Patient is a 35 years old golf coach. Patient had a history of going over his ankle on both sides. General health status of the patient is good. Patient’s activity ranges from a round of18holes of golf and driving range for 60mins a day. Patient’s activity includes more walking. The main problem of the patient is pain and stiffness in right ankle. Patient had a history of slowly developed pain and stiffness over the last 4months during his full time coaching job. The aggravating factors of his problem were powerful driving range shots for 30mins and walking for 40mins. The easing factors of his problem are rest and heat for 40mins. In the 24hours pattern of pain, patient has stiffness on rising and which gets easier with gentle activity.
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On palpation there is puffiness to anterior and lateral aspect of right ankle. On examination the resisted dorsiflexion is weak and painful. There is a decreased range of motion of active plantar flexion. In passive plantar flexion pain is produced after resistance. The resisted plantar flexion is weak and painful. Active range of motion of inversion is reduced and painful. During passive inversion pain is felt after resistance. Resisted inversion is weak and painful. Resisted eversion is weak.
In accessory movement of talocrural joint, postero-anterior glide is stiff and the pain is produced at the end of range. In the distal tibio-fibular joint, longitudinal cephalad glide is painful before resistance and during postero-anterior glide the patient feels easier. The muscles are weak on both sides of ankle. The right ankle is weaker compared to left ankle. Anterior talo-fibular ligament and calcaneo-fibular ligaments show bilateral laxity. On palpation there is puffiness around the lateral malleolus. Heel raise of the patient is poor, which is 5 on right and 10 on right side.
SEVERITY, IRRITABILITY, AND THE NATURE OF PAIN
According to Petty (2006) severity and intensity of pain are related together. Severity can be determined by the ability of the patient to maintain the position or movement. Severity is a main factor to determine whether the patient may be able to tolerate overpressure and perform movements up to the first point of pain.
According to Hartley (1994) the perception of pain differs from person to person depending on the individual’s emotional status and his previous pain experiences. The intensity of pain depends on the number of nociceptors in the site of injury and the surrounding tissues. Intensity of pain can be more in the areas of high innervation than the area of poor innervations.
According to Hengeveld & Banks (2003) the intensity of pain is subjective and it varies from person to person. In this case the intensity of pain of the patient is 4/10 of visual analogue scale. The patient can play a round of18holes of golf a day and practices on the driving range for 60mins a day. He also walks for a long distance. In spite of pain the patient was able to perform his activity. So the patient’s severity of pain may be low to moderate.
Hengeveld & Banks (2003) says that irritability depends on activity causing the pain, the intensity of the activity and the time taken for the pain to subside after the activity is stopped by the patient. According to Petty (2006) irritability can be determined by the time taken for pain symptoms to ease. The symptom is said to be irritable, when the symptom persist after the activity producing pain is stopped. If the symptoms are irritable the patient will not be able to tolerate movements for longer durations. The symptoms may even get worse with activity. So the testing movements should be done with caution. In this case the aggravating factors are powerful driving rage shots for 30mins and walking for 90mins. Similarly the easing factors are rest and heat for 40mins. So the irritability of patient may be moderate to high.
However according to Hartley (1995) aching pain is related to the structures like deep ligament, deep muscles, tendon sheath, chronic bursa, compact fascia. Further Magee (2008) argues that, when pain is caused by an activity and eases with rest indicates that there is a mechanical problem which is related to movements. Occasional pain may indicate that there is a mechanical involvement and it is related to movement and mechanical stress. In this case the pain is intermittent and deep in nature. The patient has pain after activity and the pain resolves with rest. So the pain may be mechanical, intermittent and deep in nature
MANUAL THERAPY TREATMENT
In this case, the main problem of the patient is stiffness rather than pain, in the right ankle. Maitland’s grade4 mobilisation with postero-anterior glide of talus on ankle mortise can be given to improve range of motion of plantar flexion. The glide can be given in grade 4, because it is stable and controlled compared to grade3 (Hengeveid & Banks, 2003). Here the ankle mortise is a concave surface and the dome of talus is convex. When ankle mortise is fixed and talus is moved, plantar flexion occurs by concave-convex rule. (http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINmotion/JointStructionAndFunciton.htm, Date accessed: 13/12/2009)
However before treatment the important factors that should be taken into account are patient’s objective marker of pain, loss of range of motion and movements causing pain and these factors should be evaluated after treatment sessions. In Maitland’s technique, there is no standard duration for the treatment, but the duration of the treatment should not be more than 2minutes. The duration of the treatment can be altered based on the severity, irritability and nature of the symptoms of the patient. Since the irritability of the patient is moderate to high, the initial treatment can be given for the duration of 30 seconds, with one or two repetitions to avoid exacerbation of the symptoms. After observing the objective marker, duration of the treatment can be progressed to 1 to 2mins and the repetitions can be progressed gradually. The patient can be positioned in prone lying with knee in 90 degree flexion. The starting position of the therapist can be standing by the side of patient’s right knee to have close contact with the treatment area. To give proper support to the shin, the left knee is placed on the couch. The therapist can perform the postero-anterior glide by holding the posterior surface of the calcaneus in his right hand with his thumb, fingers fanning around the calcaneus and his left hand held in supination, with his heel placed against the tibial anterior surface and the therapist’s fingers are proximally pointed. These positions can be followed to stabilise the part. The force can be applied by movement of the forearms opposing each other. The movement of the therapist’s forearms produce postero-anterior glide (Hengeveld & Banks, 2003).
Even though, there are literatures supporting the effectiveness of joint mobilisations, there is not enough controlled studies to prove that joint mobilisation can restore the normal range of motion and functions of hypomobile joint effectively (Farrel, J.P & Jenson, G.A. 1992)
EFFECT OF MAITLAND MOBILISATION
Maitland’s technique, are based on restoring arthrokinematic movements. Generally arthrokinematic motion of the joint can be restricted by the ligaments, capsules of the joint and periarticular fascia. The elastic properties of these connective tissues are based on the arrangement of the collagen bundles. In ligaments and tendons, the collagen bundles are arranged parallel to each other with elastic bundles in between them. When the connective tissue structures are unloaded, the collagen bundles show a crimp formation in their structure. This crimp results in production of slag in the connective tissue structure. During the phase of loading, slag is stretched first, followed by the stretching of main bundles. In contrast the fascia and aponeurosis have multilayer collagen bundles but have less crimping and slack compared to ligaments. Initially when the load is applied, structures with less slack are first subjected to stress, followed by the other bundles. The bundles of the fascia which have least slag will first resist the tensile stress. If the stress is increased then the ligaments which have more slag will resist the tensile load. After further deformation, the other bundles will act to resist the stress. To obtain elongation of the connective tissue on the whole, all the bundles should be subjected to required stress. This principle can be explained with the help of stress strain curve.
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In this graph, x-axis represents the stress and y-axis represents the corresponding strain produced by the load. The curve shows a slope, which indicates the connective tissue resistance to a load. The collagen bundles which are still slag, represent the toe region. The curve also represents the physiological loading range, which is then followed by the stage of microscopic failure. If the stress still increases the curve will proceed to the stage of macroscopic failure and may even result in the rupture of the connective tissue. Based on this concept Maitland’s grade 4 technique aims to produce permanent elongation (plastic deformation) of the tissue by inducing low level of micro-failure in the connective tissues, there by increases the range of motion (Therkeld, 1992).
There is no enough evidence to prove that Maitland’s mobilisation can be done in full weight bearing and functional position. Its reliability is based on the clinician’s treatment experience and patient’s reaction to the treatment (Farrel, J.P & Jenson, G.A. 1992)
The other problems of the patient are poor heel raising due to the weakness in the muscles of ankle joint and pain. In this case Maitland’s grade1 mobilisation can be given to reduce pain by pain gate mechanism. As the patient is a golf coach, he needs good heel rising and strong ankle muscles for good performance in the game and to prevent further injury to ankle joint. Strengthening exercises to the muscles of plantarflexion, dorsiflexion, inversion and eversion can be taught to the patient to correct the muscular imbalance of the patient. Then the heel raising should be encouraged gradually and can be progressed if there is no pain. Balance training with the help of wobble board can be taught to the patient. The final phase of treatment is functional training. The patient can be trained to gradually increase the intensity and the duration of drive shots in the game. Walking can be encouraged in a stable surface.
Additional to manual therapy the effective means of rehabilitation of sports injuries should consist of soft tissue massage, electrotherapeutic modalities, proprioceptive neuromuscular facilitation, strengthening exercises, co-ordination training, endurance, flexibility, improving stability and educating the patient about the injury mechanism and methods of prevention (Farrel, J.P & Jenson, G.A. 1992). Sports therapist should mainly concentrate on prevention of the injury rather treating when the injury has occurred.
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