TRACK + BASEBALL + SOCCER = SPRAINED ANKLES

This spring season is prime time for strained and sprained ankles.  An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe, depending upon how much damage there is to the ligaments.

Most sprains are minor injuries that heal with home treatments like rest and applying ice. However, if your ankle is very swollen and painful to walk on — or if you are having trouble putting weight on your ankle at all, be sure to see your doctor.

Without proper treatment and rehabilitation, a more severe sprain can weaken your ankle—making it more likely that you will injure it again. Repeated ankle sprains can lead to long-term problems, including chronic ankle pain, arthritis, and ongoing instability.

Description

Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.

Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.

If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

A twisting force to the lower leg or foot can cause a sprain. The lateral ligaments on the outside of the ankle are injured most frequently.

Cause

Your foot can twist unexpectedly during many different activities, such as:

• Walking or exercising on an uneven surface
• Falling down
• Participating in sports that require cutting actions or rolling and twisting of the foot—such as trail running, basketball, tennis, football, and soccer
• During sports activities, someone else may step on your foot while you are running, causing your foot to twist or roll to the side.

Symptoms

A sprained ankle is painful. Other symptoms may include:

• Swelling
• Bruising
• Tenderness to touch
• Instability of the ankle—this may occur when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

If there is severe tearing of the ligaments, you might also hear or feel a "pop" when the sprain occurs. Symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

Doctor Examination

Physical Examination

Your doctor will diagnose your ankle sprain by performing a careful examination of your foot and ankle. This physical exam may be painful.

• Palpate. Your doctor will gently press around the ankle to determine which ligaments are injured.
• Range of motion. He or she may also move your ankle in different directions; however, a stiff, swollen ankle usually will not move much.

If there is no broken bone, your doctor may be able to tell the severity of your ankle sprain based upon the amount of swelling, pain, and bruising.

Imaging Tests

X-rays. X-rays provide images of dense structures, such as bone. Your doctor may order x-rays to rule out a broken bone in your ankle or foot. A broken bone can cause similar symptoms of pain and swelling.

Stress x-rays. In addition to plain x-rays, your doctor may also order stress x-rays. These scans are taken while the ankle is being pushed in different directions. Stress x-rays help to show whether the ankle is moving abnormally because of injured ligaments.

Magnetic resonance imaging (MRI) scan. Your doctor may order an MRI if he or she suspects a very severe injury to the ligaments, damage to the cartilage or bone of the joint surface, a small bone chip, or another problem. The MRI may not be ordered until after the period of swelling and bruising resolves.

Ultrasound. This imaging scan allows your doctor to observe the ligament directly while he or she moves your ankle. This helps your doctor to determine how much stability the ligament provides.

Grades of Ankle Sprains

After the examination, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.

Grade 1 Sprain (Mild)

• Slight stretching and microscopic tearing of the ligament fibers
• Mild tenderness and swelling around the ankle

Grade 2 Sprain (Moderate)

• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint

Grade 3 Sprain (Severe)

• Complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instability occurs

Treatment

Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.

A three-phase program guides treatment for all ankle sprains—from mild to severe:

• Phase 1 includes resting, protecting the ankle and reducing the swelling.
• Phase 2 includes restoring range of motion, strength and flexibility.
• Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities)—such as tennis, basketball, or football.

This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Home Treatments

For milder sprains, your doctor may recommend simple home treatment.

The RICE protocol. Follow the RICE protocol as soon as possible after your injury:

• Rest your ankle by not walking on it.
• Ice should be immediately applied to keep the swelling down. It can be used for 20 to 30 minutes, three or four times daily. Do not apply ice directly to your skin.
• Compression dressings, bandages or ace-wraps will immobilize and support your injured ankle.
• Elevate your ankle above the level of your heart as often as possible during the first 48 hours.

Medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help control pain and swelling. Because they improve function by both reducing swelling and controlling pain, they are a better option for mild sprains than narcotic pain medicines.

Nonsurgical Treatment

Some sprains will require treatment in addition to the RICE protocol and medications.

Crutches. In most cases, swelling and pain will last from 2 to 3 days. Walking may be difficult during this time and your doctor may recommend that you use crutches as needed.

Immobilization. During the early phase of healing, it is important to support your ankle and protect it from sudden movements. For a Grade 2 sprain, a removable plastic device such as a cast-boot or air stirrup-type brace can provide support. Grade 3 sprains may require a short leg cast or cast-brace for 2 to 3 weeks.

Your doctor may encourage you to put some weight on your ankle while it is protected. This can help with healing.

Physical therapy. Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.

• Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
• Strengthening exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
• Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
• Endurance and agility exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

Once you are pain-free, resistance exercises may be added to your therapy program.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Surgical Treatment

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment.

Surgical options may include:

• Arthroscopy. During arthroscopy, your doctor uses a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
• Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures. In some cases, he or she will reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.

Immobilization. There is typically a period of immobilization following surgery for an ankle sprain. Your doctor may apply a cast or protective boot to protect the repaired or reconstructed ligament. Be sure to follow your doctor's instructions about how long to wear the protective device; if you remove it too soon, a simple misstep can re-tear the fixed ligament.

Rehabilitation. Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

Outcomes

Outcomes for ankle sprains are generally quite good. With proper treatment, most patients are able to resume their day-to-day activities after a period of time.

Most importantly, successful outcomes are dependent upon patient commitment to rehabilitation exercises. Incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain. If a patient stops doing the strengthening exercises, the injured ligament(s) will weaken and put the patient at risk for continued ankle sprains.

Chronic Ankle Sprains

Once you have sprained your ankle, you may continue to sprain it if the ligaments do not have time to completely heal. It can be hard for patients to tell if a sprain has healed because even an ankle with a chronic tear can be highly functional because overlying tendons help with stability and motion.

If pain continues for more than 4 to 6 weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces and participating in sports that require cutting actions or rolling and twisting of the foot.

Abnormal proprioception—a common complication of ankle sprains—can also lead to repeat sprains. There may be imbalance and muscle weakness that causes a reinjury. If you sprain your ankle over and over again, a chronic situation may persist with instability, a sense of the ankle giving way, and chronic pain. This can also happen if you return to work, sports, or other activities before your ankle heals and is rehabilitated.

Prevention

The best way to prevent ankle sprains is to maintain good muscle strength, balance, and flexibility. The following precautions will help prevent sprains:

• Warm up thoroughly before exercise and physical activity
• Pay careful attention when walking, running, or working on an uneven surface
• Wear shoes that are made for your activity
• Slow down or stop activities when you feel pain or fatigue

"FLAT FEET" IN CHILDREN

Flatfeet (also known as pes planus) describes a condition in which the longitudinal (lengthwise) and/or medial (crosswise) arches of the foot are dropped down or flat. The entire bottom of the bare foot is in contact with the floor or ground surface during standing, walking, and other weight bearing activities. The condition is often present at birth (congenital) in one or both feet. When only one foot is affected, the problem is referred to as unilateral pes planus or flatfoot. When both feet are involved, the condition is bilateralflatfeet.

This guide will help you understand:

• what parts of the foot are affected
• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the foot are involved?

The Anatomy of the foot is very complex. When everything works together, the foot functions correctly. When one part becomes damaged, it can affect every other part of the foot and lead to problems. With a flatfoot deformity, bones, ligaments, and muscles are all affected. A combination of malalignments results in the flatfoot appearance. 

Bones

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint. 

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heel bone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. 

The subtalar joint allows the foot to rock from side to side. People with flatfeet usually have more motion at the subtalar joint than people who do not have flatfeet. The increased flexibility of the subtalar joint results in many compensatory actions of the foot and ankle in order to keep proper foot alignment during standing and walking.

Just down the foot from the ankle is a set of five bones called tarsal bones. The tarsal bones work together as a group. They are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting. 

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges. 

Ligaments and Tendons

Ligament are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. 

The large Achilles' tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to rise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. Failure of the posterior tibial tendon is a major problem in many cases of pes planus.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

The spring ligament complex is often involved in the flatfoot condition. This group of ligaments supports the talonavicular joint. The spring ligament complex works with the posterior tibial tendon and the plantar fascia to support and stabilize the longitudinal arch of the foot. Failure of the ligaments that support this arch can contribute to flatfoot deformity. Injury, laxity(looseness), or other dysfunction of the ligament and tendon structures can result in deformity of the foot and/or ankle resulting in pes planus. 

Muscles

Most of the motion of the foot is caused by the stronger muscles and tendons in the lower leg that connect to the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.

There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems.

Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot.

Causes

What causes this problem?

Flexible flatfoot refers to a foot that looks flat when standing but appears to have an arch when the foot isn't resting on the floor or against a flat surface. Sometimes the term fallen arches is used, but doctors prefer not to use this term in favor of the more accurate medical term pes planus. 

Most babies and young children have what looks like flat feet. This is normal. Before the bones are formed, much of the foot and ankle are still made up of soft tissue, fat, and cartilage. The arch has not formed fully yet. The joints are still hypermobile when the child starts to get up on feet to walk. This is when the flatfoot deformity becomes obvious and parents may become concerned that something is wrong with their child's foot. The vast majority of children will grow out of their flat foot deformity. Even if the deformity does not fully correct with age, it is unlikely to cause the child any difficulty in the future.

Stress and activities during early childhood requiring strength in the feet are actually the training needed to develop normal muscle, tendon, ligaments, and bone in the foot and ankle. But in some cases, the arch doesn't form and the foot remains flat into adulthood. Flatfeet do tend to occur in families as an inherited condition.

There are many possible causes for the flatfoot condition. Biomechanically, many soft tissue structures must connect and support one another to prevent a flatfoot deformity. Tibial (lower leg bone) rotation, hindfoot alignment, and position of the joints of the foot, midfoot, hindfoot, and ankle are all important factors. There is no one cause of flatfoot deformity that can be identified.

In the flexible flatfoot, the bones are usually normal - but the supporting ligaments are lax or loose. The joints are hypermobile. As the soft tissues and joints of the foot and ankle try to maintain a normal foot position, increased stress is placed on them. This can lead to fatigue and loss of strength resulting in a sagging of the arch. This can affect the chain of anatomical structures all the way up the leg.

There are some uncommon causes of flatfoot that do affect the bones. A Tarsal Coalition refers to a condition where two or more bones in the midfoot or hindfoot fail to form separately during development. They remain connected together, altering the bone structure of the foot and limiting flexibility of the foot. This is a different type of flatfoot deformity altogether and is commonly referred to as a spastic flatfoot. This type of flatfoot deformity is not flexible. In fact, the foot is quite rigid due to the abnormal connection between the bones of the foot. This condition can be painful. 

Symptoms

What does the condition feel like?

For most children, the flexible flatfoot deformity causes no symptoms. They do not suffer from pain, swelling, or sore feet. Children with flexible flatfoot deformity may wear out shoes a bit different from a normal person, but there usually is not any reason to be concerned.

In moderate to severe cases, the patient may report fatigue and tired, sore feet after standing on them all day. During those times, they may limit their own activities.

In the uncommon severe cases, calluses may appear where pressure occurs as the bones make contact with the floor or hard surface. The loss of joint stability may alter the foot's ability to absorb the load and conform to uneven ground or surfaces.

Rarely, the flatfoot deformity may get worse with age. Excess pressure on the surrounding soft tissues (ligaments, capsules, tendons, muscles) can lead to other problems such as malalignment of the patella (kneecap), hallux valgus (Bunions), and rotation of the knee and hip.

When the flatfoot deformity is the result of a tarsal coalition, the situation is different. The foot may become painful. The child may begin to complain of foot and ankle pain after a minor twisting injury and the pain not resolve after a normal healing period. The symptom of pain combined with decreased motion and flatfoot deformity should suggest a more serious problem in the foot. 

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools the physician uses to diagnose this condition. Clinical tests can be done to differentiate flexible flatfoot from rigid flatfoot. The examiner will check mobility in the forefoot, hindfoot, and ankle. Muscle weakness and/or muscle tightness will be assessed. The wear pattern on the shoes can offer some helpful clues. 

X-rays or other more advanced imaging such as CT scans or MRIs may be ordered but these are rarely needed. The examiner may be able to see and feel a prominent bump with tenderness around the area when an Accessory Navicular bone is present. X-rays will show if there is an accessory navicular or tarsal coalition as part of the problem.

A very simple test called the wet footprint can be done at home or in the doctor's office. The patient places the foot in water and then places the foot down on a piece of paper or thin cardboard. After making a footprint, the foot is lifted off the paper. Someone with a flat foot will leave a complete footprint where the sole makes contact with the paper.

The physician may have you perform a single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). 

Treatment

What treatment options are available?

Nonsurgical Treatment

There may be no treatment needed for mild cases of flatfeet, especially flexible flatfeet. This condition often corrects itself in time as the child grows and develops. Young children should be encouraged to walk barefoot whenever it is safe to do so. This will increase sensory input into the foot. At the same time, navigating various floor and ground surfaces helps build strength and stability.

For older children and adults, a simple modification to the shoe may reduce the fatigue and discomfort in the foot. Sometimes purchasing shoes with a good arch support is sufficient. Try to find a comfortable shoe with an arch support, firm heel counter (back of the heel), and a flexible sole (bottom). Supporting the arch helps decrease the tension in the posterior tibialis tendon. Stretching the Achilles' tendon helps maintain normal motion of the hindfoot, which in turn, helps maintain alignment of the midfoot.

For other patients, an off-the-shelf (prefabricated) shoe insert works well. The goal is to support the foot and prevent further stretching of lax ligaments and tendons. These supports will not reverse the structural deformity and they will not build and arch by wearing them over time. These inserts simply help the shoe better fit the foot and support the structures of the foot. Improving alignment can take tension off the soft tissue structures, reduce fatigue, and improve the biomechanics of standing and gait (walking).

Further treatment is usually not needed for the flexible flatfoot deformity. Surgery is rarely needed for this condition. Patients with severe symptoms that do not respond to conservative care may benefit from further orthopedic evaluation and treatment. In rare cases, surgical intervention to correct the problem and realign the foot may be suggested.

Surgery

For children with a shortened Achilles' tendon, a program of stretching exercises or serial casting may help reduce pressure on the talus bone and offer significant pain relief. Severe cases of flatfoot (pes planus) may require surgery to reconstruct the arch or fuse the bones. This is very rare as conservative (nonoperative) care is usually sufficient.

Children with tarsal coalition or an accessory navicular bone require orthopedic evaluation and management. Surgery is done to correct the problem by the early teen years (before skeletal maturity). 

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Flatfeet seen in very young children just starting to walk often resolve with time. The very act of gripping with the toes to maintain support and balance along with the development of the bones forms the arches.

For older children who still have flatfeet, stretching and strengthening exercises won't cause an arch to form where there isn't one anatomically. But these activities can help ease any pain or discomfort caused by the condition. The same is true for any supports or shoe inserts that are used. However, shoe inserts or shoes specially-made to improve their condition tend to allow them to increase their desire to perform physical activity, as it does not correlate with a conditioned response to expect pain following exercise.  We recommend seeing a specialist then coming into us here at Champion Performance and Physical Therapy for exercises to improve your child's ability to be active and get exercise without pain. 

After Surgery

Corrective surgery is only done in cases of severe, painful and disabling flatfoot position. This is very rare. Reconstructive surgery for tarsal coalition or an accessory navicular bone requires a period of immobilization in a cast followed by rehabilitation to restore strength in the foot and ankle. In some cases, more than one operation is needed as the child grows and develops. Pain relief and joint stability are the goals.