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Ankle Injury Management and Rehabilitation

Presented by: Paul Hermann

Andrew Ellis BSc (Ex. Sci), M. Phty

Paul Hermann B.Sc.(Cli.Sc.), M.H.Sc.(Osteo), M.Ex.Sc(S&C), Member AOA

Ankle

Injury Management and Rehabilitation

Paul Hermann

Osteopath & Exercise Scientist B.Sc.(Clin.Sc), M.H.Sc.(Osteo), M.H.Sc.(S&C)

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What we will cover today… 1. Some epidemiology of ankle injuries and what commonly presents in

clinic

2. Structuring a stage based approach to ankle rehabilitation

3. Identifying and addressing imbalances that may have predisposed

patient to injury and/or increase potential for re injury

4. Restoring patient specific function

Ankle Injury Incidence

• In Australian Sport - 16% of all injuries with less than 20% of those being a primarily medial injury

• In AFL 2013 - 3.7 new injuries per club last year (compared to 2.6 in 2012) causing 12.1 games missed per club (10.5 in 2012)

• Anecdotally in clinic it seems recurrence is high

22nd Annual Australian Football League Injury Report 2013

The Western Australian Sports Injury Study, Stevenson et al, 2001 (Deakin University)

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What do we want to know?? This may be very important for late stage rehab and for injury recurrence prevention • History of the injury:

• Site of pain • Onset • Mechanism of Injury - very important

• Inversion injury? • Eversion injury? • Forced Dorsiflexion with rotation - ? injury to syndesmosis • Compressive forces involved - ? osteochondral injury

• Previous History of injury

• Contact vs non contact injury • Direction of forces involved • Speed or degree of impact

What do we want to know??

• When did injury occur? • Gradual or acute onset? • Aggravation of pre - existing condition? • Was something heard or felt? • Associated sounds or sensations? • Pops, cracks, buckling, giving way……? • Localised injury site versus generalised area • What are the pain characteristics? • What is the behaviour of the symptoms?

What do we want to know??

• What is the level of irritability? • Etiological factors and biomechanical

considerations: • Training surface, training regime and changes

made to it • What footwear was being worn? • Equipment used? • Requirements of competition……? • Training stage/period

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GAIT

• Step length

• Weight bearing

• Pain - if present where and when? What exactly reproduces it?

• Range of motion during gait

• Balance

• Alterations in foot posture

• Try different gait styles

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EXAMINATIONS

• Active/Passive Movements: • Plantarflexion / dorsiflexion

• Inversion / Eversion

• Resisted Movements: • Eversion – if possible (in acute ankle injuries

resisted movements may not be possible)

• In cases of persistent pain following ankle injury, weakness of the peroneal muscles should be assessed

EXAMINATIONS

• Functional Tests: • Lunge test

• Single leg standing balance - knee locked and unlocked -what reacts?

• Standing leg swings – results may surprise you

• Hopping - if appropriate

PALPATION • Distal fibula

• Lateral malleolus

• Lateral ligaments

• Talus

• Peroneal tendon(s)

• Base of 5th metatarsal

• Dome of talus

• Medial ligament

• Sustentaculum tali

• Sinus tarsi

• Anteroinferior tibiofibular ligament (AITFL)

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SPECIAL TESTS

• Anterior Draw:

• Lateral talar tilt:

• Balance/Proprioception:

IMAGING:

• Ottawa ankle Rules

• Radiographic series of the ankle is only required if one of the following are present:

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Ottawa Rules

• Bone tenderness @ posterior edge of the distal 6cm of the medial malleolus

• Bone tenderness @ posterior edge of the distal 6cm of the lateral malleolus

• Totally unable to WB both immediately after injury & (for 4 steps) in the emergency department

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Ottawa Foot Rules

• Bone tenderness of the navicular

• Bone tenderness at the base of the 5th MT

• Totally unable to WB both immediately after injury & (for 4 steps) in the emergency department

LATERAL LIGAMENT INJURIES

• Often occur in activities with changes in direction, uneven surfaces: netball, football, basketball…

• Usually inversion and PF

• Usually ATFL before the CFL

LATERAL LIGAMENT INJURIES

• GRADE 1: mild stretching and no instabilities / abnormal laxity (compare)

• GRADE 2: partial but incomplete tear with mild instability & firm end point

• GRADE 3: a complete tear of the ATF and CF ligaments with gross laxity and instability

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Ankle Injury Rehabilitation • Stages:

• Early/Initial

• Intermediate

• Advanced

• Return to Sport/Function

Brukner, Peter & Khan, Karim (1999) Clinical Sports Medicine. Mc Graw - Hill Book Company: Australia.

What I commonly see in recurrence is that patients did the following: Injury

Initial Care

Basic Rehab – PROM, AROM & Strength (isolated)

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What I commonly see in recurrence is that patients did the following: Standing Balance (wobble

board)

Back to work, sport, life

Re injury

Problem?? Recurrence? Why? Non Specific

Incomplete

No Functional Re Introduction Stage

Only Static Balance Ex’s - no dynamic

Didn’t address previous imbalances…etc etc etc

Ankle Injury Rehabilitation

Acute: • RICE:

• Bracing/Taping:

• Determination of Grade of damage (I, II, or III).

• 24-48 hrs non-weight bearing (dependant).

• Progression to partial weight bearing then full.

• Passive mobilisation (esp dorsi flexion - towel)

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Early Stage: • Starts when partial weight bearing is achievable.

• Can be completed sitting or standing dependent on damage.

• ROM: seated dorsi/plantar flexion, inversion/eversion using a towel.

• Wobble Board seated using above movement patterns.


Early Stage: • Loaded ROM - standing (lunge dorsiflexion).

• Static Standing wobble board or Stability Disc/Matt (AROM + Balance).

• Strengthening (eversion/inversion using resistance band).

• Normally things stop here….


Strengthening Exercises: • Squatting – various angles

• Calf raises – uni & bilateral – full pain free ROM

• Toe and Heel Walking

• The Moon Walk

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Return to Activity Exercises: • Landing – lunge to land, lunge with leap to land –

toe landing, heel landing, sideways leap to land, 1 foot to 2 foot landing, 2 foot to 1 foot landing, landing eyes closed THEN….

• Jogging, Hopping, Skipping

• Progress to change surfaces also

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Return to Sport/Work/Activity. • Dependant on the demands of the activity.

• Evaluate what is important to the individual.

• Program all the activities they need to do to be able to participate normally.


Other Information: • Maintain fitness.

• Pool activity. (swimming – fitness)

• Upper body strength.

• Use of crutches.

• Use of braces.

TAPING

Therapeutic

Preventative

Stirrups

Figure six / eight

Heel locks

Braces

Orthotics

Grade 3 injuries

Surgery versus conservative

Trial of initial conservative at least over 6 weeks

Recurrent episodes of instability or persistent pain may warrant surgery or at the least a referral for opinion

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Medial ligament injuries

Less common

Can occur with lateral ligament

Often involve fractures

Treatment same, but longer period required for rehabilitation

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The “Problem Ankle”

Patient continues to complain of pain and recurrent instability

Persistent swelling and impaired function three to six weeks post injury

Accurate diagnosis is essential

Possible Problems

Undiagnosed fracture

Other bony abnormalities

Ligament, tendon, synovial or neurological dysfunction (or all the above!!)

Missed syndesmosis injury

Sinus Tarsi Syndrome

Osteochondral damage

An injury or small fracture of the cartilage surface of the talus Not uncommon in compressive injuries

Injury with actual loss of part of the chondral surface and underlying subchondral bone,

Injury to the superficial cartilage surface with a crush cartilage injury or shear tear of the cartilage surface,

Subchondral cyst type injury with a cyst formation deep to the cartilage surface but an intact overlying cartilage and bone surface.

Examine the foot at 45º PF and attempt to rotate the talus out of the ankle mortis

Try and reveal tenderness of the dome of the talus MRI / isotopic bone scan

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Avulsion fracture base of the 5th

Metatarsal Can occur with avulsion injuries Results from avulsion of the peroneus brevis

tendon from it’s attachment to the 5th metatarsal

X-ray should show it Immobilisation for pain relief (1-2 weeks) Protected mobilisation and rehabiliation


Small osseous canal running from an opening anterior & inferior to the lateral malleolus in a posteromedial direction to the point posterior to the medial malleolus.

Space occupied by the interosseous ligament Lined by synovial membrane Contains small blood vessels, fat and

connective tissue


www.epainassist.com

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May occur secondary to an ankle injury

May occur as an overuse injury secondary to excessive subtalar pronation

Pain is experienced at the anterolateral opening of the sinus tarsi

Often worse in the morning but improves with loading

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Causes

Chronic overuse secondary to poor biomechanics (excessive pronation)

Often secondary to inversion injury

The joint is prone to synovitis both in the acute situation and also in the chronic situations such as gout, inflammatory arthropathies and osteoarthritis

Clinical features:

Poorly localised pain, more over the anterolateral aspect of the lateral malleolus

Greater pain in the morning May decrease with exercise Difficulty with uneven ground and perturbations Often full ROM in the ankle joint, however the

subtalar ROM is restricted May reproduce pain on either passive inversion

or eversion

In The Journal of Sports and Physical Therapy, Japanese

researchers discovered, individuals with chronic ankle instability

(CAI) had a distal fibula positioned more lateral compared with

healthy individuals with no CAI. In effect, those who had suffered

serious syndesmosis injuries in the past and ended up with a wider

distance between the fibula and the tibia, suffered more ongoing

ankle pain than those without a tibfib separation.*

Research says even a 1mm displacement of the talus within the

mortise (due to a wider placed fibula) can reduce the contact area in

the talocrural joint by 42% (Ramsey and Hamilton 1976).

Kobayashi et al (2014). 'Fibular malalignment in individuals with chronic ankle instability.' JOPST. 44(11); pp 841-910.

Ramsey and Hamilton (1976). J Bone and J Surgery Am. 58(3); 356-357.

Syndesmosis Injury PREVIEW ONLY


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Image: www.ssorkc.com

Syndesmosis Injury Syndesmosis Injury

• Mismanaged syndesmosis injuries, resulting in an excessive amount of tib/fib opening, can lead to early onset arthritic changes and chronic ankle instability. The talus bone moves around in the now wider tibfib articulation.

• Widening of the fibula may be as a result of: • Poor initial management; patient weight bears too early

and this forces the fibula more lateral to the tibia as the syndesmosis ligaments are trying to heal.

• The degree of damage is so severe that normal restoration of length of these ligaments is not possible without surgical intervention

Sports Injury Bulletin. Issue No. 169, November 10, 2014

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Compliance • Why don’t patients follow all the way

through with their rehab?

• Pain is a strong motivator – remove the pain and you remove the motivation

• We need to educate it simply, so they can understand completely: • What has been damaged, how to heal it,

what imbalances are present and WHY it is important to address the imbalances for THAT person.

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Seek to understand their motivators

• Find the thing that motivates THEM.

• Show them a plan visually and show them where they are on that plan – you need “buy in” to the plan early on for the best results.

• What is it that they LOVE doing - sport, walking, hiking, dancing, playing golf when they are 90 years old, gardening. Explain what they need to do reduce the chance of injury so they can keep doing those activities

Prochaska, J. O., & DiClemente, C. C. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: theory, research and practice, 1982,19, 276-288.

Thank you

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PREVIEW ONLY · What is the level of irritability? Step length ... PREVIEW ONLY These notes are a preview. Slides are limited. Full notes available after purchase from