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Ankle therapy In the balance

Issue 02/2016

Conservative, functional treatment is the established route in cases of ankle injury, but opinion is often divided when it comes to specific measures. With recurrence rates startlingly high, one treatment step has come into focus – stabilization of the joint to counteract supination. Orthoses reduce inversion movements and enable controlled loading of the ankle. Their effectiveness has been demonstrated through studies and practical application.

 

Barely anything to see during sonography: Olaf Hinze being checked over by Dr. Sven Authorsen two weeks after the sprain.
Barely anything to see during sonography: Olaf Hinze being checked over by Dr. Sven Authorsen two weeks after the sprain.

The numbers speak for themselves: 40 percent of all sports injuries involve the same part of the body – the ankle. By far the most common one is lateral twisting of the foot , also known as spraining, which usually affects the lateral capsular ligaments. Sprains are prevalent outside of sport too, ranking among the most frequent everyday injuries. It is no coincidence that sprains are so common.
The ankle acts as the body’s outpost and, ultimately, makes walking and running possible. The interaction between the upper and lower parts of the ankle is what drives the forward motion, as the foot is lifted, lowered and rotated. The upper ankle in particular is extremely susceptible to injury. The parts that form the ankle joint – the talus, fibula and tibia – are subjected to a great deal of stress. When standing, a person’s full body weight bears down on this hinge joint , while running or jumping can create a load on the joint structure that is equal to three or four times the person’s body weight.

Evening out impact

The forces that arise during walking, running and jumping are directed through a structure that is both complex and fragile. Nature has built a considerable degree of sturdiness into the ankle. Normally, a compact joint capsule firmly holds the functional upper and lower parts together, secured by strong ligaments. However, if the foot tilts, everything changes. Just a few millimeters in the wrong direction and you end up with a sprain. The capsule ligaments, which are normally so strong, are suddenly very weak when the foot first makes contact with the ground in the wrong position. The leverage forces are tremendous, as Olaf Hinze found out the hard way. The 46-year-old was playing indoor football with his teammates when it happened to him. “I was just about to start dribbling the ball ,” says the amateur footballer, reliving the fateful moment. “The problem was, my left foot didn’t want to come with me.” The consequence of this delay was a classic football injury – supination trauma, the most common form of sprain.

Combating recurring injury

Test passed: standing on one leg on a soft surface requires a stable ankle in order to keep one’s balance.
Test passed: standing on one leg on a soft surface requires a stable ankle in order to keep one’s balance.

This was the first time that Olaf Hinze had sprained his ankle, which is unusual for someone his age. Supination trauma is so common that lack of attention to this injury and its dangers is a widespread problem – especially when it comes to considering the risk of the injury recurring. Statistics have shown that almost one third of all people who have sprained their ankle still suffer from chronic complaints in the form of new sprains or persistent instability years after the initial injury (see reference 1). There is also a significant risk of osteoarthritis. However, at the moment when the injury occurs, there is a more pressing concern. The thought that ran through Olaf Hinze’s head was “I hope the ligaments don’t tear.” They were indeed fine, but the physician’s diagnosis after the MRI scan was little consolation for the amateur footballer from Velbert: “First-to second-degree sprain, distension of the posterior talofibular ligament , normal anterior talofibular ligament , clear lateral bleeding into the subcutaneous fatty tissue.”

Not a trivial injury

It’s very important to the physician that the MalleoLoc fits perfectly. Patient Olaf Hinze appreciates the feeling of security that the orthosis gives him.
It’s very important to the physician that the MalleoLoc fits perfectly. Patient Olaf Hinze appreciates the feeling of security that the orthosis gives him.

The injury that football enthusiast Olaf sustained for the first time is all too common to his treating orthopedist , Dr. Sven Authorsen. “Every week, we see around three to four sprains in our practice,” says the specialist in orthopedics and trauma surgery who works in Heiligenhaus, near Essen, Germany. “One misstep is all it takes,” says Dr. Authorsen (see also the interview on p. 21). “People of all ages come to us with sprains of varying degrees of severity,” he adds. “Sometimes the ligaments are intact , sometimes they’re only torn slightly, and sometimes there’s a major tear, but usually they’re significantly distended.” According to this physician, one factor is especially important when it comes to treatment: time. More precisely, the time that has elapsed between the injury and adequate initial treatment. Time and again, Dr. Authorsen sees patients who have waited too long because they didn’t think it was necessary to seek medical care. “If I can reduce the swelling early on, then I can progress to the next stage of treatment relatively quickly,” says the orthopedist. “This allows me to take effective action against the risk of the injury recurring.” On the evening of his accident , Olaf Hinze followed the rule familiar to all footballers – RICE (Rest , Ice, Compression, Elevation) – before going straight to Dr. Authorsen the next morning. Because the swelling was moderate, the physician didn’t have to use a tape bandage and simply prescribed the MalleoLoc orthosis. Dr. Authorsen often opts for this ankle orthosis when treating his patients in order to expedite the rehabilitation phase, which involves the early stages of functional therapy, while preventing a new sprain. “Compared to other orthoses, it has the great advantage that its sole is rigid too, which provides a good amount of stability for counteracting supination,” says the physician. It can be used with or without shoes – “The patient can even wear it in the shower or while sleeping.”

Crash mat as a training surface

Sleeping in the MalleoLoc is exactly what Olaf Hinze did, at least for the first night , because it provided such a feeling of security. The next day, the IT project manager went about his daily business as usual in the office, wearing the orthosis in his shoe. “I was pleased to have it ,” he says. “Without its support , I wouldn’t have been able to walk around visiting my colleagues, or get up the stairs.” Two weeks after he sprained his ankle, Olaf is back at Dr. Authorsen’s practice for a follow-up appointment – and there is barely any swelling or bruising to be seen. The patient stands with both his feet on a crash mat. The physician explains that this is to help him see how it feels to tilt his ankle again and to start regaining some stability. To illustrate his point , the orthopedist throws a pen to Olaf, who catches it deftly, with just a hint of strain in his smile – and the MalleoLoc on his left foot. This patient looks to be well prepared for his upcoming physiotherapy. As for a repeat injury? Not a chance.

 

Ref. 1: Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach.
J Athl Train. 2008 Sept-Oct; 43(5):523-9.

Pictures: istockphoto.com/lzf, Stefan Durstewitz