post-injury) the swelling and bruising had reduced but the pain started to increase again after extended periods of walking during the course of a weekend. The patient reported that movement in her ankle had been limited since the injury, putting this down to stiffness of the joint rather than pain. She was attending the clinic because of this stiffness and discomfort when walking. She recalled no previous injury to the ankle.

Interpretation of subjective assessment The injury hypothesis derived from the information described above suggested an ankle inversion sprain, possibly affecting the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), and possible peroneal tendon involvement. Inadequate healing and management had caused prolonged swelling and chronic instability, creating insufficient movement and occasional pain.

Initial objective examination When the patient was first assessed at 4 weeks post-injury, there was still noticeable swelling and some bruising around the lateral malleoli, anterior talus, posterior ankle and metatarsals of the right foot. She was walking very tentatively on the foot, which indicated some underlying instability and neuromechanical deficiencies. The patient was advised not to do any further walking for observational purposes because of swelling and pain at the injury site. Examination revealed no deformity

or muscle hypertrophy, or heat or redness. However, there was noticeable tenderness around the medial and lateral malleoli (5/10 on a VAS pain scale) and medial deltoid ligaments (5/10), as well as the CFL (6/10) and ATFL (8/10). There was no other tenderness over the lower leg or foot. There was limited active movement in dorsiflexion and plantarflexion (Figure 2) and reduced inversion and eversion, which was most likely limited by the swelling and lack of functional strength. There was no pain on active movement but a limited range of movement (Table 1). Baseline measurements of the

swelling were made and a goniometer was used to assess the amount of active movement. Passive movements were appropriate as the injury had

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TABLE 1: RANGE OF MOVEMENT AND SWELLING AT PRESENTATION ACTIVE MOVEMENT

Dorsiflexion Plantarflexion Inversion Eversion

Left malleoli circumference Right malleoli circumference Mid-metatarsal circumference

Right foot 11o

10o 1o 1o

–– –– –

Left foot 20o 27o 16o 8o

–– –– ––

Right – –

–– ––

23 cm 25 cm 25 cm

SWELLING

Left – –

–– ––

22 cm 24 cm 23 cm

dorsiflexion plantarflexion

occurred some time previously and healing had already occurred in some form. In this way, the degree of stiffness of the ankle was revealed, with a limited to no bounce (and pain) at end-range. The total range was very limited, which explained the difficulty in walking. Due to this swelling, pain and limited range, no resisted movements were carried out, and treatment was started directly.

TREATMENT The patient made seven visits to the clinic in total and the treatment evolved according to her progress during that time.

Session 1 The swelling and bruising were the priorities, especially the former in order to restore range of movement and enable further rehabilitation. Ice application helps because the initial temperature drop causes a constriction of small localised blood vessels, preventing hemorrhaging

Figure 2: Plantar and dorsiflexion (video available online)

(5). Compression from strapping also helps reduce swelling (6). Therefore, the ankle was then strapped and ice was applied for 20 minutes as recommended by Garrick (5). The ankle was elevated during this treatment, allowing gravity to work on the lymphatic system and reduce build up of hydrostatic pressure (7). When the ice was removed, both the swelling and the pain score were reduced. A horseshoe compression bandage was applied following the ice to stabilise the joint and further compress the injury site. Due to the time lapse between injury and presentation, management would differ from that for an acute lateral sprain. The healing processes was already well underway so chronic instability was more of a concern than promoting acute repair. The client was advised to keep the leg elevated as much as possible, with minimal walking and driving until the swelling and pain were under control. The

BOX 1: PROBLEMS WITH INADEQUATE MANAGEMENT AND POSSIBLE DIFFERENTIAL DIAGNOSIS

Most cases of ankle ligament injury are resolved satisfactorily with correct treatment and rehabilitation, This enables the pain and swelling subside and soft tissue structures to heal and progressive exercises can be used to increase movement, strength and joint stability.

Patients who try to progress too quickly or use an ineffective rehabilitation program can develop a state of chronic instability in the weeks post injury. This is commonly seen in sports, so the key to successful rehabilitation is accurate diagnosis and effective management. In cases like this one, there may be other underlying conditions behind the extended injury. Undiagnosed fractures or other bony abnormalities may be limiting the rehabilitation process and can be easily missed on x-rays. If the condition fails to improve satisfactorily, referral for further testing is in order, because of the possibility of synovial or neurological lesions.

sportEX dynamics 2010;26(Oct):11-14