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ankle trauma, its types , complication, treatment, and physical therapy
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MAJDE 1
Physical therapy department
3rd year 2013-2014
Traumatology rehabilitation
Ankle Trauma
MAJDE 2
Table of Contents
I. Over View of ankle trauma: .................................................................................................................. 3
1. Ankle Anatomy .................................................................................................................................. 3
2. Types of ankle trauma: ...................................................................................................................... 4
II. Ankle Sprains:........................................................................................................................................ 6
1. Classification: .................................................................................................................................... 6
2. History and Assessment: ................................................................................................................... 7
a. History ........................................................................................................................................... 7
b. Assessment .................................................................................................................................... 8
3. Treatment: .......................................................................................................................................12
a. Goals: ............................................................................................................................................12
b. Acute Phase (first 2-4 days) ..........................................................................................................13
c. Sub-Acute stage (days 3 to 14) ......................................................................................................14
d. Early Rehab (week 3) ....................................................................................................................14
e. Late Rehab (week 4) .....................................................................................................................16
f. Functional Rehab (week 5+): ........................................................................................................25
III. High Ankle Sprain Injury ...................................................................................................................27
IV. Lisfranc Joint Injury...........................................................................................................................27
V. Plantar Fasciitis ....................................................................................................................................28
VI. Os Trigonum Syndrome ....................................................................................................................31
VII. Ankle fracture: ..................................................................................................................................32
1. Signs & Symptoms ............................................................................................................................32
2. Classification: ...................................................................................................................................32
3. Assessment:......................................................................................................................................36
4. Treatment: .......................................................................................................................................38
a. Phase I: 0 6 weeks ......................................................................................................................38
b. Phase II: 6 9 weeks .....................................................................................................................39
c. Phase III: 9 weeks to release .........................................................................................................40
VIII. Conclusion: .......................................................................................................................................41
MAJDE 3
I. Over View of ankle trauma:
Ankle injuries can happen to anyone at any
age. However, men between 15 and 24
years old have higher rates of ankle sprain,
compared to women older than age 30 who
have higher rates than men. Half of all ankle
sprains occur during an athletic activity
1. Ankle Anatomy
MAJDE 4
2. Types of ankle trauma:
Ankle injuries are defined by the kind of tissue. The ankle is where three bones meet -- the tibia and
fibula of your lower leg with the talus of your foot. These bones are held together at the ankle joint
by ligaments. Tendons attach muscles to the bones to do the work of making the ankle and foot
move, and help keep the joints stable.
A fracture describes a break in one or more of the bones. A sprain is the term that describes damage
to ligaments when they are stretched beyond their normal range of motion. A ligament sprain can
range from many microscopic tears in the fibers that comprise the ligament to a complete tear or
rupture. A strain refers to damage to muscles and tendons as a result of being pulled or stretched too
far. Muscle and tendon strains are more common in the legs and lower back. In the ankle, there are
two tendons that are often strained. These are the peroneal tendons.
fracture bone
sprain ligament
strainmuscle tendon
MAJDE 5
MAJDE 6
II. Ankle Sprains:
1. Classification:
Grade I - mild stretching of the
ligament without joint instability.
Grade II - partial rupture (tear) of
the ligament but without causing
joint instability (or with mild
instability of the joint).
Grade III - complete rupture (tear)
of the ligament with instability of
the joint. Sometimes this is simply
called a severe ankle sprain.
What Causes a Sprained Ankle?
Ankle sprains can occur simply by rolling your ankle on some unstable ground.
What are the Symptoms of a Sprained Ankle?
At the time of the injury you may hear a popping or cracking sound and will notice swelling, bruising and
ankle pain. Lateral or medial ligament sprains are usually
acutely tender over the injured ligament. Depending on
the severity of your ankle sprain, you may have trouble
walking or standing on your foot.
Which Ankle Ligaments are Commonly Sprained?
1. anterior talo-fibular ligament (ATFL)
2. calcaneofibular ligament (CFL)
3. posterior talo-fibular ligament (PTFL)
MAJDE 7
2. History and Assessment:
a. History
i. Last name:
ii. First name:
iii. Age:
iv. Gender :
v. Marital state :
vi. Number of children :
vii. Job:
viii. Telephone number, address :
ix. Risk factors :
x. Diagnosis:
xi. Surgical intervention:
xii. Allergy :
xiii. Referent doctor:
xiv. Admission date :
xv. Date of surgery :
xvi. Date of accident
xvii. Past medical history:
xviii. past surgical history
xix. Radiologic report
MAJDE 8
b. Assessment
Pain:
Location
Type
Degree
Stimulators
Relieving agents
Observation:
Standing alignment
Shoe wear
Swelling or effusion
Skin color, texture, temperature, moisture,
and scars
ROM:
test right Left #
active passive active passive Active passive
dorsiflexion
Plantar flexion
Supination
pronation
Inversion
eversion
MAJDE 9
Accessory ROM tests:
Talocrural joint:
Anterior gliding
Posterior gliding
1st metatarsophalangeal test:
Superior glide
Inferior glide
Muscle Assessment:
muscle right Left notes
Gastrocnemius
Peroneals
Anterior tibialis
Posterior tibialis
Extensor hllucis longus
Extensor degetorom
longus
Flexor hllucis longus
Flexor degetorom longus
Special tests:
a) Anterior drawer test
b) Thompson test
c) Homan`s test
d) Tinel`s test
e) Leg lengths
MAJDE 10
a- Anterior drawer test:
Purpose: To test for ligamentous laxity or
instability in the ankle. This test primarily
assesses the strength of the Anterior
Talofibular Ligament.
Test Position: Supine or Sitting.
Performing the Test: The examiner
stabilizes the anterior distal leg with one
hand & grasps the patient's calcaneus and
rear foot with their second hand. The
examiner then places the patient's foot
into 10-15 degrees of plantar flexion and
translates the rear foot anteriorly.
A positive test results if the talus
translates forward. Positive test results
are often graded on a "0 to 3 scale", with
0 indicating no laxity & 3 indicating gross
laxity.
b- Thompson test
Purpose: to examine the integrity of the
Achilles' tendon
Position: With the patient lying prone on the
table with his or her foot extended beyond
the end of the table the examiner squeezes
the calf.
Results: A normal non-injured response to
this maneuver is slight plantar flexion of the
ankle. Lack of ankle movement can indicate a
rupture of the Achilles' tendon.
MAJDE 11
c- Homan`s test:
Purpose: to determine the presence of
a deep vein thrombophlebitis
Position: the patients knee is in an
extended position and the examiner
forcefully dorsiflexes the patients
ankle. However, some individuals seem
to have a different opinion on how this
test should be applied,they believe to
assess properly Homans sign, the
patients knee must be in a flexed
position instead of an extended
position.
Results: A positive sign is indicated
when pain in the popliteal region and
the calf is elicited as the foot is
dorsiflexed. A positive sign doesnt automatically conclude a DVT. In fact, a positive Homans sign can be
elicited due to factors such as superficial phlebitits, Achilles tendonitis, and injury to the gastroc and plantar
muscles. Further conditions such as herniated intervertebral discs and shortened heel cords can also result
in a false positive. A negative Homans sign, on the other hand, doesnt automatically conclude an absence
of DVT.
d- Tinel`s test:
Purpose: to detect irritated nerves
Position: It is performed by lightly tapping (percussing) over the
nerve
Result: a positive test is when a sensation of tingling or "pins and
needles" in the distribution of the nerve
MAJDE 12
3. Treatment:
a. Goals:
Short term :
o Injury Protection
o Pain Relief
o Control Inflammation
Long term:
o Regain Full Range of Motion
NWB - Non-Weight Bear
PWB - Partial Weight Bear
FWB - Full Weight Bear
o Strengthen your Ankle and Calf Muscles
o Restore Joint Proprioception & Balance
o Restore Normal Function
Walking
Running
Jumping & Landing
Speed & Agility
Sport-Specific Skills
o Resume Sport
Graduated Training
Return to Competition
MAJDE 13
b. Acute Phase (first 2-4 days)
the initial treatment is RICE
Rest: In the early phase you`ll most likely be unable to walk on your sprained ankle. Our first aim is
to provide you with some active rest from pain-provoking postures and movements. In most
cases, you will need to be non-weight bear. You may need to be placed in an ankle walking boot,
a supportive ankle brace or utilize crutches.
Ice is a simple and effective modality to reduce
your pain and swelling. Please apply for 20-30
minutes each 2 to 4 hours during the initial
phase or when you notice that your injury is
warm or hot.
Compression: A compression bandage, tubigrip
compression stocking or kinesiology supportive
taping will help to both support the injured soft
tissue and reduce excessive swelling.
Elevation: Elevating your injured ankle above your
heart will assist gravity to reduce excessive
swelling around your ankle.
Other treatments may include:
TENS
Joint mobilization
Light massage
Acupuncture
The patient also mustn`t do any HARM:
Heat
Alcohol
Running
Massage
MAJDE 14
c. Sub-Acute stage (days 3 to 14)
The sub-acute stage begins by bearing weight on the ankle to pain tolerance. This is graduated
from partial weight-bearing with a Plastic Cast Walker and crutches to full weight-bearing
without crutches. A normal walking pattern should be encouraged and there should be no
limping.
Ice therapy can be continued so long as there is pain. When possible the ankle should be
elevated. Electrotherapy treatment should be continued and augmented with gentle massage to
encourage the dispersal of swelling towards the back of the knee.
Ankle pumping exercises can be started and progressed to being done in water. Exercises in
water are effective because they involve only partial weight-bearing and because the hydrostatic
pressure provided by the water has the effect of encouraging the swelling to disperse.
d. Early Rehab (week 3)
After two weeks most of the rehabilitation is achieved through active exercise, although the
physiotherapist may help regain range of movement by carrying out passive mobilising techniques. This
involves the physio gently moving the bones of the ankle to help restore range of movement and relieve
stiffness.
Exercise 1 The first exercise is to help restore the ankle's range of movement.
Sitting on the floor, the ankle is pumped forward and back.
20 repetitions, 5 times daily.
The patient progresses to doing the same exercise while sitting on a high bench or chair, letting the feet hang down.
MAJDE 15
Exercise 2: This exercise uses a Resistance Band to strengthen the dorsi
flexor muscles that pull the toes back towards the knee.
Sitting on the floor, a resistance band is tied around the foot, with the other
end attached to a fixed object in front of the foot; slowly the foot is pulled
back towards the knee.
Exercise 3: This exercise is designed to strengthen
the plantar flexor muscles that push the foot down,
sitting on the floor, with the legs out straight,
a Resistance Band is tied around the foot, and the other
end held in the hand. Slowly, the foot is pushed forward
and then relaxed.
Exercise 4: This exercise is a progression of the
previous plantar flexor strengthening exercises.
The patient stands with their hands resting against a wall so that it is taking some of their body weight.
With both feet, the patient pushes up on the toes so the heels rise up off the floor. This position is held for 2
seconds and then the heels are slowly lowered.20 repetitions, 5 times daily.
Once this becomes easier, the same exercise is done but without any hands against the wall. Once this has
been mastered, the patient progresses to doing the exercise with the toes positioned on a block, so that the
heels have to come down lower before pushing up.
The final progression to this exercise is to do it on the affected ankle alone.
MAJDE 16
Exercise 5: This exercise is designed to strengthen the evertor muscles that enable the foot to turn outwards.
Standing up, the base of the foot is turned outwards, held for 2 seconds and then relaxed.
20 repetitions, 5 times daily.
Proprioception exercises: can be done while partial weight-bearing
first, then progressed to full weight-bearing, such as using a Wobble
Board. The Wobble Board together with Ankle Brace are commonly
used in the rehabilitation of ankle instability. Wobble boards are
designed to assist the re-education of the proprioceptive system by
improving sensory nerve function. Research has shown that wobble
board training improves single leg stance ability and balance, while
other studies have suggested that patients with ankle instability who
underwent wobble board training experienced significantly fewer
recurrent sprains during a follow-up period than those who did not
follow the training program.
e. Late Rehab (week 4)
Progressive strengthening of the muscles around the ankle should be continued, as should the
proprioception exercises. To prepare for a return to functional activities the intensity of exercise should be
increased. The use of an Ankle Brace or Ankle Taping can provide essential support at this stage.
Taping and Bracing the ankle can help to reduce recurrent ankle injury. A research study has shown the
injury incidence in students with taped ankles was 4.9 ankle sprains per 1000 participant games, compared
with 2.6 ankle sprains per 1000 participant games in students wearing ankle braces. This compared with
32.8 ankle sprains per 1000 participant games in subjects that had no taping or bracing.
Basic plyometric exercises should be commenced.
Plyometric drills decrease the reaction time of the nervous system in response to external stimuli. This
allows the muscles to contract faster to prevent falling or twisting an ankle. The technique was first used
during the 1960's and 70's by eastern European athletes, who organized hopping and jumping techniques
into specific plyometric drills.
As the athlete plants their foot before jumping, the muscle that will produce the jump is stretched. As the
muscle contracts, the pre-stretched energy is released, producing kinetic energy (movement) which
enhances muscle power. By doing plyometric drills the time taken for the stretch to be converted into
kinetic energy is decreased.
Before initiating plyometric activities there must be a sound strength base, otherwise the risk of injury is
increased. As a general rule the athlete should be comfortable in squatting 60% of their body weight, at a
MAJDE 17
rate of 5 repetitions in 5 seconds, before these exercises are commenced. The athlete should be able to
stand on one leg, with eyes both open and shut, for 30 seconds and should be able to long jump the
distance of their own height.
Ideally, plyometric training should be done under the supervision of a trainer or chartered physiotherapist.
Quick feet drills:
Quick feet drills using a rope ladder are a form of plyometric activity. Lateral (sideways)
The progression is to multi-directional patterns using the rope ladder, moving from left to right
MAJDE 18
Then back, from ri
Continuing the sideways pattern. Note the muscle work in the quads to control the movement.
This lateral exercise puts a controlled load through the collateral ligaments of the knees and
ankles.
MAJDE 19
Forward jump drills:
Double footed forward jumps over a 30cm barrier.
The progression of this exercise is to do it using one leg...
MAJDE 20
Cross jump drills:
Cross jumps help to train power. The starting position is with one leg in front and the other
behind.
with the front leg moved back and the back leg moved forward to land.
MAJDE 21
Box jump drills :
Double footed box jumps encourage explosive power. Note the use of the arms to help generate
force.
The knees are tucked in as the box is cleared...
and the landing is controlled by eccentric muscle work.
MAJDE 22
Consecutive box jumps can be undertaken using a sequence of boxes.
MAJDE 23
then off.
The same exercise can be done on one leg.
MAJDE 24
Multi-directional jump drills;
The progression from straight line jumps is multi-directional jumps and, as an advanced exercise,
multi-
MAJDE 25
then off, moving round the trampette.
f. Functional Rehab (week 5+):
The progression to functional activities can begin once the patient can jog without pain and is comfortable
doing plyometric drills. The idea of this stage is to progress from gentle exercise to the high intensity at
which games are played. All exercises are preceded by a warm up. As each exercise is a progression they
should be completed at least one day apart, under the supervision of a chartered physiotherapist.
Exercise 1 Variable pace running with the gradual introduction of turns.
This involves running round a 20m diameter figure-of-eight course. The figure-of-eight
course puts very gentle stress on the ankle and prepares the player for later turning drills.
The pace is limited to walk, jog or half pace running and is determined by the
physiotherapist who shouts out the desired pace. The physiotherapist also shouts the
commands stop and start. This re-introduces the player to the variable demands of a
game of football.
The session should last about 25 minutes.
Exercise 2 Variable pace running with gradual turns and various starting positions.
The player starts at one end of the course and makes a 30m run up to a 20m diameter
semicircle, around which they gently turn before completing another straight 30m run
back to the finish. The pace of the run is dictated by the physiotherapist and is either a
jog or half pace. The starting position should be different for each run (standing, lying on
back, lying on front, sprint start position, squatting, right side lying, left side lying,
jumping, hopping, facing backwards).
MAJDE 26
The patient should aim to complete 20 runs.
Exercise 3 A progression of exercise 1 - variable pace running with slightly tighter turns.
Run round a 10m diameter figure-of-eight course. The figure-of-eight course puts stress
on the ankle and prepares the player for later turning drills. The paces used are walking,
jogging, half pace running, and three-quarter pace running, as determined by the
physiotherapist who shouts out the desired pace. The physiotherapist also shouts the
commands stop and start.
The session should last about 25 minutes.
Exercise 4 A progression of exercise 2 - variable pace running with gradual turns and various
starting positions.
The player starts at one end of the course and makes a 30m run up to a 20m diameter
semicircle, around which they gently turn before completing another straight 30m run
back to the finish. The pace of the run is either three-quarter or full pace, as dictated by
the physiotherapist. The starting position should be different for each run (standing, lying
on back, lying on front, sprint start position, squatting, right side lying, left side lying,
jumping, hopping, facing backwards).
The player should aim to complete 20 runs.
Exercise 5 Two 5m diameter circles are placed 30m apart. Travelling at full pace the player makes a
run, with a football at the feet, goes around the far circle and then back to the finish.
This should be repeated 20 times.
Exercise 6 As exercise 5, but single cones are used instead of 5m diameter circles.
Exercise 7 Six cones are placed 5m apart in a straight line. The player completes a shuttle run, at full
pace, turning alternately to the left and right.
This should be repeated 10 times.
MAJDE 27
III. High Ankle Sprain Injury
A sprained ankle is the most common ankle injury in sport. A High Ankle Sprain refers to soft
tissue damage to the ligaments of the ankle Syndesmosis, which is the joint between the Tibia
(shin bone) and Fibula (splint bone). This ankle ligament damage is characterised by ankle pain
and a swollen ankle.
Severe High Ankle Sprains may need surgery although physiotherapy treatment is effective for
moderate injuries. In the early stages it is important the follow the PRICE protocol for treatment of
a sprained ankle protection, rest, ice, compression and elevation.
Common High Ankle Sprain signs & symptoms:
A history of ankle trauma.
Pain just above the ankle.
Swollen ankle.
Assessment and treatment are similar to any ankle sprains.
IV. Lisfranc Joint Injury
A Lisfranc injury is a cause of foot pain that may be difficult to diagnose. This infrequent foot injury occurs
when there is high energy trauma to the top of the foot. This trauma may occur in road traffic accidents or
during sports such as soccer when a player kicks the sole of an opponents boot. Because of the history of
direct trauma to the top of the foot it is difficult to differentiate from a Tarsal bone fracture or bone
bruising. There may or may not be a swollen foot.
Treatment is dependent on the severity of the injury. If there is a sprain of the Tarso Metatarsal ligament,
with no widening of the Metatarsals evident onx-ray , then conservative management should suffice.
Where there is more severe Tarso-Metatarsal ligament damage, the prognosis is not so good. This ligament
damage causes instability at the Lisfranc joint complex, which is evident on x-ray as widening between the
Tarso-Metatarsal joints. Many orthopaedic consultants advocate surgical fixation to reduce the likelihood of
developing arthritis of the foot.
MAJDE 28
Common Lisfranc Joint Injury signs & symptoms:
A history of trauma to the top of the foot.
Foot pain on separating the Metatarsals.
Foot pain when walking, running and turning.
Assessment and treatment are similar to any ankle sprains.
V. Plantar Fasciitis
Explanation:
Plantar Fasciitis is a common foot condition that causes heel pain and
pain in the sole of the foot. Plantar Fasciitis is inflammation of the
Plantar Fascia. During walking and running, as you 'toe-off', the Plantar
Fascia becomes taut and helps the foot act as a lever to pus h off with
force. It is one of the primary stabilizing structures of the arch on the
inner side of the foot..
Inflammation of the Plantar Fascia usually occurs at the point where it
attaches to the heel bone. Plantar Fasciitis is reasonably common in
older individuals, where the movement in the joints of the foot has
become restricted and strain on the Plantar Fascia is increased. It may
also occur in individuals who do a lot of standing, walking or sporting
activities, usually as a result of overuse. It tends to be more common in
females and in people who are overweight.
Plantar Fasciitis Signs & Symptoms:
Plantar Fasciitis produces foot pain over the inside of the heel and this usually radiates down the inside of
the sole of the foot. This foot pain usually occurs with activity and is also typically present in the morning
when taking the first steps of the day.
Plantar Fasciitis can be diagnosed by a doctor or physiotherapist, if pain is present on touching the affected
area, and/or on stretching the Plantar Fascia (by pulling the toes up). The diagnosis of Plantar Fasciitis can
be confirmed on an Ultrasound scan, when the fascia has a thickened appearance
Plantar Fasciitis Treatment:
Plantar Fasciitis is inflammatory in nature and the key to successful treatment is to determine what is
causing the inflammation and address this problem. In most sporting individuals the cause is overuse and
the most important advice is to allow adequate rest, to take the strain off the Plantar Fascia and allow the
affected tissues time to heal.
MAJDE 29
In some cases of Plantar Fasciitis there may be a problem with the biomechanics of the foot, contributing
to the problem. The usual findings are a foot that 'over pronates', where the inner arch of the foot rolls over
too much during walking an d running. This can lead to tightness in the Achilles tendon and recent research
has suggested that a tight Achilles tendon can increase strain on the Plantar Fascia.
Conservative treatment, such as physiotherapy, aims to reduce local inflammation and address any
biomechanical problems. While the Plantar Fascia is still painful it may be treated with Ice Packs and anti-
inflammatory drugs prescribed by a doctor.
Once the pain has subsided, stretching the Plantar Fascia is effective in encouraging the tissue to regain its
normal alignment. This helps the healing process and can relieve the symptoms of Plantar Fasciitis.
Prolonged stretching of the Plantar Fascia can be achieved using a Night Splint which is worn during sleep.
Research indicates that night splinting can significantly reduce Plantar Fasciitis symptoms in over 80% of
cases - particularly pain on the first few steps after waking up each morning.
Stiff joints around the foot and ankle can be treated using mobilisation, where the physiotherapist gently
moves the joints manually to remove the stiffness and restore the normal range of movement.
MAJDE 30
Taping has been shown to be an effective treatment for Plantar Fasciitis. The tape supports the Plantar
Fascia and removes some of the strain that can aggravate the condition.
Plantar Fasciitis settles with conservative treatment in 95% of cases.
MAJDE 31
VI. Os Trigonum Syndrome
Os Trigonum Syndrome Explained:
Os Trigonum Syndrome refers to pain in
the back of the ankle that is caused by
impingement of soft tissues on a bony
prominence at the back of the Talus bone.
This prominence is present in 1 in 20 of
the population but, in professional
footballers, it is reported to be present in 1
in 5. This is thought to be due to repeated
hyper plantar flexion (pushing the ankle
forwards) during footballing activities.
Due to the impingement, the soft tissues
at the back of the ankle become inflamed
and painful.
Os Trigonum Syndrome Signs & Symptoms:
Pain in the back of the ankle is the first indicator of Os Trigonum Syndrome. On examination by a doctor
or chartered physiotherapist the area in front of the Achilles tendon can be painful to touch, and the bony
prominence may even be palpable. The diagnosis of Os Trigonum Syndrome can usually be confirmed by x-
ray views of the ankle from the side.
Os Trigonum Syndrome Treatment:
Rest from the activities that aggravate the condition is required for 4 to 6 weeks, to allow the soft tissues to
settle down and heal. Physiotherapy treatment consists largely of ice therapy. Ice Packs applied for twenty
minutes every couple of hours may help with the pain. The Aircast Ankle Cryo/Cuff is the most effective
method of providing ice therapy as it can provide continuous ice cold water and compression for 6 hours
and significantly reduce ankle pain and swelling.
A doctor may prescribes anti-inflammatory medication, or administer acorticosteroid injection to reduce
the soft tissue inflammation. If there are persistent symptoms of ankle pain and swelling from Os Trigonum
Syndrome, an orthopaedic consultant may operate to remove the offending bony prominence.
Rehabilitation with a physiotherapist following this procedure usually takes between 4 and 8 weeks before
full sports activities can be resumed.
MAJDE 32
Os Trigonum Syndrome Prevention
In individuals who have a bony prominence at the back of the Talus bone, then success in preventing Os
Trigonum Syndrome may be limited. However, using an Ankle Brace that prevents excessive ankle plantar
flexion (pushing the foot down, like pressing the pedals of a car) may help to prevent soft tissue
impingement and the development of Os Trigonum Syndrome.
VII. Ankle fracture:
1. Signs & Symptoms
There is typically a history of twisting or trauma accompanied by a great deal of ankle pain and an
inability to use the affected ankle. Any suspected broken ankle needs to be urgently transferred
to hospital for assessment by a specialist trauma doctor. 'Open' fractures, where the bone
fragments push through the skin, are patently obvious but all serious ankle injuries require a full
assessment and an x-ray evaluation.
2. Classification:
According to Weber and Lauge-Hansen Classification
Basically there are three main types of ankle fractures.
Weber classified them as:
type A - infrasyndesmotic
type B - transsyndesmotic
type C suprasyndesmotic
MAJDE 33
type A infrasyndesmotic
Occurs below the syndesmosis, which is intact. According to Lauge-Hansen, it is the result of an adduction force on the
supinated foot.
Stage 1 - Tension on the lateral collateral ligaments results in rupture of the ligaments
or avulsion of the lateral malleolus below the syndesmosis.
Stage 2 - Oblique fracture of the medial malleolus.
MAJDE 34
type B transsyndesmotic
This is a transsyndesmotic fracture with usually partial - and less commonly, total - rupture of the
syndesmosis.
According to Lauge-Hansen, it is the result of an exorotation force on the supinated foot.
Stage 1 - Rupture of the anterior syndesmosis
Stage 2 - Oblique fracture of the fibula (this is the true Weber B fracture)
Stage 3 - Rupture of the posterior syndesmosis
or - fracture of the malleolus tertius
Stage 4 - Avulsion of the medial malleolus
or - rupture of the medial collateral bands
MAJDE 35
type C suprasyndesmotic
This is a fracture above the level of the syndesmosis. Usually there is a total rupture of the syndesmosis
with instability of the ankle.
According to Lauge-Hansen, it is the result of an exorotation force on the pronated foot.
Stage 1 - Avulsion of the medial malleolus
or - ligamentous rupture
Stage 2 - Rupture of the anterior syndesmosis
Stage 3 - Fibula fracture above the level of the syndesmosis (this is the true Weber C fracture)
Stage 4 - Avulsion of the malleolus tertius
or - rupture of the posterior syndesmosis
MAJDE 36
3. Assessment:
Observation:
o Gait
o Posture
o heel walking(L4-S1)
o toe walking((s1-S2)
o Heel raise
Pain assessment:
o Location
o Scale
o Type
o Aggravators
o Relievers
ROM:
Right Left #
active passive active passive active Passive
Dorsi flexion
Plantar flexion
inversion
eversion
MAJDE 37
Skin Trophic assessment:
Observation:
Skin color
Scars
Edema
Atrophy
Measurements:
Measure edema between lateral and medial malleolus
Muscle assessment:
muscle right Left notes
Gastrocnemius
Peroneals
Anterior tibialis
Posterior tibialis
Extensor hllucis longus
Extensor degetorom
longus
Flexor hllucis longus
Flexor degetorom longus
Neurologic assessment:
right left
Light touch
Pin brick
tactile
Thermal
pain
MAJDE 38
Reflexes:
right left
patellar
Ankle jerk
Babinski
Palpation:
Dorsal pedal
Posterior tibial artery pulses
Soft tissue
Bony landmarks
4. Treatment:
a. Phase I: 0 6 weeks
Goals for Phase I:
1. Pain and swelling control
2. Normal ROM of non-involved joints
3. Safe/functional gait with or without assistive gait device
A. Orthotics: Patient is immobilized in insert, cast or walking boot as directed by the physician.
May remove walking boot for bathing and AROM
B. Gait training: Weight-bearing to be determined by the physician. If WBAT, patient should be
progressed from WBAT with crutches to FWB without crutches
C. ROM: Work to restore normal ROM of non-involved joints. If in walking boot, may remove boot
for gentle AROM of involved ankle/foot.
Ankle Fx ORIF: AROM started during 1st post op visit (DF,PF, INV, EV), Achilles towel stretching as
tolerated.
Ankle Fx w/out ORIF: Pain free AROM (do not exceed 10 degrees of Dorsiflexion), PROM
Dorsiflexion to neutral during 1st 2 wks, progress to 5 degrees of pain free PROM by 4 weeks, then
10 degrees by 6 wks. Avoid inversion/eversion ROM until 4 weeks post accident. Begin
MAJDE 39
active Inv/Ev ROM at start of 5th wk. PROM Inv/Ev and joint mobs after 6th wk.
Metatarsal /Foot Fx: Ankle AROM as tolerated, If passive Dorsiflexion is necessary, perform w/ foot
supported on floor unweighted during gastroc/soleus stretch. Avoid towel roll stretching to
prevent undistributed forces/torque throughout the metatarsals.
D. Soft tissue management: wound monitoring (avoid getting stitches wet), swelling control, scar
massage, desensitization
E. Modalities: Utilize for pain, inflammation, swelling control, and muscle re-education as
necessary
b. Phase II: 6 9 weeks
Goals for Phase II:
1. Functional ROM
2. Functional strength
3. Normal gait
(transfers, housecleaning etc.)
5. Begin work/sports activities
A. Orthotics: Gradually discontinues use of walking boot when directed by physician, use air-cast,
rocket-soc etc as ordered by physician
B. Gait-training: If patient has been NWB, begin progressive weight-bearing, patient should be
progressed from WBAT with crutches to FWB without crutches
C. ROM: Work to restore full P/AROM of ankle and foot, including sub-taler joint mobility/mobs
ics, thera-band, heel lifts etc),
weightbearing activities, conditioning activities (bike, treadmill). If ankle ORIF, t-band
strengthening may begin at beginning of 3rd week if ROM is progressing.
E. Balance/Proprioception: Single leg stance activities, balance beam, BAPs board etc.
jump, zig-zags etc.)
MAJDE 40
G. Modalities: Utilize for pain, inflammation, swelling control, and muscle re-education as
necessary
c. Phase III: 9 weeks to release
Goals for Phase III:
1. Good strength
2. Return to sports activities
A. Orthotics: Continue strengthening/conditioning/functional activities as needed
MAJDE 41
VIII. Conclusion:
MAJDE 42
I. Over View of ankle trauma:1. Ankle Anatomy2. Types of ankle trauma:
II. Ankle Sprains:1. Classification:2. History and Assessment:a. Historyb. Assessment
3. Treatment:a. Goals:b. Acute Phase (first 2-4 days)c. Sub-Acute stage (days 3 to 14)d. Early Rehab (week 3)e. Late Rehab (week 4)f. Functional Rehab (week 5+):
III. High Ankle Sprain InjuryIV. Lisfranc Joint InjuryV. Plantar FasciitisVI. Os Trigonum SyndromeVII. Ankle fracture:1. Signs & Symptoms2. Classification:3. Assessment:4. Treatment:a. Phase I: 0 6 weeksb. Phase II: 6 9 weeksc. Phase III: 9 weeks to release
VIII. Conclusion: