The Ankle & Lower Leg in Sports Medicine

Physical Education

Ankle and lower leg injuries are common in a variety of sports. Some injuries are minor but all should be investigated as seemingly minor injuries often turn out to be larger problems. Many ankle injuries are occur due to overexertion or during high velocity movements or shifts in momentum. The following common injuries and rehabilitation can help reduce injury severity and training loss.

The Rolled Ankle

When an athlete rolls an ankle this can occur in many different scenarios and you will need to ask certain questions to determine the severity and type of injury.

• How did you create the injury? (Knowing how the injury occurred can reveal the type of damage that has occurred i.e., running rolled foot backward creating a sprain.

• How did you twist your foot inward, backward, or outward? (By asking this question, one can determine if the injury is an eversion ankle sprain or inversion sprain. This can show where the sight of actual injury and will provide information for how to treat.

• Can you stand on the foot? (The ability to place weight on the foot shows the severity of the injury. If the injury is so severe that weight cannot be maintained then there is the possibility of a break or fracture.)

• Which directions can you turn your foot if at all? (Being able to turn the foot in specific directions can indicate the site of damage and the severity.)

• Where is the location of the pain? Where does it hurt? (This shows the site of pain.)

• Is the pain sharp, stabbing, or burning? (This question can determine the type of injury because sharp pains are indicative of breaks whereas burning pain is more indicative of torn ligaments or cartilage.)

Field Tests, Determining the Severity of the Injury, & Means of Transportation

Testing for the severity of the injury there are three tests that can be used.

Anterior Drawer Test- This test evaluates the anterior talofibular ligament by securing the leg with one hand and applying an anterior pull on the heel with the foot held at the plantar flexion a forward shift of more than 8 mm is indicative of ligament tears.

Eversion test- Bending the knee 90 degrees while the heel is held from below by one hand while the other hand holds the lower leg. The hand on the heel is used to push the calcaneus and talus into eversion while the other hand holds the lower leg and pushes grips the lower leg laterally and pushes towards the middle. This will test the deltoid ligament and possible muscle damage in that region.

Inversion (Supination)- The knee is flexed 90 degrees while the heel is held from below by one hand while the other hand holds the lower leg. The hand on the heel is placed to the side and is used to push the calcaneus and talus inward and the other hand holds the lower leg in the middle and pushes laterally. This will look for damage in the plantarflexion; anterior talofibular ligament; dorsiflexion; and calcaneofibular ligament.

Depending upon the severity of the pain and the ability of the injured athlete to move, crutches could be used. If any movement seems too painful, a stretcher should be used in order to avoid further damage.

Achilles Tendon Rupture

Symptoms of Tingling around the back and side of his ankle, but the pain seemed to quickly dissipate. Immediate swelling was visible in the posterior ankle area and the gastrocnemius and soleus (calf) muscles. The athlete was unable to put weight on his left foot, and could only move taking “baby steps” with all of his body weight on the right leg.

High speed shifts in direction such as basketball players running full speed across a court and shifting directions on one foot present a danger of injury. If an injury occurs in these types of situations, a loud popping sound may be heard and possible sense of being kicked in the back of the heel resulting in the leg buckling when the athlete attempts to move. In this instanced, the likelihood of Achilles Tendon Rupture is high and common symptoms of this injury include:

• sudden pain at the back of the ankle
• aloud popping noise is often reported
• inability to contract the calf muscles or point the foot away from the body

One would assess this injury by asking the injured athlete to move the foot inward and outward and judge the degree of damage. One would have the athlete discontinue further activity in the sport because this type of injury requires medical attention. Issue the athlete crutches and begin icing. The athlete will need to be transported to a medical professional or hospital. Treatment may include either surgical repair of the tendon, or casting.

Medial Tibial Stress Syndrome (MTSS) or Shin Splints

Most athletes develop MTSS due to overtraining. The medial tibial stress syndrome (MTSS), is also known as “shin splints” and the treatment and rehabilitation for this injury includes:

• Ice massage and Achilles tendon stretching 3 to 4 times a day. Nonsteroidal anti-inflammatories such as aspirin are recommended to relieve inflammation and pain.
• Gentle stretching of the leg muscles that includes the calf, heel cord, and hamstring is essential before and after exercising to treat MTSS.
• Orthotics may be used in instances where the foot has other issues such as arch problems.
• Gentle flexibility and strengthening exercises for the muscles involved should also be added to the workout.

The primary treatment for MTSS is rest. Continuing to take part in the sport or activity that caused the injury will not allow it to heal. After the pain has subsided, low impact and stress training exercises can begin. For instance, swimming would be an alternative to running. After progressing through low impact exercises the athlete can begin his or her sport but at a less intense pace. Lower intensity workouts should last for three to six weeks in order to avoid relapses. Recurring pain is the signal that the intensity of exercise is too high or that not enough rest has been allocated for the injury.

Ankle Rehabilitation Exercises

Five exercises used in the rehabilitation of the ankle that progress from simple to advanced include the alphabets, windshield wiper, seated calf raises, single leg stand, and eversion and inversion isometrics.

Exercise 1 The Alphabets- Have the injured person sit with the foot flat on the floor and facing straight. Have them draw the entire alphabet one letter at a time by moving the injured ankle and using the great toe as the “pen”. Do two sets of 10 to 15two to three times a day.

Exercise 2 Windshield Wiper- have the injured person sit with the edge of the heel on the floor. Have them rotate the foot of the injured ankle to mimic a windshield wiper blade: Perform two sets of 10 to 15 two to three times a day.

Exercise 3 Seated Calf Raise- Have the injured person sit with the injured foot flat on the floor. Have them lift the heel of the injured ankle as far as possible while keeping the toes on the floor and then return the heel to the floor. Do two sets of 10 to 15 repetitions, two to three times a day.

Exercise 4 Single Leg Stand- This is a partial weight-bearing exercise in which the injured person will stand while placing one hand on a table. Have them shift some of their weight to the injured foot for 15 seconds. Increase the time spent of the weight bearing on the injured foot by 15 seconds until 45 seconds is achieved. Then gradually increase the amount of weight supported by the injured foot until full body weight is used. Perform two sets of 10 to 15 repetitions, two to three times a day.

Exercise 5 Eversion And Inversion Isometrics- (Eversion) Have the injured person stand and place the outside of the injured foot against an object such as a table leg. Then have them push outward with the foot for 2 to 3 seconds. Perform two sets of 10 to 15 repetitions, two to three times a day.

(Inversion) Have the injured person stand with the inside of the foot against an object such as a table leg. Then have the person push inward for 2 to 3 seconds. Perform two sets of 10 to 15 repetitions, two to three times a day.

Perhaps the most effective way to reduce injuries of the lower leg and ankle is to monitor training to make sure the athlete does not over train. Identifying and treating injuries immediately will also have the positive impact of reducing loss of training and for certain worsening injuries.