Fraser, a promising young Australian Rules football player who had sustained an inversion sprain of the ankle. I saw him soon after the episode and it seemed like the rehabilitation process would be short and straightforward. I was confident enough about this to inform the coaching team that Fraser would shortly return to the training paddock, ready for the upcoming final series. As it turned out, I was wrong. Injury specialist, Dr. Alexander Jimenez assesses the case further.
A couple of weeks passed; Fraser’s ankle selection of motion returned and he managed to finish stationary balance exercises and strengthening exercises. However he couldn’t hop on the bad leg or operate without ankle pain. I began to think that this rehabilitation cycle might become a little extended.
He was then sent to see a sports doctor to seek further explanation as to why the injury was taking so long to heal. The sports doctor thought that the young footballer should adopt a “wait and see strategy,” sitting outside the rest of the season and starting to train again in the brief off-season. This advice did not go down well either with the athlete himself, or the coaching team.
Six weeks after, when I next saw Fraser, he still could not jump on the leg pain-free, so was still unable to do any running. He had rehabilitated his ankle as far as he could, but just could not get past this step. He still had swelling over the ATFL, but had full range of motion with no laxity in any of the supporting ligaments.
It was then that I tried a different treatment technique, a posterior glide of the fibula in the lateral malleolus. I recorded the fibula in a posterior direction, and Fraser managed to jump pain-free for the very first time in 19 weeks. It was a miracle.
Or maybe not: Brian Mulligan, the mythical New Zealand physio, has provided the physiotherapy profession with numerous guide techniques to help fix joint immobilities and subluxations. This is but one of the invaluable therapy methods he prescribes (1).
I saw Fraser again 10 days later and he had been up to conducting 1.5km without pain; he was also positive that he would complete his rehabilitation before pre-season training.
The fascinating thing about all this is that I’d already attempted Mulligan’s posterior glide two months earlier, with no effect — no decrease in pain nor increase in function. Why did tape and the manual gliding of the fibula belatedly help, and why had it not assisted at a previous stage?
The answer can be found in the anatomy of the anterior ankle. Irritation in the lower edge of the inferior tibio-fibular ligament and the very front of the anterior talo-fibular fascia can thicken these ligaments, setting up a series of knock-on effects. The irritated and thickened tissue becomes vulnerable to getting pinched between the tibia and talus as the foot is dorsiflexed. The ligaments may also begin to rub on the joint capsule of the ankle, which can inflame the synovial lining of the capsule, causing synovitis. Finally, the inflamed ligaments can form too much scar tissue along the front and side of the ankle joint, creating a small mass of tissue called a meniscoid lesion. Dorsiflexing the ankle can trap the tissue between the edge of the ankle joint, causing pain, popping, and a feeling that the ankle will give way and not support body weight.
The tape helps to offload the fibula or move the pressure away from the antero- lateral surface of the ankle. Fraser was then able to load up the ankle with running and hopping — with small, if any, soreness.
However, my first effort at this therapy, had, I think, been too early, once the area was probably still overly inflamed to reply positively. Only when the structures had all calmed down was it possible to proceed in the rehabilitation.
When treating acute ankle sprains, caregivers are educated to encourage the client to regain ankle dorsiflexion as soon as possible, because study shows that the earlier the person regains this motion, the earlier they will be back to normal function. In years past I have awakened many customers pain by making them do repeated dorsiflexion exercises, or simply by mobilizing the anterior ankle joints.
Now I’m being much more competitive about pushing my clients to recover this dorsiflexion, as sometimes this can clearly result in more irritation — slowing rather than speeding recovery. There was not anything unusual about Fraser’s ankle injury concerning the origin — it was only a great deal of damage to a very sensitive portion of the ankle joint.
I feel the moral of this brief story is that the therapist needs to add up all the information offered by the patient and treat them without using a pre-determined recipe. Think anatomically, picture what has happened to the tissues and don’t be afraid to revise your strategy as you proceed; this will direct you to better treatment choices and the patient will recover quicker.
1. Brian Mulligan. Manual therapy –”NAGS”, “SNAGS”, ”MWMS” etc. (5th ed) 1995. Wellington. Plane View Press.