Foot and ankle joint

Ankle sprain

Skrecenie-stopyEvery year thousands of Poles sprain an ankle. The ankle is sprained when movements in the ankle joint are considerably exceeded and as a consequence the synovial capsule and ligaments are damaged. In most cases, i.e. as many as 95%, it is all about a foot inward subluxation.

Despite the fact that it is one of the most frequent injuries, only about 10% of injured persons visit a doctor. This is because these people ignore the severity of the injury and are unaware of potential consequences related to inability to restore the joint’s functions.

Not only sportspersons are likely to sustain ankle injuries but anyone in their everyday life. Sadly these injuries are often ignored and neglected, which in effect leads to negative consequences. They may result in chronic instability accompanied by acute pain.

Symptoms
An ankle sprain is related to partial or total damage to ankle capsule-ligament structures. For this reason it is important that we define the mechanism in which the injury was sustained. The range of symptoms is often dependent upon the tissue damage degree.

A three-grade ankle sprain scale:

I grade: strained ligaments and synovial capsule, minor pain, swelling and limited movements, lack of instability

II grade: synovial capsule tear and partial ligament rupture, substantial pain, considerable swelling, partial instability, walking with a limp

III grade: synovial capsule tear and total ligament rupture, joint instability with considerable swelling and acute pain, walking difficulties

Pain is most frequently experienced in the front-side part of the ankle joint, which may suggest a damage to anterior talofibular ligament. Taking into consideration the complexity of the injury, it is advisable to consult an orthopedist, diagnostician or physiotherapist in order to protect the foot against growth of the injury, or foster return to activities.

Causes
Most frequently we sustain the injury when we “twist” or sublux” an ankle joint which is loaded and when the foot is improperly positioned during running, landing after jumping or marching. The risk of injury is most frequently related to activities which require considerable twists and rotations (tennis, basketball), or running on uneven ground. The injury may also be a result of previous injuries, lack of muscle balance, prioproceptive sensation disorders (the so-called proprioception), general ligament flabbiness and improper foot function (biomechanics) when moving, e.g. flat foot.

What to do?
Similar to other sport injuries, in the first place we should follow the principle of PRICE: P – protection, R – rest, I – ice, C – compression and E – elevation (elevation of the limb above the heart level). The injured should avoid activities which increase the blood flow and growth of swelling, e.g. extensive load to the injured joint, use of warming ointments or heat in the form of hot bath.

A detailed diagnostics based on physical examination, X-ray screening and ultrasound examination is obligatory for twisted feet. It allows specifying the injury severity and prevents serious changes, such as ruptures, fractures and dislocations.

Further treatment is dependent upon the degree of the damage. If during clinical testing an orthopedist eliminates all serious abnormalities (e.g. fracture) on the basis of the imaging examination, improving activities can be taken under a watchful eye of a physiotherapist. Such a fast intervention taking a form of individual rehabilitation program with adapted load fosters return to activity and secures against further injuries.

Initially, this sort of rehabilitation focuses on reduction of pain and swelling as well as restoration of full joint movements. Another stage of the rehabilitation is stabilization training which is aimed at rebuilding stability in the foot. We should remember however that a stabilizer may turn out to be useful shortly after the seriously damaged ankle joint has been healed.

Exercises
In the aftermath of the injury it is necessary to do well-thought exercises throughout the rehabilitation, which must be supervised by the physiotherapist and attending physician (doctor). The exercise difficulty is adapted on a case-by-case basis and must be gradually increased, depending on the stage of the rehabilitation. Exercises presented below by MA Kamila Drygas – a Rehasport Clinic physiotherapist – may protect your joint against another injury.

Skrecenie stawu skokowegoStabilization and proprioception exercises:

Static exercises on a stable surface
The basic exercise is standing on one leg with one’s eyes open and closed. Further exercises also require one-leg-standing but we need to stand one our toes, half-crouch or move another leg in various directions, the so-called “four corners of the world”.

Static exercises on an unstable surface
Another stage is related to the aforementioned exercises on various surfaces: mattress, cushion, sensorimotor disk, Bosu or trampoline.

Dynamic exercises on a stable surface
At this stage we take diverse steps forward and backward, jump on one leg over low obstacles or jump on both legs and land on one leg. These exercises are expected to imitate functional activities and adjust the joint to everyday loads.

Dynamic exercises on an unstable surface
At another stage we do the aforementioned exercises on various surfaces. Steps can be taken on the cushion or balance disk whereas jumps on the mattress or sensory-motor cushions. The exercises of this type are used at the final stage of the rehabilitation.

Tibia muscle strengthening exercises:

Peroneus muscle strengthening exercises
During side subluxation, peroneus muscles are subject to rapid and extensive stretch, which results in inappropriate functioning. Thanks to isolated reinforcement of peroneus muscles, both in shortening and lengthening of the muscle (the so-called eccentric movement), it is possible to reconstruct their proper function. The outward movement of the foot stimulates these muscles.

Ankle joint extensor muscle strengthening exercises (the so-called dorsiflexion)
Tibia anterior compartment muscles also support the outward movement of the foot. In the case of twisting injury, this direction may entail a deficit in terms of the range. Lifting a foot and fingers stimulates muscles to perform their functions.

Tibia posterior muscle strengthening exercises
It is equally important that we strengthen calf muscles (triceps surae, tibialis posterior) because despite their extensive tension they also prove to be weak, which contributes to inappropriate deflection from the surface when walking. Insufficiency of the tibialis posterior may lead to tendon pain on the medial side of the foot.

Restoration of proper function

The ankle joint injury entails involuntary limb relief. This also influences large groups of muscles in the area of a knee joint or hip. It is essential that we carry out a detailed quality assessment of our movement and entire lower limb function during functional tests under an eye of the physiotherapist. Before we proceed with a dynamic training, it is necessary that we assure a proper balance.

How to prevent it?
An ankle sprain is a rapid injury and it is difficult to assure its complete prevention. It is however advisable to pay more attention to general training because lack of stabilization and extensive body movements increase the likelihood of the injury. It should focus on muscle balance, improvement of lower limb stabilization and improvement of movement patterns typical of the function in question.

A foot is an important element of the locomotor system. It is feet that our body rests on. It is feet that determine stability of our joints. A sole of the foot is a very important part of the body which serves to collect information about irregularities in the ground, thanks to which our nervous system can generate instant reaction via muscle tension. Every irregularity in the foot, such as flat foot, high arch, club foot and heel deformity, may affect the position of the knee, hips as well as backbone. And the other way round – lack of balance in the area of for example hip will affect the ankle and foot.

Anatomy, causes, symptoms and methods of treatment discussed by:
Kamila Drygas, Rehasport Clinic physiotherapist
Natalia Reke, Rehasport Clinic physiotherapist