Patient is a 35 years old golf coach. Patient had a brief history of exceeding his ankle on both edges. General health status of the individual is good. Patient's activity amounts from a round of18holes of golf and travelling range for 60mins per day. Patient's activity includes more walking. The main problem of the individual is pain and rigidity in right ankle. Patient had a brief history of little by little developed pain and rigidity over the last 4months during his regular instruction job. The aggravating factors of his problem were powerful driving a vehicle range images for 30mins and walking for 40mins. The easing factors of his problem are snooze and temperature for 40mins. Within the 24hours style of pain, patient has stiffness on increasing and which becomes easier with gentle activity.
On palpation there may be puffiness to anterior and lateral aspect of right ankle joint. On evaluation the resisted dorsiflexion is weakened and painful. There's a decreased flexibility of dynamic plantar flexion. In passive plantar flexion pain is produced after amount of resistance. The resisted plantar flexion is weak and painful. Productive range of motion of inversion is reduced and unpleasant. During passive inversion pain is thought after level of resistance. Resisted inversion is poor and unpleasant. Resisted eversion is weakened.
In accessory motion of talocrural joint, postero-anterior glide is stiff and the pain is produced by the end of range. In the distal tibio-fibular joint, longitudinal cephalad glide is painful before amount of resistance and during postero-anterior glide the individual feels easier. The muscles are weakened on both attributes of ankle. The right ankle is weaker compared to left ankle joint. Anterior talo-fibular ligament and calcaneo-fibular ligaments show bilateral laxity. On palpation you can find puffiness surrounding the lateral malleolus. Heel raise of the individual is poor, which is 5 on right and 10 on right area.
SEVERITY, IRRITABILITY, AND THE TYPE OF PAIN
According to Petty (2006) severeness and power of pain are related collectively. Seriousness can be determined by the power of the patient to maintain the positioning or movement. Seriousness is a primary factor to ascertain whether the patient may be able to tolerate overpressure and perform moves up to the first point of pain.
According to Hartley (1994) the conception of pain differs from person to person depending on individual's emotional position and his prior pain experiences. The strength of pain depends upon the number of nociceptors in the site of personal injury and the surrounding tissues. Power of pain can be more in the areas of high innervation than the area of poor innervations.
According to Hengeveld & Bankers (2003) the level of pain is subjective and it ranges from person to person. In this case the level of pain of the individual is 4/10 of aesthetic analogue scale. The individual can play a rounded of18holes of golfing a day and techniques on the traveling range for 60mins per day. He also strolls for an extended distance. In spite of pain the individual could perform his activity. Therefore the patient's intensity of pain may be low to modest.
Hengeveld & Bankers (2003) says that irritability depends upon activity leading to the pain, the depth of the activity and enough time used for the pain to subside after the activity is halted by the patient. Relating to Petty (2006) irritability can be determined by the time used for pain symptoms to help ease. The symptom is reported to be irritable, when the symptom persist after the activity producing pain is stopped. In case the symptoms are irritable the patient will not be in a position to tolerate motions for longer durations. The symptoms may even get worse with activity. So the testing motions should be achieved with caution. In this case the aggravating factors are powerful driving a car rage pictures for 30mins and walking for 90mins. In the same way the easing factors are snooze and high temperature for 40mins. Therefore the irritability of patient may be moderate to high.
However relating to Hartley (1995) aching pain is related to the structures like deep ligament, deep muscles, tendon sheath, chronic bursa, small fascia. Further Magee (2008) argues that, when pain is caused by a task and eases with snooze indicates that there is a mechanised problem which relates to movements. Periodic pain may suggest that there surely is a mechanical participation and it is related to movements and mechanical stress. In this case the pain is intermittent and deep in nature. The individual has pain after activity and the pain resolves with snooze. So the pain may be mechanised, intermittent and profound in nature
MANUAL Remedy TREATMENT
In this circumstance, the primary problem of the individual is stiffness somewhat than pain, in the right ankle. Maitland's class4 mobilisation with postero-anterior glide of talus on ankle joint mortise can get to improve flexibility of plantar flexion. The glide can get in grade 4, since it is stable and controlled in comparison to level3 (Hengeveid & Banking companies, 2003). Here the ankle joint mortise is a concave surface and the dome of talus is convex. When ankle joint mortise is set and talus is shifted, plantar flexion occurs by concave-convex rule. (http://www. pt. ntu. edu. tw/hmchai/Kinesiology/KINmotion/JointStructionAndFunciton. htm, Particular date accessed: 13/12/2009)
However before treatment the critical indicators that should be considered are patient's objective marker of pain, loss of range of motion and movements leading to pain and these factors should be assessed after treatment lessons. In Maitland's technique, there is absolutely no standard length of time for the treatment, but the duration of the treatment shouldn't be more than 2minutes. The duration of the procedure can be altered based on the severe nature, irritability and nature of the symptoms of the individual. Because the irritability of the patient is moderate to high, the initial treatment can be given throughout 30 a few moments, with a couple of repetitions to avoid exacerbation of the symptoms. After watching the objective marker, duration of the treatment can be advanced to at least one 1 to 2mins and the repetitions can be progressed gradually. The patient can be situated in prone lying down with leg in 90 degree flexion. The starting position of the therapist can be standing by the side of patient's right knee to obtain close contact with the procedure area. To provide proper support to the shin, the kept knee is located on the sofa. The therapist is capable of doing the postero-anterior glide by holding the posterior surface of the calcaneus in his right side with his thumb, fingertips fanning about the calcaneus and his kept hand held in supination, with his heel placed up against the tibial anterior surface and the therapist's hands are proximally directed. These positions can be used to stabilise the part. The power can be applied by motion of the forearms opposing one another. The movement of the therapist's forearms produce postero-anterior glide (Hengeveld & Banks, 2003).
Even though, there are literatures supporting the effectiveness of joint mobilisations, there is not enough controlled studies to show that joint mobilisation can regain the normal range of motion and functions of hypomobile joint effectively (Farrel, J. P & Jenson, G. A. 1992)
EFFECT OF MAITLAND MOBILISATION
Maitland's technique, derive from restoring arthrokinematic motions. Generally arthrokinematic movement of the joint can be restricted by the ligaments, capsules of the joint and periarticular fascia. The stretchy properties of the connective tissues are based on the set up of the collagen bundles. In ligaments and tendons, the collagen bundles are arranged parallel to one another with stretchy bundles among them. If the connective tissue structures are unloaded, the collagen bundles show a crimp development in their structure. This crimp results in creation of slag in the connective cells structure. During the phase of loading, slag is extended first, accompanied by the stretching of main bundles. On the other hand the fascia and aponeurosis have multilayer collagen bundles but have less crimping and slack in comparison to ligaments. First when the load is applied, structures with less slack are first subjected to stress, followed by the other bundles. The bundles of the fascia that have least slag will first withstand the tensile stress. If the strain is increased then the ligaments which have more slag will avoid the tensile weight. After further deformation, the other bundles will respond to resist the strain. To acquire elongation of the connective tissues overall, all the bundles should go through required stress. This concept can be explained by using stress strain curve.
In this graph, x-axis symbolizes the stress and y-axis signifies the corresponding stress produced by the load. The curve shows a slope, which signifies the connective cells resistance to lots. The collagen bundles which remain slag, represent the feet region. The curve also signifies the physiological launching range, which is then accompanied by the level of microscopic inability. If the stress still escalates the curve will proceed to the level of macroscopic failure and may even cause the rupture of the connective tissues. Based on this concept Maitland's quality 4 technique seeks to produce long lasting elongation (plastic deformation) of the tissues by inducing low level of micro-failure in the connective cells, there by increases the range of motion (Therkeld, 1992).
There is not any enough proof to prove that Maitland's mobilisation can be done completely weight bearing and efficient position. Its trustworthiness is dependant on the clinician's treatment experience and patient's reaction to the treatment (Farrel, J. P & Jenson, G. A. 1992)
SECONDARY TREATMENT
The other problems of the individual are poor heel elevating because of the weakness in the muscles of ankle joint and pain. In cases like this Maitland's grade1 mobilisation can get to lessen pain by pain gate mechanism. As the patient is a golfing mentor, he needs good heel increasing and strong ankle muscles once and for all performance in the game and to prevent further injury to ankle joint. Strengthening exercises to the muscles of plantarflexion, dorsiflexion, inversion and eversion can be taught to the individual to improve the muscular imbalance of the individual. Then your heel boosting should be motivated steadily and can be advanced when there is no pain. Balance training with the help of wobble table can be trained to the patient. The final phase of treatment is practical training. The patient can be trained to gradually raise the depth and the length of time of drive pictures in the overall game. Walking can be inspired in a stable surface.
CONCLUSION
Additional to manual therapy the effective means of rehabilitation of sports injuries should contain soft tissue rub, electrotherapeutic modalities, proprioceptive neuromuscular facilitation, strengthening exercises, co-ordination training, strength, flexibility, improving stability and educating the individual about the personal injury mechanism and ways of avoidance (Farrel, J. P & Jenson, G. A. 1992). Sports therapist should mainly concentrate on avoidance of the accident rather treating when the damage has occurred.
