Ankle and Foot

Ankle sprains are common lower limb injuries that can occur during sports or everyday activities. They usually occur when a person lands onto an uneven surface while jumping or running, but often just a simple mis-step during a routine daily activity can cause ankle sprain.

A sprain is an injury to a ligament. A strain is an injury to a muscle.

Ligaments are structures that limit excessive movement in a joint (as opposed to muscles which move a joint). When an ankle sprain happens, the ligament is stretched too far, and is either partially or completely torn.

There are two broad categories of ankle sprain:

• INVERSION ANKLE SPRAINS

The most common ankle sprain (90%) occurs when the foot is forced inwards (inverted) causing sprain to the outer, or lateral ligaments. The three lateral ligaments potentially effected include the anterior and posterior talofibular and calcanofibular ligaments. Pain and swelling will be on the outside of the ankle.

• EVERSION ANKLE SPRAINS

Less commonly (10%) the ankle is forced outwards (everted) causing sprain to the inner, or medial ligaments. The deltoid ligament is the ligament effected and pain and swelling will be on the inner side of the ankle.

Typically the degree of pain and swelling will correlate with the degree of damage. Bruising may appear to downwards from the source of sprain after a few days due to the effect of gravity.

There are 3 grades of ankle sprain.

Grade I (First Degree) injury is the mildest. The ligaments have been over-stretched but not actually torn (although there may be microscopic damage). There is no obvious instability in the joint.

Grade II (Second Degree) injury is more severe and involves partial tearing of the ligaments. Although painful and weak, the ankle is still stable.

Grade III (Third Degree) sprain is the most severe. This involves significant or complete tearing of the ligaments, resulting in instability of the ankle joint.

Chronic or recurrent ankle sprains often occur when people have a decreased capacity to judge where their foot is in relation to their leg (called a proprioceptive deficit). These people may require additional stability exercises, such as ‘wobble board’ balancing, to strengthen the muscles that stabilise the ankle. Ankle supports and chiropractic adjustments to the ankle, knee, hip and pelvis are also helpful in restoring lower limb function.

Severe sprains should be X-rayed to check for ankle fracture.

More severe sprains can tear the ligaments above the ankle (syndesmosis ligament). This is known as a high ankle sprain.

CHIROPRACTIC AND SELF-CARE

ACUTE PHASE

• RICE = Rest, Ice, Compression and Elevation
• Avoid unnecessary weight bearing
• Depending on severity light soft tissue techniques and non-weight bearing exercises can begin

REHAB PHASE

• Gradually improve activity
• Ice after activity if required
• Stretching and strengthening exercise
• Deep soft tissue techniques
• Spinal/pelvic/lower limb adjustments to improve balance and muscle tone

Morton’s Neuroma is a condition where the tarsal nerve becomes swollen between the toes, producing pain and occasionally numbness either side of the toes. This occurs most often between the 2/3 and 3/4 toes.

Usually the pain is mild and intermittent, but will often remain for many months or longer.

Symptoms often improve with changing footwear, orthotics and deep soft tissue techniques.

There are 3 peroneal muscles that are located in side (peroneus longus and peroneus brevis) and front (peroneus tertius) of the lower leg.

With exercise it is normal that muscles will swell as increased blood flows into the active muscle. The peroneal muscles are unique in that they have fibrous sheaths that form a lateral (side) and anterior (front) compartments. These compartments limit the space in which this swelling can occur.

• ACUTE COMPARTMENT SYNDROME

This usually follows a traumatic injury such as a lower leg fracture or tear of a peroneal muscle. The increased pressure caused by bleeding and inflammation compresses the muscle, blood vessels and nerves. This results in continuous worsening pain in the lower leg. Nerve compression may result in foot drop. This is a condition that requires fascial release surgery to reduce the compartment pressure and avoid permanent injury.

• CHRONIC COMPARTMENT SYNDROME

Unlike the acute form, chronic compartment syndrome only occurs following exercise and pain resolves with rest. Runners mostly develop anterior compartment syndrome, while soccer players and cyclist normally develop deep posterior syndrome.

CHIROPRACTIC AND SELF-CARE

Chronic cases can usually be managed conservatively with the following:

• • • Alter training schedules/intensity
    • Ice after exercise
    • Orthotics if over-pronation of the foot is a problem
    • Spinal and lower limb adjustments to improve muscle balance
    • Some chronic cases may still require surgery

The plantar fascia is the connective tissue that originates at the base of the heel (Calcaneus) and runs forward to insert to mid-foot and toes.

Plantar fasciitis occurs when the fascia becomes inflamed. Pain is located in the heel or arch of the foot and can be severe when weight bearing. This often feels like the heel is bruised.Typically the pain is worse when you first walk, such as after getting out of bed or after sitting for a period of time. Once you are up and about the symptoms usually improve.

Pain is often worse after standing on hard surfaces, walking in shoes without arch support (such as thongs) or spending long periods on your feet.

The condition is also known as ‘Policeman’s Heel’, which relates to a bygone time when a police officer would ‘Walk the beat’.

THE CHIROPRACTIC APPROACH

Getting rest to reduce pressure on the plantar fascia is important in the early stages. Avoiding running, jumping and other aggravating activities is important to allow the inflammation to settle. Ice to the heel for 20 minutes x3/day can also help.

A chiropractor will be interested in the balance throughout your lower limb and may perform adjustments to joints in the spine, pelvis, hips and knees as well as the feet. Deep trigger point therapy to release muscle tension in the feet may also be used.

Stretching (especially of the calves and under surface of foot) will be an important part of your rehabilitation and lessen the chance of recurrence.

See Exercises/Ankle

You may be advised to use shoes with shock-absorbing soles or fitted with a rubber heel pad. Often custom fitted orthotics are needed to address pronation or supination of the feet and benefit long term support.

The plantar plate is a ligament that is originates from the under-surface of the metatarsals (long bones of foot) and attaches to the bases of the toes. Persistent pain on the undersurface of the foot and base of toes may be a result of plantar plate tear.

This is most commonly affects middle-aged women, is often related to over-pronation and tends to affect the 2nd toe more often. Often a tear will result in the toes may splaying, clawing or deviating up or to one side. The sensation is often described as ‘Walking on the bones of your feet.’

Initial conservative treatment involves taping, off-load padding, altered footwear and activity modification. Orthotics are often required to reduce over-pronation. More serious tears require surgical correction.

Chiropractic can have an important role, however, referral to a podiatrist is almost always also recommended with this condition.

Pronation is the normal action of the foot rolling inwards during the heel contact, mid stance and toe-off portions of gait. This allows for normal transition of weight from the out side to the inside of the foot allowing for efficient movement and minimal stress on the foot and lower limb.

Video normal pronation: http://www.youtube.com/watch?v=WSw-w3LtLUo

In the case of over-pronation the roll of the foot increases beyond the normal 15 degrees, leading to excessive strain on supporting structures. Over time this lead to foot pain, knee pain, hip and low back pain. Various syndromes have been linked to over pronation such as plantar fasciitis, patella-femoral syndrome, shin splints and hip bursitis.

Video over pronation: http://www.youtube.com/watch?v=pODcT55_7zA

As over pronator may have normal arches when non-weight bearing and only flatten out during stance or gait. True flat feet (pes planas) will show flattened arch in both the non-weight bearing and weight-bearing positions.

Certain strengthening exercises, along with soft–tissue and adjusting techniques to the feet, lower limb and spine are often helpful.

Often and over-pronator will require fitted orthotics. These are best if they are customized to the individual foot.

We do our own molds and testing for over-pronation in house. The molds are then sent to Orthotic Assist where the results are interpreted by podiatrist, Paul Dowie, to determine the most suitable type of orthotic.

This way both the foot and spinal parameters can be evaluated.

Shin splints is an overuse injury that creates pain on the outer edge of the shin bone (tibia). This is thought to be due to inflammation of the outer (lateral) peroneal muscles where they attach to the tibia. These muscles lift the foot during running and walking.

Shin Splints can be brought on by:

• Sudden increased distance or intensity of training workouts
• Hill running
• Inappropriate footwear
• Poor biomechanics of the lower limb – such as over-pronation

Pain is located anywhere over the outer front of the shin. As with many overuse injuries, pain is worse at the start of exercise, better once you have been active a little while, then worse again with continued activity. Often the degree of pain forces the activity to be halted.

Diagnosis is usually made based on history and diagnosis. A stress fracture or compartment syndrome also needs to be ruled out.

Management of Shin Splints involves the following:

• Modifying activity – this may involve replacing running with cycling or swimming
• Icing shins after activity
• Stretching and strengthening exercises
• Using orthotics if required
• Soft tissue techniques to reduce painful trigger points in muscles
• Graduated return to activity – after initial period of no running begin with half intensity work outs on soft terrain

Sever’s disease (also called calcaneal apophysitis) is a common cause of heel pain seen most often in boys. It may be related to the increased rate of bone growth relative to muscle growth that occurs in the period just prior to puberty. This results in a relative stretching of the calf with the Achilles tendon pulling on the back of the heel (calcaneus).

Young children have bones that have not fully ossified (turned fully to bone), leaving cartilaginous weak spots that are prone to inflammation and injury.

Symptoms of Sever’s includes:

• Pain at the heel or base of the Achilles tendon
• Tenderness and swelling of the heel
• Pain that worsens with exercise – especially running and jumping
• Evidence of tight calves – stiffness that is worse in the morning, or tendency to walk on toes

A diagnosis is normally made based on history and physical examination. X-rays may be required to rule out a stress fracture, but no X-ray findings will be present with Sever’s and the source of the problem is with the cartilage rather than the bone.

Treatment is mostly to do with management, as Sever’s is a self-limiting disease that a child will grow out of. Management may include:

• Reducing sporting activity
• Improving footwear
• Wearing heel lifts to reduce strain on Achilles attachments – this should be a temporary change only
• Gentle stretching of the calf – as long as this does not aggravate pain
• Soft tissue and joint adjustments to the lower spine and lower limb to improve posture and body balance.