Ankle Issues


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Ankle Issues

Welcome to Synergy Therapeutic Group’s guide to psoriatic arthritis. 

Psoriasis is a disease that most people think of as primarily a skin disease because the condition causes a persistent rash in various areas of the body. Psoriatic arthritis is a type of joint disease that occurs in roughly seven percent of people who have psoriasis. Psoriatic arthritis affects people of all ages, but most get it between the ages of 30 and 50. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and usually the arthritis comes on slowly, however, this is not always the case. No matter what, patients with psoriatic arthritis must unfortunately manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

This guide will help you understand:

  • how psoriatic arthritis develops
  • how doctors diagnose the condition
  • what can be done for the problem
  • what Synergy Therapeutic Group’s approach to rehabilitation is

ANATOMY

Where does psoriatic arthritis develop?

Psoriatic arthritis can affect any joint. Its symptoms often seem like the symptoms of rheumatoid arthritis (RA) or degenerative arthritis of the spine. X-rays can be used to show the difference between psoriatic arthritis and other diseases. In psoriatic arthritis, X-rays show a very distinctive type of bone destruction around the joints as well as certain patterns of swelling in the tissues surrounding the joints.

Patients with psoriatic arthritis fall into three groups. The first group involves patients who have what is called asymmetric arthritis. This means that only a few joints are involved and that it does not occur in the same joints on both sides of the body. (For example, only one wrist and one foot are affected.)

An equal number of patients fall into the second group and suffer from symmetric polyarthritis. This means that arthritis occurs in several corresponding joints on both sides of the body. (For example, both elbows, both knees, and both hands are affected.) The polyarthritis type of psoriatic arthritis is much like RA.

A third group has mostly axial disease. This refers to arthritis of the spine, the sacroiliac joint (where the pelvis and bottom of the spine meet), or the hip and shoulder joints. Patients do not necessarily stay in the same category. Over time, the pattern may change. Doctors use these categories to better understand the disease and to follow the progression of the arthritis but the overall treatment is basically the same.

CAUSES

Why do I have this problem?

The exact cause of psoriatic arthritis is not known. Many factors seem to be involved in its development. Heredity plays a major role. People who are closely related to someone with psoriatic arthritis are 50 times more likely to develop the disease themselves. Recent studies have located genetic markers shared by most people who have the disease.
Sometimes injuries seem to set off psoriatic arthritis. Infections also contribute to the disease. It is known that strep infections in children can cause psoriasis. Some researchers think that the arthritis may be an immune system response to bacteria from the skin lesions.

SYMPTOMS

What does psoriatic arthritis feel like?

All people who suffer from psoriatic arthritis have psoriasis (the skin rash). Some patients have very few areas of rash while other patients have psoriasis over a large portion of their bodies. The skin lesions of psoriasis are reddish, itchy, and have silvery scales. These areas can range in size from the size of a pencil dot to large areas the size of your palm. Psoriasis usually shows up on the elbows, knees, scalp, ears, and abdomen, but it can appear anywhere. In people with psoriatic arthritis, the psoriasis most often affects fingernails or toenails. The nails may have pits or ridges, or they may be discolored or appear to be separating from the skin.

Psoriatic arthritis can affect any joint. Symptoms often seem like those of any other type of arthritis, such as joint swelling and pain. Some joint symptoms are unique to psoriatic arthritis:

  • The joints nearest to the fingernails and toenails are affected more. (These joints are called distal interphalangeal, or DIP joints.)
  • The affected fingers and toes take on a “sausage-like” appearance.
  • The bones themselves become inflamed (called dactylitis).
  • The tendons and ligaments become inflamed where they attach to bones. (This is called enthesitis and is especially common in the heels.)
  • Bony ankylosis of the hands and feet develops. (This means that the joints stiffen and become frozen in awkward positions.)
  • The joints grow inflamed where the bottom of the spine meets the pelvis. (This is called sacroiliitis.) Patients often notice no symptoms, but the inflammation can be seen on X-rays.
  • The vertebrae of the spine become inflamed. (This is called spondylitis.)
  • The eyes become inflamed.


About five percent of patients with psoriatic arthritis will develop a form of arthritis called arthritis mutilans. This type of arthritis affects the small joints of the hands and feet. It is especially severe and destructive. The destruction caused by arthritis mutilans can result in deformity of the hands and fingers.
Rare symptoms include problems with the aortic heart valve, extra tissue formation in the lungs, and metabolic disorders that affect the tissues.

DIAGNOSIS

How do health care professionals identify the condition?

A detailed medical history with questions about psoriasis in your family, will help your healthcare professional make a diagnosis. Patients with psoriasis may have other forms of arthritis, and the symptoms of psoriatic arthritis often look like other types of joint disease. This means that your doctor will probably do tests to rule out other diseases.

Blood studies will help rule out RA. (The RA test is usually not positive in patients with psoriatic arthritis.) Efforts are being made to find ways to identify psoriatic arthritis through a blood test. The presence of specific biologic elements called biomarkers (biologic evidence of disease) would make it possible to look for evidence of this disease before it progresses, or even before it starts. Psoriatic arthritis is common in people who test positive for HIV, the AIDS virus. As a precaution, your doctor may test your blood for HIV, especially if your symptoms are severe.

Physicians must also use other diagnostic tools such as X-rays, ultrasonography, and Magnetic Resonance Imaging (MRIs) in order to definitively diagnose psoriatic arthritis.  Each one of these tests provides a little different information. For example, X-rays of affected joints will be studied both to rule out other diseases and to identify characteristics of psoriatic arthritis.

Ultrasonography, the use of sound waves to create a picture of what’s going on inside, provides a better look at the whole package: bones, joints, and soft tissues. This diagnostic test is also noninvasive and does not expose the patient to any radiation. Ultrasound also has the ability to show small changes in the nails and early signs of inflammation in tendons and small joints.

MRIs can show bone marrow edema, tenosynovitis and early joint erosion. Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon. Unfortunately reliability is a problem with MRIs because what one examiner sees may not be the same as another observer. Changes in the small joints of the hands and feet don’t show up well on MRIs like they do with ultrasonography.
One advantage MRIs do have over ultrasonography is the availability of whole body MRIs. By scanning the entire body, it is possible to identify areas of inflammation undetected by clinical examination.

Until blood studies are able to find biomarkers indicating the presence of psoriatic arthritis, physicians will have to continue to use a combination of different tests to diagnose the problem. The information these tests provide is important in determining treatment.

TREATMENT

What can be done for the condition?

Dealing with psoriatic arthritis involves treating both the skin lesions and the joint pain. Many lotions and creams are made for skin affected by psoriasis. 
PUVA therapy, which stands for psoralen combined with ultraviolet A (UVA), may be helpful for the skin lesions. PUVA therapy uses topical cream medications that are rubbed on the skin lesions and affected joints. Following application of the cream, the skin area is placed under a lamp that emits a special ultraviolet light. The light triggers chemicals in the medication cream that treat the rash lesions and in some cases may also help the pain in the joints.

Treatment of arthritis symptoms depends on which joints are affected and the severity of the disease.

The first drugs most doctors prescribe are nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin and ibuprofen are NSAIDs, as are many prescription pain relievers. Other medications known as disease-modifying antirheumatic drugs (DMARDs) are used in patients with high levels of pain or particularly bad arthritis. These medications work in different ways to regulate the immune system and thereby control the arthritis.
One of the most commonly used disease-modifying medications for the treatment of psoriatic arthritis is methotrexate. DMARDs like methotrexate not only controls symptoms, they also slow the progression of disease.  That’s what makes them “disease-modifying”.  Methotrexate can control bad skin symptoms as well as help the arthritis symptoms. For some patients, it may be necessary to combine methotrexate with another drug (e.g., infliximab) to get the desired results (decreased joint pain, swelling, and stiffness).

Infliximab is a type of disease-modifying medication in a class called anti-tumor necrosis factor (TNF) agents. The anti-TNF agents are a special type of antibody referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor. Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.

Oral medications (pills taken by mouth) are under investigation and might be available in the future for the treatment psoriatic arthritis.  These include ustekinumab, apremilast, and tofacitinib. Each of these medications works in a slightly different way to regulate the immune system.

Doctors will sometimes prescribe a combination of drugs. Cortisone injections into sore joints can also help relieve pain. Surgery may be called for in the rare cases of unmanageable pain or loss of joint function.
In addition to medicinal treatment your doctor will ask you to see a Physical Therapist to maximize the strength and mobility of your joints. 

REHABILITATION

Treatment for psoriatic arthritis at Synergy Therapeutic Group can assist the management of your disease alongside the use of your prescribed medications.  Physical Therapy cannot cure your disease, but it can assist in managing your pain and preventing a decline in your joints due to the disease process. Physical Therapy will focus on the effects of psoriatic arthritis on your joints rather than the skin lesions that are part of the disease.

During your first visit to Synergy Therapeutic Group your Physical Therapist will take a detailed history from you. They will want to know when the arthritis first started bothering you, which joints you have pain in, how often they bother you, the level of pain, and what sort of activities irritate or relieve your pain. They will also inquire about the associated skin lesions as well as any family history you may have of the disease, and any previous or current treatments you are undergoing, including which medications you are taking. Finally, they will ask about your work and recreational activities and will want to know if your arthritis limits you in any of these activities.

If your arthritis has affected any joints in your lower extremities your Physical Therapist will want to watch the way you walk to see if your arthritis has affected your gait. They will also assess your overall posture and alignment to determine if you have developed any bad posturing habits or improper alignment due the disease. They will advise you on proper posturing and walking techniques and if needed, will discuss using a walking aid such as a cane/stick if they feel it is necessary to take some of the stress off of your joints.

Next your Physical Therapist will assess and measure the range of motion in any joints that have been affected by the arthritis. Strength of the muscles surrounding these joints will also be determined. For any joints that have a decreased range of motion or are at risk of losing their range of motion, your therapist will prescribe range of motion exercises. Stretches will be prescribed for any muscles around the joints that are deemed to be tight and pulling adversely on the area. Strengthening exercises will be prescribed for any weak muscles or muscles that your therapist determines are at risk of losing strength over time due to the disease process.

Often doing exercises in a warm therapy pool can be easier on your joints and more comfortable so your therapist may encourage this for you.  In addition, cardiovascular exercise can also be done more comfortably while in the pool (ie: water running, water aerobics, or swimming.) Doing a cardiovascular exercise of some sort is extremely important to managing your psoriatic arthritis as it keeps the body and joints limber and is excellent for your overall physical and mental well being.   Stress can make your symptoms worse so cardiovascular exercise is an excellent method of helping to decrease your overall stress. If you are overweight, cardiovascular exercise is particularly important to assist you in weight reduction as the added weight on your joints can accelerate the wear and tear on them and increase any pain you may feel.  If you are not interested in the pool or prefer exercise on the land you could use a stationary cycle, a stepper machine, an elliptical, or simply walk. Your therapist can help to design a cardiovascular program that suits your individual needs, and can advise on which type of exercise would be best for you.

In some cases of psoriatic arthritis, electrotherapy such as transcutaneous nerve stimulation (TENS) may be useful to decrease your joint pain. Your Physical Therapist may also use hands on techniques such as massage for the muscles surrounding your joints, or mobilizations to encourage increased range of motion in your joints.  Often the use of heat can be very soothing for your joints, so this may be used in conjunction with other therapy treatments. If you find the warmth soothing to your joints your therapist will encourage you to apply heat at home as well.

Unfortunately your psoriatic arthritis will not go away. However, there are many treatment options to help you manage this disease. Together with advice from your doctor, your Physical Therapist, and any other healthcare professionals that are involved in your treatment you should be able to find a management program that will work for you.

Portions of this document copyright MMG, LLC.

Synergy Therapeutic Group provides services for Physical Therapy in Carbondale and Du Quoin.


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Lower Leg Fractures

Welcome to Synergy Therapeutic Group’s guide to lower leg fractures.

In this guide we are concerned with fractures of the lower leg between the knee and ankle. The two bones in the lower leg are the tibia and fibula. We will limit this discussion to fractures of the shaft, or mid section of these two bones. Fractures of the lower end of the tibia and fibula are covered in ankle fractures. Fractures of the upper end of the tibia are covered in knee fractures.The tibia bone is the largest and most important bone of the lower leg. It is quite vulnerable to injury. There is no overlying muscle to cushion impact on the front and inner side of the bone. The tibia is relatively easy to fracture with twisting or bending forces. As a result, fracture of the tibia is one of the most common major long bone fractures encountered in adults. Fracture of the tibia has a reputation for complications including failure to heal, or nonunion, so the management of this injury needs a careful approach from orthopaedic surgeons.

Usually, when the shaft of the tibia is broken the fibula, the smaller bone of the lower leg, is broken as well. This bone serves mainly as an anchor point for muscle and hardly bears any weight. As a result it does not need to be perfectly straight when it heals. It is sometimes surprising to patients that the doctors pay so much attention to the tibia and so little to the fibula.

This guide will help you understand:

  • what parts of the lower leg are involved
  • what the symptoms are
  • what can cause these fractures
  • how health care professionals diagnose these fractures
  • what the treatment options are
  • the Synergy Therapeutic Group’s approach to rehabilitation

ANATOMY

What structures are most commonly injured?

The tibia is shaped a little like an inverted trumpet with a long straight shaft flaring out at the knee. The shaft has a triangular shaped cross-section and the inner front portion of the bone has only skin overlying it. If you put your finger on the inner side of the knee and run it down all the way to the inside of the ankle you can feel bone all the way down.

There are muscles surrounding the tibia on the outer side and at the back; the fibula is completely surrounded. Because the bone is just under the skin it is quite common for the jagged end of the bone to come through the skin when it breaks, causing an open fracture. Fractures occur almost anywhere along the shaft of the tibia but the most common site is about two thirds the way down.

The blood vessels and nerves that supply the foot are quite close to the bone. It is not uncommon for fractures of the shin, especially open fractures to involve damage to either the blood supply to the foot or the nerve supply or both.

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

Related Document: Synergy Therapeutic Group’s Guide to Knee AnatomyKnee Anatomy Introduction

CAUSES

How do fractures of the lower leg commonly happen?

The tibia and fibula can be broken by a number of different forces, impact against the leg, compression, bending forces or twisting forces. It is possible to break the fibula in isolation, without fracturing the tibia, although this is an uncommon situation caused by a direct blow to the outer side of the leg. Isolated fracture of the tibia is slightly more common but usually both bones break.

It is important to remember that whenever bones are broken there is also damage to muscle, tendon, ligament and often nerves and skin. This soft tissue injury does not show on X-ray but it contributes greatly to the pain and swelling of the injury – and may affect the eventual outcome.

TYPES

What Types of fractures can occur?

The different patterns of fracture of the tibia and fibula relate to the different mechanisms of injury. Oblique fractures are usually caused by a bending force or direct impact. Transverse fractures result from compression and spiral fractures result from twisting forces.

The more force applied; the more likely it is that there will be multiple fragments. The term used to describe multiple fragments is comminution; a fracture of this type is referred to as a comminuted fracture. It is also more likely that the displacement of the fracture fragments by the greater force will push one or more of them out through the skin, causing an open fracture.

Fractures of the tibia are common in high energy accidents such as MVAs or falling from a height. The leg may get caught in machinery causing severe fractures with extensive skin loss and potential for major injuries to muscle, tendons, nerves and arteries. Sports such as skiing, contact sports and tobogganing all cause their share of leg fractures. Falls in the elderly do sometimes cause fractures of the shin bone; in these cases the fractures should be considered fragility fractures. Pathological fractures through abnormal deposits in bone occur rarely.

SYMPTOMS

What symptoms do lower leg fractures cause?

People who suffer a fracture of the tibia and fibula have immediate pain at the site of the fracture. The pain is made worse by any movement of the limb. Often the leg is deformed, either twisted or bent, and sometimes there is a wound where the bone has come out through the skin.

In the case of an isolated fracture of the fibula you may be able to walk, but with nearly all other fractures it is impossible to bear weight. Within a few minutes of the injury the leg will swell up. If there have been injuries to the nerves or arteries the foot may be numb or cold.

Within hours of the injury there will be significant bruising. Fracture blisters are seen quite often after fractures of the tibia. Pain, swelling and bruising are evident for weeks after a break regardless of the treatment. This is because of the soft tissue injury, bleeding into the muscle compartments, and compromised circulation in the injured area. The worse the soft tissue injury the more likelihood there is of stiffness or weakness of the nearby knee and ankle joints.

Aching discomfort in the affected area and some pain on stressing it may continue for many months while the fracture is healing and consolidating. It should gradually diminish as the fracture heals and regains normal strength. Where metal implants have been used to treat the fracture, tenderness, mild aching, and cold intolerance may persist until the implants are removed.



EVALUATION

How will my fracture be evaluated?

First aid treatment at the scene of the accident should consist of keeping the victim warm, splinting the leg, and transporting him/her to hospital. An assessment at the scene should include dressing any wounds and checking for numbness of the foot. It is not usually necessary to straighten the leg unless it cannot be splinted otherwise.

In the Emergency Room the focus is on treating shock, making the patient comfortable, ruling out other injuries, and getting the correct x-rays to evaluate the fracture. It is important to obtain x-rays that include the ankle and knee. If an isolated fracture of the shaft of the fibula is diagnosed this may be treated by the emergency doctor and followed by your family doctor. Fractures of the shaft of the tibia usually result in referral to an orthopaedic surgeon.

The orthopaedic assessment may include an evaluation of the general medical status of the patient and the risks of anesthesia. The history of the accident and the forces causing the fracture will be assessed and the limb carefully examined for wounds, blistering, skin problems, neurological or vascular loss and for signs of injury to the knee or ankle. The X-rays will be reviewed and more X-rays obtained if necessary.

The treatment plan will be discussed with the patient giving consideration to the nature of the fracture, the patient’s health status, level of activity, occupation and expectations. The most important feature of the fracture is whether it is stable or not. An unstable fracture is likely to shorten, angulate or rotate and may need treatment with surgery.

OUR TREATMENT

What treatments should I consider?

An isolated fracture of the fibula may be treated in a cast for protection or may be left alone. The bone will heal without interference and the aims of treatment are to manage the pain. Using crutches for a few weeks is usually recommended.

The treatment of fractures of the tibia is controversial. Some orthopaedic surgeons take the view that most such fractures should be treated by operation. This is supported by scientific studies that show with surgery the fracture healed more reliably and with better alignment. Others prefer to avoid an operation unless it is clear that the outcome will be poor without surgery.

There is also controversy about the type of operation best suited to this injury. There is such variation in the patterns of injury and treatment that research studies to answer some of these questions are very difficult to organize. Most orthopaedic surgeons would agree that treatment has to be individualized and matched to the patient’s injury pattern, medical status and expectations.

Nonsurgical Treatment

Treatment in a cast may be recommended when the fracture pattern is stable, there are no other major injuries and the patient is fit enough to carry the weight of a cast around. The pattern of injury most suited to cast treatment is a spiral fracture because it is inherently stable. Transverse fractures are also relatively stable. Oblique fractures are inherently unstable and likely to shorten. However, the amount of shortening is unpredictable and may be acceptable.

It is not unusual to begin treatment with a cast and then change course. In order to avoid an operation, cast treatment may be started initially and surgery later recommended if the bone fragments move and the position becomes unacceptable.

In some situations the cast can be applied without an anesthetic. The lower leg is hung over the side of the bed so that gravity keeps it straight. The cast is applied from toes to knee in this position and this splints the fracture in the reduced (straight) position. Then the leg is lifted onto the bed and the cast is continued up above the knee to form a long leg cast. The knee is bent about 40 degrees in the cast to prevent rotation and allow the leg to swing through during crutch walking.

Quite often it would be too painful to apply a cast without a general or regional anesthetic. The procedure is then done in the OR, the fracture is manipulated into a good position and the long leg cast applied. X-rays may be taken at this stage to confirm that the fracture is in a good position. If it is not, further manipulation may be undertaken or the surgeon may decide to operate. The option to continue on to an operation if closed treatment is not acceptable would be discussed with the patient ahead of time.

Once the cast has been applied it may be split to allow the leg swelling to occur without undue compression of the tissues. As the swelling goes down the cast may become loose and need to be tightened or replaced. Follow-up in the cast clinic at frequent intervals is usually recommended. X-rays will be taken to confirm good position of the fracture and assess healing as it takes place.

If the fracture has moved, it may be possible to correct the position by wedging the cast. This involves cutting the cast three-fourths the way around at the level of the fracture leaving a hinge of intact cast on the convex side of the deformity. The leg can then be straightened and a wedge inserted into the opening in the cast on the concave side to hold the cast – and the bones – in the new position. Once x-rays have confirmed that the new position is acceptable, more plaster is applied over the cast to make it rigid once again.

Casting material is either plaster of Paris (POP) or some form of fiberglass. POP is cheaper and easier for the surgeon to work with, molding the cast to the shape of the leg. Fiberglass is lighter and more durable. Unlike POP is doesn’t disintegrate if it becomes wet. However, if it does get wet the soggy padding may cause skin problems. It is better to keep any cast dry.

Casts are normally changed after six weeks. If there is x-ray evidence of healing the surgeon may select a shorter, patellar tendon bearing cast or brace and allow some weight bearing. It is normal for some form of splinting to continue for at least three months. The length of time the fracture needs to be protected by a cast or brace depends on the amount of healing. There is a risk of re-fracture until full healing of the fracture has been achieved. So, there is no “normal” length of time to be in a cast after a tibia fracture.

SURGERY

All open fractures need surgery to clean up and irrigate the wound. It does not follow that the fracture should be treated surgically as well as the wound. However, in many cases cleansing the wound is followed by fixing the fracture. It is believed on the one hand that an immobile fracture is less likely to get infected and is easier to treat if it does; on the other, surgery disturbs the blood supply and increases the exposure of the bone to contaminants so may increase the risk of infection. A compromise approach is to delay definitive fixation of the fracture until the open fracture wound has started to heal. Either way, an open fracture is a compelling reason for surgery on the wound.
Surgery on the fracture may consist of open reduction and internal fixation with a plate, closed reduction and fixation with an intramedullary rod, or reduction and external fixation. The fundamental reason for undertaking surgery is the surgeon’s opinion that the result of surgery would be better than the outcome following cast treatment. In this context “better” means healing faster, stronger, in better position with less complications with quicker return to normal function.

Open Reduction and Internal Fixation (ORIF)

The operation involves exposing the fracture and moving the fragments back into the correct position. This position is then held by a metal plate secured above and below the fracture with screws. Plates are now available which match the shape of the tibia almost exactly. This allows a minimally invasive approach to plating the tibia where the plate is introduced under the skin.

Intramedullary Rod Fixation

In this procedure the fracture is straightened (reduced), a small hole is made in the bone just below the knee and a guide wire is passed across the fracture inside the bone. A reamer is often used to make sure the fit is tight. Then a rod is slid into the hole inside the bone from the top. It is passed over the guide wire and into the lower fragment. To prevent the fracture shortening the bone is secured to the rod with transverse (locking) screws. The big advantage of this technique is that the fixation is very strong.

External Fixation

The bone is held in the correct alignment and length using a frame outside the leg. This is attached to the bone with transfixing pins or screws. This technique allows access to the wound, it is minimally invasive preserving the blood supply and it can adjusted later to correct any deformity. External fixation is more commonly used with more severe open injuries and very unstable fractures.

After the surgery a splint may be used for pain relief. However, there is no need for prolonged cast immobilization of the fracture – the metal hardware holds it still. In most cases the wound is dressed and movement of the foot, ankle and knee is encouraged. Weight bearing through a fracture treated with surgery is not usually recommended until x-rays show there are signs of healing (six weeks).

Hardware Removal

After the fracture has healed the metal implants may cause minor symptoms. Plate and screw areas may be tender; more rarely the hardware irritates tendons that should move over the bone. In some people there is a dull constant ache and cold intolerance. If these symptoms become significant enough, the hardware can be removed. This is a relatively simple operation but the issue of hardware removal causes many patients a lot of concern.

It is often uncertain what the benefits of hardware removal surgery will be. People are concerned that the bone will be weakened and re-fracture or that they will experience discomfort as bad as the pain they had after the original surgery. Hardware removal does require an operation to expose the plate or the rod but the incidence of re-fracture of the tibia is low and the pain after surgery is less severe and short lived. The long-term results of hardware removal have been studied and shown to be very satisfactory with few problems and a high rate of satisfaction.

How long does it take to heal?

There is no “typical” fracture of the tibia and recovery depends to a large extent on the severity of the original injury. Clearly the outcome expected from a stable closed spiral fracture will be different from the result after the leg has been mangled in machinery.

The normal healing times are six weeks to achieve 50 percent of eventual strength, three months to reach 80 percent of eventual strength, and 18 months to complete the process of consolidation and remodeling of the fracture. If this is the only injury this time scale usually suggests change to weight bearing with some protection at six weeks (e.g., walking cast); unrestricted weight bearing and gradual return to sports or heavy working activities at three months; and consideration of hardware removal after 18 months.

REHABILITATION

If you have been immobilized, rehabilitation with a Physical Therapist at Synergy Therapeutic Group will begin once the brace or cast is removed. Prior to this, simple toe wiggling exercises will be your only exercise. In cases where your full cast has been replaced by a patellar tendon bearing cast/brace (which allows knee motion) then it is important to also maintain knee range of motion even if you are not able to weight bear through that leg.  

If you have had surgery to fixate your lower leg fracture, then rehabilitation at Synergy Therapeutic Group will begin as soon as your surgeon recommends it. Sometimes therapy will be recommended even before you are allowed to fully weight bear. In other cases, rehabilitation will not be recommended until full weight bearing begins. Each surgeon will set his own specific restrictions based on the type of fracture, surgical procedure used, personal experience, and whether the fracture is healing as

expected. 
Even if Physical Therapy for the injured leg has not yet begun, at Synergy Therapeutic Group we highly recommend maintaining the rest of your body’s fitness with regular exercise.  You can use an upper body bike if you are non-weight bearing or a stationary bike once weight bearing is allowed. If the surgeon fits you with a brace that allows you to take partial weight through your leg (i.e. walking cast) then you can even use a stationary bike while wearing it. Weights for the upper extremities and other leg are also strongly encouraged. Your Physical Therapist can provide a program for you to maintain your general fitness while you recover from your fracture.

If you are using crutches, your Physical Therapist will ensure you are using them safely and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use them on stairs. If you are no longer using crutches, your Physical Therapist will assist with gait re-education. Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee; hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your Physical Therapist will advise you regarding the appropriate time for you to be walking without any support at all.

When the initial cast or brace is removed, patients may experience pain when they start to move their ankle joint or bear weight through the lower leg. This pain is from not using the joints regularly while you were immobilized, or it may be from concurrent soft tissue injury that occurred when you fractured your leg. Your Physical Therapist will focus initially on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the fracture site or anywhere down the extremity. In addition, our Physical Therapist may massage the leg and ankle to improve circulation and assist with the pain.

The next part of your treatment will focus on regaining the range of motion and strength in your ankle, foot, and entire lower limb. Your extremity will look and feel quite weak and atrophied after the period of immobilization. Your Physical Therapist will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. These exercises may include stationary cycling and the use of theraband to provide some resistance for your lower leg. We may even give you exercises for areas such as your hip or back as these areas help to support the lower limb when you are weight bearing. If necessary your Physical Therapist will mobilize your joints. This hands-on technique encourages the stiff joints of your ankle, foot, and lower leg to move gradually into their normal range of motion. Fortunately, the initial phases of gaining range of motion and strength after a lower limb fracture go quickly. You will notice improvements in the functioning of your limb even after just a few treatments with your Synergy Therapeutic Group Physical Therapist. As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. Your Physical Therapist will also prescribe exercises for you to regain this balance and proprioception. This might include exercises such as standing on one foot or balancing with both feet on an unstable surface such as a wobbly board or a soft plastic disc. Advanced exercises will include agility type exercises such as hopping or moving side to side.  Eventually we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in.  

Generally, the strength and stiffness one experiences after a lower limb fracture responds very well to the Physical Therapy we provide at Synergy Therapeutic Group. With our initial one-on-one Physical Therapy treatment along with the exercises of your home program, the strength, range of motion, and proprioception gradually improve towards near full recovery/function over a period of 3-6 months even though the actual final stages of bone healing won’t occur for another 6-12 months after that. If your pain continues longer than it should or therapy is not progressing as your Synergy Therapeutic Group Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the fracture site is tolerating the rehabilitation well and ensure that there are no hardware issues that may be impeding your recovery.

Synergy Therapeutic Group provides services for Physical Therapy in Carbondale and Du Quoin.

COMPLICATIONS

What are the potential complications of this fracture?

Stiffness

This consequence of the treatment of a fracture of the tibia makes it clear that the process can sometimes take a long time. Not using the muscles and joints for an extended period can result in deterioration and an increased risk of posttraumatic osteoarthritis of the knee or ankle. This was more common when long leg casts were used for extended periods. The injury itself does not damage the joints (although the muscles may certainly be injured) so early mobilization is effective in preventing this complication. In order to prevent this complication an exercise program as outlined in the Rehabilitation section is needed once the bone is healed strongly enough to withstand stress.

Fat Embolism Syndrome (FES)

This rare but serious condition can occur after about one in fifty tibial fractures. Fat globules from the bone marrow enter the blood circulation via damaged vessels and pass to the lungs and brain. Under certain conditions this sets up an inflammatory response compromising lung function and clouding consciousness. Often the first sign is confusion, followed by respiratory problems. The condition itself is short lived and self-limiting but the patient may need intensive care, including ventilator support, in the short term. Formerly, this rare condition was fatal in 10 percent of FES cases; with early recognition and aggressive supporting treatment this figure is now much less. However, it does remain one of the few complications of otherwise straightforward fractures that can provoke an emergency.

Infection

Open fractures are common tibial injuries and have an increased risk of infection because the bone comes through the skin and is contaminated at the scene of the accident. Surgical site infections can also occur when a fracture is operated on. This means that infections caused by bacteria are seen in a number of patients with tibial fractures (two to five percent). Most patients who have an open fracture or an operation receive antibiotics to reduce the chance of this complication. An infection is suspected when the wound remains red, tender, and swollen longer than normal. If it breaks open, if pus drains from the wound, or if bacteria are cultured from the wound, the diagnosis is confirmed.
High doses of antibiotics are given intravenously and in most cases the wound is opened to clean out dead and infected tissue and prevent pressure build up. In some situations, beads containing antibiotics are placed in the wound for a few days to achieve high local levels of the medication.

Fixation of the fracture is usually maintained until the fracture is healed. Then the implants may be removed because cracks or scratches on the surface may harbor bacteria.

The aim of treatment is to heal the infection and the fracture. Established bone infection may be very difficult to eliminate and may cause failure of healing. Most often the measures taken to treat the infection do result in healing the fracture and eliminating the infection. It is undeniable, however, that an infection results in a lot more trouble and usually some additional surgery.

Compartment Syndrome

Compartment syndrome occurs when bleeding into the muscle compartments in the leg raises the intra-compartment pressure to levels that slow or stop blood flow in those compartments. Muscles in the leg (and arm, hand and foot) are contained inside compartments bounded by tough inelastic sheets of fibrous tissue. There are four compartments in the leg. The anterior compartment is the soft region in the front outer side of the leg – to the outer side of the shin bone. The lateral compartment is on the outer side and there are two posterior compartments in the calf at the back of the leg.

Even quite a small amount of bleeding into one or more of these compartments can cause a problem. This problem can be made worse if the leg is compressed from the outside by a cast or tight dressing. The fundamental problem is that the muscle tissue will die if there is insufficient blood supply. Dying muscle is very painful and unremitting pain is the most reliable sign of a compartment syndrome. However, all fractures are painful and it is sometimes difficult to distinguish between the pain that is normally present after a fracture and the pain of a compartment syndrome. In the latter case the pain is made worse by contracting or stretching the affected muscle; this is one of the reasons the doctors, nurses, and Physical Therapists insist that patients move their toes, feet and ankles after a fracture.

If a compartment syndrome is diagnosed an emergency operation is needed to release the pressure. This is called a fasciotomy and may involve a big opening of the skin of the leg. Once the skin is opened the muscle compartments are also split open and the pressurized contents allowed to bulge out. This relieves the pressure and the blood supply to the muscle can resume. If this procedure is done before any muscle dies the long-term outlook is good, although the wound may require skin grafting and be unsightly. If some muscle death (necrosis) has occurred these parts may shorten up causing contractures and clawing of the toes as well as weakness of the affected muscle.

Chronic exertional compartment syndrome sometimes occurs months or years after the injury. When the patient returns to heavier activities or sports he/she finds that the leg rapidly becomes painful. The pain is made worse by moving the foot or pressure over the muscle and is slowly relieved by resting. This condition can be investigated by measuring the intra-compartment pressures before and after exercise. It is relieved by fasciotomy and the outcome after treatment is usually satisfactory.

Nonunion

Of all the long limb bones the tibia has the worst reputation for not healing. Nonunion is a clinical diagnosis. It means that in the doctor’s opinion, the bone will not heal without further intervention. Delayed union is the state where the bone is taking longer than normal to heal but there is sill a chance it will heal without surgery. Obviously there is an overlap between these two complications as all “nonunions” were “delayed unions” at an earlier point.

Clinically, a non-united tibia is found to be painful and to hurt more on bearing weight or on stressing the leg. The pain does not get better with time as occurs with normal healing. Often one cannot feel any movement at the fracture site, but in florid cases one can. The x-ray shows a gap between the fracture fragments and in some cases the formation of a pseudo-joint. It may be necessary to get a CT scan of the region to make sure of the diagnosis. Getting a good image is often made difficult by the presence of metal implants used to treat the fracture.

Treatment of a nonunion is individualized to each different case. Nonunion is more common if the original injury was treated nonoperatively. If surgery has not been undertaken before, the treatment will likely be rigid internal fixation and bone grafting. Bone grafting alone has been used and may be combined with removal of a small section of the fibula if it is thought that the healed fibula is holding the fracture fragments apart. If the fracture has already been operated on the fixation will most likely be replaced with some other system that imposes compression on the fracture site.

In really difficult cases, the Ilizarov technique may be used. The nonunited segment of bone is removed and freshened ends of normal bone are held together with an external frame. A second cut is made in the normal bone higher up the leg and the frame is used to lengthen the bone over time.
In most cases of nonunion surgery does achieve healing and the long- term outlook is good. Infected nonunion is a particularly difficult problem with a higher failure rate. The main adverse long-term outcome is loss of function caused by the prolonged treatment. If it takes years to heal the bone the muscles and joints of the leg are unlikely to recover fully.

Malunion

If the bone heals in a position that is shortened, angulated, or rotated it may be said to be mal-united. Often this is not a significant problem and does not interfere with long-term function. Studies of malunion have not shown a significant risk of later arthritis of the knee or ankle.
Sometimes the degree of shortening or rotation may not be acceptable. Treatment would then require surgical correction of the malalignment. Surgical correction of a malunion requires cutting the bone, restoring the alignment then fixing the tibia using either internal fixation with a plate, intramedullary rod or external fixation device. These methods are usually successful in correcting the problem and giving a good long-term outcome.

Summary

A fracture of the leg below the knee usually involves both bones of the shin, the tibia and the fibula. Fractures of the tibia are serious injuries which take many months to heal. There is a wide spectrum of injury from simple stable spiral fractures to severe open injuries with bone loss and massive damage to muscle, nerve and blood vessels. In most cases treatment is successful in its aims of saving the patient’s life and limb, healing the fracture, and restoring function, but treatment can be prolonged and there are many complications to avoid.

Portions of this document copyright MMG, LLC


INTRODUCTION

 Physical Therapy in Carbondale and Du Quoin for Ankle

Welcome to Synergy Therapeutic Group’s patient resource about ankle sprain and instability.

An ankle sprain is a common injury and usually results when the ankle is twisted, or turned in (inverted). The term sprain signifies injury to the soft tissues, usually the ligaments, of the ankle.

This guide will help you understand:

  • how an ankle sprain occurs
  • how the condition is diagnosed
  • what can be done to treat a sprain

ANATOMY

What part of the ankle is involved?

Ligaments are tough bands of tissue that help connect bones together. Three ligaments make up the lateral ligament complex on the side of the ankle farthest from the other ankle. They are the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The common inversion injury to the ankle usually involves Two ligaments, the ATFL and CFL. Normally, the ATFL keeps the ankle from sliding forward, and the CFL keeps the ankle from rolling inward on its side.

Ankle Ligaments

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Why do I have this problem?

A ligament is made up of multiple strands of connective tissue, similar to a nylon rope. A sprain results in stretching or tearing of the ligaments. Minor sprains only stretch the ligament. A tear may be either a complete tear of all the strands of the ligament or a partial tear of only some of the strands. The ligament is weakened by the injury; how much it is weakened depends on the degree of the sprain.

Connective Tissue

The lateral ligaments are by far the most commonly injured ligaments in a typical inversion injury of the ankle. In an inversion injury the ankle tilts inward, meaning the bottom of the foot angles toward the other foot. This forces all the pressure of your body weight onto the outside edge of the ankle. As a result, the ligaments on the outside of the ankle are stretched and possibly torn.

A severe form of ankle sprain, called an ankle syndesmosis injury, involves damage to other supportive ligaments in the ankle. This type of injury is sometimes called a high ankle sprain because it involves the ligaments above the ankle joint. In an ankle syndesmosis injury, at least one of the ligaments connecting the tibia and fibula bones (the lower leg bones) is sprained. Recovering from even mild injuries of this type takes at least twice as long as from a typical ankle sprain.

Related Document: Synergy Therapeutic Group’s Guide to Ankle Syndesmosis Injuries

SYMPTOMS

What does an ankle sprain feel like?

Initially the ankle is swollen, painful, and may turn ecchymotic (bruised). The bruising and swelling are due to ruptured blood vessels from the tearing of the soft tissues. Most of the initial swelling is actually bleeding into the surrounding tissues. The ankle swells as extra fluid continues to leak into the tissues over the 24 hours following the sprain.

People who have sprained an ankle often end up spraining the ankle again. If the ankle keeps turning in with activity, the condition is called ankle instability. Patients who have ankle instability lose confidence in their ankle to support them, especially on uneven ground. They often have swelling around the ankle that doesn’t go away. Pain and swelling in a joint can cause a reflex where the body turns off the muscles around the joint. This can cause times when the ankle feels like it is going to give way, meaning it may have a tendency to twist again very easily.

People who have had several mild ankle sprains or one severe sprain are prone to impingement problems in the ankle. The ligaments that were sprained may become irritated and thickened, causing them to get pinched near the edge of the ankle joint.

Related Document: Synergy Therapeutic Group’s Guide to Ankle Impingement Problems

DIAGNOSIS: ANKLE SPRAIN PHYSICAL THERAPY IN CARBONDALE AND DU QUOIN.

Following an assessment your Physical Therapist at Synergy Therapeutic Group will advise you of the findings and  create an individualized therapy program.

He or she may request additional testing to help define the true nature of your injury. Below is a guideline of what you might expect during rehabilitation for an ankle injury.

When you visit Synergy Therapeutic Group, we will do a physical examination to evaluate the injury and determine which ligament has been injured.

Our Physical Therapist will move your ankle in different positions in order to check the ligaments and other soft tissues around the ankle.

Some of our tests involve placing stress directly on the ankle ligaments to see if the ankle has become unstable and to find out if one or more ligaments have been partially or completely torn. If a complete rupture of the ligaments is suspected, our therapist may refer you to a doctor for stress X-rays.

TREATMENT: ANKLE SPRAIN PHYSICAL THERAPY IN CARBONDALE AND DU QUOIN.

Non-surgical Rehabilitation 

Even if you don’t need surgery, you will likely need to follow a program of rehabilitation and exercise for your ankle injury. When you visit Synergy Therapeutic Group for Physical Therapy in Carbondale and Du Quoin, we can create a program to help you regain ankle function. It is very important to improve strength and coordination in the ankle.

Swelling and pain are treated with modalities like ice or electrical stimulation. If swelling in the ankle is severe, our therapist may also apply massage strokes from the ankle toward the knee with your leg kept in an elevated position. This helps get the excess tissue fluid moving out of the ankle and back into circulation. Your Physical Therapist may issue a compression wrap and instruct you to wrap your ankle and lower limb and to elevate your leg.

Many of the specific nonsurgical treatment options that we use at Synergy Therapeutic Group depend on whether your problem is an ankle sprain or ankle instability.

Ankle Sprain

The best results after an ankle sprain come when treatment is started right away. Our Physical Therapists will use treatments to stop the swelling, ease pain, and protect the injured ankle from weight-bearing activities. A simple way to remember the essential steps of initial treatment is by the letters in the word RICE. These stand for rest, ice, compression, and elevation.

  • Rest: The injured tissues in the ankle need time to heal. Crutches will prevent too much weight from being placed on the ankle in the early days after injury.
  • Ice: Applying ice can help ease pain and may reduce swelling.
  • Compression: Gentle compression pushes extra swelling away from the ankle. This is usually accomplished by using an elastic wrap or compression sock.
  • Elevation: Supporting your ankle above the level of your heart helps control swelling.


Our Physical Therapists may also apply specific hands-on treatment called joint mobilization to improve normal joint motion. These treatments restore the natural gliding motion between the ankle bones that may be restricted following injury. This form of treatment speeds healing and improves function after an ankle sprain. It may also help clients to return more quickly to their activity or sport.

Small nerve sensors inside the ligament are injured when a ligament is stretched or torn. These nerve sensors give your brain information about the position of your joints, a sensation called proprioception or position sense. For example, nerve sensors in your arm and hand give you the ability to touch your nose when your eyes are closed. The ligaments in the ankle work the same way. They send information to your nervous system to alert you about the position of your ankle joint. Our Physical Therapist will help you retrain your position sense as a way to steady the ankle joint and protect you from spraining your ankle again.

Another effective treatment for ankle sprains is disc training using a circular platform with a small sphere under it. While sitting or standing, patients place their feet on the platform and work the ankle by tilting the disc in various directions. This form of exercise strengthens the muscles around the ankle, and improves balance and joint position sense.

Your Physical Therapist may also recommend medications. Mild pain relievers may help with the discomfort. Anti-inflammatory medications can help ease pain and swelling and get people back to activity sooner after an ankle sprain. These medications include common over-the-counter drugs such as ibuprofen. Talk to your doctor or pharmacist if you have specific questions about which pain reliever is right for you.

As treatment progresses, our Physical Therapist will have you gradually begin putting weight through the joint. Casts are uncommon unless the sprain is very severe or the ankle is broken because soft tissues weaken when they are kept immobile. Braces are available that can be worn to support the ankle, but still allow weight bearing. These are the most popular treatment for helping reduce strain on the healing tissues.

When you get full ankle movement, your ankle isn’t swelling, and your strength is improving, our Physical Therapist will help you gradually get back to your work and sport activities. We may issue an ankle brace for athletes who intend to return quickly to their sport. 

Although the time required for recovery is different for each patient, healing of the ligaments usually takes about four to six weeks, but swelling may be present for several months. 

Physical Therapy for Ankle Instability in Carbondale and Du Quoin

If the ankle ligaments do not heal adequately, you may end up with ankle instability. This can cause the ankle to give way and feel untrustworthy on uneven terrain. If your ankle ligaments do not heal adequately following an ankle sprain, your Physical Therapist may suggest several things.

We may recommend changes in your footwear to help keep your ankle from turning in. Placing a heel wedge under the outer half of your heel blocks the ankle from rolling, as does a flared heel built into your shoe. In extreme cases, our therapist may prescribe a plastic brace, called an orthosis, to firmly hold your ankle from rocking side to side. Some patients feel a sense of steadiness from wearing high-topped shoes. Patients with ankle instability should avoid wearing high-heeled shoes.

Physical Therapy treatments at Synergy Therapeutic Group will likely be initiated to help restore joint range of motion, strength, and joint stability. Many people who have ankle instability have weakness in the muscles along the outside of the leg and ankle. These are called the peroneal muscles. Our Physical Therapist can teach you strengthening exercises for these muscles to help you control the ankle joint and improve joint position sense.

Post-surgical Rehabilitation

Patients usually take part in formal Physical Therapy after surgery. Rehabilitation after surgery can be a slow process. Although the time required for recovery varies, as a general guideline you should expect to attend Physical Therapy sessions for two to three months, and should expect full recovery to occur over six months.

Rehabilitation proceeds cautiously after reconstruction of the ankle ligaments. Most patients are prescribed an ankle brace to wear when they are up and about, and they are strongly advised to follow the recommendations about how much weight can be borne while standing or walking.  You may be restricted to non-weight bearing for up to 12 weeks. We will also provide you with instructions to make sure you are using crutches safely and only bearing the recommended amount of weight on your foot.

Your first few Physical Therapy treatments are designed to help control pain and swelling from the surgery. Our Physical Therapist may use ice and electrical stimulation treatments during your first few therapy sessions, progressing to massage and other hands-on treatments to ease muscle spasm and pain. Our Physical Therapist will use treatments to help improve your ankle range of motion without putting too much strain on the healing ligaments.

After about six weeks we may have you begin doing more active exercise. Exercises are used to improve the strength in the peroneal muscles. Our Physical Therapist in Carbondale and Du Quoin will also help you retrain position sense in the ankle joint to improve the stability of the joint.

At Synergy Therapeutic Group, our goal is to help you keep your pain under control, improve range of motion, and maximize strength and control in your ankle. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Synergy Therapeutic Group provides Physical Therapy in Carbondale and Du Quoin.

PHYSICIAN REVIEW

If a complete rupture of the ligaments is suspected, you may need to see a doctor for stress X-rays. These X-rays are taken while the ligaments are placed in a stretched position. The X-ray will show a slight tilt in the ankle bone if the ligaments have been torn.

SURGERY

Surgeons will occasionally do procedures right away in athletes who tear a lateral ankle ligament. In most other cases of torn ankle ligaments, surgeons will try nonsurgical treatments before doing reconstructive surgery of the ligaments.

Ligament Tightening Procedure

Chronic ankle instability can happen when the lateral ankle ligaments are stretched or torn and the ankle keeps giving way. Surgery can be done to tighten the stretched ligaments and improve the stability of the ankle. The surgery usually involves the ATFL and the CFL.

In this procedure, an incision is made in the skin that lies over the lateral ligaments. Using a scalpel, the surgeon cuts the ATFL and CFL in half.

Holes are drilled along the lower end of the fibula bone, the small bone of the lower leg. The two ends of the cut ligament are overlapped and sewn together. The surgeon uses the drill holes in the fibula to hold the stitches to the bone.

A large band of connective tissue crosses the front of the ankle just below the lateral ligaments. This band, called the ankle retinaculum, holds the tendons in place. The surgeon pulls the top edge of the ankle retinaculum upward and sews it into the fibula. This helps reinforce the reconstructed ligaments.

The following images show each step of the ligament tightening procedure:

Step 1


Step 2

Step 3

Step 4

Tendon Graft Procedure

Another type of reconstruction is done using a tendon graft. If your surgeon feels that the stretched and scarred ligaments are not strong enough to simply repair in a ligament tightening procedure, then the ligaments must be reinforced with a tendon graft.

In this procedure, the surgeon removes a portion of one of the nearby tendons to use as a tendon graft. The tendon most commonly used attaches the peroneus brevis muscle to the outside edge of the small toe. A section of this tendon is put in place of the torn lateral ligaments.

After making the skin incision, the surgeon drills a hole in the fibula near the attachment of the original ligament. A second drill hole is made in the area where the ligament attaches on the talus (the anklebone).

The tendon graft is then removed (or harvested) and woven between these holes to recreate the ligament complex.

After surgery, you will probably be placed in a cast or brace for about six weeks to allow the tendon reconstruction to heal. Following removal of the cast, Physical Therapy will be required to regain full use of the ankle.

Portions of this document copyright MMG, LLC.


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Shin Splints

Welcome to Synergy Therapeutic Group’s patient resource about Shin Splints.

Pain along the front or inside edge of the shinbone (tibia) is commonly referred to as shin splints. The problem is common in athletes who run and jump. It is usually caused by doing too much, too quickly. The runner with this condition typically reports a recent change in training, such as increasing the usual pace, adding distance, or changing running surfaces. People who haven’t run for awhile are especially prone to shin splints after they first get started, especially when they run downhill. Shin splints on the front of the tibia are called anterior shin splints. Posterior shin splints cause pain along the inside edge of the lower leg.

This guide will help you understand:

  • how shin splints start
  • what shin splints feel like
  • how this condition is treated

ANATOMY

What parts of the leg are involved?

The lower leg is made up of two bones. The shinbone is the larger of the two bones. It is called the tibia. The small, thin bone that runs alongside the tibia from the knee to the ankle is the fibula.

The tibia and fibula provide a connecting point for several muscles that move the foot. The main muscle that bends the foot upward connects on the front (anterior) of the tibia. It is called the anterior tibialis. The posterior tibialis, which pulls the foot down and in, attaches along the back (posterior) and inside edge of the tibia. Together, the anterior and posterior tibialis muscles are called the tibialis muscles.

The tibialis muscles have tiny fibers that fasten the muscle to the bony surface of the tibia. This bony covering, or membrane, is called the periosteum (peri means around, and osteum means bone).

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Why do I have shin splints?

Shin splints usually result from overuse. Repeated movements of the foot can cause damage where the tibialis muscles attach to the tibia. Soon the edge of the muscles may begin to pull away from the bone. The injured muscle and the bone covering (the periosteum) become inflamed.

Overuse commonly happens after changes in training. Increasing running speed and distance and running on hard or angled surfaces can contribute to overuse. Overuse can also occur from running in flimsy footwear or in shoes with soles that are worn out.

Anterior shin splints tend to affect people who take up a new activity, such as jogging, sprinting, or playing sports that require quick starts and stops. The unfamiliar forces place a heavy strain on the anterior tibialis muscle, causing it to become irritated and inflamed. This commonly happens when people who aren’t regular runners decide to go on a long jog. The anterior tibialis muscle must work hard to control the landing of the forefoot with each stride. Running downhill puts even more demands on this muscle in order to keep the forefoot from slapping down. People who run on the balls of their feet or who run in shoes with poor shock absorption also tend to get anterior shin splints.

Posterior shin splints are generally caused by imbalances in the leg and foot. Muscle imbalances from tight calf muscles can cause this condition. Imbalances in foot alignment, such as having flat arches (called pronation), can also cause posterior shin splints. As the foot flattens out with each step, the posterior tibialis muscle gets stretched, causing it to repeatedly tug on its attachment to the tibia. The posterior tibialis muscle attachment eventually becomes damaged, leading to pain and inflammation along the inside edge of the lower leg.

A stress fracture in the tibia is a serious problem that at first may have the same symptoms as shin splints. A stress fracture is a crack in a weakened area of bone. Continual stresses from running on hard surfaces or from heavy strain in the tibialis muscles can weaken and eventually fracture the tibia. People with shin pain who try to work through it sometimes end up developing a stress fracture in the tibia.

A concerning complication of shin splints is compartment syndrome. Compartment syndrome is a condition where pressure from muscle damage and swelling builds up inside a section, or compartment, within the body. There are four compartments in the lower limb. As the pressure builds in the compartment, the small blood vessels (called capillaries) that supply blood to the muscles in the compartment are squeezed shut. This happens when the pressure in the compartment is higher than the blood pressure that keeps the small blood vessels open. When the muscle loses its blood supply it begins to ache, like a muscle cramp.

If the pressure continues to rise, it can squeeze the larger blood vessels and nerves as well. Patients may feel coldness, numbness, and swelling in the lower leg and foot. If pressure builds up and is not treated, it can cause serious tissue damage in the leg and foot.

Pressure

SYMPTOMS

What do shin splints feel like?

Dull, aching pain is felt where the involved tibialis muscle attaches to the tibia. Redness and swelling can also occur in this area. Tenderness is felt where the muscle attaches to the bone.

Anterior shin splints are usually felt on the front of the tibia, especially when using the anterior tibialis muscle to bend your foot upward.

Posterior shin splints produce symptoms along the inside edge of the lower leg. Small bumps may also be felt along the edge of the tibia in this area.

Symptoms of shin splints generally get worse with activity and ease with rest. Pain may be worse when you first get up after sleeping. The sore tibialis muscle shortens while you rest, and it stretches painfully when you put weight on your foot.

DIAGNOSIS

The diagnosis of shin splints is usually made through physical examination and evaluation of your medical history. When you visit Synergy Therapeutic Group, our Physical Therapists will ask questions about your training schedule, footwear and may also want to know whether you’ve recently begun a new sport that requires running or jumping.

The physical examination allows us see exactly where your leg hurts. We may move your ankle in different positions and have you hold your foot against applied pressure. By stretching the tibialis muscles, and by feeling where these muscles attach on the tibia, we can begin to tell where the problem is.

A test for measuring pressure in the sore leg may be needed if you have symptoms of compartment syndrome. Our Physical Therapist checks pressures within the tissues of the leg, before and after exercise, to see if exercise causes the pressure readings to go up.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at Synergy Therapeutic Group have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Synergy Therapeutic Group provides services for Physical Therapy in Carbondale and Du Quoin.

OUR TREATMENT

Non-surgical Rehabilitation

The Physical Therapists at Synergy Therapeutic Group will help you recover through treatments designed to reduce pain and inflammation and, whenever possible, address the underlying problems causing your shin splints. The length of the Physical Therapy program varies for each patient, but as a guideline, you might expect to devote four to six weeks to your recovery and rehabilitation.

Reducing Inflammation

The purpose of your initial treatments at Synergy Therapeutic Group will be to reduce inflammation.Some of our patients suffering from shin splints receive iontophoresis, a technique where a mild electrical current is used to push a topical steroid medicine into the sore area. Ultrasound treatments, often used in combination with topical steroids, are also effective in halting pain and inflammation.To speed your recovery, our Physical Therapists may also use deep tissue massage along the junction where the sore tibialis muscle meets the tibia, followed by gentle stretching of the calf and tibialis muscles.

Our Physical Therapists will show you how to properly ice, rest, and if necessary, tape the injured area. Special taping techniques may be used to support the sore tissues and ease pain. However, we recommend that taping be used to help the area heal, not as a way to keep on training.

Foot Support

Your Synergy Therapeutic Group specialist will evaluate your posture and alignment to see if you have problems with pronation (arch flattening), a condition that we commonly see associated with posterior shin splints. Sometimes a small heel wedge, placed under the inside edge of the heel, is enough to ease tension on the posterior tibialis muscle. For more severe problems of pronation, we may recommend foot orthotics to support the arch and reduce stresses on the posterior tibialis muscle.

Rest and Recovery

During your recovery, stop doing the activity that caused the problem and avoid heavy training and sports activity for three to four weeks, or at least until the symptoms are under control. Rest and the application of cold packs play a key role in decreasing pain and inflammation in the early stages of treatment. Only after the pain starts to go away, should you begin to resume your normal routine.

Resuming Activity

As your pain starts to go away and you begin doing more normal activities, we will help you develop a recovery program to avoid overuse while training. This may include evaluating your running style, and suggesting tips on footwear and the use of shock-absorbing insoles. Knowing your training schedule, pace, and the surface you use can guide us in making personal recommendations as you attempt to safely resume your sport.

Post-surgical Rehabilitation

If surgery is required, your Synergy Therapeutic Group rehabilitation program will have some additional elements. You may need to use crutches for several days after surgery. Many patients are able to bear some weight on their foot within the first week. A protective dressing will cover your incisions, and the stitches are usually removed within 10 to 14 days (unless they are absorbable stitches, which will not need to be taken out).

Our Physical Therapists will help you recover and gradually return to your normal activity level. We may recommend the use of a stationary bike within 10 to 14 days of your surgery. If you are a runner, our Physical Therapy program may enable you to begin a light jogging program within six weeks and resume full activity within eight to 10 weeks, although the time required for recovery and rehabilitation varies for each individual.

Synergy Therapeutic Group provides Physical Therapy in Carbondale and Du Quoin.

PHYSICIAN REVIEW

Your doctor may order X-rays to make sure you don’t have a stress fracture. However, recent stress injuries may not show up on X-ray for the first few weeks. In these cases, a bone scan may be ordered. A bone scan involves injecting tracers into your blood stream. The tracers then show up on special X-rays of your leg. The tracers build up in areas of extra stress to bone tissue. The extra stress can be caused by a stress fracture or an inflamed periosteum (bony covering). This condition is called periostitis.

Your doctor may also order a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to create pictures of your body in slices. The MRI scan shows tendons as well as bones. It also shows abnormal swelling or scar tissue. An MRI is painless and requires no needles or injections.

SURGERY

Surgery is rarely needed to correct problems of shin splints. However, shin splints that are complicated by compartment syndrome may require surgery, sometimes immediately.

If compartment syndrome is discovered and diagnostic tests show high pressures within the tissues of the lower leg, surgery may be recommended right away. The procedure to remove the pressure is called fasciotomyFascia is the connective tissue around and between muscles and organs. The surgeon makes a few small incisionson either side of the lower leg. The nearby layer of fascia within several compartments is cut and removed to reduce the pressure within the compartment. The incisions are left open at first. Tissue pressures are checked over a period of two to three days. The wounds are then closed.

If the problem has been present for more than three months, the surgeon may only need to make one or two incisions to cut the layer of fascia and reduce pressure inside a single problem compartment.

Portions of this document copyright MMG, LLC


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Ankle

Welcome to Synergy Therapeutic Group’s patient resource about Peroneal Tendon Subluxation.

The peroneals are two muscles and their tendons that attach along the outer edge of the lower leg. The peroneal tendons are enclosed in a fibrous tunnel that runs behind the outside ankle bone (the lateral malleolus). Damage or injury to the structures that form and support this tunnel may lead to a condition in which the peroneal tendons snap out of place. This condition is called peroneal tendon subluxation.

This article will help you understand:

  • how peroneal tendon subluxation happens
  • how doctors diagnose the condition
  • what can be done to treat this problem

ANATOMY

The primary muscles supporting the lateral (outer) part of the ankle are the peroneals. These two muscles and their tendons lie along the outside of the lower leg bone (fibula) and cross behind the lateral malleolus (the outside ankle bone).

Lateral Part of Ankle

The tendons of the peroneal muscles pass together through a groove behind the lateral malleolus. The tendons are kept within the groove by a sheath that forms a tunnel around the tendons. The surface of this sheath is reinforced by a band of ligament called a retinaculum. Contracting the peroneals makes the tendons glide in the groove like a pulley. This pulley action points the foot downward (plantarflexion) and outward (eversion).

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Tendons attach muscles to bone. Tightening a muscle puts tension on the tendon, which can move bone. Many tendons in the body are held in place by supportive connective tissue, such as a ligament or retinaculum. If the supportive tissue has been damaged or injured, the tendon may be free to slip out of its normal position. This is called subluxation. When the subluxed tendon slips back into place, this is called relocating. A tendon that forcefully snaps out of position and can’t relocate has dislocated.

Damaged Supportive Tissue

Subluxation

The main cause of peroneal tendon subluxation is an ankle sprain. A sprain that injures the ligaments on the outer edge of the ankle can also damage the peroneal tendons. During the typical inversion ankle sprain, the foot rolls in. The forceful stretch on the peroneals can rip the retinaculum that keeps the peroneal tendons positioned in the groove. As a result, the tendons can jump out of the groove. The tendons usually relocate by snapping back into place.

The injury to the retinaculum may be overlooked at first while treatment focuses on the injury to other ankle ligaments. This means the subluxation may begin much later, and it may not seem to be caused by the initial ankle sprain. If not corrected, this snapping of the tendons can become a chronic and recurring problem.

An acute dislocation of the peroneal tendons is rare. It occasionally happens during sport activities that force the foot up and in, for example during skiing, ice skating, or soccer. At the moment the foot turns up and in, the peroneals violently contract to protect the ankle. This can cause the retinaculum to tear, allowing the tendons to slip out of the groove.

Differences in the anatomy of the groove may predispose some people to peroneal tendon subluxations. The groove may be too shallow. Or the ridge that helps deepen this groove may be too small or even absent. Sometimes, the retinaculum that keeps the tendons in the groove may be too loose. In these cases, patients may not recall any injury to explain the persistent snapping of the peroneal tendons.

SYMPTOMS

What does peroneal tendon subluxation feel like?

Patients describe a popping or snapping sensation on the outer edge of the ankle. The tendons may even be seen to slip out of place along the lower tip of the fibula. It is common to feel pain and tenderness along the tendons. There may also be swelling just behind the bottom edge of the fibula.

DIAGNOSIS

Diagnosis of peroneal subluxation begins with an examination of the ankle. Your Physical Therapist at Synergy Therapeutic Group will move your ankle into different positions to see when the tendons snap out of place and if they relocate. One test involves holding pressure down on the ankle as you pull your foot up and out. Our Physical Therapist feels behind the fibula during this test to determine if the tendons are popping out of place. If your Physical Therapist in Carbondale and Du Quoinsuspects a tear in the retinaculum, you may be referred for additional medical evaluation by a doctor.

OUR TREATMENT

Non-surgical Rehabilitation

Nonsurgical treatment for peroneal tendon subluxations includes a program of rehabilitation exercises to help control symptoms. At Synergy Therapeutic Group, our Physical Therapists will create a specialized program to help you improve the strength and coordination of your ankle, and more quickly regain normal ankle function.

Post-surgical Rehabilitation

When you visit Synergy Therapeutic Group, your initial treatments will be used to help control pain and swelling from the surgery. Our Physical Therapist may apply ice and electrical stimulation during your first few Physical Therapy sessions, as well as massage and other hands-on treatments to ease muscle spasm and pain. Our Physical Therapy is designed to help improve ankle range of motion without putting too much strain on the injured area.

Typically, after about six weeks of treatment, our therapist will help you increase your activity level. Your Synergy Therapeutic Group Physical Therapist will slowly add exercises to improve the strength in your peroneal muscles and help you regain position sense in your ankle joint to improve its overall stability.

Rehabilitation after surgery can be a slow process, but our professionals will custom design a Physical Therapy program to speed your recovery. Recovery and rehabilitation varies for each patient, but as a guideline, you may expect to attend our therapy sessions for two to three months, with full recovery typically requiring up to six months.

At Synergy Therapeutic Group, our goal is to help manage your pain, improve your range of motion, and maximize strength and control in your ankle. When your recovery is well under way, regular visits to our office will end. We will continue to be a supportive resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Synergy Therapeutic Group provides Physical Therapy services in Carbondale and Du Quoin.

PHYSICIAN REVIEW

If your doctor suspects a tear in the retinaculum, X-rays may be taken to determine if the torn retinaculum has pulled off a piece of the fibula bone. This is called an avulsion fracture. X-rays are also used to look for other injuries to the ankle.

Your doctor may also order a magnetic resonance imaging (MRI) scan of your ankle. MRI scans can show abnormal swelling and scar tissue or tears in the tendons. However, MRIs won’t always show subluxation of the peroneal tendons.

If your injury is acute, treatment without surgery may involve placing your ankle in a short-leg cast for four to six weeks. Your physician may also prescribe medications. Anti-inflammatories can help ease pain and swelling and get you back to activity sooner. These medications include common over-the-counter drugs such as ibuprofen. The goals are to allow the torn retinaculum to heal and to prevent chronic subluxation. Your doctor may advise you to begin Physical Therapy once the cast is removed.

SURGERY

Many patients with peroneal tendon subluxation will eventually require surgery, especially when symptoms have not been controlled with nonsurgical measures. The following are different surgical procedures designed to help the peroneal tendons remain in their proper position.

Retinaculum Repair

Retinaculum repair is gaining popularity. This procedure restores the normal anatomy of the retinaculum that covers and reinforces the tendon sheath around the peroneal tendons.

In surgery to repair the retinaculum, the surgeon first makes an incision along the back and lower edge of the fibula bone. This lets the surgeon see the spot where the retinaculum is torn.

Incision

The surgeon uses a burr to create a trough along the fibula bone next to the original attachment of the retinaculum. The torn edge of the retinaculum is then pulled into the trough and sutured in place. The skin is closed with stitches.

Sutured

Groove Reconstruction

Groove reconstruction is done to deepen the groove so the peroneals stay in place behind the bottom tip of the fibula. In this procedure, the surgeon first makes an incision along the back and lower edge of the fibula bone.

Incision

The surgeon cuts a small flap in the bone near the bottom corner of the fibula. The surgeon then carefully folds the flap back, like a hinge. With the hinge held open, the doctor scoops out a small amount of bone under the flap to deepen the groove.

Deepen the Groove

The surgeon closes the flap on its hinge and tamps it in place. A screw may be used to hold the flap down.

Closing the Flap

Next, the tendons are returned to their location behind the tip of the fibula. Repair of the retinaculum may also be required with this procedure (see above). The skin is closed and sutured.

Bony Blocks

The purpose of a bony block is to form a barrier that keeps the tendons from slipping out of place. The block is usually formed with bone taken from the lower end of the fibula bone.

To create a bony block, the surgeon opens the skin along the lower edge of the fibula. The surgeon then measures a small area on the back of the fibula, near the lower tip of the bone. A special tool is used to cut this small section of the fibula. The cut only goes partway through the bone.

The surgeon slides the small block of bone backward, out of its original spot. The bone may be rotated slightly to create a solid barrier that will help keep the tendons from sliding around the lower edge of the fibula. A screw is inserted through the small block of bone into the fibula. The screw keeps the bony block in its new location until it heals.

The surgeon checks the fit to make sure the tendons can glide behind the new block of bone without slipping out of place. The skin is then closed and sutured.

Portions of this document copyright MMG, LLC.


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Ankle

Welcome to Synergy Therapeutic Group’s patient resource about Peroneal Tendon Problems.

Problems affecting the two peroneal tendons that lie behind the outer ankle bone (the lateral malleolus) are common in athletes. These problems mainly occur in the area where the two tendons glide within a fibrous tunnel behind the lateral malleolus.

This guide will help you understand:

  • how peroneal tendon problems develop
  • how doctors diagnose the condition
  • what can be done to treat this problem

ANATOMY

The peroneals are two muscles and their tendons that lie along the outside of the lower leg bone (the fibula) and cross behind the lateral malleolus (the outer ankle bone). The term medial refers to a point closer to the center of the body. So the ankle bump on the inside edge of the ankle (closest to your other ankle) is the medial malleolus. The term lateral refers to structures furthest from the center. Major muscles that support the lateral part of the ankle are the peroneus longus and the peroneus brevis.

The tendons of these two muscles pass together in a groove behind the lateral malleolus. (Tendons attach muscles to bones.) The tendons are kept within the groove by a sheath that forms a tunnel around the tendons. The surface of the tunnel is reinforced by a band of tissue called a retinaculum. Contracting the peroneal muscles makes the tendons glide in the groove like a pulley. The pulley action causes the foot to point downward (plantarflexion) and outward (eversion).

Downward (Plantarflexion)

Outward (Eversion)

Animation of plantarflexionAnimation of eversion
  

The peroneus brevis tendon connects to a bump on the base of the fifth metatarsal. This spot can be felt midway down the outer edge of the foot.

Peroneus Brevis Tendon

The peroneus longus tendon lies behind and below the peroneus brevis tendon. It wraps down and under the foot by way of the cuboid bone, the outer tarsal bone just in front of the heelbone (the calcaneus). The peroneus longus tendon angles forward under the sole of the foot and connects to the bottom of the main bone of the big toe. This tendon stabilizes the arch of the foot when walking.

Peroneus Longus Tendon

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Why do I have this problem?

Peroneal tendon problems mostly occur where the tendons glide within the pulley behind the lateral malleolus. Their movement can cause irritation of the lining of the tendons. This condition is called tenosynovitis. The irritation can also occur after an ankle injury, such as a blow to the outside of the ankle or an ankle sprain.

Repetitive ankle motions in sports, such as running and jumping, can lead to wear and tear on the tendons inside the groove. A high arch puts extra tension on the peroneal tendons within the groove and has also been found to cause peroneal tendon problems.

Peroneal tendon problems commonly occur from an ankle sprain. During the typical inversion ankle sprain, the foot rolls in. This type of injury sprains or tears the ligaments that support the lateral part of the ankle. The forceful stretch on the peroneals when the foot rolls in can also cause a lengthwise tear in the peroneal tendons.

An inversion ankle sprain can also cause the peroneal tendons to momentarily slip out of the groove. This is called subluxation. Peroneal tendonitis often occurs during the recovery period after an ankle sprain. Because the ankle is unstable, the peroneals may need to work harder to give needed support to the damaged lateral ankle ligaments. The overwork sets them up for subluxation.

Related Document: Synergy Therapeutic Group’s Guide to Peroneal Tendon Subluxation

In some patients, a peroneal tendon problem is caused by degenerative changes in the tendons themselves rather than by inflammation around the tendons. The tendon itself becomes abnormal. Doctors call this condition tendonosis.

In tendonosis, the tendon becomes weakened. Tendons are made up of strands of a material called collagen. (If you think of a tendon as a nylon rope, the collagen is the nylon strands.) Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, some fibers break, and the tendon loses strength.

Collagen

Degeneration

Over time, the tendon thickens as scar tissue tries to repair the damaged tendon. The area of tendonosis in the tendon is weaker than normal tendon. The weakened, degenerative tendon may tear. This usually causes a lengthwise split in the peroneal tendons rather than a rupture. These splits or tears are most common in the peroneus brevis tendon, probably because it lies in front of the peroneus longus. It is more vulnerable to friction because it rubs against the groove in the fibula bone.

Tendon Splits

SYMPTOMS

What do peroneal tendon problems feel like?

Patients with peroneal tendon problems usually describe pain in the outer part of the ankle or just behind the lateral malleolus. This pain commonly worsens with activity and eases with rest. Patients may have swelling behind or under the lateral malleolus. They may notice more pain when pressure is applied along the tendons.

DIAGNOSIS

The diagnosis of peroneal tendonitis is usually made by examination of the ankle. The physical examination helps determine where the tendons are inflamed, ruptured, or degenerated. Your Physical Therapist at Synergy Therapeutic Group will move your ankle into different positions, checking the peroneal tendons by holding your foot up and out against the therapists downward pressure. Stretching the foot up and in can also be used test whether the tendons hurt.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at Synergy Therapeutic Group have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

OUR TREATMENT

Nonsurgical treatment for peroneal tendon problems helps control symptoms. Surgery is usually not considered until it has become impossible to control symptoms without it.

Non-surgical Rehabilitation

Even if you don’t require surgery, you may need to follow a program of rehabilitation exercises. The Physical Therapists at Synergy Therapeutic Group can create a program to help you regain normal ankle function, improving strength and coordination your ankle.

Initial treatments may involve resting and protecting the sore tendons. We may need to immobilize your foot and lower leg in a short-leg walking boot for two to four weeks. In less severe cases, we may have you use a stirrup ankle brace, arch support, or lateral heel wedge to take tension off the sore tendons.

Your Physical Therapist may use heat, ice, and ultrasound treatments to reduce pain and swelling. Stretching, strengthening, and ankle coordination exercises are sometimes added as symptoms ease.

Post-surgical Rehabilitation

Patients with peroneal tendon problems are usually placed in a short-leg cast for four to six weeks after surgery, then a special walking boot may be worn for another four weeks. Rehabilitation after surgery can be a slow process. Although recovery varies for each patient, as a guideline, you may need to attend Physical Therapy sessions at Synergy Therapeutic Group for one to two months, and you should expect full recovery to take up to four months.

Your first few Physical Therapy treatments at Synergy Therapeutic Group are designed to help control pain and swelling from the surgery. Our therapist may use ice and electrical stimulation treatments during your first few Physical Therapy sessions, in addition to massage and other hands-on procedures to ease muscle spasm and pain. We also provide treatments to help improve ankle range of motion without putting too much strain on the healing tendons.

It is possible that, after about four weeks you may be able to incorporate more active exercise. Your Physical Therapist will slowly add exercises improve the strength in your peroneal muscles. We will also help you regain position sense in the ankle joint to improve its overall stability.

At Synergy Therapeutic Group, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your ankle. When you are well under way, regular visits to our office will end. Although we will continue to be a resource,  you will be in charge of doing your exercises as part of an ongoing home program.

Synergy Therapeutic Group provides Physical Therapy services in Carbondale and Du Quoin.

PHYSICIAN REVIEW

Your doctor may order X-rays to make sure there is no fracture or other problem. A magnetic resonance imaging (MRI) scan of your ankle may also be done. MRI images can show if there is abnormal swelling or scar tissue in the tendons and can also show lengthwise tears in the tendons.

Your doctor may also prescribe medications. Anti-inflammatory medications can help ease pain and swelling and get you back to activity sooner. These medications include common over-the-counter drugs such as ibuprofen.

In rare cases, cortisone can be injected into the sore tendons to relieve symptoms that won’t go away. Cortisone is a powerful anti-inflammatory medication. Because there is a risk that cortisone will cause a tendon to rupture, doctors are very cautious about injecting cortisone into the peroneal tendons.

SURGERY

Tendon Release

When the lining of the tendon is painful and inflamed (as in tenosynovitis), the goal of surgery is to remove the irritated tissue from around the tendon. This operation is called tendon release. This procedure is done by carefully dividing the tendon sheath that encloses the tendon. Once the sheath is opened, the surgeon clears away the irritated tissues around the tendon. The sheath is not stitched back together. The gap in the sheath will eventually fill in with scar tissue. The skin is closed with sutures.

Sheath Opened

Irritated Tissues Removed

Debridement

The procedure for surgically treating tendonosis is similar to the method used for tenosynovitis. However, extra measures are taken to thoroughly remove (debride) the degenerated tissue around and within the involved tendon.

Tendon Repair

Tendonosis may require repair if a preoneal tendon is split down its length. This type of tear mainly affects the peroneus brevis. The surgeon fixes this problem by first dividing the sheath around the tendons. If the split is smaller than one-third the width of the tendon, the torn portion may simply be removed. Larger splits are sutured along the length of the tendon. The tendon sheath is repaired, and the skin is closed with sutures.

Dividing the Sheath

Sheath Repaired

Portions of this document copyright MMG, LLC.


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Osteoarthritis of the Ankle

Welcome to Synergy Therapeutic Group’s patient resource about Osteoarthritis of the Ankle.

Injuries of the ankle joint are common. While ankle fractures and ankle sprains heal pretty well, they can lead to problems much later in life. This is due to the wear and tear that occurs over the years after the injury. This condition is called osteoarthritis (OA) or posttraumatic arthritis. Trauma means injury, and the term posttraumatic arthritis is used to describe arthritis that develops after an injury.

This document will help you understand:

  • how arthritis of the ankle develops
  • how doctors diagnose the condition
  • what treatment options are available

ANATOMY

The ankle joint is made up of three bones: the lower end of the tibia (shinbone), the fibula (the small bone of the lower leg), and the talus (the bone that fits into the socket formed by the tibia and fibula).

The talus sits on top of the calcaneus (the heelbone). The talus moves mainly in one direction. It works like a hinge to allow your foot to move up and down.

Ligaments on both sides of the ankle joint help hold the bones together. Many tendons cross the ankle to move the ankle and the toes. (Ligaments connect bones to bones while tendons connect muscles to bones.) The large Achilles tendon in the back is the most powerful tendon in the foot. It connects the calf muscles to the heel bone and gives the foot the power for walking, running, and jumping.

Tendons

Inside the joint, the bones are covered with a slick, smooth material called articular cartilage. Articular cartilage is the material that allows the bones to move against one another in the joints of the body. The cartilage lining is about one-quarter of an inch thick in most joints that carry body weight, such as the ankle, hip, or knee. It is soft enough to allow for shock absorption but tough enough to last a lifetime, as long as it is not injured.

Articular Cartilage

Related Article: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

OA is usually considered a type of degenerative arthritis, or wear-and-tear arthritis. Doctors consider OA pretty much the same whether it appears years after an injury to the joint or whether it appears without any history of injury. It behaves more or less the same way.

Degenerative Arthritis

Over the past several years, there has been increasing evidence that OA is genetic, meaning that it runs in families. OA that occurs without any injury may prove to be related to differences in the chemical makeup of articular cartilage. People are born with these differences.

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. The cartilage can be bruised when too much pressure is exerted on it. This damages the cartilage, although if you look at the surface it may not appear to be any different. The injury to the material doesn’t show up until months later. Sometimes the cartilage surface is damaged even more severely, and pieces of the cartilage are ripped from the bone. These pieces do not heal back and usually must be removed from the joint surgically. If not, they may float around in the joint, causing the joint to catch and be painful. These fragments of cartilage may also do more damage to the joint surface.

Once this cartilage is ripped away, it does not normally grow back. Unlike bone, holes in the surface are not simply replaced by the cartilage tissue around the hole. Instead the defects are filled with scar tissue. The scar tissue that forms is not nearly as good a material for covering joint surfaces as the cartilage it replaces. It just can’t support weight and isn’t smooth like true articular cartilage.

An injury to a joint, even if it does not injure the articular cartilage directly, can alter how the joint works. This is true for a fracture where the bone fragments heal differently from the way they were before the break occurred. It is also true when ligaments are damaged that lead to instability in the joint. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it wears out faster.

Over many years this imbalance in the joint mechanics can lead to damage to the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Finally, the joint is no longer able to compensate for the increasing damage, and it begins to hurt. The damage occurs well before the pain begins.

In summary, arthritis may come from differences in how each of us is put together based on our genes, a condition best described as OA. Or arthritis may develop years after an injury that leads to slow damage to the joint surfaces, a condition probably best described as post-traumatic arthritis. Either way the joint is worn out, and it hurts. For the purposes of this document, we will refer to both types as OA.

SYMPTOMS

Pain is the main problem with arthritis of any joint. This pain occurs at first only related to activity. Usually, once the activity gets underway there is not much pain, but after resting for several minutes the pain and stiffness increase. Later, when the condition worsens, pain may be present even at rest. The pain may interfere with sleep. The joint may swell, fill with fluid, and feel tight, especially following increased activity. As the articular cartilage starts to wear off the joint surface, the joint may squeak when moved. Doctors refer to this sound as crepitation.

OA will eventually affect the motion of a joint. The joint becomes stiff and loses flexibility. Certain movements can become painful, and it may become difficult to trust the joint to hold your weight in certain positions. The body has a pain reflex such that when a joint is put into a position that causes pain the muscles around the joint may stop working without warning. This reflex can cause a person to stumble or even fall when arthritis affects the ankle joint.

When OA has reached a very severe stage, the bone itself under the articular cartilage may become worn away. This can lead to increasing deformities around the joint. In the final stages, the alignment of the bones can begin to form odd angles where they meet at the joint.

DIAGNOSIS

The diagnosis of OA begins with a history of the problem. Details about any injuries that may have occurred to the joint, even years before, are important in helping up understand why the condition exists. Whether or not other family members have OA may also shed some light on the problem.

Following the history, the Physical Therapists at Synergy Therapeutic Group will examine the ankle joint and possibly other joints in your body. It will be important for us to see how the motion of the ankle has been affected. The alignment of the ankle will be assessed. The nerves and circulation going to the legs and ankle will be checked. Your therapist will watch you walk to see if you have a noticeable limp.

Our Physical Therapist may also refer you to a doctor for X-rays or other diagnostic tools that can aid in obtaining an accurate diagnosis, prior to the start of your Physical Therapy program.

OUR TREATMENT

What can be done for the condition?

The treatment of OA of the ankle can be divided into the nonsurgical means to control the symptoms and the surgical procedures that are available to treat the condition. Surgery is usually not considered until it has become impossible to control the symptoms without it.

Non-surgical Rehabilitation

Rehabilitation services, such as those offered at Synergy Therapeutic Group, play a critical role in the treatment plan for ankle joint arthritis. Treatment usually begins when the ankle first becomes painful. The pain may only occur at first with heavy use and may simply require the use of mild anti-inflammatory medications such as aspirin or ibuprofen. Reducing the activity or changing from occupations that require long periods of standing and walking may be necessary to help control the symptoms.

The main goal of your Physical Therapy program is to help you learn how to control symptoms and maximize the health of your ankle. Our therapist will instruct you on techniques you can use to calm your pain and symptoms. We may advise may use rest, heat, or topical rubs. Our Physical Therapist will work with you to improve flexibility, balance, and strength. Our Physical Therapist in Carbondale and Du Quoinwill also provide training to help you walk smoothly and without a limp, which may require that you use a walking aid such as a walker, crutches, or cane.

Braces that reduce the motion in the ankle can also be beneficial in reducing pain. Special braces that transfer some of the body weight to the knee can help protect the ankle. These braces are called patellar tendon bearing braces. They are quite large and bulky and may not be well tolerated by some patients.

We may recommend modifying your shoe with a rocker sole may give some relief of symptoms. The rocker sole replaces your normal sole with a rounded one, allowing your foot to roll as you move through a step. This can help take stress off the ankle as you walk.

If you don’t need surgery, we may recommend that range-of-motion exercises for the ankle be started as pain eases, followed by a program of strengthening. Our program then advances to include strength and balance exercises. Your Physical Therapist will give you tips on keeping your symptoms controlled. Although recovery time varies among patients, as a guideline, you may progress to a home program within four to six weeks.

In cases of advanced OA where surgery is called for, patients may also see our Physical Therapists before surgery to discuss exercises that will be used just after surgery and to begin practicing using crutches or a walker.

Post-surgical Rehabilitation

Your ankle will be bandaged with a well-padded dressing and a splint for support after surgery. Most patients are instructed not to place weight on their foot for a period of time after surgery. After arthroscopy, this period typically lasts about one week. Although recovery time is not the same for everybody, after ankle joint replacement, most patients are usually advised to avoid placing weight on their foot for up to 12 weeks.

Physical Therapy sessions, such as those provided by Synergy Therapeutic Group, may be needed after surgery for up to two months. When you visit Synergy Therapeutic Group, your first few treatments will be used to help control the pain and swelling after surgery. Treatments provided by our therapist may include electrical stimulation, ice, and soft tissue massage. We may also use hands-on joint movements and stretching to improve your range of motion and flexibility.

Our Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the ankle joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your Synergy Therapeutic Group rehab program advance, you may be instructed in an independent program.

Our Physical Therapist will also work with you to safely increase the amount of weight you are able to place on your foot. Our goal will be to help you walk comfortably and with a smooth walking pattern. Some of the exercises you’ll do are to help strengthen and stabilize the muscles around the ankle joint. Your Physical Therapist will provide tips on ways to do your activities while avoiding extra strain on the ankle joint.

Synergy Therapeutic Group provides Physical Therapy services in Carbondale and Du Quoin.

PHYSICIAN REVIEW

Your physician may take regular X-rays to see how severely the joint is damaged. This is usually the most important test to determine how bad the OA has become. How much articular cartilage is left in the ankle joint can also be estimated with the X-rays.

If there is any question whether the arthritis may be coming from something other than OA, blood tests may be ordered to look for systemic diseases such as rheumatoid arthritis. A needle may be inserted into the joint to remove some of the joint fluid. This fluid may be sent to a lab to look for crystals due to gouty arthritis or signs of infection.

Newer medications such as glucosamine and chondroitin sulfate are being used by orthopedic surgeons more commonly today. These medications seem to be effective in reducing the pain of OA in all joints.

An injection of cortizone into the joint can give temporary relief from symptoms of OA. Cortisone is a powerful anti-inflammatory medication. When injected into the joint itself, cortisone can help relieve the pain. The pain relief is temporary and usually only lasts several weeks to months. There is a small risk of infection with any injection into a joint, and cortisone injections are no exception.

There are also new injectable medications that lubricate the arthritic joint. These medications have been studied mainly in the knee. It is unclear if they will help the arthritic ankle joint. These injectable medications are not usually prescribed for this condition yet.

SURGERY

Eventually, it may be necessary to consider surgery for OA of the ankle. There are several different types of surgery that can be performed to help with your condition. Which procedure is recommended by your surgeon will be determined by many things. These include how much the degeneration in the ankle has progressed, how active you are, how old you are, and what other medical problems you have. Each type of procedure has risks and benefits that should be discussed with your surgeon. The choices for surgery are arthroscopic surgery to clean up the joint, fusion of the joint, or replacing the joint with an artificial ankle joint.

Arthroscopic Debridement

Sometimes when OA of the ankle occurs, loose pieces of cartilage and bone float around inside the ankle joint. These loose bodies can cause irritation in the joint, leading to inflammation. They can also get caught between the joint surfaces of the ankle. This can cause a sharp pain when it happens. The cartilage surfaces of the joint also become rough, with flaps of cartilage that peel off the surface, much like paint peeling off the ceiling. Bone spurs, or outgrowths, form around the joint and can grow larger over time. These bone spurs can rub against the soft tissues around the ankle joint when the ankle moves, again causing pain and swelling.

The arthroscope can help the doctor remove these loose bodies and bone spurs and smooth the cartilage surfaces of the ankle joint. The arthroscope is a special TV camera that is inserted through small incisions (one-quarter of an inch) around the ankle. Small surgical tools can also be inserted through these incisions to work in the ankle joint.

Ankle Fusion

When the ankle joint becomes so painful that it is difficult to walk, surgery may be suggested to fuse the ankle joint. An ankle fusion is sometimes also called an ankle arthrodesis. In this operation, the three bones that make up the ankle joint (the talus, the tibia, and the fibula) are allowed to grow together, or fuse, into one bone. Once this is done the ankle no longer is able to move, but with a successful fusion the pain is gone. Most people with a successful fusion of the ankle are able to walk without much trouble, and in some cases it is almost impossible to tell that the ankle is stiff. But it is very difficult to run because you lose the ability to push off with the toes. The foot can’t bend down.

Ankle Fusion

Most people will need some changes made to their shoes following an ankle fusion. Because the ankle no longer moves, it is difficult to roll over the top of the foot when you take a step. For this reason, shoes are usually fitted with a rocker sole. This allows the shoe to roll instead of the foot. A special heel is sometimes built on the shoe to absorb some of the shock.

The ankle fusion is a good operation, especially for a young, active person. It is usually the preferred option for post-traumatic arthritis of the ankle. Once the ankle is successfully fused it can last a lifetime, and no other operations are expected later unless there are problems. But there are complications associated with the ankle fusion, and not all ankle fusions are successful.

Related Document: Synergy Therapeutic Group’s Guide to Ankle Fusion

Artificial Ankle Replacement

Because no one wants to lose the ability to move the ankle, much research has been done trying to perfect an artificial ankle replacement. Until now, the artificial ankle has not been nearly as successful as the artificial hip or knee.

The ankle is a difficult joint to replace for many reasons. The socket (usually called the mortise) is actually made up of two bones, the tibia and the fibula. These two bones move against one another slightly when we walk. This makes it difficult to get the artificial ankle socket to stay connected to the bone.

The biggest problem with the older artificial ankle designs is that they loosened after a relatively short time and began to cause pain. When using the newer artificial ankle designs, surgeons have tried to solve this problem by actually fusing the tibia and fibula together during the operation and placing screws across the two bones. This has dramatically increased the success rate for the artificial ankle replacements done today. Many surgeons are now beginning to use the artificial ankle for post-traumatic arthritis instead of doing a fusion. Patients are able to keep the motion in the ankle and avoid some of the problems associated with the ankle fusion.

Related Document: Synergy Therapeutic Group’s Guide to Artificial Ankle Replacement

Portions of this document copyright MMG, LLC


INTRODUCTION

Physical Therapy in Carbondale and Du Quoin for Ankle

Welcome to Synergy Therapeutic Group’s patient resource about Ankle Syndesmosis Injuries.

An ankle injury common to athletes is the ankle syndesmosis injury. This type of injury is sometimes called a high ankle sprain because it involves the ligaments above the ankle joint. In an ankle syndesmosis injury, at least one of the ligaments connecting the bottom ends of the tibia and fibula bones (the lower leg bones) is sprained. Recovering from even mild injuries of this type takes at least twice as long as from a typical ankle sprain.

This guide will help you understand:

  • how ankle syndesmosis injuries occur
  • how doctors diagnose the condition
  • what can be done to treat it

ANATOMY

syndesmosis is a joint where the rough edges of two bones are held together by thick connective ligaments. The connection of the lower leg bones, the tibia and fibula, is a syndesmosis. The tibia is the main bone of the lower leg. The fibula is the small, thin bone that runs down the outer edge of the tibia.

Only a few joints in the body are syndesmosis joints. In addition to the ankle syndesmosis (the connection of the tibia and fibula), syndesmosis joints are also located in the lower spine, where the top of the triangular-shaped sacrum bone fits between the pelvis bones.

Most joints in the body are synovial joints. Synovial joints are enclosed by a ligament capsule and contain a fluid, called synovium, that lubricates the joint. The ankle syndesmosis sits next to the ankle synovial joint, where the tibia meets the talus bone.

Ankle Synovial Joint

The ankle syndesmosis is supported and held together by three main ligaments. The ligament crossing just above the front of the ankle and connecting the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The posterior fibular ligaments attach across the back of the tibia and fibula. These ligaments include the posterior inferior tibiofibular ligament (PITFL) and the transverse ligament.

The interosseous ligament lies between the tibia and fibula. (Interosseous means between bones.) The interosseus ligament is a long sheet of connective tissue that connects the entire length of the tibia and fibula, from the knee to the ankle.

The syndesmosis ligaments hold the bottom ends of the tibia and fibula in place. This arrangement forms the upper surface of the ankle joint. The ankle joint is a hinge joint. The hinge is formed where the tibia and fibula sit above the talus bone. This connection is called a mortise and tenon, a stable connection that woodworkers and craftsmen routinely use to create strong and stable constructions.

Mortise and Tenon

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Doctors do not completely understand how syndesmosis injuries occur, though they appear to happen most often when the foot is forced upward and outward. Such injuries frequently happen in high-level football players, although snow skiers also account for a high percentage of syndesmosis injuries.

Many times, a patient describes having sprained an ankle. It isn’t until later, when standard treatments for the ankle sprain aren’t helping, that further testing shows a syndesmosis injury.

An ankle syndesmosis injury involves a sprain of one or more of the ligaments that support the ankle syndesmosis. A ligament is made up of multiple strands of connective tissue, similar to a nylon rope. A sprain stretches or tears the ligaments. Minor sprains only stretch the ligament. A tear  may be either a complete tear of all the strands of the ligament or a partial tear of only some of the strands. The ligament is weakened by the injury. How much it is weakened depends on the degree of the sprain.

Multiple Strands of Connective Issue

Partial Tear

Mild syndesmosis sprains usually involve a stretch or slight tear in only one of the ligaments making up the syndesmosis. Moderate tears of the ankle syndesmosis may lead to ankle joint instability, which make the ankle mortise loose. In severe tears of the ligaments, the ends of the tibia and fibula actually spread apart. This condition is called diastasis.

SYMPTOMS

Syndesmosis injuries are the most severe sprains of the foot and ankle. They also cause the most problems for people trying to get back to normal activity, especially athletes hoping to resume intense running, cutting, and jumping.

Mild to moderate syndesmosis sprains may at first feel like a routine sprained ankle. Symptoms include pain and swelling on the outside of the ankle.

Outside of the Ankle

If the problem has been ongoing, patients may have pain due to an unstable ankle joint. They may feel vague pain around the ankle. Attempts to turn or twist the injured foot may cause sharp pain in the ankle joint. Pain may radiate upward along the side of the lower leg. And the ankle may feel weak, like it can’t be trusted to hold steady, even during routine activities.

Unstable Ankle Joint

Related Document: Synergy Therapeutic Group’s Guide to Ankle Sprain and Instability

DIAGNOSIS

The diagnosis of syndesmosis injuries is usually made by examining the ankle. Your Physical Therapist at Synergy Therapeutic Group will move your ankle in different positions in order to check the ligaments and tendons around the ankle. The syndesmosis is stressed by turning the ankle outward while holding the lower leg still. Another test, called the squeeze test, is done by grabbing the calf just above the ankle joint and squeezing it. Pain with this test is a hallmark of a syndesmosis injury. Tenderness can usually be pinpointed over the front ankle ligaments (the AITFL) and possibly over the posterior fibular ligaments (the PITFL and transverse ligaments). 

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at Synergy Therapeutic Group have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

OUR TREATMENT

Non-surgical Rehabilitation

Even if you don’t require surgery, you may need to follow a program of rehabilitation exercises. Our Physical Therapists at Synergy Therapeutic Group can create a program to help you regain ankle function. It is very important to improve strength and coordination in the ankle. An ankle syndesmosis injury is more complex than a simple ankle sprain. The healing time can be more than twice as long, and getting back to normal activity is usually a more gradual process.

Mild Syndesmosis Sprains

Mild syndesmosis sprains are treated much like a regular ankle sprain. Treatment includes mild pain medications and anti-inflammatory medicine such as ibuprofin. Patients rest the ankle for a short time to reduce swelling and pain. Unlike a regular ankle sprain, our Physical Therapist much more likely to recommend using crutches to keep weight off the foot for several weeks if a syndesmosis sprain is suspected.

Our Physical Therapist will recommend treatments of ice and compression (such as an elastic wrap) to help alleviate swelling and encourage a faster return of normal ankle movement. An ankle brace is typically worn during the rehabilitation period.

As the ankle heals, patients progress to normal walking. Your Synergy Therapeutic Group Physical Therapist will start you on a series of exercises to strengthen the outer ankle muscles and to maximize balance.

Related Article:   Synergy Therapeutic Group’s Guide to Ankle Sprain and Instability

Moderate Syndesmosis Sprains

Moderate syndesmosis injuries that do not show a diastasis on X-ray may be treated nonsurgically. Your doctor may place you in a cast for approximately four weeks. Our Physical Therapists recommend that you use crutches to keep from putting weight on the foot during this time. After your cast is removed, you may be placed in a walking boot and allowed to gradually place more weight on their foot over another three to four weeks. You doctor will probably take periodic X-rays to make sure the ankle mortise isn’t separating. Although recovery varies among patients, it is likely that your Synergy Therapeutic Group Physical Therapy program will gradually intensify over about a three-month period.

Post-surgical Rehabilitation

For two to four weeks after surgery, patients usually wear an ankle splint and avoid placing weight down when standing or walking. Then a stirrup brace may be worn as the amount of weight put on the foot is gradually increased. Rehabilitation after surgery can be a slow process. Although each patient recovers at a different pace, you may expect to attend your therapy sessions at Synergy Therapeutic Group for two to three months, and full recovery could take up to six months.

When you visit Synergy Therapeutic Group for rehabilitation, your first few Physical Therapy treatments will be designed to help control pain and swelling from the surgery. Our Physical Therapist may use ice and electrical stimulation treatments during your first few therapy sessions. We may also apply massage and other hands-on treatments to ease muscle spasm and pain. Treatments are also used to help improve ankle range of motion without putting too much strain on the ankle.

Gentle ankle movements can usually be started after two to four weeks. You may begin easy ankle motions on a stationary bicycle. After about six weeks you may be able to begin doing more active exercise. Exercises are used to improve the strength in the ankle muscles. Our Physical Therapist will also help you regain position sense in the ankle joint to improve its stability. A careful progression to running and other impact activities begins a minimum of 12 weeks after surgery.

At Synergy Therapeutic Group, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your ankle. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Synergy Therapeutic Group provides Physical Therapy services in Carbondale and Du Quoin.

PHYSICIAN REVIEW

Your physician may order X-rays to determine the severity of the syndesmosis injury. Stress X-raysare done to see if the tibia and fibula splay apart. The stress X-ray is done with the foot angled outward. An enlarged gap between the tibia and fibula indicates a diastasis (mentioned earlier). X-rays are also used to check for other problems, such as a fracture in the leg or ankle.

Doctors usually suspect a syndesmosis injury when patients have severe pain that lingers after what was thought to be a routine ankle sprain.

SURGERY

Syndesmosis injuries that cause ankle instability may require surgery. Some doctors prefer to try nonsurgical treatment first. However, if at any point during treatment an X-ray shows a diastasis, surgery will probably be recommended.

Screw Fixation

Surgery for a syndesmosis injury is designed to reduce the separation between the tibia and fibula. If there are no barriers keeping the tibia and fibula apart, the surgeon may simply need to place screws through the two bones to hold them together while the ligaments heal.

To begin the procedure, the surgeon bends the ankle slightly upward. A clamp may be placed around the lower leg to squeeze the tibia and fibula together, reducing the separation. This places the two bones in the proper alignment.

Working from the outer side of the leg, the surgeon inserts a screw through fibula into the tibia. This is done with the aid of a fluoroscope. A fluoroscope is a special X-ray machine that allows the surgeon to see the live X-ray picture on a TV screen during surgery. Using the fluoroscope allows the surgeon to direct the drill and place the screws into the right spot to hold the bones in the right position. This can usually be done through small, quarter-inch incisions in the side of the ankle. Some surgeons place a second screw right above the first screw.

Surgeons generally use a screw with a large head. This ensures easy removal of the screw after two or three months.

Open Incision

If the tibia and fibula can’t be squeezed together, the surgeon may have to make an incision on the front edge of the ankle. This allows the surgeon to find and remove any scar tissue or other barriers that are keeping the bones apart.

In both procedures, X-rays of both ankles are taken after the screws are in place. Comparing the X-rays lets the surgeon see if the space between the tibia and fibula is now the same on both sides.

Portions of this document copyright MMG, LLC


ANATOMY

Physical Therapy in Carbondale and Du Quoin for Ankle Impingement

Welcome to Synergy Therapeutic Group’s overview of the anatomy of the ankle.

The ankle joint is formed where the bones of the lower leg, the tibia and the fibula, connect above the anklebone, called the talus. The tibia is the main bone of the lower leg. The fibula is the small, thin bone along the outer edge of the tibia.

The ankle joint is a hinge that allows the foot to move up (dorsiflexion) and down (plantarflexion). The ankle is a synovial joint, meaning it is enclosed in a joint capsule that contains a lubricant called synovial fluid.

Strong ligaments surround and support the ankle joint. The ligament that crosses just above the front of the ankle and connects the tibia to the fibula is called the anterior inferior tibiofibular ligament (AITFL). The anterior talofibular ligament(ATFL) supports the outer edge of the ankle. The ATFL goes from the tip of the fibula and angles forward to connect with the talus.

The talus rests on the the heelbone (the calcaneus). The joint formed between these two bones is called the subtalar joint. The calcaneus extends backward below the ankle, forming a shelf on which the talus rests.

Two small bony bumps, called tuberosities, project from the back of the talus, one on the inside (medial) edge and one on the outer (lateral) edge.

In some people the lateral tuberosity is not united to the talus. The separate piece of bone is called an os trigonum. This separation of the os trigonum from the talus is usually not a fracture. About 15 percent of people have an os trigonum. An os trigonum sometimes causes problems of impingement in the back of the ankle.

Related Document: Synergy Therapeutic Group’s Guide to Ankle AnatomyMuscles of the Ankle

CAUSES

Pinching of tissues in the front of the ankle is called anterior impingement. Athletes who have had several mild ankle sprains or one severe sprain are most likely to have anterior impingement. This is especially true for athletes who repeatedly bend the ankle upward (dorsiflexion), such as baseball catchers, basketball and football players, and dancers. Over time, irritation along the front edge of the ankle can lead to impingement.

Irritation in the lower edge of the AITFL and the front of the ATFL can thicken these ligaments. The irritated ligaments become vulnerable to getting pinched between the tibia and talus as the foot is dorsiflexed. These ligaments may also begin to rub on the joint capsule of the ankle. This can inflame the synovial lining of the capsule, a condition called synovitis.

A similar problem can happen after an ankle sprain. As the torn or ruptured ligament heals, the body responds by forming too much scar tissue along the front and side of the ankle joint. This creates a small mass of tissue called a meniscoid lesion. Dorsiflexing the ankle can trap the tissue between the edge of the ankle joint, causing pain, popping, and a feeling that the ankle will give out and not support your body weight.

Over time, damage from past ankle sprains may also lead to the formation of small projections of bone called bone spurs. Bone spurs can form along the bottom ledge of the tibia bone or on the upper surface of the talus. As the ankle hinges into dorsiflexion, the bone spurs may begin to jab into the soft tissues along the front edge of the ankle joint, causing symptoms of anterior impingement.

Posterior impingement occurs in the back of the ankle. It is most common in ballet dancers who must continually rise up on their toes, pointing their foot downward into extreme plantarflexion. Other athletes are rarely affected but may have problems if they routinely plantarflex their feet.

The usual cause of posterior impingement is an os trigonum (described earlier). This normal fragment of bone is a separation of the lateral tuberosity from the talus. When an os trigonum is present, it can cause problems, especially among ballet dancers who constantly rise up on their toes into the dance position called pointe. Pointe is a position of extreme ankle plantarflexion. As the foot points downward sharply, the os trigonum can get sandwiched between the bottom edge of the tibia and the top surface of the calcaneus (the heelbone). This can trap the tissues above and below the os trigonum, leading to symptoms of posterior impingement.

Posterior impingement can also occur in a ballet dancer who has had a previous ankle sprain. Damage from the past ankle sprain may create too much instability in the ankle. As the dancer rises up on the toes, the talus may be free to slide forward slightly. This allows the shelf of the heelbone to come into contact with the back of the tibia, pinching the soft tissues in between. Posterior impingement from ankle instability can also happen in other athletes. But this is uncommon, because forceful plantarflexion is rarely required in other sports.

Related Document: Synergy Therapeutic Group’s Guide to Ankle Sprain and Instability

SYMPTOMS

Anterior impingement may feel like ankle pain that continues long after an ankle sprain. The ankle may feel weak, like it can’t be trusted to hold steady during routine activities. When anterior impingement comes from ligament irritation, pain and tissue thickening are usually felt in front and slightly to the side of the ankle. This is the area of the ATFL. The pain worsens as the foot is forced upward into dorsiflexion. If the ligaments have irritated the synovium of the ankle joint capsule, throbbing pain and swelling from inflammation (synovitis) may also be felt in this area.

Symptoms of posterior impingement include pain behind the heel or deep in the back of the ankle. There is usually tenderness just behind the bottom tip of the fibula, by the outer ankle bone. Pain is usually worse when the foot is pointed down into plantarflexion. A painful clicking sensation may also be felt as the foot is twisted in and out.

DIAGNOSIS

The diagnosis of ankle impingement is usually made by examining the ankle. Our Physical Therapist will manipulate your ankle to see which movements or positions cause your pain. If anterior impingement is suspected, we may bend your ankle upward or ask you to squat down. To check for posterior impingement, our therapist may push your foot downward or have you rise up on your toes. Tenderness can usually be pinpointed over the tissues that are being pinched.

Your Physical Therapist at Synergy Therapeutic Group may also refer you to a doctor for X-rays or other diagnostics helpful in accurately assessing your ankle impingement.

OUR TREATMENT

Non-surgical Rehabilitation

Even if you don’t require surgery, you may need to follow a program of rehabilitation exercises. The Physical Therapists at Synergy Therapeutic Group can create a program to help you regain ankle function. It is very important that you improve strength and coordination in the ankle.

Initially our Physical Therapist will advise you to rest the ankle for a short time to reduce swelling and pain. A special walking boot or short-leg cast may be recommended to restrict ankle movement for up to four weeks. Patients may also want to consult with their doctor or pharmacist regarding mild pain medications and anti-inflammatory medicine, such as ibuprofen. An ice pack can also help alleviate swelling and may encourage a faster return of normal ankle movement.

Once you begin your Synergy Therapeutic Group rehabilitation program, your recovery may involve doing a series of exercises including stationary cycling, range of motion, and ankle strengthening.

Post-surgical Rehabilitation

After debridement surgery, patients are usually placed in an ankle splint, and begin their recovery by using crutches. The amount of weight put on the foot is gradually increased over a period of approximately one to two weeks. Although recovery time varies among individuals, our patients generally advance quickly in rehabilitation and are often able to resume normal activity within four to six weeks.

Rehabilitation after excision of the os trigonum is a slower process. We may advise you to attend therapy sessions for two to three months, with full recovery sometimes taking up to six months. Patients are often kept in the ankle splint for up to two weeks, and crutches are used during this time as the amount of weight borne on the foot is gradually increased.

After removing the stitches and the ankle brace, our patients are often able to begin formal Physical Therapy. When you start your rehabilitation program at Synergy Therapeutic Group, initial treatments begin with gentle range-of-motion exercises for the ankle and toes. The first few Physical Therapy treatments are also designed to help control pain and swelling from the surgery. Our therapist may use ice, electrical stimulation treatments, massage and other hands-on procedures to ease muscle spasm and pain.

As the symptoms from surgery begin to ease, our Physical Therapist may show you how to do easy ankle motions on a stationary bicycle. After three or four weeks we may advise you to start doing more active ankle exercises. Exercises are used to improve the strength in the ankle muscles. Our therapist will also help you regain position sense in the ankle joint to improve its stability.

At Synergy Therapeutic Group, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your ankle. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Synergy Therapeutic Group provides Physical Therapy services in Carbondale and Du Quoin.

PHYSICIAN REVIEW

Your doctor will probably order X-rays if impingement is suspected. X-rays can show if there are bone spurs on the tibia or talus. In cases of posterior impingement, an X-ray can show if an os trigonum is present. You may be asked to squat down or rise up on your toes during the X-ray. This helps show if impingement is due to bone pinching the soft tissues.

A bone scan may be recommended in select cases, such as when surgery is being considered. In general, MRI scans are not helpful for impingement problems, but they may be ordered to check for other ankle problems that could be causing your pain.

If the doctor believes that pinching in the back of the ankle is from an os trigonum, a numbing medication may be injected into this area. If it feels better, the problem is a posterior impingement from the os triogonum. If the pain doesn’t change, the problem could be in the tendon that runs along the inside edge of the os trigonum.

Your doctor may recommend a steroid injection into the painful area. Steroids are strong anti-inflammatory medications. A steroid injection can help relieve irritation and swelling in the soft tissues that are being pinched, reducing their tendency to get pinched.

SURGERY

If nonsurgical treatments do not work, surgery may be recommended. The type of surgery will vary depending on the location and cause of ankle impingement.

Debridement is the most common surgery for anterior ankle impingement. Many surgeons prefer to perform this procedure with an arthroscope. An arthroscope is a tiny TV camera that can be inserted into a very small incision. It allows the surgeon to see the area where he or she is working on a TV screen.

To begin, two small incisions are made through the skin on each side of the impingement area. The surgeon inserts the arthroscope to see which area of the tendons or joint capsule are irritated and thickened. The arthroscope lets the doctor see if a meniscoid lesion (mentioned earlier) is present. A small shaver is used to clear away (debride) irritated tissue from the affected ligaments. The surgeon also debrides the tissue forming a meniscoid lesion and any areas of the joint capsule that are inflamed. Small forceps may also be used to clear away irritated or inflamed tissue.

Debridement

Small bone spurs on the tibia or talus are removed. If the spurs are large, the surgeon may decide to create a new incision over or next to the spur. This allows a special instrument, called an osteotome, to be inserted. The surgeon uses the osteotome to carefully remove these larger bone spurs.

Bone Spur Removal

Before concluding the procedure, a fluoroscope is used to check the debridement and to make sure no bony fragments remain. A fluoroscope is a special X-ray machine that allows the surgeon to see a live X-ray picture on a TV screen during surgery. When the surgeon is satisfied that debridement and removal of bone fragments is complete, the skin is stitched together.

Os Trigonum Excision

The goal of an os trigonum excision is to carefully remove (excise) the os trigonum to alleviate pinching of the tissues above or below it. It is standard to use an open surgical method which requires a one- to two-inch incision over the outer part of the back of the ankle. An arthroscope is not routinely used for os trigonum excision because there are many nerves and blood vessels in the back of the ankle that could be injured by an arthroscope.

This surgery begins by placing the patient face down on the operating table. The surgeon makes a small incision over the lateral side of the back of the ankle, just behind the outer anklebone. A retractor is used to carefully hold the nearby tendons, nerves, and blood vessels out of the way. The surgeon locates the os trigonum. A scalpel is usually sufficient to dissect the os trigonum. However, if a bony bridge binds the os trigonum to the talus, the surgeon may need to use a chisel or osteotome.

A fluoroscope is used to check for any remaining bony fragments. When the surgeon is satisfied that all bone fragments have been removed, the skin is stitched together. Patients are placed in a special splint designed to protect the ankle and to keep the foot from pointing downward.

Portions of this document copyright MMG, LLC