Case Study by Kate Franzke
Sever ATFL Sprain

Present Condition
Left Ankle Pain

History of Present Condition
Seven weeks ago the patient sustained a running and eversion injury to the ATFL (anterior talofibular ligament), causing a lot pain and swelling. An X-ray showed nothing of note, however the patient was still complained of a lot of pain and has continued with non-steroidal anti-inflammatory drugs along with rest, ice and elevation. Over a 24 hour period the patient noted that the pain became worse towards the end of the day.

Objective Assessment
• Swelling of the left Achilles, medial and lateral ligaments.
• Range of movement in ankle – Dorsiflexion – 10 degrees, plantar flexion – 3/4, inversion/eversion – ¼, and unable to single leg stance.
• Very stiff subtalar joint, ankle joint, inferior tib-fib joint, calcaneum (Heel Bone).
• Very tight gastrocnemius (Calf Muscle)

Treatment

1st Session
Ultrasound showed deep frictions of medial and lateral ligaments, passive movements, accessory movements and glides of subtalar, inferior tib-fib joint, ankle joint, calcaneum, soft tissue release of gastrocnemius/soleus. I issued the patient with calf stretches and inversion/eversion range of movement exercises.

2nd Session
By the second session the patient had achieved plantargrade foot position in standing, and I continued the same treatment plan for a further 3 sessions with laser of the ankle ligaments. After these sessions she had achieved fill inversion, eversion and plantar flexion range of movement. However she was still stuck at plantargrade position with dorsiflexion.

To relieve the patient’s pain, I tried acupuncture using the eyes of the ankle, ATFL, BL60 and K3 acupuncture points with joint and soft tissue mobilisations. After a few sessions the patient was still stuck in plantargrade.

Assessment by Senior Physiotherapist
Due to the situation I approached my senior to assess the patient and provide her opinions. In the meantime I asked the GP to request and MRI scan to check the extent of any soft tissue damage.
On assessment, Sam (Senior Physiotherapist), thought possibly a thickening or bony block was the cause of the stiffness at the subtalar joint, especially palpable in plantarflexion. She had a discussion with the patient regarding a repeat X-ray to confirm whether it was bony vs soft tissue damage.

Sam discussed the mechanics of the STJ (subtalar joint) and the possibility of surgery if the problem was a bony block. She also discussed MRI vs X-ray. The patient had an MRI scan booked and in the meantime I continued treatment as the patient wished. I focused on mobilising the STJ/calcaneum, DTF, ATFL and soft tissue release of the gastrocnemius with stretches. The patient returned to walking on the treadmill, spinning classes and gait re-education.

The patient is continuing with treatment on a weekly basis, which consists of ultrasound to the ATFL, DTF along with joint and soft tissue mobilisations, and increased exercises at the gym.

Reflection
Be patient and realise that some injuries just need time and consistent rehabilitation. Overall there was a positive outcome as the patient’s gait was improving and surgery was avoided, which they were extremely happy about.