Flatfoot (in medicine Pes planus) is a condition in which the medial longitudinal arch of the foot is diminished or absent. Around 30% of adults have pes planus, however the majority does not have any symptoms. Flatfoot may be congenital or acquired.

Congenital:

• Rigid: due to structural bony abnormalities (tarsal coalition, vertical talus)leading to poor shock absorption.
• Flexibile (often hereditary and common in children), it leads to stress of muscle, ligaments. Speed is lost due to no rigid lever for propulsion

Acquired leading to a diverse range of deformity and symptoms.

Causes

1. Adults
   • acquired: dysfunction of the tibialis posterior tendon (most common), tear of the spring ligament, rupture of the tibialis anterior (both rare).
   • physiological: lack of normal arch development (possibly due to ligamentous laxity).
   • degenerative changes:osteoarthritis, inflammatory arthropathy, fractures.
   • neuropathic: diabetes, polio, etc.
2. Children

• physiological: infants often have minimal arch, while many toddlers have flattening of the long arch, with forefoot pronation and heel valgus on weight-bearing. However by the age of 10 most of the children spontaneously develop a strong normal arch.
• abnormal development of the foot may be due to: neurological problems (such as polio, cerebral palsy) or bony (fusion of two or more tarsals “tarsal coalition”), ligamentous abnormalities.

There are many contributing factors such us:

• Footwear: shoes which limit toe movement; high heels.
• A tight Achilles tendon or calf muscles (heel cord contracture).
• Obesity
• Ligamentous laxity (Marfan’s syndrome, pregnancy, etc).
• Repetitive microtrauma (higher mileage in running)
• Bony abnormalities, eg rotational deformities, tibial abnormalities, coalition (fusion) of tarsal bones, equinus deformity.
• Other factors causing foot pronation, eg hip abductor weakness and genu valgum

Diagnosis

• Observe the flatfoot: With the patient standing, look at his or her feet from above and behind. Loss of the arch is visible, with the medial side of the foot close to the ground. Look at the feet from behind – with Pes Planus the heel bone is everted or in valgus (outwards). The forefoot is abducted relative to the hindfoot. More than 2 toes can be seen outside the heel.

• Is the flatfoot flexible?: Ask the patient to stand on tiptoe. With flexible flatfoot, this will reveal the arch, and the heel will move inwards (varus position).
• Look for signs of tibialis posterior dysfunction^[(if history is suggestive of this).
• Ask the patient: to do 10 unsupported heel raises (stand on one foot on tiptoe, unsupported). Patients with tibialis posterior dysfunction will be unable to do this

Flatfoot (Pes planus) may present as a symptomatic (causing pain in the foot) or asymptomatic (causing no pain) findings on examination. Therefore may cause or be associated with other bio-mechanical causes of pain such as:low back pain, genus valgum (knock knees), medial or anterior knee pain, shin splints, achilles tendinopathy, increased risk of ankle sprain, plantar fasciitis. This is due to poor shock absorption by ligaments and muscle of the foot, thereby all the impacts are transmitted to the joints above-ankle, knees, hips, low back,neck, etc. Fibrous contracture of the peronei muscles may be noted.

Do not forget to look at the patient has a whole as flatfeet may cause headaches!!! Remember to consider other areas (see picture below) and…

…to look at the shoes.

Runners and flat foot. 

It is generally accepted by professionals that a person with flat feet tends to overpronate in his or her running form. However, persons with flat feet may also have a neutral or underpronating gait. Pronation is a natural form of shock absorption during running and walking, when the ankle rolls inward and the weight distribution in the foot shifts medially. Overpronation is excessive pronation; it disrupts the alignment of the leg and may result in injuries due to over-stressing of the knee and leg. With normal, or neutral, running shoes, a person who overpronates in his or her running form may be more susceptible to shin splints, back problems, and tendonitis in the knee. Running in shoes with extra medial support or using special shoe inserts, orthoses, may help correct one’s running form by reducing pronation and may reduce risk of injury.

Very good link explaining normal pronation,under pronation and over pronation in running.

 Treatment. 

Treatment can be either non-surgical or surgical.

• Non-surgical treatment:
  • Othotics (orthotic devices such as arch supports and custom-made orthoses).
  • Muscle rehabilitation
  • Manipulation
  • Dry needling
  • Soft tissue
  • Stretching exercise
  • Taping

• Surgical
  • Arthrodesis, or welding (fusing) one or more of the bones in the foot/ankle together
  • Osteotomy, or cutting and reshaping a bone to correct alignment
  • Excision, or removing a bone or bone spur
  • Synovectomy, or cleaning the sheath covering a tendon
  • Tendon transfer, or using a piece of one tendon to lengthen or replace another

Complications 

Hallux Valgus (because more weight is borne by the medial metatarsals when the foot hyperpronates). Plantar fascitis. Metatarsalgia. Tibialis posterior dysfunction (because hyperpronation stretches this tendon). Knee pain. Low back pain/SIJ pain as flatfoot may reduce the shock-absorbing features of the foot. 

Hints

1. Flatfoot may be due to other causes such as Charcot and posterior tibialis dysfunction, see a physiotherapist, osteopath, chiropractor for further information or advices.
2. Wear shoes with low heels and wide toes.
3. Lose weight if appropriate.
4. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort .
5. Arch supports used without correcting heel cord contracture can make symptoms worse.

Heel cord stretching is an important part of treatment, as a tight Achilles tendon tends to pronate the foot.

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Piriformis syndrome is a neuromuscular disorder that is caused when the piriformis muscle compresses the sciatic nerve. The piriformis orginates from the sacrum and attaches to the femur. The sciatic nerve is the largest nerve in the body (L4-S3) and usually emerges below the piriformis muscle, however variations have been shown in many studies (see Figure 1).

Figure 1, anatomical variations in the relationship of the sciatic nerve to the piriformis muscle.–

The patient may complain of a deep aching pain in the buttock or a radiating sharp pain that extends along the middle of the rear thigh. Sometime numbness and tingling can continue to the calf and toes. These symptoms can be accompanied by low back pain and worsen after prolonged sitting. However a thorough exam by a physician should be conducted to exclude a more serious origin such as an herniated disc pressing upon the sciatic nerve, which could mimic those symptoms.

Causes
Several factors can predispose patients to developing this conditions. Some of these factors are:
• Joint stiffness (hip, lower back, SIJ)
• Worn shoes
• Muscle tightness(especially piriformis and adductor muscle) and muscle weakness.
• Leg length discrepancy
• Feet problems
• Inappropriate or excessive training
• Poor biomechanics
• Inadequate warm up
• Poor pelvic or core stability
• Poor posture
Piriformis syndrome is more common in activities such as running, sprinting, jumping, squatting or lunging, that require repeated use of this muscle. Possible because as the primary muscles of the hip become fatigued, smaller muscles such as the piriformis must work harder to maintain form. However there are many other external factors that may lead to an overuse injury such as advancing mileage too quickly, excessive mileage, wearing work shoes (or with poor support), terrain, poor running technique, etc.

Diagnosis.
There is no definitive test for the piriformis syndrome. Often there is a history of repetitive and vigorous activity such as running for long-distance. Diagnosis of piriformis syndrome is made thanks to a combination of the patient’s report of symptoms, tests to reproduce symptoms (FAIR, SLR with internal/external hip rotation, Freiberg, Pace, etc) and finding of a tender point over the piriformis muscle, which may be felt as a sausage-shaped mass.Occasionally MRI may be required to assist diagnosis.
Treatment.
Many techniques could be used to release the piriformis and varies among osteopaths, physiotherapists and chiropractors. Treatment may comprise a combination of:
• Joint manipulation
• Dry needling
• Electrotherapy (e.g. ultrasound)
• Taping
• Soft tissue massage
• Stretching exercises
• Muscle energy techniques
• Education
• Biomechanical correction
• Ice
• Exercises to improve flexibility, core stability,strenght.
• Technique correction
• Plan to return to sport
• Shoe lift or foot orthoses
Prevention
Warm up properly before activity and increase intensity gradually.
Stretch the piriformis, hip muscles (the gluteal group, the lateral rotator group, the adductor group and the iliopsoas group), hamstrings, quadriceps in order to adequately reduce pain and increase range of motion.
Strenght the hip extensor, hip abductors and external rotators to reduce strain on the piriformis. As a matter of fact as the primary muscles of the hip become fatigued, the smaller accessory muscles, such as the piriformis, must work harder to maintain form. Trying to compensate for stronger muscles is how the piriformis becomes strained.

Figure 2 shows piriformis stretch and strengthening of the hip external rotators and abductors.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen help reduce the pain and inflammation. Return to running Weeks it takes to return to normal form:
• 2 weeks off=4 weeks to recover
• 3 weeks off=6 weeks to recover
• 4 weeks off=8 weeks to recover
Before start running again you should be able to walk 1 hour without pain. Aerobic conditioning can be maintained in the swimming pool or cycling.

Gradually add Hill runs.

Rehabilitation Schedules:

4 weeks schedule(2 weeks off running):

• 1st week 50% of preinjury distance 75% of preinjury pace
• 2nd week 75% of preinjury distance 75% of preinjury pace
• 3rd week 85% of preinjury distance 85% of preinjury pace
• 4th week 100% of preinjury distance 85% of preinjury pace

6 weeks schedule(3 weeks off running):

• 1st week 50% of preinjury distance 75% of preinjury pace
• 2nd week 60% of preinjury distance 75% of preinjury pace
• 3rd week 70% of preinjury distance 75% of preinjury pace
• 4th week 80% of preinjury distance 85% of preinjury pace
• 5th week 90% of preinjury distance 85% of preinjury pace
• 6th week 90% of preinjury distance 90% of preinjury pace

8 weeks schedule(4 weeks off running):

• 1st week 35% of preinjury distance 50% of preinjury pace
• 2nd week 40% of preinjury distance 50% of preinjury pace
• 3rd week 50% of preinjury distance 60% of preinjury pace
• 4th week 60% of preinjury distance 75% of preinjury pace
• 5th week 70% of preinjury distance 75% of preinjury pace
• 6th week 80% of preinjury distance 85% of preinjury pace
• 7th week 90% of preinjury distance 85% of preinjury pace
• 8th week 90% of preinjury distance 90% of preinjury pace

Hints

Acupuncture works very well on the piriformis. You may need to see a doctor to rule out a herniated disc or (If you feel pain on both sides) to rule out stenosis of the central canal (narrowing of the hole the spinal cord goes through). The sacroiliac joint must be treated simultaneously with the piriformis if the joint is a factor. See a chiropractor or osteopath to be evaluated for lumbar and sacroiliac joint dysfunction.

Don’t drive and do not sit for long periods. If you are being advised to have surgery for “piriformis syndrome,” be sure to try trigger point therapy and sacroiliac joint release first

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

Achilles tendinopathy (or Achilles tendinitis) is a repetitive strain (overuse) injury , which leads to pain on the Achilles tendon about 2-6 cm above the insertion on the calcaneus (bone of the ankle). Despite many practitioners still use the term “tendinitis”(implying that the fundamental problem is inflammatory), many studies have shown that histologically there is non-inflammatory intratendinous collagen degeneration. It is very common in running and jumping sports, but it is also seen in elderly and sedentary people. The Achilles tendon is the thickest and strongest tendon in the body. It serves to attach three muscles (gastrocnemius, soleus and plantaris) to the calcaneus bone.

Causes

• Inadequate warm-up or stretching.
• Overuse (jumping, running, etc).
• Inappropriate shoes or hard surfaces (reduced shock absorption).
• Gastrocnemius-soleus dysfunction.
• Body weight.
• Direct trauma.
• Flatfoot/overpronation/underpronation/pes cavus.
• Leg Length Discrepancy.
• Poor technique.
• Poor flexibility.
• Rapid changes in: 

1. shoes
2. running surface (from grass to road)
3. distance or speed
4. surface inclination (running uphill)

Diagnosis

• History. Onset, duration and aggravating factors should be documented. Achilles tendinopathy usually presents with pain 2-6 cm above its insertion, often worse at the beginning of a training session and after exercise. However patient may complain pain during exercise/stretching/daily activities (walking, stair climbing) and morning stiffness.
• Physical examination. Patient should be examined standing and prone. Patients with Achilles tendinopathy may or may not have visible swelling (however in chronic conditions a visible “soft lump” enlargement may be seen). In addition patients may have:

1. Increased pain along medial/lateral margins of tendon.
2. Pain with passive dorsiflexion or stretching.
3. Increased pain with side squeeze test.

•  “Painful arc sign” helps to distinguish between tendon and paratenon lesions.The “painful arc” sign helps to distinguish between tendon and paratenon lesions. In paratendinopathy, the area of maximum thickening and tenderness remains fixed in relation to the malleoli from full dorsiflexion to plantar flexion, whereas lesions within the tendon move with ankle motion.
• Special Test. Thompson test to exclude Achilles tendon rupture.

• Ultrasound scan may be used to confirm the diagnosis.

Treatment Acute
1. Rest and ice
2. Ultrasound to tendon
3. Soft tissue calf muscles/myofascial release/trigger points
4. Osseous mobilization/manipulation of foot/pelvis/spine
5. Heel lift bilaterally, it helps to reduce the stress on the Achilles tendon.
6. K-Tape
7. Gentle stretching (decrease adhesions).
8. Acupuncture/Dry needling.
9. Wear well padded and supportive shoes

Post-acute
1. Ice after exercise.
2. Continue osseous mobilization/manipulation of foot/pelvis/spine.
3. Warm up/down and stretching.
4. Train in higher heel shoe or with small heel lift.
5. Until pain subside avoid running uphill, downhill or jumping.
6. Eccentric exercise.
7. Muscle energy techniques.
8. Continue massage, ultrasound, dry needling or acupuncture.
9. Correct muscle weakness, training errors, biomechanical abnormalities, poor equipment, muscle tightness.

Risks.

• Chronicity (prematurely return to training, improper shoes, bad habits).
• Achilles tendon rupture

Hints.

Treatment should be continued for 4-6 weeks, usually pain decrease in 10-14days, stiffness may last persist longer.

Avoid overtraining and progress slowly in new activity.

Do not sprint of do hill running if you are not used to it. Wear shoes that are suited to your foot type, avoiding wearing worn out shoes or high heels or running in low heeled shoes.

Warm-up and stretch especially gastrocnemius and soleus. Isolated eccentric strength training has been shown to be effective for treating Achilles tendinopathy.

Use an Achilles tendon support. Progress slowly in new activity, avoiding overtraining. Partial rupture are found after steroid injections.

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

The word spondylolisthesis comes from the Greek words spondylos, which means “spine” or “vertebra,” and listhesis, which means “to slip or slide”. Spondylolisthesis is a condition in which one of the bones of the spine (vertebrae) slips out of place onto the vertebra below it (anterior or posterior). This most commonly occurs at the lumbosacral junction with L5 slipping over S1, but it can occur at higher levels as well.
Grading. A commonly adopted method of grading spondylolisthesis is the Meyerding classification. Each grade is determined by the amount of shift between the two vertebrae. The vertebrae are divided into 4 quarters and graded as follows:
• grade I : 0 – 25 %
• grade II : 25 – 50 %
• grade III : 50 – 75 %
• grade IV : 75 – 100 %
• spondyloptosis : > 100 %

Causes
Spondylolisthesis has several main causes:

1.  Congenital (or dysplastic): congenital means “present at birth.” Congenital spondylolisthesis is the result of abnormal bone formation (usually a defect in the articular processes of the vertebra), putting the vertebra at greater risk for slipping. It usually happens in the area where the lumbar spine and the sacrum come together: the L5-S1 area.
2. Isthmic: isthmic spondylolisthesis is caused by a defect, or fracture, of the parts interarticularis; a bone connecting the upper and lower facet joints. The fractures are called spondylolysis; if the vertebra slips forward because it’s not being held in place properly, it’s called spondylolisthesis. Gymnasts, weight lifters, and football linemen are especially prone to this kind of spondylolisthesis. Most common in younger people and tends to affect the L5-S1 vertebral levels.
3. Degenerative: with aging, the discs (the cushions between the vertebral bones) lose water, becoming less spongy and less able to resist movement by the vertebrae. The facets can’t control the spine’s movement as well, and they become hypermobile. It usually occurs in older people and most commonly affects the L3-L4 or L4-L5 level.
4. Traumatic: traumatic spondylolisthesis is caused by an injury which leads to a spinal fracture or slippage.Similar to the isthmic, the traumatic spondylolisthesis also involves a fracture. However, it’s a fracture of any other part of the vertebra other than the pars interarticularis. The facet joints, for example, can fracture, separating the front part of the vertebra from the back part.
5. Pathological: it results when the spine is weakened by disease, such as osteoporosis, an infection or tumor weakening the bones and leading to a fracture that split the vertebra, causing instability and a potential slip.
6. Post-surgical (or iatrogenic): it refers to slippage that occurs or becomes worse after spinal surgery. It is caused by a weakening of the pars, often as a result of a laminectomy,

As a quick summary, spondylolisthesis can be caused by:

• a birth defect
• fractures
• spondylolysis (a defect or fracture in the pars interarticularis)
• degeneration due to age or overuse
• tumors
• surgery

Risk factors

Risk factors include a history of repetitive trauma or hyperextension of the lower back or lumbar spine. Athletes such as gymnasts, weight lifters, and football linemen who have large forces applied to the spine during extension are at greater risk for developing isthmic spondylolisthesis.


Diagnosis
Patients are often asymptomatic and little or no correlation is found between degree of “slippage” and clinical presentation or pain.
Symptoms and signs may include:

• Lower back pain which may increase with extension.
• Hamstring tightness, hypertonic low back muscles.
• Pain, numbness, or weakness affecting one or both lower extremities only if the slippage causes pressure on the nerves.
• Possible hyperlordosis of lumbar spine.
• Possible pronounced spinous at involved segment, and/or depressed spinous at segments immediately above.
• Weakness in the legs.
• Stiffness of the lower back.
• The neurological exam usually is within normal limits.

Imaging.
X-ray: The lateral view may demonstrate the pars defect, while the oblique projection may show the presence of bilateral pars defects with an appearance resembling a Scottie dog with a collar (the collar is the pars defect.).In addition, plain radiographs also may demonstrate congenital types of spondylolisthesis and the changes of spondylosis. In the setting of trauma, fractures may be apparent. Note that other causes of the patient’s symptoms may be demonstrated, such as an osteoid osteoma, Paget disease, and osteolytic lesions. The grade of spondylolisthesis can be measured by using the lateral view.

Computed tomography (CT): CT scanning of the lumbar spine yields information regarding spondylolisthesis and its cause, along with other possible conditions, such as disk disease, disk herniations, spondylosis, and spinal canal stenosis. Other associations, such as spina bifida, may be seen. In patients with radiculopathy, CT myelography can yield information regarding nerve-root impingement and its etiology, such as disk herniation, abscess, or neoplasm.

Magnetic resonance imaging (MRI): MRI has the distinct advantage of being able to image the spine in any plane without exposure to radiation. Typically, the axial and sagittal planes are used, but images in the coronal plane can also be acquired easily, if needed.

Limitations If present, spondylolisthesis usually is detected on plain radiographs. A spondylolysis may not always be visible. CT scanning is more sensitive for detecting spondylolysis, but occasionally this can be missed, since scanning occurs in the plane of the spondylolysis or from volume averaging. Sagittal reconstruction images are of help in patients with these findings. MRI reveals spondylolisthesis on sagittal views. Spondylolysis may not be readily apparent on MRIs, especially if there is a mild degree of bony sclerosis. Other sclerotic lesions in the pars interarticularis, such as osteoblastic metastases, may give similar appearances.

Treatment
Treatment for spondylolisthesis depends on several factors, including the age and overall health of the person, the extent of the slip, and the severity of the symptoms. Often is conservative, however more severe spondylolisthesis (grade 3 or grade 4) might require surgery.

Conservative treatment
Although nonsurgical treatments will not repair the slippage, exercises and appropriate back care (proper lifting, posture, etc.) can help minimize or resolve symptoms.
Rest and medication: The patient should take a break from sports and other activities until the pain subsides. An over-the-counter non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen or naproxen, might be recommended to help reduce pain and inflammation (irritation and swelling). Stronger medications might be prescribed if the NSAIDs do not provide relief. Epidural steroid injections — in which medication is placed directly in the space surrounding the spine — might also help reduce inflammation and ease pain, however it is not recommended to receive these more than three times per year. A brace or back support for a short period of time may be beneficial, however long-term use can lead to atrophy of the paraspinal muscles.
• Osseous mobilization and manipulation may be directed at segment above the slippage to improve biomechanics.
• Electrotherapy modalities: TENS, IFC, US.
• Massage and acupuncture may be beneficial to reduce erector spinae myospasm and low back trigger points.
• A program of exercise and/or physical therapy will help increase pain-free movement, and improve flexibility and muscle strength. Periodic X-rays are done to determine if the bone slippage is continuing.
Exercises: Stabilization exercises are the mainstay of treatment. These exercises strengthen the abdominal and/or back muscles, minimizing bony movement of the spine. Generally, eight to 12 weeks of aggressive daily treatment with stabilization exercises are needed to achieve clinical improvement.

AVOID exercises such as sit-ups, leg lifts/flutter kicks, and running during your recovery. Perform low impact aerobic training to maintain cardiovascular fitness, promote healing, and reduce pain (bike, swim, elliptical trainer, ski machine, etc.). These should be performed with minimal to no pain.

Surgery

Surgery might be necessary if the vertebra continues to slip or if the pain is not relieved by conservative treatment (at least 3 to 6 months) and begins to interfere with daily activities. The main goals of surgery for spondylolisthesis are to relieve the pain associated with an irritated nerve, to stabilize the spine where the vertebra has slipped out of place, and to increase the person’s ability to function. Usually two surgical procedures are used to treat spondylolisthesis.
1. The first procedure is a decompressive laminectomy, which involves removing the part of the bone that is pressing on the nerves. Decompression is usually performed in patients with radicular leg pain. Although this procedure can reduce pain, removing a piece of bone can leave the spine unstable.
2. The second procedure, called spinal fusion, is performed to provide stability.The most common procedure is a posterolateral fusion which involves putting bone graft material between the transverse processes to encourage a fusion. Fusions are usually augmented with rods and screws to provide stability while the bony fusion becomes solid. The hardware is usually not removed unless complications such as breakage occur. Fusions can also be performed from an anterior approach with removal of the disc and insertion of a cage of some sort augmented with bone or some form of fusion material. Some infusions involve both an anterior and a posterior approach. New minimally invasive surgery (MIS) procedures often involve removal of the disc, insertion of a graft to restore the spinal alignment and insertion of rods and screws to produce stability. These MIS procedures are performed through a series of small incisions with minimal blood loss and very short hospital stays. Success of surgery depends on proper patient selection. Not everyone with a spondylolisthesis improves with surgery.

Hints

Most common complication is nerve root impingement/radiculopathy. Lumbar stenosis and cauda equina syndrome may result when a significant slip has occured.
In older patients presenting with radiculopathy and neurogenic intermittent claudication, with or without back pain, a diagnosis of degenerative lumbar spondylolisthesis should be considered.
The spondylolisthesis itself normally does not heal, but exercises and appropriate back care (proper lifting, posture, etc.) can help minimize or resolve symptoms. Occasionally, in cases of severe slippage, surgery to stabilize the segments may be required.
Plain myelography or CT myelography are useful studies to assess spinal stenosis in patients with degenerative lumbar spondylolisthesis. CT is a useful noninvasive study in patients who have a contraindication to MRI, for whom MRI findings are inconclusive or for whom there is a poor correlation between symptoms and MRI findings, and in whom CT myelogram is deemed inappropriate.
Patients with pain, numbness and tingling in the legs may benefit from an epidural steroid (cortisone) injection.
Individuals with spondylolisthesis should exercise caution and avoid contact sports and heavy physical labor if possible (heavy lifting, carrying heavy back packs, using jack hammers, digging work, etc.).

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome

An ankle sprain also known as a twisted ankle, rolled ankle, floppy ankle, ankle injury or ankle ligament injury, is a common medical condition where one or more of the ligaments of the ankle is torn or partially torn.
There are three types of ankle sprain:

1. Inversion: the most common type of ankle strain (70-85% of ankle sprains). It affects the lateral side of the foot leading to a stretch or damage of the lateral collateral ligaments such as the anterior talofibular, posterior talofibular and calcaneofibular ligament. Peroneal muscle&tendons may be strained leading to lateral leg pain and dynamic instability. In the worse scenario injury to the superficial peroneal nerve may occur causing weakness in eversion.
2. Eversion: less common than inversion sprain. It affects the medial side of the foot leading to a stretch or damage of the deltoid ligament.Often is quiet severe and fractures are common. May require surgery.
3. High ankle sprain: rare. It affects the ligaments above the ankle that join together the two long bones of the lower leg, called the tibia and fibula. It is usually happens if the foot is forced up, or if the leg is forcefully twisted while the foot is planted. This injury can occur either by itself or with an inversion or eversion sprain.

Classification
The amount of force determines the grade of the sprain (amount of damage or the number of ligaments that are damaged). A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3. (See Table below).

Causes
Improper landing on foot due to:

• Uneven surface
• Genu varum or valgus, tibia varum, etc.
• Body weight too lateral on foot during stance.
• Improper position of foot prior to heel strike.

Muscle imbalance: weak evertors (peronei/fibularis muscles), tight invertors (tibialis anterior & posterior)
Proprioceptive deficit which could be due to pre/existing injury. As a matter of fact proprioception is important in protecting ankle from sprains by proper position of foot before the foot strikes the ground.

Diagnosis
History: a carefully taken history will elicit the mechanism of injury and provide valuable clues as to the ligamentous structures that may be injured. For example, an athlete who steps in a hole while running on uneven terrain will most likely suffer a plantarflexion/inversion injury and damage the anterior talofibular ligament. On the other hand, an anterior lineman who has a teammate land on the back of his ankle while his foot is externally rotated will suffer a dorsiflexion/external rotation injury with suspected damage to the syndesmosis. Other important historical features to obtain from the athlete include whether there was a perception of a “pop” at the time of injury; whether the athlete was able to continue to play after the injury; whether the athlete was able to bear weight on the ankle after the injury; and the time elapsed before swelling ensued. A history of ankle injury or an inadequately rehabilitated ankle that has been previously injured are other features that should be important to note.
Observe gait: Can the patient support his full body weight? does he limp? An inability to bear weight suggests severe injury or fracture (see guideline). Download guidelines for acute injury of the ankle —> click here
Observe carefully the ankle for swelling, deformity, and ecchymosis. Note amount of bruising and location (often takes 24-72 hours), however more the ankle is bruised and greater is the injury.
Palpation:

1. tenderness is anterior to lateral malleolus, if the anterior talofibular ligament is injured.
2. tenderness is inferior to lateral malleolus, if the calcaneofibular ligament is injured.
3. when tenderness is superior or posterior to lateral malleolus, consider X-Ray..
4. tenderness is in the medial ankle, if the deltoid ligament is injured, however eversion sprain may require x-ray to rule out avulsion fracture of the medial malleolus/ fibula fracture.
5. Palpate the base of the fifth metatarsal, the anterior process of the calcaneus, the lateral and posterior processes of the talus, and the peroneal tendons should be palpated since injuries to these structures may mimic an ankle sprain.

Provocative test (proceed carefully and only if you believe it is safe):

1. Anterior drawer test to evaluate the anterior talofibular ligament.
2. Inversion talar tilt test to evaluate the calcaneofibular ligament .
3.  Eversion talar tilt & rotation stress test to evaluate the deltoid ligament. (Kleiger test).
4. Thompson’s test to evaluate Achilles tendon rupture which may mimic ankle sprain (Thompson’s test)
5. Finally, the integrity of the peroneal tendons can be tested. The peroneus brevis and peroneus longus travel behind the posterior aspect of the lateral malleolus. They are kept in place by a fibrous retinaculum that can be torn or injured. If this occurs, the tendons can sublux from the groove in which they sit in the posterior aspect of the lateral malleolus. This can be assessed by stabilizing the lower extremity with one hand with the other hand placed behind the heel. The foot is placed into dorsiflexion and eversion. An anterior force is then applied, which may reveal the subluxation of the tendons over the lateral malleolus. The physical examination should be completed by performing a careful neurovascular assessment of the distal foot.

Treatment
Accurate diagnosis should be made and more serious injury excluded before starting any treatment.
A physiotherapist may help more than a chiropractor or osteopath in the early phase stage
Early phase: initially ankle sprain should be treated using the abbreviation PRICE.

1. Protect: Open Basket Weave Tape for sever edema, closed Basket Weave with minor swelling.
2. Rest by reducing weight bearing (crutches as needed)
3. Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction (important during first 24hrs).
4. Compression with tape or wrap to control edema, however should not be too tight up to 72hrs
5. Elevation to control edema up to 72hrs

Early mobilization following ligamentous injury stimulates collagen orientation and promotes healing, even though full strength of the injured ligamentous structure may not be achieved for several months.
Consider pulsed US, Electrotherapy, manipulation of foot, ankle, knee, back, etc. (ankle manipulation opposite direction of mechanism of injury), isometric contraction.

Late phase (usually 72hrs post injury):

• Alternate hot and cold, however control swelling with cold and do no apply heat until edema or bruise subside.
• Manipulate joints as needed
• Wean from crutches
• US and switch to closed basket weave or lace-up splint (which may be cheaper for the patient in the long-term)
• Treat trigger point.
• Stretch muscles but avoid muscles that have been stretched during the injury.

Rehabilitation has variable timing depending on the severity of the injury. However the following points should be followed under a physiotherapist supervision:
1. Restore strength, starting with isometric exercises.
2. Partial weight bearing to full weight bearing, resisted plantar flexion and dorsiflexion. Walking in the pool or in advanced stage running with a jacket in deep end of pool.
3. Movements that are similar to the mechanism of injury should be avoided.
4. if pain or swelling increase then treatment may be too aggressive. However remember to ice the area after exercising.
5. After 10-14 days post injury, increase walking distance and speed, otherwise cycling or rowing.
6. Elastic bands can be used and start jogging if pain free and full ROM.
7. Strength plantar flexors muscles (toe raises).
8. Balance drills to improve proprioception (easy task)
9. When patient is able to perform the points above then more challenging tasks can be given, such as tilt board and wobble board to improve balance and proprioception. Ex. while patient is standing on the wobble board the therapist could pass him a ball. Patients should be taped when participating in high risk activities.
10. Improve coordination and strength, forward run, backward run, figure 8, zigzags 45°, stops and go, etc.
11. Make sure flexibility is 100% and strength is almost 100% before returning to high risk activities.

Surgery
Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment. Surgical options include:
• Arthroscopy: A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
• Reconstruction: A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.
Complications
Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. This can also happen if you return to work, sports or other activities without letting the ankle heal and become rehabilitated.
Hints
Read ankle injury guidelines  before referring patient for X-ray, however X-ray is also suggested when patient does not respond to treatment or there is a worsening or persistent signs&symptoms.
Refer in case of: failure to respond to conservative treatment, vascular insufficiency, significant neurologic deficit, fracture, ankle instability.
If the injury happen on field, return to play if: minimal pain, normal ROM, minimal edema, normal vascular and neurological function, able to perform one leg stand, heel walk, toe walk, walk and other functional tests related to the sport. Apply Gibney tape
Recurrent sprains may be due to poor proprioception.
Warm-up before doing exercises and vigorous activities
Pay attention to walking, running or working surfaces
Wear good shoes

Dott. Emanuele Luciani

Osteopath, physiotherapist, hatha yoga teacher

Osteopath registered with the General Osteopathic Council (GOsC)

(number 8232http://www.osteopathy.org.uk/home/)

 "Centro Studi Tre Fontane"

Via Luigi Perna 51, Rome