Physiotherapy with 5 basic ankle stabilize exercise for ankle sprain and ankle snapping

 

Ref: https://www.aspetar.com/journal/viewarticle.aspx?id=138#.Y0DzTXZBy3A

The ankle is one of the most commonly injured joints in sports. Many people have asked me about annoyed ankle pain that has the potential to include resting swelling, loose joints, and ankle twist easily. The most resting swelling is always at the location of ATFL (anterior tibiofibular ligament) that can occur from normal standing and walking. Loose joints is the unstable joint feeling or we can call joint laxity that can feel discomfort around the ankle and tight calf muscle. Too easy ankle twisting including walking on normal surfaces or normal stairs. 

The cause of these symptoms is poor rehabilitation after an ankle sprain or ankle trauma. Normally, an ankle sprain can heal itself after taking medicine and rest. So, the patients ignore physiotherapy programs for ankle injury. However, the injured structure i.e. ligaments and tendons are weaker than before injury that induce poor circulation, poor joint position sensation, muscle weakness, muscle reaction time, and the injured site become vulnerable. 

These mechanics can explain the symptoms as above: resting swelling is made by poor circulation, loose joints are made by muscle weakness, and easy ankle twisting is made by muscle weakness and poor joint position sensation. Therefore, Two theories that cause ankle instability in general are mechanical instability and functional instability. Mechanical instability refers to the measurement of ligamentous weakness, whereas functional instability comes from a neuromuscular system deficit.

Left lateral ankle illustrated mild swelling in chronic ankle instability
(Ref: https://www.preferredfootankle.com/)

The therapeutic ankle stabilization exercise is a very essential part after an ankle sprain or injury because the rehabbed ankle will have normal internal structure strength and active neuromuscular function. The program is associated with strengthening muscle around the ankle joint, proprioceptive training, and flexibility.

"To strengthen ankle muscles need some resistance from elastic exercise bands or tubes or cable which is not very heavy. Normally, I arrange for my patients between 2 - 5 kilograms."

 

Elastic (rubber) band exercise (upper picture) and loop exercise (lower picture)

5 basic ankle stabilizer strengthening exercise

Exercise #1: Alphabet exercise: write the capital letter “A to Z” by toe tip and ankle. It needs 10 - 15 rounds a day. (slow speed)

Exercise #2: Ankle eversion with dorsiflexion: bend ankle upward with outward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)

Exercise #3: Ankle eversion with plantar flexion: bend ankle downward with outward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)

Exercise #4: Ankle inversion with dorsiflexion: bend ankle upward with inward (big toe finger side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)

Exercise #5: Ankle inversion with plantarflexion: bend ankle downward with inward (little toe side) and hold 5 seconds for 10 - 15 reps/set of 3 sets. (slow speed)

  About 85% of ankle sprain occurs due to inversion injury, this injury occurs due to the number of stabilizing bones on the outside or side which causes the pressure on the foot to be reversed. The ankle joint is prone to injury because it is unable to resist medial, lateral, pressure and rotation strength.  When an ankle sprain occurs, damage does not only occur to the structure of ligament integrity but also to various mechanoreceptors around the ankle. 

Inversion ankle twist (sprain) is the most common ankle sprain
(Ref: https://www.hprsphysio.com.au/)

Rehabilitation of athletic injuries requires the prescription of sport-specific exercise and activities that challenge the recovering tendons, ligaments, bones, and muscle fibers without overstressing them. Rehabilitation must take into consideration normal tissue size, flexibility, muscular strength, power, and endurance. Firstly, control of swelling and effusion must be accomplished with frequent application of external pressure, modalities such as cryotherapy, and active range of motion (ROM).

A significant predisposing factor for the development of chronic ankle instability is the history of at least one previous lateral ankle sprain. The risk of developing chronic ankle instability is as great after a severe ankle sprain as after one or more minor sprains. So, inappropriate ankle rehabilitation can induce recurrent ankle sprain and develop chronic ankle instability afterward.

Star excursion in ankle joint biofeedback training
(Ref: https://www.grsm.ca/)

One goal of rehabilitation is to develop strength and neuromuscular control so that the ankle and foot are better controlled and protected during stance and impact. Adequate strength is necessary for normal movement patterns. The importance of developing correct motor patterns while subjects perform flexibility and strength exercises cannot be overemphasized.

Ankle strengthening by elastic band
(Ref: https://www.physioproperth.com.au/resources/exercises/ankle-rehabilitation/)

We have seen stiffness of calf muscle and achilles tendon in chronic ankle instability patients that make ankle range of motion limitation especially ankle dorsiflexion. By anatomy, the tightness of the achilles tendon tends to be ankle plantarflexion with inversion which is the most common ankle sprain pattern because insertion of medial achilles tendon force direction. Moreover, this stiffness causes discomfort and anterior ankle pain sometimes. So, stretching the calf and achilles tendon is one important part of ankle rehabilitation. (You can research more information on https://yimphysionearme.blogspot.com/2022/07/physiotherapy-with-9-options-to-stretch.html )

Advance calf stretching
(Ref: https://www.knee-pain-explained.com/)

Both strength and flexibility are not enough to complete ankle recovery. Balance training in ankle damage patients can improve postural control and the proprioceptive sense and is widely used as a treatment method to improve the stability of the ankle joints. The balance ability associated with ankle damage is affected by various forms of sensations, including visual and cutaneous sensations. Among them, the proprioceptive sense is obtaining stimuli through conscious/unconscious processes in the sensory motor system and is divided into motor sense (kinesthesia) that sense the movements of the limbs and joint position sensation that sense the static positions of the limbs. When the proprioceptive sensory function has deteriorated, the postural control ability, protective reflex ability, joint movement ability, and balance ability to respond to postural sways become more likely to be deteriorated. 

Balance training on uneven surface
(Ref: https://lermagazine.com/)

The goal of rehabilitation is to return an athlete to the same or higher level of competition as before the injury. Patients have to train sports specific when basic ankle physical fitness is good enough. It includes sports skill, movement, sports postural control, agility, and plyometric. This part of rehabilitation is like a comprehensive exercise before returning to routine training with the team or completion. It can be done by a sports scientist or fitness coach or physiotherapist (as option). 

Plyometric and agility drill
(Ref: https://www.physioroom.com/)

Reference: 

https://www.researchgate.net/publication/349134664_Glute_Exercise_and_Basic_Exercise_Therapy_Improve_Ankle_Stability_in_Patients_With_a_Chronic_Ankle_Sprains 

https://www.researchgate.net/publication/324802170_Effects_of_ankle_strengthening_exercise_program_on_an_unstable_supporting_surface_on_proprioception_and_balance_in_adults_with_functional_ankle_instability 

https://www.researchgate.net/publication/5298401_The_Effectiveness_of_Active_Exercise_as_an_Intervention_for_Functional_Ankle_Instability

https://ijshr.com/IJSHR_Vol.5_Issue.4_Oct2020/IJSHR0052.pdf

http://www.oliverfinlay.com/assets/pdf/mattacola%20&%20dwyer%20(2002)%20rehabilitation%20of%20the%20ankle%20after%20acute%20sprain%20or%20chronic%20instability.pdf 

Physiotherapy with basic 9 stretching to improve low back pain in flat back syndrome

Flat back posture
(Ref: https://www.orthobullets.com/)

            I have taken care of some patients who had low back pain which is associated with decreased lumbar spine lordosis. Some of them got pain from sports activities such as cycling in triathlons.

    The decreased lumbar spine lordosis or hypo-lordotic lumbar curve consists of posterior pelvic tilt that ASIS level is same or higher than PSIS level, and lumbar spine trend to straight that means flexion. 

    We have seen the hypo-lordotic lumbar curve in common two posture including 

(1) Sway - back posture, the lower component illustrates lumbar spine flexion (flattening) of lower lumbar area, pelvis posterior tilt, hip joints hyperextended with anterior displacement of pelvis. Because we focus on tightness of structure in this article, the muscle shortness consists of hamstrings, upper fibers of internal oblique, and low back muscles.

Dark gray area represents muscle weakness in sway - back posture
(Ref: https://www.pinterest.com/)

(2) Flat - back posture, the characteristic of this posture associated with lumbar spine flexed (straight), pelvis posterior tilt, hip joints extension. The muscle shortness has been found at the hamstring, but abdominal muscles are strong that may or may not shortness. Sometimes, Gluteus maximus is included as well. 

Dark gray area represents muscle weakness in flat - back posture
(Ref: https://www.pinterest.com/)

Both of them have hamstring shortening where hamstring anatomy attachment is at the ischial tuberosity, and this structure moves superiorly as the pelvis tilts. Hamstring tightness is a common finding in the LBP patient. 

I have found not only all muscles as above, but also both quadratus lumborum (QL) in low back pain with lumbar hypo-lordotic. They are taut and trigger both sides so that they are not improved by massage and stretching. I have skipped massage and stretching on QL and applied another technique to release them. Moreover, I have always seen TFL tightness in flat back posture more than hyper lordosis posture. 

Muscles around pelvic that hamstring and gluteus maximus are the key of tightness
(Ref: https://musculoskeletalkey.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

 

Basic 9 stretching to correct posterior pelvic tilt. (Please stop stretching and consult a physiotherapist or doctor if you feel worse pain and/or numbness.)

Exercise #1: Stand toe touch double legs: Keep back straight and/or pelvic anterior

tilt together with knee straight during stretch. Reach as far as you feel some tension

that means no need to push excess muscle length. Your range of motion will increase

gradually in the future.

Exercise #2: 90-90 SLR with knee straight: Straight target knee as far as you feel some

tension that means no need to push excess muscle length. Your range of motion will

increase gradually in the future.

Exercise #3:  90-90 SLR with knee straight with belt assisted: Put the belt at the ball of foot.

Straight target knee as far as you feel some tension that means no need to push excess

muscle length. Your range of motion will increase gradually in the future. 

Exercise #4: Doorway with knee straight: Keep back straight and/or pelvic anterior tilt 

together with knee straight during stretch. Reach as far as you feel some tension that

means no need to push excess muscle length. Your range of motion will increase

gradually in the future. You can apply it with a table, chair, fence, or any stable

structure as well.

Exercise #5:Supine cross leg: Do not lift shoulder and pelvic from the floor during stretching.

For more stretch, pull the knee to the opposite shoulder.

Exercise #6: Supine figure 4: Keep back straight during stretching to prevent back pain.

For more stretch, keep the knee and chest closer. 

Exercise #7: Basic Cobra with lateral bending stretch: During stretching needs to keep

pelvic on the floor.

Exercise #8: Modified Cobra with lateral bending stretch: During stretching needs to keep

pelvic on the floor.

Exercise #9: Seat torso rotation stretch.

 The flat back,  as the name implies, is a type of sagittal imbalance in the spine, and it is characterized by loss of the lordotic curve. There is a straight back in both the lumbar and thoracic areas except that there is some degree of flexion in the upper thoracic area that accompanies the forward head position. 

The flexible flat - back posture appears to be more common among certain cultures than among others. Asians seem to exhibit this type of posture more frequently than most Americans or Europeans. This type of flat - back does not give rise to as many problems of low back pain as does the lordotic back, or the sway - back posture. The range of motion in extension is usually normal and may be excessive.

Passive lumbar extension test
(Ref: https://www.uma.es/)

Although the pathogenic mechanism remains unclear, poor posture and lack of exercise are major causes of spinal deformity. The normal curve of the spine is known to have a buffering effect against gravity and provides optimal, coordinated body movements. An abnormal spinal curvature is associated with musculoskeletal and nervous systems problems.

The flexible functional state impairment of muscles in the flat-back posture demonstrates gluteus maximus is shortened and hypoactive; in hamstring parts are also shortened yet hyperactive.

90-90 SLR test for hamstring tightness
(Ref: https://bendandmend.com.au/)

The sway - back posture is one in which there is a posterior displacement (swaying back) of the pelvis. The pelvis is in posterior tilt and sways forward in relation to the stationary feet causing the hip joint to extend. The effect is equivalent to extending the leg backward with the pelvis stationary. With posterior pelvic tilt, the lumbar spine flattens and hence there is no lordosis although the long curve in the thoracolumbar region (which is due to the backward deviation of the upper trunk) is sometimes mistakenly referred to as a lordosis. (the term sway - back posture is an appropriate label and requires that the word “sway - back” not be used synonymously with the word “lordosis”)

Pelvic in sway back posture is in front of torso
(Ref: https://ebrary.net/)

In the past, the words “lordosis” and “sway - back” were used interchangeably in referring to the curvature in the low back and lower thoracic arrears. The postural differences between the lordosis and the sway-back postures were recognized in posture and pain. Separating the use of these terms also differentiated these two postures. They are distinctly different with respect to the anteroposterior tilting of the pelvis, the position of the hip joint, and the accompanying muscle imbalance that exist.

Functional state of muscles flexibility deficit in the sway-back posture show the shortened

muscles are suboccipital, sternocleidomastoid, scaleni, chest muscles—pectoralis major and minor, erector spinae lumbar part (lower part), upper fibers of abdominal muscles, gluteus maximus, and hamstrings. All these muscles demonstrate hyperactivity (except for the lower part of lumbar erector spinae, posterior part of internal oblique abdominal muscle, gluteus maximus, and hamstrings.

Gluteus maximus muscle length assessment 
(Ref: https://www.physio.co.uk/)

Clinically, often assume that tighter hamstring muscles will limit anterior tilt of the pelvis. It has been argued that anterior tilt of the pelvis will be reduced because the hamstrings attach to the ischial tuberosity, and this structure moves superiorly as the pelvis tilts, increasing the distance between the attachments of the hamstrings. However, the line of action of the hamstrings is almost vertical, and the attachment to the ischial tuberosity is only slightly posterior to the femoral head. 

This minimal posterior force tending to posteriorly rotate the pelvis is likely to be outweighed by activity of the hip flexors tending to anteriorly rotate the pelvis. Therefore, any change in the length of the hamstrings may not alter the total range of pelvic tilt. The study has shown that no association exists between hamstring muscle length and total range of pelvic motion during forward bending in asymptomatic subjects.

Pelvic posterior tilt force direction
(Ref:https://healthfitinc.com/)

Although hamstring stretching may not affect pelvic tool posture, stretching the short hamstring muscles to correct the faulty alignment is recommended strongly. Short hamstring muscles, because of their attachments to the posterior leg and to the ischial tuberosity, may limit hip flexion ROM. The restricted hip motion is coupled with excessive lumbar motion. Stretching short hamstring muscles to increase hip flexion, therefore, may affect lumbar motion during forward bending. Excessive lumbar motion would increase tensile loads on the spine and thus could result in LBP. The short hamstring muscles cause back pain due to their influence on lumbopelvic rhythm during forward bending. 

SRL stretch
(Ref: https://www.hss.edu/)

Based on the studies described, standing lumbopelvic posture has not been clearly related to muscle length. Furthermore, there is insufficient data to determine the effect of hamstring muscle stretching on standing lumbar and pelvic posture or the relative amounts of lumbar and hip motion during forward bending. Stretching was performed with the patients positioned supine by actively extending the knee with the hip flexed. The SLR measurement method was used first, followed by the AKE method. The results of this study suggest that there is no relationship between hamstring muscle length and lumbopelvic posture. There was some indication, however, that stretching the hamstring muscles may affect motion during forward bending. The data gathered in this study suggest that a 3-week program of hamstring muscle stretching (1) will not alter standing lumbar and pelvic postures, (2) will produce greater forward bending as a result of increased motion at the hips, and (3) may alter the pattern of lumbar and hip motion during forward bending. 

Stand forward bending stretch
(Ref: https://www.verywellfit.com/)

One case study report suggested the lumbar extension traction which is used to restore lordosis to the elliptical normal L1–L5 of the absolute rotation angle value of −40°. It was used for treatment as a part of the chronic low back pain rehabilitation program resulting in large increases in sagittal lumbar lordosis, decreased anterior sagittal balance and a minimization of pain levels in two patients diagnosed with FBS suffering from chronic low back pain. Two chronic low back pain with flat back posture patients in this study demonstrated improvement significantly after intervention at least 16.5 weeks.

Biomechanically, lumbar extension traction increases lordosis due to lumbar extension traction creating a deformation in the soft tissues (muscles, ligaments, and discs) of the lumbar spine. Tendons, ligaments, and discs, all display visco-elastic properties. When the soft tissues of the spine are subjected to a sustained load for a given time, these tissues undergo two major processes, creep and stress relaxation. Creep is the amount of deformation occurring in the tissues and stress relaxation is a reduction in the amount of the internal stress found in the tissue over time. 

Creep phenomenon graph
(Ref: https://web.iit.edu/sites/web/files/departments/academic-affairs/academic-resource-center/pdfs/MaterialsCreep.pdf)

In extension creep loading of cadaveric lumbar specimens, during the first 5 minutes much of the initial deformation is recoverable strain energy (elastic). Most of the non-recoverable strain (permanent deformation) energy takes place from 5 to 20 minutes; at 20 minutes a plateau effect takes place. It is the non-recoverable strain energy that results in the permanent deformation or resting length change of the spinal tissues. The two patients in this study performed extension traction for 20 minutes to take advantage of the visco-elastic deformation in the spinal tissues.

If this type of posture exists without low back pain, it is not necessary to change it. If the back is painful, and restoring the normal anterior curve is indicated.

Reference :

http://www.norrishealth.co.uk/library/sdarticle.pdf

https://d-nb.info/1166557340/34

https://www.mdpi.com/1660-4601/18/20/10923/htm 

https://watermark.silverchair.com/ptj0836.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAsMwggK_BgkqhkiG9w0BBwagggKwMIICrAIBADCCAqUGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMjEMqUKs03vtPoJ-fAgEQgIICdtNoCBekqxzlyP7XaRxkJDjk82KXkEGVKY2R090TUzcP0c6NFC1oowVjkl_LvNhGk1daUTmmCImrhrhVDPbNhMTl4gz-1H87fF3Zw42eNjQvuv3ELCbOISwPxPTKzrusg0kk-R4FrHtudhiw-dv7d00eS46T73OFjvPhd1MbiSAow_kqRXUzcFMTWsPfn0heEFEhyWG20mfa-PKaeEWtLgJIVV7iWAu-0Tv4x2JxKp7hGF4zUGZls4QrDQvWz95VkrsrbW8dvOO0iN2ocr_PrInxrgFQXp7thYClvmXySqOH7T-5Lg8aC43X2gJjmufTDHE-Yu9l1kZhcpvdUnNih509fufqNwZk21gLkD5aFNNNcvkF9Qsw0YhDc74zlYQie4oLZvPoi2RvFBIl1mTo3GjAD6POQeaG_uGfViMaNdC4BlTNrSK9dZhX2FngHt7SvwQ8WJQUNDhHk0h78qjQh4t0TDA6uwHGBL7vXU8h6A1169_BC4Qbugw7bKiXEoC37PMhe7cSJgFl61yYaKiKmscKnxIiOnSG0ALEwkU0Mgu2Xpy1jXBNiOnJkUb3Ch-npQV1Q6XKhUjbVOgsGWz4sHYHC0vSNHxwWf9fuELpOqHidAnjh5em27yt7CNB-KFvlAPrG6PV8fXLN0Ild8ATDYwAtbW_VS0VT4nelUDl5vmY-qDC5Xxg1WTr7XA0xk5yYbuBJnJ2x0PLuqrQwkP-ZM8qbRmynczNFpMazJasQ_pdl_1d1Mkcnc3caVLqyWtImXFU8Zull9-CChnOlIVk_QHd4rkWmp7anK3lIypT_Z-z6coSFeccRJg7zf0CpXPGbj3k23OMmQ 

https://www.researchgate.net/publication/326852561_Non-operative_correction_of_flat_back_syndrome_using_lumbar_extension_traction_a_CBPR_case_series_of_two

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110233/

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