Ankle Pain

Mentoring Minutes: Chronic Ankle Sprains

The all-to-common inversion ankle sprain. How to assess and treat to improve outcomes and limit them from turning into chronic ankle instability. Research is pretty clear: balance and proprioceptive training until the cows come home, then progress to single leg hopping.

Reference & Notes:

Van Ochten JM et al., Chronic Complaints After Ankle Sprains: A Systematic Review on Effectiveness of Treatments. JOSPT.  2014 Nov, 44:11, 862-71 

  • 23,000 ankle injuries daily; up to 34% of ankle sprains continue to have symptoms 6 months later.

  • 20 RCT’s included to evaluate most beneficial treatment for decreasing pain and function, and reducing recurrences.

  • Initial treatment: POLICE (Protected Optimal Loading, Ice, Compression Elevation;

  • Biggest benefit at 4 weeks was following proprioceptive training (use of wobble boards, discs, airex, bosu; progressed from eyes open to closed; static to dynamic training (Lateral and change or direction single limb hoping).


Mentoring Minutes: Achilles Tendinopathies

Notes & References

-       wrong use vs over use  - Not every tendon problem is the same; location matters

o   Midsubstance- Most common: associated with over/wrong use; treat with load and reload;

-Most common (have ICF guidelines); goal is to stiffen it (so isometrics/eccentrics verse stretches)

-Can use tape, soft tissue, heel lifts, some modalities, all can help with pain (for the itis), but do not reload tendon, needed for Osis treatment

-Treatment: slow and controlled, involving cognition (think about it), need to exceed elongation than during walking (on step); high volume required, and overload it;

- Progression from flat ground to step to adding weight

- Goal with treatment is to make tendon more organized, thinner, faster reaction time;

-Palpation: if very localized, may more degeneration/thickening, verse entire tendon than more related to inflammation;  

o   Tenosseous junction (insertional)- associated with collagen disease, wide age range- teat surgery, casting, shockwave; Avoid resistive exercises, more to rest and boot/immobilize

-Running technique/skill training (change how they load the foot/calcaneus);

- Look at rear foot and mid foot mechanics.

Muscle Tendinous Junction: associated with immobilization (deprived loading); treat with progressive reloading- more rare, often inflammatory and need rest first

Sports Med. 2012 Nov 1;42(11):941-67. doi: 10.2165/11635410-000000000-00000.

Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning.

Rowe V1, Hemmings S, Barton C, Malliaras P, Maffulli N, Morrissey D.


- Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence.

J Orthop Sports Phys Ther. 2015 Nov;45(11):876-86. doi: 10.2519/jospt.2015.5885. Epub 2015 Sep 21.

A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation.

Silbernagel KG, Crossley KM.

Mid protion; 2-6 cm proximal to insertion (55-65%)

Eccentric protocol: 15x3, knee straight and 15x 3 knee bent; 2x a day, 7 days, no more than 5/10 during and after next day, slowly add load.

Return to sport: 3x15 with weight off step SL heel raises; 3x15 eccentric off step with weight, and 3x20 quick rebounding heel raises - 3 days recovery - need to load heavy, and speed

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Clin J Sport Med. 2009 Jan;19(1):54-64. doi: 10.1097/JSM.0b013e31818ef090.

Nonoperative treatment of midportion Achilles tendinopathy: a systematic review.

Magnussen RA1, Dunn WR, Thomson AB.

Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy.


Sports Med. 2013 Apr;43(4):267-86. doi: 10.1007/s40279-013-0019-z.

Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.

Malliaras P1, Barton CJ, Reeves ND, Langberg H.

  • CONCLUSION: There is little clinical or mechanistic evidence for isolating the eccentric component,
  • Concentric- eccentric loading better (3 sec up, 3 sec down)- time under tension-  3 sets of 10-20, enough load to be painful in third set

J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. doi: 10.2519/jospt.2016.6494. Epub 2016 May 12.

Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running.

Willy RW, Halsey L, Hayek A, Johnson H, Willson JD.

  • Treadmill running resulted in greater achilles tendon loading compared with overground running ; peak concentric ankle power greater with Treadmill runnning


Am J Sports Med. 2015 Jul;43(7):1704-11. doi: 10.1177/0363546515584760. Epub 2015 May 27.

Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial.

Beyer R1, Kongsgaard M2, Hougs Kjær B3, Øhlenschlæger T2, Kjær M2, Magnusson SP4.

  • chronic  mid portion achilles tendinopathy;
  • eccentric training 3x15 7x week, 12 weeks vs: Heavy slow resitance 3x week, knee flexed seated, and knee extended standing (15 rep max to 6 rep max);
  • sports allowed if < 3; 4-5/10 while training if subsides next session
  • Both groups: improved pain, and sports assessments, reduction in tendon thickness and neovascularization
  • Patient satisfaction > in heavy slow resistnace group (96 vs 76%), with higher compliance (96% vs 76%))

Mentoring Minutes: Ankle Sprains


Injury. 2016 Nov;47(11):2565-2569. doi: 10.1016/j.injury.2016.09.016. Epub 2016 Sep 9.

Factors associated with pain intensity and physical limitations after lateral ankle sprains.

Briet JP1, Houwert RM2, Hageman MG3, Hietbrink F4, Ring DC5, Verleisdonk EJ6.

Swelling, tenderness, and ecchymosis don't correlate with time to functional recovery in patients with a lateral ankle sprain. It is established that psychosocial factors such as symptoms of depression and low pain self-efficacy correlate with pain intensity and magnitude of limitations in patients with musculoskeletal disorders.


We studied the correlation between pain self-efficacy or symptoms of depression and (1) ankle specific limitations and (2) pain intensity in patients with a lateral ankle sprain. Further we explored the correlation between estimation of sprain severity (grade) and (3) pain intensity or magnitude of ankle specific limitations.


Eighty-four patients with a lateral ankle sprain prospectively completed the Pain Self Efficacy Questionnaire, the Olerud Molander Ankle Score, Ordinal scale of Pain and the Patient Health Questionnaire-2 at enrollment and the Olerud Molander Ankle Score and the Ordinal scale of Pain three weeks after the injury. Factors associated with higher ankle specific limitations and symptoms were investigated in bivariable and multivariable analysis.


When accounting for confounding factors, greater self-efficacy (p=0.01) and older age (p<0.01) were significantly associated with greater ankle specific symptoms and limitations three weeks after the injury and explained 22% of the variability in ankle specific limitations and symptoms. There was no correlation between the grade of the sprain and pain intensity or ankle specific limitations or symptoms.


Psychosocial factors (adaptiveness in response to pain in particular) explain more of the variation in symptoms and limitations after ankle sprain than the degree of pathophysiology. The influence of adaptive illness descriptions and recovery strategies based on methods for improving self-efficacy (i.e. cognitive behavioral therapy) might enhance and speed recovery from ankle injuries and merit additional investigation.

-Higher self efficacy and younger age significantly associated with better ankle specific symptoms and limitations

- Lower pain intensity correlated with a greater self efficacy and younger age 3 weeks post injury

- Grade of sprain did not correlate with ankle specific symptoms and limitations or pain intensity 3 weeks post injury.


Br J Sports Med. 2013 Jul;47(10):620-8. doi: 10.1136/bjsports-2012-091702. Epub 2012 Dec 6.

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review.

Sman AD1, Hiller CERefshauge KM.

To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury.


Systematic review.


An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information.


Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard.


The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests.


This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

- Highest Sensitivity: inability to perform SL hop 89%; Syndesmosis lig tenderness (92%)

-Highest specificity: pain out of proportion (79%); Squeeze test (88%)

- Syndesmosis injury4x more  likely to be present with positive syndesmosis lig tenderness and/or DF/ER stress test


Prediction of Lateral Ankle Sprains in Football Players Based on Clinical Tests and Body Mass Index

Phillip A. Gribble, PhD, ATC, FNATA*Masafumi Terada, PhD, ATC, Megan Q. Beard, PhD, ATC, ...

- Ant direction reach most related to recurrent ankle sprains


Simplifying the Star Excursion Balance Test: Analyses of Subjects With and Without Chronic Ankle Instability

Authors: Jay Hertel, PhD, ATC1Rebecca A. Braham, PhD2Sheri A. Hale, PT, PhD, ATC3Lauren C. Olmsted-Kramer, PhD, ATC4

- Conclusions

The posteromedial component of the SEBT is highly representative of the performance of all 8 components of the test in limbs with and without CAI.


Br J Sports Med. 2014 Mar;48(5):365-70. doi: 10.1136/bjsports-2013-092763. Epub 2013 Aug 26.

The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review.

Loudon JK1, Reiman MPSylvain J.

L ateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes.


Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains.


This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination 'ankle', 'sprain', 'injuries', 'lateral', 'manual therapy', and 'joint mobilisation'. The methodological quality of individual studies was assessed using the PEDro scale.


After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed.


For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function.

Ankle Sprains - Exercises For Rehab And Prevention

Ankle Sprain.jpeg

Ankle sprains are the most common injury in sports and the most common joint injury in daily life - we see them all the time.

Since it's so common - people should know what to do immediately following an ankle sprain, shouldn't they?

It would also be helpful if they knew a few simple exercises that will help them recover and also prevent future ankle sprains.  

This week's Patient Education article gives your patients the basics for acute treatment following an ankle sprain, and a simple, proven exercise progression with videos to help recover and prevent future injury.  

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Mentoring Minutes: Post Ankle Fracture

Welcome to PhysioU’s Mentoring Minutes! Each episode of Mentoring Minutes directly applies a clinical approach with relevant research for effective results.

How do we get patients with post ankle fracture back to function? Watch today’s episode of Mentoring Minutes with Dr. Marshall Lemoine to see how we can assess and address the two impairments related to post ankle fracture!

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