Reflections after sports injury clinic:
Sports injury patient: New patient assessment, patients chief concern was Achilles pain. Patient medical history indicated multiple knee surgeries, IT band insertion irritation, 2nd phalanx surgery (both feet) for “curly-toes” dx as a child, pt went through the following orthopaedic assessments:
- 1st MTPJ ROM (3-5mm)
- Jacks Test (not much range of motion)
- MTJ ROM (normal 1:1)
- STJ Eversion, Inversion (NWB; 2:1 within the normal ratio)
- Ankle ROM (2nd Ankle ROM test was done via off-loading Gastroc) (limited, and spongy resistance, even with off-loading gastroc)
- Rearfoot in relation to the forefoot (NWB) (forefoot was in valgus position) [questionable as I believe I did this test wrong]
- Tibia in relation to retrocalcaneal (WB) (tibia was in a normal position in relation to the calcaneal)
- Pelvic rotation test (Checking for anterior/posterior rotation) (pelvis was not anteriorly nor posteriorly rotated)
- Leg-Length Test (a very minor discrepancy, 1-2mm)
- Single-limb leg stance (ankle instability was detected)
- Tip-Toe raise (calcaneal inverted normally)
- FPI (+5)
The following reflex tests were done alongside partial circulation assessments [ABPI was not done, DP and PT were palpated and dopplered]
- Plantar reflex test
- Ankle reflex test
- Patellar reflex test
After performing the above orthopaedic assessments and reflex tests, the results indicated that the pt had restricted dorsiflexion at the ankle joint, with normal to moderate range of motion at the mid-tarsal joint and sub-talar joint. The patient also had diminished proprioception, with absent results after ankle reflex test; coming to the conclusion that the pt has structural limitation [I forgot this part] this contributed to the pt’s overall genu valgum and FPI, which was within the normal range according to FPI however, pt was adamant that she had flat feet. Pt did mention that she had lost all confidence and needed some reassurance since she had started physical activity relatively recently after weight loss and her feet were in pain. After inquiring, the patient stated that her pain alleviated after rest. Therefore the following exercise prescription was made: tip-toe raises 10 repetitions, twice a day for 5 days a week and to improve proprioception, the patient was prescribed single-limb leg stances without touching the wall for support [I also forgot this part and how much was prescribed]
Correlation of ankle instability and limited ankle range of motion:
A study conducted by Basnett et al in 2013, investigated the correlation between chronic ankle instability and ankle range of motion and balance. Ankle range of motion was measured in the weight-bearing stance and while the dynamic balance was measured using STAR (Star Excursion Balance Test) the SEBT tests for flexibility, proprioception and strength in patients with suspected chronic ankle instability (Basnett, et al., 2013). However, today’s patient underwent the full orthopaedic assessment according to the new patient assessment guidelines.
The study determined that there is sufficient positive evidence to suggest that patients with reduced ankle dorsiflexion range of motion impact dynamic balance in patients with chronic ankle instability (Basnett, et al., 2013). Ankle dorsiflexion range of motion was the key component in explaining why the single-limb anterior reach component of SEBT has a 31% variation in individuals with chronic ankle instability (Hoch, et al., 2012).
However, the study also admits that there was a variation in reach distances that could not be explained by ankle dorsiflexion range of motion stating that there could be neuromuscular components as to the contributing variable that was not explored (Basnett, et al., 2013).
Ankle dorsiflexion range of motion has an impact on mechanics in jogging and running and impacts balance in older individuals, squat and gait biomechanics in healthy individuals with CAI (Basnett, et al., 2013). Reduced ankle dorsiflexion range of motion has also been shown to be a contributing risk factor in individuals with lower extremity and knee-joint pathologies. An interesting factor gleaned from this study is that a reduction in ankle dorsiflexion range of motion is a contributing factor in individuals with a history of lateral ankle sprains and after questioning the patient seen today, she mentioned that she frequently gets sprains (Basnett, et al., 2013).
The authors of this study do mention a limitation in their study, they did not take into consideration that ligamentous insufficiency as a variable and therefore state this as a demographic that has been left out of the study due to most of its participants being quite young (Basnett, et al., 2013). The study is also clinically relevant due to the fact that the anterior reach component of SEBT is important in dynamic proprioceptive tasks in patients with chronic ankle instability this can direct the clinician's diagnosis and subsequent management in individuals with CAI (Basnett, et al., 2013).
References
Basnett, R. C. et al., 2013. Ankle dorsiflexion range of motion influences dynamic balance in individuals with chronic ankle instability. International Journal of Sports Physical Therapy, 8(2), pp. 121-128.
Hoch, C. M. et al., 2012. Dorsiflexion and dynamic postural control deficits are present in those with chronic ankle instability. Journal of Science and Medicine in Sport, 15(6), pp. 574-579.
Macrum, E. et al., 2012. Effect of limiting the ankle-dorsiflexion range of motion on lower extremity kinematics and muscle activation patterns during a squat. Journal of sports rehabilitation, 12(2), pp. 144-150.
Plinsky, J. P., Rauph, J. M., Kaminski, W. T. & Underwood, B. F., 2006. Star Excursion Balance Test as a Predictor in Lower Extremity injury in high school basketball players. Journal of orthopaedic and sports physical therapy, 36(12), pp. 911-919.
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