Treatment of the Stiff Ankle

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Treatment of the Stiff Ankle

• Mark Labrecque B.Sc., D.C.

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Learning Objectives

• Provide an introduction of manual therapy
  treatment for the stiff ankle
• Demonstrate examination, mobilization and
  manipulation techniques for the ankle/foot

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Introduction

• Ankle sprains are one of the most frequent
  problems in clinical practice
• Proprioception and ROM in dorsiflexion play a key
  role in the prediction of lateral ankle sprains
• Treatment protocols that target these risk
  factors for ankle sprains should then improve
  patient outcome
• The literature supports the use of manual therapy
  -including mobilization, manipulation and
  functional techniques such as postisometric
  relaxation techniques

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Introduction (continued)

• Manipulative therapy for ankle sprain has been
  commonly included in the multimodal approaches to
  care- exercise, stretching, activity
  modification, orthotics and modalities
• No single exercise or rehabilitation protocol has
  been demonstrated to be superior in treating
  recurrent ankle sprains

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Anatomical Considerations

• There are 26 bones of the foot
• Rear foot- talus and calcaneus
• Mid foot- navicular, cuneiforms (3)
• Fore foot- metatarsals, phalange
• Which one has no tendons attached to it?

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Recent Research

• Immediate Effects of Manipulation of the
  Talocrural Joint on Stabilometry and
  Baropodometry in Patients With Ankle Sprain
• Sandra Lopez-Rodriguex, PT, DO, et al.
• JMPT March/April 2007 30186-192

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Recent Research

• The application of caudal manipulation of the
  talocrural joint modifies the pattern of behavior
  of the load support at the level of the foot as
  compared with placebo manipulation in a sample of
  athletic individuals with grade 2 ankle sprain.
• Results support the hypothesis that manipulation
  of the ankle exerts proprioceptive effects
• The mechanical effect is reflected on changes in
  the percentage of load on the forefoot and
  rearfoot both unilaterally and bilaterally

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Resent Research

• A Prospective, Single-Blinded, Randomized,
  Controlled Clinical Trial of the Effects of
  Manipulation on Proprioception and Ankle
  Dorsiflexion in Chronic Recurrent Ankle Sprain
• Eckard Kohne, MTechChiropractic, et al.
• Journal of the American Chiropractic
  Association July 2007 44 7-17

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Recent Research

• Manipulation is an effective modality in the
  improvement of both proprioception and
  dorsiflexion in chronic recurrent ankle sprain
• Multiple treatments of ankle manipulation (six)
  found to be superior to a single manipulative
  treatment
• Careful manipulative therapy in conjunction with
  exercise may offer effective therapy for
  recurrent ankle sprain

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Definitions

• Mobilization-
• A gentle coaxing of a movement by passive
  rhythmical oscillations performed within or at
  the limit of normal range of movement. A form of
  manual therapy applied within the physiological
  passive range of joint movement characterized by
  a non-thrust increase in passive joint play.

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Definitions

• Manipulation
• manual manoeuvre during which the joint complex
  is suddenly carried beyond the normal
  physiological range of movement, without
  exceeding the boundaries of anatomical integrity.
  The usual characteristic is a thrust- a brief,
  sudden and carefully administered impulsion
  that is given at the end of the normal passive
  range of movement.

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Manual Assessment of the Ankle

• Anterior/posterior glide
• Forced dorsiflexion of both feet

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Treatment

• Goals
• Break adhesions within the affected joint
• Restore proprioceptive feedback
• Normalize joint biomechanics

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Talus Dysfunction

• Typically moves anterior during an inversion
  ankle sprain
• Signs
• Limited firm dorsiflexion of involved foot
• Tender talar fossa

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Differential Diagnosis

• Short achilles tendon
• Tight gastrocnemius and/or soleus
• Congenital anomalies eg. Equinus foot
• Anterior tibial bone spur
• Proximal/distal fibula involvement

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Examination/Mobilization/Manipulation of the
Anterior Talus

• Long axis distraction
• Bilateral hand contact over dome of the talus
• Ankle in eversion and dorsiflexion
• Long axis thrust- elongation and posterior

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Examination/Mobilization/Manipulation of the
Anterior Talus (continued)

• Anterior-posterior
• Drop piece works well (mechanically assisted
  device)
• Heel at edge of drop piece
• Hand contact on talus
• Thrust anterior to posterior

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Manual treatment of the Foot

• Treatment is respectful to the normal arches of
  the foot

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Talocalcaneal Joint Dysfunction

• The subtalar joint- articulation between the
  talus and the calcaneus
• Signs
• Decreased mobility
• Medial/lateral
• Internal/external rotation
• Tenderness at talocalcaneal joint

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Examination/Mobilization/Manipulation of the
Calcaneous

• Contact medial/lateral surface of the calcaneous
• Medial- Lateral glide
• Thrust either medial or lateral
• Long Axis Distraction
• Contact on the calcaneous
• Apply a long axis distraction

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Midtarsal Joint Dysfunction

• Navicular
• Cuneiform
• Medial, middle, lateral
• Middle is important for the transverse arch
• Cuboid
• Important for the lateral longitudinal arch

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Midtarsal Joint Dysfunction (continued)

• Signs
• Decreased mobility
• Tenderness
• A lump- if anterior
• Indented- if posterior

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Examination/Mobilization/Manipulation of the
Midtarsals

• Navicular- anterior
• Contact hand over the navicular
• Thrust inferior isolating the joint not pulling
  on the knee and hip

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Examination/Mobilization/Manipulation of the
Midtarsals

• Cuboid/cuneiforms- anterior
• Contact on top of the involved joint(s)
• Thrust anterior to posterior

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Posterior Midtarsals

• Very frequent
• Contact thumb on plantar surface of the foot on
  the involved articulation
• Thrust posterior to anterior

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Metatarsal Joint Dysfunction

• Common with recurrent ankle/foot problems
• Signs
• Pain at metatarsal base
• Dropped metatarsal arch
• Decreased mobility

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Examination/Mobilization/Manipulation of the
Metatarsals

• Posterior (dropped)
• Contact hand on top of the foot while the fingers
  surround the distal 2 to 5 toes touching the
  plantar surface of the metatarsals
• Thrust with a quick palmar flexion
• Can do one joint at a time with and/or long axis
  distraction

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The End