Post operative/injury rehabilitation of the ankle

Have you ever injured your ankle, or know someone who has required surgery for their ankle?

It is a joint of the body that is commonly injured. Unfortunately, it is not as stable as the hip joint, as stability is compromised for the range of motion it provides. It supports our entire weight, day in and day out. Until we are unable to use it effectively, does it really hit home how much it can set one back in terms of mobility and daily activities.

Appropriate rehabilitation of this joint is vitally important. By approaching your rehabilitation with the right mindset and level of dedication, you can restore as much of its previous function as possible.

Ankle Anatomy Overview

Understanding the anatomy of an injured location in the body can provide much more clarity to patients in the recovery process.

The structure of the ankle is complex - consisting of three bones: the tibia, fibula and the talus of the foot. The talus fits between the tibia and fibula much like a mortise and tenon joint. The fibula and tibia form the mortise, whilst the talus is the tenon component.

The ankle is a hinged synovial joint offering plantarflexion and dorsiflexion, as well as inversion and eversion movements (via the subtalar joint, formed by the calcaneus and talus; this joint contributes to ankle range of motion but is not classed as part of the ankle joint) (Moore et al., 2017).

The fibula is very exposed on the outer aspect of the lower leg, and as such is vulnerable to fracture. It is also a much less dense bone than the tibia.

The tibia, fibula and talus are bound together by strong ligamentous structures, including:

- The syndesmosis

- The lateral ligament complex (Anterior Talofibular Ligament; Posterior Talofibular Ligament; Calcaneofibular ligament)

- The Deltoid ligament (on the inside of the ankle) (Moore et al., 2017)

Housed within the ligamentous structures (and muscle fibres of muscles around the ankle) are proprioceptive nerve fibres. Proprioception (kinesthesia) is the sense that lets us perceive the location, movement and action of parts of the body (Squire, 2009).

These nerve fibres are highly important to stability at the ankle joint. Without this sensory capability, the brain and nervous system would essentially be flying blind, completely unaware of the motion and position of our main source of support on the ground.

Muscles supporting the ankle and acting at the ankle include:

- Peroneus/Fibularis (interchangeable name) longus: eversion; assists plantarflexion

- Peroneus/Fibularis brevis: eversion and plantarflexion actions

- Gastrocnemius: two heads [medial (inner) and lateral (outer)] that perform plantarflexion

- Soleus: performs plantarflexion

- Tibialis posterior: assists plantarflexion; performs inversion

- Tibialis anterior: dorsiflexion; assists inversion

- Flexor hallucis longus: flexion of the hallux/”big toe”

- Flexor digitorum longus: flexion 2nd, 3rd, 4th and 5th toes

Common conditions/injuries affecting the ankle joint

Ankle Ligament Sprain/Rupture

The lateral ligament complex of the ankle is the weakest. Of these, the ATFL (anterior talofibular ligament) is especially prone to sprain or rupture. Due to its lack of density and how its fibres run in a particular direction, it is vulnerable in inversion injuries (“rolling of the ankle”). Rolling the ankle in high heeled shoes, whilst playing sport or when suddenly losing footing on irregular surfaces can produce this injury. On top of ligament partial tear and stretch (sprain) and/or rupture, oedema (from the resulting inflammatory response), the highly important proprioceptive fibres are damaged. Without efforts to rehabilitate the ankle properly, future sprain or ligament rupture is likely.

Symptoms: swelling, bruising, loss of range of motion/stiffness, inability to weight bear on affected side

Ankle fracture

A fractured ankle results when one or more of the bones forming the ankle are broken. As mentioned previously, the fibula bone is frequently fractured. However, the tibia and talus can also be fractured (Moore et al., 2017).

Possible mechanisms of fracture at the ankle:

- avulsion (strong tendinous/ligamentous pull on bone causes a fragment of bone to be displaced from the attachment site)

- compound (where the fracture breaks the skin and bleeding occurs; also called an open fracture)

- stable (the surfaces at the fracture site are in alignment and not displaced)

Classified types of ankle fracture:

- lateral malleolus (outer protuberance of the lower portion of the fibula bone)

- medial malleolus (inner protuberance of the lower portion of the tibia bone)

- posterior malleolus (the protuberance at the back of the ankle that is the back of the tibia bone)

- Bimalleolar (both lateral and medial malleoli are fractured)

- Trimalleolar (lateral, medial and posterior malleoli fractures and the most severe!) (Bickley, 2016)

The Ottawa Ankle Rule

Manual practitioners, general practitioners and nursing staff use this method to determine the necessity of radiographs to investigate potential fracture/s. It is an effective screening tool that prevents unnecessary imaging (as ankle sprains are a prevalent injury often mistaken for ankle fracture).

With relation to ankle fracture (the Ottawa Rules are also used for foot fracture detection), XRAY is indicated if any of the following are present:

- Bony tenderness along the lower 6cm of the tibia OR fibula and their malleoli

- Inability to bear weight immediately AND the first four steps into the emergency department

Symptoms: swelling, bruising, inability to bear weight, distorted appearance of the foot/ankle, bleeding, bony protrusion through the skin (Bickley, 2016)

Achilles Tendonitis

Achilles tendonitis is inflammation of the achilles tendon (the mutual tendon of the triceps surae: soleus and gastrocnemius connecting them to the calcaneus); most commonly a result of overuse affecting younger, athletic individuals. It can also affect non-athletic individuals with biomechanical issues of the foot and ankle. This condition can be both acute and chronic. Excessive tightness of triceps surae results in high tension levels in the Achilles tendon and microtears and inflammatory response (Stoffel, 2010).

Ankle Arthritis

Arthritis can develop in the ankle for many reasons. There are different types.

- Osteoarthritis: onset following previous trauma/”wear and tear” to the ankle joint, whereby inflammatory processes and force have resulted in irregularity of the joint surfaces (cartilage degeneration)

- Inflammatory arthritis: this form of arthritis involves hypersensitivity of the immune system, where an inflammatory response ensues within the ankle joint from immune cell activity; common forms are rheumatic, psoriatic and lupus related types.

- Septic/infectious arthritis: this form develops as a result of an infection invading the ankle joint space, causing an inflammatory response that thereby results in joint damage/degeneration. Fever and chills will be symptoms involved along with symptoms of arthritic pain and inflammation (Bickley, 2016)

Stages of Rehabilitation

The best prognosis/outcome from rehabilitation of the ankle involves due diligence and progression through the different stages. The stages of rehabilitation can be viewed much like the structure of a pyramid diagram. A strong foundation is required to advance up to the summit of the pyramid and the final stage. This holds true for post-operative and post-injury related rehabilitation. Consultation with your GP is advised to organise referral to an osteopath, physiotherapist or other rehabilitative professional that can develop a programme for you and assess your unique injury and circumstances.

Range of Motion and Flexibility

After the initial stages of symptom management (pain, oedema/swelling and ability to weight bear), restoration of ankle range of motion (plantarflexion, dorsiflexion, inversion and eversion) and flexibility of muscles, ligaments and tendons is highly important.

Without enough range of motion, return to normal activities of daily living is near impossible and bodily compensations in other areas is likely.

This stage will involve exercises that stretch joint structures to remove stiffness and muscular restriction that are limiting ankle range of motion.

Proprioception

Although not the first stage to progress through, this stage is absolutely vital. Proprioceptive rehabilitation exercises are capable of restoring proprioceptive fibres to the surrounding muscular, tendinous and ligamentous structures of the ankle joint (that may have been damaged in the injury and/or surgical process) (Moore et al., 2017; Stoffel et al., 2010; Dwyer & Mattacola, 2002).

This stage involves testing, challenging and re-training of these nerve fibres – typically in the form of coordination and balance exercises. A highly beneficial rehabilitative tool that promotes this is the stability/therapeutic/”wobble” board. Restoration of proprioception is integral to prevent future re-injury, as a result of instability (Stoffel et al., 2010; Dwyer & Mattacola, 2002).

Strength

This stage is the final progression of the rehabilitative programme for the ankle. It should only be implemented once capability is demonstrated with exercises from the aforementioned stages – this foundation prior to strength training is important to prevent re-injury or injury aggravation.

It will involve implementation of exercises that strengthen not only the muscles, but the ligamentous and tendinous structures of the ankle. These will be very individual to the patient’s mechanism of injury and other restrictions that may be part of their recovery (Dwyer & Mattacola, 2002).

The best outcomes from rehabilitation are often achieved through willpower, consistency and compliance throughout the programme. Although your osteopath or other health professional wish to see your success, it can only be achieved by taking responsibility for your role as well.

Take care all,

Lenore Dyson

REFERENCES

Bickley L. S.Bates’ Guide to Physical Examination and History Taking. Wolters Kluwer. 12thEd. (2016)

Dwyer, M. K. & Mattacola, C. G. Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train. 2002 Oct-Dec; 37(4): 413–429. 

Hoagland, T. M. Ankle Joint Anatomy. (https://emedicine.medscape.com/article/1946201-overview). 25/05/2015 (Accessed 19/05/2020)

K. K. Stoffel, R. L., Nicholls A. R. Winata, A. R. Dempsey. Effect of ankle taping on knee and ankle joint biomechanics in sporting tasks. Medicine and Science in Sports and Exercise. (March 2010) pp.2089-2097

Moore K. L., Dalley A. F., Agur A. M. R. Clinically Oriented Anatomy. Lipincott Williams & Wilkins.8thEd. (2017)

Squire L. R. Encyclopedia of Neuroscience. Elselvier Ltd (2009)