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Help with a patient who is constantly spraining his ankles, once every 3 months!

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kerrie, Jan 24, 2011.

  1. Kerrie

    Kerrie Active Member

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    Hi All,

    I was wondering if y'all could give me some help with a patient that I am due to see tomorrow who is being reffered to us from the urgent care centre in our trust. I'll give you a basic low down of what the referral says and then if some people could spit ball it would be much appreciated :)


    That kinda what I have been provided with in terms of information. Now granted that I don't know yet if he is inversion spraining or eversion spraining but I commonly thought, and please excuse the naivety, that someone who feels unstable on their feet is commonly a cavus style foot with chronic lateral ankle instability and would therefore inversion sprain?

    Any help on this matter, including helpful papers because I will be researching tonight, so that I can go in with some arsenal would be appreciated

    Thanks alot guys :drinks
  2. Hey Kerrie.

    Assuming it is lateral instability and bearing in mind that I recently had a referral for someone with a bunion on their heel (referrals not always accurate)...

    Lateral instability is about kinetics as much as kinematics. Consider the supination resistance test (your last pod now;)). From memory, Craig showed that FPI was a poor predictor of supination resistance whereas STJA is a better one. So it is entirely possible to have a "slightly flat foot" and still have lateral instability.

    You're thoughts betray you Kerrie. Trust not position, for it will deceive you at every turn. Use the force(s), let them guide your actions.
  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Medial malleolar pain can be a sign of either medial or lateral ankle instability depending on the structures involved.

    On history and examination you'll soon work our which way he goes.

    Naturally, this will probably boil down to either superficial/deep deltoid attenuation (medial) or ATFL or CFL attenutation (lateral). No doubt his particular mechanics will explain why (ie cavo-varus vs PPV).

    Treat with appropriate orthoses relative to his particular mechanics to attempt to prevent recurrence. Consider Richie brace or similar also as a next step, but this will probably interfere with work too much.

    Finally, lateral ankle recontruction (Brostrom procedure) if very effective, deltoid repair less so.

    Very fix-able.

  4. Kerrie

    Kerrie Active Member

    Just reading a paper on prolonged peroneal reaction time and it's relation to ankle instability, what are everyones thoughts on that?
  5. Griff

    Griff Moderator

    Hey Kerrie,

    My initial gut feeling is that this chap may have a significant tibial varum. It is this skeletal morphology that tends to generate referrals from non Podiatrists for 'lateral instability with a slightly flat foot' in my experience.

    The varus attitude of the tibia essentially results in the foot being presented to the ground in an inverted position in terminal swing phase. (Obviously this can be an underlying factor for inversion injury). When ambulating on flat surfaces there will have to be an external STJ pronation moment in order to achieve a plantigrade foot position. Hence the apparently confusing situation of a laterally unstable foot which also pronates in stance.

    LL has given great advice regading the malleolar pain. Only thing I would possibly add is that I have seen a lot of medial malleolar pain in individuals who repeatedly invert their feet which turned out to be subchondral bruising (the impact of the medial malleolus on the talus/calcaneus perhaps?). I too have found Brostrum repairs to be incredibly beneficial when conservative care isn't cutting the mustard.

    Like Rob says, check the transverse plane position of the STJ axis and the supination resistance test (our assumptions being they will be lateral and low respectively). Then design orthoses as appropriate.

    Let us know your full findings tomorrow

  6. efuller

    efuller MVP

    Talliard's paper on sinus tarsi syndrome described increased peroneal reaction time. He blamed it on proprioceptive damage which doesn't make sense. It does make sense if you think about a foot that is maximally pronated, causing pain in the sinus tarsi, then the person does not contract their peroneal muscles because it would increase compression in the sinus tarsi. Talliard's paper also noted ankle instability on uneven terrain which also makes sense in terms of you are more likely to get an unexpected supination moment from the ground and then start supinating and you reach a quite inverted position before the peroneals can kick in.

  7. Griff

    Griff Moderator

  8. Admin2

    Admin2 Administrator Staff Member

  9. davidh

    davidh Podiatry Arena Veteran

    Hi Kerrie,

    You could try a simple fix before going all complicated:eek:

    Some frictions direct to the painful area proximal/distal to the lat malleoli.
    Some mild manipulation to the ankle (stretching the joint in inversion and eversion/dorsiflexion and plantarflexion).
    Finally OTC insoles with a 5mm felt lateral forefoot wedge.

    You may want to consider prescription orthoses (which I find tend not to work well unless the soft tissue component is also addressed).

    Oh, and check his shoes are not very worn down.
  10. David why would soft tissue treat the lateral malleoli when the medial malleoli area is paiful ?

    Kerrie find out whats hurting 1st, then workout why then treat which should include both mechanical means as well as physical.
  11. davidh

    davidh Podiatry Arena Veteran

    Michael, I clearly didn't read Kerrie's post properly:eek:.

    Your advice is spot-on.

    On re-reading I would suspect Post Tib dysfunction on the left side, but I'm not about to make a diagnosis from an internet description.
    If the pt is spraining his ankes frequently my advice about the frictions and stretches at the lateral malleoli is still applicable.
  12. Ian Linane

    Ian Linane Well-Known Member

    Hi Ian
    Thanks for the paper reference. If you get a copy I'd be interested in looking at it.
  13. METaylor

    METaylor Active Member

    Ligaments that are strained usually don't regain full strength - 70-80% is usual and from then on are at increased risk of straining again. Collagen undergoes a sort of plastic change with more than 4% increase in length - a very tiny amount. To restart the healing cascade, injections of a mixture of glucose and lignocaine is very effective if given at the sites of strain ie where the tenderness is, ie at the site of attachment of the ligament to the bone. This is called prolotherapy, and you could google and see if anyone is teaching it where you live/work. I teach it in Australia and it is taught in many other countries. In this guy, find out how the original strain happened and think of the outside of the curve and the ligaments that must have taken the most strain, then look at the ends of those ligaments - skeleton and anatomy books are a great help. See my website www.drmtaylor.com.au for the recipe and more detail and look up on PubMed - now good refs on achilles and plantar tendinopathy - but the easiest is lateral ankle sprain for you podiatrists that know your anatomy. The most common one I treat in the foot is tib posterior syndrome at the insertion of the tendon in the medial arch - a few treatments are usually necessary - fantastic results, and then the arch will support itself again - and no need for expensive orthotics - OOh what am I saying!! Can also relieve pain in the first MTP joint and lately getting good results around the cuboid as well - the more anatomy of the foot I learn, the better I get at it.
  14. Ian Linane

    Ian Linane Well-Known Member

    Hi Dr Taylor
    As well as providing the injections to the affected sites of the foot and ankle, in this instance ligament strain, would you further encourage any rehab work that may improve soft tissue function or reinforce the treatments you provide?
  15. Griff

    Griff Moderator

    Will be with you anon sir
  16. METaylor

    METaylor Active Member

    depends where the lesion is - exercises mainly help muscles to get strong and if the underlying ligament is strong, the muscle can relax and just do what it should do, ie move the joint, instead of 'trying' to help hold it from wobbling. However a bit of movement helps align the new ligaments in the correct alignment ie where the existing ligaments are. I think it has been shown that movement also stimulates new connective tissue growth. However prolotherapy is so effective and walking is so impossible to avoid that exercise is not all that necessary, except eccentric exercises for achilles tendinopathy.
  17. davidh

    davidh Podiatry Arena Veteran


    I know colleagues who obtain good results with prolotherapy.

    You stated "prolotherapy is so effective".
    Do you have any good research refs to substantiate that?
    I'd be interested in looking at them if you could post some (or if this has already been discussed here perhaps someone else could point me in the direction of a good ref or two.
    Thanks in advance.

  18. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Dr Taylor

    Surely you jest!

    Are you actually saying that prolotherapy, which has yet to prove its bona fides according to my understanding of the literature, can repair a degenerative tendon or ligament to the point of restoring full functional stability?

    I have some belief that prolotherapy might improve the symptomatic management of many enthesopathic complaints, but saying that it is even superior to the very average results of direct surgical repair (eg posterior tibial tendon, or ATFL repair), is surely blowing your trumpet a little loud.

    Any evidence you care to bring forth to sway our opinion?

  19. markleigh

    markleigh Active Member

    I couldnt help but respond to Dr Taylors comments about, "and no need for expensive orthotics". I was lead to believe a course of prolotherapy too be quite expensive & people were encouraged to purchase other supplements/vitamins to aid the healing - not a cheap option I would have thought.
  20. METaylor

    METaylor Active Member

    There are over 60 references to prolotherapy on PubMed including the one by Michael Yelland and podiatrist Kent Sweeting on Achilles tendinopathy - Br J of Sports Med 2009;
  21. Ian Linane

    Ian Linane Well-Known Member

    Hi Dr Taylor

    Thanks for getting back to me and the information. Like David i know people who use it with some reasonable and some good results. Equally like LL, though, I am a little sceptical on some of our comments in your post. Perhaps you could clarify them in answering LL's question. Genuine request on my part.
  22. Ian Drakard

    Ian Drakard Active Member

  23. davidh

    davidh Podiatry Arena Veteran

    Thank you. Another point came up on this thread which I don't feel the need to discuss in any great detail, but I'd like your thoughts. I think the point has already been well made that expensive orthotics and a course of prolotherapy probably costs the same or similar.

    You said:
    fantastic results, and then the arch will support itself again - and no need for expensive orthotics - OOh what am I saying!!

    From the above quote I'm assuming that you don't believe that ground reaction force is ever a contributing factor in these cases.

    Is this in fact the case?
  24. Dear Kerrie
    May I give you an excellent protocol to deliver to your patient.
    It depends on him retraining his proprioception by use of a wobble board which we use in my clinic and I can help you with my method of use of this. This approach is vital.
    Then as I teach in my Foot Mobilisation courses for Podiatrists you have to have a effective Ankle Joint Rehabilitation programme as part of your treatment options.
    Also you need to look at the mobility of the Ankle and Foot joints and also the Myofascial status of the key muscles.
    You may wish to learn my method which I teach as I can see you are a Podiatrist whom is determined to help your patients.
    Brian Joseph DO, FHEA

  25. and that advert was bought to you by Joseph the secret foot mobiliser. I can teach you if you pay me.

    Joseph I tent to read most posts on here, may I suggest you drop the advert bit and offer some real advice or ask questions it´s getting somewhat long in the tooth.
  26. Kerrie

    Kerrie Active Member

    Dear All,
    Well what can I say, I have seen the guy, designed the insoles and reviewed him and I am pleased to say that there is total relief.
    He did have significant tibial varum which was contributing to his problem but 99% was a psychological fear that he was going to go over, when I gait assessed him he was clinging onto the walls for fear he would go over NO JOKE!
    Bascially I drew little dots on all the reference points in his ankles and knees and made him stand in front of a full length mirror and then connected the lines on what was wrong to show him (he went home looking like a dot to dot) then I made up some nice orthosis with rearfoot medial wedging. Got him to improve his core stability and confidence and he seems happy :) so success for the pods again :)
    Thanks for all your help guys it is much appreciated
  27. RobinP

    RobinP Well-Known Member

    The Ian Griffiths crystal ball strikes again.....

    BTW what was his STJ axis alignment like and what was his supination resistance like?


  28. Kerrie

    Kerrie Active Member

    It appeared to be laterally deviated and therefore I obviously had to place a minimal amount of force on the arch in the supination resistance test but I dunno my method at doing that test is probably heavily flawed, can't say it's usually in my aresnal but I knew that I was going to have to report back on him so I did every test I could think of ;)
  29. RobinP

    RobinP Well-Known Member

    Kerrie,, I sometimes wonder if I should not watch someone walk into the room and not look at the referral before assessing their sub talar joint axis alignment and kinetics. I don't trust myself not to "find" the axis alignment that the pathology would suggest!

    i'm sure Mr Isaacs has a name for this - confirmation bias?

    Before the whole vector of the orthotic reaction force arose, I'm sure that I was applying the force at different angles in order to acheive the results I was expecting. Obviously not concious of it but since the vector thing, I have been very strict about the way in which I apply the force.

    Anyway, the point being, "I hear you sister"

    Well done for posting your findings, even if you are not sure of them


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