Thomas is a 64 y/o active male who presents with posterior a…
Thomas is a 64 y/o active male who presents with posterior ankle pain. He reports the posterior ankle pain started after landing from a jump 2 days ago. In fact, he remembers quite vividly that there was a loud pop like a gun. Further discussion reveals that Thomas did not suffer from pain prior to the onset of pain, with the exception of a persistent, worsening centralized lower back pain. Aggravating activities for the ankle pain are walking any distance, attempting to go up a ladder, and any attempts to stretch his calf. Easing activities for the ankle pain are simply avoidance. He denies any patterns for his back pain. Goal for physical therapy Return to active lifestyle since he has really made it part of his persona after beating prostate cancer 13 years ago. Past medical history Prolonged hydrocortisone usage (~12 months) for his back pain. Stomach pain related to this medicine. Recent weight loss of 10lbs over 2 months. Relevant objective testing (-) thompson test, (+) pain/edema to palpation of the achilles tendon, 4/5 plantar flexion strength with pain limiting further repetitions. ~ 5cm difference in figure 8 ankle circumferential measurement. Based on these findings, the most appropriate phase I (screening for medical referral) action would be