Acute ankle inversion injuries

Part 1 - Assessment - Learning objectives

Subjective

1. What structures are likely to be injured in a plantar flexed/inversion injury

2. What structures are likely to be injured in an eversion injury
3. What structures are likely to be injured in an inversion-eversion injury
4. What are the criteria for ordering an ankle XR series?
5. What are the criteria for ordering a foot XR series?

Objective

1. Acutely on the field, what tests should be performed?

2. How should you manage an acute injury in the first 72 hours?
3. What is relative rest?
4. How long should ice be applied for?
5. What taping techniques can be used in the early stages?
6. Who should you refer patients to?

Anatomy and In the clinic (see the handout for further anatomy)

1. Where is the ATFL

2. Locate the CFL, Deltoid ligament, joint line, peroneus longus, brevis and tertius
3. What is the path of the peroneus tertius run and attach?
4. Locate TD & H
5. How do you perform testing of the ATFL?
6. What is a Grade 1 injury to the ATFL and expected recovery time?
7. What is a Grade 2 injury to the ATFL and expected recovery time?
8. What is a Grade 3 injury to the ATFLand expected recovery time?
9. What are you testing with an inversion stress test?
10. What ROM tests would you perform in the clinic on an acute ankle inversion injury?
11. When would you perform a DF Lunge test?
12. What information does a peroneal strength test provide?
13. What information might you gain from a heel raise test?
14. How can you start balance testing?
15. What functional tasks will you assess acutely?

Discussion

• Why is there a large recurrence rate for ankle injuries?

Part 2 Learning Objectives

16. What is relative rest?

17. What exercises will you use to increase ankle ROM in the early stages?
18. When writing the alphabet with your foot, should capitals or little letters be used?
19. How can you reduce muscle tone without increasing inflammation?
20. How do Mulligan's MWM's work?
21. How can you improve PF/Inv?
22. How can you improve Ankle DF?
23. What colour nail polish should your patient be wearing if you are doing MWM's on
their ankle?
24. When should joint mobilisation be incorporated into your treatment?
25. What role does strengthening have following ankle injury?
26. What muscles need to be reactivated?
27. How can you perform muscle reactivation?
28. How can you avoid using toe extensors during muscle activation?
29. Palpate the Peroneus Longus near the Superior end of the fibula
30. When should balance training start?
31. What exercises can be used to commence balance training?
32. When are heel raises in shoes useful?
33. What height heel raises will you provide patients?
34. What taping can you use as a progression from bracing or stability taping?
35. When should you remove heel raises?
36. How can your patient maintain the CV fitness while walking and running is limited?

Practical

1. Perform early ankle ROM exercises?

2. Practice MWM for PF/Inf
3. Perform MWM for DF
4. Guide correct peroneal activation
5. Palpate the Peroneus Longus during muscle activation, and check the Peroneal
tendon posterior to the lat malleolus
6. Put heel raises in your shoes and assess your gait
7. Mulligans MWM Taping

Discussion

• Why is inflammation important in the early stages?

• Why should the toe extensors not be used during Peroneal activation exercises?
Lateral Ankle (picture courtesy of Primal Pictures 2009 - www.anatomy.tv)
 Inversion injuries
Acute ankle inversion
injury • not just ATFL
• specific assessment can direct your treatment for a swift recovery
Presented by Russell Wright, Physiotherapist
• common place on sporting field, innocuous
• significant 20% recurrence CAI - means rehabilitation is
Copyright Clinical Edge 2011 important to prevent chronic inactivity when they can’t return to
www.clinicaledge.com.au
their usual sporting activities

subjective assessment specific questioning

• mechanism of injury

• 1. landing on an uneven surface • on mechanism of injury can help give you

insight into likely structures injured
• 2. pushing off laterally from an acute cutting manouver

• uneven surface encompasses: • - PF ATFL

• someone else’s foot - basketball

• finding a pothole when running - any of the football codes

• - EV Deltoid
• off field injuries including stepping on an uneven section of pavement, or • - no EV compression injury medially (synovitis)
stepping off a gutter, often in high heels or inebriated

Objective testing treatment day 0-3

• on the park/ where the action occurred:
• PRICER 48-72hrs
• 1. red flags - a fracture with the ottawa ankle rules
• protect - brace or tape
• 2. palpate - get a quick feel in, to localise the tender parts
before the inflammation process flows down to sensitise • relative rest - ADLs as best possible
everything.
• ice - analgesia to kick in
• the other tests can wait for the clinic as it’s won’t change your • compression - elastic bandage, tubigrip, complete taping with U padding
treatment anyway. & it’s best to avoid them hating you for the
extra unnecessary pain. • elevate - while your icing
• referral - to you
 objective testing in the ottawa ankle rules
clinic
• 1. red flags - OAR
• XR of ankle required if
• 2. palpation • bony tenderness posterior edge of lateral
malleolus to 6cm above this point
• 3. ligament testing

• 4. ROM • bony tenderness posterior edge of medial

• 5. strength malleolus to 6cm above this point
• 6. balance • unable to WB now or immediately after injury
• 7. function

ottawa foot rules palpation

• XR of foot required if • ATFL, CFL, Deltoid Lig

• bony tenderness at the base of the 5th • Joint line
Metararsal or over the Navicular
• Peroneals
• unable to WB now or immediately after
injury • TD & H

grading of atfl sprain ROM

• Grade 1 - good stability without laxity, tender
ATFL (2-4 weeks RTP) • Inv, PF, Ev
• Grade 2 (partial tear) - increased laxity with end • Mid to forefoot supination and pronation (to
feel, ATFL tender (4-6 weeks RTP) eliminate mid foot injury)

• Grade 3 (rupture) - Gross laxity, no end feel • DF Lunge test

(6-8 weeks RTP)
 strength balance

• RIMT Peroneus longus/revis • Single leg balance test 30 secs

• Heel raise (look for inv or toe gripping) • Star balance test

treatment - rom swelling

• ROM limited by: • limit excessive inflammation with

• swelling • compression
• increased muscle tone • ice (with elevation)
• joint subluxation (?) • movement (PF/DF, Inv/Ev, writing)

mulligans pf/inv mwm for dorsiflexion

• Only if improves pain or ROM • Post glide of Talus, post support of tibia
• Post-sup glide of distal fibula
• Assist DF
• Patient assists PF/Inv
• Relax in DF
• Only in comfortable range
• Maintain glide for whole movement • Go further
• 3 x 6-10 • Maintain glide while return
 strength
• Activation in isolation of the Peroneals
• Reintroduce the brain to the muscle
• In SL, point foot up towards ceiling
• Keep toe extensors relaxed (monitor this)
• Palpate Peroneus Longus
• 5 x 10 reps
function
• Restore normal gait as soon as possible
• Heel raises (both shoes) if DF limited
• Mulligans tape (only if decreases pain/increases
ROM)
endurance
• Swim, ride, paddle
• Maintain cardio-vascular fitness with cross-
training
balance
• Start as soon as comfortable (in 1st week)
• Start with SL stance, slight knee flexion
• Include core stabilisers
• Progress to star excursion balance test
mulligans taping
• From Inferior Fibula in posterior-superior direction
• Provide post-sup glide of lat malleolus while applying
tape
• Only if improves ROM/decreases pain
• Apply protective undertape
• Can be used as a progression from brace/stability taping
treatment
address the issues identitfied
• 1. ROM - DNT, MWM
• 2. strength - Peroneal sidelying
• 3. balance - SL, star excursion
• 4. function - heel raises & Mulligans taping
• 5. endurance - swim, ride, paddle