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Physical therapy for ankle complaints.
When you sprain your ankle, you often tear or strain one or more ankle ligaments. In the Netherlands, most ankle injuries occur on the soccer field. This happens with or without an opponent nearby. With an ankle ligament tear, usually the talofibular ligament is affected first. This is the ankle ligament that sits most forward anatomically. This is where the first strain occurs during a sprain. Depending on the severity of the injury, the other ankle ligaments will also be injured. In 5-20% of all cases that arrive at the emergency room with ankle injuries, we speak of a bone fracture. Should an ankle fracture be suspected during the first physical therapy appointment, we use the Ottawa ankle rules. This is a means of assessing whether there is a reason to request an x-ray. Further injury that can occur as a result of inversion trauma is injury to the syndesmosis. This is a structure of fibers that runs from the tibia to the fibula. This syndesmosis is very important in the stability of the ankle joint. In theory, the syndesmosis holds the tibia and fibula together. In approximately 11-18% of all inversion traumas, there is injury to the syndesmosis. When there is injury to the syndesmosis, recovery takes significantly longer. In general, the duration of recovery depends on several factors. When no other structures are affected, the greatest decrease in pain occurs within the first 2 weeks. A small group keeps complaints for a longer period of time. Often these are complaints of instability, meaning the feeling when you sink through your ankle. The chance of ankle injury is greater when you have had a previous injury to your ankle. A good rehabilitation after ankle injury is crucial and will help to prevent a new injury.
Anatomy and function of the ankle joint
A joint is a place in the body where several bone parts come together. In the ankle, this is the tibia(femur) with the fibula(calf bone)and talus(ankle bone). We also call this joint the upper ankle joint. Between these bone parts is cartilage which has a very smooth surface so it can move smoothly. To control the ankle joint properly, there are different types of ligaments in and around the ankle. On the inside and outside are ligaments that provide passive stability. Tires, bones, capsules and the position of joints provide passive stability you have no control over. Active stability is controlled by muscles and tendons. So you do have control over this. Active and passive stability together determine how strong a joint is.
Diagnosis of ankle injury
Most cases involve damage to the anterior ankle ligament the talofibular ligament anterius
- The other ankle ligaments calcaneofibulare ligament and posterior talofibulare are affected with a more severe ankle injury
- Some cases also involve damage to the syndesmosis, which is a structure that connects the fibula to the tibia
A distinction is made between mild, moderate and severe ankle ligament injuries when there is no fracture.
Grade 1 is only a strain. The ankle is usually tender for a few days but often recovers without problems within 1 to 2 weeks at most.
Grade 2 here there is a partial rupture of the ankle ligaments. This is characterized in particular by considerable swelling and blue discoloration within a few days.
Grade 3: This involves a complete tear of one or more ligaments. The risk or further injury in the ankle is greatest here. Consider a fracture of one of the bone parts or damage to the syndesmosis. Often significant swelling and blue discoloration within a day. Walking will also be difficult or even impossible here.
Immediately after the injury, it is often not possible to make a statement about the severity. Within 3-5 days we can already make a better statement about this. The reason is the swelling and topicality. Because of the pain, many tests are not reliable. If there is pressure pain on the outside of the ankle along with an enlarged drawer(read on) then for 90% there is a chance that it is damage to the ankle ligament(s).
Physical tests for ankle injuries
There are a number of tests described to understand possible ankle ligament damage:
The front drawer is a test to test the slack of the ankle ligaments. The person lies supine on the treatment couch. The foot and ankle come outside the treatment couch. The examiner includes the person's heel and with the other hand the tibia is fixed about 10cm above the joint. The foot is allowed to point forward 10-15 degrees for maximum relaxed position of the joint. After this, the examiner pulls the foot forward in relation to the tibia. The test is positive when the foot can move more than 1cm forward relative to the unaffected side.
Squeeze test from syndesmose
The person sits on the treatment couch with hanging legs. The examiner grasps the lower leg on both sides. The examiner starts at a higher position of the lower leg and squeezes the shin and fibula toward each other. The examiner grabs different points closer and closer to the ankle joint. With severe injury to the syndemosis, the bone parts give way from each other which will produce recognizable pain for the person.
Exorotation click test
The person sits with the legs hanging off the treatment couch. With one hand, the examiner holds the lower leg in the same position. With the other hand, the examiner holds the foot in a neutral position while the foot is turned outward. With recognizable symptoms, the test is positive. What type of lesion is present depends on the location of the pain experienced. On the front, there may be syndesmotic injury. On the inside, the inner ankle ligament may have damage. If the pain is felt on the outside, then there was injury to the outside of the ankle.
Surgical intervention or conservative treatment
- Ankle injuries are not operated on in the vast majority of cases.
- Sometimes when there is persistent instability, surgery can offer a solution.
- In some cases, there is a complex fracture that needs to be repaired.
In people who are highly active and would like to play a sport where you have to jump, turn or cut down with chronic instability, surgery can be an added benefit in most cases. It must then be clear what the reason for this persistent instability is.
The different stages in the treatment severe ankle injury
Successful rehabilitation consists of several stages and steps. Good strength, stability and control is necessary to safely return to your sport. Both after a surgical procedure and with conservative management.
After an injury where there is damage to tissue, in this case the ankle ligaments or other structures of the ankle, several stages of tissue repair take place. Immediately after it occurs, the inflammation phase starts. Here, the body goes to work clearing out damaged tissue in the affected area and making room for new. This phase is characterized by pain, swelling, blue discoloration, heat and inability to bear weight. During this phase, it is important to rest especially. The physical therapist mainly advises on the policy and expectations of recovery. In addition, some exercises can be given to restore the mobility of the ankle joint.
The inflammation phase takes about 7-9 days on average and progresses into the proliferation phase. In this phase, new connective tissue is produced. This tissue is not yet strong enough and should therefore not be subjected to heavy loads. During the transition from the inflammation phase to the proliferation phase you will notice that complaints such as blue discoloration, pain, etc. will decrease. The ability to exercise more also increases.
In the remodeling phase, the newly created connective tissue is remodeled as the name implies. Thus, collagen tissue (laid out in proliferation as type 3) is transformed to type 1. The difference is that type 1 collagen tissue is much stronger than type 3 tissue. Under pressure and tensile forces demanded of the various connective tissue structures in remodeling, the body makes sure that tensile strength of the fibers becomes stronger to accommodate as many forces as possible. This makes that in this phase of recovery, load capacity increases but also actually builds up must become. We do this in several stages from basic strength to sport-specific training.
In this phase, we focus primarily on symptom reduction. There is often swelling, pain and reduced mobility of the ankle joint. Manual techniques with exercises to increase mobility are most commonly addressed in this phase.
Strength and stabilization phase:
This phase involves more of a build-up in strength. Stabilizing exercises are also included. General fitness may also be worked on in between.
The final phase focuses particularly on maximum strength, jumping power and explosiveness. This is all necessary to quickly change direction within your sport. Competitive fitness is also worked toward so that you can continue to perform under fatigue. The quality of movement must remain good under these conditions. The chance of re-injuring your ankle is many times greater under fatigue.
Rehabilitation at Physio Fitaal
Severe ankle injuries can be unpleasant, especially after surgery. Our specialists will guide and motivate you as much as possible during this process. Fysio Fitaal works with specialists in the field of sports rehabilitation. Through the combination of expertise, extensive facilities and passion for sports, you have come to the right place.