STATE OF ART REVIEW ON MUSCULOSKELETAL PRACTICE
Dr. dr. Tirza Z. Tamin Sp.KFR (K)
Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo Hospital
Ankle sprains are common injuries that affect athletes of all ages and in all sporting activities. An estimated 28 000 ankle injuries occur in the United States each day. In sport, ankle injuries are the most common injury, with some estimates attributing upward of 45% of all athletic injuries to ankle sprains1 Most ankle sprains result from damage to the lateral ligament structures (anterior talofibular, calcaneofibular, and posterior talofibular ligaments) after a stress on an inverted and plantar-flexed (supinated) foot. Sprains are usually graded on the basis of severity and range from mild (grade I) to severe (grade III): The grading scale is a spectrum from no significant structural injury to complete rupture of the ligamentous structures. Landing from jumps, landing or stepping on another athlete’s foot, trauma at heel strike during running, and stressing the foot while in a fixed position are common mechanisms for ankle sprains.1 Ankle sprains are common among physically active individuals, particularly those who participate in court and team sports. Reinjury is also problematic in those engaging in high-risk sports, such as basketball.2
A. Anatomy of the Ankle
The ankle joint itself is connected by three separate bones; the talus works as the hinge that allows the ankle to move up and down (dorsi and plantar flexion), the tibia also known as the “shinbone” forms the medial part of the ankle, the fibula forms the lateral part of the ankle. Both the tibia and the fibula connect into the top of the talus. The whole three-boned structure is connected to the top of our heel bone called the Calcaneus.3
Picture 1. Bones that comprise the joint Picture 2. Ankle Ligament
The anterior inferior tibiofibular ligament is the one that connects with the tibia and the fibula and goes above the front of the ankle. The posterior fibular ligaments goes to the back of the tibia and fibula. The final ligament, the interosseous ligament is the one that goes between the tibia and the fibula.3 The Achilles Tendon attaches or gastrocnemius and soleus (calf muscle) to the calcaneus (heel bone). Posterior tibial tendon attaches to the underside of the foot for arch support and to turn the foot laterally and medially. Anterior tibial tendon attaches and helps us raise the foot. Posterior and Anterior tibial tendon together are called the peroneals.3 Muscles of the ankle peroneus longus consist of peroneus brevis, anterior tibialis, posterior tibialis, extensors hallucis longus, flexor hallucis longus, extensor digitorum longus, flexor halluces, gastrocnemius, and soleus.3 6
Picture 3. Muscles of the Ankle
B. Ankle Sprain
Recent epidemiological studies in high school athletes have found ankle sprains to be the most prevalent soccer injury amongst boys and girls (16% and 20%, respectively). Eighty percent of acute ankle sprains make a full recovery with conservative management, while 20% of acute ankle sprains develop mechanical or functional instability resulting in chronic ankle instability. Chronic ankle instability can lead to early degenerative changes in the ankle due to unbalanced loading on the medial side of the ankle.4 7 The reason lateral part of the ankle so weak is anterior talofibular ligament is the ligament that has the greatest impact on the lateral part of the ankle. Unfortunately, the anterior talofibular ligament is both the weakest and the smallest out of all three of the ligaments in the ankle.4
Three-quarters of ankle injuries involve the lateral ligamentous complex, comprised of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body’s center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. Treatment of acute ankle sprains generally can be successfully managed with a short period of immobilization that is followed by functional rehabilitation. Patients with chronic ankle instability who fail functional rehabilitation are best treated with a Brostrom-Gould anatomic repair or, in those patients with poor tissue quality or undergoing revision surgery, an anatomic reconstruction.5
Almost all of the ankle sprains occur at the moment of termination from running or jumping and landing on the foot. When the foot strikes the ground, the ankle will be in plantar flexion and the foot will be supinated (sole facing upwards). Stability is mitigated due to the medial malleoulus becoming more distal (far apart) then the lateral malleolus. The injury tends to be more severe if the affected foot is planted and weight-bearing at the time of impact. The peroneal tendons are also at risk in a combination of mechanical stretch and overload as they attempt to event the foot back into neutral alignment. Mechanical instability occurs when ligaments fail to remodel to normal length, allowing motion beyond normal physiological limits. The peroneal muscle become over-forced and fall upon the anterior talofibular ligament. This creates a rolling ball effect after the ATF is completely torn, the stress is overted to the Calcaneo fibular ligament and eventually to the Posterior Talofibular ligament.5
C. Evaluation and Examination
Evaluation includes medical history, history of present illness, social history, and medications. Examination consist of appearance, pain, palpation, and range of motions. Functional Outcomes and activities includes squat, stand on toes, stand on heels, stand on one foot or other with eyes open, stand on one foot or other with eyes closed, (single leg stance or Romberg, stand on toes on one foot or other, walk on toes, run, jump, jump and squat; timed get up and go and LE Functional Scale (LEFS). The modified Romberg test can demonstrate proprioceptive deficiencies of the ankle, indicating the presence of functional instability. Special tests includes neutral position of talus, anterior drawer sign (tests anterior talofibular ligament, with inversion also tests calcaneofibular ligament), talar tilt (tests calcaneofibular ligament), and squeeze test of the mid fibula and resistedexternal rotation test respectively (more spesific and sensitive evaluations for syndesmotic injury typically identified by pain over the anterior inferior tibiofibula ligament and interosseous membrane).6
Clinical evaluation includes; etiology of the injury (how did it happen), has the ankle been previously injured, the first signs for severity of the sprain are for ecchymosis (bruising), tenderness, and swelling, and stress test (pushing on the ankle to determine abnormal movement). Anterior Drawer Test- A test that uses loads of weight to determine the integrity and stability of the ankle. Talar Tilt test- This tests is used by cupping the heel of the injured ankle and inversion stress is applied. Thompson Test- tests the Achilles Tendon. It is performed with the person laying down and pressure is applied to the gastrocnemius and soleus. Differential diagnosis are fracture, tendon injures, osteochondral or chondral injuries of talar dome, peroneal or sural nerve irritation.6 9
Establish diagnosis by onset, history, and clinical examination. Problem list includes pain, impaired ROM, impaired strength, impaired gait, impaired joint play, impaired balance/proprioception, edema, and impaired functional mobility. Prognosis depends on a history of previous sprains, dynamic muscle strength, proprioceptors, the type and level of sport activity, and surgical treatment. Typically acute Achilles tendonitis is highly reversible and the prognosis is excellent. Achilles tendinosis is also very treatable but typically takes a longer period of time to become a symptomatic. Goals (with measurable parameters and with specific timelines):6
- Decrease pain or independent self-pain management
- Increase ROM
- Increase strength
- Maximize gait
- Maximize function
- Improve balance
- Independence with home exercise program
- Return to sport or premorbid activity level
Achilles tendon disorders are more common in older athletes than young athletes (teenagers and child athletes).6 The Grades of Ankle Sprain are on a Scale of 1-3
- Grade I (First degree) : no loss of function, no ligamentous laxity (negative anterior drawer and talar tilt tests), little or no hemorrhaging, no point tenderness, decreased total ankle motion of ≤50 , and swelling of ≤ 0.5 cm
- Grade II (Second degree) : some loss of function, positive anterior drawer test (anterior talofibular ligament), negative talar tilt test (no calcaneofibular ligament involvement), hemorrhaging, point tenderness, decreased total ankle motion >50 but <100 and swelling >0,5 cm but <2,0 cm
- Grade III (Third degree) : near total loss of function, positive anterior drawer and talar tilt test, hemorrhaging, extreme poin tenderness, decreased total ankle motion >100, and swelling >2.0 cm. 10 Grade III injuries have been further divided according to stress radiograph results, with anterior drawer movement of :
- Grade IIIA : ≤ 3mm
- Grade IIIB : >3mm
Picture 4. Grade of Ankle Sprain
E. Treatment of Ankle Sprain
Long-term immobilization should be avoided, while short-term immobilization has been shown to be beneficial regardless of severity. The incorporation of early manual therapy such as soft tissue massage and joint mobilizations can be used to decrease stiffness and swelling while increasing range of motion. Physical agents used in conjunction with these manual therapy techniques can increase the return to normal gait and progression to therapeutic exercise. Along with this return to normal, active range of motion, a balance and strength training program will enable the gradual return to activity. Each individual injury should be assessed based on severity with a focus on interventions that will effectively decrease the occurrence of reinjury.7
A systematic review conducted by Kerkhoffs et al, found that early weight bearing with support improved the overall resolution of symptoms associated with a lateral ankle sprain. This early weight bearing progression should incorporate an appropriate gait-assistive device and bracing, as needed.11 Early weight bearing and movement have also had effects on restoring normal range of motion and decreasing swelling. Even in those with severe Grade III lateral ankle sprains, early weight bearing and movement improved recovery of ankle mobility and produced a quicker return to activity without affecting long-term mechanical stability.Early bracing using below-knee casting and semirigid support have been shown to decrease symptoms and disability. The use of lace-up braces has produced a greater reduction in short-term swelling and disability compared to semirigid bracing.7
Similar to early weight bearing with support, manual therapy has been shown to improve the overall resolution of a lateral ankle sprain. Restoring motion, decreasing pain, and decreasing swelling can facilitate a return to normal activity level. Decreasing swelling around the ankle using manual lymphatic drainage techniques can increase the athlete’s proprioceptive awareness as well as decrease the risk of ankle stiffness. Lymphatic drainage techniques can incorporate gravity as well as manually applied massage techniques. Soft tissue and joint mobilizations have been used to improve ankle range of motion. Active mobilization in subjects with Grade II lateral ankle sprains has produced an increase in talocrural dorsiflexion range of motion. Low-grade passive anterior–posterior glide of the talus in relation to the talocrural joint was found to increase dorsiflexion range of motion as well as facilitate a normal stride with gait.7
Vicenzino et al found that weight bearing and non-weight bearing mobilizations with movement improved posterior talar glide deficits and weight bearing dorsiflexion range of motion when compared to a control group 12. The mobilization with movement technique also appears to be an effective intervention to restore ankle function in those with CAI. Range of motion, subjective feeling of instability, and dynamic postural control can improve as a result of joint mobilization. Based on the available evidence, clinicians should include manual therapy techniques into their rehabilitation program in those with acute lateral ankle sprains as well as those with CAI.7
Picure 5. Cryotherapy
Picture 6. Intermittent Compression Devices
Picture 7. Electrotherapeutic Modalities
Picture 8. Thermal Modalities
The phases consist; acute phase – days 1-3. Sub-acute phase -2-4 days to 2 weeks, rehabilitative phase -2-6 weeks post-injury, functional phase -6 weeks post-injury, prophylacticc phase – prevention of re-injury8. Goals of program in acute phase (days 1-3) are decreasing effusion and pain, protecting from further injury, allowing protected gait, early mobiliztion can lead to earlier return to work and patient comfort.8
Table 1. Acute Phase Treatment
Goals of program in sub-acute phase (2-4 days to 2 weeks) are decreasing and eliminating pain, increasing pain free ROM, protecting from re-injury with bracing or splints, limiting loss of strength and using modalities to decrease effusion.8
Picture 9. Sub-acute Phase Treatment
Picture 10. Rehabilitative Phase Treatment
Picture 11. Functional Phase Treatment
F. Prevention of Ankle Sprain
Balancing exercises can help greatly increase the ankles strength therefore preventing injury. Stand on one foot. Now reach with the opposite leg outward in all directions, forward, sideways, backwards, diagonally, etc. Reach out as far as possible and hold for three to five seconds. Each direction offers a different challenge to your balance and trains the receptors of the ankle, knee, and hip. The farther you reach the harder the balance leg is working. Start small and work your way up. You can also reach with your arms, as this challenges your balance differently. High top sneakers sfor sports that require lateral moving and jumping are essential. The sneakers to the right are used for dancing and should only be used for this purpose. Sneakers must also fit properly and must not be too narrow or large. Sometimes well-fitting sneakers are not enough, additional ankle support is needed. 9
- Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D.J Athl Train. 2013 Jul-Aug;48(4):528-45.
- McGovern RP, Martin RL. Managing ankle ligament sprains and tears: current opinion. Open Access J Sports Med. 2016 Mar 2;7:33-42.
- Hoagland TM, Young CC, Gest TR. Ankle Joint Anatomy. Available at: http://emedicine.medscape.com/article/1946201-overview.
- Chan KW, Ding BC, Mroczek KJ. Acute and Chronic Lateral Ankle in the Athlete.Bulletin of the NYU Hospital for Joint Diseases 2011;69(1):17-26.
- Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011;69(1):17-26.
- Case Type / Diagnosis: Achilles Tendinopathy. Standard of Care: Achilles Tendinopathy. Department of Rehabilitation Services Physical Therapy.
- McGovern RP, Martin RL. Managing ankle ligament sprains and tears: current opinion. Open Access J Sports Med. 2016; 7: 33–42.
- Gennady K. Sprained Ankle. 2014. Available in http://www.footvitals.com/ankle/sprained-ankle.html
- Cook Jill, Gaylene Mckay. 2006. Evidence Base Clinical Statement : Physiotherapy management of Ankle Injuries in Sport. Australian Physiotherapy Association.