	2
FAAM Sports	0 to 2 pts	—	2
ALR-RSI	0 to 3 pts	—	3
SLST	0 to 3 pts	—	3
Heel Raise Test	LSI target ≥ 90 %	—	—
HHD Turners	LSI target ≥ 90 %	—	—
HHD Inverters	LSI target ≥ 90 %	—	—
SEBT (Synthetic score ANT+PM+PL)	0 to 7 pts	—	7
Side Hop	0 to 5 pts	—	5
Figure-of-8	0 to 3 pts	—	3
Total	Sum	—	25

Clinical lecture: score 11 = more favorable profile. The score does not replace clinical judgment or analysis of sport requirements.

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Conclusion & Recommendations

Decision:

✅ Return to Sport completed ⚠️ Return to Training only ❌ Resale not recommended

Proposed return date

Rescheduling planned

Specific recommendations

Therapist's comments