CASE STUDY - TREATMENT OF ANKLE PAIN POST RECONSTRUCTIVE SURGERY

Jimi Windmills

ABSTRACT

This case report presents the treatment of ankle pain, 12 years after reconstructive surgery, that was the result of a car accident. For the purpose of confidentiality the patient will be referred to as Markus.

Markus is a 48 year old male, who in 1999 was involved in a car accident, which shattered his right ankle. The ankle was crushed so badly that when necrosis began, in hospital, the doctor recommended amputation. Perhaps by luck, Markus was assigned a surgeon who, perhaps feeling a tad ambitious that day, decided that even though the ankle had pretty much exploded, because the skin had not broken, all the parts for a reconstruction must logically still be contained within. Markus spent three months in traction on painkillers with his ankle still in a crushed state before the necrosis subsided, and they were able to begin the operation.

Markus has been able to walk on his ankle and gets around with perceived ease. However, he has experience pain and swelling in the ankle, which is especially bad after any period of prolonged use. The ankle, although painful serves well enough for walking even though its range of movement (ROM) is restricted to almost zero.

CASE HISTORY

Markus's main complaint was that after a period of standing or especially walking, his ankle would swell, and throb with pain. This pain had caused him to resign from his previous position as a night fill worker for Woolworths. I first treated Markus in the clinic three days after he had left his keys on the train and had had to run back to the train station, which (especially when walking can be a problem) had caused significant swelling and pain in his ankle.

Markus currently works on the weekends at the markets as a fairy floss vendor. In this position he tends to be on his feet all day.

In the initial consultation, Markus reported the following signs and symptoms.

• Sharp pain in the morning, especially with the first few steps of the day.
• Active and passive movement restricted to an extent as to be functionally not present.
• Disturbed neural sensations - pressing one location would elicit a touch sensation in a different location on the foot.
• Pain in the metatarsals with any amount of walking.
• Pain feels deep as opposed to superficial
• Most intense area of pain is inferior to the lateral malleolus
• Palpable deficiency in the stomach channel, particularly in the lower leg. There was an unusual 'pocket' with a 'bubble' of air under the skin in the area lateral to ST36. This is suggestive of muscle having been removed or relocated during surgery.
• Overuse 3 days prior (Monday) had caused significant pain and inflammation from the following day through to Thursday, our first consultation.
• Palpation of the ankle itself revealed that the foot and ankle while noticeably swollen were not hot to touch, in fact tending toward cool, and a little clammy. Normal bony landmarks of the talus, navicular, cuboid and cuniforms, were distorted, and in places impossible to navigate. This was a result of the reconstruction during surgery.

Tongue: Red, slightly dry, with peeled edges. Pulse: Wiry.

The diagnosis was Bony Bi obstructing Qi and Blood in the channels, collaterals, and joints of the right foot.

During this session I had Markus fill out an initial Measure Yourself Medical Outcome Profile (MYMOP2) form, so we could begin to track the outcome of the treatments over the next few weeks. This initial MYMOP2 recorded pain and swelling as assessable symptoms and rated them toward the worse end of the severity scale. Markus filled out follow up MYMOPS's each session. A discussion of points and treatment techniques, plus the outcome measures will follow the case history.

In the second session Markus reported that a new neural pain had developed since the last treatment. In that week he had also started wearing new orthopaedic inserts. The pain was in the area medial to the first metatarsal, between the points SP3, and SP4, and would begin within minutes of walking. We found that this was most likely cause by a compression or entrapment of the medial plantar nerve, a branch of the anterior tibial nerve. Markus reported that except this new pain, all symptoms were the same, but last weeks more acute pain and swelling had reduced by half after the treatment. We continued with the same point proscription as the first session, with the addition of an ahshi point between SP3 and SP4 with needle head moxa, at the location of the new pain.

The third session began with Markus reporting that he could stand all day working at the markets without causing pain, this was a terrific result for Markus as it allowed for him to maintain his income without having to endure pain for several days after working. He noted that there was still tenderness when getting out of bed, and long periods of use would still trigger swelling. The nervy sensation at SP3/4 was still persisting. Again, we continued our treatment protocol, as we were beginning to see some very real, and promising results.

In the fourth treatment Markus reported a reduction in the nervy sensation at SP3/4, and that overall his ankle was much better, and that there was considerably less swelling after excessive use. A new 'grabbing' sensation was noticed below the lateral malleolus in the area of BL62, which Markus said would, 'grab' and then quickly let go. This sensation was not painful, just unusual. In this session I paid extra attention to BL62, making sure to maintain stimulation, by often returning to the needle and stimulating it between insertions of other points.

In our final session, Markus reported that the nerve pain at SP3/4 had completely resolved, as had the 'grabbing' sensation at BL62. He said that his ankle could handle much more use before becoming swollen. When it did swell, the severity was greatly reduced and the swelling would resolve over a much shorter period of time, within hours rather than days. Pain with extended periods of use had all but disappeared. It was only extreme use such as running that would elicit pain.

TCM DIAGNOSIS, and TREATMENT

In the initial session we diagnosed Markus as having Bony Bi obstructing Qi and Blood in the channels, collaterals, and joints of the right foot. Thus, the approach taken in this case was essentially to address the pain and swelling locally by dispersing excess's such as stagnation and bony bi. Point prescription stayed the same, with the exception of the addition of an Ahshi point between SP3 and SP4 as mentioned in the case history. Most points had needle head moxa as an additional therapeutic aid to help move stagnation, and address the bony bi. All points were needled with 30X0.25mm needles, and strong Qi obtained at each point. The character ^ after a point signifies that needle head moxa was applied to the needle at that location.

The points used were GB34, GB39, GB40^, GB41^, ST36^, ST40^, ST41^, ST43^, LV3^, LV4^, KD3, KD5, KD6^, BL62^, SP5^, Ahshi point located between SP3/4^.

OUTCOME AND DISCUSSION

In this case the outcome was measured using the MYMOP2, with measures two patient nominated symptoms, and an associated activity to be measured. Markus nominated ankle pain as the first symptom and swelling as the second, with the associated activity being walking. In the MYMOP2 follow up survey, a third symptom can be nominated if one has arisen. As Markus noted neural pain between SP3 and SP4 in the second session, this became out third measured symptom. General well-being is also recorded

Symptoms are measured on a scale of 0 – 6, with 0 being 'as good as it could be' and 6 being 'as bad as it could be'. Lower scores therefore, represent better outcomes. The following graph and table show the progress of relieving symptoms over five sessions.

Symptom	Session 1	Session 2	Session 3	Session 4	Session 5
Ankle Pain	5	3	3	1	1
Swelling	4	3	2	0	1
Walking	5	3	3	1	1
Pain SP3/4	N/A	3	3	2	0
Wellbeing	2	2	1	6	1

We can see from this table that pain and swelling that started as quite severe, after 5 treatments, had improved dramatically. The abnormally high score in well-being in the fourth week was due to a bout of influenza that Markus suffered that week.

The next graph and accompanying table represents the scores for each session, totalled and averaged, to give an indication of the overall progress of the treatment. Lower scores are better.

Session	Treatment Score Average
Session 1	4
Session 2	2.8
Session 3	2.4
Session 4	2
Session 5	0.8

Given the nature of the condition and the length of time since surgery, it seems unlikely that complete, functional range of motion in the ankle joint could be restored. However, in this case it is likely possible to achieve long term reduction, or with extended treatment, complete negation of pain. Given the results of the outcome measures, I feel that with an extended course of treatment, Markus could make significant progress toward relief of pain and swelling completely.

CONCLUSION

This case report presented the treatment of pain and swelling of an ankle 12 years post reconstructive surgery. I have demonstrated the eficacy of this treatment, and shown results measured with the MYMOP2 survey. The results presented here are particularly important, as they have allowed the patient, to maintain his income in a manner that does not cause significant discomfort and pain, thus contributing a great deal to the patients quality of life.