comminuted fracture of her left distal tibia and fibula (Fig. 2). This was the result of a heavy tackle during an overseas match five months previously. Initial management was surgery (open reduction with

Figure 3:

Replacement of internal fixation with Ilizarov external fixation device

non-noxious stimulus). These were evident during light touch. Mechanical hyperalgesia (exaggerated response to a painful stimulus) was also evident with digital pressure testing (6). The appearance of the skin in the affected limb was mottled, with excess sweating and raised skin temperature. These signs were indicative of peripheral sensitisation while the allodynia and autonomic changes hinted that there was also an element of central sensitisation. Although these clinical features are consistent with an early complex regional pain syndrome (type 1), no area of secondary hyperalgesia was detected away from the left leg, and so a definitive diagnosis was difficult to make (7).

internal fixation) in the country that the injury occured in. The surgery was reviewed on the patient’s return to the UK and a decision was made to remove the metalwork and fit an Ilizarov external fixation device (Fig. 3). The aim of the Ilizarov frame is to improve tibial alignment and support the fracture site, thereby allowing an early return to weight-bearing (5). The frame was gradually extended over a 4-month period and during this time weight-bearing was progressively increased with adjuncts of Exogen™ (to stimulate bone growth), Compex™ (muscle stimulation for generalised quadriceps muscle wasting), soft tissue releases and mobilisations around the foot and ankle, as well as a comprehensive upper body, core, and pelvic rehabilitation programme to maintain a degree of strength and function. The overall management of her treatment during this time was undertaken by the physiotherapists contracted to work with the Women’s Rugby Football Union team. Toward the end of this period, static cycling was introduced while the patient was fitted with the Ilizarov frame in-situ in order to re-start her conditioning programme. A check x-ray at the 18-week mark revealed good bony union and therefore the decision was taken to remove the frame. Following a further 2 weeks of treatment, a referral was made to the residential rehabilitation programme at the IRU for an initial week of assessment and treatment. On examination, the patient presented with significant swelling in her left leg, and although she was now fully weight-bearing, her gait was considerably antalgic due to stiffness and loss of movement at the mid-tarsal, sub-talar, and talo–crural joints, plus associated generalised weakness of the whole lower limb. Other objective markers included loss of active dorsiflexion in weight-bearing (toe to wall – 4 cm on the left versus – 9 cm on the right with the knee touching the wall) and generalised ankle pain of 6/10 on a visual analogue scale (VAS) with one repetition of a single-left-leg hop test. No pain was directly associated with the fracture site. Sensory testing of the patient’s left leg demonstrated a degree of hyperaesthesia including allodynia (pain from a

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The patient also completed the recreational (sport) section of the Lower Limb Tasks Questionnaire (8). This is a validated measure of lower limb function across a number of activities. It involves self-rating with scores from 4 (no difficulty) to 0 (unable to achieve the task), with a total possible score of 40. Her score was 14, with 5 of the 10 tasks rated as 0 or 1 (indicating severe difficulty achieving the task).

Intervention The conventional physiotherapy treatment instigated by the team physiotherapists was continued and progressed, with the addition of a gym-based exercise routine. The latter aimed to improve proprioception, motor control and early loading through the lower limb. This was supplemented by conditioning sessions in a flume pool and on a static bicycle, as well as hot and cold baths for the left leg to reduce swelling. The issue of hyperaesthesia was addressed by introducing the graded motor imagery (GMI) – a concept developed by Lorimer Mosely (2) and David Butler (Fig. 4) and based on the seminal work undertaken by Ramachandran in the late 1990s (1). Initially limb laterality testing was undertaken to ascertain whether the patient was able to visually discern her left from

TYPES OF PERIPHERAL SENSATION ABNORMALITY n Hyperaesthesia: Abnormal increase in sensitivity to stimuli of the senses. n Tactile hyperaesthesia: Increased touch sensitivity. n Auditory hyperesthesia: Increased sound sensitivity.

n Paraesthesia: Abnormal tingling, tickling, itching or burning sensations, usually associated with peripheral nerve damage.

n Allodynia: “Other pain” arising from stimuli that don’t normally provoke pain. It is not the same as referred pain although it can occur in areas other than the point of stimulation.

n Hyperalgesia: Increased sensitivity to pain, often caused by damage to nociceptors or peripheral nerves. Complex regional pain syndrome: chronic progressive disease associated with severe pain, swelling and skin changes. In Type I there no nerve lesions are seen. In Type II there is obvious nerve damage.

sportEX medicine 2010;45(Jul):13-16