Achilles

 The expression lateral ankle sprain is used loosely and in lemans terms commonly refers to a lateral ligament injury; where during play the foot is found in a inverted and plantar flexed position placing pressures on ATFL and CFL beyond that which they can tolerate resulting in tear or rupture of the structures(Brukner, P.,2013).
Lateral ankle sprains have been identified as the most common structural injury amongst athletes outside of non-specific bruising (Beynnon, B. D., Murphy, D. F., & Alosa, D. M. 2002). There have been a number of predictive factors flagged throughout the research identifying both intrinsic and extrinsic influences which have potential to cause lateral ankle sprains. One of the most positively linked intrinsic factor associated with lateral ankle sprains, is in fact previous history of a sprain. The initial injury is believed to cause a partial differentiation of the ankle, rendering it unstable biomechanically as a result of ligament compromise. Additionally, muscle reaction time, more specifically closed-loop efferent reflex response, was shown to be slower in previously injured athletes reducing the stabilizing effect of the gastrocnemius and tibialis anterior, suggesting a neuromuscular deficit (Beynnon, B. D., et al.2002)
Postural sway has also been shown to influence an athlete’s risk of ankle sprain. Taking into consideration that an athlete changes their centre of gravity multiple times within seconds of play, this is a key finding when it comes to rehabilitation as it is influenced by both the central and peripheral nervous system. Other intrinsic predictive influences which have been flagged but to date have not been individually proven include; gender, height, weight, limb dominance, anatomical foot type, foot size, hypermobility and muscle strength although clinically these finding may help in developing an overall reasoning for the injury.
Extrinsic risk factors influencing ankle sprains have primarily been observed through prospective studies inclusive of bracing, taping, shoe type and the duration and intensity of competition.
There have been a number of studies looking at the use of ankle braces and rigid taping in the prevention of ankle sprains, many of which have shown nil association in the prevention of an initial ligamentous injury; however consensus amongst researchers appears to be that the use of n ankle brace or taping has a positive influence in reducing a re-occurrence of injury. Given these findings contradict each other from a biomechanical standing, it is reasonable to deduct that the presence of a compressive force such as that previously mentioned provides proprioceptive feedback to the athlete.
Shoe Type has been found to have nil association with the incidence of ankle sprain injury. In two well-controlled studies comparing high top basketball shoes to light weight infantry boots and high top basketball shoes vs low top basketball shoes during military training exercises it was shown there was no difference in the incidence of ankle sprains. Additionally, when addressing duration of time played on field, field position and intensity of competition, no difference was found over one thousands hours of basketball game play. However, it should be noted that injury was more likely to take place during officiated game play rather than practice.

Initial Appointment
A 23 year old female attends our clinic for an initial appointment regarding an acute ankle injury of the left foot which occurred while working at a high profile trampoline gymnasium. The patient is unable to positively assure the podiatrist in which way her foot moved, however believed it was a sudden dorsiflexion and lateral rotation at the ankle joint. The patient attended hospital via ambulance and received X-Ray imaging of her foot while there, she was informed that no fracture was present, however, was unable to bring films or report to appointment for confirmation. She attends the appointment with crutches which are considered to be too high for effective functioning.
The patient described the pain as 8/10 on the VAS Pain Scale and is currently taking 1500mg of paracetamol every 4hours for the pain.
In the last 24hrs the patient has used ice 20minutes on, 20minutes off while awake – as well as compression bandaging and has get her leg elevated where possible.

The patient discloses that she has no known allergies or medical conditions and is currently taking 3x500mg paracetamol tablets every 4 hours.

Footwear worn by the patient most of the time are 0degree heel pitch/drop flat soled skate branded shoes. She participates in no structured exercises; however, full-time employment requires a considerable about of trampolining (6-7hours five days a week).

Patient orientated goals were as follows:
1. Return to work as soon as possible
2. Participate as a bridesmaid in wedding interstate in one months’ time
3. Become pain free and functional

Subjective and Objective observation found the following key findings:
Unable to stand/walk unassisted.
Swelling at both medial and lateral malleoli as well as across the dorsal aspect of the foot.
Bruising present at Medial Malleoli and insertion of Peroneus Brevis
Pain on Palpation of medial malleoli, dorsal aspect of retinaculum and muscle belly of peroneus brevis.
Pain on passive movement of abduction and dorsiflexion
Pain on resisted movement of abduction and dorsiflexion

Treatment on initial appointment was foregone.
Education on inflammation and swelling, as well as the use of pain relief – patient can use both paracetamol and ibuprofen as directed via packet instructions as these work on different receptors and limits chances of overdose – using above prescribed amounts can be dangerous.
Continue to Rest, Ice, Compression bandage and Elevate until review appointment in 2 days for discussion of x-ray and ultrasound results for which the patient has been referred.

Imaging
Plain radiograph (non-weight bearing) of the left foot revealed neither recent fracture nor recent bony injury. No destructive or erosive bony changes and no abnormal peri-articular soft tissue calcification noted. Non contributing mild degenerative change, subchondral schlerosis and minor osteophytic lipping of the articular surface was present at the 1st MTPJ.
Ultrasound of the left foot and ankle with particular targeting of areas of concern displayed a small quantity of hypoechoic fluid within the tendon sheath of the peroneus brevis tendon, consistent with traumatic tenosynovitis. A small joint effusion was noted, although it was not indicated where exactly. Otherwise all other tendons and ligament appear to be intact with no tear identified.
Therefore it was concluded via the imaging that the patient had suffered traumatic injury resulting in traumatic tenosynovitis and a small left ankle effusion

Furthermore, it was indicated that if clinical suspicion of soft tissue or subtle osteochondral injury remained high then MRI would be of benefit.

Appointments
Below is a summary of the sequential appointments following the initial (discussed above) and secondary consult (at which no treatment was performed).

Appointment # Subjective Objective Treatment Review Time
3

 

6/10/13

Patient has been able to weight bear for 2 days.
Pain has continued to reduce and both paracetamol and ibuprofen use has ceased.Returned to work, in office but unable to complete most tasks
“Will I be ready for wedding in October?”
Increased pain and restrict ROM at L/ankle joint when compared to R/ankle.
Control of active movements Very PoorSL stance <5sec

Local swelling and bruising has decreased

Initial rehabilitation program demonstrated, explained and tested with patient (see below)

Education to only wear runners at present.

Education to keep movement linear where possible and not to let pain increase over a 3/10

 

 

 

 

2/7

4

 

8/10/14

Patient attends with increased pain and bruising due to housemate accidently kicking her in the traumatized area.
Has been completing prescribed exercises daily and becoming less shaky.
Pain on Palpation of L/navicular.
Pain on active Abduction.
Eversion taping to reduce lateral ankle pain for 2/7
Exercises to continue as prescribed.
 

 

 

5/7

5

 

13/10/14

Patient brings footage of the incident which shows the rapid dorsiflexion and eversion moment on landing.
Patient in less pain and able to walk heel to toe now
Increased plantarflexion and abduction strength.

Dorsiflexion and Adduction strength remain similar.
Decrease in localized swelling and bruising.

Exercises advanced:

SL Stance in front of mirror with nil support.

Inversion taping for continued arch support and offloading of medial structures.
Heel to Toe walking to increase ankle joint ROM.

 

 

 

 

 

5/7

6

 

20/10/14

Patient no longer feels any pain, however, does not feel stable.
States walking on foam boundaries at work causes lateral instability.States doing exercises religiously as want to return to netball (social).
Increased Abduction, Adduction, Dorsiflexion and Plantarflexion strength.

Control during active Adduction and dorsiflexion still poor.

Advancing Exercises:
Standing on pillow 10sec x 6sets twice daily.
Heel Raises DL concentric, SL eccentric 8-12reps x 3 sets x 2 daily.
AB+Adduction increased to double strength Theraband 8-12reps x 3 sets x 2 daily.
Education to continue wearing supportive shoes.
 

 

 

 

 

5/7

7

 

25/10/14

Still 0/10 on VAS Pain Scale.

Has been completing calf exercises and Theraband exercises but not SL pillow stance as she had forgotten.

States going to wedding interstate in 5 days but will not be wearing heels.

Balance and Strength still require continued improvement. Treatment was designed on the presumption patient would continue to improve while away for the next 4/52 and would require exercise advancements.

WEEK 1-2
SL Heel Raise 8-12reps x 3 sets x 2 daily.
SL pillow stance 10sec x 6sets x 2 daily.

WEEK 3-4
SL Heel raise off step8-12reps x 3 sets x 2 daily.
SL pillow stance 20sec x 6sets x 2 daily.

 

Education that that the following 4/52 will be strength and conditioning.
4/52 after that will be direction change and increased impact activities, orthotic prescription and re-testing.

 

 

 

 

 

 

 

 

 

 

 

 

 

5/52

8

 

16/11/14

Patient Continued exercises as prescribed while interstate for 4weeks.

Small tweak of ankle when getting out of the limousine which may have decreased strength

Heel Raises 12-15reps x3 sets with Good control.
Able to hop x3 with nil pain although feels weak.Able to hop x2 laterally but feels very unstable.
Advancing Exercises:
Hop Scotch 1-1-2-1-2-1-1
3x 3m cutting direction change.
8 x 3sets x 2 daily.Heel Raises SL 8-12reps x 3 sets x 2 daily.
SL pillow stance 15sec x 6sets x 2 daily.

Continue to use heat if sore.
Education that if patient returns to next appointment pain-free podiatrist will sign return to modified duties certificate.

 

 

 

 

 

 

 

1/52

9

 

22/11/14

Completed all exercises over the last week with 0/10 pain but feeling fatigued. Abduction and Adduction strength now equal to R/foot and control is too. Dry needling x5 L/Gastrocnemius.
Dry Needling x 5 tibialis anterior.Soft Tissue Massage 10min

 

 

 

4/7

10

 

26/11/14

Patient attends for casting appointment
(orthotic casting process and prescription below).
– Windlass mechanism poor on weight bearing.
– Resisted resupination.
Casted while weight bearing for 1 pair of custom orthotics  

 

2/52

11

 

12/12/14

Patient remains pain free and is excited to receive new orthotics New runners look appropriate for patient and for insertion of orthotics. Orthotic Dispense.
Full length cover cut to suitable length for shoes.
Correction of biomechanical issues observed.
 

 

2/52

12

 

20/12/14

Patient attends for Return To Sport Assessment.
Nil Pain is present, patient feels strong and stable.
 

Return To Sport Assessment specific for Netball.
(see below for tests complete and results)
 

 

6/12

 

Custom Orthotic Process
The custom orthotic design and prescription process was complete with the patient in a weight bearing position using the Vertical Foot Alignment System. The device allows for the practitioner to have complete control in the design and prescription of the cast, with adjustments being able to be made with the patient providing instantaneous feedback, while biomechanical factors are being corrected. The benefit of this device is the ability to not place the foot in a position which its weight bearing range of motion cannot meet and the allowance for tissue expansion on weight bearing.
Additionally, if the cast does not meet the practitioner’s expectations on removal from the patient’s feet then, modifications can be made via cast manipulation or the prescription questionnaire.

Furthermore, the casting process was not begun until the podiatrist was pleased with the patient’s range of motion of the foot and ankle in comparison to the uninjured limb. This allowed for a more accurate prescription to help stabilize the foot in future play.

Initial Rehabilitation Program

Component Exercises Sets and Reps Notes
Strength (activation &control)
Theraband Abduction 3 x 8-12 Single Leg
Theraband Adduction 3 x 8-12 Single Leg
Theraband Plantarflexion 3 x 8-12 Single Leg
Theraband Dorsiflexion 3 x 8-12 Single Leg, Use stable chair or table to support other end of Theraband.
Proprioception
Single Leg Stance (in front of mirror) 6 x 10sec Have area of support available in case foot fatigues
Movement Patterns
Linear Movements Only Until Podiatrist advises otherwise Focus is heel to toe movements to increase range of motion at ankle joint.

* Each area was advanced on appointment as the patient showed improvement and ability to progress. Given the acute nature of this particular injury the progression was slow and steady as not to fatigue the area of concern and increase the chances of re-injury

Return To Sport Assessment
The patients Return To Sport Assessment was individually tailored to the activities in which they wished to complete post discharge; in this case a return to full task work at the trampoline gymnasium and return to social netball. As such the following Assessment specific to her goals was designed and scores recorded.

Activity Left (injured) Right Notes
SL Calf Raises 23 17 Good, within even range – continue to strengthen both sides
Hopping 26 30 Landing mechanics require work
Cued reaction from stationary position 10/10 9/10 Results are positive
SL Stance (defence) 5/5 5/5 Good defensive reach and control
Jump Squats 5 completed Landing mechanics require work
Direction Change 10/10 Landing mechanics require work
Running on Treadmill (5min) 800m completed within 5min Landing mechanics require work

The Return to Sport Assessment was considered to be completed successfully and the patient able to return to sport and full time work, however, post discharge instructions were put in place and education delivered regarding re-injury or set back may require further treatment.
Post discharge instructions were primarily involved with the softening of landing mechanics and the benefits of seeing an exercise physiologist or strength and conditioning coach regarding this matter.

6 Monthly Review Post Discharge
The six month review appointment was scheduled a long time in advance for our patient. Despite exhausting all available modalities to contact the patient after their missed appointment, we were eventually able to talk to them via phone call. The following responses were obtained in response to how the patient was progressing:
* There has been a full return to work activities including trampoline jumping and training.

* The patient is contemplating moving interstate once more, therefore no commitments regarding sport have been made as a
result.

* The patient has not changed her shoe choices and orthotics are only worn in those which she chooses to place them in.

* There have been no injuries in the last 6months
Discussion
There is significant importance to the use of long term reviews and it is disappointing that we were only able to make contact with the patient via phone call.
The absence of the patient in attending their long term review has been recognized as not a sole blame upon the patient. It has highlighted the need for clinicians to stay in contact with patients who have been temporarily discharged over shorter time frames to ensure loss of contact does not occur. As such we will develop a protocol to best attend to this issue over the coming weeks.
Although patient education was believed to be appropriate regarding return to sport, the six month long term review would have ensured the podiatrist that information given to the patient was being followed and that a direct return to game play had not occurred. Additionally, this would have given the practitioner the opportunity to re-assess and refer if necessary for the development of landing mechanics with our patient.

Conclusion
The patient initially attended our clinic following an acute ankle injury of the left foot while performing work duties. At the time of initial consult she was on a high dose of paracetamol (1500mg every 4 hours) and pain level was perceived to be an 8/10 on the VAS Scale.
The patient’s treatment followed a structured exercise program with low level advances when the podiatrist was sufficiently happy with the completion of each individual activity after the first 72 hours.
Over ten weeks of combined physical therapy and a structured exercise program to develop neuromuscular connection, strength of the extrinsic/intrinsic leg muscles and proprioceptive ability our patient was completely pain free and able to return to sport/normal activity with precaution.

 

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