Ankle pain workshop

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Ankle Pain Workshop by Michael Dermansky of MD Health Pilates

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Ankle pain workshop

  1. 1. Ankle Pain Workshop MD Health Physiotherapy
  2. 2. Ankle • 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 http://www.bartleby.com/107/95.html
  3. 3. Ankle • 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) http://content.revolutionhealth.com/contentimages/h9 991457_002.jpg
  4. 4. 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 http://www.sportsinjuryclinic.net/cybert herapist/front/lowerleg/shinsplints.htm syndrome, causing further pain and loss of function
  5. 5. 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: Tibialis posterior • 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_pr oblems.html
  6. 6. Ankle • 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 highimpact 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 http://www.eorthopod.com/images/ContentImages/ ankle/shinsplints/leg_shinsplints_cause02.jpg
  7. 7. 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_edu cation/6478/achilles_tendon_problems.html
  8. 8. 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 plantarflexion 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/r heumpix/Plantar_anatomy_for_patient.jpg
  9. 9. Assessing the Ankle
  10. 10. 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 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
  11. 11. 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 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
  12. 12. Ankle Eversion ROM: • Eye-balling (10) • Client in supine position and instructed to actively evert ankles • Note ROM and pain patterns Ankle Inversion ROM: • Eye-balling (10) • Client in supine position and instructed to actively invert ankles • Note ROM and pain patterns
  13. 13. Ankle PF strength • MMT • Stabilise tibia • Client instructed to actively PF ankle • Note pain patterns • Compare both sides Ankle DF strength: • MMT • Stabilise tibia • Client instructed to actively PF ankle • Note pain patterns • Compare both sides
  14. 14. Ankle eversion and inversion strength: • MMT • Stabilise tibia • Client instructed to actively evert or invert ankle • Note pain patterns • Compare both sides
  15. 15. Significant Findings from the Ankle
  16. 16. 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
  17. 17. 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 weightbearing 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
  18. 18. Achilles tendinopathy: • Pain with jumping/hopping • Decreased PF strength compared with nonpathological side • Biomechanical predisposing factors • Excessive foot pronation • Calf weakness • Poor muscle flexibility, eg tight gastrocnemius • Poor ROM – restricted DF
  19. 19. 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
  20. 20. 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
  21. 21. Treating the Ankle
  22. 22. 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-toside running/hopping
  23. 23. 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

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