Think Outside the Ortho Box: A Case Study In Unexpected Bruising
In clinical practice, it’s easy to focus on the musculoskeletal system—after all, that’s the bread and butter of chiropractic care. But sometimes, the presentation doesn’t fit neatly into an orthopedic box. This case study highlights how bruising without musculoskeletal injury can occur in older adults, why that matters, and what chiropractors need to consider in their differential diagnosis.
Case Summary
A 68-year-old female presented to our office one week after a fall. She had tripped and landed on her knees, causing her right ankle to be forced into rapid plantar flexion. By the time she arrived at the clinic, she had significant bruising on the dorsal aspect of the ankle, but surprisingly:
No swelling
Full pain-free range of motion
Normal orthopedic and neurologic exams
Intact strength and sensation
Only mild point tenderness on palpation
The patient was able to bear weight without discomfort. However, she was alarmed by the discoloration, fearing she had done significant damage to the joint.
This case challenges the assumption that bruising equals musculoskeletal trauma. Instead, it reveals the vascular fragility that may be present in older adults and underscores the importance of clinical discernment.
Why Not All Bruises Are Sprains: Understanding Microvascular Injury
In the absence of muscle, tendon, ligament, or bone damage, bruising is most often due to microvascular rupture, especially in older adults. As we age, the integrity of our vascular system and subcutaneous tissue changes.
Age-Related Vascular Changes in Seniors
Capillary Fragility: Small blood vessels become less elastic and more prone to rupture under stress.
Thinning Subcutaneous Tissue: As we age, the fat and connective tissue under the skin diminish, providing less cushioning for vessels.
Decreased Skin Turgor: This leads to increased vulnerability to shear stress.
Slower Healing: Reduced collagen synthesis and vascular responsiveness delay bruise resolution.
In this case, the forced plantar flexion likely stretched the skin and superficial vasculature over the dorsal ankle, leading to localized ecchymosis without any structural compromise.
When the Musculoskeletal Exam Is Negative
Injuries with bruising but no swelling, no pain with motion, and normal strength can often confuse the patient and provider. Chiropractors must learn to interpret what is not there:
Key Negative Findings in This Case:
Negative orthopedic testing
No joint laxity
No effusion or edema
Full active and passive ROM
Strength testing normal
No neurological deficits
When in doubt, the Ottawa Ankle Rules can help exclude fracture:
Bone tenderness at the posterior edge of either malleolus?
Are you unable to bear weight both immediately and in the clinic?
Chiropractic Insight: Reframing the Mechanism of Injury
In a younger athlete, this fall may not cause any injury at all, thanks to more resilient and adaptable tissues. However, in older individuals, the same force can stress less elastic structures—particularly the vascular system—leading to tissue damage without any musculoskeletal injury. Chiropractors should be aware of these age-related vulnerabilities and consider non-musculoskeletal causes when evaluating injuries in older patients.
Differential Considerations for Isolated Bruising:
Superficial capillary rupture
Medication-induced fragility (e.g., blood thinners)
Nutritional deficiencies (vitamin C, K)
Diabetes-related vascular changes
Coagulopathy or platelet disorders
How Bruises Heal: Understanding the Colors of Ecchymosis
Patient reassurance often starts with explaining what they’re seeing in the mirror. The color of a bruise reflects its age, and understanding the healing stages can reduce unnecessary anxiety.
Stages of Bruise Healing:
Red/Purple (0–2 days): Fresh blood pooling under the skin.
Blue/Dark Purple (2–5 days): Breakdown of hemoglobin into biliverdin.
Greenish (5–7 days): Conversion into bilirubin.
Yellow/Brown (7–10 days): Reabsorption and healing.
Total healing time varies but is often 10–14 days, longer in older adults or those with impaired circulation.
Chiropractic Management of Falls in the Elderly
While this case did not result in musculoskeletal injury, the incident still warrants clinical attention and chiropractic oversight. Falls in older adults predict future risk, even if the first fall seems minor.
Chiropractic Strategies to Support Older Adults After a Fall:
| Fall Risk Screening | Strength & Mobility Exercises |
|---|---|
|
• Balance assessment (e.g., TUG test, single leg stance) • Review of medications • Gait evaluation |
• Ankle stabilization drills • Proprioceptive retraining • Glute and core activation |
| Environmental & Lifestyle Modifications | Patient Education |
|
• Footwear assessment • Home hazard checklist (rugs, lighting, stairs) |
• Reassure when imaging and exams are negative • Educate on the normal bruising process • Encourage movement to support circulation and healing |
For a detailed approach to fall risk management, check out this recent article by Tom Michaud from www.humanlocomotion.com
Educational Takeaways for Chiropractors
This case highlights a subtle but crucial clinical pearl: not all post-fall bruising equals orthopedic injury. In the chiropractic management of elderly patients, we must:
Key Clinical Reminders
Don’t overlook vascular explanations for discoloration
Use the Ottawa Rules to exclude fractures confidently.
Educate patients on bruise healing stages.
Screen every fall patient for future fall risk, even if this one was “just a bruise.”
Consider comorbidities that may affect healing (e.g., blood thinners, diabetes)
Conclusion
Chiropractors are uniquely positioned to support aging patients with adjustments and a broad perspective on fall mechanics, vascular changes, and healing timelines. In this case, the patient didn’t need an MRI or orthopedic consult. She needed a clinician who understood what was happening beneath the surface—and could explain that she didn’t sprain her ankle... she simply bruised more easily.
And that’s often the real value of evidence-informed chiropractic care.
Smarter Tools. Better Outcomes.
Clinical insight doesn’t happen by accident. It’s built through experience, research, and the right tools. ChiroUp gives you all three.
