Case Study: Ankle Sprain

1- Collecting data:
1.1-Personal information:
- Name: Mohammad Haj Hassan
- Age: 28 Years old
- Gender: Male
- Job: Adjudant
- Hobbies: Handball
- Date of trauma: 25-8-08
- Date of first physical therapy session: 17-11-08
1.2-History:
Upon going downstairs, the patient twisted his right foot inward on a stone where he
feels pain. The patient went at the same day to the hospital and consulted an orthopedist
where an x-ray was done to his right ankle. Then the orthopedist diagnosed his case as
ankle sprain.
A pedius cast (from the toes to the mid calf) is put for 23 day accompanied with
analgesics.
1.3-Medical history:
Before this trauma, and during playing handball, the patient was affected by three
sprains in the right ankle joint. One of them in 1999, the other in 2003, and the last in
2007.
1.4-Surgical history:
The patient is not exposed to any surgery in his life.
1.5-Risk factors:
-Smoking: No.
-Diabetes: No
-Hypertension: No
-Alcoholism: No
-Allergy to certain medications: No

2-Exams and Assessments:

2.1-Plan of assessment:
-General assessment
-Radiological assessment
-Articular assessment
-Pain assessment
-Trophic assessment
-Muscular assessment
-Functional assessment
2.2-Results of assessment:
2.2.1-General assessment:
The patient arrived to the clinic walking normally without any disturbances or any
alterations.
2.2.2-Radiological assessment:
The x-ray was done and shows no appearance of any fracture in the right ankle.
2.2.3-Articular assessment:
a) Observation: -The right ankle joint has no abnormal attitudes.
- Edema is not observed.
.
- Color of skin is normal.
b) Palpation:
- All the bony marks are palpable and normally placed (medial and
lateral malleolus)
- Normal temperature
c) Mobilization: - Active and passive movements of the right ankle are complete and
without limitations.
d) Retraction test: - The patient has a retraction in his right gastrocnemius muscle.
(this test is performed when the patient is lying supine and his
knee are fixed and compressed by the therapist in an
extended position and the therapist passively make
dorsiflexion to the patients right foot).
2.2.4-Pain assessment:
- Location of pain: In the anterior aspect of the right ankle between the two malleoli
-Depth of pain: Superficial.
-Irradiation: No.
-Causes of pain: - When standing or walking for long time.
- When holding heavy weights.

2.2.5 -Trophic assessment:

2.2.5.1-Cutaneuos trophy: Observation shows no scar, no edema, and normal color of
skin.
2.2.5.2-Muscular trophy: Observation shows no amyotrophy of the muscles compared
to the normal leg.
Circumference measurement was done and the results are
summarized in the following table:
Segment: Leg
16 cm from the apex
of patella.

Right
40cm

Left
40cm

Difference
0cm

2.2.5.3-Bone trophy: Observation shows no difference between the bones of the to

sides
2.2.6-Muscular assessment:
The plantar flexors and plantar extensors of the right ankle are slightly weaker
than the normal side
2.2.7-Functional assessment:
-The patient can do all the daily living activities normally, but he becomes tired if he
overused his right ankle.
-He still can not practice or play handball.
3. Conclusion:
-Pain appears when standing for long time or when holding heavy objects.
-Muscle weakness of his dorsiflexors and plantarflexors
- Retraction of his right gastrocnemius muscle.
- Functional disturbances.
4. Treatment:
4.1-Objectives:
- Short term: - Pain relieving
-Muscle strengthening
-Long term: - Regaining of functional movements.
-regaining of his sport activities.

4.2-Applications:
4.2.1-Ultrasound: Pulsed ultrasound applied for 7 minutes on the painful area (right ankle
joint)
4.2.2-Electrotherapy (TENS): It is a pain relieve therapy which is applied on the painful
area for 10 minutes where the two electrodes are put on the lateral and medial malleoli.
4.2.3-Stretching exercises:
-The patient is sitting (half lying position) with his right knee straight. He holds a
towel and loops it around the ball of his right foot. The patient slowly pulls back until he
feels his right upper calf is stretched.

-The patient is in standing position facing a wall. He places his right affected foot
behind the left normal one with his toes are pointed upward ( keeping his heels down and
his back leg straight) .The patient slowly bend his front knee ( left knee) until he feels his
right calf stretched.

The patient must do these exercises in 30 repetitions.

4.2.4-Strengthening exercises:
-Plantarflexion of the right ankle for 60 times with 7 kg used as resistance.
-Dorsiflexion of the right ankle for 60 times with 5 kg used as resistance.
- Inversion of the right ankle for 60 times with 1.5 kg used as resistance.
4.2.5-Methods to speed up recovery:
PRICE is the most convenient method for speeding up recovery:
-Positioning: The right ankle must be splinted, taped, or braced to prevent further
injury.
-Rest:
The patient must rest from all activities that cause pain or limping.
(the patient can use a cane until he can walk without pain or limping).
-Ice:
The patient can put a plastic bag with ice on the right ankle for 15-20
minutes, 3-5 times a day for the first 24-72 hours.
-Compression: The patient can wrap an elastic bandage from the toes to the mid calf
of the right foot, using even compression.
-Elevation:
The patient must elevate his right ankle above his heart level.
4.2.6-Proprioceptive technique:
This is done using a fremen plate to increase balance. The patient flexes his knees
and tries to stand on the plate without fixing his hands.

Ankle Joint
1-Ankle Anatomy:
The ankle joint is also called the talocrural joint. It is a synovial hinge joint formed by
the connection of three bones: The tibia, the fibula, and the talus bones.
1.1-Tibia (shin bone): -It is the larger, medial, and weight bearing bone of the leg.
-It articulates at its proximal end with the femur and the fibula, and
at its distal end with the fibula and the talus
-Its proximal end is expanded into a medial condyle and a lateral
condyle.
-the tibial tuberosity is located on the anterior surface the tibia and
It is a point of attachment for the patellar ligament;
-The medial surface of the distal end of the tibia forms the medial
malleolus which articulates with the talus.

1.2-Fibula:

1.3-Talus:

- It is parallel and lateral to the tibia, but it is smaller than tibia.

- Its proximal end, the head, articulates with the inferior surface of
the lateral condyle of the tibia.
- Its distal end has a projection called the lateral malleolus that
articulates with the talus bone.
- It is the main bone of the ankle located in the posterior part of the
foot.
-The top of the talus fits inside a socket that is formed the lower
end of the tibia and the fibula.

2-Anatomical components of ankle:

2.1- Articular capsule: It surrounds the ankle joint and encloses its synovial cavity, and
unites its articulating bones.
2.2-Ligaments:
2.2.1-Lateral collateral ligaments:
-Anterior talofibular ligament: It is attached to the anterior margin of the fibular
malleolus and inserted into the talus bone.
-Calceneofibular ligament:
It arises from the depression infront of the apex of
the lateral malleolus and inserted into the lateral
surface of the calcaneus.
-Posterior talofibular ligament: It arises from the medial surface of the lateral
malleolus and inserted into the posterolateral
tubercle of the talus.
2.2.2-Medial collateral ligaments:
2.2.2.1-Superficial fibers: - Deltoid ligament: It arises from the medial malleolus and
inserted into the sustenaculum tali of the calcaneus.
2.2.2.2-Deep fibers:
-Anterior talufibular ligament: It arises from the tibia and
inserted into the medial aspect of the neck of the calcaneus.
-posterior talufibular ligament: It arises from the tibia and
inserted into a deep fossa on the medial surface of calcaneus.

2.2.3-Anterior ligaments: It arises from the anterior margin of the lower end of the tibia
and inserted into the upper surface of the anterior part of the
neck of the talus.
2.2.4-Posterior ligaments: It arises from the tibia and fibula and inserted into the
Posteromedial tubercle of the talus.
.

2.3-Articular cartilage:
Inside the ankle, the bones are covered with a slick material called articular cartilage.
This durable material covers the ends of the tibia, fibula, talus, and calcaneus bones. The
articular cartilage lining is about one-quarter of an inch thick. This allows the ankle bones
to move smoothly against one another and acts as a natural shock absorber. Articular
cartilage is soft enough to allow for shock absorption, but tough enough to last a lifetime,
as long as it is not gusinjured.
2.4- nerves:
- sciatic nerve.
- Tibial nerve.
- Peroneal nerve.
- Sural nerve.
2.5- Blood vessels:
- femoral artery.
- Popliteal artery.
- Anterior tibial artery.
- Posterior tibial artery.
.
3-Movements and related muscles:
3.1-Plantar flexion: - Bending of foot at ankle joint in the direction of plantar. (inferior
surface)
- Muscles related to this movement: Soleus, gostrocnemius,
plantaris, Tibialis posterior, flexor hallucis posterior, and flexor
digitorum Longus.
3.2- Dorsiflexion: - bending foot at ankle joint in the direction of dorsum.
- muscle related to this movement: Tibialis anterior, extensor
hallucis Longus, extensor digitorum longus, and peronius tertrius.
3.3- Inversion:
- The sole movement at the entertarsal joint so that they face each
other.
- Muscle related to this movement: Tibialis posterior, flexor hallucis
Longus, and flexor digitiorum longus.
3.4- Eversion:
- Movement of soles laterally at intertarsal joint so that they face
away From each other.
- Muscle related to this movement: Peroneus longus and brevis.

4-Ankle Sprain
4.1-Definition: a sprain is a forcible twisting, wrenching, or turning of the joint that
causes stretching and tearing of its ligaments that hold the ankle and foot bones together
and can lead to instability and re-injury. The most, type is the inversion ankle sprain in
which the foot is rolled inward.

4.2-Types of ankle sprains:

- First degree ankle sprain:
* Some stretching or mild tearing of the ligament.
* Little or no functional loss - the joint can still function and bear some weight
(...but hurts!!!).
* Mild pain
* Some swelling
* Some joint stiffness.
- Second degree ankle sprain:
* Some more severe tearing of the ligaments
* Moderate instability of the joint
* Moderate to severe pain - weightbearing is very painful
* Swelling and stiffness
- Third degree ankle sprain:
* Total rupture of a ligament - there is a loss of motion
* Gross instability of the joint - joint function is lost
* Severe pain initially followed by no pain
* Severe swelling

Lebanese University
th

Faculty of Public Health- 4 Branch

Physiotherapy Department

Training Report
Kamal Okais clinic
From 17-2-2009 to 3-4-2009

Submitted to: Mme. Rabab Zoghbi

Admitted by: Cynthia Houchaimi
2nd year physiotherapy

1. Collecting data:
1.1-Personal assessment:
-Name: Fadi Maalouf
-Age: 28
-Gender: male
-Profession: kitchen worker
-Marital status: single
-Address: Maalaka
-Date of trauma: about 3 month
-Diagnosis: medial collateral ligament compression
-Doctor's reference: Dr. Hamze Mazloum
-Physiotherapist in charge: dr.Kmal Okais
-Date of first session: 16-3-2009
1.2-History:
1.3-Medical history:
-Naproxen
-Anti-inflammatory
1.4-Surgical history:
-Surgical of the left arm and forearm after fracture
1.5-Risk factors:
-Alcoholism: No
-Smoking: No
-Obese: No
-Diabetes: No
-hypertensive: No
-Drug: No
2-Assessment and exam:
2.1-Plan of assessment:
2.1.1-General
2.1.2-Radiological
2.1.3-Pain assessment
2.1.4-Articular
2.1.5-Trophic
2.1.6-Muscular
2.1.7-Pain
2.1.8-Functional

2.2-Result of assessment:
2.2.1-General:
The patient is arrived to the clinic walking with limping on the left leg.
2.2.2-Radiological:
IRM was done to the patient on the left knee and a small blood was shown at medial
border of the knee.
2.2.3-Pain assessment:
-Location: on the medial aspect of the knee
-Quality: ache
-Intensity: 2/10
-Depth of pain: superficial
-Time: when standing and at weight bearing
-Aggravating factors: in standing position at long time
-Easily factors: at rest and extension of the left knee
-Irradiation: on the posterior aspect of leg and at ankle joint
2.2.4-Articular assessment:
a-Observation:-No presence of edema
-Normal color of skin.
-Attitude in flexion compared with the right knee
b-Palpation:-Normal temperature
-All bony marks are palpable and normally placed (lateral and medial
epichondyl and lateral maleollus)
c-Measurement:
1-Articular volume:
Segment
Left
Right
difference
Center of patella
39,5cm
42cm
2,5cm
2-Goniometry:
Goniometric measurement was done to the patient left and right knee and the
result are obtained in the following table:
Movement
Left
Right
Active
Passive
Flexion
118
120
122
Extension
0
0
0
Note: we measure the articular volume by tape measurement and the goniometry is
measured by goniometer.

e-Rretraction test:
Muscles
Illiopsoas
Adductors
Hamstring
Quadriceps
Gastocnemuis

Left
+
+
+
+
-

Right
+
+
-

f-Conclusion:
The difference on the center of patella due to the edema and the degree
Note: we measure the articular volume by tape measurement and the goniometry is
measured by goniometer.
2.2.5-Trophic assessment:
2.2.5.1-Cutaneous trophicity:
a-Observation:-Edema is presented
-No scar
-Normal color
b-Palpation:-Normal temperature of skin
-All bony marks are normal
2.2.5.2-Muscular atrophy:
a-Observation: No difference between the 2 limbs
b-Palpation: loss of tonicity of the left lower limb in comparison to the other lower
limb
c-Measurement:
Circumference measurement was done and the results are summarized in the
following table:
segment
Left
Right
Difference
Above the base
At 5cm
41cm
43cm
2cm
of patella
At 10cm
44cm
46 cm
2cm
At 20cm
52cm
54cm
2cm
Apex of patella
At 12cm
35cm
38cm
3cm
Note: the measurement is done by tape measurement
d-Conclusion:
Edema is presented on the left leg, so amyotrophy can be assured

2.2.6-Mucular assessment:
The muscular grade testing is summarized in the following table:
Muscles
Gluteus medius
Quadriceps
Hamstring
Tensor fascia lata
Adductors
Gastrocnemuis

Left
4
4
4
4
4
4

Right
5
5
5
5
5
5

Conclusion: there is no muscle weakness

2.2.7-functional assessment:
She has a moderate difficult when she was walking between rooms and when she
standing for hours.
She has a difficult to getting into or out of a car and to going up or down of stairs
She is unable to putting on her shoes and to rolling in bed
2.3-Conclusion:
The patient has a sever pain and edema in left knee and she has a limitation in flexion
and extension movement
3-Treatment:
3.1-Objective:
a- Short term:-Relieve pain
-Reduce edema
-Regain of active and passive range of motion
-Muscle strengthening
b- Long term: Regain of normal functional activity
3.2-Applications:
Ultrasound: Pulsed ultrasound applied for 14minutes on the painful area (left-3.2.1
.knee joint) for relieving pain
Electrotherapy (TENS): It is a pain relieve therapy which is applied on the-3.2.2
.painful area for 10 minutes where the two electrodes are put on knee
:exercises -3.2.3

The patient is in supine position; he performs an isometric contraction of the

quadriceps muscle with weight supported on the distal leg (2kg)
the patient is in sitting position; he performs a knee flexion with resistance
.applied by elastic thera-band
4-Instuction:
The patient should perform the exercises demanded by the therapist
The exercises are:
- Isometric contraction of the quadriceps muscle
-Flexion of the knee in prone position
-walking normally