The Ankle: Best practice for recognition and assessment of ankle instability
The following points are taken from various contributors, Issue Number 2, 2017, Sports Physio, an Australian Physiotherapy Association publication.
Ankle injuries not only make up 15% of reported sports injuries, but are common amongst the general population.
There are numerous ligaments about the rear foot whose purpose is to stabilise the ankle. So ankle and rear foot instability are the terms commonly used today.
Most ankle injuries are caused when an athlete rolls over the outside of the ankle, eversion, and strain, tear or avulse (tear from the bone) ligaments leading to lateral instability. If not carefully and properly rehabilitated, chronic or long term instability may result. Many ankle sprains progress to chronic ankle instability because of poor management and inattention to rehabilitation exercise.
When the ankle is rolled inwards, it Is called inversion and often leads to injuring the deltoid ligament plus/minus the deep tibiofibular ligament. Inversion injury can lead to bony injury as well as damage to many of the other ligaments about the ankle. The joint between the fibular and tibia that forms to malleolus (the “lump” on the outside of the ankle) is called a syndesmosis. In some cases, the syndesmosis joint can be damaged or even separated. Syndesmosis injuries can be difficult to diagnose and may require CT scan to assess severity. Rehabilitation can be either conservative or surgical: either way, the correct exercises are required to avoid longer term instability.
Post recovery issues
Functional activities like running and jumping are often troublesome after initial recovery from ankle injury. Longer term, deformity of the ankle joint, scarring and impingement of the tendon of tibialis posterior can lead to poor foot mechanics and damage to other tendons critical to optimal function of the foot.
The physio will look at your foot in rest, observe its position relative to the other foot, when standing then when squatting, double and single leg calf raises and depending on severity, hopping etc.
What you can tell your therapist about the injury is very important! How the injury occurred is significant. What happened! Did the injury happen when walking, or running, jumping landing or taking off, did it swell immediately, was there and noise, e.g crack or pop, did play continue. Could it be walked on was it iced straight away, did ice aggravate the injury…………
There are several orthopaedic tests that can be performed by the physio to isolate the injured structures so that rehab can be better directed. What is important is to consider the various movements available at the major joints of the ankle. Remember that the ankle must be able to flex up and down as well as rotate, abduct and adduct, and mostly simultaneously!
Ice and compression are initial management techniques to minimise swelling. If there is pain with ice, it may indicate a fracture. Depending on severity, either rigid tape strapping or perhaps a moon boot may be required. Early in rehab, treatment is gentle and conservative. Progress slowly moves to more aggressive and challenging techniques and exercise as time goes by and deemed appropriate by the physio and patient. Generally, radiological investigation is not necessary unless pain persists after six to eight weeks. (due mainly to X-ray being notoriously unreliable for detecting fractures of the ankle.)
It is important to return the ankle to full movement in all directions as well as ensure there is strength equal to the other ankle before returning to full activities or play resuming sport.
This achieved by a graded exercise program that includes high level balance activities.
Often, conservative management well conducted will result in excellent outcomes for the injured ankle. There will be some cases where surgery is required. These cases, unless obvious from the outset and dealt with immediately, are best addressed when pain and laxity persist after 6 to 8 weeks .