Mystery knee pain and ankle wobble
This poster came about because a client hadn’t been able to do her favorite sports for years. She first wanted me to solve a problem with her knee pain. I did that. Then she mentioned a perception of instability, that made skiing, snowboarding, and inline skating feel unsafe. However, it turned out that her ankle, not her knee, was the culprit.
I watched her do a single leg stand and lunge, and noticed her ankle wobbled. On the table, without moving, her foot was passively rotated in. When I put slight pressure, it made a 90° angle with her leg!
This is not normal. The illustration with the arrow shows the maximum normal rotation, about 120°. The other picture shows hers. But she had no ankle pain!
This was a mystery. I had been doing a case report series on ligament healing, so I already knew the ligaments of the ankle pretty well. Her ankle assessments showed two weak ligaments.
I looked up research, and contrary to intuition, a complete tear of the most commonly sprained lateral ankle ligament (ATFL) may present with no pain. Apparently, according to research, the body and brain shut off nerve reception.
The nervous system may even diminish sensation in the whole foot that contributes to ankle instability. (For more about how I treat ankle sprains, see Sprained Ankle.)
I worked on her ankle ligaments with the gentle Ortho-Bionomy® techniques I had been using for other clients. It helped, so I wrote up my report. I submitted the abstract, which is a structured research summary, to the Massage Therapy Foundation (MTF) for the 2016 International Massage Therapy Research Conference (IMTRC).
The poster story gets complicated
After I submitted it, I discovered new research to prevent ankle reinjury (see Sprained Ankle). What was different? I hadn’t been doing enough exercises specifically to increase sensory awareness. Amazingly, a week later, the client came back with a reinjury!
So I worked on her ankle with the new research insights. I was grateful to find that it was even more effective than my original treatment series. Her ankle finally stabilized, and she could run again. The picture to the right shows her improved ankle.
Then the Massage Therapy Foundation (MTF) notified me that they accepted my abstract. But now what to do? It was not the same case report! I needed to include a changed treatment series and outcome.
When they accepted the revised abstract (here it is in print, International Journal of Therapeutic Massage and Bodywork), I finally prepared this poster. So, this poster is a story of both my client’s healing, and my process of following research for her benefit.
This story also illustrates the limitations of a single case report. There can be many variables that influence the outcome. Without larger studies, we can’t know with certainty what those are. Even with our best current reasoning and therapeutic experience, there will always be more to learn! Such is the nature of science.
Where did the poster go?
This one is 36″ x 48″, and printed on cloth so it is easier for me to cart it around. I first presented it at the IMTRC, May 2016, in Seattle, WA. I next showed it at the American Massage Therapy Association National Convention, October, 2016, in Milwaukee, WI. The International Journal of Therapeutic Massage and Bodywork, courtesy of the Massage Therapy Foundation, published the abstracts both times.
Why do Case Reports? Weak in the evidence chain, but still have value.
The purpose of case report research is to share new techniques, or potentially novel ways to heal a condition. Or complications that arise in standard practice procedures. A single case report doesn’t prove anything. If it has value, larger scale research will always be needed.
In this case, the researcher who published the article on preventing reinjury was kind enough to let me consult with him. As he told me, his research subjects are from a relatively uniform population of young athletes with recent injuries. He called it, his “nice, neat tidy laboratory research.”
My client would not have fit his inclusion criteria for controlled studies. Her injuries had accumulated over many years, as you can see from the poster timeline (below). She also had previous knee surgeries that would have excluded her from his research. She otherwise would have met his inclusion criteria. Like the others in his research, she had:
- A history of ankle sprains.
- A recent history of her ankle turning under.
- Been unable to participate in sports because of a perception of instability.
- Diminished sensation in foot and ankle.
He told me he was appreciative of hearing about my case study series, with her and others. It gave him ideas to investigate for his next larger scale research study. He emphasized that is one of the values of case reports. Martha Brown Menard, PhD, in Making Sense of Research has an even greater respect for case reports. She cautions not to confuse the detailed observation and reasoning of a case report with anecdotal evidence. She adds that it may be the first step in developing a hypothesis. This can be illustrated by the timeline below.
Poster Timeline (Recommended by CARE Guidelines on Case Report Writing) gives a visual story of treatments and their results
What is of value in this case report & poster?
My conclusion raises the hope that “this case may inspire larger studies that include previous knee surgery and/or older populations.” And, that this treatment “may contribute to quality of life and renewed opportunity to be physically active for adults with CAI [chronic ankle instability]”.
Because the techniques are within the scope of practice of a massage therapist, this also widens the opportunity for other MT’s. And, this is the first time ankle research includes insights from Ortho-Bionomy’s philosophical approach of gentle touch and respect for the body’s self-healing capacity.
Do you want to be involved in ankle research?
I am still doing my case report series on manual therapy for ligament injuries. And I am still accepting participants! Or, if you are a practitioner, and want to write a case report or present a poster, I am happy to share any tips I can give you. Call with any questions: 503-708-2911.
Or, you may schedule an appointment here: Schedule Appointment