Treatment of Soft Tissue Ankle Injuries - Essay Example

TREATMENT OF SOFT TISSUE ANKLE INJURIES Words used 2604 TREATMENT OF SOFT TISSUE ANKLE INJURIES Introduction Soft tissue ankle injuries can be defined as injuries that do not constitute fractures of the bones, but are injuries that affect tissues surrounding the ankle (Carr 2003). According to Carr, “ankle injuries are frequent injuries that are not only familiar to patients, but also to physicians; they are the most common injuries resulting from recreational sports” (Carr 2003, p. 2362). Similarly in Derman’s study on early management of acute soft tissue injuries in sport, ankle injuries is among the most familiar types of injuries that befell rugby players,with“soft tissues ankle injuries occur at a rate of between 69 and 218 injuries per 1000 playing hours” (Derman 2010, p.3). With accordance to Carr and Derman’s findings, this essay review the research in relation to soft tissue ankle injuries by first expounding on the essence of assessment of the injuries, and then provide detailed information on the management of soft tissue injuries. It will also classify the injuries according to their severity and their respective interventions. Assessment of the soft tissue injuries Assessment of the injury is one of the key things that need to be observed in treating and managing an ankle injury as it aids in recognising the severity of the injury to employ the right interventions. For instance, most of the ankle injuries require simple interventions in order to be managed. However there are some ankle injuries, which might necessitate surgery because of their severity. In his study, Derman (2010) also found that failure of correct diagnosis of the soft tissue injuries as well as their treatment results to long-term breaks that may become chronic. Oxford Radcliffe Hospitals (2008) emphasized that signs and symptoms of the soft ankle injuries such as mild ache to sudden pain, swelling, bruising, and inability to move the ankle normally need to be addressed as early as possible. Management of Soft Tissue Injuries The basic symptoms of these injuries include mild ache to sudden pain and warmth. In addition to causing pain, they also result tosigns such as swelling, bruising, inflammation, and inability to move the ankle normally (Oxford Radcliffe Hospitals 2008). The presence of these symptoms and signs enhances a healthcare provider to provide necessary interventions to the injuries. In most occasions, delayed intervention to soft tissue injuries result to more severe consequences; the affected body part may result to the ankle not functioning properly. Phase 1 consists of two phases, that is, tissue destruction phase that lasts from 0-60 minutes and the acute inflammatory phase that lasts from 0-72 hours. Unlike Phase 1, Phase 2 (repair and regeneration phase) lasts between 2 and 42 days. According to Derman, this phase is associated with not only phagocytosis of the necrotised tissue, but also regeneration of tissue fibres (Derman 2010). Additionally, Derman asserts that this phase is also associated with the production of a connective tissue scar along with capillary in-growth into the injured tissue (Derman2010, p. 2). Phase 3 (the tissue remodelling phase) on the other hand lasts between 21 days and one year. It is characterised by contraction as well as reorganisation of the scar tissue. This phase is also associated with other subsequent recovery of the soft tissue (Derman 2010). Treatment processes in phase 1 of soft tissue injury Derman asserts that the most important time for management of any soft tissue injury is the initial 24-hour. This period leads to minimisation of not only bleeding, but also occurrence of secondary tissue hypoxia (Derman 2010). Derman (2010) claims that PRICED (which is expanded in the next paragraph) principles is the most practiced and effective principle of management of soft tissue injuries. The components making up this management principle include: “P-Protection, R-Rest (immobilisation), I-Ice (cryotherapy), C-Compression, E-Elevation, and D-Drugs, usually refer to use of the anti-inflammatory agents” (Derman 2010, p.5). D can also stand for Diagnosis, which is also very crucial in management of soft tissue injuries. All components that result to PRICE are very crucial; they lead to minimisation of the extent of the injury as well as bleeding. Phase 2: Repair and Regeneration “Brown postulates that this phase takes place after the swelling has reduced and the patient is ambulating without any problem (Brown 2010). The reduction in swelling encourages patients to ambulate with ease where the ankle is restored to its full range of motion as the muscles strengthen the affected tissues. The exercises involved in this phase include having the patient write alphabetic letters with the toes of the affected leg as well as do a one-legged squat with the heel of the affected leg touching the ground (Brown 2010). This exercise restores dorsiflexion of the affected leg which is responsible for normal movements. Phase 3: Tissue remodelling phase Phase 3 aims to restore proprioception (Brown, 2010) or else it may result to further injury if not managed in time. The testing in this phase includes checking whether the patient can manage to maintain balance with the affected leg just like the uninjured side. Diagnosis Drennan and McCarthy assert that the physical exam is the basis of diagnostic evaluation of soft tissue injuries where it involves observing the site of the injury (Drennan and McCarthy 2010). They also claim that palpation of bony as well as ligamentous structures aid significantly in diagnosis for most injuries. Although the Ottawa ankle rules (OAR) provide guidance to physical examination when looking for possible fractures that may have resulted from the injury, it is evident that radiography aids in diagnosis of severity of the injuries (Drennan and McCarthy 2010). The Ottawa Ankle rules As postulated by Drennan and McCarthy (2010, p. 379), the Ottawa ankle rules are a set of medical guidelines that aid in assessment of possible fractures of the ankle and foot. The guidelines aid physicians in determining which patients require radiographs after sustaining an ankle injury. According to them, it achieves this “by combining the ability to walk four steps with physical findings of localised tenderness at the posterior edge or tip of malleolus, the navicular, or the base of the fifth metatarsal, to achieve a result that is correlated with the existence of a fracture” (Drennan and McCarthy 2010, p.379). The rules also aid significantly in reducing the cost involved in the treatment process by avoiding unnecessary processes such as imaging by 30-40% (Deal and Grace 2012). Imaging Although imaging is mostly used in diagnosis of injuries associated with serious injuries, it is evident that it is applicable in identifying the causes of soft tissue injuries. Classification of Injuries According to Deal and Grace (2012, p. 48), “injuries are often graded according to severity which determines the most appropriate treatment.” There are three grades of injuries: grade 1, grade 2, and grade 3. The three grade of injuries are detailed in the appendix. Interventions Grade 1 and 2 injuries can be addressed differently depending on the severity of the injuries. For instance, acute injury management involves application of first aid management such as PRICE which involved minimisation of the extent of the injury as well as bleeding, homeopathy that involves treating a patient with diluted medicine so as to trigger the body’s natural healing process, and acupuncture which involves bringing to balance flow of energy by application of heat or pressure on the affected ankle tissue (Deal & Grace 2012). Protection Oxford Radcliffe Hospitals claim that it is crucial for the injured ankle to be protected from undue stress which may lead to further damage or delay healing process (Oxford Radcliffe Hospitals 2008). According to the hospital, this means an individual opt to discontinue from activities that may increase his or her symptoms. Rest Rest involves removing the player from the field to protect him or her from sustaining further damage to the injured site. It also leads to minimisation of bleeding and pain. Additionally, it also makes the victim more comfortable. Derman also claims that placing of the injured person to rest immediately after trauma prevents the rupturing of muscle stumps, which leads to the reduction of the formation of a large gap within the muscle as well as the size of haematoma. Additionally, he claims that rest prevents the increase of the size of the connective tissue scar as well as reduce the healing process period significantly (Derman 2010). Thus, it is crucial for one to do away with any activity as much as possible after a soft tissue injury for a long period so as to enhance the repairing process of the body as well as restore majority of the functions. Ice (Cryotherapy) Ice is also crucial in management of soft tissue injury. This is evidenced by its ability to lower tissue temperature, which is responsible for increasing bleeding, tissue metabolism, and muscle spasm. Ice also provides pain-relieving effect alongside minimising inflammation and oedema. Additionally, use of ice in managing soft tissue injuries decreases the occurrence of secondary hypoxic injury (Derman 2010). Derman also claims that there is scientific evidence that proves cryotherapy contributes significantly towards soft tissue healing. According to him, studies in both animal and human suggest that cryotherapy reduces the deep tissue temperature (Derman 2010). Thus, it is crucial for the ice to be applied for 20 minutes of each hour or an alternation of ice and no-ice to be applied on the injured tissue for each 20 minutes for a 48 period hour as postulated by Derman. However, application of ice is associated with ischemia and frostbite. Thus, it is recommendable for one to place ice within a towel before wrapping it around the affected area. Additionally, it is crucial for the recommended time for ice application to be taken seriously because its extension may delay the healing process. Compression Compression involves use of either firm bandages or elasticised bandages. It can also involve a combination device such as cryocuff, which is associated with the provision of both compression and cryotherapy. However, elastic bandage is the most effective because it is snug and also pave room for expansion when the muscles contract as well as get filled with blood. Usage of a firm bandage may result to reduction of blood flow which is associated with the causation of ischemia. The assumption behind the employment of compression in managing soft tissue injuries is that the increased pressure exerted by the bandage or device leads to the reduction of bleeding which also lowers the swelling and inflammation which are associated with loss of function, excessive pain as well as slowing of blood flow because of vessel restrictions (Derman 2010). According to Derman, this assumption has been evidenced by addition of compression to the ice therapy technique; a combination of compression and ice is more effective in managing soft injuries than ice alone (Derman 2010). Therefore, compression is so essential in the management of the soft tissue injuries. Elevation Elevation of the affected limb after an acute injury is very common. The assumption behind this practice is that it leads to the reduction of the hydrostatic pressure that is responsible for the accumulation of extracellular fluid (Derman 2010). Derman argues that it is essential for the injured limb to be raised above the level of the pelvis for some period in the initial 48 hours after the injury in order to reduce the accumulation of extracellular fluid in the tissues adjacent to the injured part as well as help the blood flow. The elevation increases venous return of the flowing blood to the systemic circulation, and as a result reduces edema that is responsible for pain. Drugs Derman asserts that pharmacological agents are very essential for management of pain (Derman2010). He also claims that most injured athletes use analgesics and anti-inflammatory agents in reducing pain, swelling and inflammation. Some of the pharmacological agents used in the treatment of pain because of soft tissue injury include Acetylsalicylic acid that has an anti-inflammatory effect when used at higher doses and Paracetamol that does not alter with the inflammatory response or blood clotting process. However, it is also evident that non-steriodal anti-inflammatory drugs delay the healing process. Apart from impeding the inflammatory phase of healing, NSAID also results to gastro-intestinal symptoms. Just like grade 2 chronic injury, “grade 3 injury is managed by employing first aid management (PRICE, acupuncture, homeopathy) electrophysical therapy, heat therapy, joint mobilisation, exercise rehabilitation and training” (Deal & Grace 2012). Unlike grade 1 and grade 2 types of injuries, grade 3 injury may require surgery as well as participation of specialists. Thus, grade 3 will not be discussed extensively in this research. Elastic tubular support bandage Bucholz (2012) found out that “many types of injuries such as soft tissue sprains and minor fractures are effectively treated by support and analgesia with mobilization of the affected area encouraged after a relatively short period (a period within 24 hours).” According to him, tubular elastic support bandages such as Tubigrip elastic tubular support bandage are the most used in treating such soft tissue injuries. They provide tissue support in the treatment of soft tissue injuries. Latham and Radomski (2008) in their work also related the effective functionality of tubular elastic support bandages with their ability to provide compression and positioning which is very fundamental in reducing swelling as well as enhancing restoration of functions. According to Latham and Radomski (2008, p. 580), the tubular bandages control edema by providing graduated stable pressure support on the affected part. Additionally, they also claim that the tubular bandages also provide support by holding worn out tissues together enhancing contraction that is crucial in healing process through the compression force they provide. Tubigrip also provides not only lasting support, but also effective support with complete freedom of movement for the affected limb. However, it is also evident that Tubigrip snags easily as well as its edges unravel quickly leading to variation of the exerted pressure. Back Slab Cast In some occasions, soft tissue ankle injuries may be because of grade 3 injury which is associated with small bone fractures. According to Kingsnorth and Majid (2001), injuries associated with fractures are effectively managed by use of back slab cast.In his book, Halim (2001, p. 163) asserts that back slab cast such as plaster of Paris is one of the effective methods of temporarily immobilising part of a limb after an injury. Additionally, it stabilizes the injured and as a result provides analgesia and prevents extension of soft tissue damage. The back slab cast however is also associated with some complications. For instance, it is evident that too tight cast leads to neurovascular problems like compartment syndrome. On the other hand, too loose a cast may also allow fracture ends to move and as a result impair with the healing process. It is also evident that rough ends of the cast may cause skin damage. Additionally, it is evident careless handling of a wet cast may result to indentations which can result to pressures sore underneath the cast (Castledine and Close 2009). Thus, it is recommendable for the cast to be applied effectively with a palm in order to reduce more injuries as a result indentations or rough edges. Conclusion and Recommendation Soft tissue ankle injuries are injuries that do not constitute fractures of the bones. They are among the most familiar types of injuries that befell rugby players. According to Derman, “soft tissues ankle injuries occur at a rate of between 69 and 218 injuries per 1000 playing hours” (Derman 2010, p.3). Their signs and symptoms include mild ache to sudden pain, swelling, bruising, and inability to move the ankle normally. Early interventions to soft tissues injuries are very crucial; they prevent small injuries from advancing and leading to more severe complications. According to Derman (2010) PRICED principle is the most practiced and effective principle of management of soft tissue injuries. In some severe cases, Elastic tubular support bandage as well as Back Slab Cast is used in the management and treatment of soft tissue ankle injuries. For effective management and treatment of soft tissue ankle injuries however it is recommendable for one to employ the Ottawa ankle rules because they are not only very sensitive, but also cost effective (they reduce the number of unnecessary imaging and radiographs). It is also appropriate for the victim of the soft tissue ankle injury to employ PRICED as a first aid management because it is the cornerstone for treatment of all types of soft tissue injuries. Reference List Brown, C. (2010) IAAF Medical and Anti-Doping Commission Authors. California: San Mateo. Bucholz, R. (2012) Rockwood and Greens Fractures in Adults: Two Volumes Plus Integrated Content (Rockwood, Green, and Wilkins Fractures). New York: Lippincott Williams &Wilkins. Carr, J. (2003) Fractures and Soft Tissue Injuries of the Ankle. New York: Elsevier Science. Castledine, G. & Close, A. (2009) Oxford Handbook of Adult Nursing, New York: Oxford University Press. Deal, M. & Grace, S. (2012) Textbook of Remedial Massage, Amsterdam: Elsevier Australia. Derman, W. (2010) “Trends in Modern Medicine- Early Management of Acute Soft Tissue Injuries in Sport.” BokSmart, pp. 1-27. Drennan, J. & McCarthy, J. (2010) Drennans the Childs Foot and Ankle, New York: Lippincott Williams &Wilkins. Halim, I. (2008) Essential Revision Notes in Surgery for Medical Students, New York: PasTest Ltd. Kingsnorth, A. & Majid, A. (2001) Principles of Surgical Practice, New York: Cambridge University Press. Latham, C. & Radomski, M. (2008) Occupational Therapy for Physical Dysfunction, New York: Lippincott Williams & Wilkins. Oxford Radcliffe Hospitals 2008, Ankle Sprain Advice, viewed 11 June 2014, http://www.ouh.nhs.uk/patient-guide/leaflets/files%5C090427anklesprainadvice.pdf [Accessed 4th July 2014] Schmidt, A. & Stannard, J. (2011) Surgical Treatment of Orthopaedic Trauma, New York: Thieme. Appendix Classification of Injuries Grade 1 Grade 1 soft tissue injury involves slight stretching and some light damages to the fibrils of the ligament. Deal and Grace (2012) assert that its symptoms include localised pain after involving in activity. This level of injury does not involve loss of strength. Grade 2 This level of injury involves incomplete tearing of the ligament. It is associated with unusual looseness of the ankle joint when the ankle joint is assessed and moved in certain ways. It is also associated with pain and swelling. Pain is because of muscle contraction. Deal and Grace claim that this level of injury also leads to loss of strength as well as movement limitation. Grade 3 This level of injury is more serious than either Grade 1 or Grade 2 injury. It is associated with loss of stability as well as energy. Assessment of the soft tissue injuries According to Carr (2003), some of the soft tissue ankle injuries can only be effectively managed by replacing the fractured bones, and this can only be done by employment of surgery. Similarly, Schmidt and Stannard(2011)also assert that treatment of minor ankle injuries often involves relief symptoms as well as prevention of further injuries whereas severe ankle injuries call for well-padded plaster splint in order to be managed effectively. Phase 3: Tissue remodelling phase Although some of the injuries can be effectively treated through employment of the three overlapping and interwoven phases, it is crucial to identify and exclude any other injuries that occurred. In connection to this, Drennan and McCarthy (2010, p. 379) in their study found out that some soft tissue injuries of the limb are difficult to identify and because of this, they may become more distressing than bony injuries. According to them, recognition as well as aggressive treatment of these injuries is very crucial. Management of soft tissue injuries It is essential for early interventions to be made on soft tissues to prevent the small injury from advancing and leading to more severe complications. As early treatment affects the healing response and rehabilitation, it is recommendable for immediate intervention to be applied on the victim of soft tissue injury (Derman2010). Derman also postulated that “the treatment process of soft tissue ankle injuries follows three overlapping and interwoven phases irrespective of the underlying mechanism” (Derman2010, p. 2). Ottawa Ankle Rules Drennan and McCarthy (2010) postulate that the Ottawa ankle rules have a sensitivity of about 100%. According to them, this is evidenced by the ability of the instrument to isolate fractures of the ankle from those of the mid-foot (Drennan & McCarthy 2010, p. 379). Grade 3 This type of injury involves complete tear of the ligament. According to chapter ten of the book by Brown, this injury leads to gross instability if an ankle joint is pushed in any direction (Brown 2010, p. 5). This injury is associated with significant pain, swelling as well as loss of strength. According to Deal and Grace (2012, p. 49), the pain resulting from this injury starts with activity and persists during and after activity. Imaging According to Drennan and McCarthy (2010, p. 380), AP and lateral radiographs aid in diagnosis of injuries such as Lisfranc fracture-dislocation that are often missed with non-weight-bearing films. They also claim that computed tomography is essential for assessing bone injuries such as those having intra-articular extension. This is as a result of some of the soft tissue injuries being caused by fractured bones. Additionally, they assert that magnetic resonance imaging (MRI) assist in assessment of ligamentous as well as osteochondral injuries. Read More