The use of anti-inflammatories is widespread in the treatment of musculoskeletal injuries and pain (Paoloni et al. 2009). This has in part led to the common misconception that inflammation is an inherently negative occurrence which needs to be stopped or at least limited rather than the essential healing process that it is (Garnham, 2009). In this case study the use of anti-inflammatories for a common musculoskeletal complaint will be discussed with the impact on the prescribing clinician’s clinical reasoning highlighted.
Presentation & Initial Management
The case in question is one of a 29yr old man (Patient B) who suffered an inversion injury to his right ankle whilst playing football. He attended the Emergency Department (ED) where he was diagnosed as an ankle sprain following a negative x-ray and given elbow crutches to facilitate early weight bearing, tubigrip for additional support and paracetamol 500mg for pain relief. He was given a physiotherapy appointment for five days later.
At the physiotherapy appointment the patient continued to complain of significant discomfort, worse with weight bearing and continued swelling which also worsened with weight bearing and towards evening. On examination Patient B had significant swelling spreading from the forefoot to the distal lower leg. Bruising was significant being present into both the forefoot and the medial ankle but being most significant over the lateral aspect. Range of motion was limited with swelling, stiffness and pain, most notably into inversion and dorsiflexion. The patient had widespread tenderness as would be expected but was most tender over the lateral ligamentous complex, especially the anterior tibiofibular ligament (ATFL) and calcaneofibular ligament (CFL) with notable point tenderness at the distal fibula, approximately at the origin of CFL. Diagnosis was one of a high grade ankle sprain.
Management & Case Progression
The primary barriers to progress identified at this stage were all products of the acute inflammatory reaction present in the ankle from the time of injury. This inflammatory reaction produces significant oedema, pain, hyperalgesia, and erythema leading to decreased and painful range of motion (RoM) and difficulty weight bearing (van den Bekerom et al. 2010).
Options for management at this stage included to continue with current management, increase analgesia medication, add NSAID therapy or immobilize the ankle for period of time. After discussion with the patient regarding treatment options he was keen to try a period of immobilization and continue with his RICE self treatment at home. Apart from the information discussed with him regarding the reasons for and against NSAID therapy he personally felt that his pain was relatively well controlled, via paracetamol use as required (PRN) and that it was the physical weight-bearing which he was struggling with. Consequently the patient was given an aircast boot and instructed to continue with RoM exercises, RICE self management and paracetamol PRN.
The patient progressed well achieving normal full weight bearing (FWB) gait and full activity of daily living (ADL) function within six weeks of injury. However when progression to higher level function was attempted, the patient had a corresponding increase in symptoms of pain and swelling as well as morning stiffness post activity. Examination revealed point tenderness over the anterior medial talar dome and over the anterior lateral gutter. Working diagnosis at this point was potential talar dome pathology and synovitis. Both talar dome pathology and anterior lateral gutter synovitis are common sequelae of injury in the recalcitrant ankle sprain (Paoloni et al. 2009). The patient was somewhat disappointed with this setback and discussion regarding options led to the prescription of diclofenac 50mg three times daily. This significantly reduced the patient’s symptoms and allowed return to...
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