Ankle Pain Workshop

MD Health Physiotherapy

Ankle

http://www.bartleby.com/107/95.html

• Talocrural, inferior tibiofibular and subtalar joints

• The talocrural joint is a synovial hinge joint with a joint capsule and associated ligaments

• Predominately allows dorsiflexion/ plantarfelxion

• Subtalar joint allows for complex movement of supination and pronation

• MCL (Fan-shaped deltoid ligament)– Controls valgus stresses

• LCL– 3 bands (anterior and posterior talofibular and

calcaneofibular ligaments)– Controls varus stresses– Are weaker and more susceptible to injury than

the MCL

Ankle

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• Collateral ligament injuries– LCL

• Is usually injured in inversion and plantarflexion from “rolling” the ankle, or landing on uneven surfaces

• ATFL is usually injured before CFL, as the ATFL is taut in plantar flexion and is relatively weaker

• Isolated ruptures of the CFL and PTFL are rare• Divided into 3 grades based on severity• Swelling usually appears rapidly

– MCL• Much stronger than the LCL• Mechanism of injury is eversion• Sometimes associated with fractures

(eg. medial malleolus or talar dome)

Ankle• Anterior shin splints (medial tibial stress syndrome)

– Inflammatory traction phenomena on the medial aspect of the tibia – can also be called medial tibial traction periostitis

– Chronic traction (usually of the medial soleus) occurs from excessive pronation or overuse and repetitive impact loading

– Contributing factors include:• Excessive foot pronation• Training errors, incl. recent increase in activity• Incorrect/poor shoe design• Running on hard/unforgiving surfaces• Decreased bone mineral density• Poor hip and knee biomechanics• Inflexibility

– Inflammation can lead to anterior compartment

syndrome, causing further pain and loss of functionhttp://www.sportsinjuryclinic.net/cybertherapist/front/lowerleg/shinsplints.htm

Ankle• Tenoperiostitis – tibialis posterior

– The tibialis posterior functions to invert the subtalar joint, is the main dynamic stabiliser of the hind foot against valgus, and provides stability to the longitudinal arch

– The cause of injury is usually overuse, and is due to:

• Excessive walking, running or jumping• Poor foot biomechanics (ie. excessive subtalar

pronation – this increases eccentric tendon loading during supination for toe-off)

– It may also present as a tenosynovitis secondary to rheumatoid arthritis, or

seronegative arthropathies http://www.eorthopod.com/public/patient_education/6489/posterior_tibial_tendon_problems.html

Tibialis posterior

Ankle

http://www.eorthopod.com/images/ContentImages/ankle/shinsplints/leg_shinsplints_cause02.jpg

• Tibial stress fracture– Continual stresses from running on hard surfaces or from

heavy strain in the tibialis muscles can weaken and eventually fracture the tibia

– Commonly caused by activities that involve high-impact running and jumping

– Patients with shin pain who try to work through it sometimes end up developing a stress fracture in the tibia

– 90% of tibial stress fractures affect the posteromedial tibia, usually in the middle third

– Anterior tibial stress fractures are quite resistant to treatment and have a propensity to develop a non-union

Ankle• Achilles tendinopathy

– May be mid-portion or insertional (less common)– Associated with collagen fibre disarray – focal losses

of normal fibre structure– The paratendinous structures can be

oedematous or scarred– There are areas of hypervascularity, but lack

of tissue repair– Predisposing factors include:

• Overuse factors (increased training loads,

decreased recovery times)• Change in surface, footwear• Abnormal biomechanics (excessive

subtalar pronation, hip and knee dysfunction)• Poor muscle flexibility ad weakness

http://www.eorthopod.com/public/patient_education/6478/achilles_tendon_problems.html

Ankle• Plantar fascia pain

– Includes both plantar fascia strains and plantar fasciitis– The plantar aponeurosis provides static support for the

longitudinal arch and dynamic shock absorption

– Risk factors for development of plantar fasciitis:• Repetitive activities that involve maximal plantar-

flexion of the ankle and simultaneous dorsiflexion

of the MTP joints (eg. running)• Pes planus or pes cavus• Non-supportive footwear• Reduced ankle dorsiflexion• Obesity• Tight proximal myofascial structures,

especially the calf, hamstring and gluteals

http://www.uptodate.com/patients/content/images/rheumpix/Plantar_anatomy_for_patient.jpg

Assessing the Ankle

Ankle Plantarflexion (PF) ROM:• Goniometer• Landmarks

• Lateral malleolus• Shaft of tibia• Line of 5th metatarsals

• Client instructed to actively PF ankle

• Note pain patterns• Compare both sides

Ankle Dorsiflexion (DF) ROM:• Goniometer• Landmarks

• Lateral malleolus• Shaft of tibia• Line of 5th metatarsals

• Client instructed to actively DF ankle

• Note pain patterns• Compare both sides

Ankle anterior drawer (ATFL):• Stabilise tib/fib• Knee should be slightly flexed• Anterior drawer calcaneus

through joint line• Note quality of movement, ROM,

end-feel and pain patterns• Compare both sides

Inferior tib/fib stability:• Stabilise tib/fib• Passively invert ankle with PF• Note quality of movement, ROM,

end-feel and pain patterns• Compare both sides

Ankle Inversion ROM:• Eye-balling (10)• Client in supine

position and instructed to actively invert ankles

• Note ROM and pain patterns

Ankle Eversion ROM:• Eye-balling (10)• Client in supine

position and instructed to actively evert ankles

• Note ROM and pain patterns

Ankle DF strength:• MMT• Stabilise tibia• Client instructed to actively PF

ankle• Note pain patterns• Compare both sides

Ankle PF strength• MMT• Stabilise tibia• Client instructed to actively PF

ankle• Note pain patterns• Compare both sides

Ankle eversion and inversion strength:

• MMT• Stabilise tibia• Client instructed to

actively evert or invert ankle

• Note pain patterns• Compare both sides

Significant Findings from the Ankle

Grades of ankle instability:• Grade 1

• Ligament Stretch – No tear• Minimal swelling tenderness• No function loss• No mechanical instability

• Grade 2• Torn ATFL, Intact CFL• Moderate pain, swelling• Mild joint instability

• Grade 3• Torn ATFL, CFL (PTFL)• Significant pain, swelling, lost ROM• Functional and mechanical

instability

Shin splint – general:• Noted from subjective assessment• Pain produced with palpation of:

• Tib ant and tib post for muscular shin splints

• Tibia for bony shin splints• Some pain may be reproduced with weight-

bearing DF and PF• Bony shin splints may indicate micro fractures

occurring within the tibia itself• Resulting inflammatory process causes pain

and localised swelling along the bone

Achilles tendinopathy:• Pain with jumping/hopping• Decreased PF strength compared with non-

pathological side• Biomechanical predisposing factors

• Excessive foot pronation• Calf weakness• Poor muscle flexibility, eg tight gastrocnemius• Poor ROM – restricted DF

Lateral ligament tear:• Positive ligament testing

• Anterior drawer assess ATFL integrity• Talar tilt test assess integrity of the

calcaneofibular ligament (laterally) and the deltoid ligament (medially)

• Grades of instability• I: there is no abnormal ligament laxity• II: reveal some degree of laxity but have a

firm end feel• III: gross laxity without a discernible end

point• Subjective Hx:

• noted trauma • instability

Plantar fascia pain:• Subjective

• Pain worse in morning and improves during the day

• Pain with walking• Pain reproduced with resisted PF• Pain reproduced with DF stretch• Biomechanical factors

• Activities that require maximal PF of the ankle and simultaneous DF of metatarsophalangeal joints – running, dancing

• Excessive pronation

Treating the Ankle

Ankle ROM:• Aim of Rx is to improve ankle ROM without

compromising pathology• Can be used for any pathology but note stage of

healing• STW (gastrocs, peroneals): can ease muscle

spasm and decrease pain inhibition• Ankle mobs: AP, PA, physiological fl/ext/eve/inv

• Once ankle ROM is improved and ankle joint more stable, progress to plyometric exercises

• skipping, jumping, running, hopping, side-to-side running/hopping

Ankle strengthening:• Aim of Rx is to improve ankle strength without

compromising pathology• Can be used for any pathology but note stage of healing

• STW (gastrocs, peroneals): can ease muscle spasm and decrease pain inhibition

• Strengthening: heel raises, lunges• AMC: decrease resistance on reformer to maximise

eccentric control when adding HR to exercise• Plyo: skipping, jumping, running, hopping, side-to-side

running/hopping

• Monitor pain behaviour. If Lx, hip, knee or ankle is irritated, exercises should be eased off and focussed on easing pain (RICER) or focus on another joint, eg. knee