The aim of this essay is to provide a factual study and evaluation of the implications of a lateral ankle sprain and the pathopysiological processes that may be involved. This study discusses the social and psychological factors that may impact on the patient’s experience of such injuries, highlighting the importance of . The following case study on Mr Attallah Khan provides a platform to discuss presenting biopsychosocial factors that need to be considered when devising a management plan.
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Mr Khan sprained his ankle whilst taking part in a three legged race. He ‘turned over’ on his right ankle experiencing intense pain with inability to bear weight. The main structures within the ankle that would be affected in this type of injury would be the three main lateral ligaments that help to prevent the ankle form rolling forward and outward together with the muscles of the lateral compartment, peroneus longus and peroneus brevis.( re the anterior talofibular ligament, the posterior tablofibular ligament and the calcaneofibular ligament.) Hubbard T, Wikstrom E, states that anterior talofibular ligaments (ATFL), reported to be the weakest is the first ligament injured. This is followed by calcaneofibular ligament (PTFL) and finally to the posterior talofibular ligament (PTFL). X-rays of right ankle showed no fractures.
Mr Khan is a week post injury and at sub acute level of inflammation. The subacute stage is when healing and repair occurs. As a result of the inflammation Mr Khan has experienced soreness and swelling that causes him a lot of discomfort at the end of the day. He uses the crutch to help him get about but finds it difficult managing stairs and manoeuvring around the office. Hubbard T, Wikstrom E states that in order to regain stability of the ankle joint, immediate care and rehabilitation should focus on enhancing ligament healing.
2. Mr Khan lives with his wife and two children. He has been recently promoted to Partner in a city law firm. He is fairly active and enjoys family activities such as playing with the children and family walks. Mr Khan may feel immense pressure and anxiety to carry on with his normal daily duties at home and at work despite his injury. He suffers from ‘tension headaches’ which may be a result of heavy work pressures as a result of his demanding position, for this he takes ibuprofen. Although Mr Khan takes for his headaches it may slow down the healing of the damaged ligaments. “NSAIDs work by inhibiting the production of prostaglandins, substances that are involved in pain and also in the creation of collagen” Warden S.J et al ( 2009) Collagen is the key element of most tissues and without prostaglandins collagen cannot be made which will hinder the repair of the tissue. By taking such painkillers Mr Khan may continue daily duties without the signals of pain resulting in further injury to the affected area. Mr Khan also continues to work and has to also commute to the city and meetings, this lack of rest and weight bearing on the ankle may further delay the healing process. Mr Khan has forthcoming plans to travel in four months to America and then to Pakistan this will make a quick recovery his main priority.
Mr Khan is a successful professional, intelligent and very motivated. With this in mind (Hegna T, Sveram M 1990) states that it is important to structure a rehabilitation plan that may influence motivation during recovery and it is necessary to try and identify which factors arouse each individual’s motivation so that strategies can be used to enhance it. In order provide a successful plan for rehabilitation it would be necessary to set achievable, realistic goals in line with Mr Khan desired outcome which to walk again uninhibited by pain or swelling. To achieve full compliance may prove to be very difficult but the practitioner being seen as the professional whose role is to help patients achieve their objective may promote patient adherence. In Mr Khan’s case the management plan must include functional activities that are designed to initiate full recovery of the injury which will in turn allow Mr Khan to “get on with his life”.
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Management of Mr Khan’s lateral ligament injury will involve protection, rest, ice ,compression and elevation (PRICE) and function rehabilitation ie. Early mobilisation with support states Mattacola G, Dwyer K (2002). Research shows that early mobilisation of the joint will stimulate collagen bundle orientation and therefore stimulate healing. The primary goal for Mr Khan is to manage the pain, control the inflammation and protect the joint so that healing can take place. Hubbard T, Wikstrom E, (2010). state that in the acute stages of healing it is important to protect the lateral ligament of the ankle because the damage caused would have caused increased laxity. Protection is required with ankle bracing to prevent re-injury while the ligament heals. Rest is a necessary element to Mr Khan’s plan, this may however be difficult to enforce as Mr Khan is a very active man and may feel it necessary to place his treatment plan secondary to his family and work commitments. Enforcement of this rule may require discussions with Mr Khan in order to identify the factors that may hinder him from fully resting his ankle, this may also require the supervision and cooperation of the rest of his family. Factors to consider may be his workload as a new partner in the solicitors firm in which he works, together with the fact that the climbing of stairs with a crutch to get to his office is proving very difficult for him. This may require a temporary relocation of his office to the ground floor or a period of working at home until Mr Khan is able to bear weight on the ankle. Mr Khan is an intelligent man and needs to appreciate the logic in the activities he has been asked to do. It is important for the rehabilitation plan to reflect Mr Khan’s objectives but equally as important is the requirement for Mr Khan to cooperate and fully embrace the plan in order for it to be successful. Mr Khan must also elevate the ankle to reduce the swelling which will result in less pain; an ice compression will also assist in this process. With less pain present Mr Khan may begin to engage in gentle mobilisation techniques leading onto exercises that restore motion and strength usually within 48 to 72 hours of injury. It is vital that the patient has complete confidence and have an understanding that if they cooperate and comply with each stage of the plan it will eventually lead to a successful outcome. Dividing the rehabilitation up into short term goals such as reducing the inflammation resulting in less pain progressing to long term goals will allow both patient and practitioner to monitor and measure the success of the treatment and make adjustments where necessary. When short term goals are accomplished this then provides encouragement and motivation for future stages in the treatment. Mr Khan must understands that if the inflammation is first addressed and dealt with then the pain will subside leading to increased range of motion and joint stability, thus leading to a return of activities of daily living (ADL). Patients can become non-compliant to treatment plan if they do not appreciate the rationality behind what they are asked to do. Ley. P. (1988) states that by “Improving communication by either increasing the amount of information provided or by using special techniques can often led to increased understanding, recall and satisfaction.”
Mr Khan is impatient and frustrated with his injury and feels that it is an obstacle to fulfilling the commitments he faces with this in mind it is important to explain why it is necessary to engage with to the treatment and failure to do so may lead to a delayed recovery, that may prevent him from not only continuing in his weekend walks with the family but also may result in him having to cancel his forthcoming travel plans. The Biopsychosocial model of health best fits this case as it is vital to take into account the biological, psychological and socio-cultural factors surrounding Mr Khan’s case. By not focusing on the injury in isolation but taking into account Mr Khan’s lifestyle, mind-set, commitments, education, perception of control and his ultimate goals, a precise achievable treatment plan can be devised to help restore him not only back to full, pain-free mobility but to his role in society as a husband, father and lawyer.
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