CASE STUDY ANKLE

BY MARTIN POTTS, SPORTS MASSAGE THERAPIST

INTRODUCTION This case study explores the difficulty presented by common injuries that have been inadequately managed. Certain injuries, which are normally very simple and uncomplicated to treat, can become problematic if they are inadequately managed in the early stages. The injuries sustained by this patient were a common grade II sprain to the anterior talofibular ligament (ATFL) and a grade I sprain to the calcaneal fibular ligament (CFL) (Figure 1). These ligaments are frequently injured during ankle inversion sprains, which are a very common injury to the lower extremity although they are not always sports- or activity-related. Estimated global incidence rates are around 10,000 people per day so these injuries have become regular sights for the medical profession (1). This study hopes to demonstrate the importance of an effective initial diagnosis and treatment of the injury at an early stage, highlighting the need for clinical understanding and the reasoning process and for learning how to make a differential diagnosis. After establishing a diagnosis, it is necessary to apply relevant treatment protocols and adapt them to the specific injury. Using evidence-based approaches with measurable outcomes we can identify whether the treatment and rehabilitation protocols are effective in a specific patient or client. This case shows that all injuries should be considered individually, even if they are seen regularly by a practitioner and present the same diagnosis. Watching the patient’s ankle and seeing how it reacts to treatment and rehabilitation is an important part of fast but effective treatment. Many studies present evidence for ensuring ankle stability and neuromuscular retraining before any sort of activity or sport is commenced. Hawkins et al. (2) identified the lateral side of the ankle as being much more prone to injury than the medial

CASE STUDY: AN ANKLE INVERSION SPRAIN

Certain injuries that are normally very simple and uncomplicated to treat can become problematic when they are inadequately managed, especially in the early stages of an injury. This case study describes the progress of a sprain to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), with possible peroneal tendon injury, complicated by inadequate healing and management during the initial stages. This caused prolonged swelling and chronic instability, and created insufficient movement and pain.

Lateral collateral ligament - anterior

talofibular part

context is the lack of effective rehabilitation before returning to activity.

THE PRESENTATION A 38-year-old woman came to the clinic presenting a 4-week-old injury to her right ankle. On entering the clinic I could see she was partially weight- bearing but in some discomfort. Her normal gait pattern was affected quite significantly.

Lateral collateral ligament - calcaneofibular part

Figure 1: Lateral ligaments of the ankle

PRONE TO INJURY THAN THE MEDIAL SIDE

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THE LATERAL SIDE OF THE ANKLE IS MORE

side, mostly due to its structure and ligamentous support. Ellis (1) found that injury to the lateral ligaments caused a prolonged state of instability that couldn’t be fully restored. Willems et al. (3) found that certain people are more susceptible to inversion injuries and are in a state of chronic instability. A particular problem with inversion injuries is the amount of times injury re-occurs to the same structures, which happens frequently in sport, according to Gauffin et al. (4), and these re-injuries become harder to manage the more they occur. One reason for the high injury re-occurrence rate within the sporting

Subjective information The patient recalled “going over” on her right ankle while dancing. She remembered an inversion movement at the ankle joint when trying to land after a dance move in which she spun around several times in the air. Swelling was sudden, extending from the top of her ankle to her toes. Secondary bruising of her lower leg, ankle and foot followed the next day and she was unable to weight bear. She arranged to see her GP 48 hours post-injury, who referred her to the hospital for an x-ray. This came back clear the following week, so she managed to maintain a non-weight bearing state for a few more days before returning to work (11 days post-injury). During this time the only treatment applied was rest and occasional use of ice. During the next week the pain eased but there was still some discomfort, and the swelling and bruising were still present. Another week later (25 days

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