### Abstract
This case report presents a history, diagnosis, prognosis and treatment of a young tennis athlete on scholarship to Florida State University. He sustains an acute ankle injury while in a tournament in the last month of high school that jolts him into realizing the injury hurdles that may lie ahead in the college athletic world. He and his parents choose alternative and complementary sports medicine rather than traditional methods and procedures for the health care of the young athlete. This case report details the procedures used to manage the acute ankle injury – Chiropractic, Acupuncture, Cold Laser – and the latest athletic training methods for sports rehabilitation are given in the integrative sports injury care given this athlete.
**Key Words:** Alternative, Complementary, Integrative, Chiropractic, Acupuncture, Cold Laser
### Introduction
Leonardo da Vinci called the human foot, which contains nearly 25 percent of the human’s bones and an elegantly functional arrangement of ligaments, tendons and fascia, a marvel of bioengineering and a work of art. Centuries after that observation by da Vinci, researchers continue to discover more about how the feet work, what can go wrong with motility maneuvers, and why (1).
Since 1990, Anderson Reed, a Daphne, Alabama resident and standout student at Bayside Academy in Daphne, Alabama, had been aspiring to greater heights in his chosen athletic endeavor of tennis (2). This year he graduated at or near the top of his class to go on to the University of his choice. He had a wide choice of colleges to select from by his sophomore year in high school when he became the top ranked tennis player in the State of Alabama. Reed played in tournaments across the United States through his high school career and accomplished a top 10 national ranking in tennis.
The young athlete narrowed his field of schools down to Georgia Tech, Vanderbilt, Louisiana State University, University of Alabama and Florida State University. After visiting the schools, talking with the administration, players, coach, and coaching staff at each college he felt informed enough to make a decision. His selection turned out to be Florida State University in Tallahassee.
His academic performance had been as good as his tennis record over the last four years, and it was reflected in the colleges and universities that sought Reed for their student body. Reed had decided on his collegiate career based on the academics of the school and the tennis program of Florida State University. Florida State has competed in the National Collegiate (NCAA) Sweet Sixteen finals each year for the past five years. They have top participants in the professional ranks, so he knew the coaching was going to be some of the best and – another plus – it was fairly close to home for him.
### Athlete and Injury
Last year at a state tournament in Mobile, Alabama, Reed was returning a hard volley and came down from a jump in the air, as he had done a thousand times before for a return shot. This time, however, he went down to the court in pain. He couldn’t move without severe pain. He had to forfeit the match and the game that day. His father and mother happened to be there and brought him home. They immediately called the practitioner they had depended on to keep Reed in good playing health for the last fifteen years. They all came together at the Integrative Medicine Centre office. The young athlete was taken to an examination room. It didn’t take long to determine that he had indeed sustained a bad ankle contusion with strain and sprain. The doctor thought he should be taken to the hospital for radiographs (X-rays), imaging (MRI), or both.
At the hospital the ER physician examined and followed up with radiographs and an MRI. It was determined he had sustained a grade III strain/sprain to the ankle (3). The radiologist had pointed out a couple of stress lines that he felt in most individuals would have been fractures (4). The diagnosis was a strain/sprain of the right ankle. Reed was to be out of action for the first time in his athletic career with an ankle injury. He had suffered mild shoulder, neck, wrist, and low back strains (5) over the past ten years, but nothing that kept him out of action more than a few days. This time was going to be different.
The team of Integrative Sports Medicine Specialists had seen hundreds of these injuries and had taken care of some of the best athletes in the world. They saw this as a good opportunity to illustrate the unified professional cooperation of the group.
Figure 1 Lateral View – Reed’s Right Ankle
### Biomechanical Analysis
The injury stunned Reed, his family and friends. Seeing him hobble around on crutches for weeks was just not what they were used to. But there were three components to this injury they had to understand. Because of the excessive flexibility of his body, especially the foot, over-pronation could easily have caused a fracture to occur. The three components that were involved, any one of which could have resulted in the injury were: a) too-rapid pronation (a turning-in of the foot); b) too extensive a degree of pronation; and c) pronation for too long a time.
When jumping, the athlete maintains pronation from the time of ground contact all the way into what’s called the propulsion phase. (At the propulsion phase, the foot should be very rigid to propel the body forward.) With a late-phase over-pronation, the foot is hypermobile (loose) and in danger of injury (6). Simply put, the body is applying a high level of force against the ground to propel the body forward while the foot is also excessively rolling inward. This inward foot rotation is transferred up the kinetic chain, alternating joint function. The uncontrolled load results in a high impact foot strike (6). So the athlete has reacted too fast, too excessively, and too long. The most difficult part for most people to understand is that he was just doing what his mind directed his body to do with the shot he was returning (6).
While traditional treatment methods for muscle, tendon and ligament injury have always emphasized rest, ice, compression and elevation (RICE), the team felt Reed should start functional treatment right away in order to retard scar tissue development (7).
### Methods and Materials
The team discussed the treatment plan after the consultation and examination, and determined that the athlete required a minimum of eight weeks of therapy, to consist of a physical examination (orthopaedic and neurological) (8,9), applied kinesiology or manual muscle testing to determine the weakened structures (10), acupuncture for quick pain control (10,11), and chiropractic for pelvic and low back compensation correction (6,8,10,12) as well as sports therapy procedures (13,14).
One new innovation in sports therapy, the Laser Therapy, a 500 mW cold laser (15,16), was to be utilized for the innovations provided by photobiostimulation technology within the last few years of Sports Medicine application and research (16). Medical Laser Systems has been working with doctors on a number of laser investigations, and this therapy seemed to be a good integrative approach to use. The laser utilizes acupuncture points that have been used in foot and ankle injuries in martial arts for hundreds of years with safety and efficiency (17).
Rehabilitative help from athletic training procedures and expertise was invaluable (18). The role of the Athletic Trainer’s (AT) involvement with the rehabilitation began early. Having worked with athletes for years, the AT was in tune with the mind and body needs of Reed’s injury from the start. There was the obvious need for some immobilization with an injury such as this, but the vital benefit of movement to promote healing in the affected area was not to be ignored (18).
The initial rehab session involved testing the ankle for range of motion (ROM) in relation to pain. The athlete needed to work in ranges where discomfort was 1-4 on a scale of 10 (19). This assessment was done in open chain fashion as the affected ankle tested in every possible position to locate the primary hindrances to healthy ROM.
What was found was there were a few positions in ROM (i.e. dorsiflexion) that caused greater degrees of pain than others. Once located, “pain-free zones” of ROM were used to work the ankle in those zones with resistance bands in a seated position. Some pain-free ROM with light resistance in the injured ankle progressed into the areas where discomfort was evident. The stimulus was kept passive as opposed to forcing any ROM that was not compliant. It must be noted here that the non-injured ankle was trained with the same resistance and workload. Well-established research literature indicates that working a non-injured limb results in strength improvement in the injured contralateral side. This is referred to as “cross-transfer” and even in immobilization situations reports show 10-77% (of healthy side) strength increases (20).
The athlete’s progress in ROM was quite amazing. He was seen 3-4 days per week through the rehab process in combination with his acupuncture and chiropractic treatments. Stability drills were added to the program. With the ankle, a healthy joint must have both mobility and stability (20). The ankle can be quite an uncooperative joint for an athlete, since if either the stability or mobility is compromised the other attribute suffers. Being a tennis player means the demands of repeated acceleration, deceleration, and change of direction are inherent. Proficiency in these athletic skills requires high degrees of mobility in the ankle joint. However, once that mobility threshold has been violated (as was the case with this injury), stability is the number one priority. Mobility cannot be restored to the athlete’s ankle without the presence of stability. Stretching of the lower leg was done with precision and care, to locate the ROM for that day as opposed to being competitive and forcing progress.
Though “ankle stability” was the focus, the vital fact is that the human body works in kinetic chains, meaning no specific area of the body (i.e. ankle) is an island unto itself. For example, the restoration of the ankle is intimately affected by mobility and stability in other key areas such as the hip and knee (21,22). We did not want our athlete performing closed chain movements on the injured ankle that would compromise ipsilateral hip function through compensations to “protect” the ankle. Standing exercises were implemented that required a “regulated stimulus” to the injured ankle. Reed performed these drills barefoot on a cushioned surface that required him to flex his feet into the surface.
After he developed the necessary stability in the ankle, it was time to implement lunge type drills with assistance from a resistance band around the waist. The bands are used in this case to _unload_ the drill so that less of the athlete’s bodyweight is placed on the injured ankle. The progression was to go into controlled horizontal force drills where the subject would move laterally while attached to the resistance band. This gradually reintroduced the ankle to deceleration forces as well as change-of-direction demands. These drills, and others similarly performed with trunk rotation, re-educated the kinetic chain that includes the hips and other core muscles as well as the shoulders.
Figure 2 Dr. Mike Allen, Dr. John Stump, Sports Medicine Specialist, with Anderson Reed
Reed followed the treatment and rehab plan exactly as was suggested and established a routine that had him back in competitive condition within the predicted 8 weeks.
It is reported, “Reed has been a natural athlete from the beginning of his career; not taking any medications, steroids or athletic enhancements has been his prerogative.” There was no question or desire for anti-inflammatory therapy during the treatment or rehabilitation phase. The athlete understood the theory that medication may give him short-term benefit but nothing permanent (23). He followed the daily grind of the exercises and the muscle therapy explained to him each week. The manual muscle testing (AK) showed the progress being made each week. His speed, strength and agility were there as before the injury. The relationship between the force of movement and the velocity of movement was well understood (24,25).
### Conclusion
Beginning high-competitive athletics at an early age, this young man just experienced what every athlete has to face, human frailty and lack of total control, the fact that athletic injury hurdles come up suddenly, unannounced and as quickly as moguls down a ski slope.
The sports injury team had worked with athletes from elementary to professional and Olympic levels during their career. They knew there are times when this happens to the best of athletes; it’s part of the price that each athlete has to pay climbing to the top of their athletic endeavor. Some athletes take it in stride and know and understand, but the knowledge is difficult for others. They just can’t understand why the body doesn’t always respond as quickly and as efficiently as it should to a mental command and when it tries, sometimes the communication breaks down.
This athlete has a great future ahead. He crossed this injury hurdle just as he had all other hurdles put in front of him, with hard work and patience. He took on his treatment and rehabilitation as if it was part of the challenge of the game, and it is a very important part. Our athletic staff would not be surprised at all to see him at Wimbledon in the near future if he continues to follow the work ethic he has set up for himself in the early stages of his athletic career. We want to thank the Physicians and staff of Thomas Hospital for their contribution and help with the imaging of the ankle.
Please address any questions, comments or suggestions to the authors at the following email address: [email protected] or visit www.alternative-concepts.com
### Applications in Sport
This article was written for the coaches, trainers and other sports health related personnel not familiar with the benefits of working in an Integrative Sports Healthcare facility. In this type of facility there are chiropractic, acupuncture, laser, nutrition and many non-traditional clinical applications that can speed an athlete’s injury toward recovery, in addition to the traditional approach in Sport Medicine.
### Acknowledgements
The authors wish to thank the radiology staff at Thomas Hospital, Fairhope, Alabama, especially the physicians who consulted with us in this case.
### References
1. Keele, KD with a commentary by Carlo Pedretti, Corpus of the anatomical works in the collection of her Majesty the Queen, New York: Johnson, 1979-1981. 3 vol. See also his fundamental study, Leonardo da Vinci’s elements of the science of man, New York: Academic Press, 1983.
2. American Academy of Orthopaedic Surgeons The Young Athlete New York, NY, July 2009.
3. Hole JW, Human Anatomy & Physiology, Wm C Brown Brothers, Oxford 1995 pages 172-200.
4. Fore, David and Radiology Staff, Thomas Hospital, Fairhope, AL. May 2009.
5. Gibble, M and Ashton, J. Young Athletes Fight Sports Injury www.CBS.Com June 2009.
6. Schafer RC. Clinical Biomechanics Musculoskeletal Actions and Reactions. Williams & Wilkins, Baltimore, 1998, pages 579-582.
7. Hammer, W. New Trends in Treating Muscle Injury. Dynamic Chiropractic, March, 2009.
8. Jenkins, DB Functional Anatomy of the Limbs and Back W.B. Saunders Company, Philadelphia, 1991.
9. Cyriax, J Orthopaedic Medicine Vol I & II Bailliere Tindall, London, 1984.
10. Micozzi M Fundamentals of Complimentary and Alternative Medicine Saunders Elsevier, 2006 pp 223-225.
11. Ibid pp255-73
12. Mayor DF Electroacupuncture Churchill Livingstone, London 2007 pp 191-195.
13. Oschman JL Energy Medicine: The Scientific Basis Churchill Livingstone London 2000 pp 165-193.
14. Stump JL Neuroma Pain of the Foot Successfully Managed with Laser Therapy Practical Pain Management, May 2009 pp 47-51.
15. Medical Laser Systems, Brandford, CT
16. White J and Kaesberg-White K Laser Therapy and Pain Relief. Dynamic Chiropractic. October 1994. 12(21).
17. Deadman P, AL- Khafaji M, and Baker K. A Manual of Acupuncture Journal of Chinese Publications. East Sussex, England. 2001.pp 10-20.
18. Konin JG Clinical Athletic Training SLACK Inc., Publishers, Thorofare, NJ 1996.
19. Irvin RL Classification of Chronic Pain. Pain. Supplement 3. 395-396.
20. Muscolino JE. The Muscular System Manual. Elsevier Mosby, St Louis, 2005.
21. Liebenson, C. Building Speed and Agility. Dynamic Chiropractic, June 2009.
22. Miller, John P. and Croce, Ronald V. (2007). “Analysis of Isokinetic and Closed Chain Movements for Hamstring Reciprocal Coactivation”. Journal of Sport Rehabilitation (16): 319–325.
23. Mishra DK, Friden J, Schmitz MC, et al. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am, 1995; 77(10): 1510-9.
24. Munn, J., Herbert, R., & Grandevia, S. (2004). Contralateral effects of unilateral resistance training: a meta-analysis. Journal of Applied Physiology, 96, 1861-1866.
25. Lee, M., & Carrol, T. (2007). Cross Education: Possible mechanisms for the contralateral effects of unilateral resistance training. Sports Medicine, 37, 1-14.
### Authors
John Stump did his undergraduate work in biology at the University of Maryland and a Master’s and Doctorate in Sports Medicine at the United States Sports Academy. In addition he accomplished a doctorate in Chiropractic from Palmer College in Davenport, Iowa. He went on to do postdoctoral work in Oriental Medicine and Acupuncture in Japan, China and Korea. In addition he holds black belts in Judo, Karate, and Kempo.
Dr. Stump is armed with a unique perspective on health care from an eastern and western scientific view. Because of this Dr. Stump was asked to be a team doctor for the South Korean government in 1986 for the Asian Games and 1988 Seoul Olympics. He is the author of numerous scientific articles, and has coauthored 4 textbooks. The latest textbook publication Stump contributed to being Electroacupuncture, edited by David Mayor, published by Elsevier 2007. Later that year he released a non-fiction account of the tragic stroke he survived (“A Stroke of Midnight” Alternative Concepts Publishing, 2007.) John is now writing a unique east-west anatomy text for McGraw-Hill to be released in 2011. He is a National Faculty member of the United States Sports Academy.
Mike Allen did his undergraduate work at the University of Tennessee at Knoxville and graduated in 1999. He did post-graduate studies in Sports Medicine at the United States Sports Academy and Athletic Training at the University of Mobile in Alabama. He is presently assistant Clinic Director at Southwest College of Acupuncture, and attends patients at a clinic in Denver, Colorado. In addition he is Consultant in Acupuncture to the Integrative Medicine Centre, Fairhope, Alabama since 2005.
Bob Saxon did his undergraduate work biology at Loch Haven University in Pennsylvania. He graduated from New York Chiropractic College with his DC degree in 2000. He has worked at the Integrative Medicine Centre for the past three years as Assistant Clinic Director, Chiropractic Department. He is also certified in Acupuncture by the International College of Acupuncture. In addition he teaches Anatomy and Kinesiology for Blue Cliff College in Mobile, Alabama.
Vince McConnell is a certified fitness trainer and athletic preparation specialist. Coach McConnell has been working with private clients, as well as high school, collegiate and professional athletes. He has written numerous articles for various fitness magazines and is often a guest on TV and Radio programs. He owns and operates McConnell’s Athletics in Fairhope, Alabama.
### Corresponding Author
John L. Stump, DC, PhD, EdD
Integrative Medicine Centre
315 Magnolia Avenue
Fairhope, AL 36532
<[email protected]>
251-990-8188
John Stump did his undergraduate work in biology at the University of Maryland and took his Master’s and Doctorate in Sports Medicine at the United States Sports Academy. In addition he accomplished a doctorate in Chiropractic from Palmer College in Davenport, Iowa. He went on to do postdoctoral work in Oriental Medicine and Acupuncture in Japan, China and Korea. He also holds black belts in Judo, Karate, and Kempo.
Dr. Stump is armed with a unique perspective of health care from an eastern and western scientific view. Because of this Dr. Stump was asked to be a team doctor for the South Korean government in 1986 for the Asian Games and 1988 Seoul Olympics. He is the author of numerous scientific articles, and has coauthored 4 textbooks. The latest textbook publication Stump contributed to was Electroacupuncture, edited by David Mayor, published by Elsevier in 2007. Later that year he released “A Stroke of Midnight” (Alternative Concepts Publishing, 2007), a non-fiction account of the tragic stroke he survived. John is now writing a unique east-west anatomy text for McGraw-Hill to be released in 2011. He is a National Faculty member of the United States Sports Academy.
