Case Study 4- Muscloskeletal

Paul McMaster is a 30 year old delivery van driver who overbalanced at work whilst loading parcels into his van. He sustained an inversion sprain of the left ankle 3 days ago and has a severe sprain to the lateral ligament complex of the ankle. At present it is difficult to diagnose precisely as the ankle is very swollen/bruised and painful on certain movements and he requires crutches to walk. There is No Bony Injury to the ankle, but he is keen to return to activities as soon as possible. He has a pronounced limp and in not weight bearing evenly through the ankle, showing obvious pain as a result. He lives with his girlfriend in a 2nd storey flat.
Subjective assessment
30 year old maleDiagnosed with inversion sprain Pain when weight bearing on injured leg and requires crutches. PMH - NilDH - NilSH - Working as a delivery man, keen to return to activities as soon as possible.Lives with girlfriend in a 2nd strey flat.
History of present condition:
3 days ago-overbalanced at work while loading parcels into van.
Twisted weight-bearing plantarflexed foot sustaining an iversion sprain to left ankle.
No breakage or fracture.
Expected Signs & symptoms:
Severe sprain-
Complete tear to muscle.
significant muscle weakness and severe loss of function.
Severe pain followed by no pain.
Minimum to no pain on isometric contraction.
Bruising (ecchymosis), swelling, and tenderness
Gross joint instability.
Pronounced limp in left foot during left stance of gait cycle,weight bearing causing obvious pain.

Objective Assessment: tests to determine if there is any abnormal motion at the joint which would indicate how badly a ligament has been torn.

Active movements:
Plantarflexion – 0-15
Dorsiflexion – 0-55
Inversion – 0-20
Eversion – 0-10
Passive movements(assissted):
Plantarflexion
Dorsiflexion
Inversion
Eversion

Special Tests:
Anterior drawer sign:-
Tests lateral ligament and medial ligament integrity.
Patient prone with knee flexed.
Apply posteroanterior force to talus with ankle in dorsiflexion and then plantarflexion.
Expected signs- excessive anterior movement(both ligaments affected) or movement on both side only(ligament on that side afffected)
Talar tilt:-
Tests –in adduction tests mainly the integrity of calcaneofibular ligament but also anterior talofibular ligament.
-in abduction tests integrity of deltoid ligament.
Patient lying prone,supine or on side with knee flexed.
Tilt talus into abduction and adduction with patients foot in neutral.
Positive sign- excessive movement.
Thompsons test:-
Tests Achilles tendon rupture.
Patient lying in prone position with feet over edge of plinth.
Squeeze calf muscle.
Positive sign-absence of plantarflexion.
Gait analysis:-
Pronounced limp in left foot during left stance of gait cycle,weight bearing causing obvious pain.
Basic anatomy of ligaments in ankle
Three ligaments make up the lateral ligament complex on the side of the ankle farthest from the other ankle. (Lateral means further away from the center of the body.) These include the anterior talofibular ligament (ATFL), the calcaneofibular ligament(CFL), and the posterior talofibular ligament (PTFL). A thick ligament, called the deltoid ligament, supports the medial ankle (the side closest to your other ankle).
Ligaments also support the lower end of the leg where it forms a hinge for the ankle. This series of ligaments supports the ankle syndesmosis, the part of the ankle where the bottom end of the fibula meets the tibia. Three main ligaments support this area. The ligament crossing just above the front of the ankle and connecting the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The posterior fibular ligaments attach across the back of the tibia and fibula. These ligaments include the posterior inferior tibiofibular ligament (PITFL) and the transverse ligament. The interosseous ligament lies between the tibia and fibula. (Interosseous means between bones.) The interosseus ligament is a long sheet of connective tissue that connects the entire length of the tibia and fibula, from the knee to the ankle.


What is an ankle sprain?
An ankle sprain occurs when there is a stretch or tear in one or more of the ankle ligaments. Ankle ligaments are slightly elastic, fibrous bands of tissue that keep the anklebones in place.
Depending on the severity of the injury, an ankle sprain is classified as follows:
Grade I - Pain is present, but there is minimal ligament damage and minimal loss of function.
Grade II - There is moderate ligament damage, with a somewhat loose ankle joint.
Grade III - One or more ligaments is completely torn, and the ankle joint is very loose or unstable.