Monday Musings: Foot/Ankle Injuries and Physical Therapy
Written on July 30, 2012 at 6:55 am, by Eric Cressey
It’s been white some time since I typed up a “Random Thoughts” post, so I thought I’d bring it back for today. I’ve usually got a few dozen things rattling around my brain at all times, so if I can dump one of them here, hopefully I’ll replace it with something noteworthy. Today’s question is somewhat “Andy Rooney-esque.”
Have you ever noticed that doctors are less likely to prescribe physical therapy for foot and ankle issues than any other problem? I might be skewed by my perspective in this part of the country, but I doubt it, as Boston has a great medical reputation. “Just walk on it” is the advice I often hear folks say they’ve gotten. Would you do that for a hip or knee replacement? As I discuss in my e-book, The Truth About Unstable Surface Training, following inversion ankle sprains, a lot of folks wind up with functional ankle instability due to a proprioceptive deficit of the peroneals; this muscle group just doesn’t turn on quickly enough to prevent “re-sprains” from occurring.
Additionally, some individuals present with some considerable “anterior jamming” that can’t be addressed by classic ankle mobilizations, and these individuals can benefit greatly from good manual therapy and joint manipulation by a qualified professional. Lastly, breaking a big toe can be a big deal; it’s dangerous to assume that it’ll just magically heal perfectly if someone walks on it for months – and it can be problematic to brace a foot in an immobile position for an extended period of time and wind up with stiffness or compensation patterns.
Along those lines, though, maybe they just aren’t prescribing physical therapy for these issues because there aren’t specialized physical therapists. I know of a lot of wrist/hand physical therapists, but no true foot/ankle specialists on the PT side of things. Sure, there are PTs who do foot/ankle as part of their normal practice (and some who do it very well), but you’d think that the weight-bearing joints that connect us to the ground would receive even more specific attention than wrist/hand issues. Perhaps this lack of specialization has emerged because the foot and ankle are so complex and misunderstood; it could be a good “niche” for some of you up-and-coming physical therapists to pursue.
Again, these are just some Monday musings off the top of my head. To the general fitness folks out there, push hard to get physical therapy after a foot/ankle issue. To the rehabilitation specialists and strength and conditioning professions out there, I’d love to hear your thoughts in the comments section.
Sign-up Today for our FREE Newsletter and receive a four-part video series on how to deadlift!
|
July 30th, 2012 at 7:37 am
This is such an important post Eric. Because so many of my clients followed their MD’s advice and did NOTHING about their ankle injury- they often come to me with months, if not years, of impaired gait, pain, dysfunction.
Double neative coming here-
I have never had a client who did not have long lasting issues from untreated ankle issues. Same with people who have whiplash injuries- while the pain may go away in the short term- long term damage has been done. A careful medical history helps- but often clients even “forget” about the initial injury and don’t include it in their histories. Most likely because their MD said it was no big deal. Also- you have to wonder WHY someone has repeated ankle injuries… they can’t just be that clumsy!
July 30th, 2012 at 7:38 am
Crazy timing! Had this exact situation happen to a client yesterday. I rolled the ankle also about 18 months ago and still face anterior jamming that no mobilization can seem to address. Your random thoughts, sir, might just be the advise we needed. Cheers!
July 30th, 2012 at 8:45 am
Great comments, Kathy; thanks!
July 30th, 2012 at 9:18 am
Hey Eric;
I agree with the points you made in todays post. Quite honestly, if you do not have a solid foundation, how can the rest of you function properly without putting everything else out of whack? I am fortunate enough to work closely with a therapist who does some great work with athletes and their ankle injuries, but he is the first one I have encountered. We certainly need more professionals who believe treating ankle injuries properly in the early stages of injury is important.
July 30th, 2012 at 11:35 am
When I was in school for athletic training and even in physical therapy school we were always taught the RICE principle (rest, ice, compression, elevation) and until recently that was how I approached an acute ankle sprain. The clinic where I work has all the Gary Grey video digest series DVDs. His video on ankle sprains has really changed my approach to tx. His version of the RICE principle is Restorative care, Ice, Compression, Early exercise. Since using the ideas that he presents in his lecture, it is not uncommon to have an athlete leave the facility with normal gait, full DF ROM, and decreased pain after their first visit. Now ofcourse they aren’t healed and we have to educate the Pt about tissue healing, etc. I found the PDF outline of the video if you would like to check it out.
http://www.grayinstitute.com/media/2.10_Ankle_Sprains_Manual.pdf
July 30th, 2012 at 1:01 pm
Good posting. I am a PT, and find that most ankle sprains are not prescribed therapy, unless they seek out an orthopedic specialist. GP’s almost never send a patient to PT for “just a sprain”. Many times only a couple of visits is enough to re-establish good arthrokinematics, establish a home program, and assess for compliance. Keep it the good work!
July 30th, 2012 at 3:29 pm
You are so right that something needs to be done to any injury no matter how small it seems. If it still hurts after treatment sounds like it is time to get another opinion.
http://www.pulled-muscle.com/sprained-ankle
July 30th, 2012 at 3:37 pm
Great comment, Tyler; thanks!
July 30th, 2012 at 3:39 pm
Aren,
Great post – and definitely some effective approaches, in my experience. Early exercise is HUGE, even if it is just unloaded motion.
July 30th, 2012 at 4:31 pm
Hands down the smartest ankle/foot and gait experts on the Internet. Pages and pages of great info. http://thegaitguys.tumblr.com/
July 30th, 2012 at 4:47 pm
Hey Eric,
This has been my experience as well. Although I typically see this much more often with chronic issues as opposed to an acute sprain.
It’s typical for me to see people who have had on and off foot issues for years and, like you mentioned, never had had any real therapy other than to do their “A, B, Cs.”
The most common thing I see is a severe dorsiflexion deficit.
I agree the biggest issue with treating the ankle/foot is it’s just damn hard to figure out all the things going on in there.
With that said, I’ve had clients who have been to multiple podiatrists and have never even heard the term “over pronate” or a “supinated foot.” Which I don’t think should be complicated for a podiatrist not overly concerned with prescribing orthotics.
I’m pretty sure you’ve recommended it here before, but for anyone interested, Sahrmann’s second edition dealing with the foot has probably been the most helpful resource for me. It was definitely the hardest section to comprehend though.
July 30th, 2012 at 7:03 pm
Eric, it amazes me some days how many doctors disregard the need for proper rehabilitation of injury.
I did some single leg work tonight and could really tell which ankle I sprained in high school. That is after having gone through formal PT and doing my own work to try to improve. Balance still needs some work..
Not only is rehab important, but we must continue to also work on full-kinetic chain rehab and not focusing on the individual joint completely…
July 30th, 2012 at 7:04 pm
I would say most don’t prescribe PT unless the patient is still symptomatic at their first or second follow up, often weeks after the initial injury. I think often if PT was prescribed initially there would have been less visits overall. Having had a severe combination inversion/eversion sprain myself, I have a strong interest in this topic and was considering making it a niche. Still reference the truth about unstable surface training. Good post Eric!
July 31st, 2012 at 4:26 am
Foot and ankle rehab needs to be MUCH more than just band exercises and stretching for the ankle. Our team incorporates a full, bilateral, lower extremity program. Great post!
July 31st, 2012 at 7:03 am
I had an elbow injury (radial head fracture) a few months back and the advice I heard was the equivalent of the “just walk on it” that you mentioned for an ankle. I wonder if it has the same implications for other joints?
Mine’s not healing up so well so I wouldn’t be surprised to find that to be the case.
Thanks for sharing this.
July 31st, 2012 at 8:43 pm
ERIC, awesome post and so true. I am a physical therapist and can truly say that the ankle is incredibly overlooked when it comes to therpy and return to prior level of function…ESPECIALLY in athletes!!! The demands on an athletes ankles is often incredible and as you and others here have mentioned, is the foundation for the entire body. Here is some food for though….traditional RICE (rest, ice, compression, elevation) of an ankle sprain.
Rest: We take an injury that results in pain, swelling, and decreased proprioception and we rest it…result= increased swelling due to decreased circulation and removal of fluid, a further decrease in proprioceptive input to the muscles and joints of the ankle, longer return to sport time and prior level of functioning
ICE: by the time we see the patient/ athlete they are usually no longer in the acute phase and the swelling is present at the injury…result= we add ice to the injury and further decrease circulation and removal fluid which can actual further enhance swelling, we stiffen the joint and surrounding tissues and this in turn further decreases ROM at the ankle (may give some pain relief with ice…only benefit I can see)
Compression: This one I can agree with as it does seem to have a positive benefit on reducing swelling.
Elevation: sure, sounds great but does it really decrease swelling that much? We have a high level athlete for example and we expect them to magically get better if we prop their leg up?
Instead lets do this…compression and PROM/ AAROM with special flex band ankle traction set-up to promote restoration of ankle ROM. (decreased ROM is often the cause of pain in this type of injury). AROM promotes increased circulation to the area and thus the removal of fluid, new blood = nutrients to the injury and increased rate of healing. Follow this with progressive proprioceptive training to restore ankle function and proprioceptive input and you have a DRAMATIC decrease in return to sport time and also a much lower risk of re-injury.
Using this approach, I saw a sever ankle sprain limp into the clinic on a Friday…have 1 45 minute therapy session….leave that session jogging with no pain…and she ran a marathon 2 days later and almost made her goal time.
Pretty good results.
Eric, what are your thoughts on this model?
August 1st, 2012 at 4:48 am
Good point Eric, I consistently find that GP’s (as they’re called in the UK) are pretty crap with almost any musculoskeletal injury, but especially with ankles; “just rest it” seems to be about the extent of their care and/or knowledge!
I went through such nonsense when i badly sprained my ankle at age 18 (‘m 35 now) and it took about 18months to get better, as I didn’t have any good therapy on it.
Indeed that ankle didn’t really get better until last year when I started barefoot running. And now it feels as strong as the other, and is happy being rolled and dragged all over the place 🙂
A point I also learned in my Kinesiology studies (the Applied Kinesiology kind, not exercise type) was to explore what sort of metaphor people may be playing out/living out by continually going over on their ankle. Another way of asking this is, ‘what could be the connection between your ankle weakness/imbalance and what’s going on in your life right now, or when you went over on it?’
It’s not always relevant, but only takes a moment to ask and is sometime revelatory and is the ‘thing’ they need to deal with to allow them to heal.
Great post, keep em coming,
George
August 1st, 2012 at 6:56 am
Anterior impingement is quite common post inversion injury. It’s caused by 3 things in combination or stand alone. Pes plan us or low arches will cause impingement of the lateral joint mortice, scarring of the ATFL ligament post sprain and anterior impingement of the Talar dome on the tibial plafond will also cause dorsi flexion issues. All of these are treatable with physiotherapy early on at around day 4-6. Again early mobilization!
Tate From Melbourne.
August 1st, 2012 at 7:04 am
Very well said, Mike. Small hinges can swing big doors over time, so letting these things get worse and worse can be a serious problem. Early interventions are key.
August 1st, 2012 at 7:05 am
Jared,
I would strongly encourage you to get that checked out by a good physical therapist. You don’t want to wind up with a stiff elbow long-term. Drop me an email at ec [at] ericcressey.com with your location and I’ll see if I can find you someone near you.
August 1st, 2012 at 7:08 am
Jonathan,
I think it’s a tremendous model and one that we employ. As my buddy Neil Rampe has said, there is a difference between neurology and physiology. We see bruising and get freaked out, as bruising can’t possibly mean “move it.” You don’t stop moving a quad contusion, though, right?
I will say that elevation does seem to hold water (no pun intended) with certain issues. Post-op Tommy John cases do much better acutely when they keep the arm elevated; those guys can get to work much earlier on ROM because the swelling is lower when the elbow is above the shoulder for most of the time.
Thanks for your contribution!
August 1st, 2012 at 7:09 am
Amen, Tony!
August 1st, 2012 at 7:09 am
Great contribution; thanks, Tate!
August 1st, 2012 at 7:09 am
Great post, George! Thanks!
August 1st, 2012 at 11:48 am
You make some very good points Eric. As a Podiatrist I see acute ankle injuries and chronic ankle instability several times a day.
The current evidence-based treatment guidelines for acute ankle sprain do support early mobilization as well as proprioceptive training and hip strengthening (even in Grade 1 ankle sprains). Do all Drs send these acute patients to physical therapy? Sadly no.
Part of the reasoning these patients are not getting the rehab they need may be 1. Lack of knowledge by Drs of benefits 2. Inability to find physical therapist who can adequately treat these patients. 3. Restrictions of patients insurance do not cover physical therapy 4. You give patient at-home tehab and compliancy is very low or ….the big one 4. Patient doesn’t follow up or refused physical therapy despite referral.
I know many very good physical therapists who treat nothing but foot & ankle injuries but this is a minority in the physical therapy community. Often this lack must be picked up by fitness professionals and strength coaches.
I do agree there needs to be more attention and functional rehab for foot and ankle injuries. But there are a myriad of reasons for why this may not be done sufficiently.
Any article on the need for more attention on the foot and ankle I like. So great thoughts!
Dr Emily
August 1st, 2012 at 6:10 pm
Eric, I agree with your comment about elevation being helpfull in specific cases…i should have been a little more specific with my comment… I myself shattered my radius / ulna in 7 places and elevation was crucial to prevent swelling and compartment syndrome. I totallg agree with your exsmple as well. I guess when I question the effectiveness of elevation is when it is used improperly or exclusively by itself. If were going to call it elevation, we shouldn’t just sit with the leg horizontal on the couch…. Get it up there and let the ankle drain!!! Hahaha
Great posts eric and thanks for the feedback! You are a true professional!
August 1st, 2012 at 7:41 pm
Hi Dr. Splichal,
Thanks for your great contribution; I wish we had more folks fighting the good fight like you are! I appreciate your input.
August 2nd, 2012 at 3:56 pm
This is a little off topic but I think it is important that we change this misconception. Physical therapy is not a treatment. Therefor, physical therapy is not prescribed like Motrin. An MD refers a patient to a physical therapist who uses their professional judgment to examine diagnosis and treat a patient. An MD would not prescribe neurology, they would refer to a neurologist. This may seem like a small point but I think it goes to the perception of PT.
August 2nd, 2012 at 6:34 pm
I would like to say that Dr Emily is right about a few things. From her reasons about patient compliance and doctors knowledge of therapy to help speed up the healing process. But the one thing that was mentioned was a study that stated early mobilization is not recommended but As common sense As this seems there is a study that contradicts even this. (pubmed ) but the majority of PTs and ATCs that i know and have worked with and for me have all had excellent knowledge of foot and ankle injuries. So much so I went on a education spree to enlighten the public with a website about foot and ankle injuries. http://www.footandankleclinicinny.com . Eric keep up the good work. I love reading your blog. I’m a big fan.
August 3rd, 2012 at 5:27 am
Thanks, Joe! I appreciate the great insights and kind words.
August 10th, 2012 at 7:55 am
Eric,
These are all great comments. I had a fifth metatarsal fracture caused by an ankle inversion just over 2 month ago. My orthopedic specialist treated me with a boot and crutches for about 7 weeks, and then released me from treatment with no physical therapy. I was rather shocked by this. As soon as I started walking without the boot, the ankle issues from the initial injury and subsequent immobilization became unbearable. I have been seeing my chiropractor who is certified in chiropractic neurology for therapy and function rehabilitation. I have made significant progress in just 2 weeks, and I believe that the joint mobilization has been key to jumpstarting this process.
August 10th, 2012 at 2:35 pm
Danette,
Thanks for your post. Sadly, this is all too common. Hopefully the medical community will wake up on this front sooner than later!
August 15th, 2012 at 5:03 pm
Have none of ye heard of podiatrists?
June 24th, 2013 at 11:04 pm
I think the inflammatory process is very poorly understood in most acute care settings, but particularly foot and ankle pathology. Even something as simple as knowing when to apply cold vs heat to match the stage of inflammation is butchered time and time again.