ANKLE FRACTUREA CASE HISTORY(Keywords: Ankle fracture #, Ankle joint pain, ankle anatomy, ankle exercises, twisted ankle, sprained ankle, ankle pain, foot and ankle pain) Research shows that despite injuries most people who engage regularly in sporting activities are much healthier than their couch potatoes counterparts. Generally they have less pain, from arthritis for example, however...
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The diagram above gives a very simplistic idea of the:
In fact they are extremely complex joints.
In fact they are extremely complex joints.
The subtalar joint allows for the rolling action of the foot, so-called inversion and eversion, and thus a vital part or the normally functioning ankle.
CASE HISTORY
Mrs S fell off her bicycle when she took her eye off the road ahead (where her husband was riding) to look at a helicopter passing by. He braked and she didn't notice until too late, her front wheel touched his back wheel and she fell off, striking her ankle on the curb. She had immediate severe ankle joint pain, and guessed the worst, but they were miles from anywhere. She was unable to walk, but by using the other foot for power she was able to ride to the nearest help. X-rays confirmed two ankle fractures. The lateral malleolus was plated by an orthopaedic surgeon and her ankle was put into "gips", plaster of paris. The ankle fractures healed perfectly well and the severe ankle joint pain subsided; the surgeon was supremely happy with the result, but Mrs S not. She could only walk "stap-voor-stap". The surgeon poohed-poohed any need for therapy. "It will heal on its own. Just give it time..." But it didn't... a sister in a major hospital, she used her initiative and took herself off to for physiotherapy. After fourteen weeks, she had greatly reduced pain, but the ankle still swelled alarmingly during the day, and walking was difficult and very restricted, and deep in the ankle she had stabs of pain. She walked into the clinic, unable to dorsiflex and evert the ankle, giving her a strange step-before-step gait. Not surprisingly, you can't walk normally with a fixated subtalar joint, and the ankle mortise joint was also restricted. Eight physical therapy treatments hadn't helped a great deal. What certainly contributed was the ankle exercises given. Those would be very beneficial once the subluxation of the calcaneus bone had been reduced.
CONSULT 1: KENNISMAKINGS-GESPREKANKLE FRACTUREHer husband being a patient, asked for advice. "Send her for a "kennismaking-gesprek", a getting-to-know-the-doctor consult." I suggested, having no idea whether I could help her ankle joint, or not.Holland is unique as far as I know in that patients are often advised to first consult a new doctor (for no charge) when they have no illness, just so that s/he can go through the patient records without the worry of a new crisis. In Chiropractic we use it to great effect for the patient who is anxious or uncertain about whether to consult a chiropractor. There's no treatment. A short consult, eyeball-to-eyeball, a brief exam, "do I want to trust my bod to this doctor" (my doctor says he's a quack, and I may end up in a wheelchair, or have a stroke). From the chiropractor's point of view, it's an opportunity to see if this is a condition where Chiropractic can contribute. After fracture, there was doubt on my side too... an examination of the ankle takes no more than five minutes, five mintues to view the X-rays, and another five minutes to explain to the patient the philosophy of Chiropractic. In this instance particularly what will happen to the hyaline cartilage in her ankle joint if the normal movement is not restored. Immobilisation arthritis.
CONSULT 2: FULL HISTORY and EXAMINATIONANKLE FRACTUREMrs S is a petite middle aged woman, her weight perfect at 56 kg. Fortunately she is also a non-smoker - difficult fractures don't heal well. Surprisingly, there were minimal findings in her low back or pelvis, usually the case after three months of limping, six of them with a heavy cast. No fixations, not restricted range of motion, only some tenderness of the left sacro-iliac joint.The consult was early in the morning, and minimal swelling was visible in the ankle joint. By the end of the day... A fine scar was visible where the lateral malleolus had been successfully plated) Dorsiflexion was slightly limited at 15* (normal 20*) Plantar flexion was more limited at 30* (50*) Subtalar inversion was normal 5* (fortunately not increased: torn ligaments) Subtalar eversion was ZERO (normal 5*). The joint was solid as concrete.
Fortunately the slight movement between the lower tibia and fibula bones (the so-called inferior tibio-fibular syndesmosis - a slightly moveable joint often ruptured by a trans-malleolar fracture.) appeared normal. Rupture of the anterior-inferior-tibio-fibular-ligament (AITFL), the mostly commonly injured ligament in an inversion ankle sprain, the posterior-inferior-tibial-fibular-ligament (PITFL) and the strong inter-ossesous-ligament (IOL) appeared unlikely on manual palpation of the joints. They are vital to maintain the stability of the ankle mortise joint.
MUSCLESThere was no weakness or pain on resisted isometic contraction of the ankle joint muscles. Tightness and deep tenderness in the achilles tendon and soleus muscles were found. There were no active trigger points.
PHILOSOPHY OF CHIROPRACTIC
"The world is indoctrinated in medicine. People are born in a medicine cabinet and grow up in a drugstore. They have been brainwashed, hypnotized, mesmerized and drugged to believe their life-force comes from the Outside-In. Chiropractic must un-brainwash them and demonstrate that health comes from Inside-Out." - Dr. B.J. Palmer, D.C.
All patients know the basis of Medicine, but very few know much about Chiropractic, so I always start with a brief explanation of the rationale behind Chiropractic therapy.
TREATMENT PROTOCOL after Ankle FractureFurther, I explained to Mrs S the three phases of Chiropractic care. How I would need to see her twice a week for probably 3-4 weeks in the TREATMENT PHASE, and thereafter the importance of a REHAB PHASE. Continuing to do some simple but vital exercises to restablish muscle tone and suppleness, stretching of that achilles tendon, and getting the normal proprioception back into the joint and tissues was vital. Otherwise more foot and ankle pain and twisted ankle was likely in the future.ASIDE: I find that patients with heel spurs and chronic foot pain almost always have a subtalar fixation, probably stemming from an old sprained ankle, or perhaps ankle fracture. In her case, an occasional treatment in the MAINTENANCE PHASE may or may not be needed. With such a slim, active woman, if she continued to do the exercises, I suspected that I may be able to discharge her without the need for the occasional, regular treatment usually necessary for more chronic conditions. I gave her some simple "alphabet" exercises, and the first chiropractic treatment for her foot and ankle pain.
FUNCTIONAL INSTABILITY with Ankle FractureIt is now commonly accepted that after fracture and ligamentous damage (so-called MECHANICAL INSTABILITY), that Function Instability often follows. Sudden, slight inversions of the ankle are detected by mechanical receptors deep in the ligaments of the lateral ankle, instantly activating the Peroneal muscles, responsible primarily for eversion. Failure of these of these mechanical receptors to activate the nerve responsible (Superficial Peroneal nerve) results in Functional Instability.Rehab of the joint complex, and the nerves and muscles involved in this "proprioceptive" action is vital to prevent Functional Instability. (Bozzelle, Kishner, et al. April 2010). They report a 80% recurrence rate for lateral ankle sprains.
CONSULT 3: ANKLE FRACTURESubjective: Mrs S reported some temporary "after pain" after the first treatment, which she handled easily with ice treatment.Objective: The range of motion of the ankle joint was still limited and restricted in both the ankle mortise (dorsi- and plantar-flexion), and subtalar joint (eversion). Assessment: No change in the condition. Plan: Chiropractic manipulation of the talo-tibial (mortise) joint and the talo-calaneal (subtalar) joints. Checked that the exercises were being done correctly.
CONSULT 4: ANKLE FRACTURES: Mrs S reported that walking was better.O: There was perhaps some improvement in eversion, though not in plantar- and dorsiflexion. A: Progressing as expected. P: As before.
CONSULT 5: ANKLE FRACTURES: Mrs S reported that she could walk much better, without the deep stabs of pain. The ankle still swelled in the late afternoon.O: Eversion was definitely improved. Dorsiflexion remained very tight. A: Time to start with Active Release Treatment of the achilles tendon. P: Add ART to the regimen. ASIDE Today a new patient. A tall young man of 33, three years ago a successful back operation by all accounts, but with a chronic old ankle injury. In March he had an ankle operation to improve eversion of the ankle, but the increased limping after the operation, has set off a terrible sciatica. The case is further complicated by a short leg on the same side - leg length inequality - and mildly restricted hip flexion and adduction... probable Femero acetabular impingement syndrome. Eversion of the ankle was zero, and the Slump test extremely positive. All of these will have to be addressed for a successful outcome...
CONSULT 6: ANKLE FRACTURES: Mrs S is progressing magnicently, far better than expected. Her halted stepping gait was over and she could walk relatively normally. The ankle still swelled in the evenings, but much less so, she reports.O: There is at least 2* of eversion now, and dorsi- and plantar-flexion are improving. A: Improving better than expected**. P: Introduce resistive eversion exercises using an old bicycle tube. Suggest she purchase a wobble board***.
CONSULT 7: ANKLE FRACTURES: Still better. She reports she can now walk down the stairs for the first time without difficulty.O: Still a slight limp. No oedema (but it's morning). Dorsiflexion is normal now, plantar flexion and eversion still limited. The achilles tendon is quite thick and stiff. A: Good progress. P: Ask her husband to stretch the achilles tendon every evening. Alas it's "afscheid-dag". Those long Dutch words. I'm going into semi-retirement, and have had to hand her over to a colleague. "Divorce day", literally translated.
"Sitting behind the geraniums" is a euphism for going into retirement! Except it will be sitting behind the Cape violets! Niet echt, not really, just nice to joke.
*** Watch this space for "Make your own Wobbleboard for less than two dollars".
ATHEROSCLEROSISNever will I forget being asked to go to a hospital and do a medico-legal physical examination on a man who broke his leg two years previously. Despite two operations, steel plates and pins, every time he put weight on the leg it again fractured.Next to his bed was an ashtray overflowing with butts. There was no palpable arterial pulse in the lower leg: atherosclerosis. The artery was so furred with plaque that there simply wasn't enough blood getting to the fracture site for it to heal. The surgeon confided with me that an amputation was in the offing.
PATHOPHYSIOLOGY OF ATHEROSLEROSIS ... 
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SMOKING KILLS
1 in 5 deaths - half a million Americans per year
Risk factors are additive: STROKE RISK FACTORS PAINKILLERS
JUST 1 CIGARETTE PER DAY
"Even brief exposure to tobacco smoke causes immediate harm to the body."
Surgeon General
"Lying to ourselves is more deeply ingrained than lying to others."
Fyodor Dostoevsky
$193 billion per year
Health care costs and lost productivity
Occasional smoking or just second-hand smoke damages DNA causing cancer.
"Most smokers are already well aware of their increased risk of acquiring lung cancer. Fewer people know about the patients I see every day, those with cancer of the lips, mouth, nose, throat, sinuses or larynx (where the voice box is located).These cancers account for about 6 percent of all cancer diagnosed annually in the U.S. Ninety percent of these cancer victims can blame their illness directly on tobacco use."
Paul Donald, M.D.
Over 1,000 Americans per day die directly from smoking.
Heart attack signs ...
EMPHYSEMA - worse than cancer
LIVING DEATH
"Tobacco smoke damages every organ in your body - not just your lungs" Surgeon General
CAUSES OF OSTEOPOROSIS
CAUSES OF OSTEOPOROSIS ...