Case Study…..16yr old netball player with an acute L) ankle sprain.By Katrina Egan

Case Study

 

16yr old netball player with an acute L) ankle sprain.

 

 

Subjective

 

  • Pt presented complaining of pain in the left ankle, with accompanying swelling and mild bruising.
  • She presented at the clinic 2 days following a unusually small movement while changing directions during a game of netball, causing a forced inversion of the left ankle.
  • The pain and swelling was immediate, causing her to discontinue play.
  • At initial consultation the pain was as bad as it was initially and was constant in nature.
  • Pain was aggravated by any weight bearing or movement at the ankle joint, and she was mobilising with the use of 2 crutches.
  • Pain was eased with rest, however was achy at nights, disturbing sleep.
  • There was no previous injury, her general health was excellent and she was not taking any medication.
  • The ankle was x-rayed on the day of the accident and no fracture was evident.
  • This young girl was looking forward to returning to sports, but as this was the end of the netball season she was more concerned about beginning tennis practice.

 

Rationale
  • Asked mechanism of injury to give indication of structures damaged and force inflicted on these structures.
  • Impt to find out how long ago the injury was, what happened immediately i.e. swelling, unable to play, so to determine the extent of the damage and then how the pt managed it in the first 24-48 hrs.
  • Found out what part of the season it was, and how that effected the individual, so as to come up with goals.
  • From this subjective exam able to determine the acuteness and severity of this sprain, indicating care was to be taken in objective testing.  Symptoms looked to be easy to reproduce b/c of nature of mechanism of injury and intensity of discomfort.
  • Nil neurological exam seemed warranted at this stage due to nil description of pins and needles.
  • The appropriate treatment was becoming very clear following this subjective assessment.

 

Objective Examination

 

  • To observe the ankle was grossly swollen and bruised, with the majority of the swelling in the lateral aspect of the distal 1/3 of leg and around both med. and lat. Malleoli
  • AROM: p/flex was full but pain EOR, d/flex was full and pain free, inversion was restricted by 20% due to pain, eversion was full, but discomfort EOR.
  • Resisted Movts – Pain with eversion and d/flex
  • TOP – distal peroneal tendons, all around lat mal. Including ant, lat and posterior portions of ligament and tender around the inferior aspect of the med. mal.
  • Nil numbness or tingling, and full sensation
  • Anterior draw was not assessed at this stage due to severe pain, nor was 1-legged balance due to inability to weight bear.

 

Rationale
  • Interesting to note the site of the swelling and the stage and extent of the bruising.
  • Obvious from restriction and pain provocation in ROM the most significantly damaged structures, that was the ant and lat portions of the lateral lig.
  • Pain on resisted eversion indicated some peroneal m/s damage
  • Didn’t test anterior draw or balance to acute nature of injury.  Need to take each assessment as a separate issue, and test what is appropriate.
 
 
Short Term Goals

 

  • Dec. pain and swelling within 3 days
  • Gain full ROM in 5-7 days
  • Get off crutches within 7 days

 

Long Term Goals

 

  • Reduce pain and swelling
  • Regain proprioception, strength and full ROM

§  Return to tennis training in 4-6 weeks

 

Treatment Notes

 

Day 2              Rx:      very gentle STM (soft tissue massage)

                                    Pu/s @ 0.8 w/cm for 4 mins   

                                    10 mins ICE

                                    U foam med and lat, rigid tape and elastic bandage

                        Advice:  ice 3-4 hourly, stay off it, gentle ROM ex’s

Rationale

  • The goals of the first Rx were to set the scene for the best possible healing environment, thus assisting the rehab. From the beginning stages.  Thus focussing on reducing swelling, bruising and pain.  It was important to give pt a clear understanding of the injury and the management plans and time lines.
  • This first Rx achieved the desired results, with good reduction of swelling and a positive and confident attitude from the pt.

 

Day 4              S:         feeling easier, pt pleased with progress

                        O:        Swelling markedly reduced, partic. around U foam

                                    Bruising has increased

Surprisingly not as TOP (tender on palpation) as thought

                        A:        Benefited from compression, healing process under way

                        Rx:      more firm STM and gentle fricts to lat ankle

                                    Pu/s and ice a/a.  Re-wrapped a/a

                                    Started on 20% TWB with crutches

Rationale

  • There was a great need to get this pt off the crutches as she had a history of wrist pain, and was unable to tolerate the crutches. 
  • Also wanted to start the gait pattern as soon as possible, and get some weight bearing.

 

Day 6              S:         con’t improvement

                        O:        swelling and bruising con’t to subside

                                    Able to walk with 90% wt bearing

                                    Con’t to be TOP in both med and lat aspects

                        Rx:      fricts, STM and p/us a/a

                                    Heat vs ice

                                    Re-bandaged without U foam

                                    Working towards being off crutches over the w/end

                                    Encouraged con’t stretching of calf m/s

Day 9              S:         Doing well, off crutches completely

                        O;        walking with flat footed gait

                                    Swelling and bruising con’t to reduce

                                    Able to stand on 1 leg, but very poor balance

                        Rx:      a/a

                                    Gait re-education – heel-toe

                                    Started 1 legged balancing

Rationale

  • Now that wt bearing is tolerable able to start proprioceptive training and ensure gait returns to normal pattern.

 

Day 11            S:         Reports she is walking as normal, but has slight discomfort with walk and was sore after full day at school yesterday.

                        O:        1 legged balance still very poor

                        Rx:      a/a

                                    Stretching T.A.

                                    Mobilising TC jnt

Day 13                        S:         pt has feeling of plateau, and getting quite frustrated.

                                    Feeling quite sore in ankle with full day of wt bearing

                        O:        Very TOP of the lat mal. partic to tapping

                        Rx:      a/a including re-bandaging

Advice – to reduce walking, take it easy over the w/end.  Suggested that if concerned that there was an undetected #, should go and get it -x-rayed again.

Rationale

  • I didn’truly believe there was a fracture, however both the pt and her mother were convinced there was, therefore was best just to let that be confirmed.
  • Once this was disregarded, progress was much greater, with increased pt confidence.
  • However, I did miss that fact that she was not taking Voltaren and this did help to increase progression.

 

Day 16                        S:         went and had an x-ray immediately upon leaving previous visit!

                                    No # was detected, but pt prescribed Voltaren, which helped

                                    reduce pain, and pt much happier.

                        O:        Less TOP, min. swelling and nil bruising

                        Rx:      a/a plus introduced 1 leg SKB’s, t/band eversion and 15min walks.

Day 18                        S:         Walking around school now OK, just aches EOD

                                    Reports hasn’t done t/band ex’s

                        O:        con’t to be TOP all 3 portions of lat lig.

                        Rx:      fricts / STM to lat ankle

                                    U/s @ 1.2 w/cm for 3 mins

                                    10 mins H.P.

                                    Going over ex’s at home, and encouraged hitting ball vs wall.

Rationale

  • Progress was continuing and pt was keen to get back into tennis.  Felt hitting a ball against a wall would be good psychologically as well as extending her physically

 

 

Day 20                        S:         Has now discarded tubigrip.  Coped well with tennis ball hits.

                        O:        Less TOP

                        Rx:      a/a encouraged jogging over the w/end

Day 23                        S:         Walking long distances and hitting ball for 30 mins with no probs

                        O:        TOP to deep pressure only over ATFL

                        Rx:      fricts with deep pressure, went over hopping and rebound running

Rationale

  • Pt went thru a very uncomplicated progression with key milestones being achieved.  She is now returned to tennis training with tape initially.
  • She is coming into to be checked in approx 7-10 days, but has been instructed to continue proprioception training and eversion t/band ex’s.
  • I think this severely sprained ankle was rehabilitated well, with the co-operation of a motivated pt and a supportive mother.
  • I feel very strongly about the importance of the initial ice and compression, and the benefits of staying off the ankle for the first few days at least.

Katrina Egan… M.HSc (Hons)

Based in Mooloolaba Sunshine Coast Queensland Australia

Katrina is a NZ trained physio holding a Masters degree. She is one of the few qualified Manipulative Physiotherapists on the beautiful Sunshine Coast in Australia.

Still a strong All Blacks New Zealand Rugby supporter, (we will forgive her for that!!) Katrina enjoys what the coast offers, paddling and swimming regularly with the Maroochydore SLSC. As a former international athlete (1992 World Surf Ski Champion), a national kayak coach and a recent finisher of the Coolangatta Gold, Katrina has a very good understanding of the athletic body and the need to keep training. Kat’s passion is her two dogs, Mana and Kia. Her canine and physio interests combined in completing a Level 1 Canine Physio course last year, and she is very happy to exchange ideas about your four legged family members.

As the practice principal Kat leads with enthusiasm and an excellent hands-on approach. After 20 years in the profession she has the experience and knowledge to assist everyone. Katrina also has a great network of other professionals that she is also happy to refer you to if necessary

www.johnhartfitness.com

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