The document discusses various topics related to ankle rehabilitation including: - Special tests used to determine the extent of ankle injuries like the anterior drawer test. - Common ankle pathologies like ankle instability, which can be mechanical or functional. - Treatments for ankle injuries including RICE, bracing, and rehabilitation exercises. - Specific injuries are described like inversion ankle sprains, eversion sprains, and syndesmotic ankle sprains. - Other conditions addressed include posterior ankle impingement and ankle arthritis.

1. MUSKAN RASTOGI

2. • BASIC ANATOMY
• SPECIAL TESTS
• PATHOLOGIES
• ANKLE
REHABILITATION
CONTENT
S

5.  Use to determine the extent of injury
into the anterior talofibular ligament
primarily and to the other lateral
ligaments secondarily.
 The patient sits on the edge of a
treatment table with the ankle at a 90-
degree angle.
 The therapist grasps the lower tibia in
one hand and the calcaneus in the
palm of other hand.
 The tibia is then pushed backward as
the calcaneus is pulled forward.
 A positive anterior drawer sign occurs
when the foot slides forward,
sometimes making a clunking sound as
it reaches its end point and generally
indicates a tear in the anterior
talofibular ligament. Sn. 0.58/Sp. 1.0/+LR 4.0/-LR 0.57

6.  Used to determine the extent of
inversion or eversion injuries.
 Foot is positioned at 90-degrees to
the lower leg and stabilized, the
calcaneus is inverted.
 Excessive motion of the talus
indicates injury to the
calcaneofibular and possibly the
anterior and posterior talofibular
ligaments.
 The deltoid ligament can be tested in
the same manner except that the
calcaneus is everted. Sn. 0.5/Sp. 0.88/+LR infinity/-LR 0.42

7.  Used primarily to determine injury to
the structures that support the distal
ankle syndesmosis, including the
anterior tibiofibular ligament, the
posterior tibiofibular ligament and the
interosseous membrane.
 The patient should be seated with the
knee flexed and the legs over the end
of the table.
 The athletic trainer uses one hand to
stabilize the lower leg and the other to
hold the medial aspect of the foot and
rotate it externally.
 External rotation of the talus applies
pressure to the lateral malleolus,
causing a widening of tibiofibular joint.
 Pain in the anterolateral ankle may
indicate injury to the syndesmosis,
whereas pain over the deltoid ligament
indicate sprain of that structure.
Sn. 0.20/Sp. 0.85/+LR 1.31/-LR 0.94

8.  Used to determine if there is a sprain
to the distal tibiofibular
syndesmosis.
 The patient is seated with the ankle
in neutral.
 The clinician cups the calcaneus and
talus and with the lower leg
stabilized, attempts to translate the
talus laterally.
 The test is positive if pain is
increased and there is excessive
lateral translation compared to the
opposite side.
Sn. 0.25/Sp. NA/+LR 6.30/ -LR 0.28

9.  Is done to determine the presence of
excessive medial translation of the
calcaneus on the talus in the
transverse plane.
 The athletic trainer uses one hand to
hold the talus in subtalar neutral,
then glides the calcaneus in a medial
direction on the fixed talus.
 In a positive test, there is excessive
movement, indicating injury to the
lateral ligaments. Sn. 0.58/ Sp. 0.88/ +LR 4.67/-LR 0.48

10.  Not to be done when patient is unable to bear weight.
 WALK ON TOES- TESTS PLANTAR FLEXION
 WALK ON HEELS- TESTS DORSIFLEXION
 WALK ON LATERAL BORDER OF FEET- TESTS INVERSION
 WALK ON MEDIAL BORDER OF FEET – TESTS EVERSION
 HOP ON INJURED ANKLE- tests functional deficits

11.  OTTAWA ANKLE RULES- to determine the need of radiographs after acute ankle
injury secondary to the risk of fracture.

13.  Seen in 20% who have had repeated ankle sprains.
 Footballer/Soccer players with previous injuries seen commonly.
 Two types instability are seen
1. Mechanical instability
2. Functional instability
 Mechanical instability is essentially laxity that physically allows for movement
beyond the physiologic limit of the ankle’s ROM.
 Functional instability has been attributed to proprioceptive and/or neuromuscular
deficits that negatively impact postural control and thus stability and balance.
 TREATMENT
1. Joint mobilization using posterior talar glides to improve postural control.
2. Functional Rehabilitation using proprioceptive and muscle exercises. e.g., tilt-
board training.
3. Use of ankle brace or tape to provide external stabilization.
4. Balance training

14.  MECHANISM OF INJURY
1. Most common mechanism of injury is an inward movement of the sole of the foot(inversion) and
the front of the foot moving towards the center line of body(adduction).[ Inversion+ plantar
flexion+ adduction=supination]. Depending on the force and degree of supination, different
injuries can occur-
• Tearing of anterior talofibular ligament
• Fracture of fibula on a level with the joint line
• Fracture of the medial and lateral malleolus
• Dislocation of talus

15.  TREATMENT
POLICE principle is used as soon as possible to control hemorrhage and swelling.
Once swelling is reduced, a walking cast or brace may be applied.
Immobilization usually lasts for 7 to 9 weeks.
2. Another mechanism is an outward turning movement of the sole of the foot(eversion) and
the front of the foot away from the center line of the body (abduction).A combination of eversion,
dorsiflexion and abduction =pronation. Depending on force of pronation, these injuries can
occur-
• Tearing of deltoid ligament or fracture of medial malleolus
• Tearing of syndesmosis
• Fracture of fibula above the level of ankle joint
• Dislocation of talus

16.  INVERSION ANKLE SPRAIN
• Reported in 90% of ankle injuries.
• injury to the lateral ligaments.
• Anterior talofibular ligament is mainly affected.
• Inversion can cause both an avulsion to lateral malleolus and fracture to medial
malleolus- Pott's fracture.
• Females are at higher risk for injuries.
• It’s a number one predictor of recurrent ankle injury.
• They are divided into 3 grades- Grade 1 ligament sprain, Grade 2 ligament sprain
and Grade 3 ligament sprain.

17.  EVERSION ANKLE SPRAIN
 ETIOLOGY-5 to 10% of all ankle sprains
deltoid ligament is affected
 Is less common than the inversion ankle sprain, largely because of the bony and
ligamentous anatomy.
 More severe than inversion sprains and take longer to heal.
 Complains of severe pain over the foot and lower leg.
 Patient is unable to bear weight on foot.
 Both abduction and adduction causes pain.
MANAGEMENT
 POLICE and no weight bearing is recommended.
 NSAIDS given orally or topically.
 Focus on posteromedial muscle and balance activities.
 Inner heel wedge shoe insert.

18.  SYNDESMOTIC ANKLE SPRAIN/HIGH ANKLE SPRAIN
ETIOLOGY- isolated injuries to the distal talofibular joint
 Syndesmotic ligaments i.e. anterior and posterior talofibular ligaments are torn with
increased external rotation or forced dorsiflexion and are often injured in conjunction
with a severe sprain of medial and lateral ligament complexes.
SYMPTOMS AND SIGNS
 Severe and prolonged pain
 Loss of function in the ankle above the talocrural joint.
 Heterotopic ossification
 Pain in lower leg when ankle is passively externally rotated or dorsiflexed.
MANAGEMENT
 Hard to treat and take months to heal.
 Long periods of immobilization
 Surgical fixation

19.  Posterior impingement syndrome is most common in ballet dancers. It occurs with weight bearing
with the foot in plantar flexion. It is usually, but not always, associated with an os trigonum, a small
accessory (extra) bone found just posterior; however, an os trigonum can be present without causing
pain. The bone can exist in 3–14% of normal feet.
 Impingement may also be caused by a fracture of the posterior process of the talus.
 This injury is caused either by micro-trauma of repeated hyperplantar flexions, as with dancers, or
of an episode of acute powerful hyperplantar flexion, as in soccer players. The dancers’ repetitive
activities in pointe and semipointe causes enormous stress to this area.
Symptoms and diagnosis
 Tenderness is felt behind the lateral malleolus of the ankle.
 Pain is felt behind the lateral malleolus of the ankle when the toes are pointing downwards,
especially with weight bearing.
 An X-ray will usually show an accessory bone fragment (os trigonum) just posterior of the talus .
Because the majority of these bone fragments are asymptomatic, its presence does not mean that it
is the cause of the problem.
 Diagnosis is confirmed if injecting local anesthetics into the area temporarily relieves pain.

20. Treatment
The athlete should:
• Modify activities to avoid plantar flexion.
• Begin physical therapy to strengthen ankle muscles for better
support.
 The physician may:
• Prescribe anti-inflammatory medication.
• In refractory cases, inject corticosteroid medication into the area
to reduce inflammation.
• In cases that do not respond to the above, operate to remove the
bone fragment and soft tissue. This disorder only rarely needs
surgery. This can be performed with an endoscopic technique using
an arthroscope. Return to sport is possible after 6-8 weeks.

21.  The incidence of ankle arthrosis is low compared with that of arthrosis of the hip and knee
joints. It is most commonly present after fractures about the ankle, especially when a
fracture heals in a non-anatomic position .
 Other predisposing factors include stage 3 and stage 4 osteochondral lesions of the tibia or
the talar dome. Long-standing ligament instability with chondral damage over a long time
may cause osteoarthritis.
 Treatment is symptomatic and includes unloading of the joint surfaces and reducing the
reactive inflammation with nonsteroidal anti-inflammatory drugs. When ‘catching’ and
‘locking’ sensations are present, arthroscopic debridement and removal of loose bodies or
osteophytes may be necessary.
 Ankle arthrodesis is an option if conservative measures fail. The functional disability after
an ankle arthrodesis can frequently be well compensated for, especially in a young patient.
Today, ankle replacement has been developed and could be an option in older patients.

22.  Each arch of foot contributes to balance, movement, support and shock absorption.
 Any of the arches of foot can suffer supportive ligament sprains.
 Once the ligaments are stretched, they fail to hold the bones of foot in position.
 When an arch is weekend, it cannot absorb shock as well as it normally would.
 Causes include overuse, overweight, fatigue, training on hard surfaces and
wearing shoes that are non-supportive or in poor condition.
 Includes cold ,compression and elevation.

23.  Pain in proximal arch and heel.
 Due to heel spurs, plantar fascia irritation and bursitis.
 Occurs in people with pes cavus.
 Pain in anterior medial heel. Then this pain moves to central portion of plantar fascia. It's increased
when patient bears weight during running, walking or standing
 Symptoms can last as long as 8 to 12 weeks.
 Soft orthotic works best ad should be worn all times.
 Use heel cup compresses the fat pad under the calcaneus providing a cushion under the area of
irritation.
 Taping
 Achilles' tendon stretching and in exercises that stretch plantar fascia in arch.

24.  Can occur in the superior medial articular surface of the talar dome.
 One or several fragments of articular cartilage and its underlying subchondral
bone are either partially detached or completely detached and moving within joint
space
 Due to repeated episodes of ankle sprains.
 SYMPTOMS/SIGNS
 The patient may complain of pain and effusion with signs of progressing atrophy.
 Complaints of catching, locking or giving way particularly if fragment is detached.

25.  Most common in sports
 Occur after ankle sprains or sudden dorsiflexion of ankle.
 S/S
May be mild or severe.
Most severe injury is partial or complete avulsion or rupturing of Achilles tendon.
Patient feels acute pain.
Extreme weakness on plantar flexion.
 MANAGEMENT

26.  Includes tendinitis, tenosynovitis and tendinosis
 Achilles' tendinitis- inflammation of tendon
 Achilles’ tenosynovitis- inflammation of tendon sheath
 Achilles’ tendonitis-cause scarring and fibrosis that can restrict the Achilles
tendon’s motion within tendon sheath
 Symptoms
Generalized pain and stiffness about Achilles tendon
Uphill walking or hill workouts usually aggravates the condition.
Reduced gastrocnemius and soleus muscle flexibility in general that may worsen
as condition progresses

27.  Occur within the tendon substance itself.
 Approximately one to two inches proximal to insertion of tendon into calcaneus.
 Causes of rupture include poor conditioning and overexertion.
 Ruptures usually occur when a sudden, eccentric force is applied to dorsiflexed foot.
 Ruptures of Achilles tendon must be surgically repaired.
 Rehabilitation may take up to the year before the athlete is ready to return.
 Test- Thompson test