The assessment and treatment of musculoskeletal injuries can be complicated; what works for one patient may not work for the next patient. There are times when orthopedic testing may not give a clear indication as to what may be causing a patient's pain (Hegedus et al. 2017). Other times a patient may present with a seemingly straightforward injury, however after months of treatment there may be no improvement on their condition.
My professional interest is the rehabilitation of sports injuries, I have been fortunate to work at a sports medicine clinic as part of a multidisciplinary team that includes orthopedic surgeons, sports medicine doctors, pedorthists and sports physiotherapists. My colleagues have helped me build a deeper understanding of sports injuries by looking at human body through a different lens. Drawing from five lessons I have learnt from my colleagues, this article will examine the ankle and present some clinical pearls.
1. Shoes Dampen Incoming Sensory Information
A surge in the popularity of minimalist shoes can be attributed to the 2009 book Born to Run by Christopher McDougall. This book profiles a group of runners from the Tarahumara tribe in Mexico who run either in bare feet or in minimalist footwear. Running with minimalist shoes naturally leads to a high cadence and short stride running form that has been shown to reduce the instances of repetitive strain injuries. One of the reasons that kicking off the running shoes can decrease injuries is that the ankle is densely populated with mechanoreceptors and shoes damped incoming sensory information.
Switching to Vibram Five Fingers will by no means be a panacea for running injuries, but it is good to have options if high stability shoes are not your thing. If you or your patients are making the transition to minimalist footwear it is important to make a slow transition to avoid injuries.
2. Some People Have Extra Bones
A couple years back a varsity soccer player came to see me because of ongoing lateral ankle pain. After an intake and orthopedic assessment it was still not clear what could be causing this ankle pain. The patient had pain on plantar flexion and was unable to perform a full squat due to limited ankle range of motion. Treating the ankle I used a variety of manual techniques including joint mobilization and IASTM. There was a slow improvement in the ROM of the ankle but the pain was still there.
A couple weeks later after a MRI and an ultrasound, the physician made the diagnosis of an inflamed Os Trigonum. The os trigonum is an extra bone behind the talus, often it is connected to the talus by a fibrous band. The presence of an os trigonum in one or both feet is congenital, only a small number of people have this extra bone and it is more common in females. It can become evident during adolescence when one area of the talus does not fuse with the rest of the bone, creating a small extra bone.
Medically speaking these extra bones are called accessory ossicles, they are secondary ossification that are separate from the adjacent bone. In most cases they have been there since birth, there are conditions when they may occur as a result of local degenerative disease or trauma (myositis ossificans). Accessory ossicle are not an uncommon findings throughout the body, it is usually only if they become inflamed that you will notice these extra bones.
3. Some Prefer RICE, Some Prefer MEAT
Most can relate to the swelling, bruising and subsequent pain from rolling your ankle. This is a very common sports injury and most people have a full recovery in 6 weeks. Traditionally treatment of an ankle sprain consists of “RICE” (Rest, Ice, Compression, Elevation). The last couple of years there have been many who suggest moving towards a “MEAT” (Movement, Exercise, Analgesics, Treatments) protocol.
It is important to note that the RICE protocol does not have to be tossed aside in favor of MEAT, elements of both protocols remain useful. Remind the patient ‘Motion is Lotion’ when it comes to joint health, encourage optimal loading of the joint and tissue around the affected joint.
In my personal experience one of the most effective ways to mitigate the swelling and discomfort of an ankle injury is electroacupuncture. Stimulation of the tibialis anterior muscle and the peroneal muscles creates continuous passive movement at the ankle.
4. Some People Have Buttons in their Ankle
A high ankle sprain, also known as a syndesmotic sprain is a sprain of the syndesmosis and/or ligaments that connect the tibia and fibula; they comprise approximately 15% of all ankle sprains. A syndesmosis is a slightly movable fibrous joint in which bones are joined together by connective tissue. High ankle sprains are described as high because they are located above the ankle in the distal tibiofibular joint.
Unlike the common lateral ankle sprains, when ligaments around the ankle are injured through an inward twisting, high ankle sprains are caused when the lower leg and foot externally rotates. Syndesmosis sprains have received increasing recognition during recent years because of a heightened awareness of the mechanism, symptoms, and signs of injury.
There are a number of tests I recommend including in any assessment of a suspected high ankle sprain, they are:
• The Squeeze test
• The External rotation test
• The Passive dorsiflexion test
Patients with high-grade syndesmosis injuries often cannot perform a single-leg heel raise. Patients report pain over the anterior and often posterior distal fibular joint. If the syndesmosis is torn apart as result of bone fracture, surgeons will sometimes fix the bones together with a syndesmotic screw, temporarily replacing the syndesmosis. When the natural articulation is healed, the screw may be removed.
Another surgical method is tightrope fixation, this is aimed at stabilizing the syndesmosis to reduce the instability at the distal tibiofibular joint. This is completed by threading a wire through the tibia and fibula and is then held in place by two suture buttons. The benefit of this procedure is that it reduces the need for any further surgery where screws were previously needed to be removed following an internal fixation. After a tightrope fixation there may be a numb patch around the operation site and soft tissue irritation where the tightrope buttons left in. As a massage therapist it is important to be aware that a traumatic injury to the ankle will increase the likelihood of post-traumatic osteoarthritis developing in the future.
5. A Stress Fracture of The Talus is Unlikely to Show up on an X-Ray
A stress fracture of the talus is uncommon but can develop in runners and triathletes accumulating high mileage. Symptoms of a stress fracture of the talus include pain on the outside of the ankle which develops gradually. The pain will get worse with exercise particularly running and ease with rest. Other symptoms may include night ache, pain during certain movements of the foot and ankle or pain on firmly touching the talus. There is likely to be tenderness and possibly swelling over the sinus tarsi which is a small canal where nerves pass into the ankle. Bone scans and CT scans can confirm the diagnosis as a stress fracture is unlikely to show up on an X-ray until healing has begun.
Managing musculoskeletal injuries requires more than just knowledge of orthopedic injuries, it requires the ability to assess and treat the patient through a biopsychosocial lens. On paper, the assessment and treatment of ankle injuries may seem straightforward. However, patient presentation may not always be reflective of what is described in books and articles. The key to the assessment and treatment of any injury is a deep knowledge of the form and function of the human body. It is important to keep an eye out for novel ways to treat sports injuries unconventional tools like, electroacupuncture, IASTM and cupping.
More to Explore
Hegedus, E.J., Wright, A.A., Cook, C. (2017). Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers. Br J Sports Med.
Hermans, J.J., Beumer, A., de Jong, T.A.W., Kleinrensink, G.J. (2010). Anatomy of the distal tibiofubula syndesmosis in adults: a pictorial essay with a multimodality approach. Journal of Anatomy. (OPEN ACCESS)
Hunt, K.J. (2013). Syndesmosis Injuries: Curr Rev Musculoskelet Med.
Hunt, K.J., Phisitkul, P., Pirolo, J., Amendola, A. (2015). High Ankle Sprains and Syndesmotic Injuries in Athletes. J Am Acad Orthop Surg.
Norkus, S.A., Floyd, R.T. (2001). The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Journal of Athletic Training.
Takao, M., Ochi, M., Oae, K., Naito, K., Uchio, Y. (2003). Diagnosis of a tear of the tibiofibular syndesmosis. J Bone Joint Surg Br.
Williams, G.N., Allen, E.J. (2010). Rehabilitation of Syndesmotic (High) Ankle Sprains. Athletic Training.
Zhao, M., Gao, W., ... Tang, B. (2017). Acupressure Therapy for Acute Ankle Sprains: A Randomized Clinical Trial. PM R.