Int J Physiother.

Vol 3(3), 263-266, June (2016) ISSN: 2348 - 8336

CASE STUDY
IJPHY MANAGEMENT OF AN ATYPICAL ANKLE SPRAIN PATIENT THROUGH
HYPOTHETICO DEDUCTIVE REASONING MODEL OF CLINICAL
REASONING IMPLEMENTED BY INTERNATIONAL CLASSIFICATION
OF FUNCTIONING, DISABILITY AND HEALTH: A CASE STUDY
*
¹Mohammad Habibur Rahman
¹Md. Shofiqul Islam
¹Ehsanur Rahman
²Samena Akter Kakuli
²Shamima Islam Nipa
³Md. Obaidul Haque

ABSTRACT
Background: Clinical reasoning is a process by which physiotherapists interacted with patients, their family and other health- care
professionals. It is the thinking process that professionals tend to apply in clinical practice. Given that novice as well as expert
practitioners prefer to go through some steps while they were dealing with unfamiliar cases. This process is known as hypothetico
deductive reasoning. This reasoning approach involved the generation of hypothesis based on clinical data and knowledge and
testing of hypothesis through further inquiry. We are expert in musculoskeletal physiotherapy treatment and favoring the atypical
history of patient we went through step by step from assessment to discharge
Methods: A case based study through hypothetico deductive reasoning model of clinical reasoning. The objective of the study was
to investigate the physiotherapy management strategies of an atypical ankle sprain patient through hypothetico deductive reason-
ing which comprised of cue acquisition, hypothesis generation, cue interpretation and hypothesis evaluation by implementing
International Classification of Functioning, Disability and Health (ICF).
Results: The patient responded well to treatment as patient reported that 100% swelling decreased, could bear more weight (95%)
on foot, decrease pain (1 cm on 10 cm VAS scale), improved muscle strength by manual muscle testing by grade V in ankle planter
flexors (PF) as well as dorsiflexors (DF), invertors as well as evertors and the functional status of patient was improved by 80%
according to lower extremity functional scale.
Conclusion: Clinical reasoning is an important approach in physiotherapy. It helps the practitioners in decision making and choos-
ing the best alternative options for the well being of patients. We think it is necessary for all practitioners to have sound proposition-
al and non-propositional knowledge in order to provide effective management protocol for patients focusing ICF. Even though we
have been treating patients with musculoskeletal problems on regular basis, the atypical pattern of this patient give us the impres-
sion not to use pattern recognition all time for all patients rather using hypothetico deductive reasoning (HDR) where appropriate.
Keywords: Clinical reasoning, ankle sprain, hypothetico deductive reasoning, cue acquisition, hypothesis evaluation and ICF.

Received 24th March 2016, revised 07th April 2016, accepted 17th May 2016

10.15621/ijphy/2016/v3i3/100824

www.ijphy.org

¹Assistant Professor, Department of Physiotherapy,

Bangladesh Health Professions Institute, The academic CORRESPONDING AUTHOR
institute of the Centre for the Rehabilitation of the Para-
lysed, Savar, Dhaka, Bangladesh. *1
Mohammad Habibur Rahman
²Senior Clinical Physiotherapist, Department of Physiother-
apy, Centre for the Rehabilitation of the Paralysed, Savar, Assistant Professor
Dhaka, Bangladesh. Department of Physiotherapy
³Associate Professor & Head, Department of Physiotherapy, Bangladesh Health Professions Institute
Bangladesh Health Professions Institute, The academic in- The academic institute of the Centre for the
stitute of the Centre for the Rehabilitation of the Paralysed, Rehabilitation of the Paralysed
Savar, Dhaka, Bangladesh. Savar, Dhaka, Bangladesh.
This article is licensed under a Creative Commons Attribution-Non Commercial 4.0 International License.
Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0)

Int J Physiother 2016; 3(3) Page | 263

INTRODUCTION mechanism of injury as an inversion ankle sprain while
Clinical reasoning was a process by which therapists in- playing basket ball at school.
teracted with patients, their family and other health- care ii) Was pain in the injured site or referred from other parts
professionals [1]. Clinical reasoning was the groundwork of body?
of professional’s clinical practice. It was the thinking pro- The reason for asking the question was to detect the source
cess that professionals tend to apply in clinical practice [2]. of symptoms. Sometime, sympathetic source might have
Moreover, clinical reasoning was not only focuses on find- an influence over the neuro vascular injury of ankle [9].
ing associations between theory and practice but also to iii) Which activities of your ankle provocate pain?
evaluate patient’s assessment, treatment and management. iv) Were you feeling pain during resting position?
It was an ongoing process and it did not stop at completion The reasons for asking the se questions were to identify the
of patient management. Therefore, it helped practitioners nature and severity of injury. Patient told that, pain was
in extenuating reasons behind the patient’s management 0/10 at rest but with any weight bearing or pressure the
protocol. In addition with, patient management plan could pain became very intense just to the injured area.
be gained through theory as propositional and professional v) Any change of skin color in foot and ankle.
experience as non-propositional knowledge. It helped the vi) Were there any abnormalities of skin temperature?
practitioners to determine the best possible management vii) How did you recognize cooler foot?
guideline for patients with logic [3]. As Physiotherapists The reasons for these questions to ask were to determine
are health professionals, it was the utmost need for each any neuro or vascular involvement with ankle injury. Pa-
professional to maintain the standard of reasoning process tient answered that she was feeling cooler, dryer foot and
in physiotherapy practice [4]. This type of reasoning was purple color of skin in compare with the left side. All those
totally dependent on the diagnostic process [5]. Edwards, questions answers helped to format generation of hypoth-
et al. (2004) recommended that physiotherapy practi- esis.
tioners were required to consider diagnostic process as well Hypothesis generation was important part of the systemat-
as the personal context of individual patient and the envi- ic problem-solving process. It was an inductive reasoning
ronment where patient stayed [6]. However, Jones, et al. which provides a set of specific observation to a general-
(2000) stated that the personal context of patients should ization [8].
be different from one to another [7]. As a result the context After cue acquisition about the patient and answering the
predominately focused on patient’s physical, psychological, reason, few hypotheses were generated which are written
social and cultural concerns which in turn would be re- as follows:
garded as good physiotherapy practice.
i) There was relationship between mechanism of injury
The aim of the study was to interpret hypothetico deduc- and ankle sprain.
tive clinical reasoning model with a single case which we ii) An inversion injury of ankle was more responsible to
already saw previously. Now we are discussing the clini- cause complex regional pain syndrome along with vascular
cal reasoning procedures that we gained while treating a structure involvement than typical ankle sprain.
patient with neurovascular injury of ankle. We think the iii) There was relationship between neural impingement
discussion regarding case study would help physiotherapy and vascular injury of ankle.
practitioners during clinical practice.
Hypothesis generation was proceeded by cue interpreta-
As this was a complex case to detect initially we carried tion. This stage involved the interpretation of cues generat-
out diagnosis and management plan steps by steps. Jones ed from the initial encounter and focused on the confirma-
(1992) stated that novice as well as expert practitioners tion of cues. This significantly contributed to the original
would like to go through some steps while they were deal- hypothesis or alternatively, the rejection of cues unrelated
ing with unfamiliar cases [3]. This process was known as to the original hypothesis [8].
hypothetico deductive reasoning. In fact, it is a model of
clinical reasoning oriented in medical research. There are Our primary aim to take the history was to help us to un-
four stages of this type of reasoning: firstly cue acquisition, derstand all the factors leading to her current state of dis-
secondly hypothesis generation, thirdly cue interpretation ability. It helped us to detect clinical examination. Second-
and fourthly hypothesis evaluation. ary aim included understanding the mechanism of injury,
the state of inflammation and the possible pathobiological
Generally cue acquisition means the initial informa- mechanism causing pain and movement impairment. We
tion-gathering stage during the process of clinical reason- did not consider any psychological implication as she and
ing. It involved recognizing data needed for an individual her mother were curious about the condition. The history
case [8]. and clinical presentation of signs and symptoms suggest-
We asked a lot of questions to patient and among those ed a more complicated problem than just a lateral ankle
here only writing the some of them for example: ligamentous sprain. On physical examination, she had de-
i) What was the mechanism of injury? creased sensation to touch in the superficial peroneal nerve
The reason for asking the question was to identify which distribution. She was actually surprised to discover the
structure of ankle could be damaged. Patient told that the fact. Dorsiflexion of the left ankle was 8 degrees but only

Int J Physiother 2016; 3(3) Page | 264

2 degrees on the right side. Planter flexion was also limit- treatment, there was no satisfactory result. At that time,
ed on the right side (20 degree) compared with a left (45 we changed our treatment option and provided her neuro-
degree). In contrast eversion was normal. We found posi- dynamic mobilization for sciatic and peroneal nerves, and
tive neurodynamic examination of peroneal nerve whereas thoracic rotation as a home exercise program. Hunt (2004)
tibial or sural nerve did not show any discomfort. She also stated that thoracic rotation would have effects on sym-
had no history of ankle injuries or any history of spinal pathetic nervous system [12]. This in term had an effect
complaints. She complained of cooler right foot and leg. to improve the fluid dynamics of the vascular supply and
The planter and dorsal aspects of the lateral part of right the axoplasmic flow in the affected area. This might have a
foot appeared dryer than left foot. The history was unusu- positive blow on the nutrition of sympathetic fibres. This
al for a sprained ankle which typically heals more quick- ultimately would help to minimize the dry and cooler foot
ly. The possible problem we considered for this patient is signs and improve ankle joint range of motion. A leg hind
neurovascular injury and we discussed patient condition foot orthosis was provided, partial weight bearing was ad-
with her mother. These cues really match the hypothesis vised and static bicycling exercise was also advised for 10
two and three. Therefore, it required hypothesis evaluation minutes three times daily. The patient responded well to
to identify the most valid one. treatment as she could bear more weight on foot, skin be-
The final stage of hypothetico deductive approach was hy- comes warmer, decrease pain (9 cm decreased on 10 cm
pothesis evaluation. In this stage, the evidence collated was VAS scale). The outcomes swelling decreased to zero, pain
evaluated in relation to its relative merits, advantages and to 1/10 cm, muscle strength in all directions grade V, im-
disadvantages and possible contribution to the confirma- provement of gait parameters and weight bearing abilities
tion or rejection of the original hypothesis [8]. In this stage, by 95% and participate in basket and social gathering was
we made weighing up the pros and cons of each possible also improved by 80% (Table – I).
explanation for patient’s signs and symptoms and choos- Variables Day-1 Week 1 Week 2 Week 4
ing the one favored by the evidence. After completion of Pain 9/10 6 6/10 1/10
all ideas, we would like to say the hypothesis number two Swelling Grade 2 Grade 1 Slight Zero
supports the evidence. Ivins (2006) stated that neurovas- Dorsiflexion (Rt) 2º 8º 10º Full
cular injury should be as a part of differential diagnosis Planter flexion 20º 23º 25º Full
for ankle sprain [10]. A simple inversion injury of ankle Manual muscle testing
can cause physical impairments and associated structure/ in inversion, eversion, 3/5 3+/ 5 4/5 5/5
tissue source, delays healing process. World Health Orga- DF & PF

nization (2002) describes any injury causes not only phys- Weight bearing ability Nil
Walk 6
Running Jumping
minutes
ical impairments, but also causing limitation in activities,
restriction in participation and contextual factors which Self-reported function 30% ADL 60% ADL 80% ADL 95% ADL
have been perfectly described by ICF [11]. Conversely, ICF
Throw, Throw,
gives a standard language and framework for the descrip- Participation in sports Nil passing dribbling Full court
tion of health and health-related conditions. According drills Half court
to ICF, patient showed disease/condition as ankle sprain,
impairments as pain, muscle weakness, swelling, changes Table-I: Four weeks Treatment and Rehabilitation Flow-
in skin color, temperature, decrease range of motion and chart
kinesthetic sensation. Activity limitations were walking, CASE REPORT
schooling, playing basket ball and running. Participation Ms. X is a 15 years old girl injured her right ankle approx-
restrictions were unable to participate in social gathering, imately 3 to 4 weeks ago. She described the mechanism of
personal factors were 15 years old girl and psychological- injury as an inversion ankle sprain while playing basket
ly depressed about prognosis. Environmental factors were ball at school. She described as if she heard a pop sound
living in 4th floor and school was 20 kilometer (km) away at the time of injury. She also experienced severe pain and
from house. was unable to place any weight on the right foot. Her coach
PHYSIOTHERAPY TREATMENT advised her to take rest, apply ice, elevation and a compres-
The atypical natures of symptoms actually force us to dis- sion bandage wrap. She was also advised to walk with ax-
cuss the condition in a case conference where we set goals illary crutch while bearing as much as weight as tolerated.
for her depending on ICF. The short term aim of treatment Following two days of this approach, she was not improved.
was to minimize pain, swelling, to increase neuromobility, Patient and her mother became anxious. X was not able
to increase range of motion, to increase thoracic mobility to walk with crutch. Her uncle and aunty who were living
and to improve weight bearing ability within 2 weeks. In with her thought it might be her psychological expressions
addition, the long term to make her independent and re- of pain. Regarding these issues, her mother brought her to
turn to sports with 4 weeks. The treatment we provided ice general physician (GP) and he suggested X- ray and there
for 10- 15 minutes every 2 hourly. In addition, we advised was no evidence of fracture. Then GP diagnosed as right
her to perform 10 repetitions of knee extension exercise lateral ankle sprain. GP prescribed medication and non-
and advised her to continue it at home. After five days of weight bearing gait and advised her to perform ankle dor-

Int J Physiother 2016; 3(3) Page | 265

siflexion and planter flexion exercise with pain tolerance. [5] Payton OD. Clinical reasoning process in physical
She was not improving after 2 weeks of treatment. Thereaf- therapy. Physical Therapy, 1985; 65(6): 380-382.
ter, Ms. X and her mother both became worried about the [6] Edwards I. Jones M. Carr J. Mayer AB. Jensen GM.
prognosis and future life of Ms. X. GP decided to refer her Clinical Reasoning Strategies in Physical Therapy.
at Centre for the Rehabilitation of the Paralysed (CRP) for Physical Therapy, 2004; 84 (4): 312-330.
physiotherapist evaluation and management. [7] Jones M. Jensen G. Edwards I. Clinical reasoning in
DISCUSSION physiotherapy. In: J. Higgs. And M. Jones. Eds., 2000.
Clinical Reasoning in the Health Professionals. OX-
Clinical reasoning is the thinking and decision making FORD: Butterworth Heinemann, 2000: 117-120.
process that helps practitioners to use judgment and de- [8] Elstein AS. Shulman LS. Sprafka SA. Medical problem
cision making during clinical practice. Conversely, appro- solving: An analysis of clinical reasoning. Cambridge,
priate use of clinical reasoning skills help to deliver quality MA: Harvard University Press, 1978.
of service. As the case was atypical in nature we selected [9] Smart K. Doody C. The clinical reasoning of pain by
HDR model in diagnosis and treatment which was based experienced musculoskeletal physiotherapists. Manual
on developing hypothesis and progression and refining Therapy, 2007; 12(1): 40-9.
those based on observations and outcome. The physiother- [10] Ivins D. Acute ankle sprain: an update. American
apy practitioners in future time would draw conclusion by Family Physician. 2006; 74(10): 1714-1716.
using HDR model of clinical reasoning while treating of an [11] World Health Organization (2002). Towards a Com-
unfamiliar case. mon Language for Functioning, Disability and Health:
REFERENCES ICF: Available at: http://www.who.int/classifications/
[1] Jones MA. Rivett DA. Clinical Reasoning for Manual icf/training/icfbeginnersguide.pdf [Accessed 04 Janu-
Therapist. 1st edition; 2003. ary 2016]
[2] Higgs J. Jones M. Clinical Reasoning in the Health Pro- [12] Hunt G. Ankle sprain in a 14-year-old girl. In: Jones
fessionals. 3rd edition; 2008. MA. Rivett DA. 2004. Clinical Reasoning for Manual
[3] Jones, MA. Clinical Reasoning in Manual Therapy. Therapist. Oxford: Butterworth –Heinemann, 2004.
Physical Therapy. 1992; 72(12): 876-877.
[4] Kennedy M. Inexact sciences: Professional education
and the development of expertise. Review of Research
in Education. 1987; 4: 133-136.

Citation
Mohammad Habibur Rahman, Md. Shofiqul Islam, Ehsanur Rahman, Samena Akter Kakuli, Shamima Islam Nipa,
Md. Obaidul Haque. (2016). MANAGEMENT OF AN ATYPICAL ANKLE SPRAIN PATIENT THROUGH HY-
POTHETICO DEDUCTIVE REASONING MODEL OF CLINICAL REASONING IMPLEMENTED BY INTERNA-
TIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH: A CASE STUDY. International
Journal of Physiotherapy, 3(3), 263-266.

Int J Physiother 2016; 3(3) Page | 266