Background & Etiology (Cause)
The ankle is made of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.
Bones and Joints
There are three bones that come together to form the ankle joint. The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, these are called the lateral malleus and medial malleolus. The ankle is made up of two joints, the inferior talocrural joint and the subtalar joint.
The inferior tibiofibular joint is located between the large bone of the lower leg (tibia) and the smaller fibula, which then attach to the talus bone of the foot to form the talocrural joint. The talocrural joint is sometimes called the true ankle joint and is responsible for dorsiflexion and plantar flexion (up and down) movement of the foot. The joint between the tibia and talus bears the most of our body weight.
Beneath the talocrural joint is the subtalar joint. The subtalar joint is located between the talus bone and calcaneus or heel bone. This joint is responsible for ankle inversion (turning in) and eversion (turning out).
Running between the tibia and fibula is a fibrous membrane called the interosseous membrane. This membrane joins the tibia and fibula all the way up the lower leg, extending toward the knee. At the upper end, near the outside of the knee, is the superior tibiofibular joint.
Any restriction or dysfunction of these joints can produce symptoms in the ankle. The bony joint surfaces all have articular cartilage that covers the ends of the bones. The articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other.
The ankle joint and subtalar joint are held together by strong fibrous connective tissues. Ligaments connect bone to bone. There are three major ligaments on the lateral (outside) aspect of the ankle; they are the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament.
The inside (medial) aspect of the ankle has a complex of several ligaments, which tend to be much stronger than the lateral ligaments. These ligaments are the anterior and posterior tibiotalar ligaments, the tibionavicular ligament and the tibiocalcaneal ligament
An ankle dislocation occurs when the talus bone is moved out of its normal alignment with the ends of the tibia and fibula. Ankle dislocations can occur with or without fractures, but they occur far more often with a fracture of the lateral or medial malleolus. Ankle dislocations also commonly occur in conjunction with ligament injuries, like sprains and tears.
- Previous injuries, like ligament damage, that cause instability in the ankle joint.
- Forceful muscle contractions
- Participation in athletic activities, particularly those that require running or jumping activities with subsequent trauma
- Traumatic force, from accidents (motor vehicle) or contact sports (football).
- General ligamentous laxity
- Intense pain that occurs acutely at the time of injury
- Swelling and bruising at the ankle joint
- A visible deformity of the ankle joint
- Difficulty moving the foot and ankle
- Inability to weight bear on the involved leg
Physicians reduce acute dislocations using several techniques, which may or may not require radiographic examination.
- Age and activity level are factors that guide treatment
- In young athletes (15 to 25 years old) surgical intervention is considered based on the high risk of recurrence, apprehension, impact on sports participation and quality of life
- Generally arthroscopic repair is used for the younger population
- There is a lower rate of occurrence among 25 to 40 year olds therefore members of this population respond better to conservative interventions
- People 40 years old and over have an even lower rate of recurrence, but do have increased risk of residual disability from nerve or vascular injuries
- Conservative treatment whether post surgical or non-surgical is typically recommended
- Typically a period of immobilization with the ankle held in internal rotation is recommended
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis, and the goals of the patient or client. Common interventions in the treatment of Ankle Dislocation include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation while helping to restore motion following a period of immobilization. Movements should avoid positions that place the ankle in the position that produced the dislocation (Apprehension Sign).
- Therapeutic Exercises (TE) including exercises to strengthen the muscles in the ankle and increase stability.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example, jumping) in daily use of the involved lower extremity.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the ankle and tendons.
- Home program that includes strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Procedures that your physician may recommend and perform in addition to physical therapy.
- Relocation and initial immobilization of the dislocated ankle
- REST and ICE
- The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
- Steroidal Injections to reduce inflammation
- Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
- Surgery to correct underlying pathology and avoid instability and repeated dislocations. This may include procedures to tighten the ligaments.
Most people recover full function following a course of conservative care of physical therapy to strengthen and stabilize the ankle following the immobilization period. Those with more involved conditions, like a ligament tear will require surgery and intensive physical therapy afterward to restore full function. When fractures or surgery are involved recovery to full function will take longer.