Foot and ankle injuries cover a very wide range of conditions and for that reason we’ll talk only about the general principles for treatment rather than go into detail on each condition.
People tend to protect their foot/ankle injuries excessively for a day or so after which they brush it off as minor (“It was just my ankle but its OK now”) injury. If you take nothing more from this piece, please remember: Ankle and foot injuries are NOT MINOR!
For many years, people were taught to treat an acute ankle/foot injury by keeping weight off it, doing the standard RICE (Rest, Ice, Compression, Elevation) principles and strengthening the ankle once it is pain free by using a resistance band. Who knows why it was seen as important to be able to pull a dangling foot to either side as rehabilitation?
Things have certainly changed since then! The major change came in when someone pointed out that the foot’s biomechanics are altered significantly when it is in a weight bearing position. We want to be able to use the foot again as normal (which involves weight-bearing more than 90% of the time) so… lets rehabilitate it in a weight bearing position!
The guidelines for ankle injuries now call for pain-free use as soon as possible (not to be rested). It should also be protected enough to allow optimal function by wearing a lace-up brace for 12 months after the injury-no matter how ‘minor’ the injury was. Further generals tips include the need for full “dorsiflexion” and Talus “adduction” range of movement. Without these two, you are fighting a losing battle.The chance of re-injury is still around 30% at the moment and also roughly 30% of people will not recover to their previous level of function These figures should drop as more people receive correct rehabilitation.
After suffering a foot or ankle injury, there are a number of things that should be assessed. Firstly your Physiotherapist will need to rule out a fracture (The Ottawa ankle rules contain good guidelines). Following that, in the next 3-4 days, your therapist will establish a diagnosis. The history of the injury, which includes the mechanism, is incredibly important and so is the way your ankle has responded since the injury (bruising, swelling, shape, bony tilts, toe positions and the way you walk.) Hard, gel-like swelling within 24hrs indicates that there may be neural involvement and pain aggravated mainly during single leg squatting means that there could be cartilage damage in the joint. Both of these injuries will need an extended healing and rehabilitation period. There are also a number of clinical tests that can help to establish the diagnosis.
The clinical grading used for these injuries are: I: Niggling pain and the inability to run, II: A positive anterior drawer’s test and limping, III: Inability to bear weight but no fractures.
The objective tests used to establish what the starting point for rehabilitation are done with the eyes closed and special attention will be given to the shape/position of the foot as well as the alignment of the rest of the body.
The most important thing with ankle rehab is that the patient must be committed throughout the process and needs to focus 100% when doing the exercises. Most other rehab exercises can be done while thinking of other things. NOT the foot or the ankle!
Have you ever tried to spread your toes? To lift your arch using only the muscles in your foot? To contract a single, specific muscle in your foot like you would your biceps? We were never taught to do these things yet we expect our feet to do it while we are running around on a sports field or climbing stairs in high heels. This is the reason why ankle rehab can still fail today even with ‘doing’ the correct exercises and this is why commitment and concentration are so important.
Rehab guidelines:
Active ankle rehab takes 6-10 weeks and return to normal exercise/function could happen in 6-8 weeks providing that the patient is fully committed as discussed above. All exercises need to be done in front of a mirror to increase feedback to the patient. Hip and knee stability are as important as the local ankle stability and compensations on the opposite side must be avoided from the start.
Find the amount of support needed to walk pain free from day 1! If this means that you need to wear a moon boot and use a crutch or 2 then do it. By bearing some weight from the very start (vs having your foot dangle in the air between 2 crutches) you are speeding up you recovery already. Naturally, you need to reduce the support (and bear full, pain-free weight as soon as possible) as your injury heals. Taking this into account, old RICE principle has been changed to a POLICE principle which is Protect, Optimal Loading, Ice, Compression and Elevation. If you still have pain even without bearing weight on the injured side, you should take pain killers and anti-inflammatory medication as needed.
BUT the jury is still out on any use of ice and anti-inflammatory medication so try to keep both of those to a minimum until we know where to draw that line…