ryc. 1. Obraz znaczego uszkodzenia więzadła piszczelowo-skokowego przedniego

The article presents evaluation of the effects of the high power laser therapy in a handball player after the injury to ankle joint ligaments.

Description of the study

The study was carried out on a 19-year-old female gymnast with a 12-year-old experience who trains 24 hours a week and exhibits a high sports level. The gymnast sustained a torsion injury to her ankle joint after a fall from the balance beam during her specialist training.

Immediately after the injury, the patient cooled the limb on her own, according to the PRICE rule. She came for the therapy after three days, describing the feeling of instability and stabbing pain on the medial side of the ankle joint with moderate oedema. She rated her feeling of instability and pain to be 6 on a 10-point scale.

Physiotherapy was taken up together with the high power laser therapy using Polaris HP. Parameters of the procedure were: wavelengths of 808 nm and 980 nm; power from 1 to 5 W for every source at a dose from 10 to 30 J/cm2; duty cycle from 20 to 80%, grading the power as well as dose and duty cycle. The first four sessions used the frequency of 3,000 Hz and then 700 Hz was applied. The procedures were performed dynamically in the areas of oedema and injured ligaments. In addition, the patient took on manual lymphatic drainage, transverse massage, other active exercise and resistive exercise and after a few days sensomotoric exercise. The procedures were performed every 2 days.

The ultrasound examination was performed ten days after the injury, that is, after two therapeutic sessions.

Polaris HP high power laser therapy unit
Polaris HP high power laser therapy unit

 

Result of the ultrasound examination

Lateral compartment: No signs of a significant injury were found within the ATFL capsular ligamentous complex; the ligament with a preserved line, slightly widened, with oedematous lesions. The Doppler ultrasound test did not find any signs of an increased blood flow through the ligament. The CFL and PTFL have a normal fibre line: the ligaments do not show any signs of insufficiency in the dynamic test. The tendons of fibular muscles without any signs of dislocation, but oedematous lesions of retinacula were found. Normal amount of the fluid in the tendon sheath.

Medial compartment: Oedematous lesions in superficial and deep layers. Oedematous lesions with the loss of fibre continuity in the superficial layer of the tibiotalar ligament and tibiocalcaneal ligament: the lesions span around 10 mm (from the tibial edge) and most certainly are responsible for pain in that area. Signs of partial breaking in the deep fascicle: the normal outline of the anterior tibiotalar ligament fibres was not found: the image showing considerable damage. The posterior tibiotalar ligament is widened and swollen. The tibionavicular ligament is widened, with oedematous lesions and non-homogeneous. The bifurcated and talar ligaments (calcaneonavicularis fascicles) exhibit intensified oedematous lesions, without any signs of an increased blood flow, which suggests the first degree injury. Slight synovial membrane hypertrophy (most likely reactive) and the fluid in the tendon sheath of the tibialis posterior muscle: without any signs of breaking the continuity of the fibres and an increased blood flow through it.

ryc. 1. Obraz znaczego uszkodzenia więzadła piszczelowo-skokowego przedniego

Fig. 1: Considerable damage to the anterior tibiotalar ligament.

ryc. 2. Obraz uszkodzonego więzadła piszczelowo-skokowego oraz piszczelowo-piętowego

Fig. 2: Damaged tibiotalar ligament and tibiocalcaneal ligament.

Posterior compartment: Normal amount of the fluid in the FHL sheath. Synovial membrane hypertrophy without any significant signs of oedema in the interosseous ligament; PTFL oedema (injury) as described; without proliferative changes.

Anterior compartment: The dynamic test did not show any signs of lesions of an anterior ankle impingement. Increased amount of the fluid in the ankle joint. To the extent available to diagnostics, cartilaginous surfaces in the talocrural joint with even contours, without any signs of the damage to the cartilaginous surface: further MR diagnostics. No signs of the damage to the tibiofibular syndesmosis, inferior fascicle, were found. Small oedematous lesions in the inferior fascicle.

Conclusions: Post-traumatic lesions in the medial compartment with more intensified lesions in the deep layer of the deltoid ligament, particularly the anterior part.

Result of the repeated ultrasound examination

Soft tissues:

Lateral compartment: The same image like in the previous examination, without any changes.

Medial compartment: Significant improvement in the affected ligaments, including the area of the ligaments of the superficial layer with post-traumatic lesions, tibiotalar and tibiocalcaneal ligaments: scarring without any significant oedema in the proximal part of the ligaments: scars are located in the distal part in this case. With respect to the much damaged anterior tibiotalar ligament, extensive regressive lesion (scar). No oedematous lesions of the posterior tibiotalar and bifurcated ligaments were found (the lesions were intensified in the previous examination). Slight synovial membrane hypertrophy remains (most likely a reactive type) as well as the fluid in the tendon sheath in the tibialis posterior muscle.

Conclusions: Post-traumatic lesions in the medial compartment healed to a considerable degree: the area of injuries involving breaking of the continuity of fibres as described in the previous examination shows scarring.

Ryc. 3. Obraz zmian bliznowatych więzadła piszczelowo-piętowego po serii zabiegów

Fig. 3: Scarring of the tibiocalcaneal ligament after a series of sessions.

Ryc. 4. Obraz więzadła piszczelowo-skokowego po serii zabiegów

Fig. 4: Tibiotalar ligament after a series of sessions.

 The patient rated her pain to be 1 on the VAS 24 days after the injury and after twelve sessions. Furthermore, she said she felt minor instability. The ultrasound examination showed the regeneration of the damaged structures to a considerable degree. Literature reads that the time for the regeneration of damaged ligaments is around six weeks.

Since the patient was not able to continue the therapy, she was recommended doing stabilisation exercises and slowly taking up training with a stabiliser or rigid taping. The patient ceased complaining about pain six weeks after the injury; still, she continues to complain about a slight feeling of instability on an uneven ground.

VAS and instability

Fig. 5: Diagram of the changes in the feeling of pain and instability before and after the therapy.

 recovery time

Fig. 6: Comparison of the typical regeneration time and with the use of the high power laser therapy.

Conclusions:

To a greater extent, the use of the therapeutic programme which includes the high power laser therapy may influence reducing the time for the regeneration of damaged ligaments and pain in patients after the ankle joint injury.

Physiotherapy was taken up together with the high power laser therapy using Polaris HP. Parameters of the procedure were: wavelengths of 808 nm and 980 nm; power from 1 to 5 W for every source at a dose from 10 to 30 J/cm2; duty cycle from 20 to 80%, grading the power as well as dose and duty cycle. The first four sessions used the frequency of 3,000 Hz and then 700 Hz was applied. The procedures were performed dynamically in the areas of oedema and injured ligaments. In addition, the patient took on manual lymphatic drainage, transverse massage, other active exercise and resistive exercise and after a few days sensomotoric exercise. The procedures were performed every 2 days.

The ultrasound examination was performed ten days after the injury, that is, after two therapeutic sessions.

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