The Impact of and rehab for a“Bad Ankle”

Jeanne Marais B.Sc. Physiotherapy (Wits)Ankle rehab is a little more involved than what we have time for today but we’ll look at static situations to give you an idea and you’re welcome to get in touch with me for more detail if you need.

About MeJust a little bit about me:I’ve been married to Grant for a whopping 9months! I’m totally horses-crazy and these are my children I enjoy playing Squash and Golf and I’m also punishing myself with some road running lately.

About Me

I qualified as a Physiotherapist from Wits in 2008 and I’ve worked in both private and public sectors.I am registered with the HPCSA or the Health Professions Council of South AfricaI am a member of the South African Society of Physiotherapy and I am on 3 of their committees.And I opened my practice almost 2 years ago.I have a passion for solving problems by addressing the root cause and thereby avoiding surgeries for my patients but still resolving their complaints.And I regularly attend courses on new developments in recovery and rehabilitation to help me reach that goal.

What do you notice?

Let start by looking at the hand-outs in front of you.

Please make a few notes on the page for what you see in each of the pictures which could indicate ankle problems.

In the first picture, the person is standing with equal weight on both feet, the photo obviously taken from behind.

What do you notice?

The second picture is taken from above with the person lying face down and the feet hanging freely over the edge of the bed.

What do you notice?

The third one has equal weight on both feet in standing again and

What do you notice?

The last picture is taken from above, again with the person standing.

What do you notice?

I’d like to give you slightly easier ones now.Tell me what you notice here?The inside half of this tyre is totally warn down in relation to the outside – The alignment is probably damaged.

What do you notice?What do you notice here?

This wobble could be from an unbalanced weight-distribution on the tyre.

What did you notice?

Getting back to the pictures of the feet, I’d like to show you what I see.

What I see

See how the left ankle is falling outward.Right has a very sharp instep.

What did you notice?

What I see

Right ankle is rotated, probably all the way up at the hip.Right inner leg muscles are pulling more than the outer muscles which is why the foot is more slanted than the right.

What did you notice?

What I see

I see a collapse of the left arch collapse due to poor stability in the foot andThe left achilles tendon is quite tight in comparison to the right, probably an attempt at compensating for the instability in the foot.

What do you notice?

What I see

There is a bunion forming. Excessive pressure on the inside of the foot (due to collapsed arch) allows the big toe to shift inwards like this.Toes are curled up indicating tightness under the sole of the foot, another sign of poor arch support or foot stability..

How can we fix this?

If your tyre is a bit under-inflated, would you take it off the car to pump it to the pressure it should be and then put it back on? I’m sure you’ll agree that you can’t do that because you need to have the tyre under the same conditions, bearing the car’s weight while checking and correcting the pressure, to know when you’ve reached the correct tyre pressure.

Which is why we should never attempt to “rehabilitate” ankle conditions with feet flapping in the air. Feet were designed to function in weight-bearing positions and just like the tyre, once you lift the foot up, you’ve changed the dynamics completely!

Not like this!

The exercises in these pictures are what we were taught in varsity. Its the reason why patients rarely ever completed their ankle rehab – they couldn’t see the benefit – and it is why so many people are walking around with problematic ankles.

Arches Right!

We can all see that the top picture is of a flat arch – I can tell you that its caused by lazy foot muscles.

The bottom picture, showing the high arch is due to increased muscle activity.

What forms the arch?An evenly sloped arch, peaking in-line with the front of the shin is formed by the supporting muscles in the foot, resulting in a good, stable base for the ankle to function on – allowing a presumably “weak” ankle to function properly again.

But an uneven arch, peaking further forward is due to very weak supporting muscles in the foot and intense compensation from a muscle running up the inside of the leg, the muscle also responsible for shin splints. You may think you have a good or a high arch but it could be a fake arch hiding severe instability in the foot.

Happy middleLooking at tyres again, can we all agree that if your tyre is a little flat, you can’t simply go to the other extreme and pump it up to 3, 4 or 5bar?Because over compensating for one problem will cause another... Weak foot muscles or an unstable base can NOT be corrected by having overly tight muscles in the leg! This is however your body’s first response to an injury and it’s also what we were taught in varsity for ankle rehabilitation.

So we need to loosen what is tight, strengthen what is weak and find the happy balance within the joints and muscles, while standing, walking, running, going up or down stairs and rapidly changing directions.

Fixing the problems

Depending on the history and the severity of the problem, we may need to start off with pain relieving treatments and external support to protect the ankle until the muscles are able to protect the joint again.This may involve soft-tissue treatments, electrotherapy, strapping and bracing and even crutches.Most importantly, the joints need to function as normally as possible, as soon as possible but always pain-free. This means that you need to take weight on that side as quickly as possible but within a safe, stable and pain-free way.

Bracing options

A moon boot may be needed for fractures and severe dislocations but this is worse case scenario!Regarding the more commonly used options:Firstly, the slip-on braces offer no support. Psychological comfort, some warmth and slight compression which isn’t a bad thing, but NO protection!Looking at the rigid “aircast” braces which do offer protection, but allow for no movement on the sides and offer no support for movements up and down. Even an injured joint has to move! We just need to keep the available movement within a safe, pain-free range.That’s where the lace-up brace comes inWe use them for: Ligament injuries, Joint instabilities, Recurrent pain / injuries,They offer good compression, allows for safe mobility and prevent excessive movements – In other words, it protects the ankle but allows for rehabilitation!

What about the knee?This is a typical example of poor stability in the foot leading to arch collapse and once we’ve corrected only the tightness and pain (the point where many people stop in the rehabilitation process) you’re left with feet and ankles collapsing inwards which can cause problems with the knee’s alignment and the integrity of the ligaments and cartilage.

What about the knee?

Here you can see how a meniscus injury can occur by pinching the one side and a strained/torn ligament on the other side.

What about the rest of the body?

You can see here that poor stability or alignment in the foot will not only affect the ankle or the knee but can impact your entire body! Which is why the correct rehab from the very start is so important!

Who can I help?• Your friend who recently sprained an

ankle.• Your husband who has given up a

favourite sport due to recurrent knee pain.• Your father who now has a high handicap

after an old ankle injury.• Your sister who’s feet burning in the

mornings with getting out of bed

Challenge!The video in the next slide is the starting point for rehabilitation of poor foot stability and control.My challenge to you is to move your big toe away from the others without any extra, unnecessary muscle activations

Can you isolate the lazy arch muscles?

Thank you!• Jeanne Marais Physiotherapy• 257 Jan Smuts Avenue, Dunkeld West• Medical aid rates• 082 334 9028