Orthopaedic Physiotherapy Grand Rounds 20 - Complex Ankle Pain: A Case of Multisystem Considerations

Overview

Ankle pain is a common presentation in physiotherapy practice. However, when symptoms persist without a clear mechanical cause, clinicians are often challenged to look beyond local impairments and consider broader systemic and contextual factors. This month’s Grand Rounds pushes physiotherapists to critically examine a complex case when a clear-cut diagnosis remains elusive.

In this course, you’ll follow an expert panel as they discuss a real-life clinical case of a 19-year-old female student-athlete with a six-month history of left anterolateral ankle pain of unknown origin. Despite some improvements with physiotherapy, she continues to struggle with full weight bearing, significantly limiting her daily function and participation in sport. 

As clinicians, how do we proceed when conventional musculoskeletal explanations–such as joint mobility deficits, strength impairments, or tissue pathology– fall short? This course invites you to deepen your clinical reasoning where mechanical findings do not capture the complexity of the presentation, and where other biological and contextual factors must be considered.

The panel discussion explores various differentials and the challenges of differentiating between them–such as joint hypermobilities, neuropathic drivers, and nociplastic pain processes, while also considering the broader psychosocial context. Throughout the session, you’ll hear each panelists’ clinical impression, hypotheses, and strategies for a case that resists a straightforward explanation. 

Topics covered include: 

• Differentiating when mechanical impairments are relevant versus when neural or systemic factors may be amplifying symptoms.

• Understanding the impact of emotional stress and past injury memories on neuropathic pain.

• Structuring a progressive rehab plan that balances mechanical interventions with neuroscience education and functional goal setting. 

Rather than focusing on a definitive diagnosis, this Grand Rounds focuses on refining differential diagnosis, clinical reasoning, and clinical adaptability. You will learn to recognize when pain presentations are inconsistent with structural findings and how to build an effective management strategy amidst clinical uncertainty.

Orthopaedic Physiotherapy Grand Rounds 20 was presented online on February 25, 2025; this is the recording from that presentation.

Objectives

By the end of this course, participants will:

1. Understand and apply structured clinical reasoning in cases of persistent ankle pain with uncertain pathology.

2. Differentiate between nociceptive, neuropathic, and nociplastic pain mechanisms using clinical hypothesis testing. 

3. Develop individualized management strategies that integrate local and systemic factors contributing to pain.

4. Approach complex cases with a flexible, patient-centered mindset when certainty is not possible. 

Audience

This course is ideal for: 

• Physiotherapists and rehabilitation professionals treating complex foot and ankle cases.

• Clinicians seeking to improve differential diagnosis and clinical reasoning.

• Healthcare providers aiming to integrate a biopsychosocial approach to managing persistent pain presentations. 

• Manual therapists and sports physiotherapists working with active individuals presenting with atypical pain behaviours.

Case Presenter

R Michael McMurray, M.Sc. (Rehabilitation), BMR(PT), B.P.E., Diploma in Sports Physiotherapy, Registered IFSPT Specialist, FCAMPT, SFR Instructor

Mike has been practicing physiotherapy for 32 years focusing on Sports and Orthopaedics. He is a Senior Instructor at the College of Rehabilitation Sciences, University of Manitoba, teaching anatomy and orthopaedics. He has traveled internationally for 25 years working with national athletes at various sporting events including Pan Am and Olympic games. He is a lifelong learner having completed his Diploma in Sports Physiotherapy in 2000 and FCAMPT in 2023.

Panelists

Bahram Jam, DScPT, MScPT, BScPT, FCAMPT

Bahram Jam graduated from the University of Toronto (1992) then he completed a Clinical Masters and a Doctorate in Physical Therapy at the University of Queensland, Australia (1999) and at Andrews University, USA (2008). 

He is an FCAMPT and the founder and director of Advanced Physical Therapy Education Institute (APTEI) and has been a chief instructor for over one-thousand postgraduate orthopaedic courses across Canada and internationally. He has presented at several national and international conferences. He currently practices in Toronto.

François Landry, PT, BScPT, FCAMPT, Examiner NOD

François Landry graduated from Université de Montréal in 1982 and began his career in Calgary, Alberta, where he began training in orthopaedic manual therapy. After going through his intermediate examination in 1991, he obtained his diploma in advanced manual and manipulative physiotherapy in 1994. He has been and continues teaching advanced musculoskeletal physiotherapy for the last 36 years. He also officiates as an examiner of the Orthopaedic Division since 2001 and was named CAMPT honorary life member in 2015 and was the recipient of the Golden Hands Award in 2023.

Melanie MacKinnon, PhD(student), MCISc Manip, MScPT, HBScKIN, FCAMPT, CAFCI, CIDN

Melanie is a practicing Physiotherapist, FCAMPT and an alumnus of the University of Toronto MScPT program (2004) and the Western MClSc Program (2009). With a passion for education, she teaches across the spectrum from pre-licensure in the Physical Therapy department at the University of Toronto to post-licensure with the Orthopedic Divisions’ AIM program, Integrated Dry Needling (IDN) and as a mentor for Western’s Advanced Health Care Practice Graduate Program (AHCP). Melanie is currently pursuing a PhD in Health Professional Education Research at the University of Toronto with an interest in how to create assessments that bridge the technical with social and humanistic elements of practice to help prepare health professionals for the realities of clinical practice.