Physiotherapy and rehabilitation
We will present the most common ankle injuries in detail. Every pathology or ankle injury comes with a description of general facts, causes that led to the development of the injury, characteristics of the symptoms, diagnosis, and the course of treatment.
Chronic ankle instability is a condition that affects the function of passive ankle stabilisation due to laxity or injury of the ligaments. Symptoms that are typical of this condition are a constant sense of instability, swelling of the joint, twisting of the foot, occasional pain, and difficulty walking or changes in the walking pattern.
Recurrent ankle sprains are common. Chronic ankle instability is strongly related to strength deficit in ankle muscles, muscle imbalance, and generally poor functional capacity of the joint. A non-functional state of muscles creates conditions where the subtalar joint can only rely on static stabilisers for support, which means the ligaments are overburdened and exposed to injury.
Chronic ankle instability is a consequence of recurrent ankle sprains or inadequate rehabilitation of an ankle sprain. In the long run, chronic ankle instability comes with a high risk of cartilage injuries and osteoarthritis of the joint due to a higher likelihood of micro-injuries.
If such symptoms appear, it is important to be examined by an orthopaedist and to be diagnosed using ultrasound or magnetic resonance imaging. In the first phase of conservative treatment, it is vital to measure muscles’ contractile properties using the TMG method.
As the first method of treatment, we recommend conservative kinesiotherapy that places emphasis on exercises that improve proprioception and stabilisation of both subtalar joints. By improving the strength of ankle muscles, the risk of recurrent sprains is reduced.
We recommend conservative kinesiotherapy that places emphasis on exercises that improve proprioception and stabilisation of both subtalar joints.
By improving the strength of ankle muscles, the risk of recurrent sprains is reduced. Surgical treatment is used in the case of severe ligament injuries or excessive functional limitations of the ankle that conservative treatment cannot improve.
The surgical procedure most often entails the reconstruction of the ligament, the removal of the scars, or sewing or shortening of the ligaments. After the surgical treatment, it is key to do postoperative exercises to strengthen ankle muscles that provide functional stabilisation to the ankle and proprioception exercises.
Ankle fracture denotes the breaking of the bones of both subtalar joints that occurs when severely spraining an ankle, falling, or landing awkwardly.
The non-contact injury mechanism is virtually the same as the ankle sprain mechanism. The fractured bones are most often heel bone and talus bone; immediately when breaking them, pain and swelling occur. Since the fracture is also accompanied by a ligament injury, the symptoms may seem similar to those of a sprain.
This is dangerous because the fractured bones may go unnoticed.
Ankle dislocation is a severe type of ankle injury where the ligaments stretch or deform to such an extent that the joint can no longer be kept in its functional anatomical position. In the event of ankle dislocation, the joint deformation is visible externally. Ankle dislocation oftentimes accompanies subtalar joint bone fractures and, in most cases, requires surgical treatment.
When spraining an ankle, it is absolutely necessary to see a doctor and undergo adequate diagnostic procedures using an X-ray or magnetic resonance imaging (MRI).
If a fracture is diagnosed, the ankle is immobilised. According to the protocol, immobilisation is followed by special exercises that strengthen the ankle muscles along with mobility and balance exercises, which improve the ankle’s function and stability. Instrumental physiotherapy is used to manage swelling.
Ankle sprains account for 45% of all injuries to lower extremity joints. Ankle sprains are one of the most common musculoskeletal injuries in general and they also have one of the highest recurrence rates. 20% of ankle sprains deform the articular cartilage and recurrent ankle sprains lead to chronic ankle instability and osteoarthritis in the long run. In most cases (85%), lateral ligaments of the ankle are injured.
The ligaments that are injured most often with ankle sprains are the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL).
Depending on the trauma severity, lateral ligament injuries of the ankle correspond to 3 different degrees of severity:
A major risk factor for ankle sprains is the shape of the innate anatomical position of the foot arch. A high and/or short foot arch causes the feet to roll inward, which makes it more likely to get injured.
The most common ankle sprain mechanism is simultaneous rolling of the ankle inward and the foot upward; this is professionally known as an inversion ankle sprain with plantar flexion. The inversion type of trauma means that our own weight places excessive pressure on the outer side of the ankle, causing the ligaments and muscles, which maintain lateral stabilisation, to stretch, partially tear, or completely tear.
If an ankle sprain is suspected, it is necessary to see a doctor and immediately undergo diagnostic imaging (magnetic resonance imaging – MRI, X-ray, or ultrasound). It is vital to exclude worse complications, such as ankle fracture or dislocation. In most cases of severe ankle sprains, x-ray imaging is performed.
In the majority of cases, the treatment of ankle sprains is conservative. Surgical intervention is necessary only in the case of accompanying complicated bone fractures, cartilage injuries, or chronic ankle instability. Treatment follows the RICE method (rest, ice, compression, elevation) for the first 72 hours after the injury. Crutches may be used to bring relief in the event of severe symptoms.
The acute phase after the injury is followed by the phase of functional rehabilitation, which includes a specialised exercise programme that has always been superior in the long-term success of treatment in comparison to the first therapeutic phase.
Ligaments provide passive stability to the ankle when performing movements. Ankle ligament injuries are common and accompany most sprains, at least to a small extent.
Ankle ligaments that are injured most often include the anterior and the posterior talofibular ligament (ATFL, PTFL) that connect the talus bone and the calf bone; the calcaneofibular ligament (CFL) that connects the heel bone and the calf bone; the cranial cruciate ligament (CCL) that connects the heel bone and the cuboid bone; and the deltoid ligament that connects the shinbone and the talus bone.
Depending on the trauma severity, lateral ligament injuries of the ankle correspond to 3 different degrees of severity:
In the majority of cases, the treatment of ankle ligament injuries is conservative. Surgical intervention is necessary only in the case of accompanying complicated bone fractures, cartilage injuries, or chronic ankle instability. Treatment follows the RICE method (rest, ice, compression, elevation) for the first 72 hours after the injury. Crutches may be used to bring relief in the event of severe symptoms. The acute phase after the injury is followed by the phase of functional rehabilitation, which includes a specialised exercise programme that has always been superior in the long-term success of treatment in comparison to the first therapeutic phase.
A heel spur (thorn in heel) is the term for a growth on the heel that is present in the form of a calcium or bone deposit or osteophyte. Heel spurs have an overall prevalence of 15%, but are more common in the elderly, with 35% of individuals in the 60-69 age group having a heel spur. Heel spurs can be asymptomatic, i.e. they do not cause any pain, but should always be treated with physiotherapy as they are a risk factor for the onset of pain. A heel spur usually hurts on one side, although 2/3 of patients also have a spur on the other heel, which they cite as a problem with the other heel in the past.
Heel spurs can grow up to 1 cm in size and can occur on the back of the heel (spina calcanei superior), as a result of overloading of the Achilles tendon process, or on the underside of the heel (spina calcanei inferior), as a result of overloading of the plantar fascia process. Plantar heel spur, on the inferior side of the heel, is due to plantar fasciitis, is the more common and usual ”heel spur” reported by patients at the time of the visit.
Risk factors for heel spurs are flat feet, increased body weight, wearing high heels, sports overload especially jumping and running, diabetes mellitus or diabetes mellitus and age. It is more common in women, athletes, the elderly aged between 60 and 69 years and diabetics.
A heel spur has a characteristic pattern of symptoms, making it easy to distinguish from other pathological conditions that cause pain in the heel area. Heel spur pain is sharp and intense, occurring mainly in the morning at the first steps in the heel area. Typically, the pain subsides or diminishes after a short distance has been walked. A heel spur is characterised by post-static dyskinesia, which means that after physical inactivity or rest, the heel always hurts intensely for the first few steps.
Although the symptoms of a heel spur depend on the size, shape and location of the spur, in most cases the pain is most intense in the morning, as the plantar fascia shortens and widens at night. Symptoms typically worsen with running and walking.
The heel spur is one of the pathological conditions that require a comprehensive conservative approach of physiotherapy and kinesiology. This means that if only one type of therapy is used in isolation, the heel spur will not be eliminated. Integrated treatment includes shockwave therapy, TECAR therapy, LASER therapy, manual therapy and kinesiology training.
Treatment of a heel spur usually lasts between 16 – 24 weeks, in case the heel spur has been present for more than a year the treatment is prolonged. To treat heel spurs, shock waves are often performed in isolation and, although they are the most effective method of ”breaking” or eliminating heel spurs, they must be performed together with specific exercises and manual therapy.
Treatment of heel spurs should include techniques to improve the quality of the connective tissue of the plantar fascia, which is achieved by exercises to strengthen the intrinsic muscles of the foot and endurance exercises to strengthen the tibial musculature.
At Medicofit, we use EMS Focused Deep Shockwaves as the leading method of treatment for heel spurs, which are the most effective tool for heel spur rehabilitation in clinical practice, with patients usually noticing the pain-relieving effects after the first treatment. Deep shock waves break down the loaded calcium into smaller units, which are then absorbed and broken down in the surrounding tissue. Shockwave therapy should be performed in combination with special exercises to strengthen the arch of the foot, which is always taken into account at Medicofit.
