Foot & Ankle
Foot/Ankle
- Ankle Sprains
- Heel Spurs
Ankle Sprain
An ankle sprain is a very common sports injury. A sprain refers to the tearing of ligaments in a joint. The joint in this case is the ankle. The ligaments are tissues which connect bones or cartilage in the joint. The ligament tear can be slight or severe, and can include one or several ligaments. Most ankle sprains are not severe, and can heal well if properly treated, permitting a safe and early return to activity. Severe ankle sprains require specialized care and can often develop into a chronic problem, such as chronic ankle instability. The ligaments of the ankle are shown below.
Anatomy
Three important ligaments cross the lateral (outside) aspect of the ankle joint and are the most commonly injured with ankle sprains.
- Anterior Talofibular (ATF) Ligament
- Posterior Talofibular (PTF) Ligament
- Calcaneo Fibular (CF) Ligament
- On the medial (inside) aspect of the ankle joint is the deltoid ligament which is composed of several ligaments. The deltoid ligament is less commonly injured.
- Deltoid Ligament
Mechanisms of injury
The injury is usually the result of twisting the ankle. In sports, the ankle twist can occur with sudden pivoting or cutting movements. The most common sprain involves an inward twist of the ankle, usually injuring the ATF and CF ligaments. Contributing factors for ankle sprain include: previous injury, weak or imbalanced muscles, inappropriate or worn out shoes, uneven surface, overweight, or family tendency.
Classification of ankle sprains
Three degrees of severity are used to grade ankle sprains. The more severe the sprain, the longer the time to recover.
- First Degree:
This is the most common sprain, and is a minor injury if not neglected. The ligaments are stretched, not torn. There may be mild swelling, but no instability. The athlete can expect to resume sports in 1-2 weeks with conservative therapy. - Second Degree:
The ankle ligaments are partially torn causing bleeding, which results in ankle pain, swelling, bruising, and discoloration. Treatment requires ankle immobilization in a brace, splint, or similar device. Recovery may take 3-6 weeks. - Third Degree:
The ankle ligaments are more severely torn, causing instability. Recovery is much longer for a third degree sprain, requiring 8-12 months for the ligaments to fully heal.
Treatment
For immediate treatment of the ankle sprain, use the RICE approach. RICE stands for Rest, Ice, Compression, and Elevation.
REST: Avoid weight-bearing on the ankle. Use crutches when standing and walking.
ICE: Ice can be applied as an ice pack, an ice bath, or an ice massage. Ice decreases the swelling, pain, bruising, and muscle spasm. Use ice for 20 minutes, 4-6 times per day, for 3 days after the injury.
COMPRESSION: A tense wrap of the ankle will help lessen the swelling and bruising. Ankle braces and stabilizers can provide both compression and stabilization of the torn ankle ligaments. See examples of these devices in the Sports Med Store. Length of time for using such devices will depend on the degree of the sprain.
ELEVATION: Raising the ankle above the level of the heart can help reduce swelling and bruising. Keep the ankle elevated for about 2-3 hours per day if possible.
Rehabilitation of an ankle sprain involves a treatment program which is divided into four stages. The rate of recovery depends upon the severity of the sprain, the amount of pain, swelling and instability, and whether tape, splint, brace, cast boot, or cast is used to immobilize the ankle.
The initial phase of treatment, State 1, includes the RICE treatment program, and lasts up to three days. Pain medication, such as Tylenol or Ibuprofen, or a prescription analgesic, may be recommended or necessary. Crutches may be necessary when the athlete is ready and comfortable to start walking. Crutches help prevent weight bearing on the injured ankle, thereby reducing the pain caused by walking.
Stage 2 of treatment usually lasts up to the first week. The ankle is supported by an appropriate device. Crutches are used, but relied upon less. Activity is allowed, and is increased as long as it is tolerated. Range of motion (ROM) exercises are strongly encouraged, even with the ankle support in place. Such exercises help overcome and prevent additional ankle stiffness. An example of ROM exercise is resting the heel on floor, using the big toe to write the alphabet in the air, and making the letters as large as possible. Contrast soaks, using hot water, then ice water, 5 minutes each, for two times each, helps relieve residual ankle swelling and stiffness.
Stage 3 of treatment usually lasts up to the second week or longer. The ankle is moved and exercised to help it regain its flexibility and strength. With proper instruction, the athlete will do such ankle exercises at home. A referral to a physical therapist may be necessary to assist the athlete, making use of specialized equipment and other treatment modalities.
Complete rehabilitation of an ankle sprain, which is Stage 4, may take several weeks to months. The injured ankle is made strong enough for the athlete to return to his sport without restrictions or risks for re-injury. The athlete first tests the ankle by standing on his toes for 20 seconds, hopping up and down on his toes 10 times, and running on his toes. Once this is accomplished, the athlete can begin jogging in a straight line, then progress to running. As the ankle becomes stronger, the athlete can start running large figures of 8's. Then, he can cut and zigzag. When the athlete can zigzag without ankle pain or instability, he is ready to return to his sport. The ankle should be supported for a minimum of six months after injury. Taping the ankle or using a lace-up ankle brace may help prevent re-injury.
Athletic shoes that fit well are better for stabilizing the foot and minimizing slippage. Such shoes should have strong, flat, even soles that are neither too spongy nor too thick. Sports such as volleyball, basketball, football, and racquetball are associated with the highest rate of ankle sprains.
Exercises with resistance
Obtain a strip (about two feet long) of elastic belting material, theraband surgical tubing (from the Sports Med Store), or a bike tire inner tube. Work you ankle in four directions as shown. As you do each tube exercise, pull the tubing taut, heel on the floor, and make sure you do the exercises only with your foot and ankle, not your whole leg. The tube should be placed at the base of your toes.
Repeat each exercise 10 times, 2 times/day.
OUT AND UP
Sit on floor or chair. Loop tubing over foot and around table leg. With heel on floor, work ankle out and up.
IN AND UP
As before, but loop tubing to provide tension against an inward move. With heel on floor, work ankle in and up.
STRAIGHT UP
Loop tubing over foot and around a table leg. With heel on floor, work ankle straight up.
STRAIGHT DOWN
Hold tube loop with hands against bottom of foot. With heel on floor, work ankle down
HEEL RAISE
Stand on one foot, slowly rise on toes, and slowly lower heel to the floor. Progress to doing this exercise on the edge of a step.
Repeat 15 times, 2 times a day.
General exercises. Swimming with swim fins and riding bicycle or exercycle can provide an excellent workout for your calf and ankle.
Exercising will strengthen muscles that support the injured area and help prevent re-injury and chronic problems. Do each prescribed exercise two times a day or more often if necessary.
Stretches
Do stretches before and after activity. Lean against a table with your back knee locked and your front knee bent. Press forward until a moderate stretch is felt in the calf muscles of your straight leg. Hold 15 seconds. Keeping both heels on the floor, bend the knee of your straight leg until a moderate stretch is felt in your Achilles tendon. The Achilles tendon is the lower portion of the calf muscle which attaches to the heel bone. Hold 15 seconds. You should feel a moderate pull, but no pain. Change legs and stretch the other leg. Repeat 15 times, 2 times/day.
I cannot give medical advice about how to treat a specific injury without evaluating the athlete first. While I may discuss general exercises to prevent and treat sports injuries, not all exercises are designed for all individuals or problems. A sports medical physician should be consulted before starting any exercise program. If an athlete is experiencing any severe pain or discomfort, he should see such a physician and obtain a specific diagnosis and treatment plan. The exercises outlined here are general recommendations and are not intended as a substitute for professional medical advice.
Plantar fasciitis and heel spurs
Plantar fasciitis is a common foot problem in athletes, especially runners. It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain. Typically, it is worse in the morning with the first few steps, after sitting or standing, or at the beginning of a sport or activity.
The plantar fascia is a thick fibrous material on the bottom (plantar aspect) of the foot. The fascia is attached to the heel bone (calcaneus), extends forward toward the toes, and acts like a bowstring to maintain the arch of the foot.
Anatomy
The injury
Plantar fasciitis usually occurs when part of this inflexible fascia is repeatedly placed under tension, as in running. Repeated tension or overload of the fascia causes inflammation at its attachment point to the heel bone. The inflammation produces pain.
Plantar fascia injuries can also occur at the midsole or near the toes. Since it is difficult to rest the foot, the problem gradually worsens and is aggravated with every step. In severe cases, the heel is visibly swollen. The problem may progress rapidly and treatment must be started as soon as possible.
If the chronic overload causes the fascia to pull away from the heel bone, then the foot reacts by filling in the space with new bone. This new formation results in the heel spur. The heel spur sometimes shows on x-rays. Heel spurs do not cause the initial foot pain, nor do they cause the problem. Heel spurs are a result of the problem. Later on, walking on a foot with a heel spur, may cause sharp pain.
Contributing factors
- Flat (pronated) feet
- High arched, rigid feet
- Improper shoes with inadequate support
- Toe running and hill running
- Soft terrain (i.e., running on sand)
- Increasing age
- Sudden weight increase
- Sudden increase in activity or training level
- Family tendency
Treatment
Improvement and pain relief may take longer than expected, especially if the condition has existed for a long time. As the injury begins to heal, the athlete should return to full activity gradually.
RICE. This stands for rest, ice, compression, and elevation.
REST. The degree of rest will depend of the severity of the inflammation. The athlete may have to temporarily stop running or playing his sport, to allow the injury to heal. Continuing the sport or activity often aggravates the injury, causing the athlete to experience pain, possibly more than initially. The athlete should use pain as his guide. Once pain begins to subside, foot exercises can be started to improve flexibility, allowing the athlete to resume his sport sometime in the future.
Ice. Ice (eg., bag of ice) can be applied to the foot for 20-30minutes, 3-4 times per day initially, and then 2-times per day. Apply ice for 15 minutes after any activity, to minimize additional inflammation caused by the activity. Ice massage is a very effective form of ice application.
Compression. This can be achieved by using an ace wrap initially, then by using tape. Then the foot is taped to maintain the arch, some of the tension on the plantar fascia is relieved.
Elevation. Elevating the foot is advised to help reduce swelling which may be the result of the acute injury or the chronic inflammation. Night Splint. A night splint holds the plantar fascia and Achilles tendon in a stretch position during sleep. If the fascia is slightly stretched during sleep, then the fascia is spared the sudden stress that occurs with weight-bearing. The night splint will help reduce the pain which occurs with the first few steps in the morning. See the night splint below and additional information in the Sports Med Store.
Medication. An oral anti-inflammatory medication may be prescribed or recommended. If no pain relief has occurred after 2-3 weeks, then an injection of cortisone and a local anesthetic into the tender area, may be advised. The injection can help relieve the pain and tenderness, and make physical therapy more effective. After an injection, the athlete should avoid returning to sports for one to two weeks. A successful injection can often spare the need for surgery. Repeated injections should be avoided.
Exercises. Stretching exercises of the foot and Achilles tendon are essential to help improve muscle tendon flexibility and strength. These exercises help reverse the muscle weakness which results from the inflammation, and enable the tendons to resume the usual demands and workloads of the sport (see section on Exercises).
Physical Therapy. This may be necessary to help reduce the inflammation in the plantar fascia. The physical therapist may use such modalities as: ultrasound, phonophoresis, iontophoresis, friction massage, electrogalvanic stimulation, and soft tissue mobilization, to treat scar tissue in the tendons caused by the chronic inflammation. Later, the small muscles of the foot will be strengthen to support the weakened plantar fascia.
Shoes. Poorly fitting shoes can cause plantar fasciitis. The athlete should select and wear a high quality running shoe that fits well and has an excellent support. After 300 miles of running in these shoes, expect to lose these supportive features due to significant wear and breakdown. It is wise to a runner to replace his running shoes after 300 miles of wear.
Heel Pads. A heel pad of felt, sponge, or a newer synthetic material can help to spread, equalize, and absorb the shock as the heel lands, reducing the pressure on the plantar fascia. It may be necessary to cut a hole in the heel pad to reduce the irritation to the painful area.
Orthosis and Arch Supports. These devices are either pre-made or custom-fitted, are inserted into the running shoe, and provide support and cushion from the heel and arch to the toes. See the orthotic below and the Superfeet model, with additional information, in the Sports Med Store.
Surgery. Surgery is occasionally required for plantar fasciitis. If all other forms of treatment have failed to provide relief, then surgery should be considered. This usually consists of surgical release of the plantar fascia at the point of greatest tension and removal of heel spurs if necessary.
Returning to sports
Weight-Bearing vs. Non-Weight-Bearing Sports. Plantar fasciitis can be aggravated by all weight-bearing sports. Any sport where the foot lands and strikes the ground repeatedly, such as running and jogging, can aggravate the problem. Non-weight bearing sports, such as swimming and cycling, are adequate, temporary replacements, and can help the athlete maintain cardiovascular fitness without irritating the plantar fasciitis.
Warming-Up. The athlete should move all major joints through their complete range of motion several times before starting play. Stretching and strengthening exercises help prevent injury.
Playing the Game. When resuming the sport of choice, play at a lower intensity. In running, run for shorter periods of time, at a slower speed, and less frequently. The athlete should choose flat, even surfaces on which to run. If the athlete experiences pain either during the run or the following morning, then he is doing too much. Resume competitive running or play once the foot has healed.
Exercises
The following exercises are designed to strengthen the small muscles of the foot to help support the injured area. If done regularly, they will help prevent re-injury. Do each prescribed exercise two times a day or more often if necessary.
Towel curls. Place towel and curl it toward you, using only the toes of your injured foot. Resistance can be increased with a weight on the end of the towel. Relax, then repeat the towel curl. Repeat 15 times, 2 times/day.
Shin curls. Run your injured foot slowly up and down the shin of your other leg as you try to grab the shin with your toes. A similar exercise can be done curling your toes around a tin can. Repeat 15 times, 2 times/day.
Stretches. Stand at arm's length from a counter or table with your back knee locked and your front knee bent. Slowly lean toward the table, pressing forward until a moderate stretch is felt in the calf muscles of your straight leg. Hold 15 seconds. Keeping both heels on the floor, bend the knee of your straight leg until a moderate stretch is felt in your Achilles tendon. The Achilles tendon attaches the muscles of the calf to the heel bone. Hold 15 seconds more. You should feel a moderate pull in your muscles and tendon, but no pain. Changes legs and stretch the other leg. Repeat 15 times, 2 times/day.
I cannot give medical advice about how to treat a specific injury without evaluating the athlete first. While I may discuss general exercises to prevent and treat sports injuries, not all exercises are designed for all individuals or problems. A sports medicine physician should be consulted before starting any exercise program. If an athlete is experiencing any severe pain or discomfort, he should see such a physician and obtain a specific diagnosis and treatment plan. The exercises outlined here are general recommendations and are not intended as a substitute for professional medical advice.