CASE STUDY ANKLE

patient’s inadequately rehabilitated ankle (see Box 1) had decreased range of movement in the joint (especially dorsiflexion), and weak peroneal muscle contraction and impaired proprioception. Having dealt with swelling and bruising, the plan was for progressions of passive then active mobilisations to the talocrural and subtalar joints in order to regain adequate range of movement (especially dorsiflexion), restore normal gait, and allow muscle strengthening and proprioceptive retraining. Therefore patient was asked to return 48 hours later.

Session 2 On returning to the clinic, there was a noticeable reduction in the swelling around the joint and mid-foot circumferences, with a slight amount of movement restored, especially in dorsiflexion, where 15o

of flexion is

needed for correct gait (see online extras for video on the biomechanics of gait in walking and running). Walking on the foot was now pain free, but there was still some swelling around the ATFL and CFL. Ice was used again and another horseshoe compression bandage was applied, with the addition of stirrups to reduce inversion movements when walking and provide additional stability and support for the lateral ligaments. The patient was asked to return in 3 days time.

Session 3 After 3 days, all the swelling

and bruising had gone and bi-lateral comparison showed both ankles to be very similar. The focus now was on continuing effective treatment without irritating the newly healed areas. Rushing rehabilitation or progressing a patient too fast is not worth the risk because it may cause a relapse to acute injury, which will frustrate the patient and increase the timeframe for further treatment. To deal with the persistent stiffness, the patient was given a range of passive mobilisations to apply, as recommended by Maitland (8). By increasing dorsiflexion and restoring gait to normal, inactive muscles like the peroneal longus and brevis and the tibialis anterior. First, movements

against gravity were demonstrated, to be carried out regularly throughout the day. Stretching exercises were devised to help increase the range of specific movements, namely the gastrocnemius, the tibialis anterior and peroneal muscles. Exercises with a latex band were included, where the gentle but effective resistance brings about early strength re-training of weakened muscles, leading ultimately to increased joint stability and preventing re-injury. The band produces concentric and eccentric loading of specific muscles or muscle groups, which is important as all the muscles of the leg must function properly in order to decelerate eccentrically and accelerate concentrically and be isometrically stabilised (9). Strengthening of the intrinsic muscles of the foot is particularly important in rehabilitation (Prentice (7) found that towel gathering with the toes was good for strengthening the intrinsics as well as the toe flexor and extensor muscles). Another essential part of ankle rehabilitation is to re-establish neuromuscular control, and early weight-bearing to reduce the loss of proprioception. A study by Willems et al. (3) reported worse proprioception and/or reduced muscle strength in people with chronic ankle instability or recurring sprains, while Rebman and Bel (10) noted a proprioception reduction of 83% in people with recurring ankle sprains. To deal with this, the patient in the current case began basic closed-eye standing exercises on a carpeted surface (progressing to single leg and different surfaces). Within the sessions so far, the patient’s foot and leg was massaged for 20 minutes, using friction on the injured ligaments to break down any build up of scar tissue and increase blood flow to the area to aid soft tissue repair. The plantar fascia was loosened off as it was particularly tight as well as the soleus, peroneal and gastrocnemius muscles.

Session 4

Mobilisations of the ankle in dorsiflexion and eversion were continued, where movement was most limited, as well as the distal tibiofubular joint ,which

ALL INJURIES SHOULD BE CONSIDERED INDIVIDUALLY

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BONY ABNORMALITIES MIGHT BE LIMITING THE REHABILITATION PROCESS

was very stiff when mobilised. Massage was applied to the peroneal and tibialis anterior muscles and the posterior calf muscles because they had considerably stiffened since starting proprioceptive retraining. Weight- bearing proprioception exercises were reduced as the emphasis shifted to non-weight-bearing exercises.

Session 5 One week later the patient’s use of resistance bands had resulted in increased movement and control overall, gaining over 15o dorsiflexion and 20o

UNDIAGNOSED FRACTURES OR OTHER

of of plantarflexion.

Proprioception and ankle stability exercises progressed thereafter with the use of wobble boards, dyna disks, bosu boards and mini-trampolines. The patient carried out 1 minute of training on each exercise on both ankles then repeated three times with sufficient rest between sets. These exercises were combined with stretching and strengthening and were carried out by the patient every other day for 2 weeks. Massage at the clinic was continued because exercising muscles that have been inactive because of injury can cause delayed onset of muscle soreness (DOMS) and tightness. This combination proved to work well.

Session 6 Four weeks after the initial ROM results were obtained, ankle movements were re-assessed using the goniometer. They revealed 16o 37o

in dorsiflexion, in plantar-flexion, 4o and 4o in inversion in eversion. These results

were very positive. The session progressed by adding in more advanced proprioceptive exercises isolating the injured ankle. The duration of each exercise was increased and functional exercises were included, such as trampoline bouncing on both feet and swimming. This was to improve muscular endurance and apply movement against resistance. Massage was continued, and effleurage

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