Patient case study – Ankle pain
Kathy, 70, came to us 14 weeks after a right ankle fracture. She had sustained a serious fracture that had to be repaired on both sides with plates and screws. She had been immobilized for 12 weeks since the surgery in a removable boot. She had seen another physical therapist for two weeks, who had given her exercises and stretched her ankle. PT hurt so much that Kathy reported she was in bed for one to two days after each session, and felt that her pain was worse than ever. When she came to us, she walked in with crutches, unable to bear weight on the operative foot.
Kathy was distraught because she had agreed to watch her seven-year-old granddaughter for the summer while the girl’s parents worked. Kathy was unable to drive, shop or bathe without assistance, and didn’t see any way she would be ready to care for a child in five weeks, when summer vacation was beginning.
Upon removing the boot, we noticed significant changes in skin color – instead of being pale, the skin was red and hot, and there was dark coarse hair on the involved foot. The surgical wounds had healed well, but she had intense pain with light touch to the surgical scars, which is known as allodynia. When her ankle was gently touched, she nearly jumped off the table with pain. Putting a little weight on the foot caused her to have burning starting at the bottom of the foot radiating to her knee.
Kathy’s condition is a good example of central sensitization (because of the allodynia) as well as an autonomic contribution to her pain, as indicated by the color and temperature changes. Learn more about types of pain.
Her first treatment and home program involved looking through a magazine and cutting out right and left feet and sorting them into piles for left, right, male and female. We then took a washcloth and touched her right foot and then her left foot in non-painful places, and Kathy paid special attention to what the left felt like and focused on those normal feelings when touching the right foot.
We saw Kathy for four sessions over two weeks during which we progressed to mirror box therapy, where she hid her right foot and put her left foot in front of a mirror. She moved her left foot in different directions, while looking at the mirror, so it appeared to be her right foot.
At the fifth session, the trophic changes and allodynia had disappeared. She was able to bear full weight on the right foot with a shoe and an over-the-counter ankle brace. We were able to begin strengthening, balance and manual therapy for range of motion. By five weeks, not only was she able to care for her granddaughter without limitation, she had returned to a walking routine as well as weekly water aerobics.
Reference: Graded Motor Imagery for Pathologic Pain; A Randomized Controlled Trial. G. Lorimer Moseley, PhD.