Not all injuries are what they seem. It is not acceptable to treat patients' symptoms without first establishing the aetiology of the presenting pathology. In other words, one must delve into the history - which is most important - and assess all factors contributing to the problem. It is surprising, mainly for the patient, what good questioning can reveal, and how the physio-therapist arrives at a different diagnosis. Without proper diagnosis one cannot treat successfully.
There are times when a differential diagnosis is missed by an inexperienced practitioner and therefore subsequent treatment and rehabilitation is ineffective, time-consuming, and expensive for the patient.
The following case-studies are examples of some tricky presentations which could have been misdiagnosed by the practitioner, were it not for a detailed history and a thorough assessment of the underlying factors.
CASE-STUDY 1: a footballer's knee
A 29-year-old footballer was referred to the Sports Injury Clinic following a reconstruction of his right anterior cruciate ligament (ACL) six months previously. The patient had been discharged by his hospital physiotherapist and was told he could return to sport, but the patient, even on gentle jogging, did not trust the knee and felt it might 'give way' under him.
The anterior cruciate ligament is a crucial stabiliser of the knee joint and controls excessive rotation coupled with forward glide of the tibia (lower leg) on the femur (thigh). When this ligament is ruptured, there is increased 'play' between these joint surfaces and the patient may experience the knee giving way when he suddenly turns or accelerates/decelerates.
The patient's right ACL was reconstructed using part of his patella tendon with a successful outcome, ie, a stable knee. He then received six months of hospital physiotherapy.
On presentation he had regained approximately 75 per cent strength of the knee. This was tested by evaluating the strength of the quadriceps and hamstring muscles of the dominant right leg and comparing to that of the left leg. The muscles were considered to have been strong when tested in a non-functional sitting position, but due to the continued symptoms of the knee giving way it was surmised that the patient had insufficient recruitment of the muscles during dynamic/ functional activities.
The key goal to this patient's treatment was therefore to functionally rehabilitate the muscles to control the knee through a series of progressive sports-specific tasks which would require the muscles to work together (co-contract) at an involuntary or reflex level. The patient was taught to monitor his own muscle activation with the help of a bio-feedback unit which was attached to the relevant muscles. When the muscle is working, the activity level is registered by audible bleeping, and the patient can thus be continually informed as to how he is using the muscle to control the knee.
Over a period of six to eight weeks, the patient worked with the bio-feedback unit to relearn co-contraction of the thigh muscles, initially in a squat position. He then progressed to lunging, hopping, jogging and running. On achieving functional control of the muscles during each task, the patient was then progressed to a higher level of difficulty. At this stage he started more sports-specific activities such as accelerating, decelerating, figure-eight running and twisting rotation of the knee. This was progressed to sprint acceleration/deceleration with a rotation component against the resistance of a band attached to his torso. All these activities were requirements needed before the patient could return to football with the full knowledge that the knee would not give way during a game.
He returned to participate in football practices eight months after the operation. Once the subjective feeling of instability and weakness had resolved, he was allowed to return gradually to full-contact football, during which time he continued to attend the Sports Injury Clinic for high-level sport-simulated exercises. The patient was discharged when he had returned to his previous level of fitness.
CASE-STUDY 2: a young runner's ankle
A 13-year-old girl came into our Sports Injury Clinic complaining of medial and lateral right-ankle pain, pins and needles in the big toe and difficulties walking and running with the foot straight.
She reported a history of turning her ankle inwards in a false start on a 1500-metre race six months earlier. She was convinced by her coach to run the race anyway, ignoring the pain, but she fainted after 1000 metres. The athlete furthermore had to walk two miles home from the competition with increasing pain.
Next day she went to a local hospital where she received a compressive bandage to decrease the swelling. She rested for one week and returned to sport still with complaints of some weakness and pain. Since then the pain had been intermittently but gradually worsening for the last few weeks. She also reported intermittent back-ache.
The athlete presented with an internally rotated leg and foot when standing and walking, also associated with pain which increased when she attempted to realign the leg. She had pain with resisted muscle testing, and with range of movement testing in all directions, especially when turning the foot outwards. Her pain was mainly on the medial side of the foot and ankle. Putting tension on the sciatic nerve with a straight leg raise and slump test also reproduced her pain.
She was tested one time with nerve mobilisation techniques, ankle joint mobilisation and friction massage over the sore tendons. The athlete reported a direct decrease in pain and had a slight improvement in ankle range of movement and walked with the foot straighter.
The next day the mother called and reported a total relief of pain, ability to move the ankle freely and run without pain. Unfortunately, the girl fell down some stairs the following day, with return of all symptoms, but pain now located on the lateral side of the ankle.
The athlete returned to the Sports Injury Centre with a very similar presentation but with pain mainly on the outside. This time the back was also assessed and slight stiffness was found. With palpation of a specific vertebra (L3), with the low back in extension, ankle pain was reproduced.
The athlete was treated as in the previous session but with the addition of vertebral joint mobilisation. Full ankle range of movement returned and the pain was totally alleviated so that the patient was able to run completely pain-free with a normal stride. The athlete has continued with a home-exercise programme and pain has not returned since.
This case presentation highlights the close connection between a joint/tendon injury, nerve irritation and connection with the back. Thorough and accurate assessment of an athlete's injury is therefore crucial.
Ulrik McCarthy Persson
CASE-STUDY 3: calf pain in a veteran runner
A 49-year-old male runner presented to the Sports Injury Centre complaining of left- calf pain after a half-mile run on a cold night five weeks previously. The calf remained sore the next day but did not affect his daily living activities. He modified his training schedule by resting for two days between each run, but the problem worsened until he was unable to train at all. Further investigation revealed that he had a two-year history of recurrent left-calf pain. He did not warm up or cool down adequately as a rule. His medical history was unremarkable.
On examination he demonstrated left-knee hyperextension, left-foot pronation and hallux valgus. He experienced calf pain on stretching, particularly on squatting with heels flat. Dorsiflexion of his left ankle was restricted by 5 deg compared to the right, and his left subtalar ankle joint was stiff. All resisted tests were clear but there was evidence of neural restriction in the calf on testing neural dynamics (Straight Leg Raise and Slump Test). His soleus muscle was tender on palpation. His shoes were worn on the outside and treadmill running revealed marked pronation (flattening) of the left foot.
The causative factors underlying this recurrent condition were found to be twofold: 1) a biomechanical problem due to a stiff subtalar joint resulting in excessive pronation and shortening of the soleus muscle; 2) poor preparation before and after training sessions. Both of these factors needed to be addressed to resolve the problem.
Treatment initially focused on the soleus muscle by using soft-tissue massage, ultrasound, and initiating a stretching and strengthening programme. Secondly, biomechanical faults were addressed and improved by increasing muscle and neural tissue length, mobilising the subtalar joint, and providing temporary orthotics to prevent over-pronation. Finally, he was given an overall daily stretching programme and was advised on correct warm-up and cool-down procedures.
By the third treatment, the soft-tissue problems had resolved, except for some residual calf tightness, but with no neural involvement. Dorsiflexion of the left foot equalled the right. He returned to his pre-injury weekly mileage, pain-free, and continues with his daily home-stretching programme.
This case-study is an example of an overuse injury caused by faulty biomechanics and poor preparation which can have an adverse effect on localised soft-tissue structures.
CASE-STUDY 4: a half-marathon runner's ankle
A 32-year-old female runner visited the Sports Injury Centre complaining of a dull aching sensation on the lateral aspect of the left ankle. She was also aware of a less painful ache medially on the same ankle, both of which had curtailed her gym visits and her training for a half-marathon.
Upon further questioning, she reported that three months before she had caught her right heel on the back of her trailing coat while walking down some stairs on the way to work. As she stumbled, she reported excessive plantar flexion with some inversion which produced marked pain in the lateral part of her left ankle. The ankle did not immediately swell but was markedly 'puffy' by the afternoon. She made some attempt to ice the ankle at work, and reported to the local casualty department the next day where she was given a compression bandage and discharged.
She did not run or exercise for two weeks and gradually returned to full activity within three weeks. Since the time of injury, she had not had any other traumatic episode but was still concerned that the outside of her lower leg still ached and swelled intermittently.
On presentation, she had decreased range of movement of the left ankle talo crural dorsiflexion. As a result, she demonstrated prolonged mid-tarsal pronation shown by flattening of the longitudinal arch during the stance phase of the gait cycle. Single-leg standing on the left revealed poor balance capability and a feeling of unsteadiness. Inversion and plantar flexion movements were painful at the end of the range. Palpation, however, of the lateral ligaments of the left ankle did not reveal any significant tenderness, although there was still some residual swelling in the area of the anterior talo fibular ligament (ATFL). Passive movement of the inferior fibula in a posterior direction was found to be hypomobile (stiff). When this was combined with inversion, pain at the end of the range was abolished.
From the examination it was hypothesised that due to the absence of pain on palpation of the lateral ligaments, the inferior tibio fibular joint was the source of symptoms. Clinically, this gains support because one would expect palpation to be painful with lateral ligament damage and also a posterior glide of the fibula would stretch the ATFL, further exacerbating symptoms. That the posterior glide of the fibula did indeed abolish pain is convincing evidence of the inferior tibio fibular joint's role in this painful dysfunction.
The patient was treated with posterior glide mobilisations of the inferior tibio fibular joint and shown how to strap the fibula into a posterior position. On her return two days later, the pain had decreased by 90 per cent and she had run for 10km without pain to 'test it out'.
Retesting of the inferior tibio fibular joint revealed normal joint play and excursion of movement. Inversion and plantar flexion movements were full-range and pain-free. Proprioceptively, single-leg balance testing was equal to the right leg and running on the treadmill confirmed full functional recovery without pain.
This case-study demonstrates the importance of a thorough examination in a supposedly classic injury, as the mechanism of injury for this patient is suggestive of lateral ankle ligament damage. However, the proposal, and confirmation by palpation, of an anteroinferior subluxation of the distal end of the fibula with associated soft-tissue damage seemed the most likely diagnosis. Treatment to correct this positional fault returned this patient to pain-free half-marathon running.