Problematic Ankle

[stansgreenarmy]

Hey There, I am new to this forum and would very much appreciate any advice that people may be able to provide, i am a new grad working in the musculoskeletal area.

This particular patient presented to me three and a half weeks ago, she had a history of lateral ligament sprain while on vacation in febuary, which she had x - rayd (clear) , recieved physio and felt better , stopped attending physio at the proprioceptive phase of her rehab as she felt so good!!

Patient attended a dance class three and a half weeks ago and did a spinning manouver, felt pain on the lateral aspect of her ankle.
Stiffness in the morning which eases out after a few minutes of walking.

Objectively she had slightly decreased stance phase, squating was painful for the ankle, SLS was greatly decd on Painful ankle, there was Pain on palpation of ATFL,
Active Tps of the peroneals, and deep in soleus,Range of DF was decreased secondary to gastroc tightness. Passive mvt of inversion was painful with no exceess laxity, similarly for anterior drawer.The impression i made of this persons condition was of a chronic ATFL Damage with assosciated soft tissue adaptations.

And have been treating it for such with Soft tissue work on effected muscles, Trans frictions to ATFL, Ultrasound, with range of movement exercises progressing to proprioceptive work.Yhis has continued for the past number of weeks with minor changes based on clinical findings.

Forgot to mention she is overpronated of bilaterally, painful foot position is worse than painfree and has been given intrinsic foot exercises with very minor improvements sen so far, last session i have used a taping technique to encourage a better foot position - yet to hear back with regards outcome of this approach.

Overall there has been some improvement , but she still reports bad days where it is as bad as before i treated her. The problem now is that she is painfree throughout the day ADL's walking (although hasnt gone running/Dancing yet), feels pain at rest and is along the anterior joint line. Many of the clinical tests vary with each treatment session and are some as bad as beginning despite her functional improvements.

I am sorry about the longwindedness of this post but wanted to include as much info as possible to get some ideas with regard the cause of this resting pain, and maintanence of some of the clinical features, as a new grad i have discussed with my seniors and they are equally as baffled with regard this ladies problem, probably something straight forward that we are missing out on , would really appreciate any advice or recommendations. Regards
StansgreenArmy()

[physiobob]

Thanks for all the nicely laid out presentation. Seems you are on the right track. I would not necessarily say she has a chronic sprain but maybe just another acute one given her lack of proprioceptive retaining in the past. This is typical of people in the dance arena (I look after a classical co. in London).

Anyway you might find that anterior and posterior glides of the talocrural (ankle) joint in various dorsiflexion ranges might assist the dorsiflexion. Make not on an AP of the tibia on the talus for any reflexive activity in the calf/achilles as this will indicate that this is slight more irritable and is adding to the reduced DF and possible anterior joint line impingment.

Best of luck but you are right on track

She just needs to understand some of the reasons why she reinjured and this time perhaps a little worse.

[linbin]

hi friend
i feel you should also check for the mobility of inferior tibiofibular joint.check the pain response with these movements,try out giving superior gliding of distal fibula.rule out sinus tarsi,release the trigger points.anterior ankle pain if present with dorsiflexion reflects reduced mobility of ankle joint

[GregasGP]

Hi all,

Did you manage to find a solution to the above?? I am having a very similar problem and have been over the last 4-5 months. Background detail below:

My name is Greg, 25 years of age and I have always been physically fit and participated in sports since I was a youngster. In May 2006 I suffered a bad sprain to my left ankle when I was 'dropped' by somebody on a night out. Whilst I rested it up and applied the usual RICE technique, I don't ever think I gave it enough time to heal properly. I then suffered another very bad sprain on my right ankle in September 2006 whilst playing football. I've attached some photos of the feet in question. Again, applied RICE and assumed all would be OK.

Fast track 9 monthsand there weren't any complications in both ankles. I had quite consistent clicking and cracking in both ankles but never any pain, not that I can remember anyway. I continued to play sports and ran quite a lot (outside) 3-4 times a week doing 2-4 miles at a time. I then went away to Mexico with the girlfriend in July and August so stopped training for a period of 2 months. When I returned in September I began training again but quite gently. Only running about 1.5 - 2 miles 3-4 times a week, but in the gym on a Treadmill. This became the start of what has been a problematic and annoying experience for the last 3-4 months.

I began having a dull ache sensation in my lower legs and ankles and the clicking and cracking began to get worse. I then went to see a Podiatrist who said I was an over-pronator and I had some generic insoles to put in my shoes and running shoes (Asics over pronator ones anyway). This caused what seemed to be more problems so I went to see a local Physio. She mentioned that my hamstrings and achilles were very tight and stretching may help so I was given a stretching programme. Whilst this has helped a little, my ankles are far from perfect. I went back to see another Podiatrist who said I have a slight leg length deficiency and I purchased some custom made insole orthotics which I continue to wear in training, at work and as much as I can. Again, little improvement.

I chose to go private and consulted BUPA where I saw a consultant who mentioned it was likely that I had Chronic Ankles Instability. I went for an MRI last week and the MRI scan confirmed that on both ankles I have, and I quote the Radiologist "Evidence of chronic anterior talofibular ligament sprains, with some diffuse thickening from the normal 2.5mm to 4.5mm. The ankle joints appear to be well preserved bilaterally and there is no suggestion of anterior impingement syndrome". There is also just a trace of fluid in the ankle joints, but no sign of any loose bodies. A small focus of sclerosis is also noted in the tip of the left medial malleoulus which may relate to a previous impaction injury. There is no suggestion of bone bruising either.

I have been placed on a Physiotherapy programme for 6 weeks and have now cut out running (tried the cutting out running part before for 3 weeks and it never helped). I am also having Ultrasound and some procipertory work exercises. However, it was recommended that a good Sports Massage may also help loosen the tightness I've been feeling in my legs and lower back to some extent, particularly the lower parts of my legs around the shinbone. Again, a lot of clicking/cracking in the ankles! Hence, I wondered if this would be a good thing or may jeapodise things?

This really is an annoying time ! I'm so looking forward to the RAF, it's all I've ever wanted to do and I've passed all the 'Intelligence and Academic' tests to become an Officer so want to ensure my fitness is up to scratch. I'm due to start in May but do have another final fitness and medical test sometime in mid/late February.

I've never had any problems like this before and am hoping they can be sorted with a bit of pace.

I have considered surgery too, but that would not lookgood on my medical records and may lead to a REJECTED application. Also, the healing time is quite long isn't it, or could I be back in full training including running within 8 weeks?

Hope you guys can help.

Thanks,

Greg

[angeloftheuk]

Dear all,
This is actually a new problem addition to the 'problematic ankle' thread, and apologies since I am not actually a physio (I am a community nurse) since this is to do with my 12 year old daughter (13 in December). I am asking you all out there since she seems to be getting nowhere at present!

Like one of the other patients she is a dancer and a very serious one (has been offered a place at a vocational full time school). 3 years ago had a right lateral malleolus fracture and an MUA to correct it, in cast for 3 weeks then weeks of traditional physio - ankle turns, strengthening with thera bands, balancing exercises then gradually weight bearing. She seemed to recover fully then 6 months later appeared to have a bad sprain. Repeated all of recovery regime except for cast.

Nothing after that till January when had fall on mini-trampette (purchase of which advised by last physios!) She had been doing a lot of dancing prior to this, some on pointe. Was startled at hospital to hear she might have a non-union of distal fibula from original fracture. Was worried re this so got second opinion. The second consultant has a special interest in non-unions and is a paediatric orthopaedic surgeon. He was not sure if if was a non-union or a kind of malformation of fibula, malformation meaning that the distal part of the fibula had never united properly with the rest. Have only just got him the original xrays and have not had a definitive diagnosis out of him 3 weeks after my daughter has come out of her cast.

Have commenced physio - therabands again, balances etc but when she does double rises there is a clicking sound in her right ankle and a brief pain when she rises up. The pain she describes as a 1 on a 1-10 pain scale. Because of this it is difficult to strengthen the ankles more. She says she tends to rise quicker and not develop control because of trying to get past the pain. The pain has not got any worse and only occurs in rises. She does not experience pain in any other situation - she walks to school forty minutes a day and is very healthy in every other way. I am worried because I do not want to cause any more damage to her ankle. But as a dancer she certainly cannot progress without resolving this problem. she has just taken (for those ballet fans out there) her rad intermediate foundation with a distinction and had commenced her intermediate training.
Even if she cannot do dance, athletics are her other great love and I am worried about her ankle in this respect also!

Any physio advice very greatly appreciated. sorry for long post.