CASE STUDY FOR UCS ACTIVE MEMBER FOLLOWING SOFTBALL INJURY TO ANKLE

NAME: JASON STIPE, UCS ACTIVE MEMBER

SPORT: FOOTBALL, GYM

INJURY: SEVERE ANKLE SPRAIN

Jason sustained a severe ankle sprain to his right ankle whilst playing softball for his work during the summer in July 2008. He landed on his ankle and it turned inwards causing considerable pain and swelling to the ankle. He went to A & E the following day where an ankle sprain was diagnosed. After 3 weeks of treating his ankle himself with ice at home he contacted us for an assessment. When Jason came in to see us one evening, the only question that he wanted answering was whether he could now start running in the gym. He reported that his ankle was 90% from the injury and he was not complaining of much pain in the ankle. He was aware that his ankle was still swollen but he was not concerned about this. We took one look at his ankle and knew from the outset that he most certainly would not be running in the near future!! Not only was his ankle extremely swollen on the inside and the outside of the ankle but it had an unusual appearance. The joint and position of the ankle did not seem at all normal and on testing the strength and stability of the ankle ligaments, we advised him strongly to seek an orthopaedic opinion as he most certainly needed an MRI scan of the ankle. We felt that the ankle was extremely unstable and any amount of running on this would have made the situation far worse. Jason was initially quite shocked at this advice as was really just seeking an opinion on whether he was ready to start running.

We referred him to a reputable orthopaedic ankle surgeon, called Mr Simon Moyes, who we work very closely with here at Physio Fitness. He was seen two days later and sent immediately for an MRI Scan. As suspected, the MRI Scan showed that he had severely ruptured all the ligaments in the ankle on the inside and the outside and had sustained some bony damage to the ankle at the same time as injuring the ligaments. A bony fragment had been pulled off from the inside of the ankle during the trauma. Mr Moyes advised him that he needed surgery immediately to stabilise the ankle. Jason was obviously not expecting this news but he booked himself in for surgery.

PICTURE OF ANKLE:

Jason underwent major ankle surgery via an arthroscopic technique (key hole surgery) to reconstruct the ligaments on the inside and outside of the ankle as well as a procedure to correct the bony damage to the ankle. He was put in an aircast walking boot to enable him to weight bear on the ankle whilst it was fixed in the boot. He wore this for three weeks and then was reviewed by Mr Moyes who then gave him the go ahead to start some physiotherapy treatment for a further three weeks with us at Physio Fitness, UCS Active.

POST OPERATIVE STATE:

Jason’s movement improved dramatically

When we reassessed Jason following the removal of the walking boot, he had considerable swelling around the ankle with very restricted movements in the ankle and forefoot. His muscles in the calf had wasted away considerably and his walking pattern was not at all good. Physiotherapy treatment consisted of some mobilisations (movements) to all the joints in the forefoot and ankle and a gentle non-weight bearing exercise programme. Over the following weeks, Jason’s movement improved dramatically and he was walking well and had regained about 80% of his normal movement. We started to prescribe exercises to stretch out the tight calf muscles and also to strengthen them as well as exercises to improve his balance which always gets affected after an injury and surgery.

              Delighted with his progress

Jason went back for a review some 3 weeks later with Mr Moyes who was delighted with his progress. However, Jason still had considerable swelling around the ankle as well as some sweating around the operation sites. Mr Moyes advised him that he was to continue with the physiotherapy treatment and wait a while longer before any impact sports were started. There is a condition that occurs very rarely after surgery called Complex Regional Pain Syndrome or Sudeck’s atrophy which we diagnosed as the cause of the persistent swelling. This is a condition where the nerves get affected and it can cause redness, sweating, swelling and sometimes pain around the surgical site or in the case of a fracture around the fracture site. We therefore had to add in some exercises to work on improving the nutrition and circulation of the nerves to influence this condition. This worked in a matter of a few sessions and the sweating has now gone and his swelling has reduced by 80%.

Jason is now doing extremely well with his rehabilitation programme which has consisted of calf raises, balance work, stretches, lunges, and he has just started running in the gym supervised by us. Jason has had his final review with Mr Moyes who was extremely happy with his progress. Mr Moyes said his ankle had healed fully and Jason was given the go ahead to start playing football again. We have been working on his ability to chop and change direction quickly as one would do when playing football, especially as he is a goal keeper and this position inevitably relies on rapid changes of direction and speed. Jason has played four games of football since and is very pleased with his ankle. He is not experiencing any pain and is back to playing at his normal pace. Jason has however decided that he won’t be playing softball again!

 Jason is delighted that he finally made the call to come and see us and that we effectively diagnosed his problem before he went running in the gym that would have made it significantly worse.

Well done to Jason for putting in the time with his exercises and we wish him all the best and a good season of football ahead.

 If you know of anyone who would benefit from this kind of approach with our excellent on site facilities please do not hesitate to contact us on 07956 472468 / 020 7183 4436.

A TRAINEE PILATES TEACHER WITH BACK PAIN

PATIENT NAME:              

Alison, Trainee Teacher of Pilates

ACTIVITY:

Pilates

CONDITION:

Constant back pain 

 Alison came to see us in January 2009 complaining of constant low back pain. Alison was studying to be a pilates teacher and this pain was stopping her from performing certain exercises during her training course.  

The pain had been with her for a couple of months. To continue with her course, and be able to learn all the different pilates exercises in required to teach patients, she needed to be able to do them herself. 

This was not possible for Alison, so she was referred to us by her pilates studio. When we examined Alison, she had very poor posture and alignment. She had a considerably stiff and sore low back, which we felt was caused by extreme stiffness in her mid back between her shoulder blades. It turned out with further questioning, that she had an old unresolved shoulder injury from two years ago. At that time, she had been diagnosed with inflammation in one of her tendons in the shoulder called the supraspinatus. This condition is called supraspinatus tendonitis. 

At the time, Alison had received a course of physiotherapy treatment at a different physiotherapy practice and the problem had settled down by about 70%. However, we found out that her mid back, the thoracic spine, had never been worked on by the physiotherapists at the time of her shoulder injury. At Physio Fitness we consider the shoulder and mid back to be closely related, and believe that if a patient doesn’t have full movement in their shoulder, then their mid back will inevitably stiffen up. Alison obviously did not have full movement in her shoulder while she still had the inflammation in the tendon. 

In our experience a patient will only ever regain full movement of the shoulder if the mid back is moving normally, and, in order to allow a tendon to fully heal, a phsyiotherapist does need to make sure there are no problems in this part of the back. 

We therefore diagnosed her problem in her low back as an overstrain injury. Alison was essentially putting too much strain on her low back to compensate for the lack of movement in her mid back. Instead of her movement coming from both areas in the back, all the movement was occurring in the low back. The low back suffered in this case. This in turn, caused the muscles in the low back to work too hard and as a result they tensed up and caused her low back joints to stiffen resulting in pain. In order for us to take the strain off the low back we had to deal with the problem higher up in her mid back. We obviously had to loosen up the lower joints too. 

Her shoulder joint was also positioned badly. It was sitting too far forwards and we had to address this too. Alison therefore had a very complex problem but it was a case of identifying the exact CAUSE to treat the EFFECT of these problems.

WHAT DID THE TREATMENT CONSIST OF? 

We worked on loosening up all the joints in her back, with what we term ‘joint mobilisations’ and manipulation. We worked on improving her posture and setting her shoulder in the correct position. We also used some taping techniques to pull the shoulder backwards to give the brain the correct information as to where her shoulder should be at all times. This allows the right muscles to be retrained to hold the shoulder in the new position. We also had to give Alison plenty of exercises to keep her mid back moving. 

HOW IS SHE DOING NOW? 

Alison can now move her back freely without pain 

Alison has responded extremely well to treatment. Her low back and mid back are now moving normally and she is no longer in pain. She is able to manage this on her own now. As mentioned earlier, her old shoulder problem was unresolved. She has just had a new MRI scan on her shoulder which has shown that she still has some inflammation in the tendon and in one of the soft tissues around the shoulder that cushions one of the muscles as it attaches into the shoulder. She is now under the care of an orthopaedic surgeon who has given her some local injections into the inflamed areas. Alison is more likely to respond to this treatment now, especially as we have corrected her movement and alignment. If we had not worked out the underlying problem, then the injections would have been unlikely to have had any positive effect. Generally, if a patient is injected in an area when the strain on the tendon has stayed the same, ie. if, as in Alison’s case, the flexibility in the spine had not been corrected, then the patient would just continue to inflame the tendon. 

We will wait to see how Alison gets on with her orthopaedic consultant for her shoulder but we are certain that she will come back and see us for her shoulder, once the surgeon is happy.

Alison is delighted that she can do her course without back pain 

Alison is no longer complaining of any low or mid back pain. She is now able to perform the exercises in her pilates classes and is extremely pleased with the treatment she has received. She had been fed up with having back pain for some time, and was deeply unhappy that this pain was restricting her from pursuing her career. Now that she is getting the right course of action for her unresolved shoulder problem, Alison has said that she can finally see the light at the end of the tunnel!

ARE YOU SUFFERING FROM ANY BACK PAIN OR A PROBLEM THAT HAS NOT SETTLED WITH TIME?

IF YOU HAVE A THOROUGH ASSESSMENT BY A PHYSIOTHERAPIST THEN THE PROBLEM CAN BE TREATED.

Well done Alison for working hard on keeping your back mobile and concentrating on your posture at all times. We will see Alison no doubt over the coming months to help her shoulder problem settle down fully once and for all! 

If you know of anyone who would benefit from this kind of approach please do not hesitate to contact us on 07956 472468 / 020 7183 4436.

Shelley Abraham                                                                                           Chartered Physiotherapist

Physio Fitness is a physiotherapy practice that is based in Hampstead NW3 & Finchley N3