David Butler has been posting noinotes since 2008. It’s now a treasure trove of over 50 posts on topics covering everything from the brain, peripheral nerves, tattoos, nudity to a bit of philosophy.
For today’s Flashback Friday here’s a very nice little clinical gem from June 2009 on a common problem.
The art of the problem sprained ankle
A common clinical presentation is a patient with a 3 month (or thereabouts) history of an inversion ankle sprain, with persisting symptoms of pain and swelling and reports of altered function. We think it is so common, that in many cases it is not even clinical – i.e. that person has not bothered to turn into a patient. Using the world of clinical experience, backed by some neuroscience, here is how to help the patient or person fix most of these problems.
The problem ankle findings
On the problem foot, there may be a slight range limitation and symptoms evoked on plantar flexion and inversion. ‘Giving way’ is common. The ankle probably still has some pitting oedema. On the neurodynamic test for the fibular (peroneal) nerve (ankle plantar flexion and inversion plus SLR) symptoms are typically worsened with pains and pullings along the peroneal tract at around 40 degrees. Frequently, there are limitations in the tests of sural (dorsiflexion and inversion and SLR) and the tibial (dorsiflexion and eversion plus SLR). On the other ‘good’ side, symptoms are much less and the range considerably higher.
How to fix – five key points
These ankles are easy to manage and are very appropriate for self management.
1. Tell the ankle owner (AO) and anyone else interested, what is probably happening. That a peripheral nerve is a bit irritated and sticky in the swelling and maybe it has had a slight sprain as well. That an ankle sprain is no insignificant event and a bit of swelling and pain is normal as the brain tries to fix the final few problems. Tell them there are little sensors in nerves and they report the chemicals, the pulls and pressures and even stress and temperature. These calm down when the brain is satisfied that the ankle is OK. Tell them that the whole central nervous system is aware of the ankle and keeping an eye on it and that’s why all ankle movement may hurt a bit. But make sure they know its all good and normal and a part of the healing process in a healthy individual. In fact they should be proud of their nervous system for looking after them, but it needs a bit of advice. Check and tell them the ankle is stable but sensitive.
2. Tease and wriggle the peroneal and other appropriate nerves. Find three or four ways to wriggle the nerves, for examples see the The Sensitive Nervous System or the DVD handbook. Wriggle in and out of some discomfort as long as the ankle owner knows that it is a good pain – maybe 6 times a day with 20 or so mobilizations until you come to an ideal baseline. It won’t need much.
3. Keep up the graded proprioceptive input. Wobble boards are OK but we don’t use wobble boards in everyday life. Walk on uneven surfaces, rocks etc. Let the ankle reconstruct its role in the brain by reducing fear of use.
4. Most ankles will improve in a few days with range restored in perhaps 2 weeks or less. Much of it can be done actively. Wriggle it into a little bit of pain if the owner understands that it is an OK pain. The ultimate ankle technique will be to take up the ankle movements first, then SLR and then wriggle the ankle.
5. But the brain won’t forget. These are novel movements superimposed on a disturbing injury. It is likely, even normal, that there will be a response of increased pain, even some swelling and perhaps disturbed sleep during the treatments. Movement improvements will usually still be obvious. No panicking please– tell the AO that it is normal, its the brain checking out what is happening and probably creating a bit of a response to seek more input and knowledge on which to base actions. And at the ankle itself there is a bit of excitement with the refreshment of new tissue movement as the sensors adjust. It’s all good – these ‘flare-ups’ will only last a day or so.
I suspect that if David had the chance to re-write the above today, there might be at least one extra key point added – another aspect of a troublesome ‘ankle’ worth considering and checking out.
What, if anything would you add to the above?
– Tim Cocks
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I’d also like to hear how David would approach this today, 5 years on.
I feel like most patients don’t digest or retain information too well, so I tend to keep it very simple. Something like: “The ankle ligaments have healed fully, but the nerve is still irritated. If I settle the nerve down with some treatment, you will find …. “.
There is one instance where I might deliberately use a lot of technical talk in a rapid fire delivery, and that would be for a patient who has made himself anxious through over-analysis. Erickson’s confusion technique can be handy for this situation. At the moment the patient’s eyes glaze over you introduce the words: “…. and so what this all means is … YOU CAN RELAX AND LET ME FIX THIS FOR YOU”.
In terms of the physical treatment, I find myself doing broadly the same thing with almost everyone, whether it’s a back, knee, ankle … whatever. A bit of interferential and a quick rub. Done.
GMI is a must don’t you think? ……it’s not a science reserved for the persist ants…….
Thanks for digging this out Tim,
I think my management these days would be reasonably similar with two small changes . The posters above have touched on them. I would test the left right discrimination abilities of the feet and I wouldn’t be surprised if there were some left right differences. I wouldn’t be surprised if there weren’t as well. If there was, I would treat and expect fairly rapid changes.
I would talk – around the notion of “well done – great inflammatory healing response, it just neds a bit of help”. And in these self management days I see no harm in jumping on the bed as Cameron might and saying “let me help you fix that” with a few techniques. I’d probably hold the ultrabullshit and interferential though !