Ankle Pathology, Assessment and Rehabilitation

Ankle Sprains
- Lateral ankle sprains are the most common, and usually occur as a result of load
placed on the joint during plantarflexion and inversion. Chronic instability is often the
result of improper treatment of lateral ankle sprains.
- The common ligaments partially or completely torn include:
1. Anterior talofibular ligament
2. Posterior talofibular ligament
3. Calcaneonavicular ligament
- Grading of ankle injuries are as follows:
1 (I): Overstretching of the ligament/s. Rehabilitation would be the best approach
2 (II): Partial tear of the ligament/s. Rehabilitation would be favoured however
sometimes surgery may be better suited to the individual
3 (III): Complete tear of ligament/s. This often requires surgery

Syndesmosis Injury
- A syndesmosis is a fibrous joint of collagen and connective tissue, and there is one
between the tibia and fibula, as well as between the radius and ulna bones.
- An ankle sprain to the syndesmosis of the leg is higher than the ankle joint itself, and
the ligament most affected is known as the antero-inferior tibiofibular ligament. It is
more disabling than an ankle sprain at the lateral collateral complex or medial deltoid
complex of the ankle.
- This injury often occurs when the foot is planted and is then twisted outwards, or
when a heavy load is placed on the ankle whilst it is dorsiflexed.

Instability
- A common test performed to test the laxity of the ligaments of the ankle is known as
the anterior drawer test.
- This test mainly assesses laxity in the anterior talofibular ligament and the
calcaneonavicular ligament.
- A positive test will have one or both of the following symptoms
1. Presence of pain
2. A feeling of the ankle ‘giving way’ compared to the unaffected side

Ankle Impingement
- Ankle impingement is the leading cause of chronic ankle pain, and is the result of
synovial or capsular irritation.
- It usually occurs as a result of
1. Trauma
2. Infection
3. Degeneration
4. Congenital disease
- Pain at the anterior aspect of the ankle is due to irritation of the anterior talofibular
ligament, and pain is felt most when the ankle is dorsiflexed. Remember the ATFL is
commonly injured during plantarflexion, however this position of the foot will stretch
the ligament, whereas dorsiflexion will irritate the ligament. Repeated dorsiflexion can
cause the impingement, and is commonly referred to as ‘Athlete’s Ankle or
Footballer’s Ankle’.
- Posterior impingement occurs in athletes who continually plantarflex their foot e.g.
ballet dancers and soccer players. Impingement occurs to the flexor hallucis longus.
Pain is generally felt behind the heel or at the back of the ankle, and occurs when the
foot is plantarflexed.

Achilles Tendinopathy
- Tendinopathy refers to the disease of a tendon, and the clinical presentation is
tenderness with palpation, and pain with movement.
- Tendinopathy results in the disruption and disorganisation of the cells normal
functioning, and is caused by overuse, poor biomechanics or functional instability.
- In more severe cases, swelling is often present
 - Achilles Tendinopathy is characterised by the gradual onset of pain and stiffness in
the Achilles region.

Plantar Fasciitis
- The plantar fascia is a band of connective tissue that runs along the underside of the
calcaneus to the ball of the foot.
- When the big toe is dorsiflexed during walking, the plantar aponeurosis tightens
around the metatarsophalangeal joint and pulls the heel and toes slightly closer
together. This raises the medial longitudinal arch and locks the bones of the foot. This
mechanism allows the foot to absorb ground reaction forces, and to act as a rigid
lever during propulsion.
- Bruising or over-stretching of this ligament can cause inflammation and sharp pain in
the heel.
Common Risk Factors
- Sports which place a large amount of stress on the heel e.g. running
- Age: with age, the muscles supporting the arch become weaker
- Weight: people who are overweight place greater load on the plantar tissue
- Prolonged periods on feet
- Pregnancy: changes occur in weight and hormones
- Walking with shoes with poor arch support or stiff soles
Signs and Symptoms
- A sharp pain in the bottom of the heel
- Heel pain that worsens with steps
- Heel pain after long periods of standing
- Heel pain after exercise. Pain does not usually occur during exercise
- Mild swelling of the heel

Gait Observations at the ankle

NB: WHAT YOU SEE IS NOT THE ACTUAL PROBLEM; IT IS THEIR COMPENSATION
AROUND THE PROBLEM
- Some people tend to flip their feet outwards when they walk during the swing phase.
This is a modified circumduction gait, and is usually caused by limited hip flexion and
ankle dorsiflexion during the swing phase when trying to prepare for the next step on
the same side.
- When ankle dorsiflexion is the only factor that is limited, we tend to see the affected
limb evert during clearance. The peroneals and toe extensors (extensor digitorum
longus and brevis) become more activated to get the foot into an everted position so
that it can clear the ground.
- An over-pronated gait pattern tends to cause hallux valgus (bunions)
Goals of Rehabilitation
- Restore ROM
- Restore strength
- Restore sensorimotor function (afferent, efferent and central integration and
processing components involved in maintaining stability in the postural system
through intrinsic motor-control properties)
- Restore/maintain cardiorespiratory fitness

Considerations of the client prior to exercise prescription

- Severity of the injury
- Debilitating effects of prior injury
- Motivation and compliance levels of the client
- Demands of the sport/work/hobbies of the client

Basic Ankle exercises in initial phases of injury

- Alphabet exercise (acute phase day 1 – 3)
- Achilles tendon stretching (within the first 48 – 72hrs)
- Windshield wipers (ankle eversion strengthening (within the first 48 – 72hrs)
- Seated calf raises (day 4 – 13)
- Partial weight-bearing single leg stance (day 4 – 13)
- Isometric inversion and eversion against stationary object (day 4 – 13)
 - Theraband plantar and dorsiflexion (day 4 – 13)
- Full weight-bearing single leg raise (approx. after week 3)
- Swimming, cycling or weightlifting (approx. after week 3)
- Wobble board or other unstable surface (approx. after week 3)
- Heel toe walking (heel strike followed by full range of motion plantarflexion)
- Heel walking
- Toe walking
- Walking on different surfaces

Guidelines for ankle instability

With chronic ankle instability, it is important to consider the following factors prior to
prescription of exercise:
- There is an increase in anterior joint laxity; strengthen both the inverters (tibialis
anterior and posterior) and the evertors (peroneals) of the ankle joint
- Decreases present in ankle dorsiflexion; stretching of the plantarflexors can assist in
improving dorsiflexion e.g. standing calf wall stretch
- Changes in gait pattern
Remember that ankle instability is likely to lead to kinetic chain dysfunctions, therefore also
consider the following factors (from the literature):
- Persons with CAI have weakness and delayed onset of the gluteus maximus that can
lead to a decrease in postural control, subsequently altering gait biomechanics
- Persons with CAI tend to have weak glute abductors i.e. glute medius and minimus,
both of which can cause alterations in postural control and gait patterns.
- Trauma to ligaments and mechanoreceptors will alter biomechanics in individuals
with CAI, therefore it is important to incorporate drills that target proprioception
specifically to increase overall ankle stability e.g. standing on a wobble board, uneven
surface or performing single leg stands.

Guidelines for Peroneal strengthening (Evertors)

- The peroneals assist in eversion of the foot (fibularis longus, brevis and tertius)
- Both peroneus longus and brevis assist in everting the foot while it is in a
plantarflexed position, whereas peroneus tertius assists in everting the foot while the
ankle in dorsiflexed.
- Strengthening of the peroneal muscles can help guard against lateral ankle sprains
and instability. A good exercise is to do eversion with a theraband while the heel is
elevated on a surface (plantarflexion position).

Guidelines for Achilles Tendinopathy (Chronic phase)

- Eccentric loading exercises are the most effective form of exercise therapy for
treating Achilles tendinopathy e.g. standing on a step and lowering the heels in turn
until you get a calf and Achilles stretch, or calf raises with an eccentric stretch (when
on toes, come down very slowly)

Guidelines for Plantar Fasciitis

- Improving gastrocnemius and soleus length is the most effective method of treating
plantar fasciitis.
- Patients can roll their foot over a solid object such as a frozen water bottle or a golf
ball for a greater stretch in order to reduce pain in the fascia. Extending the toes
backwards with one hand also provides a good stretch for the plantar fascia.
- Check a variety of factors to try and determine why plantar fasciitis is occurring in the
first place e.g. check knee, hip and ankle alignment; ankle dorsiflexion ROM, arches
of the foot (are they flat-footed or in foot supination?), gait and postural control.

Guidelines for Impingement

- Treatment for impingement is conservative, as the pain associated with this condition
is from a compression of structures at either the front or the back of the ankle
(anterior talofibular ligament, and flexor halluces longus tendon, respectively).
- Treatment generally includes:
 1. Rest
2. Therapy
3. Bracing
4. Shoe modification
5. Local injection
- It is still recommended to partake in active and passive range of motion,
plantarflexion, dorsiflexion, inversion and eversion exercises, however be mindful of
tolerance levels
- Incorporate proprioception training when there is an issue at any joint of the body!
Include both static and dynamic proprioception training for variety and an increase in
intensity e.g. static can incorporate a surface change, whereas a dynamic task can
include an unstable surface combined with a movement requiring a change in
direction.

Monitoring
- Your clients safety is of utmost importance no matter what phase of rehabilitation they
are completing! Always consider:
1. Their pre-exercise condition; is it safe for them to exercise? Are they presenting
with any contraindications?
2. During exercise, monitor the way that they present e.g. excessive sweating, pale
face, blood pressure spikes or drops, vomiting, increased pain, swelling and loss
of ROM
3. Review symptoms post exercise!