Early postoperative ankle exercise. A study of postoperative lateral malleolar fractures

Fifty-three patients with dislocated lateral malleolar fractures were randomly selected after operation for either active ankle movement and weight bearing in an orthosis or no ankle movement but weight bearing in a walking cast. At follow-up examinations after three, six, and 18 months, no differences were found between the groups except for a better linear analogue scale result at three months for the orthosis group. Active ankle movements do not improve the rehabilitation of surgically treated lateral malleolar fractures.

Effects of stair-stepping exercise direction and cadence on EMG activity of selected lower extremity muscle groups

Step ergometry has become a popular treatment mode in cardiovascular fitness and knee rehabilitation programs. The following study describes the effects of forward stair stepping at 35 and 95 steps/minute and forward and retrograde stair stepping at 60 steps/minute on the mean electromyographic (EMG) activity of the gluteus maximus, rectus femoris, vastus medialis, semimembranosus/semitendinosus, and gastrocnemius muscles. Thirty-three subjects without prior lower extremity pathology participated in the study. Analysis of variance was used to compare mean EMG activity during the knee extension phase of the different stepping conditions. Significant differences (p < 0.05) in mean EMGs of gluteus maximus, rectus femoris, vastus medialis, and gastrocnemius were noted across all cadences. The semimembranosus/semitendinosus EMG activity displayed a single significant difference between the cadences of 35 and 95. The comparison between forward and retrograde stepping identified only one significant difference in mean EMG (semimembranosus/semitendinosus). The effects of cadence on EMG activity should be considered when developing conditioning or rehabilitation programs for the lower extremity. Faster cadences result in increased peak activity of shorter duration for the gluteus maximus, quadriceps, and gastrocnemius. There is no apparent difference in EMG activity of the hamstrings due to cadence. Also, noting the minimal activation that occurs, stair-stepping exercise would not be recommended for strengthening of the hamstrings musculature.

Early ankle mobilization, Part II: A one-year follow-up of acute, lateral ankle sprains (a randomized clinical trial)

A 1-year follow-up of military members who received either early ankle mobilization or cast immobilization following a moderate or severe lateral ankle sprain was conducted to determine the long-term effects between these two forms of conservative treatment. Functional job- and sports-related disabilities together with subjective complaints were assessed. A significantly large proportion (44%) of all subjects were symptomatic at follow-up. Those receiving early ankle mobilization had slightly more residual subjective complaints compared with those receiving cast immobilization. There was, however, little effect on functional job- or sports-related disability, the early mobilization group having slightly fewer functional problems. There was no difference in subjective complaints or functional limitations by the degree of injury for moderate or severe lateral ankle sprains.

Early ankle mobilization, Part I: The immediate effect on acute, lateral ankle sprains (a randomized clinical trial)

A random clinical trial was performed to determine the immediate effects of early ankle mobilization on active duty military members with moderate and severe lateral ankle sprains. Sixty-four subjects were randomly allocated to one of three treatments: a plaster cast, an air-stirrup (Aircast Inc., Summit, New Jersey), or an elastic wrap. Each intervention lasted 2 weeks followed by 3 weeks of rehabilitation. Subjects who were allowed early mobilization returned to work and running significantly sooner than those placed in plaster casts (p = 0.029). Swelling (p = 0.009) and pain (p < 0.001) decreased while range of motion increased (p = 0.027) in the early mobilization groups. Between the mobilization groups, those in the elastic wrap performed as well as those in the air-stirrup.

Rehabilitation of the foot and ankle

The foot and ankle are frequently injured in athletic activities. In addition to acute injuries such as ankle sprains and fractures, a variety of overuse injuries are seen. A thorough knowledge of the mechanism of injury and the course of the healing process is essential for the comprehensive rehabilitation of such injuries. Recovery progresses through several phases. If selected appropriately, modalities and therapeutic exercise can work together to facilitate the healing process at each phase. Many injuries could be averted by preventive exercise, judicious use of taping and bracing, and recognition and correction of biomechanical faults.

Management of acute and chronic lateral ligament injuries of the ankle

Acute and chronic lateral ligament injuries of the ankle represent a common but persistent problem to orthopedic specialists. A comprehensive physical examination and classification system were proposed as an approach to this problem. Guidelines for both conservative and surgical management for acute and chronic injuries are described. A comparison of the most common lateral ligament repairs is provided, with emphasis on the benefits of the so-called anatomic repair.

Early mobilization versus immobilization in the treatment of lateral ankle sprains

We conducted a prospective trial at a military medical center to determine which treatment for first-time ankle sprains, early mobilization or immobilization, is more effective. Eighty-two patients with a lateral ankle sprain were randomly selected for one of two treatment groups. The Early Mobilization Group received an elastic wrap for 2 days followed by functional bracing for 8 days. Two days after injury, this group began weight-bearing and an ankle rehabilitation program. Patients in the Immobilization Group were placed in a nonweight-bearing plaster splint for 10 days followed by weight-bearing and the same rehabilitation program. Patients in the Early Mobilization Group had less pain at 3 weeks (57% versus 87%, P = 0.02); otherwise, there were no significant differences between groups in the frequency of residual symptoms. Only one patient in each group had residual symptoms 1 year after injury. Three patients (8%) in each group resprained their ankles. Ten days after injury, patients in the Early Mobilization Group were more likely to be back to full work (54% versus 13%, P < 0.001). We conclude that in first-time lateral ankle sprains, although both immobilization and early mobilization prevent late residual symptoms and ankle instability, early mobilization allows earlier return to work and may be more comfortable for patients.

[The athletic shoes as a therapeutic aid]

Sports shoe research discovered several possibilities of influencing the heel-to-toe walking behaviour of the foot which can be made use in the construction of therapeutic shoes. Early functional therapy aims at imparting moderate load stimuli to the injured and/or surgically reconstructed tissue to ensure quicker orientation of the collagen fibres of the cicatricial structures and an improved blood supply to the tissue. Modified sports shoes with variable mobility restriction and functional heel-to-toe walking support of the foot have become a meaningful therapeutic aid in the treatment of fibular ligament lesions and injuries to the Achilles tendon, both in orthopaedic and neurological problems requiring support of the sequential movements of the foot (arthrodeses, arthroses, peroneal paralyses [dangle foot], etc.) Early functional after treatment ensures that moderate load stimuli are exercised on the tissue while avoiding peak tensions, thus shortening the rehabilitation period with minimal inactivity atrophies and hence enabling quicker return to normal daily activities.

Electromyographic response of peroneal muscles in surgical and nonsurgical injured ankles during sudden inversion

Because the peroneal muscles are thought to act as a safeguard against lateral ankle injury, it is important to study their function. This study was undertaken to electromyographically assess the latency between sudden unexpected ankle inversion and the start of peroneal muscle activity. Three groups participated in the study, including subjects with lateral ankle sprain rehabilitated nonsurgically (N = 7), sprains rehabilitated following surgery (N = 6), and injury-free ankles (N = 11). Peroneal latency was assessed by dropping the subjects into inversion from a special platform. The platform was designed so that either ankle could be inverted to 35 degrees without warning. The ANOVA revealed no significant latency differences (p > .05) between the three groups. The study suggests that bilateral peroneal latency is unaffected by injury. Although it has been thought that healthy muscles provide a defense against ankle sprain, their latency is not permanently affected by ankle injury or by surgery performed to correct defects from injury. It appears that mechanoreceptor impairment may be rehabilitated and that it is not a factor in ankle injury.

Soft-tissue reconstruction of the foot and ankle

Successful reconstruction of the severely injured foot and ankle remains a challenge for the surgeon. Frequently, bone and joint injuries to this area with overlying soft-tissue injuries or losses require the coordinate management by orthopedic and reconstructive specialists. Healthy, well-functioning feet are necessary to perform daily activities. Because of the dense packaging of the specialized interdependent structures of the feet, injuries to this area commonly cause significant (composite) wounds that, if not properly managed, can lead to progressive deformity and disability. Basic principles of wound management, especially those pertaining to open fracture management--wound evaluation, debridement, fracture reduction and fixation, preservation of viable tissues, prevention of infection, early soft-tissue reconstruction, and early bony reconstruction--are applicable in the management of foot and ankle wounds. The unique anatomy of the foot complicates reconstruction by limiting the availability of local tissues. Further reconstructive difficulties arise from the functional demands placed on feet and from the distal relationship of the feet to the rest of the body. Successful reconstruction of the foot is predicated on an intimate knowledge of the unique anatomy of the region, of the functional demands required of the feet, and of reconstructive methods. The simplest appropriate technique for the injured foot that is likely to produce the best outcome should be selected. Reconstructive options from the most simple to the complex include primary closure, healing by secondary intention, grafting, flaps (local and distant), and amputation. As typified by the authors' experience, reconstruction of the soft tissues of the foot and ankle frequently requires more complex methods. Seventy percent of our patients have required free-tissue transfer reconstructions, and an additional 5% have undergone other flap reconstructions.

Sports medicine. 3. Lower extremity injuries

This self-directed learning module highlights new advances in sports-related injuries of the lower extremity. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on injuries of the hip and thigh, knee and leg, and ankle and foot. The most common injuries are primarily addressed, while less common injuries are more briefly discussed. New advances that are covered in this section include closed kinetic chain strengthening exercises and recent advances in rehabilitation after anterior cruciate ligament reconstruction.

[Novel functional studies of the stabilizing behavior of ankle joint ortheses]

For functional treatment of acute ankle sprain after surgical or nonsurgical management various special shoes and braces are in use. For a comparison under functional conditions we applied controlled inversion movements of 20 and 30 degrees to 13 subjects. The reduction of angular displacement was measured for the following orthosis: Aircast, Adimed Stabil 2, Adipromed Stabil Super, Mikros Ankle Brace, MHH-Splint Caligamed, Puschbrace and Tape. For evaluation of the neuromuscular activation surface EMGs of selected leg muscles were analyzed. A significant reduction of the induced inversion displacement was observed in all devices, although a complete inhibition of this movement was not possible. EMG activation was comparable to physiological conditions and is not correlated to the displacement characteristics. It is concluded that functional evaluation must take into consideration both the optimal reduction of the inversion and the high functional innervation.

Foot and ankle problems in dancers

Lower extremity problems, specifically in the feet and ankles, are common in dancers. This is not surprising considering the repetitive and acute stresses applied to lower limbs during this rigorous performing arts activity. When evaluating a dancer with lower extremity complaints, the nature of these demands must be appreciated. In addition to routine physical examination, static and dynamic biomechanical evaluation is paramount to analysis and treatment of leg, foot, and ankle conditions. Although a particular problem, such as painful bunion, may seem localized, it is often related to other factors, such as weak posterior tibial tendon, tight heel cords, or inadequate or forced turnout. It is incumbent on the physician to treat the specific area and, more importantly, to discover contributing factors that may be corrected by changes in technique or training. The physician caring for dancers should communicate with the instructor, physical therapist, or choreographer to facilitate the process. An overview of some common maladies and their characteristics findings are presented.

Ankle injuries in athletes

Ankle injuries are the most frequent cause of physician evaluation in a sports-oriented environment. The lateral ligaments are most commonly injured. With a detailed history, physical and radiographic examination to avoid missing underlying pathology, the primary care physician can diagnose and treat the majority of ankle injuries. Occasionally, stress radiographs, arthograms, or magnetic resonance imaging (MRI) is needed. The vast majority of ankle sprains can be treated with adhesive tape strapping or semirigid orthotics and nonsteroidal anti-inflammatory medication followed by rehabilitation. Key points of rehabilitation are control of pain and swelling acutely with nonsteroidal anti-inflammatories and RICE (rest, ice, compression, and elevation), then restoring normal range of motion, strengthening muscle groups, and retraining proprioception of the ankle joint.

Primary orthotic treatment of ruptured ankle ligaments: a recommended procedure

The results of a study after 1 and 2 years of a prospective randomised trial of operative versus conservative treatment of ankle ligament rupture, demonstrate that purely functional orthotic therapy is the method of choice. This relates both to patient need and economical considerations. The trial demonstrated that without an operation it was possible to achieve a high degree of mechanical stability, a reduction of work disability time down to 3 weeks and full sports capability within 3 months. Consequently, and as a result of the trial, the only remaining surgical indications would seem to be dislocations of the foot and ankle, ankle ligament rupture with additional intra-articular pathology, and second-stage injuries or re-ruptures. The joint-stabilising function of the prototype splint developed in this study was improved on the basis of experimental investigations, using a Y-shaped leather band (designated CALIGAMED), which is available in 6 sizes for right and left ankle.

Rehabilitation exercises for common sports injuries

Residual weakness after joint injury is a risk factor for recurrent injury. A rehabilitation program helps patients recover strength and helps prevent further injuries. Orthopedic injuries account for 10 percent of visits to family physicians, yet many primary care physicians do not routinely prescribe rehabilitation exercises for injured patients. Illustrations of exercises for the hip, knee, ankle and shoulder are included as a reference for family physicians to use when prescribing rehabilitation exercises.

[Surgical or conservative therapy of rupture of the lateral ligament of the ankle joint?]

To determine whether operative treatment is superior to conservative therapy, 60 patients were randomized to surgical suture and cast immobilisation for six weeks (n = 30) or cast immobilisation alone for the same time (n = 30) for acute rupture of the ligaments of the ankle. Variables of well being (ability to work, to do sports, dysesthesia, pain during exercise, swelling, tendency for recurrent distorsion), stability (dislocation and tilting of the talus on X-ray examination) and the radiological evidence of arthrosis were chosen as endpoints. Complete follow-up was obtained one year after the accident. In both groups we did not find any evidence of arthrosis one year after the accident. No significant differences were found between the study groups neither for the parameters of well being nor for objective criteria of stability. No correlation was found between well being and stability of the ankle joint. These results suggest that for the chosen endpoints no treatment modality can be recommended after one year follow-up. Only long-term studies using incidence of arthrosis as the most important endpoint will be able to answer the question whether conservative or operative treatment of rupture of the ankle ligaments is superior.

Early mobilizing treatment for grade III ankle ligament injuries

Eighty patients with grade III lateral ligament ruptures were treated either with total immobilization in a walking plaster cast or early mobilization in a stabilizing orthosis. The criterion for entrance was a talar tilt of more than 9 degrees and an anterior translation of more than 10 mm at stress radiography, a previously stable ankle, and a contralateral ankle showing normal stress radiographic values. Ninety-one percent of the patients were evaluated at 7 weeks, 3 months, and 1 year postinjury. While functionally treated patients reached normal mobility and resumed work and sports earlier than immobilized patients there were no differences between the treatment groups in ankle stability or symptoms during activity after 1 year. Ninety-five percent of the ankles in either group were mechanically stable after treatment. Residual symptoms were present 1 year postinjury in 13% of the functionally treated ankles and in 9% of the cast-mobilized ankles. In lateral ankle ligament ruptures causing gross mechanical instability early mobilization results in a better early functional result; however, at 1 year postinjury there was no statistically significant difference in outcome as compared to cast-immobilized ankles.

[Symptoms in area of the Achilles tendon. Etiology and therapeutic considerations]

A number of pathologic conditions can produce posterior heel pain, making it difficult to distinguish the exact cause. Only a careful physical examination allows the probable diagnosis, which is the first and most important step in a successful therapy. Pathologically, the Achilles tendon itself may be inflamed secondary to degeneration owing to a decreased blood supply or the result of a partial rupture. The inflammation can also be accompanied by microtears or calcium deposits. In most cases the tendon sheath and the mesotenon are also involved (tenosynovitis). The retrocalcaneal bursa located between the posterior angle of the os calcis and the Achilles tendon may become inflamed and hypertrophic. It is frequently associated with a prominent superior tuberosity of the os calcis. In a few cases there was also an irritation of the bursa between the Achilles tendon and the skin caused by ill-fitting shoes. Over a 3-year period, 102 patients who engaged in different sports were treated for problems in the Achilles tendon area and retrospectively reviewed with a follow up of 18.8 months. Most of them were runners (48%), followed by soccer players (15.7%) and tennis players (5.9%). The mean age was 36 years. In the vast majority of patients (n = 70, 68.6%) nonoperative treatment was successful. In this group there were 45 cases (65%) with postural abnormalities and excessive pronation requiring correction by means of orthotic appliances. In 19 patients (27%) the problems were caused by a muscular imbalance, and in 15 cases (21%) wrong training methods with overuse had caused the inflammation.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic treatment of anterolateral impingement of the ankle

We studied 31 patients (17 females, 14 males; average age, 34) with more than 2 years of followup who had chronic anterolateral ankle pain following inversion injury. All had failed to respond to at least 2 months of conservative treatment and had negative stress radiographs to rule out instability. On physical examination, tenderness was localized to the anterolateral corner of the talar dome. Magnetic resonance imaging was the most useful diagnostic screening test, showing synovial thickening consistent with impingement in the anterolateral gutter. At an average of 24 months after injury, all patients underwent ankle arthroscopy, which showed proliferative synovitis and fibrotic scar tissue in the lateral gutter, often with associated chondromalacia of the talus. Operative arthroscopic treatment consisted of partial synovectomy with debridement of scar tissue from the lateral gutter. Postoperatively, patients walked with crutches allowing weightbearing as tolerated. Average return to sports was 6 weeks. Histopathologic analysis performed on the resected tissue showed synovial changes consistent with chronic inflammation. Results of treatment after at least 2 year followup were 15 excellent, 11 good, 4 fair, and 1 poor. Since there are several distinct causes of chronic ankle pain, we prefer to call this problem "anterolateral impingement of the ankle" and believe the term "chronic sprain pain" should be discarded.

Evaluation of the results of treatment of soft tissue injury

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