Rehabilitation of Common Ankle Injuries – David McCrea

Good evening everyone, my name is David McCrea, I am one of the Senior Physiotherapists at the UPMC Sports Surgery Clinic specialising in foot and ankle rehabilitation. I am going to talk to you tonight about the rehabilitation of some of the more common ankle injuries that we see here at SSC.

Our first discussion point tonight is going to be on lateral ankle sprains and another condition called chronic ankle instability which is really a by-product of multiple lateral ankle sprains. I taught a good point to start with would be to review the anatomy of the lateral ankle complex. What we can see here is that on the outside of the ankle joint we have a series of ligaments which bridge the gap between the lower part of the shin bone to the upper part of the foot, so mainly we have 3 main ligamentous structures, one called the ATFL at the front here, one called the CFL at the side and one called the PTFL at the back and these ligaments are thick collagen based structures and what they do is they provide the outside of our ankle joint with a lot of structural integrity and stability, so how we injure there ligaments is classically referred to as a rolling or twisting of the ankle so what we can see in this picture here is we have what’s known as inversion which is essentially when the foot rotates inwards on itself kind of following the line of this blue arrow here, we have what’s called plantar flexion is when the toes are pointed downwards and then crucially what we have is wearing bearing and speed so its very uncommon for someone to tear these ligamentous structures without a high speed or high velocity movement and also rare for them to do the same without them being in a weight bearing position because then these thick ligament structures won’t be stressed enough to the point where they’ll sprain or tear.

Ankle sprains, how common are they? We can see across various different sports if we take GAA, rugby, hockey, and soccer as some of our more common field-based sports, lateral ankle sprains are consistently cited as the most common injury in these sports so they are a big issue for athletes. Secondly then what we can see is that lateral ankle sprains account for about 50% of all sporting ankle injuries, they also account for 85 of all ankle ligament sprains, so if you have a sporting ankle injury there’s a good chance it is going to be an injury to the lateral ankle and then if you have a ligament sprain it’s a very high chance that it’s going to involve some of these ankle ligaments that we discussed there on the previous slide and then finally what we can see is probably one of the biggest issues for athletes and for doctors and physios trying to manage these injuries is that lateral ankle sprains have the highest reoccurrence rate of any lower limb injury so unfortunately if you have one ankle sprain there is a higher likelihood that you then might have a second or a third ankle sprain and this thing can have repercussions for your sporting career but then also for you later in life. It is very rarely just a sprain, this is a common phrase regarding these injuries.

This is a big question for a lot of people following an incident where they roll their ankle or twist their ankle, should I get an x-ray or do I need an x-ray? As physios and doctors, we will use a set of rules to determine who needs an x-ray and who doesn’t and they are really quite a sensitive set of rules meaning that they are very good at picking up someone who actually might have a fracture associated with their sprain so we can see here that if someone is presenting with bony tenderness so meaning that there are painful to palpate along the outside of the ankle or the inside of the ankle. If they’re painful to palpate along the outside of their fifth toe or painful to palpate in this zone here a bone called navicular that there’s a high likelihood they will need an x-ray to rule out a fracture.

A lateral ankle sprain will often have a few key or distinct symptoms. So first of all you can see am image here on the left, where we can see sort of a diffuse swelling and a diffuse bruising which might track up into the outside of the shin which covers a large portion of the outside of the ankle and then even into the heel bone or the forefoot here. They’ll have a loss of ankle function so that might be an inability to put weight properly on their foot it might be a restricted range of motion and it might be a loss of strength chronic ankle instability then is really a by-product of recurring ankle sprains so this patient will describe multiple ankle sprains may be over a fairly short period of time, they’ll have a feeling of ankle joint instability and they may have episodes of giving way at the ankle joints and this is a condition that again is associated with an increased rate of post-traumatic arthritis so it needs to be taken seriously and needs to be rehabilitated.

Secondly, then we’ll touch on ankle joint osteoarthritis, so the ankle joint in terms of the bones that comprise the joint, we can see here is the tibia and the fibula where it meets a bone called the talus. This bone here the talus and the bottom portion of the tibia is lined with a cartilage structure and this joint space is filled with a fluid called synovial fluid which is almost like a lubricant within the joint.

Now following maybe a first-time ankle sprain or following repeated ankle sprains, what we can see here is that the joint starts to almost dry out so we lose some of that natural fluid and lubricant within the joint, we get a wearing of the cartilage and we get some bony growth on the edge of the joint.

How does ankle joint arthritis occur? Firstly during an ankle sprain, whether that’s a first-time sprain or recurring sprain we get a degradation of the ankle joint surfaces, so we can actually get damage to those cartilage surfaces during the incident or during the spring itself. Secondly then if we have multiple sprains we can get an ongoing instability within the joint which can lead to different bio mechanical loading which can then start to lead to cartilage degeneration. If we get cartilage degeneration and if we get a loss of fluid within the joint then we’ll get a narrowing of the joint space and we can start to get impairments out of our ankle function.

A few key symptoms that will be present in someone suffering from ankle joint osteoarthritis, so they’ll usually have a gradual onset of joint pain they might not be able to recall an incident where they’ve hurt themselves recently it might be something where they have a history of recurring ankle injuries. They will usually present with stiffness either early in the morning or after a period of that inactivity so for example they might explain a stiffness following a period of sitting down or first thing in the morning after getting up out of the bed but the stiffness will often dissolve within 30 minutes as they get moving and as they get exercising but there’s also a limit as well so if they exercise or if they weight bare for too long they might describe a progression of their symptoms as well. Across all of these conditions what common deficits exist? So from the first time spraying to the recurring sprain to the year’s later osteoarthritis what common impairments do we see in these patients? So first of all we’ll see restrictions in joint range of motion, particularly a motion called dorsiflexion which essentially is a closing of the ankle joint or the closing of the hinge joint which we’ll demonstrate later on. Secondly, we’ll see impairments of ankle joint strength so we’ll lose muscle strength in a few key muscles around the joint and finally we’ll have impairments in static and dynamic control so these ligamentous structures on the outside of the ankle play a key role in the stability of the joint and stability of the leg as a whole if we damage those ligaments either first time or reoccurring, we can start to see impairments in that control. So when it comes to rehabilitation really what we’re trying to do with any of these patients is restore normal ankle function. This might depend on the activity that person wants to return to, so for example the demands of someone who wants to maybe just walk with the dog a couple of times a week versus someone who wants to get back to playing rugby or Gaelic football will be quite different. However, if we look at the physical attributes of how a normal ankle functions the focus of our rehabilitation is really to try and restore that.

Firstly we talk about deficits or loss of range of motion as we mentioned dorsiflexion in particular, earlier on which is the ability to kind of close or hinge the ankle joint it’s a crucial motion for us walking jumping, and running, so I have a couple of exercise examples here of ways to improve that. So on the left-hand side we have a colleague of mine lying on the bed with his foot elevated nice and high now this can really help anybody who’s suffering from swelling for example because the elevation and the movement will allow for a little bit of drainage of the swelling. Now in this position, we can work on our range of motion, so you can see here that we’re working on full hinging backward and forwards as well as full circles left and right. In the second video, we’re using a tail for a simple joint stretch so we’re pulling the toes back towards our face and using the tail for a little bit of over pressure pointing the foot as far away as we can. Finally the knee-to-wall test, here is a test we can use to actually measure the performance or the range of motion of that ankle, it’s also an exercise we can use to try and improve the performance of range of motion of that ankle. We can see here the foot is flat on the ground we’re trying to drive the knee towards the wall without letting the heel lift up, encouraging this ankle joint to hinge as much as we can get it. A way of measuring your performance is measuring the distance between your toe and the wall to see how much the ankle can hinge, if we then shift our focus to restoring strength to the ankle. We have a couple of simple progressions here of a calf raise exercise, so the calf is one of the most powerful muscles around the ankle and really crucial for us when we when we’re walking, when we’re jumping and when we’re running. On the left we have a calf raise hold, so Niall is pressing up on two feet transitioning over onto one foot and holding, so the calf muscle is doing the majority of the work here however Niall’s working hard to maintain a neutral heel position, so as his heel goes straight up and straight down he’s fighting hard to not let that heel wander left and right and by doing so he’s working some of the smaller muscles either side of the ankle to stabilize that ankle position. Finally, then we have a single leg heel raise but this time with extra weight, so there’s a 10-kilo dumbbell there to make this harder and demand more from the calf muscle and demand more from those stabilizing muscles on either side. Similarly, then we want to work the calf muscle but in slightly different ways, the calf muscle is comprised of two main

muscle groups the gastroc which is the first set of exercises, and now the soleus which is a deeper-lying calf muscle that is going to be worked harder in these set of exercises. We’ll use a seated calf raise to try and strengthen the soleus. So Niall here has a heavy kettle bell resting on his knee, he’s then pressing his ankle up and trying to hold for a few seconds, the second video here he’s working a little bit more dynamically pressing that heavy weight up towards the sky and trying to slowly lower down. Then finally we’re using what’s called a smith machine to try and add even extra weight, so a lot of gyms have smith machines available to them this is a great way to load the calf muscle even more as it allows the barbell to take on the weight. We’ve discussed then restoring the ankle range of motion, we’ve also discussed restoring some strength to the ankle and we also mentioned earlier on that following a first-time ankle sprain or recurring ankle sprains that there’s a loss of control at the ankle because of the important role that these ligaments play in our control. So to restore landing control, one of the more common ways of damaging your ligaments is by landing during a sporting task so on the left-hand side we’re practicing some drop landings on two feet and on one foot. We’re standing up nice and tall it’s like someone is pulling the rope from underneath us we’re trying to drop down and stick the landing. What’s really important here is that we’re not in a rush to stand straight back up, that we actually want the ankle to work hard to stabilize us at the bottom position. Secondly, then we can add a little bit more height to this exercise, so we can drop off a box in the gym or we can box off jump off a first or second step on our stairs. Again we can do this on two feet or on one foot, what’s important again is that we don’t immediately stand up and jump out of this exercise we actually train the control element which is staying down in that position and then finally starting to work in different directions, so the lateral ligaments are going to be most stressed moving in side to side and multi-directional motions so we can do the same thing coming off a small box in the gym or coming off a first or second step in our stairs and trying to stick the landing like that.

Now these set of exercises are maybe more useful for someone who’s looking to get back to running or looking to get back to a field-based sport and these are targeting a quality known as reactive strength, it really refers to our explosiveness or our spring-like ability so our ability to absorb our body weight and naturally spring ourselves back out which is what we do all the time when we run and when we jump or we twist and turn playing a match. On the left-hand side we’re looking at an exercise we call ankling, which is staying nice and tall and trying to bounce from left foot to right foot while maintaining a nice stiff ankle. On the right-hand side is the same thing but a little bit more dynamically, so again trying to spend as little time in contact with the ground as we can making it nice and springy and nice and explosive. If we want to focus on a little bit more power output then we can look at things called pogo jumps. So again you can see here we’re spending very little time on the ground but we’re really relying on that reactive strength and that reactive spring to get us nice and high up off the ground we can do this on two legs and we can also do it on one leg and as I mentioned earlier most lateral ligament sprains happen when we are moving in multiple directions or when we encounter maybe an uneven surface that we’re not anticipating so again we want to look at that natural spring in multiple directions.

So Niall here is now working on a drop step off a box trying to spend as little time on the ground as possible trying to kick off the ground straight back up onto the box as fast as he can, similarly then we can challenge the ankle stability even more by looking at some lateral pogos so trying to bounce side to side trying to spend as little time on the floor as possible. So there are some example exercises of restoring normal ankle function following say the first-time sprain or following multiple sprains or chronic ankle instability and it’s also worth noting that exercise has been proven to be one of the most effective ways of restoring ankle function but also reducing the risk of future injury. The other thing that has been proven conservatively to manage or reduce the risk of future injury is bracing and strapping, so wearing a brace or strapping the ankle as you can see in the pictures here actually can reduce your risk of re-injury, this is probably most applicable to the people who are coming back from their first time spraying or recurring sprains it might not be as useful for people that are suffering from maybe osteoarthritis-related changes within the ankle. Here is some references for anybody who would like to read a little bit more about where I sourced my information for today’s presentation.

Hopefully, you guys learned something from this, so thank you for having me I look forward to answering any questions you might have. If you’re interested in any more information please feel free to contact me or any of my colleagues at the Sports Medicine department, the phone number is on the screen there and so thank you and look forward to any questions that you might have for me.

This is a common situation we would find ourselves in every day really in SSC, where patients have maybe had pain for a number of years following an incident that wasn’t necessarily diagnosed at the time. I think maybe my first step would be to be assessed by either a physio or a doctor again and then to make a decision on whether an MRI scan or an x-ray would be indicated at this point.

It’s probably unlikely that she’ll need an x-ray six years on but she may want an MRI scan to help with her diagnosis and then following on from the diagnosis there might be a management plan put in place, whether that’s a surgical or conservative management plan but the first step will definitely be to get assessed and then get the relevant imaging.

It is unfortunate to hear that that’s the pain has returned but it might not necessarily be a true ankle pain that you are experiencing. When you’ve had an L4 L5 lumbar disc issue essentially the pain can refer further down into the lower limb and sometimes as far as the foot and the ankle, so even though you are experiencing pain in the ankle it might not be a true ankle issue it might actually be an issue stemming from her lower back.

My first piece of advice for you might be to attend either her GP or to go back to the surgeon that performed the microdiscectomy and either the GP or the surgeon might be able to then decide whether rehabilitation would be beneficial for you.

Metatarsalgia is kind of an umbrella term for pain within the ball of the foot and it could be it could be a number of issues um but the metatarsalgia itself is sort of just an umbrella term for maybe a few different things so I do think getting assessed would help to maybe narrow down the diagnosis a little bit further and then based on the diagnosis we could try to devise a management plan for that.

Orthotics are common and they have probably mixed results and varied results, but some people can benefit from them. I think a cornerstone of managing something like metatarsalgia will be to manage the volume of weight-bearing exercise that you’re completing but also make sure that you’re actively rehabilitating your foot to make sure that your foot and ankle is at full function for those weight-bearing tasks or those long days on your feet for example.

The heel spur I suppose is exactly what it sounds like it’s a small little bony protrudance at the bottom of the heel, the calcaneus bone, and years ago it probably was taught that heel spurs were one of the main drivers of people’s heel pain but what they found was really that the heel pain surgeries were not having great success.

The heel spur might not be the main driver for the heel pain that they’re experiencing so when it comes to managing heel pain I think the first step is to get assessed again by either a doctor or a physio once you’ve been assessed we can try and highlight maybe factors that are aggravating your heel pain and also some factors that maybe help ease your heel pain and then devise and build a management plan for you where you can look at strengthening some of the intrinsic muscles within the feet strengthening some of the key muscles around the ankle and managing the volume of time you’re spending on your feet as well so you allow it to settle down in the first place.

When you fracture the bone it usually takes well depending on the bone that’s been fractured it can take roughly six to eight weeks for that bone to heal and fuse back. Now some fractures are severe enough that they’ll need surgical fixation which usually happens, though initially after the surgery the doctors in A&E department are very good at picking up on who will need a surgically fixed fracture and who won’t.

It’s common though for people kind of months and and sometimes years later to still be feeling the repercussions of that fracture and that can present in the form of say swelling, pain or joint stiffness, all of those can be helped through conservative treatments meaning things like physiotherapy and rehabilitation and they also can be helped sometimes with injections and sounds like you had some benefit to one injection but sometimes repeated injections can have a sort of a waning effect.

This is a very common picture we would see a very common scenario we’d see where people suffering from plantar fasciitis and one of the cornerstones of treating plantar fasciitis is managing the volume of weight-bearing exercise this person is doing. You mentioned that you’re in agony following your walks, so that would probably suggest that the walk your currently undertaking might be a little bit too much for your current capacity, so it’s flaring up your pain and potentially is slowing down your recovery rather than speeding it up.

The first thing would always be to try and get a good grip and a good handle on how much weight-bearing exercise they’re completing and in the background then looking at a rehabilitation program which might make them stronger and slightly more robust so they can manage more time on their feet and they can manage more walking volume.

CRPS is either complex or chronic regional pain syndrome and it’s not a common presentation following a traumatic injury but it usually does follow some sort of traumatic injury. In our presentation for tonight, it might be something like an ankle sprain and years or weeks or months later someone might be still struggling with diffuse pain within that injured area, they’ll also present with things like sensory changes to the skin so they might have redness in the skin they might have hair growth or they’ll often present with things like shiny skin and really what’s happened is the traumatic event has sparked sort of a chronic inflammation and this does go away for most people however it can be helped with rehabilitation. If this 16 year old boy is not currently working with the physio on a regular basis I probably would advise that they will because this is an injury that requires an active approach to work to solve it and a rest or a wait and see approach might just prolong symptoms.

It would be useful to have laser electrostimulation massages and how much do you have to focus on the range of movement and on the strength in terms of weeks. The achilles tendon rupture is similar to the ACL injury earlier, where it’s quite a long undertaking or quite a long rehabilitation process. It could be upwards of nine to 12 months to get back to full fitness following that. Initially, after rehabilitate or after the surgery they’ll be immobilized in a boot for roughly six weeks but then it’s important that the ankle starts to move so if the ankle is kept immobilized for too long the ankle can start to stiffen the muscle can start to atrophy as well so a big focus in the first phase following this surgery is actually going to be to restore the range of motion and to start strengthening the calf and the Achilles tendon.

In terms of massage and electro stimulation and things like that, it might offer some element of pain relief however it’s not going to restore the function of that ankle if you think about the achilles tendon as a big elastic band essentially the structural integrity of that has been compromised and no massage is really going to improve that or return that.

One of the kind of cornerstones of treating osteoarthritis alongside things like medication is strengthening exercises, so the joint is suffering and essentially losing its structural integrity a little bit as the years go on. So we need to try and use strengthening exercises to support that joint and to try and support the support structures around us.

The main couple of tips and advice in terms of strengthening if you have osteoarthritis is that the exercises by and large should be pain-free so it’s not a case of maybe no pain no gain it should be largely pain-free and we should be able to progress those exercises week on week, so the exercises week and weeks you’ll be able to get a little bit progressively harder because you’re getting stronger.

X-rays and MRI’s might not be too useful or indicated really in this case at the moment, however working with a physiotherapist to try and guide their strengthening program certainly would. So if she’s struggling to walk any prolonged distance strengthening exercises are going to be one of the foundations there to try and help her walk further and the physiotherapist is probably best suited or a strength and conditioning coach is probably best suited to actually help them in that regard.