The Care of Soft Tissue Ankle Injury - Essay Example

Soft Tissue Ankle Injury The Soft Tissue Ankle Injuries Introduction Soft tissue injuries in the ankel are the most common type of musculoskeletal injuries. In the United State more than 23,000 people seek medical assistance for ankle injuries every day. Individuals related to sports report ankle soft tissue injuries to a large extent; however these are also very common in normal people. Therefore, considering the importance of this ailment in our daily lives and numerous numbers of cases reported each day, it has been selected to evaluate the reasons causing the disease, prevention methods, diagnosis, treatment and factors affecting the disease. Ankle can get twisted any time while walking on an uneven floor, by placing feet awkwardly on the ground or when extra force is applied on the joint. These minor events can lead to the ankle sprain, fractures and even tissue injuries, thus considering the chances of occurrence of the injury in daily life practices it has been chosen for further exploration and detailed information for increasing awareness and highlight the areas where chances for further improvement are present related to the disease. In this paper a detailed overview will be presented focusing on the types of the disease, how it is developed, what clinical assessments are required for diagnosis, what subsequent diagnosis should be followed, physical monitoring and examination of the foot, Ottawarules and patient’s examination. The paper also includes different psychosocial or cultural factors which may affect the patient’s psychology, recovery and attitude. It discusses the treatment approaches which are practiced by surgeons and orthopedics in order to treat the disease. There are also certain issues which are related to the disease, these are also addressed in the essay from an ethical perspective, professional outlook and legitimate concerns. The paper is compiled with a brief summary and conclusion in the end. The Soft Tissue Ankle Injuries The Soft Tissue Ankle Injuries is a broad term which entails the injury to any structure of the ankle joint including tissues, bones, ligaments, tendons, cartilages and skin. The function of ankle joint is to support and help in propulsion of the body. This joint bears maximum loading force per surface area and therefore it is prone to develop injuries and mobility problems. Three joints are very important in diagnosing ankle injuries: the talocrural joint, the subtalar joint and the inferior tibofibular syndesmosis. The ankle joint is composed of three bones: The tibia, the fibula and the talus. Tibia is the main bone of the lower leg. In the bottom it forms medial malleolus which is the inside bump of the ankle. The fibula composes the outside bump of the ankle forming the lateral malleolus in the bottom. Lastly, the talus it is the top bone of the foot. Different muscles are responsible for controlling motion at ankle. Each muscle is connected to the bones via tendons. If joints are exposed to extra stress and pressure, these tendons can be destructed or stretched (Cunha, 2014). All the joints are surrounded by thick envelope made of soft tissues called joint capsule which surrounds all the bones and keep them intact. Inside and outside of the capsule ligaments are present, these are tough, short soft tissue bands which give extra strength to the joint capsule. Damage to these ligaments result in ankle sprains. Following ligaments are more susceptible to tissue injury in an ankle (Schumacher, 2014). the lateral ligament the medial ligament the syndesmotic ligaments the subtalar ligaments. Figure 1: Ankle and ligaments (lateral view) (Ivins, 2006) Clinical Assessment The ankle injuries can be classified on the grade of III based on the severity. Grade I: is characterized by localized tenderness. The patient is able to move normally with negligible malfunctioning. Ankle sprains are usually categorized as grade I injuries. Grade II: is featured by swelling, moderate to sever pain, bruising and abnormal motion range. Damage at the level of ligaments fall in Grade II category. Grade III: injuries show complete ligament tear and tissue damage. The symptoms are severe edema, no mobility, intense pain and bruising. The person becomes immobile due to joint instability and loss of function (Tiemstra, 2012). Type of motion causing ankle injuries The normal ankle motion is a gliding motion, up (dorsiflexion) and down (plantarflexion). Most ankle injuries occur when force is applied against the normal anatomic motion of the ankle. This can be a rotational force when the foot is placed on floor and the leg, knees and body is twisted right or left. But the cause of most soft tissue ankle injuries is bending the ankle bone too far on either side. This type of motion is known as inversion (inside) or eversion (outside) based on the movement direction. This inversion or eversion motion is performed by the subtalar joint (located beneath the ankle bone) or the midtarsal joint (located in forefoot). So, when stress is applied on these joints the ankle joint is affected resulting in injuries. Almost 90% of most ankle injuries occur in the direction of inversion (Schumacher, 2014). Assessment Methods The clinical assessment of soft tissue ankle injuries is carried out via three assessment methods (Anderson, 2002): i) Patient History ii) Physical Examination iii) Radiography Patient History: The first step in clinical assessment is to determine the joint position at the time of injury. Ask the patient about the location of pain, swelling, ability to bear weight, problem in walking, jumping or running and the functional capacity. Inquire about previous injuries, diagnostic results, treatment and any residual impairment. Also inquire about patient’s interest and participation in sports, level of physical activity performed each day and sports history. Physical Examination Allow the patient to walk and check his gait. Evaluate the level of ecchymosis and location of swelling. Using Palpation examine the medial malleolus, lateral malleolus, the fifth metatarsal, the fibula and the physis. Use palpation for soft tissues including calcaneofibular ligament (CFL), anterior talo-fibular ligament (ATFL), posterior talo-fibular ligament (PTFL), peroneal tendon and deltoid ligament. Also check the ligament laxity during physical examination. Use the talar test for testing swelling and guarding. The anterior drawer test can be used for checking ATFL with minimum pain or guarding. In case of chronic pain or recurrent sprains check for strength, range of motion and proprioception. Radiological Examination The radiographical screening is carried out for diagnosing bone abnormalities. The standard images of radiographs include lateral, anteroposterior, and mortise. Patients, who cannot bear weight, have bone tenderness in the navicular, malleoli and fifth metatarsaland those who are unable to walk after injury are recommended radiographical examination. The most common technique use is the X-ray. Other include: CT scans; resonance images (MRIs), bone scans and arthrogrmas which are used for specific soft tissue injuries. Differential Diagnosis The differential diagnosis of stress fractures may be done with bacterial infection. The soft tissue injuries can be differentially diagnosed with Peroneal subluxation, Fifth metatarsal fractures, Osteochondral fractures of the ankle, Cuboid fractures and others. Various radiographic techniques are used for correct diagnosis. All these disease have common symptoms like swelling, pain and bruising therefore differential diagnosis is important (Yu, 2014). Ottawa ankle and foot rules The Ottawa Ankle and Foot Rules are a well established set of guidelines which are used clinically for determining the use of radiography in diagnosing fractures. According to Ottawa ankle rules, the ankle radiography is required if there is an indication of bone tenderness (particularly in lateral or medial malleolus), pain in the malleolar zone and an inability to bear weight after injury. Foot Radiography is required in case of pain in midfoot region, bone tenderness (mainly in metatarsal or navicular bone) and an inability to bear weight after injury (Ivins, 2006). Figure 2: Representation of joint position (Ivins, 2006) Psychosocial and cultural factors affecting the patients Mostly the patients of ankle injuries belong to sports, they are mostly celebrities therefore they have to bear enough psychosocial stress. Researches show that patients with soft tissue ankle injuries undergo multiple psychological problems particularly if they are related to sports. A minor ankle injury can completely ruin the career of a sports person. So, the most dominant psychological factor is the stress factor which patients have to bear. This stress not only affects their recovery but also worsen the disease condition. For quick recovery in this condition strong will power is very important. In most of the cases even with minor ankle sprains the patient has to be immobile or follow restricted motions. This also develops immense pressure in mind as sitting idol multiplies cynical thoughts in mind leading to depression (Crust, 2014). It is also observed that in sports field having injury is a very critical thing and it directly impacts one’s current performance, future opportunities and long term career. Such news about the sports stars are highlighted by the critics and opponents which also build up psychosocial stress on the patients. Sportsmen with injuries have been observed to report lack of attention, disrupt coordination and increased muscular tension which causes delay in healing and sustain the injury. Not only for individuals in sports, the psychosocial factors also greatly affect patients from other field of life. If a patient with soft tissue injury is asked to stay at rest and do not walk or run, this will develop a psychological pressure on him and also how his family and people at work are going to deal with this. For studying the psychosocial factors the Biopsychosocial model of health should be taken into account, It asserts that in order to evaluate the impact of different factors on patient in soft tissue injuries the biological, psychological and socio cultural factors must be closely studied. These include patients’ life style, family response, mind set, personality traits, education, commitments, living style, self control, degree of activity, willingness, compliance with the treatment and willpower. The culture we live in is also equally important in determining the health progression of patients with ankle injuries. The most important among them is the life style which entails both the personal life style as well the environment and requirements on work. If there is place where extensive laborious work is required or too much stair climbing, walking or standing for long period is a necessity the chances for developing foot injuries are most. Similarly, for patients with ankle injuries if they have to get back to such environment chances for recurrent disease are high and also their recovery will become hampered. In such case the working culture is also very important. Treatment The instant treatment required for treating soft tissue ankle injuries is aimed for reducing pain and swelling and protect ligaments and tissues from further damage. There is a specific protocol which is followed for the treatment of acute injuries named as ‘PRICE’ where, P indicates protection, R for rest, I for ice, C for compression and E stands for Elevation. Ankle elevation and protection is done with specific device, the patient is asked for res for around 72 hours in order to make ligaments heal and ice is applied on the injured area on the ankle (Ivins, 2006). Cryotherapy Ankle injuries can be treated with Cryotherapy as claimed by the American Academy of Orthopedic Surgeons. However, much of its practical implementation in healing soft tissue ankle injuries is not found. This therapy helps in reducing recovery time and decrease pain and edema. It might be effective in combination with exercise but solely this therapy has not proved to be beneficial. NSAIDS NSAIDS have found to be effective in controlling pain sensation, swelling and swift recovery in patients with soft tissue injuries. Most prescribed NSAIDS include: naproxen, celecoxib and piroxicam. Different studies prove the effectiveness of using NSAIDS in the acute treatment however, for chronic injury it is not effective. Functional Treatment The functional treatment is consisted of three phases. In phase I PRICE protocol is started within 24 hours in order to reduce pain, decrease swelling and restrict the progression of injury. In phase II patient is allowed to exercise and move to restore motion and strength with in 72 hours. In the third phase patient is being provided endurance training, balance improving exercise and sports specific drills. The overall research quality on the application and usefulness of functional treatment in soft tissue injuries is not very overwhelming. A study of 21 trials reported that functional treatment is more beneficial for treating the immobility of ankle joints in case of sprain. Different researches have shown that functional treatment has given better results as patient return to normal as compare to immobilization treatment. Ankle Support In case on ankle injuries ankle joint is supported using semi rigid supports, tape or bandage. Various studies have studied the use of different ankle supports and compared the effectiveness of using semi rigid supports to elastic bandages. Research reveals that the semi rigid ankle support help in bringing patients back to normal routine more swiftly than elastic bandages by providing better ankle stability. The lace up ankle support proved to be more useful than the semi rigid support in reducing persistent swelling in case of chronic injury. Other methods such as tapes are found more irritating and thus decrease patient compliance therefore not recommended widely. Surgery There is a huge controversy in evaluating the efficiency of the surgical methods over conventional therapy in treating soft tissue ankle injuries. Some researches claim that surgery is more effective than conventional therapy in order to treat functional instability, immobility, time to return to sports and reduce pain. However, the quality of research available is not enough to proclaim this fact. A randomized trial showed that some patients with ankle ligament ruptures were given an option to receive surgical or functional treatment. Patients who receive surgical treatment reported chronic ankle instability, residual pain and recurrent sprains. It has been found that patient with severe injuries should opt for surgical procedures where as no evidence proves that surgical methods are superior than functional methods for mild to moderate grade injuries. Prevention Different exercises and external ankle supports are recommended for the prevention of ankle sprain. A research revealed that there was 47% decrease in ankle injuries in people who participated in sport exercises and used ankle aids. Some studies also showed the effectiveness of taping and bracing in preventing ankle injuries. These preventive measures (exercises and ankle supports) are not only useful in normal individuls but also very effective in patients with recurrent ankle sprains. A research reports that proprioceptive neuromuscular facilitation exercises and trainings are more beneficial than the normal exercises in preventing the risk on soft tissue ankle injuries (Ivins, 2006). Issues Being in a health care profession there are certain issues related to soft tissue ankle injuries. Ankle or foot injuries may occur once but can lead to hospitalization or prolonged bed rest. Hospital staff has to provide extra care for the care and treatment of these patients. If the patient is immobile then staff must be available all the time to facilitate in moving the patient. Another important issue related to ankle or foot injuries from professional perspective is the cost consumption. It must have been observed that not every hospital has a well established orthopedics department where proper care and management can be given to patients with ankle injuries (Boer et al., 2014). The reason is high expenditure in emergency treatments of such patients as well as technologies required for diagnosis and therapy. The ethical issues related to ankle injuries are related to medicine particularly sports medicine (Dunn et al., 2007). The issues which may encounter patients with ankle injuries like: pressure to participate and play for the team, use of strong but dangerous pain killers or keeping the true diagnostic picture from patient. From ethical perspective it is extremely important to keep the patient well informed about his diagnosis and required therapy. Mostly in sports there is immense pressure on players to get back on the ground due to which they are given strong pain killers which subside the pain temporarily but can lead to long term serious injury or even immobility. From ethical point of view no patient should be given external pressure to get back on work until and unless his/her injury is completely restored. The ankle and foot injuries are very common in the world therefore, there are certain legal issues associated with them. Mostly the sport players who get injured during game have to face these legal issues. For instance: One cannot return to play unless or until a satisfactory health report is obtained from the doctor. Or sometimes players are forced to participate even without complete healing which is both ethically and legally wrong. For such issues legal help is required to handle the issue. As the therapy for treating ankle injuries is much higher therefore, insurance is necessary. Various legal issue come in front when a patient interacts with the hospital bills and insurance claim so at this instance, legal assistance is very important for handling the legal issues. Conclusion Soft tissue ankle injuries are the most commonly found injuries in the world. Global figures claim that out of all ankle injuries 15-20% are ankle sprains. Out of these, 20 to 40% of ankle sprain problems develop degrees of disability and residual symptoms (Porter et al., 2010). The most commonly effected area is lateral ligament following an injury in plentar-flexed position. The diagnosis is clinical based followed by reassessment and delayed examination. Initial treatment focuses on pain management, reducing swelling and bruising and limit disease progression followed by restoration of ankle movement. The Ottawa rules have found to be very useful in diagnosing and eliminating unnecessary use of radiography. The role of surgical methods in repair of ligaments have been found in case of sever disease conditions and chronic management however, for acute setting the application is unclear. Different soft tissue ankle injuries have been categorized based on the level of inflammation and severity into three grades, The treatment of disease is also dependent on the grade. A number of psychological, social and cultural factors have also been discussed in the essay which concludes that not only patient but various other factors can influence the patient recovery from the disease. These include patients’ mindset, life style, work nature, support from family and colleagues. As ankle injuries are most common in sport related people therefore, they are also tremendously affected by multiple psychosocial and cultural factors like: stress, critiques, performance etc. The paper also highlighted issues related to soft tissue ankle injuries from professional, legal and professional perspective. Thus, it is concluded that there is enormous span of research in the field as high quality research is not available on the treatment methods also the recurrence of disease and high percentage of occurrence has made it a significant disease to be explored. List of References Anderson, S., 2002. Acute Ankle Sprains. The Physician and Sports Medicine, 30(12), pp.1-12. Boer, S. et al., 2014. Health care consumption and costs due to foot and ankle injuries in the Netherlands, 1986–2010. BMC Musculoskeletal Disorders, 15(128), pp.1-8. Crust, L., 2014. How much do psychological factors such as stress and personality contribute to the risk sports injuries? [Online] Available at: http://www.sportsinjurybulletin.com/archive/stress-sports-injuries.html# [Accessed 11 july 2014]. Cunha, J., 2014. Ankle Sprain. [Online] Available at: http://www.emedicinehealth.com/ankle_sprain/article_em.htm#ankle_sprain_overview [Accessed 10 july 2014]. Dunn, W., George, M., Churchill, L. & Spindler, K., 2007. Ethics in Sports Medicine. The American Journal of Sport Medicine, 355(5), pp.840-44. Ivins, D., 2006. Acute Ankle Sprain: An Update. American Family Physician, 74(10), pp.1714-20. Porter, K., Najran, P. & Matharu, G., 2010. Soft-tissue ankle injuries. Trauma, 12(2), pp.105-15. Schumacher, S., 2014. Ankle Sprains. [Online] Available at: http://www.footdoc.ca/www.FootDoc.ca/Website%20Ankle%20Injuries%2025.htm [Accessed 10 july 2014]. Tiemstra, J., 2012. Update on Acute Ankle Sprains. American Family Physician, 85(12), pp.1170-1176. Yu, G., 2014. [Online] Available at: http://www.podiatryinstitute.com/pdfs/Update_1989/1989_37.pdf [Accessed 11 july 2014]. Read More