SPORTS INJURIES REFRESHER ANKLE JOINT

and if possible walking. Walking may reveal a painful (antalgic) gait or lack of full dorsi-extension as in arthritis. The foot has to dorsiflex at least 5o

or the

toes will not clear the ground during the swing phase. Assess the degree of pronation by checking subtalal congruity. Get the patient to kneel into a chair to assess inversion/eversion. This should give you an idea of problems that may need orthotic treatment. Check for callus formation - commonly on the medial aspect of the great toe and the head of the first metatarsal plus the lateral aspect of the heel, all of which indicate excessive pronation.

Move n With the patient sitting, lift the foot and examine the ROM of plantar- flexion, dorsi-flexion, inversion and eversion. Repeat the tests with active movement to detect weakness. Dorsiflexion can be limited by osteophytes of the anterior lip of the talus, caused by excessive kicking e.g. football. n Test the true ankle joint and its ligaments by cupping the heel with one hand, pulling anteriorly and resisting with the other hand pushing posteriorly, held over the lower end of the anterior shin (see video 8 in Interactive extras). This is the anterior draw test of the ankle. The end-feel should be firm/ strong. A tender ATFL will show itself during this manoeuvre as well as inversion. Repeat this test but test the sub-talar joint stability by grasping the calcaneum with one hand and the other over the anterior aspect of the ankle. n Also test the subtalar joint inversion eversion movement by trying to also move the calcaneum under the ankle. Pain during this test will emanate from the joint. n An intra-articular problem causes equal limitation of both plantar-flexion and dorsiflexion- (this is the capsular pattern of the ankle). Check the other ankle for an idea of the patient’s normal ROM. n A complete rupture of the ligaments of the ankle may allow the tibia to move anteriorly 2-4cm without pain! Remember that the medial ligaments of the ankle are incredibly strong and are rarely torn unless there is disruption of the true ankle joint.

Power I get the patient to resist the above movements but a more realistic

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method is to ask the patient to stand on tip-toes, then slowly lower the heel to the ground. This tests the integrity of nerve innervation, muscles and joint in one go, and can be a supplementary test for an Achilles injury.

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R.I.C.E. IS ALWAYS THE FIRST STARTING POINT

KEY POINT: Muscles experiencing pain cannot contract fully. Injured muscles that are not working for one

day, take three days to rehabilitate. However you examine these muscles develop a routine you can use reliably and quickly. Modify the instructions so the patient understands.

Feel n By now you should be 90% sure of the lesion location. Palpation of the joint line will usually indicate osteophyte presence, ligament tenderness and tenderness associated with the subtalar joint. The exact point is just inferior to the sustenacum tali on the medial aspect of the heel. Biomechanical problems such as hyper-pronation and overuse often cause trigger points in the muscles of the shin particularly in the tibialis anterior and posterior muscles. I find correction of the biomechanical problem, +/- acupuncture, and taping helps.

TREATMENT R.I.C.E. is always the first starting point. If this does not resolve the problem, then immobilisation with tape or plaster of paris is useful to allow healing initially.

+ KEY POINT:

Effective proprioceptive rehabilitation is

probably the most important part of the healing process of the ATFL injury. Controlling pronation can be very effective in helping pain from the foot leg and ankle. There are many podiatrists and podiatric services both NHS and private one can refer to for custom made orthoses. However teaching patients to recognise talar neutrality in themselves when trying on shoes can help dramatically. Over the counter orthoses such as Carnation Powerstep and Vasyli can effect a small degree of control with good symptom resolution.

THE AUTHOR

Dr Simon Kay, MBBS MRCGP DRCOG DIPL and MSc Sports medicine, member of FSEM BASEM BMAS SOC and Honoury Education

Fellow Exeter University. Simon is a full-time GP/ Sports Physician, Yorkshire Missionary in Devon. He has been a GP for 25 years and is a keen ex-rugby player. He became interested in sports injuries since injuring his knee in 1988 and completed his Diploma in Sports Medicine in 1997, followed by his MSc in 2006. Since 1999 he has added acupuncture, SOM teaching, manipulation, podiatry and sports therapy teaching to his repertoire. He teaches students, GPs and sports therapists and has been medical officer to various rugby clubs, notably Halifax RUFC and Exmouth RFC, England SW U18 Rugby, and now Exmouth ABA. For more information visit www.sports-doctor.co.uk

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Taping methodology is available in podiatric books.

References Travell and Simons. Myofascial Pain and Dysfunction: Lower Extremities. ISBN 978-0683083675 (£74.10) Buy from Amazon http://bit.ly/9FfSTv

2. Webborn, N. The Ottawa ankle rules. sportEX medicine 1999;1:7-12

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KEY POINT: Although slightly outside the remit of this article, recognition of an acutely damaged Achilles tendon,

is vital. A history of a sudden pain like being kicked in the calf is typical. Usually this is felt when the triceps surae (gastrocs and soleus) contracts acutely as in pushing off to run or going onto tiptoes. The patient can’t go on to tiptoe, especially on the injured leg. If laid face down, the foot won’t plantarflex when the calf is squeezed. Urgent referral for surgical repair or management is required. On a personal note there have been a lot of leg, ankle and foot pains I have seen as a GP that I suspect have originated from people wearing shoes with less arch support e.g. Flip flops due to the dry weather. An alternative with good arch/orthotic support is made by Birkenstock.