Managing Ankle Impingement with Chiropractic
What you need to know
FAQ about the Ankle
How Chiropractic Can help
01
How do Chiropractors assess Ankle Injuries ?
How do Chiropractors assess Ankle Injuries ?
Dorsiflexion lunge test to assess range of motion
- when there is dorsiflexion stiffness- athletes have exaggerated hip flexion and inhibited knee flexion . Foot may rise from floor
The star excursion balance test to evaluate balance and proprioception
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RAPTURE OF ACHILIES TENDON VS Navicular Fracture
Achilles
Classically located within 2–7 cm of its distal insertion on the calcaneus , tears of the Achilles tendon (AT), the strongest tendon in the human body , are frequently not diagnosed in a timely fashion, and a rupture with a delay in diagnosis or treatment for more than 6 weeks is considered a chronic tear
What is a navicular stress fracture ?
Navicular stress fracture commonly affect athletes who participate in running and repetitive high impact sports such as track and field and basketball. Several factors have been suggested to predispose the navicular bone to stress injury.
Forces transmitted from the first and second TMT joints pass through the navicular unto the talar head medially, while the lateral aspect of the navicular does not share in this force transmission. Moreover, the contraction of the tibialis posterior attached to the medial aspect of the navicular creates tension forces medially.
This creates significant shear forces across the middle third of the navicular bone which is most vulnerable area due to its watershed hypo-vascularity.
The repetitive and high stresses of intense athletic activities create microfractures that have limited healing potential. Other factors such as female sex , decreased plantar flexion and forefoot abduction, and greater hindfoot valgus have also been linked to Navicular stress fracture
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To have Surgery or Chiropractic care?
To have Surgery or Chiropractic care?
Surgery is generally for for athletes & active labourers
Elderly , obese , sedentary and poorly controlled diabetics - smokers should be non surgical repair
Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports
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Lets explain the importance of the Flexor Hallucis Longus Tendon
The transfer of the flexor hallucis longus (FHL) tendon is the most reported, carrying, at least theoretically, a series of advantages over other local tendon transfers:
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The FHL is the second strongest plantar flexor muscle of the ankle;
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Its axis of action is in line with that of the Achilles Tendon;
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It maintains normal ankle muscle balance;
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Its harvest carries a low risk of iatrogenic neurovascular injury;
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It increases the vascularity of the reconstruction given its low-lying muscle belly
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FAQ about Patellar Dislocations
Functionality You Will Love
01
Treatment from the Chiropractor:
Gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment
Achilles tendinopathy (AT) occurs in approximately 1.85 per 1000 people and presents with functional restriction, pain and swelling at the calcaneal insertion (insertional AT) or 2–6 cm proximal to the calcaneal insertion (non-insertional AT)
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When to get surgery for Achilles problems
after 6 months of non-operative treatment, up to 45.5% of patients may remain symptomatic and undergo operative intervention
These surgical approaches are often effective, with research suggesting a success rate of over 80
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What is anterior impingement
What is anterior impingement
Anterior impingement
Anterior ankle impingement generally refers to entrapment of structures along the anterior margin of the tibiotalar joint in terminal dorsiflexion. Multiple osseous and soft tissue anatomic abnormalities have been recognized as causative factors.
Although they are often referred to as “kissing osteophytes”, these tibial and talar spurs surprisingly often do not actually overlap and abut
Anterior intra-articular soft tissues may contribute to impingement in isolation or in conjunction with bony lesions. A triangular soft tissue mass composed primarily of adipose and synovial tissues exists in the anterior joint space. These tissues are compressed after 15° of dorsiflexion in asymptomatic individuals
What are the cases of Anterior Impingement ?
Anterior osteophytes may limit the space available for this soft tissue and exacerbate its entrapment, resulting in chronic inflammation, synovitis, and capsuloligamentous hypertrophy. Post-traumatic fibrous bands , thickened anterior tibiofibular ligaments , and synovial plica , have also been identified as causative factors
Chronic lateral ankle instability has also been hypothesized to contribute to the development of both bony and soft tissue lesions associated with anterior impingement due to abnormal repetitive micromotion
Soft tissue lesions, such as synovitis in the anterior compartment or anterior lateral gutter, have been observed with high frequency (63–100 %), while anterior tibial osteophytes have often been found consistently (12–26.4 %)
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What is posterior impingement of the ankle?
Posterior Impingement
Posterior ankle impingement results from compression of structures posterior to the tibiotalar and talocalcaneal articulations during terminal plantar flexion. Similarly, this can be caused by multiple osseous and soft tissue etiologies in isolation or in combination.
Posterior ankle impingement is typically seen in athletes who execute repetitive plantar hyperflexion, such as ballet dancers and soccer players.
The underlying mechanism is compression of bone and soft tissue structures between the tibia and the calcaneus during forced plantar flexion of the foot.
Predisposing conditions include the presence of an os trigonum, an elongated Stieda process, and a fractured lateral tubercle of the talus. A more downsloping articular surface of the tibia, a prominent posterior process of the calcaneus, and a posterior intermalleolar ligament may also contribute.
Conventional radiography allows for identification of the abovementioned variants and changes of osseous anatomy. MR images can show bone marrow edema in all involved osseous structures, fluid within a non-united fracture, thickening of the posterior capsule, synovitis in the posterior joint recess, as well as tenosynovitis of the flexor hallucis longus and soft tissue edema
Ankle Impingement
What you need to know
The stability of the ankle joint is provided by three groups of ligaments: the lateral ligaments, the tibiofibular syndesmosis, and the medial ligaments. The lateral ligaments comprise the anterior talofibular, the calcaneofibular, and the posterior talofibular ligaments, the latter being the strongest of the three What is the Achilles tendon? Achilles Tendon is the strongest and thickest tendon in the human body and is also the primary plantar flexor of the ankle . It is subjected to immense loads, with 2–3 times a person’s body weight with walking, and up to ten times a person’s body weight with high-impact activities. The Achilles Tendon is comprised of the medial and lateral gastrocnemius and soleus muscles, which course distally and rotate 90° internally before inserting on the posterior calcaneal tuberosity Achilles Tendon lacks synovial sheath , it has paratenon sheath that allows the Achilles Tendon to slide and allow blood vessels to enter and supply the Achilles Tendon The average length of the ACHILIES is 15 cm. Narrowest point being 2-6 cm proximal to calcneal insertion
What causes Ankle Problems
What are the risk factors of Ankle Dysfunction? RISK FACTORS Female athletes had a significantly higher ankle sprain injury rate compared with male athletes in comparable sports including soccer, volleyball, basketball, baseball or softball, lacrosse, swimming and diving, and track and field. Lateral ankle ligament injuries occur more often in women, whereas studies have shown that men have higher rates of medial ankle sprains 4 following deficits typically seen in the injured female athlete: (1) ligament dominance, (2) quadriceps dominance, (3) leg dominance, and (4) trunk dominance. Core strengthening is recommended after injury and includes exercises to strengthen the abdominal muscles, hip muscles, and lumbar spine muscles. Age over 30 - increase chance of not returning to same level of play
What is Ankle Impingement
What is Ankle Impingement Impingement syndromes in the ankle include a broad spectrum of pathology with varying etiologies, anatomic features, and presentations. Although no official classification exists, these syndromes are generally defined by the particular anatomic area involved. Specific anterior, anterolateral, anteromedial, posterior, posteromedial, posterolateral, and syndesmotic impingements have been described Anterior ankle impingement syndrome results from compression of structures at the anterior margin of the tibiotalar joint during dorsiflexion. Anterior impingement has long been recognized as a cause of pain in athlete
Return To Play Advice with Ankle Impingement
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Different Causes of Ankle Pain
What you need to know
01
Tarsal tunnel syndrome
Tarsal tunnel syndrome is caused by compression of the posterior tibial nerve and its branches in the tarsal tunnel, a fibro-osseous canal extending from the posteromedial ankle to the plantar aspect of the foot. Possible clinical symptoms include pain and paresthesia at the medial heel and/or the medial and plantar aspect of the foot and toes, positive Tinel’s sign, and weakness of the plantar muscles.
Entrapment of the nerve can occur due to trauma or repetitive stress (athletes), foot deformity, ankle instability, spur formation, and space-occupying masses (ganglia, nerve sheath tumors, accessory muscles
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The 4 compartments of the ankle that can cause pain.
Anterior vs Medially Ankle Pain
Anteriorly, you will find the anterior tibialis, extensor hallucis, and extensor digitorum tendons (a.k.a. anterior extensor tendons). The anterior tibialis tendon is the largest, strongest, and most commonly injured of the three anterior tendons.
Acute injuries can occur in normal anterior tibialis tendons secondary to penetration or laceration injuries from a sharp object such as a hockey boot blade .
Acute injuries more commonly occur in the setting of chronic tendinosis, typically in older patients in the 60–70 age range
Medially, you will find the posterior tibialis, flexor digitorum, and flexor hallucis tendons (a.k.a. medial flexor tendons).
The posterior tibialis tendon is the most commonly injured tendon along the medial ankle, typically in middle-aged and elderly women
The flexor hallucis longus tendon is the second most commonly injured medial tendon, classically seen in dancers
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Jogger’s Foot
Entrapment of the medial plantar nerve between the abductor hallucis muscle and the plantar crossover of the flexor digitorum longus and flexor hallucis longus tendons (“knot of Henry”) is classically described in runners, typically with hyperpronation and heel valgus.
Clinical symptoms are radiating medial foot pain, tenderness, and dysesthesia along the plantar aspect of the first and second toes. MR imaging can confirm the diagnosis by demonstrating denervation edema or fatty atrophy of the abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and first lumbrical muscles
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The 4 compartments of the ankle that can cause pain.
Posterior vs Lateral Ankle Pain
Posteriorly, you will find the Achilles tendon. The Achilles tendon is most commonly injured 2–6 cm proximal to its calcaneal insertion, related to the low vascularity in this portion of the tendon
Injuries are typically posttraumatic in nature with acute tearing superimposed on chronic tendinosis.
There are different types of Achilles tendinosis, most commonly hypoxic and mucoid . The insertional portion of the tendon is interposed between the retrocalcaneal bursa (anteriorly) and subcutaneous bursa (posteriorly). These bursae can get inflamed, along with the tendon, in the setting of Haglund’s disease
Laterally, you will find the peroneal tendons: brevis and longus.
Peroneal tendon pathology can occur in the acute setting, secondary to ankle sprains, as well as in the chronic setting, in the form of tendinosis from repetitive stress, impingement from displaced fractures of the calcaneus or distal fibula, or inflammatory arthroplasty .
Stenosing tenosynovitis can be seen along the peroneal tendons, secondary to chronic friction along the tendons related to tendinosis, thick inferior retinaculum, and/or a narrowed inferior osteofibrous tunnel. Peroneal tendon instability can also be seen on imaging, typically related to superior peroneal retinacular injuries