Ankle Sprain

Ankle Sprain

We have all had one - What Happened?

Ankle Sprain Anatomy

Everyone has suffered an ankle injury or sprain at some point in their life.  The most common form of an ankle sprain is an inversion mechanism of injury.  Inversion, meaning the inward twisting of the ankle, is most common because of the anatomy of the ankle joint comprised of the distal fibula and tibia.  The medial distal tibia, or medial malleolus, is much larger than the lateral malleolus and has stronger ligaments.  The medial ligament is call the deltoid ligament, which is a broad fanlike ligament.  On the lateral aspect of the ankle, there are mainly 3 ligaments:  anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament.

A sprain is defined as partial tearing of a ligament.  Ligaments attached bone to bone and provide our skeletal system stability.  When the ankle is maximally inverted, when someone "rolls their ankle," the ligaments are stretched maximally.  One of 2 things will happen, either partial tearing of the ligaments, or indicates the ligaments are strong, the distal fibula will break.  If the force is great enough, the distal fibula will break and the medial deltoid ligament will pull strongly enough to fracture the medial malleolus.  Often this injury, called bimalleolar ankle fracture, require surgical repair.

Ankle sprains are graded on a scale of 1-3.  This refers to the severity of partial tearing of the ligament.  Generally, grade 1 is able to be "walked off," and involves less than 25% of the ligament.  Grade 2 requires some protected weightbearing with crutches and involves up to 50% of the ligament.  Grade 3, involves all of the ligaments being torn and the ankle will be unstable.

Sometimes a pop or snap was heard at time of injury.  It is very difficult to determine if there is an ankle fracture or sprain based on symptoms and a x-ray is required.  Once a fracture is ruled out, early rehabilitation is essential for return to function

Ankle pain, swelling, bruising are the most common symptoms after an ankle sprain.  Walking may be difficult but is encouraged as early as possible.  The traditional RICE treatment should be started initially.  Rice stands for rest-ice-compression-elevation.  I like to add a “N” to the end standing for NSAIDs – RICEN.

The initial treatment can be completed at home, physical therapy is definitely helpful because of their knowledge, ability is, equipment that the average person does not have available to them.  And important, often overlooked aspect of rehabilitation is massage.  Initially, in combination with elevation, light massage can help with edema and pain control.  Edema can slow down the healing process and removing it will improve healing.  After 7 days or so, deeper techniques can be implemented to increase blood flow.  After all, the foot and ankle is farthest from the heart, less blood supply means slower healing.

Cross friction massage is beneficial to break up scar tissue, increased blood flow to the ligament.  This should be done while the ligament is in a stretched position.  Pressure should be within limits of pain.  The movement should be across the tendon, back and forth like plucking a guitar string.  It will be uncomfortable but should not cause guarding.  Treatment length is advised to be 5 or 10 min. long.  Every other day versus every day is better for recovery.  If there is increased swelling, skip the next treatment to allow for the edema to resolve.

Bracing may be required to protect the ligament once returning to sport or activity.  Biking is a great initial activity because there is no lateral movements to the ankle.  Cutting sports should be the last activity to return.  Once you are able to walk in a straight line without pain, try jogging.  If able to jog, tried jumping and/or cutting activities.  Once you're able to pass these "functional" activities, he may return to her activity level.

It is very common for ankle swelling to persist for a couple of months.  Continue to treat conservatively with ice, anti-inflammatories, elevation.  Massage may be continued as needed.

There is essential to seek orthopaedic care immediately after the injury to rule out a fracture because this is very difficult to know without an x-ray.  However, it you're able to walk immediately after and his symptoms resolved after a couple of days, conservative treatment should be adequate.  It is any concern, please see your orthopaedic doctor.

Patellofemoral Syndrome

Q-angle (Quadriceps angle)

Patellofemoral Pain Syndrome

Anterior knee pain - What's Going on?

Patellofemoral syndrome (PFS) is the most common affliction encountered in the field of orthopedics. Commonly effecting women, between the ages 12-18 and 24-32, accounts for the most office visits for complaints of anterior knee pain.  PFS can also effect men, but because of anatomical differences between men and women, the later often encounter more problems.  This is because of the "Q-angle" which is a measurable angle for the hip down to the knee, is difference between the sexes.  This angle changes the angle at the knee, and alters the pull of the quadriceps muscle.  The pull on the knee cap or patella is now slightly lateral.  This can cause some compression under the lateral edge of the patella resulting in pain, increased wear, patellar instability and early arthritis.

Symptoms include anterior knee pain, pain in the front or side of the knee cap or patella.  Pain is usually worse going up or down stairs, kneeling or squatting, getting up from a chair, getting out of the car, and commonly hurts if the knee is bent for extended periods at a desk or riding in the car.

The primary treatment is multifactorial.  The old adage "RICE" is definitely part of the regimen.  Rest, ice, compression, and elevation is the treatment for the pain and inflammation.  Avoid aggrivating activities which can be running, but commonly include stairmaster, squats, lunges, and knee extension machine.  Physical therapy is usually required to increase medial quad strength, and improve the flexibility of the ITB (illiotibial band) and lateral retinaculem.

Lateral Patellar Tracking and
Chondromalacia

Bracing and kenesiotaping can be helpful adjuncts to therapy but doesn't address the underlying issue.

Massage therapy can be very helpful to stretch and release the lateral retinaculem and ITB to help improve patellar alignment and tracking. Massage can also help increase blood flow and decrease pain.

Getting the correct treatment is very important to proper recovery and return to activity.  Chronic problems may have a deeper structural cause.  This needs to be evaluated by an orthopedist with a radiograph or x-ray.  If the knee cap is coming out of place or popping in and out, this may need further treatment is physical therapy, massage, and bracing do not help.