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severe ankle sprain
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severe ankle sprain - April 19, 2000 8:08:00 AM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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I have a 22yo male patient who suffered a severe eversion sprain of his right ankle 1/10/00. Likely grade III post. talo-fibular lig. and grade II ant. talo-fibular and calcaneofibular ligs.
He currently continues to have some mild lateral edema. He is able to do single leg hop (15 sec hop test right 60% of Left). Dorsiflexion is limited to 7deg (12deg wt bear) This is what is primarily limiting his function at this time. Talo-navicular and Talo-cuboid joints are moving fair (boggy end-feel)
My question is: Does anyone have any ideas on how to regain full dorsiflexion? I would welcome any and all suggestions.
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Re: severe ankle sprain - April 19, 2000 10:59:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Edilling:
Getting dorsi flexion back is really difficult....I can sympthasize. Here are a few options, many of which you may already have tried.
1. I am not huge into manual therapy but Mulligan's Mobilization with Movement for dorsiflexion seems to work really well. A picture is available in his book.
2. Walking uphil on a treadmill several times per week for 20-30 min.
3. A dynamic splint for night-time??
4. Sustained static stretching. I occaisonally have a patient stand in slight dorsiflexion stretch (slight runner's position or on a slant board which works even better). Place a hot pack on the achilles and/or ankle. Every minute I have the patient advance further into dorsiflexion for 10 minutes total. The key is to start with almost no stretch and then to just advance slightly each minute to let the tissue accomodate. If you want to go crazy you can even ultrasound the achilles while this is occuring.
5. Perhaps the best thing is to enusre that he is in dorsiflexion for as much of the day as possible. Have him increase his stride length slightly during gait. When he is sitting and watching TV or studying etc. have him rest the front of his foot on a book.
Hope that helps.
Take care,
Marc
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Re: severe ankle sprain - April 19, 2000 7:01:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Edilling,
I think we'd all like to help, but I think I'm not alone in being a little confused . . . and I'm surprised that none of the folks who have responded so far have not raised this issue (especially Mcap who seems to know his ortho cold, so please correct me if I’m wrong):
If I remember my ortho correctly, usually, when a patient has an eversion injury, the calcaneous swings out laterally. It's fairly uncommon, or at least less common than inversion injuries.
Usually in an eversion injury, the lateral ankle ligaments (e.g. talo-fib, and calacaneo fib ligaments that you've diagnosed as grade II and III sprains) are compressed and unaffected, not stretched and sprained . . . the fib however, tends to fracture.
In inversion injuries on the other hand, the patient rolls over the lateral aspect of the foot. The lateral ankle ligaments are frequently sprained in this case.
Could you clarify for the forum if your initial description of the injury was incorrect, or if this was rather a rare and exceptional case? I would submit that the clinical problem solving process regarding the cause of limited dorsiflexion may be different depending upon the true nature of the injury.
For example, if this is truly an eversion injury, it is possible that the fib is fractured and has a negative impact upon the normal motion of ankle joints. If eversion was a misprint, and the injury is actually inversion, then we must continue searching for another cause.
Finally, what do you mean by DF being limited to 7 degrees? Is this 7 degrees dorsiflexion or 7 degrees plantarflexion? Furthermore, why is restoration of FULL ankle motion important to you if only 20 degrees of dorsiflexion is required for normal gait (necessary during midstance/loading response)?
Having said all of that, I'm a BIG fan of dynamic night splinting. Take a look at the Cascade website at [URL=http://www.dafo.com]www.dafo.com[/URL] and see if you can grab a few pearls of wisdom there.
Good topic for discussion though, I look forward to your reply, and the thoughts of others.
Drew
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Andrew M. Ball, MS, PT
MBA/PhD Candidate
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Re: severe ankle sprain - April 20, 2000 5:28:00 AM
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mcap
Posts: 652
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Drew:
You are correct. An eversion sprain is rare and the ant TF CF and PTF are usually injured during an inversion sprain. Sometimes I have seen reflexive eversion sprains that occur after an inversion sprain injuring both sides. I didn't really comment on it because the sprain happened so long ago and I also assumed that X-rays were taken to r/o avulsion fracture.
If it was indeed an inversion sprain then another thing to look at is fibular position. The THEORY states that the ATF can wrench the fibula anteriorly on the Tibia. so posterior glides and mobilization with movement for inversion sometimes help. Some of the manual therapists in the group should chime in with theories about what other bones might be out of place, etc.
Good luck.....Drew....good catch.....
-mcap
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Re: severe ankle sprain - April 21, 2000 8:03:00 PM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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[IMG]http://www.rehabedge.com/forums/biggrin.gif[/IMG] INVERSION [IMG]http://www.rehabedge.com/forums/biggrin.gif[/IMG]
Sorry for the mistake-- I did the same thing talking with my collegues at work.
This patient is making gains. He started in 2deg plantarflexion and can now get to 7deg dorsiflex. He is just not progressing as quickly as I would like so I opened it up to the forum. I appreciate your suggestions and will utilize some of them.
Drew,
Why gain full ROM??
This young man will be doing more than "normal" gait in his life. Any motion less than full (equal to opposite) will have to be compensated for further up the chain. While the effects of this may not be realized immediatly, other areas of his body will eventually pay the price for lack of full motion at his ankle.
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Re: severe ankle sprain - April 22, 2000 6:19:00 AM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Edilling
What activities other than gait are you suggesting need more than 20 degrees dorsiflexion? I agree that with less than 20 degrees of motion at the ankle that compensations will result up the chain, but I'm not sure that I agree that compensations occur when a patient has 20 degrees of dorsiflexion or more. Given this, I can't agree that "other areas of his body will eventually pay the price for lack of full motion at his ankle," without some specific clinical examples or references.
Could you provide us some examples or references for discussion?
Thanks,
Drew
------------------
Andrew M. Ball, MS, PT
MBA/PhD Candidate
[This message has been edited by Andrew M. Ball, MS, PT (edited April 22, 2000).]
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Re: severe ankle sprain - April 26, 2000 12:13:00 PM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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"Normal" ROM of ankle dorsiflexion ranges from 10 deg (Esch and Lepley) to 30 deg (Kapandji) and many places between depending on the author. Reliability of measurement of this joint, as we all know, is not that good. Statements such as 20 deg dorsiflex needed for normal gait or 160 deg shoulder flexion is enough for functional reach provide a reference point for therapists to guide practice, yet are not an endpoint for rehab of the individual who needs to function at a higher level (jumping, throwing)
A person with capsular pattern of the shoulder is likely to develop impingement if they continue to attempt to function at their end range. Another clinical example is that of the spinal fusion who, 3yrs later, gets the segment above fused. The lack of movement at the fusion is compensated for elsware in the body, in this case the segment above. (I did attempt a medline search but came up with a blizzard of unrelated research. Suggestions for search words?)
Examples also exist where apparently "normal" ROM is not enough. I have had 2 patients 2 and 4 yrs post ACL surgery who developed anterior knee pain when attempting jogging and softball respectivelly. Both had "full" extension to 180 deg but lacked 5 deg hyperext when compared to the opposite side. Restoration of some of this hyperextension (neither achieved 5 deg) resolved much of their symptoms. Regaining motor control of this motion "cured" them. I expect (but do not know) that they continued to encounter some limitations as they were not able to achieve equal ROM.
Back to the point. Restricted ankle dorsiflexion has been found to be a risk factor for ankle sprain (Kauffman et al. Am J Sports Med 27(5)585-93 "The effect of foot structure and range of motion on musculoskeletal overuse injuries" (http://www.medscape.com/server-java/MedLineApp?/member-search/getdoc.cgi?ord=12&searchid=2&have_local_holdings_file=0&local_journals_only=0) When rehabing an ankle one of my goals is restoration of full-equal ROM. As the "normal" ROM numbers are quite questionable, this goal does not specify 10, 20, or 30 deg dorsiflex. If the body needed this ROM prior to injury, it will need it after.
Activities such as running and cutting (soccer, frisbee, b-ball...) place normal stresses to the joints toward their end range. More importantly, -abnormal- and excessive stresses will often take the joint at or beyond end range. If this range is limited due to prior injury the strain load from these stresses will be greater. If the cannot get the motion at the injured joint it will create the motion through injury or ask another segment to take up the slack. (opinion)
This is why I want "full-equal" motion.
One final note. This patients opposite ankle dorsiflexion is 20 deg. [IMG]http://www.rehabedge.com/forums/wink.gif[/IMG]
[This message has been edited by edilling (edited April 26, 2000).]
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Re: severe ankle sprain - April 26, 2000 12:44:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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What a well referenced response. Thank you for that. I'll look up the specifics of the Esch and Lepley, as well as Kapandji articles , but location may be easier for me if you would be so kind as to provide a full reference.
I'll have to think about your comments. It may significantly change the way that I treat kids with CP, but some of the work of Ken Holt, PhD, PT stands in contrast to that. Why stretch a joint or release a tendon, if we're just going to slap on an dynamic response orthotic that is going to accomplish the same thing during the gait cycle? (That's kind of his thinking, not mine per se).
Nevertheless, we're talking about two very different patient populations, and it may not be appropriate to clinically apply the same clinical solution to both groups. Your comments have given me reason for pause though, let me sleep on this for a few days.
As for search terms, I'm afraid that I wasn't able to turn up much either. I tried (fusion and "spinal mobility"), fusion and "movement compensation") and a few other choice combo's. I turned up bust, but there has got to be something out there on this don't you think??? I mean, it's a basic assumption of ortho PT isn't it?
I don't think that Medline includes JOSPT in its database, and not being an ortho or sports PT, I don't tend to read it. I'd suggest that if anything has been published on this subject, that'd be a great place to start looking.
More suggestions as they come to me . . .
Drewfus
------------------
Andrew M. Ball, MS, PT
MBA/PhD Candidate
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Re: severe ankle sprain - April 27, 2000 8:27:00 PM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
Status: offline
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I cheated with the ROM references. They were off a card showing reported ROM of most joints given out with APTA renewal 1 or 2 yrs ago. Both were from their respective books.
I would agree with Mr. Holt-- with spasticity, try to affect the primary impairment which is reflexive and central nervous. I have heard told that many spastic children have functional rom when put under anesthesia. Is this true? If it is, the muscle is long enough and joint flexible enough so don't focus on them.
With my patient, his primary impairment is joint. (Although the more I practice, the more I see that every ortho patient is also neuro and vice versa.)
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Re: severe ankle sprain - April 28, 2000 7:59:00 AM
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Bobcat
Posts: 493
Joined: July 13, 1999
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One other thing to consider is, if my memory is not too foggy, the talocrural joint close-packs at the extreme range of normal dorsiflexion. I don't know if you need all thirty degrees or so, but most likely the more the better. I think the footplate goes into supination also during this movement which results in a configurationally "rigid" foot-plate by close-packing the other joints in de fooot. This all develops throughout the relatively high-impulse phase of terminal stance/preswing/push-off/what-have-you. And because the phase can impart a rather explosive amount of force depending on how a person walks, or changes speed while walking, or how much a person weighs, it is more likely that if you do not have full dorsiflexion, you may wind up pushing off abnormally upon an "unlocked" ankle rather than a nicely locked ankle, and subsequently, any requirement of further stability is dependent upon the injured ankle-owner's motor control, which will hopefully be both responsive, accurate and brisk.
So if the guy is not too skilled, and the force vector is off by a hair with a lot of force, the thrust line will take a lateral excursion beyond the limits of stable support, resulting in deflection into inversion (usually), hopefully compensated for by one of those quick saves where you awkwardly hop off to take all your weight off the leg as quickly as possible, and if not, you can wind up with annudah painful sper-rain.
Someone please correct this if it's off.
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