Achilles Pain

The achilles is the thick tendon at the back of the ankle. It is a joint tendon for the two calf muscles; the Gastrocnemius and the Soleus. The tendon connects these two muscles to the heel bone at the back of the foot (Calcaneus). The calf muscles work to point the foot/ankle away from the body. The achilles tendon helps in this movement.

Achilles pain may be due to a number of injuries. It may develop gradually over a period of time, known as an overuse injury, or it may happen due to a sudden movement or force - an acute injury.


Overuse Injuries:
  • Achilles Tendonitis
    Pain in the tendon, usually 2-3cm above heel bone, accompanied by stiffness and often a 'creaking' feeling.
  • Sever's Disease
    Also known as achilles apophysitis, occurs in adolescents where the tendon attaches to the bone.
  • Retrocalcaneal Bursitis
    Inflammation of the bursa which sits underneath the tendon near it's attachment.
  • Haglund's Syndrome
    A combination of tendonitis and bursitis.
Acute Injuries:
  • Ruptured Achilles Tendon
    A full thickness tear of the achilles tendon.
  • Partial Tendon Rupture
    A partial thickness tear of the tendon.
                            Treatment of Achilles Pain

Treatment of achilles pain will depend on the type of injury. A full rupture may require surgery, whereas a partial tear is usually casted. Overuse injuries are always treated conservatively (without surgery) initially, although may require surgery if treatment fails.

Conservative treatment often consists of:
  • Rest.
  • Ice.
  • Anti-inflammatory medications.
  • Stretching for the calf muscles.
  • Massage
  • Ultrasound.
  • Strengthening exercises, especially eccentric (with gravity, as the muscle lengthens).
  • Correction of any training errors or biomechanical problems such as overpronation.

 
 

Achilles Tendon Rupture

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A complete tear of Achilles tendon tends to occur in middle aged patients. Partial rupture occur in trained athletes and involve the lateral aspect of the tendon. Acute Achilles tendon tear commonly result from acute eccentric overload on the dorsiflexed ankle that has chronic tendinosis. Patients should be questioned about previous steroid injections and fluoroquinolones (possible link with tendon weakening).

Causes Achilles Tendon Rupture:

Injuries to Achilles tendon result from repeated stress on the tendon, which may be caused by:
  • Overuse
  • Running on hills and hard surfaces
  • Poor stretching habits
  • Tight calf muscles
  • Weak calf muscles
  • Worn-out or ill-fitting shoes
  • Flatfeet
Rupture most commonly occurs in the middle-aged male athlete. As one age, the Achilles tendon weakens and become thin, making it more susceptible to injury.

Symptoms Of  Ruptured Achilles Tendon
  • A sudden sharp pain as if someone has whacked you in the back of the leg with something.
  • This will often be accompanied by a load snap or bang noise.
  • You will be unable to walk properly and unable to stand on tip toe.
  • There may be a gap felt in the tendon.
  • There will be a lot of swelling.
  • A positive result for Thompson Test.
Diagnosis Of Achilles Tendon Rupture:

Thompson Test:
The patient is placed prone, with both feet extended off the end of the table. Both calf muscles are squeezed by the examiner alternately and compared. If the tendon is intact, the foot will plantar flex when the calf is squeezed. If the tendon is ruptured, normal plantar flexion will not occur (positive test sign).

Partial ruptures are also difficult to accurately diagnose, and MRI and Ultrasound should be used to confirm the diagnosis.


     Treatment For Achilles Tendon Rupture

There are two methods of treatment;
  1. Nonoperative Treatment of Acute Achilles tendon tear
  2. Operative Treatment of Acute Achilles tendon tear
The speed at which a patient can progress with the rehabilitation will vary and should at all times be done under the supervision of a qualified professional.

Non-operative Treatment of Achilles tendon Rupture:

Immediately following injury:
  • Rest
  • Ice
  • Compression
  • Elevation
Week 1 to 8
  • A plaster cast is applied after surgery. No stretching or exercise, just let it heal.
  • You may be able to work the upper body. Try to do something positive, it will certainly help your state of mind.
Week 8 onwards

Stage 1- Range Of Motion And Flexibility
  • Place heal raises (1-2cm) in the shoes to take some of the pressure off the achilles tendon.
  • Sports massage techniques and ultrasound can aid in this process by helping to realign the new fibres in line with the tendon.
  • Active stretching. Pull your toes upwards to stretch the achilles tendon. Very gently at first and gradually build up.
  • If active stretches produce no pain then passive stretches can commence. This involves someone or something assisting in the stretching process.
  • When a full range of motion has returned (the ruptured leg is as flexible as the other leg) then a gradual strengthening programme can start.
  • Balance exercises should also be introduced as the sense of balance and positioning is often decreased after tendon or ligament ruptures and if not re-gained, can lead to future injuries. Wobble boards (balance boards) are great for this.
Stage 2 : Strengthen The Achilles Tendon And Calf Muscles
  • Great care must be taken when commencing a strengthening programme. There is a fine line between strengthening the tendon and re-injuring it.
  • You can start strengthening exercises as soon as they can be tolerated. It may be a full month after the cast comes off before exercises can begin.
  • The athlete may feel a little pain when you first start these exercises. If the pain is intolerable then do not continue. Gradually each day the pain should be less. The athlete should not attempt to increase the level of exercise until there is no pain during or after the exercises.
The strengthening exercises must be done after a gentle warm up and stretch. The muscles can be warmed up by raising the heels up and down on the toes while seated. Heat applied directly to the tendon for example by a hot water bottle can also help. Flexibility training must be continued throughout. Remember to ice after exercise, this will help keep inflammation down. Avoid explosive or ballistic movements or this may lead to a re-rupture.

Simple Stretching Exercises Pictures (Click on the picture to read description)
Simple Stretching Exercises Pictures (Click on the picture to read description)
 
 

Achilles Tendinitis

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 Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel.

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump.

Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

Description:
Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed.

  1. Noninsertional Achilles Tendinitis
In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.

  2.   Insertional Achilles Tendinitis
Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.
 
In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.

Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active. Tendinitis of the middle portion of the tendon more commonly affects younger, active people.


                       Noninsertional Achilles Tendinitis                                              Insertional Achilles Tendinitis

Causes:
Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:
  • Sudden increase in the amount or intensity of exercise activity — for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance
  • Tight calf muscles — Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon
  • Bone spur — Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain
Symptoms:
Common symptoms of Achilles tendinitis include:
  • Pain and stiffness along the Achilles tendon in the morning
  • Pain along the tendon or back of the heel that worsens with activity
  • Severe pain the day after exercising
  • Thickening of the tendon
  • Bone spur (insertional tendinitis)
  • Swelling that is present all the time and gets worse throughout the day with activity
If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Diagnosis:
In diagnosing Achilles Tendonitis, examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays, ultrasound or MRI.

                  
                       Rehabilitation of Achilles Tendonitis


Aims of rehabilitation
  • Decrease initial pain and inflammation.
  • Improve flexibility.
  • Improve the strength of the joint.
  • Re-establish neural control and co-ordination.
  • Return to full fitness.
Decreasing Pain And Swelling
  • This is the first stage of treatment, which can last for anywhere from 3 days to several weeks, depending on the severity of your condition.
  • Ice - apply for 15 minutes at least three times a day. Every two hours if possible for the first day.
  • Rest - use crutches if needed. A good taping method is available which supports the tendon.
  • Place a heel lift of about 1cm into both your shoes to help take the stress off the tendon. Do not leave it there for ever! If the calf muscles adaptively shorten, an increased strain will be placed on the achilles tendon in the future.
  • Anti-inflammatory medication can be taken (under Doctors advice of course).
  • Maintain fitness by non weight bearing exercise such as cycling if pain allows.
Improving Flexibility
  • Once you can perform daily activities pain-free, move on to this stage.
  • Concentrate on improving the flexibility of the calf muscles (Gastrocnemius and Soleus). This will reduce the strain on the achilles tendon.
  • Two stretches in particular are important, one with a straight leg for the Gastrocnemius muscle and one with the leg bent to target the Soleus muscle.
  • Stretching should be done regularly, three times a day initially and should be maintained long after the injury has healed to prevent the injury returning.
  • Soft tissue massage techniques. This will help prevent adhesions forming within the tendon. These adhesions stop the tendon sliding smoothly in its sheath.
  • Massage should also be used on the calf muscles themselves to aid in improving the flexibility and general condition of these muscles.
Simple Stretching Exercises Pictures (Click on the picture to read the description)
Strengthening
  • The aim is to strengthen the calf muscles and the achilles tendon. It is important that you strengthen the tendon in the stretched position.
  • There has been a lot of research into strengthening exercises during the rehabilitation of achilles tendinitis. The current concept is based around eccentric conctractions. These are muscle contractions where the muscle lengthens to control a downward movement.
  • Heel drops and raises are used in the rehabilitation of achilles tendonitis. Particular emphasis should be placed on the downward phase as this is the eccentric contraction.
Simple Stretching Exercises Pictures (Click on the picture to read the description)
 
 

Posterior Tibialis Tendonitis

Picture
The tibialis posterior muscle passes down the back of the leg and under the medial malleolus (bony bit on the inside of the ankle). It inserts on the lower inner surfaces of the navicular and cuniform bones and the base of the 2nd, 3rd, 4th and fifth metatarsal bones under the foot. It is used to plantarflex the foot (as in going up on your toes) and invert the foot (turning the soles of the feet inwards).

This is an overuse injury and is thought to be due to degeneration of the tendon rather than acute inflammation. There may be a partial avulsion (where the tendon pulls away from the bone) at the attachment to the navicular bone.

Long-term injuries to the Tibialis Posterior can result in insufficiency of the muscle and a condition called Tibialis Posterior Syndrome or Dysfunction. This results in fallen arches, or flat feet.

Symptoms:
  • Pain on the inside of the foot that may radiate along the line of the tendon.
  • Pain made worse by passive eversion (therapist turns the foot outwards) or resisted inversion (therapist resists patient turning the soles of the feet inwards).
  • Crepitus (a creaking on the tendon when it moves).
Causes:
  • Prolonged stretching of the foot and ankle into eversion such as in speed skating.
  • Running on tight bends
  • Over-pronation of the foot (foot flattens or rolls in when running).
     
Treatment for Posterior Tibial Tendonitis
  • Apply cold therapy to reduce pain.
  • Stretch the muscles at the back of the lower leg - when pain allows
  • Apply electrotherapy such as ultrasound to help with pain.
  • Prescribe anti-infammatories such as Ibuprofen
  • Apply sports massage techniques to the tendon and muscle.
  • Advise on posterior tibialis exercises to strengthen the muscle and tendon
  • Prescribe orthotic inserts if required to correct poor foot biomechanics.
  • If the tendon is ruptured then it must be repaired surgically.
Physiotherapy Rehabilitation

Aims of rehabilitation:
The aims of rehabilitation of Tibialis Posterior tendinopathy can be broken down into stages:
  • Decrease initial pain and inflammation.
  • Improve mobility and flexibility.
  • Improve strength
  • Reestablish neural control and coordination.
  • Return to full fitness.
Decrease initial pain and inflammation
  • Rest - this is essential. Try to avoid any activity or movement which aggravates the condition.
  • Ice - use cold therapy throughout the rehabilitation process. Apply ice for 15 minutes every 2-3 hours initially for the first day then gradually reduce this to 3 times a day.
  • Compression - use a tube grip bandage or taping. Even better are products that specifically apply compression at the same time as cooling.
Improve mobility and flexibility
  • Perform ankle circle movements in the early stages to keep it mobile.
  • Stretching the muscles at the back of the lower leg is important.
  • Make sure you stretch the calf muscles with both the knee straight and the knee bent. This will ensure all muscles in the back of the lower leg are stretched thoroughly.
  • Perform stretching exercises 2 to 3 time a day.
  • Apply ice / cold therapy after stretching in the early stages of rehabilitation to help reduce any inflammation.
Improve strength
  • This can begin as soon as they can be performed without pain.
  • The athlete should be able to maintain fitness by swimming or cycling if pain allows.
  • To specifically strengthen the Tibialis Posterior muscle you must work the ankle into inversion (turning the sole of the foot inwards).
  • It also assists with plantar flexion (pointing the foot away) and so calf raise exercises can be useful.
Simple Strenthenging Exercises Pictures (Click on the picture to read description)

Simple Stretching Exercises Pictures (Click on the picture to read description)
 
 

Anterior Compartment Syndrome

Picture
The anterior compartment of the lower leg is at the front of the shin, just on the outside of the shin bone. This compartment contains the muscles Tibialis Anterior, Extensor Digitorum Longus and Extensor Hallucis Longus.\

The compartments of the lower leg are separated by sheaths, as shown in the picture opposite. Individual muscles are also surrounded by a sheath. Anterior compartment syndrome arises when the Tibialis Anterior inparticular becomes too big for the compartment and the sheath that surrounds it, resulting in pain. Compartment syndromes can be acute or chronic.






Symptoms
  • Pain in the muscle on the outside of the shin bone
  • There may be obvious swelling and it might be tender to touch over the front of the shin.
  • Weakness or difficulty in pointing the toes up (dorsiflexion).
  • It might hurt or feel tight to point the toes downwards (plantarflexion) as this stretches these muscles.
If the condition becomes chronic you may experience:
  • Pain that gets worse the more you use it meaning you can't exercise.
  • Pain which eases with rest but returns every time you exercise.
Causes
  • A direct impact to the front of the leg which causes bleeding and swelling within the compartment and reduces space.
  • An overuse injury, which causes swelling in the compartment.
Physiotherapy Treatment For Anterior Compartment Syndrome
  • Rest -  but try to exercise your upper body or cycle if it is not painful.
  • Apply ice and compression for 20 minutes at a time.
  • Prescribe anti-inflammatory medication e.g. ibuprofen.
  • Correct any biomechanical disfunction with orthotic devices.
  • soft tissue massage
  • mobilization (of the ankle joint)
  • Ultrasound
  • PNF stretches
  • Soft tissue massage
Exercises For Compartment Syndrome

Picture

Kneeling Stretch
Begin in four point kneeling (i.e. on your hands and knees) on a flat surface (figure 3). Keep your knees and ankles together, toes pointed. Gently take your weight back onto your ankles until you feel a stretch at the front of your ankles or shins. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free. This exercise can be progressed by placing a rolled towel under your feet as demonstrated.

Picture

Lunge Stretch
With your hands against the wall, place your leg to be stretched in front of you as demonstrated (figure 4). Keep your heel down. Gently move your knee forward over your toes until you feel a stretch in the back of your calf or Achilles tendon. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.


Picture

Calf Stretch
With your hands against the wall, place your leg to be stretched behind you as demonstrated (figure 5). Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in your calf / knee of your back leg. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.


Surgical treatment
If conservative measures fail, surgery may be an option. Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome. Also, this surgery is typically an elective procedure -- not an emergency.

 
 

Anterior Compartment Syndrome

Picture
The anterior compartment of the lower leg is at the front of the shin, just on the outside of the shin bone. This compartment contains the muscles Tibialis Anterior, Extensor Digitorum Longus and Extensor Hallucis Longus.\

The compartments of the lower leg are separated by sheaths, as shown in the picture opposite. Individual muscles are also surrounded by a sheath. Anterior compartment syndrome arises when the Tibialis Anterior inparticular becomes too big for the compartment and the sheath that surrounds it, resulting in pain. Compartment syndromes can be acute or chronic.






Symptoms
  • Pain in the muscle on the outside of the shin bone
  • There may be obvious swelling and it might be tender to touch over the front of the shin.
  • Weakness or difficulty in pointing the toes up (dorsiflexion).
  • It might hurt or feel tight to point the toes downwards (plantarflexion) as this stretches these muscles.
If the condition becomes chronic you may experience:
  • Pain that gets worse the more you use it meaning you can't exercise.
  • Pain which eases with rest but returns every time you exercise.
Causes
  • A direct impact to the front of the leg which causes bleeding and swelling within the compartment and reduces space.
  • An overuse injury, which causes swelling in the compartment.
Physiotherapy Treatment For Anterior Compartment Syndrome
  • Rest -  but try to exercise your upper body or cycle if it is not painful.
  • Apply ice and compression for 20 minutes at a time.
  • Prescribe anti-inflammatory medication e.g. ibuprofen.
  • Correct any biomechanical disfunction with orthotic devices.
  • soft tissue massage
  • mobilization (of the ankle joint)
  • Ultrasound
  • PNF stretches
  • Soft tissue massage
Exercises For Compartment Syndrome

Picture

Kneeling Stretch
Begin in four point kneeling (i.e. on your hands and knees) on a flat surface (figure 3). Keep your knees and ankles together, toes pointed. Gently take your weight back onto your ankles until you feel a stretch at the front of your ankles or shins. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free. This exercise can be progressed by placing a rolled towel under your feet as demonstrated.

Picture

Lunge Stretch
With your hands against the wall, place your leg to be stretched in front of you as demonstrated (figure 4). Keep your heel down. Gently move your knee forward over your toes until you feel a stretch in the back of your calf or Achilles tendon. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.


Picture

Calf Stretch
With your hands against the wall, place your leg to be stretched behind you as demonstrated (figure 5). Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in your calf / knee of your back leg. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.


Surgical treatment
If conservative measures fail, surgery may be an option. Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome. Also, this surgery is typically an elective procedure -- not an emergency.

 
 

Calf Strain

Picture
The calf muscles consist of the Gastrocnemius which is the big muscle at the back of the lower leg and the Soleus muscle which is a smaller muscle lower down in the leg and under the Gastrocnemius.

Gastrocnemius is the larger of the two muscles which attaches above the knee joint and inserts into the heel bone via the achilles tendon. The Soleus attaches below the knee joint and then also to the heel via the achilles. Either of these two muscles can be strained (torn).

Both muscles act to plantarflex the ankle (point the foot away from the body). As gastrocnemius attaches above the knee it also helps with bending the knee. In this position, with the knee bent, soleus becomes the main plantarflexor. If the Soleus muscle is damaged you might get pain lower in the leg and also pain when you contract the muscle against resistance with the knee bent.

Causes Of Calf Strain:
A calf strain can be caused by:
  • Stretching the calf muscles beyond the amount of tension that they can withstand
  • Suddenly putting stress on the calf muscles when they are not ready for the stress
  • Using the calf muscles too much on a certain day
  • A direct blow to the calf muscles
Risk Factors For Calf Strain:
  • Sports that require bursts of speed, such as: (Running, Basket Ball, Long jump, Soccer, Football, Rugby)
  • Fatigue
  • Tight calf muscles
  • Overexertion
  • Cold weather
Symptoms Of Calf Strain:

Grade 1
  • A twinge of pain in the back of the lower leg.
  • May be able to play on.
  • Tightness and aching in the 2-5 days after.
Grade 2
  • Sharp pain in the back of the lower leg.
  • Pain when walking.
  • There may be swelling in the calf.
  • Mild to moderate bruising.
  • Pain on resisted plantarflexion.
  • Tightness and aching for a week or more.
Grade 3
  • Severe immediate pain.
  • A sudden pain at the back of the leg, often at the muscular tendinous junction (see image below).
  • Inability to contract the muscle.
  • Considerable bruising and swelling.
  • In the case of a full rupture, often the muscle can be seen to be bunched up towards the top of the calf.
Assessment Of Calf Strain:
  1. Palpating the calf muscles - The therapist should palpate the entire calf area, looking for tight or painful area
  2. Passive range of motion - The therapist will usually assess both active (the patient moves) and passive (the therapist moves the joint) range of motion at the ankle with the knee both straight and then bent
  3. Thompson's Squeeze test - See The Video Below:



                 Treatment For Calf Strain
  • Applying R.I.C.E. (Rest, Ice, Compression, Elevation) is essential.
  • Cold therapy should be applied as soon as possible to help to quickly stop any internal bleeding.
  • Use a compression bandage or sleeve.
  • Stretching Exercises
  • Strengthenging Exercises to improve strength
  • Wear a heel pad to raise the heel and shorten the calf muscle hence taking some of the strain off it. It is a good idea to put heel pads in both shoes or one leg will be longer than the other creating an imbalance and possibly leading to other injuries including back injuries.
  • Prescribe anti-inflammatory medication e.g. ibuprofen which is beneficial in the first few days after the injury.
  • Use ultrasound treatment.
  • Use Soft Tissue Massage techniques after the initial acute phase.
Simple Stretching Exercises Pictutes (Click on the picture to read description)
Simple Strengthenging Exercises Pictutes (Click on the picture to read description)
 
 
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A broken ankle is also known as an ankle "fracture." This means that one or more of the bones that make up the ankle joint are separated into pieces. There may be ligaments damaged as well. Simply put, the more bones that are broken, the more unstable the ankle becomes.

A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may require that you not put weight on it for three months.

Causes Of Broken Ankle:

  • " Twisting " or rotating your ankle
  • " Rolled " your ankle
  • Tripping or falling
  • Impact during a car accident
Since there is such a wide range of injuries, there is also a wide range of how people heal after their injury.

Broken ankles affect all ages. Ankle fractures occur in 184 per 100,000 persons per year. During the past 30 to 40 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of "baby boomers." In 2003, nearly 1.2 million people visited emergency rooms because of ankle problems.

Anatomy Of Ankle:
Three bones make up the ankle joint:
  1. Tibia ("shin bone")
  2. Fibula (small bone on the outside of your ankle)
  3. Talus (a foot bone)

The tibia and fibula have specific parts that make up the ankle:
  1. Medial malleolus: Inside part of the tibia
  2. Posterior malleolus: Back part of the tibia
  3. Lateral malleolus: End of the fibula

Two joints are involved in ankle fractures:
  1. Ankle joint
  2. Syndesmosis: The joint between the tibia and fibula, which is held together by ligaments
  3. Multiple ligaments help make the ankle joint stable

Symptoms Of Broken Ankle:
Because a severe ankle sprain can feel the same as a broken ankle, every ankle injury should be evaluated by a physician.
Common complaints for a broken ankle include:

  1. Immediate and severe pain
  2. Swelling
  3. Bruising
  4. Tender to touch
  5. Cannot put any weight on the injured foot
  6. Deformity ("out of place"), particularly if the ankle joint is dislocated as well.

Diagnosis:
Besides a physical exam, X-rays are the most common way to evaluate an injured ankle. X-rays may be taken of the leg, ankle, and foot to make sure nothing else is injured.

Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special X-ray, called a "stress test." This X-ray is done to see if certain ankle fractures require surgery.
Sometimes, a computed tomography (CT, or CAT) scan is done to further evaluate ankle injuries.
For some ankle fractures, magnetic resonance imaging (MRI) may be done to evaluate the ankle ligaments.



              Treatment of a Broken Ankle

The treatment of each fracture should be decided upon on an individual basis. In all cases the ankle should be at least partially immobilised and rested by non-weight bearing for between 1 and 8 weeks. Minor fractures such as a stress fracture may be treated with partial weight bearing in a walking boot or with a crutch.

Most ankle fractures are immobilised in a cast for around 6 weeks. This gives the bone time to heal without the stresses of movement or weight bearing. After this period, the cast is removed and provided no complications are suspected, a rehabilitation plan should be implemented immediately.

More complex cases may require a longer period of immobilisation. A displaced fracture (where one part of the bone has become dislodged) may require reduction or even surgical fixation with metal pins or plates.

Simple Exercises Pictures For Broken Ankle ( Click On The Picture To Read Description )
 
 

Sprained Ankle

Picture
A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle.

The ligaments of the ankle hold the ankle bones and joint in position. They protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot.

A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers.

How It Happens:
Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.

Mechanism of Injury:

If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle's soft tissue structures, you may even hear a "pop". Pain and swelling result.

The amount of force determines the grade of the sprain. A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3.
  • Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament.

  • Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.

  • Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.
Assessment Of Sprained Ankle:

The Anterior Drawer Testand Talar Tilt Test are commonly used to identify signs of joint instability. The Anterior drawer test is performed by stabilizing the distal tibia anteriorly with one hand and pulling the slightly plantar flexed foot forward with the other hand from behind the heel. A positive finding of more than 5 mm of anterior translation indicates a tear of the ATFL. The Talar tilt test is performed by stabilizing the distal tibia with one hand and inverting the talus and calcaneus as a unit with the other hand. A positive finding of more than 5 mm with a soft endpoint indicates a combined injury to the ATFL and CFL. It is important to always compare the affected ankle with the contra lateral side because some patients are naturally very flexible (generalized ligament laxity), and this could result in false positive test.
Differentiating between a sprained ankle and an ankle fracture can be difficult, and sometimes an x-ray is needed.

Symptoms Of Sprained Ankle:

The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.


               Treatment For Sprained Ankle


Aims Of Rehabilitation:
The aims of rehabilitation of an ankle sprain can be broken down into separate phases:
  • Decrease initial pain and swelling.
  • Improve mobility and flexibility.
  • Improve the strength of the joint.
  • Re-establish neural control and co-ordination.
  • Return to full fitness.
Immediate First Aid for a sprained ankle:
  • Restyour ankle by not walking on it.
  • Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction.
  • Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.
  • Elevate your ankle above your heart level for 48 hours.
Phase 1

  1. Protection Options - Taping, functional bracing, removable cast boot
  2. Rest - (crutch to promote ambulation)
  3. Ice
  4. Compression - Elastic wrap, TED hose, Vaso-pneumatic pump.
  5. Elevation - Above heart level with ankle pump.

Phase 2
Decrease pain and swelling, increase pain free range of motion, begin strengthening, begin non-weight bearing proprioceptive training and provide protective support as needed.

  1. Modalities To Decrease Pain And Swelling.
  • Ice and contrast baths
  • Electrical stimulation (high-voltage galvanic or interferential)
  • Ultrasound
  • Cross-friction massage(gently)
  • Soft orthotics with 1/8-3/16 inch lateral wedge,if needed in Ankle Sprain Treatment.
  2.   Weight Bearing
Progress weight bearing as symptoms permit. Partial weight bearing to full weight bearing if no signs of antalgic gait is present.

  3.   Physiotherapy Exercises For Sprained Ankle
  • Active range of motion exercises - Dorsiflexion, inversion, foot circle, plantarflexion,eversion, alphabet.
  • Strengthening exercises - Isometrics in pain free range, toe curls with towel (place weight on towel to increase resistance).Pick up objects with toes (tissue, marble).
  • Proprioceptive training - Seated Biomechanical Ankle Platform System (BAPS).Wobble board.Ankle disc.
  • Stretching - Passive ROM- only dorsi flexion and plantar flexion in pain free range. No eversion or inversion yet. Achilles stretch. Joint mobilization (grade 1-2 for dorsiflexion and plantarflexion).
Phase 3
Increase pain-free ROM.Progress strengthening. Progress proprioceptive training. Increase pain-free activities of daily living. Pain-free full weight bearing and uncompas needed,specifically after exercise to prevent re occurrence of pain and swelling.

  1. Continue Modalities - As needed,specifically after exercise to prevent re occurrence of pain and swelling.
  2. Taping, Bracing, Orthotics - used as needed.To avoid re injury.
  3. Physiotherapy Exercises For Sprained Ankle
  • Stretching of gastrocnemius and soleus with increased intensity. Joint mobilization (grades 1,2 and 3 for dorsiflexion, plantarflexion, and eversion, hold inversion).
  • Strengthening Weight bearing exercises. Heel raises. Toe raises. Stair steps. Quarter squats.
  • Proprioceptive training ( Progress from non-weight bearing to controlled weight bearing to full weight bearing). Standing BAPS board. Standing wobble board. Single leg balance activities (Stable to unstable surfaces, without to with distractions).Proprioceptive training has a major role in Ankle Sprain Treatment.
Simple Stretching Exercises Pictures (Click On The Picture To Read Description) 
 
 

Shin Splints

Picture
The term "Shin Splints" refers to pain and tenderness along or just behind the inner edge of the tibia, the large bone in the lower leg. Shin splints--or medial tibial stress syndrome as it is called by orthopaedists--usually develops after physical activity, such as vigorous exercise or sports. Repetitive activity leads to inflammation of the muscles, tendons, and periosteum (thin layer of tissue covering a bone) of the tibia, causing pain. The bone tissue itself is also involved.

The condition is also referred as
  1. Medial Tibial Stress Syndrome (MTSS)
  2. Medial Tibial Traction Periostitis
  3. Medial Tibial Periostitis

Risk Factors Of Shin Splints
  • Flatfeet or abnormally rigid arches
  • Running/jogging
  • Dancing
  • Sudden increase in training or new vigorous impact training
  • Military training
Certain factors seem to contribute to shin splints. The condition commonly affects runners, aerobic dancers, and people in the military. Shin splints often develop after sudden changes in physical activity, such as running longer distances or on hills, or increasing the number of days you exercise each week. Flat feet are another factor that can contribute to increased stress on the lower leg muscles during exercising.

Other Causes Of Shin Splint:
Stress fracture When shin splints are not responsive to treatment, your doctor may want to make sure you do not have a stress fracture. A bone scan and magnetic resonance imaging (MRI) can often show if a fracture is present. The diagnostic tests, causes of shin splints, and treatment regimens all bear a similarity and relationship to stress fractures. It is possible that there is a relationship between shin splints and stress fracture, but this has not been clearly identified.

Tendonitis Tendonitis can be present, especially if there is a partial tear of the involved tendon. MRI can also help the doctor diagnose the presence of tendonitis.

Chronic exertional compartment syndrome An uncommon condition called chronic exertional compartment syndrome involves swelling of muscle with exertion. This happens within the muscle's usually tight compartment in the leg. These compartments are nonyielding. Swelling can raise pressure within the compartment to levels so high that blood will not flow into the muscle. This causes severe pain and is best treated surgically. The tests that are used to diagnose chronic exertional compartment syndrome are highly specialized and not easily available. They involve measuring the pressure within the leg compartments immediately after exercise.

Symptoms Of Shin Splints:
  • Pain over the inside lower half of the shin.
  • Pain at the start of exercise which often eases as the session continues
  • Pain often returns after activity and may be at its worse the next morning.
  • Sometimes some swelling.
  • Lumps and bumps may be felt when feeling the inside of the shin bone.
  • Pain when the toes or foot are bent downwards.
  • A redness over the inside of the shin (not always present).
Assessment Of Shin Splint:

A diagnosis of shin splints is suggested by a history of exercise induced pain at the distal two thirds of the leg. The pain is localized to the anterior compartment in anterior shin splints and to the distal two thirds of the posterior medial tibial border in medial tibial stress syndrome. There is exercise induced leg pain which is relieved by decreased activity. The condition is never associated with vascular or neurologic symptoms or findings.

On examination, patients with medial tibial stress syndrome will often be tender over this same part of the tibia. Patients may or may not have a small amount of detectible swelling over this part of the tibia. Some specific maneuvers, especially resisted plantar flexion (pushing down of the foot against resistance), typically causes an increase of symptoms.

In order to determine the underlying cause of the MTSS your physician may order an x-ray or a bone scan. The x-ray can detect fractures, and occasionally detect long-standing stress fractures. The bone scan will detect areas of high bone turnover; these ‘hot’ areas indicate possible stress fractures or other bone problems. Early and correct diagnosis helps in prompt shin splints treatment.

Differential Diagnosis:
  • Tibial Stress Fracture - Exertional pain at tibia; point tender tibia; pain with three-point stress; abnormal radiograph, fusiform uptake on bone scan, abnormal CT or MRI.
  • Fibular Stress Fracture - Exertional pain at fibula; pronation or valgus alignment; point-tender fibula; abnormal radiograph, bone scan, CT or MRI.
  • Acute Compartment Syndrome - Leg pain secondary to trauma, tender compartments, pain with passive movements, decreased sensations, elevated compartment pressure, paresthesias.
  • Chronic Exertional Compartment Syndrome - Exertional leg pain, no acute trauma, tender compartments, decreased sensation after exertion, elevated post exertion compartment pressures, paresthesias.
  • Congenital Anomaly - Exertional leg pain, no acute trauma, anomalous muscle such as accessory soleus, symptoms similar to chronic exertional compartment syndrome, accessory muscle identified on MRI.
  • Tumor - Night pain, abnormal radiograph, bone scan, CT or MRI.
                Treatment Of Shin Splint

Aims of rehabilitation
  • Reduce pain and inflammation.
  • Identify any biomechanical (movement) disfunctions that may be causing the problem.
  • Improve the flexibility and condition of surrounding muscles.
  • Gradual return to full activity
  • Injury prevention
The time scales needed for each stage will vary considerably depending on the severity of each individual case and also the commitment to treatment advice. The full rehabilitation process may take anywhere from 3 weeks to 12 weeks. Only move from one stage to the next when you can achieve all exercises and tasks free from pain.

What can the Physiotherapist do about shin splints
  • Rest to allow the injury to heal.
  • Apply ice or cold therapy in the early stages, particularly when it is very painful. Cold therapy reduces pain and inflammation.
  • Prescribe anti-inflammatory medication e.g. ibuprofen (always consult a doctor before taking medication).
  • Tape the shin for support - A taping worn all day will allow the shin to rest properly by taking the pressure off the muscle attachments.
  • Perform gait analysis to determine if you overpronate or oversupinate.
  • Stretch the muscles of the lower leg. In particular the tibialis posterior which is associated with shin splints.
  • Wear shock absorbing insoles in shoes. This helps reduce the shock on the lower leg.
  • Maintain fitness with other non weight bearing exercises such as swimming, cycling or running in water.
  • Apply heat and use a heat retainer or shin and calf support after the initial acute stage and particularly before training. This can provide support and compression to the lower leg helping to reduce the strain on the muscles. It will also retain the natural heat which causes blood vessels to dilate and increases the flow of blood to the tissues to aid healing.
0-3 Days :  Acute stage shin splints treatment
  • Relative rest, ice massage and whirlpool.
  • Ultrasound therapy if no bony involvement.
  • Isometrics.
  • Seated towel scrunches.
  • Cycling
  • Water activities (deep water running).
  • Gastrocnemius and soleus stretching.
  • Massage
Day 4 - Week 6 : Subacute stage shin splints treatment

This stage begins with resolution of weight bearing pain and ends with resolution of activity related pain.
  • Modalities to decrease inflammation are continued.
  • Emphasis remains on increasing flexibility.
  • Theraband exercises.
  • Towel scrunches progressed from seated to standing position.
  • Balance training are begun with progression of difficulty.
  • Aerobic fitness is maintained with cross training activities such as slideboard, water running and cycling.
Week 7 : Return to Sport stage shin splints treatment
  • Running started once pain has resolved.
  • Warm up and stretching.
  • Patients are to initially avoid running on uneven surfaces.
  • Attention is first directed to reestablishing distance, followed by speed.
  • Antipronation orthotics for patient with MTSS or low dye taping.
Simple Stretching Exercises Pictures: (Click on picture to read the description)