What are Ankle Sprains and how do they occur?

• Ankle sprains are one of the most commonly recurring among both general and athletic population.
• The primary cause of a lateral ankle sprain typically involves the foot suddenly turning inwards with an added force on the body.
• This twisting force injures the ligaments present on the outer side of ankle, namely anterior talofibular ligament (weakest and injures first), the calcaneofibular ligament (CFL) and/or the posterior talofibular ligament (PTFL).

What are Recurrent Ankle Sprains?

• After the first episode, the chances of reinjuring the same ankle increases due to an impairment in the pre-injury state of muscles and ligaments of ankle.
• Due to this, one can develop long standing pain or instability known as chronic ankle instability (CAI).
• In CAI, the ankle feels unstable or ‘gives way’ usually while walking or doing other activities, but it can also happen in just standing, with other persistent symptoms such as pain, swelling, limited motion, weakness, etc.

What are the causes of recurrent ankle sprains?

Factors associated with repeated ankle sprains include:

• Decreased muscle strength
• Limited range of motion in the ankle joint
• Reduced Balance
• Impaired proprioception (joint position sense)
• Ligamentous laxity
• A high-arched foot type

What do the injury statistics say?

• Almost 50% affected people continue to experience persistent symptoms such as pain, swelling, instability, and recurring issues for at least a year after the initial injury.
• Around 10-30% of individuals who sustain acute sprain develop CAI.

What is the Treatment/Management Options?

Initiating physiotherapy promptly following the first episode of ankle sprain reduces the likelihood of recurrence.

1. PRICE protocol: This protocol is advised for the initial management (24-76 hours) of acute ankle sprains. For more information on how to follow PRICE protocol, please refer our blog on ‘How to Manage Acute Injuries and Pain’
2. External Support: Taping or Bracing the ankle helps in reduction of swelling, prevents recurrences, and helps in early return to sport.

• Exercises: Following neuromuscular training helps decrease recurrence rate and enhances overall functional stability.
• Ankle muscle strengthening
• Balance training
• Range of Motion exercises
• Sport specific training drills (in later stages for athletes)

Note: These exercises should only be performed under the supervision of a physiotherapist.

Surgical Approach:

• When instability persists or nonsurgical methods prove ineffective, the surgeon may suggest operative management.
• Typically, this involves repairing or reconstructing the damaged ligaments. The choice of the most suitable surgical procedure is determined by the severity of instability and your activity level. Recovery duration varies based on the specific procedures undertaken.

References:

• Mugno AT, Constant D. Recurrent Ankle Sprain. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
• Sarcon AK, Heyrani N, Giza E, Kreulen C. Lateral Ankle Sprain and Chronic Ankle Instability. Foot Ankle Orthop. 2019 Jun 13;4(2).
• Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train. 2019 Jun;54(6):572-588. doi: 10.4085/1062-6050-344-18. Epub 2019 Jun 4.
• Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna J Med. 2016 Oct-Dec;6(4):103-108.

Description/Introduction:

The ligaments of the ankle joint are comprised of the medial (inner) and lateral (outer) compartments. They work together to provide stability to the ankle. The medial ligaments are thicker and stronger than the lateral ligaments because the medial bands form a mass surrounding the inner part of the ankle. This is why it’s relatively more common to see lateral ligament injuries.

Cause of Injury: Twisting/rolling mechanism i.e. walking with high heels, landing on uneven ground, playing sports

Clinical Signs and Symptoms of Ankle Injury:

• Pain and tenderness with pressure and stretching
• Swelling
• Redness and warmth
• Limping due to pain
• Difficulty bearing weight on affected foot

Physiotherapy Options to relieve ankle pain:

• Cryotherapy
• Electrotherapy
• Laser
• Ankle taping
• Exercises
• Transverse friction massage
• Gait assessment
• Balance and proprioception exercises

Self-Help Tips:

• Relative rest
• Elevate and Ice the ankle to reduce swelling and inflammation
• Support the ankle with a brace and supportive shoe
• Avoid H.A.R.M. – Heat, Alcohol, Running, and Massage

What happens during an injury?

When you get injured, the body’s natural response will be inflammation.  Signs and symptoms of acute inflammation will be swelling, redness, heat and pain.  Mainly caused by the increased blood flow associated with swelling.

Thus, initial management of an acute injury will be to reduce the inflammation and swelling.

How?

P.R.I.C.E.R.

P = Protect

R = Rest

I = Ice

C = Compression

E = Elevation

Protect

The injured area should be protected to prevent further injuries.  The injury can be protected with arm sling, braces, splint or taping and aids such as crutches can be used.

 Rest

Resting the injured area will prevent further injuries and also help start the healing process.  The injured area will usually be weak and more vulnerable to further injury.

Ice or cold therapy

Ice helps decrease blood flow to the injured area by constricting the blood vessel, thus minimise swelling / inflammation

Compression

Applying compression around the injured area helps minimize swelling by preventing the build-up of fluid.  Compression can also help relief pain by immobilizing and providing support to the area.  It should not be too tight that it interferes with blood flow.

Elevation

Elevation of the injured area (above the level of the heart) will allow fluid to drain away from the area.  With gravity, swelling or fluid can pool at the joints below.

Referral

Referral refers to consulting a Doctor or a Physiotherapist for further treatment.  Especially if you are unsure of the extend of injury and if the injury does not get better by 3 to 5 days.

PRICER should be administered within the first 48 to 76 hours after an injury.

A heel spur is a bony growth that forms under the heel bone, and it can cause sharp or nagging pain and inflammation in the heel and its surrounding areas. Heel spurs are often caused by overuse, wrong shoes, improper foot mechanics, and certain medical conditions such as plantar fasciitis.

Heel pain from a heel spur is typically felt in the bottom of the heel and can be accompanied by:

• Sharp pain when standing or walking
• Pain that is worse in the morning or after prolonged sitting
• swelling or redness in the heel
• bony protrusion that can be felt or seen on the heel

Treatment for heel pain from a heel spur may include:

• Rest and ice: Applying ice to the affected area can help reduce pain and inflammation.
• Stretching and exercises: Stretching the calf muscles and Achilles tendon and doing exercises to strengthen the muscles in the foot and leg can help improve flexibility and reduce stress on the heel.
• Orthotics: Customised shoe insoles can help correct any improper foot mechanics that may be contributing to the heel spur.
• Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) can help to reduce pain and inflammation.
• Physiotherapy: A physiotherapist can treat this using Laser, Ultrasound and Radial Shockwave therapy and  exercises to improve strength, flexibility, and range of motion.
• Surgery: In some cases, surgery may be recommended to remove the spur, but it is usually considered as a last resort.

 It is important to consult with a healthcare professional to determine the underlying cause of heel pain and the appropriate course of treatment. Additionally, some lifestyle modifications such as switching to shoes with a cushioned heel, avoiding high-impact activities, and incorporating low-impact exercises like swimming, cycling or yoga can also be beneficial in managing heel pain from heel spur.

You may contact us if you need help with your heel pain.

Foot and Heel

Plantar fasciitis is felt as a pain around the heel and arch of the foot. It can be felt as a discomfort or sharp pain in the heel on weight bearing especially after a rest period. As a person gets older, the fascia becomes less elastic. The heel pad becomes thinner and loses the capacity to absorb as much shock. There may be some swelling, small tears or bruises in the plantar fascia with the pounding force on the heel. Plantar fasciitis can also be a result of overuse in activities such as long-distance running, basketball, ballet dancing or dance aerobics. It settles down quickly if treated early and given enough rest, but may become worse and  chronic if initial symptoms are ignored.

To reduce the pain of plantar fasciitis, try these self-care tips:

• Give adequate rest to your feet. Avoid prolonged standing or high impact activities like running that cause repeated loading on the foot. If you need to stand for long time, then shift your weight from one foot to the other or use a footrest under the affected foot to offload it for a while.
• Don’t walk barefoot,especially on hard surfaces, as this puts extra stress on the plantar fascia. It is advisable to wear soft heeled footwear or footwear with scooped out heels to avoid pressure on the heel.
• Wear supportive shoes.Choose shoes with a low to moderate heel, supportive arches and good shock absorbency.
• Avoid high heels especially when you need to walk long distances or stand for long periods of time. High heel shoes exert additional pressure on the inflamed fascia and lead to more heel pain.
• Do not wear worn-out shoes.Replace old, tattered, non-supportive shoes. This is very important if you walk or run in these shoes. A good way to tell that your shoes need replacing is to look for thinned (worn) out areas on the sole of the shoe.
• Apply ice: This can be done on the painful area three or four times a day, especially at the end of the day. Icing helps to reduce pain and inflammation. Icing can also be done with a frozen bottle of water rolled under the foot while sitting.
• Massage: Self massage can be done by rolling a tennis ball under your foot while sitting. As mentioned above, a frozen water bottle can also be used.
• Change your sport.Try a low-impact sport such as swimming or bicycling instead of walking or jogging while the plantar fascia is inflamed/painful.
• Maintain a healthy weight. If you are overweight, then try to lose some weight. Extra weight can put extra stress on your plantar fascia.
• Exercise before getting out of bed in the morning or after prolonged sitting(sit to stand): Plantar fasciitis pain is usually at its worst in these two situations. A good way to combat this is to perform circular movements at the ankle (clockwise and anticlockwise) and a few seated calf stretches before weight bearing on the feet.
• Do your stretches.Simple home exercises can be done for plantar fasciitis. Perform this stretch when waking up, mid-day, and before bed. It is also very important to perform these stretches in the warm up and cool down phase of your exercise routine, even after you recover from plantar fasciitis pain. This will help to prevent any recurrences. 

Flat foot/overpronation is a condition characterized by downward collapse or flattening of the arch of the foot. During normal walking, an inward rolling of the foot (pronation) occurs naturally. This helps to absorb shock and maintain alignment of the ankles and legs. However, in overpronation, the foot moves excessively downward and inward and the arch flattens with each step, thereby causing stress and strain on the soft tissues (ligaments, muscles) surrounding the ankle. It can also cause compensatory changes in the hip and knee, which can lead to increased risk in sustaining lower limb injuries.

Flatfoot can either be congenital which means you are born with the flat feet or it can be acquired later in life. Identified risk factors include uneven leg length, knock knees, being overweight, pregnancy, and prolonged standing, walking or running on hard surfaces.

 Also, middle-aged women were found to be most commonly affected and the risk is known to increase with age. In children, conditions such as cerebral palsy and Down syndrome were both known risk factors.

Flat foot can also predispose individuals to the other injuries such as shin splints, ITB (iliotibial band) friction syndrome, low back pain, stress fracture in foot/lower leg, patellofemoral pain syndrome (PPS), Achilles tendinitis, bunions and plantar fasciitis.

Physical therapy management for acquired flat foot includes strengthening, mobility and stretching exercises. Orthotics, which includes shoe inserts, can also be prescribed to help manage the condition.

The following exercises can help fix flat foot by increasing mobility of ankle, and strengthening the muscles responsible for maintaining the arch of the foot.

1. Dynamic ankle mobilizationGoal: Increase mobility of ankle joint.

• Place one foot flat on a table or a hard surface.
• Bend your hips and knees forward until the end- range.
• Do this 10 times for 3 sets and repeat on the other leg

2. Arch setting exercise

Goal: Strengthen the muscles that maintain the arch of the foot.

  a. Sit with feet flat on floor.

  b. Push your big and second toes down to raise your arch and hold it or 5 seconds repeat 10 times for 2 sets.

Note: *Maintain contact of toes and heel on the floor while raising your arch. *DO NOT curl your toes.

4. Calf Raises with Tennis Ball

Goal: Strengthen Calf and Tibialis posterior (maintains the arch) muscles

  a. Stand with feet shoulder width apart, and put a tennis ball in between your ankles

  b. Perform calf raises by standing on toes while holding the tennis ball in-between the ankles

  c. Slowly return to starting position or eccentric strengthening of the muscles

  d. Do this 10 times for 3 sets

5. Static Gastrocnemius stretching

Goal: Stretch Gastrocnemius muscle

a.) Stand with your arms leaning on the wall in front of you.

b.) Step the leg that you want to stretch behind with feet flat on the ground, knee straight and toes are facing forward.

c.) Slowly lean and shift your weight forward, allowing your front knee to bend while keeping the back knee straight.

d.) Hold the position or 15 seconds and repeat 3 times on each side

6. Static Soleus stretching

Goal: Stretch Soleus muscle

a.) Stand with your arms leaning on the wall in front of you.

b.) Step the leg that you want to stretch behind with feet flat on the ground, knee straight , toes are facing forward (12 ‘clock).

c.) Slowly lean and shit your weight forward, allowing your front and back knee to bend until stretch is felt.

d.) Hold the position or 15 seconds and repeat 3 times on each side.

 

Our physiotherapists can help you to manage your flat foot and assist you with exercises and orthotics to take care of any pain or complications arising from your flat foot. Call us for an appointment or send your queries to: info@physioasia.com