sports injuries of ankle and foot is a seminar done by Ms. Megha ck on behalf of completing her master of physiotherapy program during the year 2020-2022

1. SPORTS INJURIES OF ANKLE AND
FOOT
MEGHA CK
GUIDE: DR. HARIPRIYA S

2. What is sports injury?
• Regular physical activity is probably the most important overall determinant of a population’s health.
Unfortunately, physical activity may extract a cost in the form of an activity-related injury
• Such injuries are categorized as an acute injury or an overuse injury depending on the mechanism of
injury and the onset of symptoms.

3. Site Acute injuries Overuse injuries
Bone
Fracture
Periosteal contusion
Stress fracture
‘Bone strain’, ‘stress
reaction’
Osteitis, periostitis
Apophysitis
Articular cartilage
Osteochondral/chondral
fractures
Minor osteochondral injury
Chondropathy
(e.g.softening, fibrillation,
fissuring, chondromalacia)
Joint
dislocation
subluxation
synovitis
osteoarthritis
Ligament Sprain/tear (grades I–III) inflammation
Muscle
Strain/tear (grades I–III)
Contusion
Cramp
Acute compartment
syndrome
Chronic compartment
syndrome
Delayed onset muscle
soreness
Focal tissue
thickening/fibrosis

4. Tendon Tear (complete or partial)
Tendinopathy (includes
paratenonitis, tenosynovitis,
tendinosis, tendinitis)
Bursa Traumatic bursitis Bursitis

5. 1.INJURIES TO BONE
Ankle and foot fractures
• Potts fracture
• Avulsion fracture
Fractures of the foot
• Chopart fracture dislocation
• Metatarsal fractures
• Stress fractures
• Perostitis
2.INJURIES TO ARTICULAR CARTILAGE
Osteochondral fracures
Osteochondropathy
3.INJURIES TO JOINT
Joint dislocation
4.INJURIES TO LIGAMENT
Sprains
5.INJURIES TO MUSCLE
Strain and Tear
Muscle contusion
Muscle cramps
Compartment syndrome
6.INJURIES TO TENDON
Tendon tear
Paratenonitis
Tenosynovitis
Tendinosis
7.INJURY TO BURSA
Bursitis

6. INJURIES TO BONES
Ankle and foot fractures
• Ankle injuries are the most common sports-related injury.
• An ankle fracture is a break in one or more bones that make up the ankle joint.
• People participating in sports such as basketball, football, soccer and skiing are at a high
risk of developing ankle fractures.
• Common symptoms of an ankle fracture include pain and swelling around the ankle,
bruising, tender to touch, inability to walk on the leg, and deformity if the ankle is
dislocated.
• Treatment varies with the type and severity of the injury.

7. Pott's fracture
• It is one of a common sporting inversion injury especially in jumping sports (e.g.
basketball, volleyball).
• They are usually a result of a forced plantarflexion/inversion movement, whereby the
complex of ligaments on the lateral side of the ankle is torn by varying degrees
• Inversion injuries are also far more common than eversion injuries due to the relative
instability of the lateral joint and weakness of the lateral ligaments compared to the
medial ligament

8. Mechanism of Injury
• A Pott’s fracture is a fracture affecting one or both of the malleoli. During activities such as landing
from a jump (volleyball, basketball).
• when rolling an ankle, a certain amount of stress is placed on the tibia and fibula and the ankle
joint.
• When this stress is traumatic, and beyond what the bone can withstand, a break in the medial,
lateral, or posterior malleolus may occur.
• Also, activities involving a sudden change of direction, such as football and rugby, can cause
fractures around the malleoli.

9. • The fracture often occurs in combination with other injuries such as an inversion injury, a
dislocation of the ankle, or other fractures of the foot, ankle, or lower leg
• Pott's fractures can vary in location, severity, and type including displaced fractures, un-displaced
fractures, bi-malleolar fractures, or compound fractures.

10. Clinical Presentation
• Persons with a Pott's fracture typically experience a sudden sharp and intense pain around the ankle
or lower leg immediately at the time of injury.
• Pain is situated at the front, back, inner or outer part of the ankle or lower leg. The patient may
have heard a “crack” as well.
• Due to the pain, the patient to protect the injury.
• In severe cases, weight-bearing may be impossible.
• swelling, bruising and pain on firmly touching the affected region of bone .

11. • When it is a displaced fracture, an obvious deformity may be noticeable and disability such as
is common in Pott's fractures cases

12. Diagnosis
• careful of the person
• increased in diameter of the leg at malleoli level suggests fibular fracture (Keen's sign of Pott's
fracture)
• Diagnosis of a Pott's Fracture can be confirmed on

13. Outcome Measures
• Clinical Demerit Points
• Maryland Foot Score
• Walking speed
• Time required to climb a set number of stairs
• Short Musculoskeletal Functional Assessment (SMFA)
• Ankle-Fracture Outcome of Rehabilitation Measure (A-FORM)
• Olerud and Molander (O&M) Questionnaire
• Lower Extrimity Functional Scale (LEFS)

14. Management
• Rest
• Displaced Pott’s fracture needs . Post-operatively, protective boot, brace, or a
plaster cast, and/or crutches are used for a number of weeks.
• Non-displaced fracture - plaster cast immobilization and the use of crutches, followed by the use of
a protective boot or brace for a number of weeks.
• should perform pain-free flexibility, strengthening, and balance exercises as part of their
rehabilitation to ensure an optimal outcome

15. • Techniques such as joint mobilization is essential to ensure optimal range of movement and
flexibility.
• The treatment may also involve electrotherapy, bracing, exercises to improve strength, flexibility
and balance, and hydrotherapy.

16. Prognosis
In the most severe cases of a Pott's fracture, patients usually make a
Return to activity or sport can usually take place in a number of weeks to months.

17. Avulsion Fractures
• An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous
attachment
• It can be caused by traumatic traction of the ligament or tendon.
• It can occur at numerous sites in the body, but some areas are more sensitive to these types of
fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial
malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but
also at the talus and calcaneus.

18. Etiology
• The typical cause of injury is an inversion of
the foot, generating tension along with the
plantar aponeurosis insertion
• A to the ankle and foot may
cause an avulsion fracture at any of these
locations

19. Clinical Presentation
• Symptoms of an ankle avulsion fracture are very
similar to an ankle sprain and it is very difficult to
differentiate without an X-ray or an MRI scan.
• Pain is usually felt immediately after injury, with an
onset of swelling.
• Bruising may develop and the patient will have
difficulty walking or weight-bearing on the ankle.

20. Diagnosis
• X-ray may be ordered by the surgeon.Other imaging methods are recommended such as MRI or CT
Scan
Outcome Measures
• Olerud ankle score
Medical Management
• usually treated conservatively
• walking boot or a walking cast can be used, which will remain in situ for 4 to 6 weeks
• Surgery is recommended where the bone is displaced from its normal position or where more than
30% of the cubometatarsal joint is involved.

21. Physical Therapy Management
• Avulsion fractures are often treated as ankle sprains
• An inappropriately managed avulsion fractures can lead to significant, long-term functional
disability
• Most fractures heal well.
• Rehabilitation following an avulsion fracture consists of 3 phases; the acute, the recovery, and the
functional phase

22. Acute phase
• Can begin at 2 weeks post-operatively
• This phase can include passive range of motion exercises and
cryotherapy and is based on the reduction of pain, inflammation,
and oedema, while keeping muscle atrophy of the lower limb to a
minimum.

23. Recovery phase
Begins once the goals of the acute phase have been met. This phase can be further divided into 3
stages:
Weeks 0-6: active ROM exercises for the toes and the MTP joints, strengthening exercises for the
ankle and foot are still premature, however. In week 2, isometric exercises for the dorsiflexors,
plantarflexors, invertors, and evertors of the foot, along with active ankle ROM movements can be
started.
Weeks 6-8: active and passive ROM exercises for the ankle and the subtalar joint with Isometric and
isotonic exercises. Exercises for proprioception and proximal strength and control.

24. 8-12 weeks: strengthening exercises for the dorsiflexors, plantarflexors, invertors, evertors, long flexors
and extensors of the toes are recommended. Full weight-bearing exercises are also permitted.

25. FRACTURES OF THE FOOT
• Fractures of the calcaneum often occur as a result of a fall from height
• Can be painful and may be accompanied by vertebral fractures
• The phalanges and metatarsals are commonly injuried by a heavy object falling onto the foot
• These fractures do not require reduction or immobilisation

26. Calcaneal Fractures
• It is a rare type of fracture but has potentially
debilitating results.

27. Etiology
• Tarsal fractures account for 2% of all fractures.
• Calcaneal fractures account for 50-60% of all fractured tarsal bones.
• Less than 10% present as open fractures.
• They generally follow high-energy axial traumas, such as falls from height or motor accidents
• 75% of the calcaneus fracture is intra-articular and the prognosis of intra-articular fracture is poor.
• 20-25% of the cases with a calcaneal fracture is associated with compression fractures of the
lumbar vertebrae.

28. • Most patients with calcaneus fractures are young, with the 20-39 age group the most common.
• Calcaneal fractures are rare in children

29. Mechanism of Injury
• Calcaneal fractures are mostly the result of high energy events leading to axial loading of the bone
• Predominantly, falls from height and automobile accidents (a foot depressed against an accelerator,
brake, or floorboard) are common mechanisms of injury. The talus acting as a wedge causes
depression and thus flatten, widen, and shorten the calcaneal body.
• Calcaneal fractures can also occur with less severe accidents like an ankle sprain or a stress
fracture in runners.
• Jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also
cause calcaneus fracture

30. Characteristics
• Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site
• The patient is not likely able to bear weight, walk, and move the foot.
• Swelling in the heel area
• Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion
significantly.
• There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus
injury.
• Skin quality around the heel must be evaluated for tenting and/or threatened skin. This is
especially important in the setting of Tongue-type calcaneus fractures

31. • Generalized pain in the heel area that usually develops slowly (over several days to weeks): typically for stress
fractures
• Deformity of the heel or plantar arch: Secondary to the displacement of the lateral calcaneal border outward,
there is a possible widening or broadening of the heel.

32. Examination
• Palpation: Tenderness over calcaneus while squeezing the heel from both sides. A squeeze test is
positive in stress fracture of the calcaneus.
• A thorough neurovascular examination is a must. For which pulse rate of ipsilateral dorsalis pedis
or posterior tibial can be compared to the contralateral limb.If there is any suspicion of arterial
injury and prompt further investigation with angiography or Doppler scanning can be done.
• Evaluation of all lower extremity tendon function.

33. Diagnosis
• Radiological examination: X-Ray, CT Scan
• Bone scan or MRI
• Mondor's Sign
• Bohler's Angle
• Critical Angle of Gissane

35. Classification
two general categories
• accounts for 25 % of calcaneal fractures
• include avulsion injuries
• Fractures involving any of the three subtalar articulating surfaces
• common results of high force axial loading
• An intra-articular fracture can be further classified into:-

36. Essex-Lopresti classification: It is based on fracture
lines using lateral radiographical images.
• Joint depression type: verticle fracture line through
the angle of Gissane separating the anterior and
posterior portions of the calcaneus.
• Tongue type:has the same verticle fracture line as a
depression type with another horizontal fracture line
running posteriorly, creating a superior posterior
fragment

37. Sander Classification:It is a widely used
classification system
4 types of fracture based on the number and
location of the articular fragments.
• Type I fractures-nondisplaced
• Type II fractures (two articular pieces)
• Type III fractures (three articular pieces)
• Type IV fractures (four or more articular
fragments) - highly comminuted.

38. Management
• There is no universal treatment or surgical approach to all calcaneal fractures.
• Treatment of calcaneal fractures depends on the individual fracture pathoanatomy, accompanying
soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient.
• The treatment of calcaneus fracture can be divided into two types: operative and non-operative
treatment.

39. Operative Care
• Surgery is the correct form of treatment.
• Intraarticular fractures are often treated operatively.
• The goal of surgery is to reconstruct the overall
shape of the calcaneum and to obtain a good
functional result.
• Done by open reduction and internal fixation.

40. Non-Operative Care
• preferable when there is no impingement of the peroneal tendons and the fracture segments are not
displaced
• despite the presence of a fracture, proper weight-bearing alignment has been adequately maintained
and articulating surfaces are not disturbed
• Extra-articular fractures are generally treated conservatively

41. Physical Therapy management: 3 phases
Day -1 to week-1 :
Precautions: fixation is not rigid unless the patient has had open reduction and internal fixation. Avoid PROM
ROM: AROM of toes, MTP joints and knee. Before casting, do not move the ankle and subtalar joint unless
rigidly fixed.
Muscle strength: No strengthening to the ankle or foot.
Functional activities: NWB stand/pivot transfers and ambulation with assistive devices.
Weight Bearing : None.

42. 2 Weeks
Precautions: fixation is not rigid unless the patient has had open reduction and internal fixation. Avoid PROM
ROM: Rigidly fixed and non-rigidly fixed fractures may range the MTP joints only.
Muscle strength: Rigidly fixed calcaneal fractures may begin isometric exercises in DF and PF as well as
inversion and eversion.
Functional Activities: NWB standing/pivot transfers for calcaneus fractures.
Weight bearing: Calcaneal fractures are NWB.

43. 4-6 Weeks
Precautions: All calcaneal fractures are still in a NWB short leg cast.
ROM: Rigidly fixed fractures are still casted. Continue AROM to the MTP joints as well as isometric exercises of
the ankle, PF and DF and inversion and eversion in the cast.
Non-rigidly fixed fractures continue AROM at the MTP joint only. The patient is still in the cast.
Muscle strength: Rigidly fixed fractures begin isometric exercises to the dorsiflexors and plantar flexors of the
ankle and the invertors and evertors in the cast.

44. For non-rigidly fixed fractures no strengthening exercises.
Functional Activities: Rigidly fixed fractures of the calcaneus and talus may continue partial weight bearing
stand/pivot transferes and a three-point gait.
Weight bearing: Rigidly fixed fractures may continue toe-touch to partial weight bearing.
Non-rigidly fixed fractures are non-weight bearing in a short leg cast.

45. Chopart fracture-dislocation
A Chopart's fracture-dislocation is a dislocation
of the mid-tarsal joints of the foot, often with
associated fractures of the calcaneus, cuboid and
navicular bone.

46. Etiology
• Among the uncommon midfoot injuries, Chopart joint dislocations or fracture-dislocations are the
most severe injuries
• It is usually caused by falls from height, traffic collisions and twisting injuries to the foot as seen in
basketball players.

47. Characteristics
• They are missed or misdiagnosed in up to 41% of cases
• The symptoms and signs of a Chopart fracture-dislocation are:
• Abnormal position of the forefoot to medial direction
• swelling of the dorsum of foot and pain in the midtarsal region when it gets strained

48. Diagnosis: Is made on plain radiograph of the foot, although the extent of injury is often
underestimated
Treatment: Comprises early reduction of the dislocation, and frequently involves open reduction
internal fixation to restore and stabilise the talonavicular joint. Open reduction and fusion of the
calcaneocuboid joint is occasionally required
Physical Therapy Managanement: PT intervention should begin as soon as possible
• maintain surrounding muscular strength and range of motion
• maintain functional independence as much as is possible
• prevent secondary complications
• effective cast care advice and mobility progression
Prognosis: With prompt treatment, particularly open reduction, and early mobilisation the outcome
is generally good

49. Metatarsal Fractures
A metatarsal bone fracture is a complete or
incomplete break in one of the five metatarsal
bones in each foot

50. Etiology
• The majority of the metatarsal fractures sustained from sport is from soccer (73%)
• 5 to 6% of all fractures treated in primary care are metatarsal fractures
• are the most common injuries of the foot
• The distribution of the fractures looks as follow
First metatarsal: 5%
Second metatarsal: 12%
Third metatarsal: 14%
Fourth metatarsal: 13%
Fifth metatarsal: 56%
Multiple metatarsal fractures: 15,6%

51. • Athletes, individuals who are obese, and individuals with osteoporosis or
rheumatoid arthritis or diabetes have an increased risk of developing metatarsal
fractures
• It also appears in sports like jogging, ballet, gymnastics, and high-impact aerobic
activities.Shoe shock attenuation can prevent metatarsal stress fractures
• The act of repetitive cyclic loading, especially in the setting of a young athlete or
military recruit, can lead to a chronic overloading predisposing one to a stress
reaction and ultimately fracture.

52. Characteristics
• Painful swelling
• Axial pressure pain
Diagnosis
• Acute metatarsal fracture
• Fractures of the proximal first through fourth
metatarsals
• A Fracture of the unfused fifth metatarsal base
apophysis
• Acute fractures of the proximal fifth diaphysis
• Jones fracture
• Stress fractures

53. Physical Therapy Management
• first days are protection, rest, ice, compression
and elevation important until the swelling is
stabilized
• joint mobilizations
• electrotherapy
• hydrotherapy
• later on excercises to increase strength,
flexibility and balance.

54. Stress fractures
A stress fracture is a fatigue-induced bone
fracture caused by repeated stress over time.
stress fractures are the result of accumulated
injury from repeated submaximal loading, such
as running or jumping

55. Etiology
• 15-20% of overuse injuries are stress fractures.
• activities such as marching and running are associated with these types of fractures
• occurs especially the second metatarsal

56. Perosteitis
• commonly seen in football, basketball, soccer,
or dance
• Periostitis is a condition that many runners are
familiar with. It is caused by inflammation of
the periosteum, a layer of connective tissue
that surrounds bone.

57. Causes
• A major increase of mechanical stress
• The periosteum is an attachment site for several muscles (soleus, flexor digitorum longus, tibialis
posterior). Overworking these muscles can create muscular tension and cause irritation at their
attachment site on the periosteum
• Foot and ankle biomechanical problems, such as uncontrolled or excessive pronation.

58. symptoms
• Bone tenderness, difficulty bearing weight on affected limb
• Pain
• Stiffness, especially when getting out of bed in morning
• Fever and chills
• Swelling of tissue around bone
• Pus forming if left untreated.

59. Physical therapy management
Phase 1
Inflammation
(until day 10)
Phase 2
Proliferation
(10 days to 8 weeks)
Phase 3
Remodeling
(up to one year)
Electrotherapy
Rest, ice, compression,
elevation
Posture and gait
assessment
Technical needs
assessment (cane,
crutches)
Manual therapy
Electrotherapy
Strengthening, flexibility
and proprioception
exercises
Mechanical stress
quantification
Taping, as necessary
Progressive exercises
Mechanical stress
quantification and training
advice
Education about prevention

60. JOURNAL NAME Scientific Journal of rehabilitation medicine
TITLE
AUTHOR
Comparative Effects of Impacts and Stainabilities of National Academy of
Sports Medicine and Combined Exercises (Neuromuscular and Core Stability)
on Functional Characteristics and Balance of Individuals with Unilateral Chronic
Ankle Injury (2021)
A Mohammadi et.al
METHODOLOGY A total of 36 male athlete students suffering from chronic ankle instability
voluntarily participated in the present study and were randomly divided into
three groups of 12: NASM excersices, combined training, and the control group.
All the participants’ performance characteristics and dynamic balance were
evaluated prior to, after, and four weeks after the exercises.
OUTCOME MEASURES Side-to-Side Hop Test, Figure-eight Hop Test, Triple Hop Test, Y balance test
CONCLUSION Doing eight weeks of combined training (neuromuscular and core stability) was
observed to be significantly more effective, compared with NASM training, in
the performance and postural control in patients with chronic ankle instability.

61. JOURNAL NAME Orthopedic trauma association
TITLE
AUTHOR
Does formal vs home-based physical therapy predict outcomes after ankle fracture or
ankle fracture-dislocation? (2018)
C M. Ferguson et.al
METHODOLOGY This prospective observational study included patients with operative bimalleolar or
trimalleolar ankle fractures with or without dislocation (n=80) at a Level I trauma
center. Patients were prescribed PT per the surgeon’s practice pattern. Patient reported
functional outcomes at 6 months and complication rates were compared between
groups.
OUTCOME MEASURES Foot and Ankle Ability Measure (FAAM)
Short Form Musculoskeletal Functional Assessment (SFMA)
CONCLUSION Comparison of outcomes between patients with operatively treated displaced ankle
fractures/dislocations with Formal-PT vs Home-PT showed no difference in SMFA
and FAAM scores. These findings suggest patients receiving supervised PT produced
a similar outcome to those under routine physician-directed rehabilitation at 6
months.

62. INJURIES TO ARTICULAR CARTILAGE
Osteochondral fractures
• It is an injury to the cartilage and bone in the talus.
Etiology:
• Twisting injuries in sports of any kind
• A fall from a height

63. Types
: Some injuries will not only affect the cartilage but the bone beneath it. This can
cause a bruise or a bone contusion to the bone itself. When associated with a cartilage tear, this
becomes more problematic
: A piece of bone and cartilage can be partially broken off but have a stable base.
: A piece of bone and cartilage can be completely broken off. However, not
displaced from its environment or its anatomical place in the bone
: A piece of bone and cartilage can be completely broken off and displaced into
the ankle joint, causing a severe injury.

65. Signs and Symptoms
• Chronic swelling
• Morning stiffness
• A feeling of locking when the ankle moves. A
click may also be felt.

66. PT Management
• joint mobilization
• electrotherapy
• use of crutches, a walking stick or other
walking aid
• use of a protective boot
• prescription of orthotics or footwear advice
• a gradual return to activity program
• a gradual return to running program
• anti-inflammatory and supplement advice
• ankle bracing
• the use of heel wedges
• the use of a compression bandage
• ice or heat treatment
• exercises to improve flexibility, strength, core
stability and balance
• hydrotherapy
• education
• activity and lifestyle modification advice
• biomechanical correction
• weight loss advice where appropriate

67. osteochondropathy
osteochondropathy refers to a group of disease involving both bone and cartilage (softening,
fibrillation, fissuring, chondromalacia)
Chondromalacia: develops when cartilage deteriorates and softens.
if diagnosed early, this condition is reversible with appropriate mediacal and physiotherapy treatment.

68. JOURNAL NAME Knee Surgery, Sports Traumatology, Arthroscopy volume
TITLE
AUTHOR
Arthroscopic lift, drill, fill and fix (LDFF) is an effective treatment option for
primary talar osteochondral defects (2020)
Kaj T. A. Lambers et.al
METHODOLOGY Twenty-seven ankles (25 patients) underwent an arthroscopic LDFF procedure
for primary fixable talar OCDs. The mean follow-up was 27 months (SD 5).
Pre- and post-operative clinical assessments were prospectively performed and
patients were radiologically assessed by means of computed tomography (CT)
scans pre-operatively and 1 year post-operatively.
OUTCOME MEASURES Numeric Rating Scale (NRS), Foot and Ankle Outcome Score (FAOS), Short
Form-36 (SF-36)
CONCLUSION Arthroscopic LDFF of a fixable primary talar Osteochodral Defects results in
excellent improvement of clinical outcomes. The radiological follow-up
confirms that fusion of the fragment is feasible in 92%.

69. JOURNAL NAME The American Journal of Sports Medicine
TITLE
AUTHOR
Allograft Versus Autograft Osteochondral Transplant for Chondral Defects of
the Talus: Systematic Review and Meta-analysis (2021)
Filippo Migliorini et.al
METHODOLOGY All studies investigating the outcomes of allograft and/or autograft
osteochondral transplant as management for osteochondral defects of the talus
were accessed. the outcomes and data concerning the rates of failure and
revision surgery were also collected and analyzed.
OUTCOME MEASURES visual analog scale (VAS), American Orthopaedic Foot and Ankle Society
(AOFAS) score, Magnetic Resonance Observation of Cartilage Repair Tissue
(MOCART) score
CONCLUSION Based on the main findings of the present systematic review, talar
osteochondral transplant using allografts was associated with higher rates of
failure and revision compared with autografts at midterm follow-up.

70. INJURIES TO JOINTS
Joint Dislocation
A dislocation is when there is an abnormal separation between the bones of a joint.
Ankle dislocations often occur along with a break in 1 or more of the ankle bones. In some cases, an
ankle dislocation can happen without a break in the ankle bones. In these cases, the ankle dislocation
occurs along with a severe ankle sprain. A severe sprain is when the ligaments are torn.
Garrick et.al reported that 45% of basketball injuries, 25% of volleyball injuries, and 31% of soccer
injuries are to the ankle.
Ankle dislocations are more commonly seen in volleyball and basketball because jumping is a
fundamental component of these sports.

71. Causes
• Ankle dislocation results from severe injury to the ankle.
• This can happen in a motor vehicle accident. It may also
happen while playing sports, especially ones that include
jumping. It is more likely to happen when you have your foot
pointed down during impact.

72. Signs and symptoms
• Immediate, severe pain
• Swelling and bruising
• Soreness to the touch
• Inability to put weight on foot

73. Diagnosis
• physical examination
• pain and swelling
• X-rays of leg, ankle, and foot to look for bone
fractures
Medical Management
• Pain killers
• closed reduction
• splints
• a cast or boot
• emergency surgery

74. Physiotherapy Management
Weeks 1 - 4
• Start ankle isometrics inside the boot immediately post-op. Do 5 repetitions of 5 second
contractions. Repeat this 5x per day.
• No ankle range of motion exercises for 4 weeks.
• Gait training with crutches to minimize compensations and to enforce touchdown weightbearing
status on the surgical leg.
Exercises:
• Toe curls and toe spreads
• Quad-sets with straight-leg raises
• Gluteal sets
• Well-leg biking
• Upper body training

75. Weeks 4 - 6:
• May start partial weightbearing still using crutches and walking boot.
• Can start using AirCast Stirrup splint for sleeping only instead of the walking boot.
• Start ankle partial range of motion (ROM) and non-weightbearing to partial weightbearing ankle isotonic
exercises.
• Soft tissue treatments for swelling, mobility and healing.
Weeks 6 - 8:
• May start weightbearing as tolerated and progressive weaning of assistive devices (single crutch to cane to no
device, if necessary).
• Can wean off boot and use AirCast Stirrup instead.
• Gait training to normalize movement patterns.
• Start to seek full ankle range of motion per patient tolerance and without flare-ups.
• Start weightbearing strength and balance exercises.
• Begin joint mobilizations to seek full range of motion.

76. Weeks 8 - 12:
• Increase functional weightbearing exercises and activities. Avoid impact and cutting activities until week 12.
• Can start to wean off AirCast Stirrup if the patient has enough dynamic control and stability of the ankle.
• Aim for ankle range of motion to be full by week 12.
• Continue with mobilizations.
Weeks 12 and beyond:
• Start sport-specific training.
• Increase the intensity of strength, balance, coordination and functional training for gradual return to activities
and sports.
• Return to specific sports is determined by the physical therapist through functional testing specific to the
targeted sport.

77. JOURNAL NAME MDPI
TITLE
AUTHOR
Isolated Medial Subtalar Joint Dislocation during Sports Activities: A
Systematic Review (2021)
Carlo B et.al
METHODOLOGY The aim of this study was to verify if a reliable conservative treatment and a
specific physiotherapy rehabilitation protocol in isolated medial dislocation of
the STJ in athletes.A systematic review of the published literature of the last 11
years was performed by applying the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines using three databases:
Pubmed, Scopus, and Web of Science.
OUTCOME MEASURES American Orthopedic Foot and Ankle Society (AOFAS) , range of motion
(ROM)
CONCLUSION A total of 12 studies were included in their review, with a total of 26 athletic
patients. Sixteen of them had good results with the correlation between the
duration of immobilisation and the outcomes.

78. LIGAMENT INJURIES
ANKLE SPRAIN

79. An ankle sprain is where one or more of the ligaments of the ankle are partially
or completely torn.
Ankle sprains are most common in basketball – with 45 percent. Soccer
accounts for another 31 percent of ankle sprains, and volleyball 25 percent

80. Epidemiology
• An ankle sprain is a common injury.
• Inversion-type, lateral ligament injuries represent approximately 85% of all ankle sprains.
• The incidence of ankle sprain is highest in sports populations.
• Poor rehabilitation after an initial sprain increases the chances of this injury recurrence.
• A meta-analysis by Doherty et al, found that indoor sports carry the greatest risk of ankle sprain
with an incidence of 7 per 1,000 cumulative exposures.
• Severe ankle sprains occur commonly in basketball players.
• Recurrence rates amongst basketball players is reported to be greater than 70%.

81. Clinically Relevant Anatomy
• Of the lateral ankle ligament complex the most frequently damaged one is the anterior talofibular
ligament (ATFL)
• On the medial side the strong, deltoid ligament complex is injured with forceful "pronation and
rotation movements of the hindfoot
• The stabilising ligaments of the distal tibio-fibular syndesmosis are the anterior-inferior, posterior-
inferior, and transverse tibio-fibular ligaments, the interosseous membrane and ligament, and the
inferior transverse ligament.
• A syndesmotic (high ankle) sprain occurs with combined external rotation of the leg and
dorsiflexion of the ankle.

82. Risk Factors
• Several intrinsic and extrinsic risk factors predispose an athlete to chronic ankle instability
• The most common risk factor is previous history of sprain
• A previous sprain may compromise the strength and integrity of the stabilisers and interrupt
sensory nerve fibres
• Sex, height, weight, limb dominance, postural sway and foot anatomy are intrinsic.
• Extrinsic risk factors may include taping, bracing, shoe type, competition duration and intensity of
activity

83. Mechanism of Injury
• usually occur during a rapid shift of body center of mass over the landing or weight-bearing foot
• When a ligament tears or is overstretched its previous elasticity and resilience rarely returns
• Reports have proposed that the greater the level of plantar flexion the higher the likelihood of
sprain
• Yeung et al, 1994, in an epidemiological study of unilateral ankle sprains, reported that the
dominant leg is 2.4 times more vulnerable to sprain than the non-dominant one.
• A less common mechanism of injury involves forceful eversion movement at the ankle injuring the
strong deltoid ligament.

84. Aspect Mechanism of injury Ligaments
Lateral Inversion and
plantarflexion
anterior talofibular ligament
calcaneo-fibular ligament
posterior talofibular ligament
Medial Eversion posterior tibiotalar ligament
tibiocalcaneal ligament
tibionavicular ligament
anterior tibiotalar ligament
High External rotation and
dorsiflextion
anterior-inferior tibiofibular
ligament
posterior-inferior tibiofibular
ligament
transverse tibiofibular ligament
interosseous membrane
interosseous ligament
inferior transverse ligament

85. Clinical Presentation
• Patient presents with inversion injury or forceful eversion injury to the ankle. May have previous
history of ankle injuries or instability.
• Able to partial weight-bear only on the affected side.
• If patient presents with description of cold foot or paraesthesia, suspect neurovascular compromise
of peroneal nerve.
• Tenderness, swelling and bruising can occur on either side of the ankle.

86. • No bony tenderness, deformity or crepitus present.
• Passive inversion or plantar flexion with inversion should replicate symptoms for a lateral ligament
sprain. Passive eversion should replicate symptoms for a medial ligament sprain.
• Special Tests: +ve Anterior Draw, Talar Tilt or Squeeze Test (depending on the structures
involved).

87. Differential Diagnosis
• The Ottawa Ankle Clinical Prediction Rules are an accurate tool to exclude fractures within the
first week after an ankle injury
• Impingement
• Tarsal Tunnel Syndrome
• Sinus Tarsi Syndrome
• Cartilage or osteochondral injuries
• Peroneal Tendinopathy or subluxation
• Posterior Tibial Tendon Dysfunction

88. Classification
There are numerous grading systems used for the
classification of ligament sprains. The traditional grading
system for ligament injuries focuses on a single ligament
• Grade I represents a microscopic injury without
stretching of the ligament on a macroscopic level.
• Grade II has macroscopic stretching, but the ligament
remains intact.
• Grade III is a complete rupture of the ligament.

89. Clinical Examination
• With an ankle sprain multiple structures may be involved, therefore a full foot and ankle
assessment is recommended
• including the mechanism of injury, observation of the patient's gait pattern, standing posture and
wear on the individual's shoes
• Any gross deformity, mal-alignment or atrophy of the musculature should also be observed and
noted as well as any oedema and/or ecchymosis.
• Palpation is used to feel for the structures that may be involved in the injury, including bone,
muscle and ligamentous structures, followed by an active and passive range of movement
assessment.

90. Physical Therapy Management
Mild Ankle Sprain
• Natural full recovery within 14 days
• Taping and follow up to evaluate healing progression
Severe Ankle Sprain
• Inflammatory phase,
• Proliferative phase,
• Early Remodelling,
• Late Maturation and Remodelling

91. Inflammatory Phase (0-3 days)
Reduction of pain and swelling and improve circulation and partial foot support-PRICE (Protection,
Rest, Ice, Compression, and Elevation)
Foot and Ankle ROM

92. Proliferative Phase (4-10 days)
Goals:Recovery of foot and ankle function and improved load carrying capacity.
Patient education
Practise Foot and Ankle Functions
Range of Motion
Active Stability
Motor Coordination
Boyce et al found that the use of an Aircast ankle brace for the treatment of lateral ligament ankle
sprains produces a significant improvement in ankle joint function compared with standard
management with an

93. Early Remodelling (11 -21 days)
Goals: Improve muscle strength, active (functional) stability, foot/ankle motion, mobility (walking, walking stairs,
running).
• information about possible preventive measures (tape or brace)
• Advice regarding appropriate shoes to wear during sport activities
• balance, muscle strength, ankle/foot motion and mobility (walking, stairs, running).
• dynamic stability - focusing on balance and coordination exercises. Gradually progress the loading, from static
to dynamic exercises, from partially loaded to fully loaded exercises and from simple to functional multi-
tasking exercises
• Alternate cycled with non-cycled exercises (abrupt, irregular exercises)
• Advise wearing tape or a brace during physical activities until the patient is able to confidently perform static
and dynamic balance and motor coordination exercises.

94. Late Remodelling and Maturation
Goals: Improve the regional load-carrying capacity, walking skills and improve the skills needed
during activities of daily living as well as work and sports.
Practise and adjust foot abilities (functions and activities)
Practise motor coordination skills while performing mobility exercises
Continue to progress the load-bearing capacity untill the pre-injury load-carrying capacity is reached
Encourage the patient to continue practicing at home

95. JOURNAL NAME Journal of Taibah University Medical Sciences
TITLE
AUTHOR
Effects of the standard physiotherapy programme on pain and isokinetic ankle
strength in individuals with grade I ankle sprain (2018)
M Salim et.al
METHODOLOGY Seven patients with acute grade 1 ankle sprain were recruited. provided with 7
days of protection, optimal loading, ice, compression, and elevation (POLICE)
treatment, and the standard physiotherapy programme consisted of towel
stretching and balancing exercises on one leg. pain and isokinetic ankle
strengths of the patient's injured and uninjured legs were compared before and
after the physiotherapy programme.
OUTCOME MEASURES 10-point Visual Analogue Scale (VAS).
Ankle strength using an isokinetic dynamometer
CONCLUSION Performing the standard physiotherapy programme for 1 week reduces pain and
improves the ankle E:I in patients with grade 1 ankle sprain.

96. JOURNAL NAME Research squre
TITLE
AUTHOR
Improvement of Mobility, Strength, Stability and Pain in Soccer Players with
Recurrent Ankle Sprains Through Myofascial Release, Strength Exercises and
Taping: A Randomized Controlled Trial.
Allois R et.al
METHODOLOGY over 4 weeks, 36 recreationally active male football players randomly allocated
to experimental group and control group. outcomes were assessed. The within-
subject effect and group interaction were obtained by means of a repeated
measures ANOVA.
OUTCOME MEASURES range of motion, strength, stability and perceived pain in the ankle joint.
CONCLUSION The combination of fascial therapy and eccentric strength training with an
isoinertial device improves ankle mobility, strength and stability in footballers
with recurrent ankle sprains. The use of taping techniques failed to provide a
greater improvement of the study variables when combined with manual
therapy and strength techniques.

97. INJURIES TO MUSCLE
STRAIN/TEAR
• An ankle strain is an injury that occurs when ankle muscles and/or their connecting tendons are
either stretched beyond their normal limits or torn outright.
• Strains may be acute or chronic.
• The muscular injury often occurs at the point where the muscle connects to a tendon, and may be a
side effect of or coexist with ankle tendonitis
• Less common than ankle sprains, ankle strains often occur due to chronic overuse of the ankle.
• This type of injury can occur due to activities such as running long distances, repeated hard
landings from jumping (such as in basketball layups or volleyball sets), or repeated hard
articulations of the ankle, such as going up on tiptoe in ballet or gymnastics.

98. Classification
• Grade I (mild) strains affect only a limited number of fibers in the muscle. There is no decrease in
strength and there is a fully active and passive range of motion. Pain and tenderness are often
delayed to the next day.
• Grade II (moderate) strains have nearly half of muscle fibers torn. Acute and significant pain is
accompanied by swelling and a minor decrease in muscle strength.
• Grade III (severe) strains represent the complete rupture of the muscle. This means either the
tendon is separated from the muscle belly or the muscle belly is actually torn in 2 parts. Severe
swelling and pain and a complete loss of function are characteristic of this type of strain.

99. Signs and Symptoms
• Swelling, bruising, or redness due to the injury
• Pain at rest
• Muscle spasms, cramps, and muscle weakness in the ankle
• Limited range of motion
Risk Factors
• Poor athletic conditioning
• Muscle and ligament fatigue
• Not warming up before activity
• Carrying excess weight.
• Inappropriate footwear
• Prior history of sprains or strains

100. Diagnosis
• Inspect the affected ankle visually
• Palpate the injury site
• Diagnostic testing, such as X-ray or magnetic resonance imaging (MRI)
Treatment
• For Grade 1 and Grade 2 strains- RICE
• NSAIDs and acetaminophen
• Grade 3 sprains and strains are usually unstable and require longer healing
• Casting
• Rehabilitation: Patients may need to undergo a series of rehabilitation treatments, such as electrical stimulation and
ultrasound, as well as strengthening exercises to help decrease pain
• Surgery. In severe and/or chronic strains that do not respond to first-line treatment or rehabilitation, one or more
types of surgery may be required

101. Muscle Contusion (Bruise)
• Athletes in contact sports have many opportunities to get a muscle contusion (bruise).
• Contusions are second only to strains as a leading cause of sports injuries
• Most contusions are minor and heal quickly, without taking the athlete away from the game.
• Severe contusions, however, can cause deep tissue damage and lead to complications that may
prevent an athlete from being able to play sports for months.

102. Cause
• Contusions occur when a direct blow or repeated blows by a blunt object strike part of the body,
crushing underlying muscle fibers and connective tissue without breaking the skin.
• A contusion can result from falling or jamming the body against a hard surface.
Symptoms
• hematoma
• If tissue damage is extensive, one may also have a broken bone, dislocated joint, sprain, torn
muscle, or other injuries.
Treatment
• To control pain, bleeding, and inflammation, keep the muscle in a gentle stretch position and use
the RICE protocol
Complications
• Compartment Syndrome
• Myositis Ossificans

103. MUSCLE CRAMPS
• Foot cramps are a type of muscle cramp that occurs most often either in the arch of the foot, near
the toes, or on the upper part of the foot
• These spasms can occur during daily activities or wake a person in the middle of the night.
• Like other muscle cramps, foot cramps can cause mild-to-intense pain until the muscle relaxes and
the cramping ends.
• A gentle massage or stretching exercises can often help the muscle return to a relaxed state.
Causes
• Low potassium
• Overexercising
• Dehydration
• Overly tight shoes
• Nerve damage

104. Treatment
light stretching and gentle massages.
If overexercising is the cause of foot cramps, a person can reduce the amount of time that they spend
exercising or decrease the intensity of the exercise.
Prevention
exercising within a comfortable limit and wearing suitable sports shoes
eating a diet rich in vital nutrients, including potassium
drinking plenty of fluids to stay hydrated
wearing well-fitted shoes
changing any medication that is causing muscle cramps, under a doctor’s instructions

105. Compartment Syndrome of the Foot
• Compartment syndrome is a condition where bleeding or edema develops in an area of the body
which is surrounded by non-expandable structures of bone and fascia, increasing the local pressure
and causing circulatory disturbance in that space.
• Athletes who participate in activities with repetitive motions, such as running, biking, or
swimming, are more likely to develop chronic compartment syndrome.
Etiology
• Incidence of compartment syndrome of the foot is low
• The calcaneal compartment seems to be at higher risk for developing compartment syndrome,
whereas the interosseous compartments are usually at a lower risk

106. • Chronic (exertional) compartment syndrome can develop through over exertion
during sporting activity.
• The muscles become fatigued and irritated resulting in an inflammatory response and
swelling.
• Sports like football, motorcross, running, tennis and gymnastics can be risk factors
Characteristics
• Pain is one of the key symptoms for compartment syndrome
• Pain with passive stretching
• Pain during active dorsiflexion of the ankle
• Increased soreness caused by moving the toes
• Pain on palpation or compressing the affected compartments
• Swelling and tightness
• Pale skin in the area of tissue damage
• Sensory deficits caused by neurological injury
• Firmness of the involved compartments
• Muscle weakness of the intrinsic foot muscles
• 5P’s- Pain, Pallor, Paresthesia, Paralysis, Pulselessness

107. Medical Management
• fasciotomy in order to remove the excess pressure
• Complications: chronic pain and hypersensitivity are possible complications and can be difficult to
manage. Sometimes claw toes develops
Physiotherapy Management
• Non-operative treatment is generally not successful
• Post-operatively, patients are advised to use ice and anti-inflammatory medication to reduce
swelling and to rest.
• An exercise programme is given to improve muscle weakness and to stimulate proprioceptive
sensors.
• Soft tissue massage-to provide lymphatic drainage.
• Passive mobilisation of the ankle joint, the metatarsals and phalanges-for increased range of
motion and mobility of joints
• lower limb stretches.
• strenghthening exercises

108. JOURNAL NAME American journal of case reports
TITLE
AUTHOR
Acute Exertional Compartment Syndrome with Rhabdomyolysis: Case Report and
Review of Literature (2018)
Brandon McKinney et.al
METHODOLOGY Presented the case of a previously healthy, high-level athlete who presented with
the acute onset of unilateral anterior leg pain and foot drop the day after a
strenuous workout. He was diagnosed with compartment syndrome and
rhabdomyolysis. His management included emergent fluid resuscitation,
fasciotomies, debridement of necrotic muscle from his anterior compartment, and
delayed primary closure. After six months of intensive outpatient physical therapy,
including the use of blood flow restriction treatments, the patient returned to
sports.
OUTCOME MEASURES VAS- pain assessment
CONCLUSION Early diagnosis and proper treatment can resolve Acute Exertional Compartment
Syndrome and reduce the pain .

109. JOURNAL NAME JCAM
TITLE
AUTHOR
ASTYM versus massage in the treatment of chronic exertional anterior
compartment syndrome of the lower leg: a randomized controlled trial (2018)
IM Ragab et.al
METHODOLOGY The purpose of this study was to compare the effects of Astym therapy and
massage in patients with chronic exertional anterior compartment syndrome of
the lower leg.
OUTCOME MEASURES Visual analog scale (VAS),
CONCLUSION ASTYM treatment is more effective than massage therapy in reducing pain,
improving overall functional level for patients with ant-CECS.

110. INJURIES TO TENDON
Tendon Tear
• A foot tendon tear happens when one of the tendons in the foot is damaged from sudden injury or
overuse
• Posterior tibial tendon: The posterior (rear) tibial tendon attaches the calf muscle to the bones of
the inside of the foot. It holds up the arch of the foot and supports the foot during walking. A tear to
this tendon is usually from a fall. But it can also be injured from overuse. This is most common in
athletes who put a lot of stress on the ankle during sports like basketball or soccer. The anterior
tibial tendon runs from the shin to the top of the foot. Injuries to this tendon are much less common
than to the posterior tibial tendon.

111. • Peroneal tendons: Tears in these tendons are usually caused by an ankle sprain or a blow to the
ankle. It can also be caused by overuse, usually in athletes who repeat movements that put stress on
the ankle.
• Achilles tendon: It is the largest tendon in the body. It can tear if sudden high stress is put on it,
especially if the calf muscle is stiff or weak and can’t take its share of the stress.

112. Symptoms
• Pain
• Swelling, redness, and warmth
• Weakness or loss of function
Causes
• fall on the foot or sudden pressure on the tendon
• repetitive use of the foot and ankle in ways that put stress on the tendon-This is more likely to
happen to athletes who put repetitive stress on their ankles
• people with high arches have a higher risk of foot tendon tears.

113. Diagnosis
• examination of the foot
• X-ray to check for broken bones and look for other damage
• MRI or CT scan

114. Treatment
• Rest
• Ice
• NSAID
• Brace or cast
• Orthotics

115. Paratenonitis
• Paratenonitis has sometimes also been referred to as ‘peritendinitis’ or ‘paratendonitis’
• commonly found in athletes as a result of overuse injury
• Paratenonitis can develop as a result of overuse or repetitive microtrauma
• Paratenonitis affects tendons with a paratenon and thus without a synovial sheath e.g. Achilles
tendon, patella tendon gluteal tendons, etc. The most common location of paratenonitis is the
Achilles tendon.
RISK FACTORS
• dancers
• long-distance runners

116. Clinical Features
Local pain and swelling, tenderness on palpation along the anatomic course of the tendon and in
chronic stages movement restriction
Complications
Chronic paratenonitis can further progress into tendinopathy and tendon tears

117. Radiographic Features
Ultrasound: On ultrasound, paratenonitis might appear as a linear hypoechoic lining around the
tendon with associated hyperaemia on colour Doppler in chronic inflammation
MRI: In the acute phase, a linear fluid-intense structure can be seen around the tendon. In the chronic
phase soft tissue, scar-like structures can be seen extending into the peritendinous fatty tissue
Differential diagnosis
• tendinopathy
• tendon tear
• tendon rupture

118. Treatment and prognosis
Treatment is usually conservative with nonsteroidal anti-inflammatory drugs, activity modification,
physical therapy .
Conservative Management
Achilles tendon overuse injuries are initially managed with rest, ice, activity modification, and
symptomatic analgesia.
Eccentric Stretching: To counteract the failed healing response to repetitive subfailure loading,
eccentric stretching has been proposed to facilitate collagen fiber cross-linking and promote tendon
remodeling.

119. Physical Therapy
As soon as possible after the initial injury, physical therapy should be started. The therapist should
initially concentrate on isometric strengthening and eventually progress to range of motion exercises
for the ankle and concentric triceps surae strengthening.

120. Tenosynovitis
Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon (the cord that joins
muscle to bone).
Causes
The synovium is a lining of the protective sheath that covers tendons. Tenosynovitis is inflammation
of this sheath. The cause of the inflammation may be unknown, or it may result from:
Diseases that cause inflammation, Infection, Injury, Overuse and Strain.

121. The wrists, hands, ankles, and feet are commonly affected because the tendons are long across those
joints. But, the condition may occur with any tendon sheath.
Symptoms
Difficulty moving the joint
Joint swelling in the affected area
Pain and tenderness around the joint
Pain when moving the joint
Redness along the length of the tendon
Treatment
Using a splint or removable brace to help keep the tendons from moving to aid healing.
Applying heat or cold to the affected area to help reduce pain and inflammation.
Medicines such as nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injection to
relieve pain and reduce inflammation.
In rare cases, surgery to remove the inflammation around the tendon.

122. Physiotherapy Management
Ice/Heat Packs - Heat can help relax and loosen tight musculature, and ice can be used to help relieve
inflammation of the extensor sheath.
Massage - Deep tissue massage at the thenar eminence can help relax tight musculature that causes
pain. (See video). Graston Technique of manual soft tissue mobilization along with the eccentric
exercise is also helpful. Graston technique includes breaking down fascia restriction, stretching
connective tissue, and promoting a better healing environment.
Stretching - Stretching the thenar eminence muscles into thumb extension and abduction can relax and
lengthen this tight musculature that causes pain.

123. Strengthening exercise to increase strength
Mobilization
Therapeutic Ultrasound has also better outcomes in pain reduction and healing
splinting
Corticosteroid injections

124. Tendinosis
Tendinosis is a chronic tendon injury. It is a common condition but is often misdiagnosed as
tendinitis.
Common in running athletes, young dancers, ice skaters and sports requiring frequent change of
direction or jumping such as
Characteristics
Pain and, occasionally, swelling and warmth in the posterolateral aspect of the ankle along the
course of the peroneal tendons.

125. Patients may relate exacerbation with rising onto the ball of the foot, running (lateral running, figure-8
running), cutting, jogging, or walking on uneven surfaces or following these activities or following a
rest period, especially upon waking in the morning.

126. Outcome Measures
LEFS (Lower Extremity Functional scale)
FAAM (The Foot and Ankle Ability Measure)
Medical Management
The primary aim of treatment is to afford pain relief, restore mechanics and return the patient to their desired level
of active participation
Physiotherapy Management
stretching, strengthening, mobilisation and manipulation, proprioceptive and balancing exercises, icing, ankle
bracing or taping during contact sports If symptoms are severe, a cast or ROM boot immobilisation is prescribed
for 10 days. After symptoms resolve, the patient begins a progressive rehabilitation programme along with a
gradual increase to full activity.

127. The use of a biomechanical ankle platform (BAPS), deep tissue friction massage, ultrasound electric
stimulation can also be included in the physical therapy

128. JOURNAL NAME Journal of Orthopaedic & Sports Physical Therapy
TITLE
AUTHOR
Resistance Exercises in Early Functional Rehabilitation for Achilles Tendon
Ruptures Are Poorly Described: A Literature Review (2020)
Agres AN et.al
METHODOLOGY To describe which resistance exercises are used in the first 8 weeks of treatment
for acute Achilles tendon rupture and assess the completeness of reporting of
the exercise descriptions. Randomized controlled trials, cohort studies, and case
series (10 or more participants) that reported using resistance exercise in the
immobilization period in the first 8 weeks of treatment for acute Achilles
tendon rupture were included.
OUTCOME MEASURES Short-term functional assessment of gait
CONCLUSION A variety of resistance exercises targeted at the ankle plantar flexors were used
as part of early functional rehabilitation after Achilles tendon rupture. However,
most studies provided inadequate description of resistance exercise
interventions.

129. JOURNAL NAME Orthopaedic Journal of Sports Medicine
TITLE
AUTHOR
Does Early Functional Mobilization Affect Long-Term Outcomes After an
Achilles Tendon Rupture? A Randomized Clinical Trial (2020)
Susanna A et.al
METHODOLOGY A total of 135 patients who underwent ATR repair, randomized to either EFM,
including immediate postoperative loading and ankle motion, or standard
treatment, were evaluated with functional tests and 5 self-administered outcome
questionnaires at 6 and 12 months postoperatively.
OUTCOME MEASURES Achilles tendon Total Rupture Score [ATRS] , Foot and Ankle Outcome Score
[FAOS], The RAND-36 subscale of general health
CONCLUSION This study demonstrated that an accelerated postoperative protocol with
immediate loading and ankle motion resulted in better general health and
vitality at 6 months. However, there were no differences between the groups in
the recovery of heel-rise function.

130. INJURIES TO BURSA
BURSITIS
Bursitis is the inflammation of a bursa, a small fluid filled sac that sits between muscles, tendons and bones to
reduce friction.
Clinically Relevant Anatomy
A Bursa appears at a junction of a tendon on the bone. A bursa is filled with a thin layer of synovial fluid. It protects
and brakes the shocks of the joint. The structures nearby the bursa can move with minimal friction due to irritation.
They have different measures and are mostly flattened.

131. Mechanism of Injury
• Overuse of the joint: for example vacuuming for hours on end
• Repetitive strain: for example picking up and lifting heavy loads
• Trauma
• Pressure
• Bacterial infection: from an unattended wound (this is called septic bursitis)
• Other inflammatory diseases: Gout for instance the gout crystals can form in the bursa and cause the
inflammation.
Etiology
• Mainly by constant friction, thumping or pressure
• The inflammation of the bursa frequently appears in combination with tendinitis
• By an overuse injury or a trauma, especially when pulling and pushing heavy items
• After a forced period of rest
• There also can be an underlying rheumatic condition
• Diabetes, osteoarthritis and disability of the thyroid gland can be associated with bursitis

132. Clinical Presentation
There will likely be pain and discomfort over the affected area, and there will often be visible and/or palpable swelling.
Diagnosis
In most cases, bursitis can be diagnosed by physically examining the patient.
Inspection
• Redness and warmth can be signs of bursitis, but these symptoms are harder to spot when treating a Bursa that is not
located superficially under the skin.
• Local tenderness or stiffness.
• Swelling can occur when inflammation gets worse.
X-ray
• Can rule out arthritis and bone deformities
• Can sometimes confirm the presence of following substances inside the bursa (By which it become visible in X-ray)
• Gout crystals
• Calcifications: When the condition is chronic or recurrent.
Bursa Fluid Punction: Can rule out infections.

133. Management
Bursitis Due to Movement/Activity (Without Infection)
• Rest the affected joint/ bursa
• Ice packages
• NSAID’s ( non steroid anti inflammatory drugs)
• Injections with steroid agents
• When improvement is noticeable, a gradual increase in exercise and activities is recommended.
Note: Resting the affected joint does not mean immobilizing it, this could hold a risk towards adhesive capsulitis.

134. Bursitis Due to Infection ( Septic Bursitis)
Antibiotics
• Aspiration of the infected bursa fluid with the use of a sterile needle should be repeated
approximately every 3 days
• Never inject with steroids.
• When the measures mentioned above are inadequate surgical interventions may be
necessary in case of the following factors:
• Surgical removal of the bursa is recommended in case of tuberculous bursitis
• Surgical incision and drainage are recommended in case of :
• Failure of adequately aspirating by needle
• Bursa site inaccessible to multiple needle aspirations
• Forming of abscess or necrosis

135. JOURNAL NAME International Journal of Physical Education, Sports and Health
TITLE
AUTHOR
Effectiveness of shockwave therapy along with contrast bath and static Achilles
stretch in patients with retrocalcaneal bursitis (2019)
S Chahar et.al
METHODOLOGY 30 patients having retrocalcaneal bursitis (female, male) fulfilling the inclusion
and exclusion criteria were recruited and were randomly allocated in two
groups. Group A subjects were given with contrast bath & Achilles stretch
exercises and group B subjects were given ESWT along with contrast bath &
Achilles stretch exercises.
OUTCOME MEASURES Pain- VAS , AROM of ankle dorsiflexion (DF) & plantarflexion (PF), Roles
and Maudsley’s (RM) score for functional ability.
CONCLUSION Study proves that extracorporeal shockwave therapy has an additional effect in
the management of retrocalcaneal bursitis.

136. JOURNAL NAME SVOA Orthopedics
TITLE
AUTHOR
Effect of 4 Sessions of Low-Level LASER Therapy on Pain in Acute and
Chronic Ankle and Foot Conditions (2022)
S Kondal et.al
METHODOLOGY Common acute and/or chronic ankle and foot conditions including Achilles
tendinitis, Plantar fasciitis, Retrocalcaneal bursitis, Calcaneal spurs, pes
planus/cavus, chronic ankle sprains were included in the study. Pain score was
recorded
OUTCOME MEASURES NPRS
CONCLUSION LASER can be used in common ankle and foot conditions to reduce pain and
improve tissue healing.

137. References
• Clinical sports medicine : Peter Brunker and Karim Khan, third edition
• Textbook of sports medicine : basic sciences and clinical aspects of sports injury and physical activity,
Michael kjaer, Michael Krogsgaard
• BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE
• Essential orthopedics: Maheshwari and Mhaskar 5th edition
• Joshi and Kotwals essentials of orthopedics and applied physiotherapy, 4th edition
• A meta-analysis by Doherty et al-Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C.
(2014). The incidence and prevalence of ankle sprain injury: A systematic review and meta-analysis
• Recurrence rates amongst basketball players is reported to be greater than 70%-Yeung, M. S., Chan, K. M.,
So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. British journal of sports
medicine, 28(2), 112-116.

138. • Clinically relevent anatomy-Malleolar fractures: nonoperative versus operative treatment. A controlled study.
Bauer M, Bergström B, Hemborg A, Sandegård J. Clin Orthop Relat Res. 1985 Oct; (199):17-27.
• A previous sprain may compromise the strength and integrity of the stabilisers and interrupt sensory nerve
fibres- Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive factors for lateral ankle sprains: a
literature review. Journal of athletic training, 37(4), 376
• Mechanism of injury-Hubbard, T. J., & Hicks-Little, C. A. (2008). Ankle ligament healing after an acute ankle
sprain: an evidence-based approach. Journal of athletic training, 43(5), 523.
• Reports has proposed that-Wright, I. C., Neptune, R. R., van den Bogert, A. J., & Nigg, B. M. (2000). The
influence of foot positioning on ankle sprains. Journal of biomechanics, 33(5), 513-519
• Van der Wees PJ, Lenssen AF, Feijts YAEJ, Bloo H, van Moorsel SR, Ouderland R, et al. KNGF-Guideline
for Physical Therapy in patients with acute ankle sprain. Dutch J Phys Ther. 2006