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Stuart, the 31 years old male client, has changed his profession from that of a telemarketer to a parking officer, the latter requiring more mobility as compared to the former profession, which involved a sedentary lifestyle. The sudden lifestyle change to increased physical mobility has not only stressed his body but as the history reveals, Stuart has suffered from numerous incidents of ankle sprains. This suggests that Stuart has difficulty in walking and his general health parameters like body weight, former lifestyle, athletic ability, gait, and foot anatomy should be taken into consideration for the establishment of a diagnosis. As his recurrent injury is foot sprain during walking, it suggests that there might be issues about anatomical aberrations in Stuart’s feet, weakness of muscles in lower limbs, some neurological factor affecting his gait, or any other coexisting disease which might be affecting his physical performance due to the increased physical demand of the new profession. All these factors need to be considered before deciding on any therapeutic intervention for this client.
As most of Stuart’s recent injuries have been instances of lateral ankle sprain happened due to inward twisting of the foot, in which case the entire body weight has to be borne by the ankle joint, the various ligaments keeping the foot in its natural position and imparting it mobility are overstretched or damaged during the injury process. As feet are an integral part of locomotion for routine activities, such injuries are not only crippling but difficult to heal due to the sensitive position of the ankle joint. Chances of re-injury are increased, and such injuries are frequent and well studied in the athletes (Thacker et al., 1999). More often than not, lateral ankle sprains cause an injury of the anterior talofibular ligament, which is described as the weakest part of the joint (Kumai et al 2002). It is the most commonly injured ligament in a sprained ankle from an inversion injury. Another ligament that can be stretched during ankle injury is the calcaneofibular ligament, a narrow, rounded cord, running from the apex of the fibular malleolus downward and slightly backward to a tubercle on the lateral surface of the calcaneus and covered by the tendons of the Peronæilongus and Brevis (Hertel 2002). Both these ligaments have critical roles in the stabilization and functioning of the ankle joint.
Lateral inversion injuries of the ankle can be evaluated by the ‘draw’ test and the ‘talar tilt’ tests. In the former, the healthcare practitioner holds the leg with one hand, at the same time trying to pull the foot forward with the other. The test is considered positive in case excessive anterior translation of the foot occurs regarding the leg (Wolf, Uhl, Mattacola, & Muccluskey 2001; Bulucu et al 1991). The other test called the talar tilt test is conducted when the physician holds the leg with one hand while turning the heel inward with the other hand. The test is positive if there is an excessive turning of the heel as a result of this procedure. Both these tests are conducted on the other sound foot as well so that a baseline can be established for measurement of responses to detect differences in the healthy ankle and the injured one about each other in each patient.
For an appropriate diagnosis, various biomechanical variables need to be assessed in persons prone to excessive ankle injuries. Total body weight, limb length, age, body symmetry, level of physical activity, sex, and profession are some of the factors, which influence foot biomechanics (Beynnon et al 2002). Observation of anatomical abnormalities in the foot is a vital clue to revealing abnormalities of gait. Patient demographics, ligament stability, muscular strength, anatomic foot, and ankle alignment, postural sway, gait mechanics, and muscle reaction time are some of the primary features needed for evaluation in cases involving repeated ankle inversion injury (Morrison & Kaminski 2007). The gait cycle is described as the period from initial contact of one foot to the subsequent contact of the same foot (Ounpuu 1994). It can be further differentiated into stance and swing phases with the former representing 60% and the latter 40% of one complete gait cycle. The stance is initiated at the point of initial contact of the foot with the ground and can be further differentiated into 4 subphases, the loading response, the midstance, the terminal stance finally culminating in the preswing. The swing phase begins with the instantaneous event of toe-off and ends again at the subsequent initial contact with the ground. These phases of the gait can be evaluated visually or with the aid of appropriate photographic and recording tools to assess abnormalities of gait.
The patient can be examined qualitatively as well as quantitatively. The qualitative evaluation includes Resting Calcaneal Stance Position (RCSP), which can be examined visually or quantified within a range of 1-5 degrees with the aid of a goniometer. Non weight bearing (NWB) and weight-bearing (WB) forefoot and rearfoot angles can be measured to conform to the visually identifiable foot deformity (Guy 2007). NWB angles include Maximum inverted tibia to calcaneus angle, Maximum everted tibia to calcaneus angle, Tibia to calcaneus neutral, Forefoot to a rearfoot relationship, Reduced forefoot to rearfoot relationship, MTJ range of motion (ROM) based on sub talar joint (STJ) position, Malleolar position, Ankle joint ROM knee extended, Ankle joint ROM knee flexed and external and internal hip ROM (Guy 2007).WB Angles and Linear Measurements include Neutral tibia to ground, NCSP, RCSP, Relaxed calcaneus to the tibia, Neutral calcaneus to the tibia, Maximum pronation, Neutral to the relaxed navicular height difference, and Leveling of the iliac crest (Guy 2007).
During the prone examination of this patient, the STJ ROM in either of the feet was observed to be normal, STJ Axis position was lateral in both feet, forefoot positioning was normal, MTJ was restricted in both feet, both the hamstring muscles were normal, and there was no discrepancy in limb length. Muscle tests revealed normal activity in both feet except for the decreased ability of eversion. Foot posture index (FPI-6) measurements were -1 each for talonavicular congruence and medial arch height yielding a total value of -2 for both feet. RCSP and NCSP were low at 2 degrees each for the left as well as right foot and navicular drop/drift were within limits at 2 mm in the sagittal as well as transverse planes for both feet. The supination resistance test was classified as ‘easy’ for both feet, while the Windlass test was observed to be hard on each foot. The lunge test revealed restriction at 40mm for the left foot and 20 mm for the right.
As evident from the observations, the patient requires an orthotic device along with the application of an appropriately sized forefoot valgus. Starting with a conservative sized valgus addition, the appropriate size can be recommended after subsequent observations. If the patient requires a forefoot valgus posting to be added to his orthotic device, the measured forefoot valgus deformity, when applied, will be reduced by the amount of rearfoot varus correction when the foot is corrected to neutral. As the patient has a history of repetitive lateral inversion sprain, along with the detectable forefoot valgus deformity, the following treatment is suggested to alleviate the painful symptoms.
The patient needs to be rehabilitated with an appropriate orthotic device in combination with foot exercises to strengthen the weakened ligaments. He should avoid excessive movement on any subsequent injury and follow the RICE (Rest, Ice, Compression, and Exercise) protocol on any fresh incidence of lateral ankle eversion. Rest is mandatory as further ankle movement can aggravate ligament injury. The application of ice is essential to minimize the circulation to reduce damage by inflammatory cells. Elevation of the ankle in the supine position is recommended to improve healing. This should be followed by compressive bandage application and later, the patient should exercise and strengthen the ankle under the supervision of a trained physiotherapist.
Additional health professionals who can assist in the management of this patient include a general practitioner who can identify any underlying predisposing factors or ailments which might be predisposing the patient to repetitive injury and a qualified radiographer who can determine the extent of the injury using appropriate radiological techniques. Radiographic measurements are recommended for such patients utilizing anteroposterior and mortise radiograph approaches for examining the ankle to determine the extent of syndesmotic injury (Uys & Rijke 2002).
Visual examination of the patient and his sudden switchover from a sedentary lifestyle to a job requiring high mobility can be identified as the precipitating causes for repetitive ankle injuries. Windlass test, which was determined as ‘hard’ in each foot, and the Lunge test, which revealed restriction of movement in both feet, are suggestive that the patient requires prosthetic assistance as well as rehabilitation therapy to assist him in adjusting to the rigors of his new job.
References
Bulucu, C., Thomas, K. A., Halvorson, T. L., & Cook, S. D. (1991) Biomechanical evaluation of the anterior drawer test: the contribution of the lateral ankle ligaments. Foot & Ankle International, 11(6), 389-393.
Guy, P.G. (2007) Introduction to Biomechanical Evaluation. Web.
Hertel, J. (2002) Functional anatomy, pathomechanics and pathophysiology of lateral ankle instability, Journal of Athletic Training, 37(4), 364.
Kumai, T., Takakura, Y., Rufai, A., Milz, S., & Benjamin, M. (2002) The functional anatomy of the human anterior talofibular ligament concerning ankle sprains, Journal of Anatomy, 200(5), 457-465.
Ounpuu, S. (1994) The Biomechanics of Walking and Running, Foot and Ankle Injuries, Clinics in Sports Medicine, 13(4), 843-863
Thacker, S.B, Stroup, D.F., Branche, C.M., Gilchrist, J., Goodman, R.A., & Weitman, E.A. (1999). The prevention of ankle sprains in sports: A systematic review of the literature. The American journal of sports medicine, 27(6): 753-760.
Uys, H. D., & Rijke, A. M. (2002). Clinical Association of Acute Lateral Ankle Sprain with Syndesmotic Involvement, A Stress Radiography and Magnetic Resonance Imaging Study, The American Journal of Sports Medicine, 30(6), 816-822.
Wolf, M.W., Uhl, T.L., Mattacola, C.G. & Muccluskey, L.C. (2001). Management of ankle sprains, AmFam Physician, 63(1), 93-105.
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