CASE STUDY: Injured Stuntperson’s Dramatic Rehab
by Robert Libbey*
In the previous article, I wrote about the history, supporting literature and research pertaining to Ligamentous Articular Strain Technique (LAST). I also discussed why manual therapy techniques that target areas of especially high concentrations of mechanoreceptors (tenoperiosteal and ligamentoperiosteal entheses) are important to incorporate into your practice.
In this article, I present an example of how incorporating LAST into your treatments could have a dramatic transformation in your clients’ rehabilitative process.
Rochelle Okoye is a Canadian stuntperson and actor. On top of this, Rochelle is an elite athlete (mixed martial arts and boxing), trained with the British Olympic Gymnastics team and is expert in more martial arts than I can name.
When I first met Rochelle, she was eight weeks post second degree right ankle inversion sprain/strain. She was non-weight-bearing, on crutches and her right ankle was heavily wrapped in a tensor (compression) bandage.
Eight weeks prior to our initial introduction, Rochelle was on a TV set in Vancouver. The scene was set for her to be running in four-inch heels, linked arm-in-arm with two other stunt professionals, all jumping off a dock, free falling 14 feet and landing on a squishy landing mat. Being in the four-inch heels, her feet were locked into full plantar flexion. Her right ankle immediately dislocated upon contact with the mat. She heard a “POP” sound and collapsed in pain. That was the last time she had put weight on that leg and foot.
For the next eight weeks she received conservative treatment from another medical professional consisting of only TENS, ultrasound and acupuncture. At this point she was still in an extreme amount of discomfort and pain, she was unable to weight bear, and had minimal active and passive ranges of motion in her right ankle. She questioned if she would ever return to the career and lifestyle she loved.
Rochelle eats, sleeps and breathes stunts and acting. The concept of having to alter her life direction was weighing heavily on her. This injury was severely affecting her social life and her psychological outlook. She was no longer hanging out with her friends from the stunt community. She had to decline a contract for an upcoming X-Men movie and other contracts that she had been looking forward to. She was losing hope and confidence that she would ever be able to return to the life she had known and loved. Although Rochelle is a happy and positive person, she was now severely depressed and at one of the lowest points in her life.
Observation and Assessment
- While lying supine with the supporting bandage removed, her right foot was plantar flexed and supinated.
- Swelling was present at both the medial and lateral malleoli and throughout the complete lower leg.
- Skin temperature was markedly colder around all aspects of the ankle.
- Dorsal pedis and posterior tibial pulses were present and felt the same when compared bilaterally.
- Tissue tension/tone of anterior, posterior and lateral compartments of the right leg were increased.
- Her tibia was positioned in external rotation on the femur.
- The hamstrings, popliteus, gastrocnemius and soleus muscles were hypertoned in a sympathetic protective state.
- The medial meniscus was tracking more anteriorly than the lateral meniscus; this is the reverse of what normal forced coupling is for the knee.
- There was pain on firm palpation around all aspects of both medial and lateral malleoli, including anterior and posterior talofibular ligamentous regions.
- There were no neurological signs or symptoms and deep tendon reflexes were normal.
- Active range of motion was non-existent. She was very apprehensive and fearful that moving the foot would cause more damage.
- Passive range of motion was 10 per cent with pain at end range.
In a 2012 paper, “The role of ankle ligaments and articular geometry in stabilizing the ankle,”1 Watanabe et al. note, “for unloaded condition, the lateral ligament accounted for 70% to 80% of anterior stability and the deltoid ligaments for 50% to 80% of posterior stability. Both ligaments contributed 50% to 80% to rotational stability. For the loaded ankle condition, articular geometry contributed 100% to translational and 60% to rotational stability. The ankle was less stable in plantar flexion and more stable in dorsiflexion.”
When Rochelle landed on her feet, they were locked in plantar flexion due to the high-heeled boots she was wearing.
Solomonow et al.2 state that the acute inflammation in ligaments that sets in within several hours may last several weeks and up to 12 months. Only up to 70 per cent recovery has been documented. Chronic inflammation can build up over several weeks, months or years, depending on dose-duration levels. Rest and recovery of as long as two years only allow partial recovery. Full recovery has never been reported.
Bouffard et al.3 published a study documenting the effects of brief static tissue stretch on TGF-B1. TGF-B1 plays a key role in connective tissue, regulating the response of fibroblasts to injury, remodeling, scarring and pathological production of fibrosis.
Langevin et al.4 stated that in cases of minor sprains and repetitive motion injuries, scarring is mostly detrimental since it can contribute to maintaining the chronicity of tissue stiffness, abnormal movement patterns, and pain. Reducing scar and adhesion formation using stretch and mobilisation is especially important for internal tissue injuries and inflammation involving fascia and organs. They proposed that therapies (massage) that briefly stretch tissues beyond the habitual range of motion, locally inhibit new collagen formation for several days after, and thus, prevent and/or ameliorate soft tissue adhesions.
The results of the Bouffard and Langevin studies show that brief, moderate amplitude (20 to 30 per cent strain) stretching of connective tissue decreases both TGF-B1 and collagen synthesis.
Based on the current research, manual/massage therapists have the potential to profoundly affect the course of tissue healing by changing the physiological environment and decreasing the sympathetic nervous system response to injury.
A response of decreased TGF-B1 could lead to decrease in fibrosis and decrease in fascial stiffening of the surrounding and injured tissues.
For the first 8 weeks of the injury, Rochelle’s ankle had not been stretched, had not been mobilised nor had the new scar tissue been challenged while it was developing. That initial treatment strategy was not based on research, did not recognise the current understanding that ligamentous injuries are now considered neurological dysfunctions nor did it take into account the biopsychosocial model of patient management.
Malcolm Gladwell describes a “Tipping Point” as “the moment of critical mass, the threshold, the boiling point.”5
This appointment needed to be the “Rehabilitative Tipping Point” for Rochelle; the point where a major change in treatment strategy and patient management was necessary. Rochelle and I determined that the main goal was to immediately and dramatically transform the direction of her rehabilitation.
We decided to shoot for the stars.
We agreed that within this initial 90-minute appointment, our goal was to have her standing, weight-bearing and walking before she left the office.
An evidence-informed practice always consists of incorporating research, principles of practice and common sense clinical experience.
Having a BPS perspective of patient management, I always communicate with patients’ pertaining to fear and anxiety of the state of the injured/affected tissues, constantly reconfirming informed consent and working within the patients’ tolerance levels. Although during this 90-minute treatment LAST was used heavily, I also incorporated fascial tissue treatment techniques, muscle energy techniques and principles of active isolated stretch.
After an orthopaedic assessment of the affected appendicular and axial articular structures, palpatory and movement assessment identified areas of dysfunction and increased densification within the injured tissues. Principles of treatment for LAST include, but are not limited to, manually disengaging the affected area from its protective/dysfunctional holding pattern/position, exaggerating the dysfunction via a combination of both direct and indirect techniques allowing the tissues to retrace their route back to a more neutral/anatomical position, then waiting at this point of tissue and neurological parasympathetic/sympathetic balance until the tissues become more pliable and supple. It’s at this point that the sympathetic protective mechanisms have diminished, allowing for a more normal resting position and function to occur. A reassessment of the permitted motion in the tissues is done to confirm more suppleness and improvement in mobility, range of motion and an improvement in kinesthetic and proprioceptive awareness.
First, we focused on returning her right talus and metatarsals to neutral positions, and decreasing densification of the surrounding tissues. This alone improved functionality immediately and decreased Rochelle’s pain and discomfort. Focusing on the densification of the interosseous membrane between the tibia and fibula was key to getting the fibula functioning normally with plantar flexion and dorsi flexion. Next, we focused on decreasing the hypertonicity of both the anterior, posterior and lateral compartments.
Attention was then given to the knee on her affected side. We addressed the increased tibial external rotation on the femur and the forced coupling dysfunction of her medial meniscus. Treatment to popliteus, gastrocnemius, hamstrings and quadriceps musculature, helped to reduce their dysfunctional influence on the knee.
We recognised that her antalgic gait had contributed to some nonspecific lumbopelvic pain, tension and dysfunction. We addressed those concerns, again incorporating LAST with MET and FM.
Next came the most crucial part of the treatment; re-education of gait, training her to function more normally, improving proprioception and kinesthetic neurological connections to the CNS. Gait was trained in reverse and balance was trained via eyes open and closed standing on the affected leg.
At the end of our 90-minute appointment, we had accomplished our goal. Rochelle was able to stand on the affected leg with minimal pain. She was able to walk with near normal gait unassisted by her crutches and she was able to leave our office walking down our stairs using the hand rail for support.
It was an emotional time for both of us.
It was the first time she had been weight-bearing on the ankle in 8 weeks. Suddenly she had hope of returning to her pre-injured life.
Throughout the treatments, we recognised when Rochelle required additional treatments from therapies that were outside my scope of practice and the appropriate referrals were made to medical practitioners.
The Next Stage
Over the next year, she continued to receive manual therapy combined with active rehab and strength training. Although much progress was made, pain was still a limiting factor preventing her from fully returning to the level of athleticism she had previously known. Ultimately, she required surgery to remove the excessive scar tissue that had developed at the site of injury during the initial 8 weeks of immobilisation. Scar tissue develops with neurovascularisation. Peripheral nerves and vasculature ingress into scar tissue, which can potentially create a painful experience. These structural changes, combined with the psychosocial effects, have been shown to cause neuroplastic changes in the CNS, contributing to the chronicity of dysfunctions.
I’m happy to say that, although it was a long journey, Rochelle accomplished her goal of returning to working full time. She now regularly contributes to the TV series “Arrow” and “The Flash”, “Wayward Pines” and blockbuster movies like “X-Men”, “Planet of the Apes” and “Deadrising: Endgame.”
What Can We Learn?
It’s obvious that no two clients or treatments are ever the same and that results vary from client to client and from treatment to treatment. What is important here is the recognition that we, as manual therapists, have the ability to profoundly affect the course of tissue healing and we can dramatically transform the direction of rehabilitation for our clients. We can give a client hope.
It’s important to recognise that to succeed in practice we must continually improve our education via live and online courses, receive mentorship from someone within or outside our profession, read research articles, apply research to our treatment strategies, practice with an evidence informed treatment plan, treat with a BPS perspective focusing on the needs of the tissues and the client, and refer to a team of trusted professionals who complement our treatments.
About the Author
Robert Libbey is a Canadian Registered Massage Therapist and educator who runs workshops and online courses on LAST. Robert will be visiting Australia in October and presenting workshops on LAST in Tweed Heads, Perth and Canberra. Download the workshop flyer for more info. Earlybird prices close on August 15. Robert is also presenting at the AMT National Conference Ocrober 12- 14. Book your place here – earlybird prices close on 13 August 2018. Learn more about Robert and LAST here.
*This article first appeared in the Massage Therapy Canada Spring 2017 magazine (pages 22-24) with the title “Action Packed”.
- Watanabe et al.(2012) The role of ankle ligaments and articular geometry in stabilizing the ankle. Clin Biomech (Bristol, Avon). 2012 Feb;27(2):189-95. doi: 10.1016/j .clinbiomech.2011.08.015. Epub 2011 Oct 13.
- Solomonow M. (2009) Ligaments: a source of musculoskeletal disorders. Journal of Bodywork and Movement Therapies, 2009;13(2):136-54.
- Bouffard NA, et al. (2008) Tissue stretch decreases soluble TGF ß1 and Type-1 pro-collagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models. Journal of Cellular Physiology. 2008;214: 389–395, 2008.
- Langevin HM, et al.(2002) Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. FASEB J. 2001;15:2275–2282.
- Gladwell, M (2000) The Tipping Point Publisher: Little, Brown Book Group ISBN: 9780349113463 ISBN-10: 0349113467