News Category: Ankle

Preventing ankle sprains in barefoot athletes such as gymnasts, dancers, and participants in martial arts is important. Sport shoes give good support and stability but are not practical in these activities.

The use of an external ankle support system is under investigation. In this study the effect of ankle support used inside a shoe is compared to wearing it without the support of a shoe. The goal is to find an external support for use in barefoot sports activities.

Three different devices were tested using two different shoe configurations. The external supports included a semirigid brace, a soft brace, and tape. The shoes used were a normal sports shoe and the same shoe with a specially designed cutout to simulate a barefoot condition. The Nike Cross Training XT shoe was used for everyone.

Passive ankle range of motion (ROM) was measured in 25 healthy adults. Motion was retested for each subject wearing the different combinations of devices and shoes. A total of eight conditions were tested for each subject.

Results showed that using any of the external supports restricted ankle motion compared to being barefoot or wearing the cut out shoe with no support. Tape provided more stability than the bracing. Results were the same for the semirigid and the soft brace.

The authors suggest soft braces can be used as a preventive measure in barefoot sports. They give good passive stability but without restricting the motion needed for the activity. Tape gives the best support but it doesn’t last more than 20 minutes. Over time, the cost of tape is much more than the expense of a brace.

Poles or hiking sticks have been shown to reduce the load on joints and increase balance and support while hiking. In this study, researchers at the Department of Kinesiology (Western Illinois University) attempt to see if wearing a backpack changes anything.

They ask the question, Will the use of poles still reduce forces on the joints when an external load (backpack) is added? They answered this question by testing 15 experienced male hikers with and without the use of hiking poles. Two different backpacks were used (light and heavy). Results were compared to trials with no backpack.

Everyone was tested while walking three miles per hour downhill at a 20-degree gradient. A special force plate was used to measure ground reaction forces. Ground reaction refers to the force through the heel to the knee from contact with the ground at heel strike. Hikers were also videotaped to look at joint angles and joint motion.

Results showed using poles did decrease the load on the joints in the leg (hips, knees, and ankles). This was true for hikers with and without backpacks and for both pack sizes.

The authors suggest using trekking poles can reduce muscle injuries from overuse and decrease the load on joints. The hiking poles also put hikers in a more upright position, which improves posture and reduces the work of breathing.

Swelling is often present after an ankle sprain. Swelling can delay healing and reduce ankle function. The main goal of early treatment is to control swelling. One way to do this is with a special form of electrical stimulation (ES) called neuromuscular electrical stimulation (NMES).

NMES causes muscles to contract. The result is a mechanical pump that increases fluid and blood flow away from the ankle and back toward the heart. In this study, 34 patients with early ankle sprains were put into one of three groups.

Group one was treated with NMES. Group two had ES at a level too low to cause muscle contraction. Group three had a sham treatment (set up the same as the other two groups but no ES was given). Everyone was treated for 30 minutes for three days.

Ankle volume, size (girth), and function were measured before and after treatment. Measurements of the uninjured ankle were also taken for comparison.

No real difference was observed in ankle volume or function among the three groups. The NMES group had improved ankle girth between the first and third treatment sessions. Overall the NMES was not effective in reducing swelling after ankle sprain.

The authors remark that this was just one way to use and test NMES on patients with ankle sprain. More studies are needed using other treatment protocols with various NMES approaches before concluding that electrical stimulation is not effective treatment for ankle sprains.

Orthopedic surgeons from the University of Iowa Hospitals and Clinics offer the first report on the impact of ankle osteoarthritis (OA) on overall health. They surveyed a large group of adults with ankle OA. Some had degenerative OA associated with aging. This type of arthritis is also called primary OA. Others had posttraumatic OA from a previous injury.

A commonly used measurement tool called the SF-36 was used. The SF-36 asks a series of questions to assess mental and physical well-being. In this study, the OA group was compared to a control group. The control group were healthy adults the same age and gender.

The authors found that patients with posttraumatic OA had more severe pain than patients with primary OA. The posttraumatic group were younger and more likely to have ankle pain earlier in life lasting longer than the primary OA patients.

For all patients with ankle OA, their condition had a major effect on their sense of physical well-being. In fact, the scores on the physical portion of the survey showed that patients with ankle OA were equal to or worse than patients with end-stage kidney disease or congestive heart failure.

Ankle pain was the greatest in patients who had other musculoskeletal problems. These other problems were not related to the foot or ankle. The authors conclude that overall musculoskeletal condition impacts patients’ sense of well-being and reduces their quality of life significantly.

Surgeons treating patients with ankle OA are advised to watch for a greater physical decline and ankle pain when other musculoskeletal problems are present.

This is the first study to look at patterns of muscle activity and joint motion at the same time in patients with ankle functional instability (FI). FI refers to the fact that these individuals twist their ankle easily. Sometimes it happens without warning or cause.

A group of adults with FI were tested using EMG (electromyography) while walking on a treadmill. The results of the tests were compared to a control group of men and women who did not have an ankle problem.

The FI group all had at least two inversion injuries severe enough to keep them off their foot for a period of time. In an inversion injury, the outer edge of the ankle gives way.

A special 3-D motion tracking system was used during walking. Infrared light-emitting markers were attached to the leg in several places. This device measured joint angles during motion. At the same time, surface electrodes were used to measure the electrical activity of the muscles.

The authors report increased ankle inversion and decreased foot clearance during walking for the FI group compared to the control group. The inverted position was held during the final swing phase of the lower leg. It was also present when the heel touched the ground and weight was accepted onto the foot and ankle.

The peroneus muscle in the ankle/foot showed increased electrical activity after heel strike in the walking sequence for the FI group. This may be a way the ankle has to offset the inverted position of the ankle joint. The pull from the muscle may offer some natural protection from further inversion injury to the ankle.

The findings in this study support the idea that hyperinversion injuries are biomechanical in nature. If the ankle isn’t positioned properly before heel strike, risk of inversion injury increases.

Rehab may be the answer to this problem. Exercises to retrain muscle control and correct position of the ankle should come first before agility drills and jump landing. Bracing and taping may help hold the joint in a neutral position as part of the retraining process.

Damage to the cartilage in the ankle occurs much less often than similar injuries in the knee. When it does occur, damaging osteoarthritis (OA) can develop later. When the cartilage is pulled away from its attachment to the bone it’s called a full-thickness defect.

In this study surgeons use arthroscopic drilling to treat stage 2 and 3 osteoarthritis (OA) of the ankle. All cases of OA were associated with full-thickness defects. OA can be caused by a previous injury such as an ankle sprain or fracture. It can also occur as a result of ankle deformity from paralysis.

Drilling into the bone and removing any fragments of cartilage helps stimulate healing of the cartilage in this area. The authors report this treatment method works better in the ankle than it does in the knee for several reasons.

First, the cartilage in the ankle is thinner and stiffer than in the knee. Faster healing with greater regeneration of cartilage cells occurs in the ankle. This may be because of unique biomechanical properties of the ankle.

After drilling, the surgeon reconstructed the lateral ligament to increase ankle stability. The operation is described in detail. The gracilis tendon from the knee was used as the donor graft to replace the torn ankle ligaments.

Results were measured by improvements in function and anatomic changes seen on X-rays. A second-look arthroscopy was also done one year later. Patients with stage 2 OA had nearly normal joint space after the drilling and stabilization of the ankle. Severe loss of joint space was still present in patients with stage 3 OA. The authors only recommend this treatment for stage 2 OA.

Ankle sprains are often treated with some type of support. Is there one that works best for first-time acute sprains? In this study, bracing versus using an elastic wrap was compared for grade I and II ankle sprains.

Patients were divided into groups based on how severe the sprain was and the treatment given. Each patient was seen for the first time within 72 hours of the ankle injury.

Grade I ankle sprains were treated with an elastic Ace wrap, an Air-Stirrup ankle brace, or an Air-Stirrup ankle brace with an Ace wrap. Grade II sprains had one extra treatment method: a fiberglass walking cast. The cast was worn for 10 days and then the Ace wrap was used.

Patients with Grade III ankle sprains were treated with the Air-Stirrup ankle brace or the walking cast for 10 days. An elastic wrap was used after 10 days for all grade III sprains.

Everyone was enrolled in the same rehab program starting during the first week after the sprain. Patients were followed until they were pain free, had full motion, and could return to sports. Other activities used to measure results included stair climbing, hopping, jumping, and toe raises.

The results showed an earlier return to preinjury level of function and activity with the Air-Stirrup and Ace wrap combination. When used together, these two supports resulted in a faster return of motion, activity, and function. This was true for all three types of sprains. Sprains treated with casting and Ace wrap took longer to recover compared to casting alon

Say the word golf and you’ve got the attention of thousands of golf enthusiasts. But for all who love the sport, billions are spent in golf-related injuries each year. The American Academy of Orthopaedic Surgeons (AAOS) reports the leading injury affects the elbow. Injuries to the spine, knee, hip, and wrist are also common.

In this report the AAOS offers golfers advice on how to avoid golf injuries. First, start a program of muscle exercises. Increasing flexibility and improving durability can help reduce the risk of common injuries.

Second, don’t take up golf without some instruction. A beginner (or anyone) who doesn’t use proper golf techniques is at increased risk for injury, especially low back injury. Third, plan a five to 10 minute warm up routine. Stretch all areas of the body, including the arms, neck, shoulders, back, and legs. Take some practice swings. Take advantage of the driving range and hit a few golf balls there before teeing off.

The authors offer specific exercises for the elbow and back, the most common problem areas. Proper posture is also reviewed. Golfers are encouraged to keep the pelvis as level as possible during stance and swing. A few golf lessons can help correct any bad habits early on.

Proper body mechanics out on the golf course can also go a long way to protecting from injury. The golfer should bend at the knees, not at the waist when planning the next shot or picking up the ball. Rest breaks or stretch breaks are always a good idea.

When a golfer injures him or herself, see a doctor or physical therapist quickly. If symptoms don’t go away after a few days of rest, ice, and support of the body part in question, then get some help. Early intervention is often the key to getting back on the golf course for that next set of holes.

Arthroscopy has changed the way surgeons treat joints. With a tiny TV camera on the end of a long, thin needle (scope), the doctor can see and work inside the joint. Smaller and smaller skin incisions are needed now because of this improved technology.

The point of entry into the joint is called the portal. Surgeons have had to find places to enter the joint without causing damage. They must avoid blood vessels and nerves. Two or three portals are used most often during arthroscopic ankle surgery. In this report, doctors describe a new (posteromedial) (PM) ankle portal.

Posteromedial means the scope enters from the back and side of the joint. A small incision is made alongside the posterior tibial tendon. It’s located just behind the medial or inner ankle bone called the medial malleolus. In this article, position of the patient during surgery and the exact method of entry are described along with a patient case report using this technique.

For this one patient, the PM portal was used to remove bone spurs along the bottom of the lower leg bone (tibia). A loose fragment inside the joint space was also taken out during the arthroscopy. Three months later, the patient was pain free and there were no further problems.

The PM method described is safe and avoids neurologic damage. It offers the surgeon easy access to the joint with a good view of the posterior compartment of the ankle. Care must be taken to avoid damage to the posterior tibial tendon.

More and more patients with joint replacements are joining the sports craze. Sports activity after joint replacement is at an all time high. In this study, rate, level, and type of sports activity after total ankle replacement (TAR) are reported for 147 patients (152 ankles).

Three fourths of the patients had posttraumatic ankle arthritis. All patients had good blood flow, bone density, and ankle stability. Participation in sports and physical activities was an important goal for these patients. Pain relief and range of motion were an important part of meeting this goal.

Before surgery 36 percent of the patients were involved in sports activity. After surgery this number increased to 56 percent. Patients with systemic arthritis were the least likely to join in sports activities.

Some of the patients who were active in sports before surgery lost their ability to participate after TAR because of pain. Others who weren’t able to play or recreate before TAR were able to start postoperatively. Biking, swimming, and hiking were the most popular activities. Other activities included tennis, bowling, skiing, golfing, and horse back riding.

Newer TAR designs offering more normal joint motion are making it possible to remain active in sports after surgery. Painful end-stage ankle arthritis can be successfully treated with TAR. As the aging of active Americans continues, the number of posttraumatic ankle patients will also rise. Quality of life is improved with better motion and function after TAR.

Ankle injuries are common in running and jumping sports, especially soccer. Ligament sprains and bone fractures are the most common traumatic injuries. Poor alignment of the ankle and an unstable joint occur in up to 30 percent of adults with previous ankle injuries. The results of a new study show that ankle osteoarthritis is common 30 years later.

Patients going to an ankle arthritis center over a period of seven years were included in this study. There were 261 cases of post-traumatic ankle sprains. Of these, 185 led to painful ankle arthritis. Thirteen percent of the 185 ankles were from ligament sprains. Over half were from sports activities. The rest occurred during daily activities.

Using measures of ankle pain, motion, alignment, and joint stability, the authors found the following results:

Osteoarthritis (OA) affects the hips and knees most often but can also cause ankle pain. Walking becomes very difficult because of joint pain and morning stiffness. This study reports on the use of three orthotics for ankle OA. Each one is used a little differently to control joint motion and align the foot and ankle in order to reduce pain.

The three types of ankle orthotics reviewed are: 1) solid ankle foot orthosis (AFO), 2) rigid hindfoot orthosis (HFO-R), and 3) articulated hindfoot orthosis (HFO-A). Th solid AFO covers the back of the calf, heel and bottom of the foot. No motion of the ankle or foot is allowed. The HFO-R covers the hindfoot and heel but not the toes. It prevents ankle motion but allows foot movement. The HFO-A fits across the lower calf, heel, and foot. It has a mechanical hinge joint to allow ankle motion but not foot mobility.

The orthotics were compared against each other and to a shoe without an orthosis. Patients walked over various ground surfaces. Ground conditions included a level surface, going up and down a ramp, and walking along a side-slope.

A motion analysis system was used to track the movement of ankle and foot. Each patient was tested unbraced and then with each of the orthotics on all surfaces. The authors report the HFO-R was the best choice for all surfaces. It held the hindfoot stable the best while still allowing the forefoot to move.

If ankle motion is to be restricted without affecting overall foot function, then the HFO-R is optimal when ankle OA pain is caused by ankle motion.

In the article the editors of The Journal of Bone and Joint Surgery reviewed the latest research in the area of musculoskeletal medicine. Over 100 medical journals were included. A brief summary of 19 foot and ankle conditions are presented.

Bone fractures, ankle sprains, instability, and arthritis are among the various topics. Plantar fasciitis, joint fusion, and tendon rupture are also covered. Symptoms, clinical exam, and special tests for each one are reviewed study by study. Unusual cases and treatment options for each condition are also discussed.

Some of the research ideas included:

You’ve probably heard of a frozen shoulder but what about a frozen ankle? Loss of motion and painful stiffness can affect the ankle just the same as the shoulder. Most often the patient has had a previous ankle injury.

In this report, surgeons present five cases of post-traumatic frozen ankle. All were treated with arthroscopic surgery approached from the front and the back of the ankle. The surgeon cut away part of the capsule and removed scar tissue and fibrous bands from around the ankle. If ankle motion was still limited, several of the ankle ligaments were also cut.

Full weight-bearing and mobilization exercises were started the next day. A splint to hold the ankle in dorsiflexion (toes pulled up toward the face) was worn at night. Gain in motion ranged from one to 19 degrees and was maintained for at least two years (follow-up period).

The authors conclude arthroscopic surgery works well for post-traumatic ankle stiffness. Without large incisions and only a few puncture holes, there’s very little wound pain. A combined anterior and posterior method is needed. Routine ankle arthroscopy doesn’t allow the surgeon to remove adhesions and scar tissue throughout the ankle.

Trauma is the most common cause of ankle arthritis in active, young adults. Ankle fusion may be the only answer to end pain in the late stages of ankle arthritis. Surgeons and their patients are interested in knowing the long-term results of this operation. This study compares a group of 26 patients who had ankle fusion with a control group of 27 healthy, same age, same sex adults.

Measures used to compare the two groups included range of motion, gait analysis, and X-rays. Questions used to measure function were also included. As expected, the fusion group had much less motion, especially when walking. X-rays showed osteoarthritic changes developing in the other joints of the ankle and foot.

A six-camera, three-dimensional (3-D) system was used to monitor walking patterns. Range of motion, cadence (steps per minute), and stride length were assessed in both groups. The ankle fusion group had a slower pace and shorter stride length compared to the control (normal) group. The fusion group also had decreased motion at the hip, hindfoot, and forefoot.

The authors suggest that anyone thinking about an ankle fusion should be carefully counseled. They should be told that ankle fusion is a salvage procedure. It will give them pain relief and improve overall function. It will not restore a normal walking pattern. The restricted ankle motion puts them at risk for arthritis in the other ankle and foot joints.

Almost one-third of all athletic injuries are ankle sprains. Finding risk factors may give players, coaches, and trainers a chance to prevent these injuries. In this study physical therapists, doctors, and athletic trainers team up to look at the effect of balance and hip strength on ankle sprains.

High school athletes (boys and girls) from a variety of sporting events were included in this study. Preseason hip strength and standing balance were measured for all 169 athletes. Other factors viewed as possible risks were also considered such as gender, loose ligaments, and body mass index (BMI).

All athletes were followed for two years. Noncontact ankle sprains were recorded during that time. Noncontact sprains occurred when the player was alone and not during a tackle or during body contact with another player.

Results showed that females had better balance but there was no difference between males and females for number of noncontact ankle sprains. A history of previous ankle sprain seemed to be the biggest risk factor. Being overweight was also a risk factor for the male athletes. When combined together these two risk factors increased the risk even more.

Hip strength and balance do not appear to have an impact on ankle sprains. Previous history of ankle sprain and being overweight are better predictors, especially for male high school athletes.

In this study orthopedic surgeons from the University of Kentucky Sports Medicine clinic report on two cases of syndesmosis ankle injury. In this type of ankle sprain, the ligaments and connective tissue holding the lower leg bones together are torn. The two bones involved are the tibia and fibula.

The authors review the ankle anatomy and testing used to diagnose syndesmosis injuries. Pain and swelling above the ankle joint line in the front of the ankle in the first 24 hours after injury is a red flag for this condition.

Syndesmosis injuries are uncommon and easy to overlook or miss at first. Plain X-rays are used to help identify the problem in the acute phase. Stress X-rays are needed to see them clearly later on if the injury is missed at first. The exact measurements for normal spacing between the bones is reviewed for plain X-rays, CT scans, and stress radiographs.

Early treatment is needed to avoid future ankle problems, especially arthritis. Treatment is determined based on the X-rays. If the space between the bones looks normal then rest, ice, and elevation are used. The patient stays off the foot for a short while. Bracing and rehab may be needed.

When a large gap between the bones is seen on X-ray then surgery is likely. One or two screws are used to hold the bones in place during healing. The patient wears a non-weight-bearing boot for six weeks. They are allowed to move the ankle. After six weeks the patient can put weight on the foot while wearing the boot. The boot can come off at the end of three months.

Athletes with syndesmosis ankle injuries should be told that healing takes longer with this type of sprain compared to other ankle sprains. Return to play is possible but delayed.

Anyone who has sprained an ankle is at risk for another ankle sprain. To prevent this, physical therapists advise doing exercises to restore the joint’s sense of position. The joint’s ability to sense movement (speed and direction) is called proprioception.

In this study researchers compared two proprioceptive tests to see if they are both affected after ankle sprain. Eighteen adults with three or more ankle sprains joined the study.

Movement in different directions was measured at three speeds. The subjects reported when they could feel movement and in what direction. The findings showed no link between the two tests. Subjects who could detect movement couldn’t always tell the direction.

The authors say the results of their study suggest two things:

In this study trainers and physical therapists report on soccer injuries in women. They tracked the number and type of injuries during one complete outdoor soccer season. All players were elite or high-level soccer players in the German national league.

Nine teams with a total of 165 players took part in this study. Information collected during the season included time spent in training and matches and details about any injuries.

They found that two-thirds of the players were injured at least once during the season. Sixty (60) percent of the injuries occurred during matches. Some, but not all, were contact-related (trauma from direct contact with another player). Most injuries were in the legs. Ankle sprains and tears of the anterior cruciate ligament topped the list. About 10 percent of the injuries affected the spine. There were fewer injuries during training and most of those were due to overtraining.

Soccer is one of today’s most popular sports around the world. Protecting soccer players from injury is an important goal. Knowing that ankle sprains and anterior cruciate ligament tears are so common will help teams focus on prevention during training. Trainers and therapists will keep studying what works best to prevent such injuries.

In this article Dr. J. Maquirrian reviews a condition called posterior ankle impingement syndrome (PAIS). The patient with this problem reports pain in the back (posterior) part of the ankle. It occurs most often when the toes are pointed all the way down. This position is called ankle plantar flexion.

Various causes of PAIS are reviewed along with ankle anatomy. Downhill runners, kickers, and dancers are affected most often. Fractures, athletic injuries, and repetitive stress are often part of the picture.

Doctors make the diagnosis based on an exam. Patient report of symptoms and X-rays, MRIs, or other imaging studies is also used. The author gives a flow sheet for treatment starting with rest. Ice, antiinflammatory drugs, and avoiding forced plantar flexion are often used.

Patients may be given a physical therapy program of strengthening exercises. Surgery is an option when conservative treatment fails. The author reviews various operative methods, depending on the underlying cause of the problem.