lateralankleinjury

LATERAL ANKLE INJURY Literature Review and Report of Two Cases Henry Pollard Ph.D., B.Sc., Grad.Dip.Chiro., Grad.Dip.App.Sc., M.Sport.Sc. *Patrick Sim B.Sc., M.Chiropractic. † Andrew McHardy B.Med.Sc., M.Chiropractic. ‡ Background: Injury to the ankle joint is the most commonperipheral joint injury. The sports that most commonlyproduce high ankle injury rates in their participatingathletes include: basketball, netball, and the various codesof football Objective: To provide an up to date understanding ofmanual therapy relevant to lateral ligament injury of theankle. A discussion of the types of ligament injury andcommon complicating factors that present with lateralankle pain is presented along with a review of relevantanatomy, assessment and treatment. Also included is adiscussion of the efficacy of manual therapy in the treatmentof ankle sprain. Discussion: A detailed knowledge of the anatomy of theankle as well as the early recognition of factors that maydelay the rate of healing are important considerations whendeveloping a management plan for inversion sprains ofthe ankle. This area appears to be under-researchedhowever it was found that movement therapy and itsvarious forms appear to be the most efficient and mosteffective method of treating uncomplicated ankle injury.Future investigations should involve a study to determinethe effect chiropractic treatment (manipulation) may haveon the injured ankle. Ankle, sport, injury, treatment, chiropractic. INTRODUCTION It is stated that the ankle is the most injured peripheraljoint1-8. Percentages of ankle injury range from 15%1,8-10to as high as 45% and 59% of all injuries in somesports2,4,6,7,11. The sports that most commonly producehigh ankle injury rates in their participating athletes include:basketball, netball, and the various codes offootball2,6,7,10,12,13. Thus, those sports and other activitiesPrinting Requests: * Department of Health and Chiropractic,Building E7A, MACQUARIE UNIVERSITY, N.S.W. 2109.AUSTRALIA. Email: hpollard@ozemail.com.au†194 Payenham Road, EVANDALE, S.A. 5069. AUSTRALIA‡ 84 Kingsway, CRONULLA, N.S.W. 2230. AUSTRALIA ACO Volume 10 • Number 1 • July 2002 that involve running, balance and quick stop-startmovements appear to be of higher risk. Table 1 presentsacute injuries associated with the lateral ankle. Table 1: Some causes of acute lateral ankle injury (adapted fromBrukner P, Khan K: Clinical Sports Medicine, Sydney: McGraw-HillBook Company Pty Ltd 1993; 447-8.) CASE REPORT 1 A twenty six year old male presented for treatment of leftankle pain and swelling of three days duration. The paincame on after being tackled during an amateur leaguesoccer game. The patient was about to gently kick thesoccer ball with the outside of his left foot when theopposing player challenged for the ball, kicking both theball and the patient’s foot. The foot was in a plantar flexedposition at the time of impact, which was on the lateralaspect of the foot and forced the ankle into extremeinversion. The patient had the foot in a relaxed positionat the time of impact as he was unaware he was about tobe tackled. The player discontinued play after beingkicked and iced the injured area. The next morning x-rays were performed showing no alteration of osseousintegrity. The patient presented for treatment on crutches (obtainedfrom the hospital), but said that he could put some weighton the foot. He described a history of several minorinversion sprains to the ankle that were completely resolvedprior to this incident. His history was otherwiseunremarkable. On inspection of the ankle, the area was very red, hot andswollen. Pitting oedema was present. There was limitedactive ROM due to the presence of swelling. Plantarflexion gave a stretch anteriorly. Passive ROM gave slightpain on inversion. Palpation to the area elicited paininferior to the medial and lateral malleolus. Both the 21 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY dorsalis pedis and tibial pulses were present. Stresstesting the ankle ligaments caused the patient to complainof slight nausea, so stress testing was recommenced at thesecond consultation. The patient received light soft tissue therapy to the ankleand 10 minutes 80-150MHz interferential to the area. Atthe second consultation stress tests were performed toassess the lateral ligament integrity. Although an end-feelwas present, some degree of pain was elicited. A workingdiagnosis of grade two lateral ligament complex strainwith medial impingement was made. Treatment continuedwith the use of soft tissue therapy and interferentialstimulation for two visits during the first week. Thistreatment assisted the reduction of the swelling. On thefourth consultation ankle mobilisations were introducedto the treatment regime, with the patient having progressedto using a cane to aid walking rather than using crutches.On the sixth treatment sub-talar distraction adjustmentswere performed with the patient noticing almostsimultaneous increased ROM, particularly in dorsi-flexion.Resistance home exercises were also given to maintainstrength. At this stage the patient was able to walkunaided. After five weeks of treatment, the patient wasseen to be walking without a limp and was able to feel astretch in the calf muscles on dorsi-flexing the ankle. Thepatient was given a wobble board to do exercises toincrease proprioception. Appointments were nowscheduled once per week (as opposed to two per week forthe first five weeks). The patient continued to improve andstraight line running was introduced at nine weeks postinjury. The patient slowly added cutting movements to thetraining regime and at twelve weeks post injury was ableto complete shuttle runs without any problem. The player started soccer again with protective strappingon the ankle which continued to the end of the season.During this time exercises to strengthen the leg musclesparticularly the peroneals were regularly performed, aswas ankle dorsi-flexion range of motion exercises. At theend of the soccer season, two months after the resumptionof play, the patient remains pain free.CASE REPORT 2 A twenty-eight year old overweight female presented fortreatment of an achilles tendon swelling and pain. Thepain came on one year earlier following being hit heavilyon the distal part of the gastrocnemius muscle by a shoppingtrolley. There was recurrent swelling in the para-tendinousarea accompanied with chronic low grade pain. Shespecifically complained of pain pressure soreness at thesite. She was referred to a physiotherapist after presentingto a medical practitioner for an opinion. On presentation, she complained that walking aggravatedthe swelling slightly. This swelling however did not22 restrict movement in the ankle. During case history takingshe did not report any previous involvement of the leg orback. Her history was otherwise unremarkable.On examination she demonstrated full active, passive andresisted range of motion of the ankle. Stress tests of theankle were unremarkable. Palpation of the involved siterevealed a painful thickening of the para-tendinous regionposteriorly with a slight swelling (approximately 5centimeters in diameter) at the site which was later identifiedas a bursal thickening. She received soft tissue therapy and interferential to theeffected tissues with stretching of the gastro-soleuscomplex. She was given four treatments with no responsein symptoms. She was then referred to a local medicalpractitioner for referral for ultrasound, who subsequentlyexcised a nodule of scarred bursal material after performingthe ultrasound. Her swelling and sensitivity to touch wereresolved completely within two weeks of the surgery.Six months following the resolution of the achillescomplaint the patient presented for treatment after fallingoff rocks whilst at the beach when on a holiday. She fellapproximately six feet, and landed with greater weight onher left foot causing an inversion strain injury. She presented on crutches three weeks later complainingof postero-lateral and medial left ankle pain. She presentedafter being cleared by x-ray and CT scans for fracture bythe local hospital. Her examination revealed severetenderness about the antero-lateral and postero-medialjoint lines without severe ligamentous rupture. Alldirections of motion were guarded. There was a pain oncompression testing of the ankle. There was no instabilitypresent on testing, but all tests produced much pain.A working diagnosis of lateral ligament strain (grade II)and synovitis was established. Treatment consisted of softtissue therapy, gentle joint mobilisations (to tolerance),cryotherapy and interferential therapy. This treatmentwas conducted over the following month at twice per weekintervals. The treatment resolved some pain, and improvedfunction and weight bearing, but following the treatmentsthere was still a significant amount of pain and runningwas not possible. More importantly, some night pain hadbecome noticeable. Re-testing the compression of theankle revealed ongoing pain. The patient was referred to a surgeon for an opinion on thelikelihood of a osteochondral lesion of the tibial plafondand / or a soft tissue impingement associated with the joint,as a cause of her symptoms. The surgeon performed an arthroscopic examination (asx-ray and CT were negative) which revealed the presenceof a grade III medial tibial plafond chondral lesion, ACO Volume 10 • Number 1 • July 2002 synovitis (probably causing the soft tissue impingement)and a meniscoid lesion. She underwent arthroscopicdebridement for the above conditions and was placed ona regime of: peroneal, active range of motion exercisesinvolving the ankle and sub-talar joints, stretching of theanterior capsule and accelerated stretching of plantarflexion for a minimum of four weeks. She was instructedto swim and partake in hydrotherapy, wear a compressionbandage for the swelling and receive soft tissue therapy tothe arthroscopic portals to prevent adhesions. Under this regime she demonstrated a steady improvementof her ankle over the following three months, and wascompletely pain free by six months.ANATOMY The ankle has a complex anatomy. A strong understandingof the anatomy and biomechanics of the ankle greatlyassists the clinician in the management of ankle injury. Adiagram of relevant anatomy is presented in figure 1. Theankle joint capsule is fairly thin and especially weakanteriorly and posteriorly14. Thus, stability of the joint isdependent upon an intact ligamentous structure. Figure 1: The anatomy of the lateral ankle (adapted from Mellion MB,Walsh WM, Shelton GL (Eds). The team Physicians handbook (Ed 2).Philadelphia: Hanley & Belfus Inc; 1997;579-92.) The ligaments of the ankle exist in two groups. Firstly,there are those that aid in maintaining the grasp of thetibio-fibular mortice on the body of the talus. Theseinclude the anterior and posterior tibio-fibular ligaments.Secondly, there are those ligaments that maintain contactwith the ankle joint surfaces and control medial/lateralglide. These include the medial collateral and lateralcollateral ligaments. Both these groups may succumb toinjury, but it is the latter group, namely the medial collateraland the lateral collateral ligaments which are mostcommonly involved1-4. Furthermore, of these medial/lateral stabilisers, it is the lateral group of ligaments thatare most commonly injured1-8. The medial collateral ligament (MCL), commonly knownas the deltoid ligament, originates from the borders of themedial malleolus and fans out distally to insert in aACO Volume 10 • Number 1 • July 2002 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY continuous line on the navicular anteriorly and on the talusand calcaneus distally and posteriorly14. It is extremelystrong and controls medial distraction (eversion stretch)and also checks motion at the extremes of eversion14.The lateral collateral ligament (LCL) is comprised ofthree individual bands that are commonly referred to asseparate ligaments. These are the anterior talo-fibularligament (ATFL), the calcaneo-fibular ligament (CFL),and the posterior talo-fibular ligament (PTFL). Generally,the LCL is weaker and more prone to injury than the MCL.The ATFL is the most frequently damaged of the LCLligaments, followed by the CFL and then the PTFL, whichis rarely injured6,10-12,14. The ATFL extends from theanterior portion of the distal fibula stretching forward toinsert on the talus. Its role in ankle mechanics is checkingplantar flexion and inversion of the ankle. Thus it is thesemovements that stress the ligament most and cause it to bedamaged. The CFL lies deep to the peroneal sheath, however it issupra capsular. It extends from the distal fibula and spansboth the upper (talo-crural) and lower (talo-calcaneal)ankle joints to insert postero-laterally on the calcaneus12.Karlsson and Lassinger11 site Brostrom, 1966, stating thatit lacks major significance, but also site Percy, et al., 1967,who have shown that it is the most important of theinversion limiting ligaments of the ankle. The function ofthe CFL is not disputed, with all authors acknowledgingthat it is the major limiting ligament to inversion of theankle6,10-12. The PTFL is the strongest of the lateral ligaments6,10-12,14.As mentioned earlier, it is rarely damaged in isolation butmay be torn in severe ankle injuries. It originates from theposterior portion of the distal fibula passing directlybackwards to insert on the posterior surface and postero-lateral tubercle of the talus6,15. Its function is in checkingdorsi-flexion of the ankle and therefore it may be involvedwith inversion sprains that have a component of dorsi-flexion. Examples of these injuries are seen when thewhole foot is in contact with the ground at the time whena damaging medial to lateral directed force occurs6.Other important anatomical structures of the ankle are theperoneal tendons and the tibia/fibula syndesmosis. Thetendons of the peroneus longus and brevis muscles run ina synovial sheath together behind the lateral malleolus.They then separate to pass around the peroneal tubercle ofthe calcaneus on their way to their respective insertions atthe base of the first metatarsal, the medial cuneiform, andto the base of the fifth metatarsal15,16. Their function in footmechanics is primarily plantar flexion and eversion;however, the peroneus brevis is also involved in maintainingthe lateral longitudinal arch. The syndesmosis betweenthe tibia and fibula is comprised of a fibrosis tissue andother associated ligaments spanning the space between thetibia and fibula. Distally, this fibrous union has an 23 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY important action in holding the tibio-fibular mortice on thetalus. This syndesmosis can be injured with lateral injuryto the ankle if there is a compressive loading that producesa spreading force at the inferior tibio-fibular joint as thetalus is forced superiorly4,10,12. THE MECHANISM OF ANKLE INJURY The mechanisms of ankle ligament injury are varied butare commonly due to inversion coupled with plantarflexion14. Thus, lateral ankle ligament injury is mostcommon, often associated with peroneal tendon strain orrupture12, accounting for in excess of 40% of all ankleinjuries10,15. Medial ankle ligament injuries are lesscommon. This is due to the strength of the deltoidligament and structure of the ankle joint itself14. However,injury may occur with excessive pronation, eversion anddorsiflexion, or pronation and external rotation4. Thesemovements may also induce sprains to the anklesyndesmosis, such injury only occurs in 10% of ankleinjuries4,10. Ligament injury is graded depending on the degree ofdamage (see table 2). Grade 1 injuries cause stretching ofthe ligament without any macroscopic tear. The joint isconsidered stable on testing. Grade 2 injuries consist ofpartial macroscopic tearing with mild to moderateinstability. Moderate swelling and tenderness are presentand the functional ability is compromised. The grade 3sprain involves complete ligament rupture associated withmarked swelling, ecchymosis and instability. Trevino etal (1994) have devised a grading system for the anklewhere grade 3 sprains are further categorised by the Table 2: Classification of ankle injury (adapted from Andreasi A.Chondral and osteochondral lesions of the talus associated withcapsulo-ligamentous lesions of the ankle joint. Chir Organi Mov1990; 75(1): 41-50.) 24 involvement of the ATFL, CFL and peroneal tendon(types 3a, 3b, and 3c) and other sub-types existing forsubluxation (medical) or dislocation12. DIFFERENTIAL DIAGNOSIS OF LATERALANKLE INJURY Pain that persists following an acute lateral ankle sprainshould alert the clinician to the possibility of other injuryconcomitant with the ligament injury. The differential listshould include several possibilities not limited to: chronicinstability, early degenerative joint disease, loose bodies,osteochondral lesions, occult fractures, intra-articularmeniscoid lesions and peroneal tendon injury (includingtendinitis, rupture and subluxation)16,17.IMPINGEMENT Ankle impingement has been long recognized as a commonsource of pain in and around the ankle18. These painsyndromes often go undiagnosed and can result from intraand peri-articular pathology, and can mimic the pain of achronic lateral ligament sprain. They can present inanterior, posterior and combined syndromes. Accordingto Henderson19, anterior impingement can result from softtissue and/or osteochondral lesions of the anterolateralcompartment of the ankle. Pathological lesions causingthese impingement syndromes include: post traumaticsynovitis, the meniscoid lesion, Bassetís ligament,impingement pads, tibial plafond and talar neckosteophytes20. MENISCOID LESION The meniscoid lesion is a common but an under-diagnosedcause of chronic antero-lateral upper ankle pain fibula21.The most common presentation is that of chronic pain andswelling over the antero-lateral aspect of the upper ankle22.Consistent with the second case presentation, soccer playersseem to be at risk of the meniscoid lesion of the lateralankle23. It is said to result from the hyalinisation of tissuetrapped between the lateral aspect of the talus and thefibula21. These lesions are frequently associated withsynovitis, and are also associated with chondromalaciaand osteophytosis21. The meniscoid lesion appears to beassociated with those patients with a chronic pain syndromethat has not been responsive to conservative care, and areoften diagnosed during arthroscopy24. CHONDRAL AND OSTEOCHONDRAL LESIONSOF THE TALO-TIBIAL JOINT Sijbrandij et al25 reported on 146 consecutive ankles thathad undergone an MRI investigation following acute orrecurrent ankle sprain. Of the 146 ankles, 42 osteochondrallesions were revealed in 26 ankles (18%). 23 of theinjuries were of the talar dome and 19 were of the talo-ACO Volume 10 • Number 1 • July 2002 tibial plafond. In 11% of cases lesions were present in theopposing bones (a kissing lesion). Of particular note wasthe fact that of the 26 ankles with osteochondral injury,only 6 of 12 talar fractures and none of the tibial fractureswere visualised with conventional radiography. Suchfindings have led many authors to recommend that MRI isthe investigation of choice for peri-articular pathology ofthe talo-tibial joint26. Stroud & Marks27 concluded that asno prospective studies have been performed to test therelative merits of CT or MRI in such cases, such arecommendation is preliminary. However, they didconclude that should a practitioner be ordering aninvestigative MRI scan, it is likely that a bone scan wouldnot be required. DiGiovanni et al16 retrospectively reviewed all aspects ofcase management of 61 patients receiving primary anklelateral ligament reconstruction. They noted that at surgeryno patient had an isolated injury to the lateral ligaments.Ogilvie-Harris et al17 in 100 consecutive arthroscopicpatients revealed that 95 of 100 patients could be classifiedinto three groups: the instabilities (lateral and syndesmotic),the impingements (anterior and anterolateral), and thearticular lesions (chondral and osteochondral). Theremaining 5% were deemed to be non-specific lesionssuch as osteoarthritis or synovitis. They concluded thatgood results can be achieved with patients with pureinstability or impingement. They also reported that patientswith an isolated articular lesion showed good resolutioncompared to a poorer outcome when the lesion was alsoassociated with instability. Bernt & Hardy28 introduced a classification system ofosteochondral lesions of the talar dome. This system isstill currently in use with an additional lesion described inthe classification system20. According to Flick & Gould29 the osteochondral lesion isa commonly overlooked cause of chronic ankle pain. It isa condition that is associated with compression loading ofthe dome of the talus by the tibial plafond thereby damagingthe osteochondral surface. It is particularly associatedwith the supero-medial and supero-lateral corners of thetalus30. If the resultant lesion is large, they tend to show upat the initial radiographic investigation. However, this isfrequently not the case25. Osteochondral lesions usually present after failedconservative therapy for ankle inversion sprains, and theygenerally present with chronic pain, swelling andstiffness16,31. In such cases it is wise to obtain additionalimaging studies to confirm the presence of such a lesion.The bone scan is the investigation of choice as it can detectall types of osteochondral lesion20. If positive, CT or MRIshould follow. Note that the CT scan only visualises thegrade II, III, IV lesions20. The MRI scan can visualise thetype I lesion32.ACO Volume 10 • Number 1 • July 2002 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY It is recommended that grade I and II lesions are casted for6-8 weeks, and that grades IIa, III, IV lesions be referredfor arthroscopic / open debridement; a procedure thatremoves the osteochondral fragment / cyst followed by thecuretting / drilling of the lesion down to bleeding bone33.Arthroscopic procedures are increasingly being performed.All lesions should undergo appropriate rehabilitation toimprove strength and coordination following the castingperiod20,30. Baker & Morales34 have demonstrated thatpatients treated with arthroscopic debridement andcurettage for osteochondral talar dome lesions demonstratea high percentage of successful outcomes with lowmorbidity. By contrast to the symptomatic lesion, Rosenberg &Mellado35 have reported the presence of a central pseudo-defect of the talus as a common asymptomatic finding dueto the insertion of the tibio-talar fibres of the deltoidligament into the talus. They caution against themisinterpretation of this lesion as a symptomaticosteochondral lesion. Andreassi36 supports this viewwhen concluding that many of the sites of theseosteochondral lesions (18%) occur with capsulo-ligamentous lesions.ASSESSMENT There is little research into the effects of manual therapyon peripheral joints especially of the ankle. Much of theresearch is in the form of case histories, commentaries orpure research into combined procedures3,4,10,12. Littleresearch has purely investigated single treatmentapproaches, and this is particularly true of randomisedcontrolled trials of manipulative treatments for ankleinjury. Methods for assessing the grade of ankle injuryvary greatly. By far the most prevalent method evident inthe literature is stress radiography37-41. By this method, anankle joint is said to be unstable if the talus shows greaterthan 10mm translation and a tilt from 9° to 15° or more40,41.Often, this method has been incorporated with the use oforthopaedic tests such as the anterior draw test and thetalar tilt test10,12,42. These tests examine the amount ofaberrant movement in the ankle following injury.Ultrasonography40, stress ultrasound9,40, bone scan (Marder& Lian 1997), magnetic resonance imaging (MRI)4,10 andpatient balance43 are other methods suggested for diagnosisof the type and degree of ankle injury. However, Blanshardet al37 found that tests utilising proprioception andultrasound had a poor degree of accuracy and recommendedcommon peroneal tenography, MRI and arthroscope fordefinitive diagnosis.TREATMENT Treatment regimes for lateral ankle sprain are indeed quitevaried. The injury type often dictates the form of the 25 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY treatment, but in many cases, several approaches havebeen used for the same injury. Grade one injuries occurwhen there is mild disruption to the connective tissue,grade two has moderate disruption whilst grade threeinjuries have severe or total disruption to the connectivetissue. The most commonly used forms of treatments aremobilisation, immobilisation, and surgery8,12.MOBILISATION Early mobilisation (pain limited weight bearing activity)is by far the most common approach in contemporarysports medicine1,4,6,9-12,38,44. Mobilisation is a generic termfor treatments where the ankle joint is left relatively freeto move in the first few days to weeks following trauma.As such, there are numerous variations and modificationson the general theme. It is seen as a low cost, high-resulttherapy1,6,38 that has been shown on multiple occasions tobe more effective in getting injured ankles functioningquicker than other treatment forms38,44. It is also noted thatthese therapies are safe and complications free9,11. Mostmethods involve a 3 phase treatment regime12,44 started assoon as the injured ankle is seen. The first phase utilisesstandard first aid (PRICER) treatment, ie the joint is Painmedication, Rested as much as possible, the ankle is Iced;a Compression bandage is applied, the foot is kept Elevatedand Referral for treatment is undertaken when possible.Ankle rest is usually performed with the use of crutches.Initially the patient is non-weight bearing with progressionto weight bearing as the pain allows. The acute phasegenerally lasts for a period of 1 to 3 days, depending on thegrade of injury. In order to promote increased removal of swelling andtissue debris, electrophysical therapies such as ultrasoundand interferential have been suggested3,45,46. These wouldbe most effective in this first phase, however, the literaturefails to provide evidence that supports these suggestions.In a double-blind study on the effect of ultrasoundtreatment on ankle injury, Williamson et al46 concludedthat the therapy was ineffective, stating that “there wasno significant difference between the results achieved bythe group treated with ultrasound and by those managedwithout”. The second phase immediately follows the first phase withthe time frame varying for each grade of injury. For agrade one injury, the second phase would generally starton day two and last two to four days. In a grade two injuryit may start on day two to three and last eight to twelvedays. With a grade three injury, the second phase may startin six to ten days and last three to four weeks. The secondphase consists of general ankle muscle strengthening,notably of the dorsi-flexor and peroneal groups, andstretching the achilles tendon. Exercises such as toewriting (where the alphabet is scribed by the foot in theair), and plantar and dorsi-flexion movements against26 resistance (eg rubber tubing or bands)1,3,4,8,11 may beperformed during this phase. The third phase involves conditioning and proprioceptivetraining. Materials commonly used include wobbleboards1,3,6,8,43,47, mini tramps and rocker boards3,6, whichare used in conjunction with a regime of increasingfunctional activities (ie progressing from brisk walking, torunning, etc, and ultimately to jumping, hopping andcutting)3,4,6,8,47. The functional activities progress throughto sport-specific exercises for the patient. This phasefollows the second phase and starts when the patient has80% strength returned to the injured site. This general 3-phase treatment regime is seen in mosttreatment plans, but with either a different emphasis or analtered format. The time frame for each phase variesdepending on a number of factors. The site and severityof the injury, the chronicity of the problem, the previoushistory of injury and the performance of aggravatingfactors by the patient with the injury are some reasons thatprolong healing. Table 3 presents causes of delayedhealing in lateral ankle strains. (adapted from Reid DC. Sports injury assessment and rehabilitation.New York: Churchill Livingston Inc; 1992; 176.) IMMOBILIZATION In cases where immobilisation is used (generally grade 2or 3 strains), the ankle is prevented from moving as soonas the diagnosis is made. Immobilisation is achieved mostcommonly through a plaster cast, although fibreglass andair casts also being used1,6,8,15,38. The period ofimmobilisation ranges between 10 days1 to 4 or 6weeks6,8,12,15,41. Following this period rehabilitation phases2 and 3 are usually undertaken. ACO Volume 10 • Number 1 • July 2002 Studies performed on the comparisons of mobilisationand immobilisation have noted that although restorationof ankle function is quickest with mobilisation, they alsoreport that in follow up examinations, the long term resultsare similar between groups1,11,38. Eiff et al1, in particular,found that the difference in time between restoration ofnormal function by mobilisation, and restoration byimmobilisation, was the same as the time the ankle waskept in plaster, suggesting that the plaster was the onlylimiting factor. To date, the literature seems to suggests that immobilisationis best performed in those patients who suffer chroniclateral instability11 or are professional athletes8,10, and thenonly in conjunction with surgery. This is refuted by Tilinget al9 who have provided evidence to suggest that thetreatment of athletes should contain functional /mobilisation techniques.MANIPULATION One treatment type applicable to this review is the articularmanipulation. Although an important sub-category ofmobilisation, it could be considered an entity unto itself.Of the literature so far screened, evidence showing theeffectiveness and methods of chiropractic treatment ofankle injury is scarce. The only articles found to date thatadvocate the use of this treatment failed to illustrate whattechniques were performed, referring only to“manipulations” and “attention to foot biomechanics”48.Other articles followed standard 3 phase treatmentregimes3,49 again without specific references to chiropracticmanagement or protocol. A recent single blinded placebo controlled study by Pellow& Bratingham50 represents the first attempt to quantify theeffect of manipulation on the recovery of grade I & IIinversion sprains of the ankle from a chiropracticperspective. They performed both subjective (short formMcGill Pain Questionnaire and Numerical Pain RatingScale 01) and objective goniometric measurements ofrange of motion and pain pressure assessments via analgometer. Whilst both the treatment and the controlgroup improved during the study, there was a significantdifference between the groups. However, due to the smallsubject numbers, a very poor statistical power was recordedfor many of these significant findings therefore heighteningthe possibility of a type two statistical error (accepting afalse null hypothesis). Thus, this study (denoted as a pilotin the abstract) remains a good early attempt to investigatethe effects of ankle manipulation on the recovery ofcommon ankle injuries and serve to highlight some of theproblems associated with conducting clinical research.Hunter48 and Logan51 suggest that chiropractic physiciansmay aid the injured ankle by re-educating the peroneal andsoleus muscle groups, an approach taken by numerousACO Volume 10 • Number 1 • July 2002 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY other non-chiropractic practitioners. Authors Miller andNarson49 have formulated protocols to deal with ankleinjury, promoting the use of conservative and functionaltreatment regimes but again avoiding suggestions on whatmanipulative techniques to use. However, most of theresearch presented is merely the opinion of the author ofthe case studies and not randomised control trials.Stavrou52, in his “Manual of Peripheral Technique”,describes various ankle manipulations and their methods.He outlines five manipulations specific to the upper anklejoint and a further six involving the lower ankle joint andrelated hind foot joints. Although the aim of eachmanipulation is clearly stated there is no narrative onindications for use or relevant patient history that wouldcall for the use of these manipulations. This lack of clear indications for the use of anklemanipulations is partially eliminated by texts such asEsposito and Stuttered who have included a detailed, jointby joint motion palpation (MP) routine in their“Chiropractic Peripheral Technique”53. Notably, anterior-posterior, posterior-anterior, and long axis extensionmotion palpation of the talo-crural and sub-talar joint arepresented with instruction on MP of the cuboid, navicular,and cuneiforms and how these restrictions of motionsshould be dealt with by manipulation. This work based onthe earlier work of Schafer & Faye54, describes the basicmechanics of applying manipulation to restricted jointmotion, but they do not integrate the severity or stage ofhealing of the injured joints (and other supportingstructures). As such, correlation of lateral ankle injurywith both static and motion palpation, as well as subjectiveindications such as pain, is absent.SURGERY The use of surgery in the correction of ankle injuries iswell documented throughout the literature. Surgery isindicated in the case of instability and joint decompressionsecondary to loose or foreign bodies (meniscoid lesions,impingement and talar dome osteochondral injuries).Arthroscopic & open debridement was considered withthe discussion on talar dome injury. By contrast, there areseveral methods used to achieve stabilisation of the unstableankle following trauma, notably the Evans-Jones, theWatson-Jones, and Chrissman-Snook procedures11. Theprocedures involved are beyond the scope of this article.For a detailed explanation the reader is referred to Karlsonand Lassinger11. Karlson and Lassinger11 promote the use of surgery onlyafter conservative methods have been tried and havefailed. These methods should also only be used followingappropriate imaging of the injury (see figure 2). Theyfurther suggest that only anatomical reconstruction withshortening, reinsertion and imbrication of the damaged 27 LATERAL ANKLE INJURYPOLLARD / SIM / MCHARDY tissues be used. This method is 90% effective and has veryfew complications. However, Weiss, Rupf, and Weinelt41,state that surgery, in conjunction with cast immobilisation,is a superior form of treatment for ankle injury. Thisopinion by Weiss et al conflicts greatly with the view ofmany other researchers6,8,9. Figure 2: Indications for investigations with persistent lateral anklepain (adapted from Mellion MB, Walsh WM, Shelton GL (Eds). Theteam Physicians handbook (Ed 2). Philadelphia: Hanley & BelfusInc; 1997; 579-92.) SUBJECTS IN ANKLE RESEARCH Research on the incidence of ankle injuries and theirresponse to different types of treatment is important to themanual therapy professions. It is important to documentprotocols for research as this underpins what practitionersare doing in their clinics for many types of injuries. Dueto the incidence of ankle injury in athletes, most researchershave utilised the athletic population in their studies2-9,13,40,41,43,48,49 . Goldie et al43, completed a comparative study between the recovery times of trained (athletic) anduntrained subjects. The subject’s postural (balance) controlwas investigated and was found to recover significantlybetter in trained subjects. This finding indicates that theuse of trained athletes in further investigations may enhancethe quality and increase the ease of obtaining usefulresults. It also suggests that any sample population for thistype of investigation should include separate trained oruntrained subjects. The use of appropriate controlpopulations would decrease the number of aberrant results.Most studies that have not used trained / athletic subjectshave a subject population too diverse from which to deriveaccurate conclusions1,9,38,40,44. These results demonstratethat the results of many studies can be potentially biasedby the way they are conducted. Only Hopper et al2, who investigated female netballers hascompleted a gender specific work, but no investigationshave been located that compare the recoveries of malesand females. The number of subjects used in ankle injurystudies range from 4 to over 1507,39,44,46. Most papers usedbetween 80 and 120 subjects to obtain theirresults1,2,8,37,38,40,41. 28 CONCLUSION This paper presented the successful outcome of two casesof similar presentation that required either a conservativeor surgical resolution to their problem. The indications forthese therapies have been discussed as has a review of thepertinent literature. Whilst managing inversion sprains ofthe ankle, a detailed knowledge of the anatomy of theankle is important in developing a plan to treat, as is therecognition of factors that may delay the rate of healing.Movement therapy and its various forms appear to be themost efficient and most effective method of treatinguncomplicated ankle injury. However, considering thelack of specific chiropractic literature on ankle injurytreatment, it would be an important investigation todetermine what effect chiropractic treatment(manipulation) may have on the injured ankle via arandomised controlled study. The criteria for producing a scientifically based idealstudy includes the production of a random controlled trialof 80-120 participants matched for sex, age and activity.Such a population would also control for the closure ofepiphyseal plate and minimises the occurrence ofdegenerative changes within the population sample. Also,care needs to be given to the selection of subjects fromspecific population groups such as trained athletes, as anyconclusions drawn from such research would be applicableto that group and not the general population.ACKNOWLEDGEMENT The authors wish to thank Peter Komarami for his assistancein compiling aspects of this paper.REFERENCES 1. Eiff MP, Smith AT, Smith GE. 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