The feedback on last months' article has been very encouraging, positive and has also sent a message that there is some clarification needed with regard to orthotics.  Although off the shelf orthotics do work for some individuals, custom orthotics are usually the best.  However, getting new orthotics for a teenager every few months is impractical and costly.  I do recommend that players try the off the shelf orthotic first and see if it does the job it is intended to do.  If not, then custom made orthotics are necessary.

The biggest problem with orthotics is non-compliance.  This means the client stops using them because they don't feel good or they just plain do not fit properly.  This needs to be avoided or you are throwing money away.  Make sure the orthotic fits comfortably.  Basically, approximately one week to slowly wean yourself into the orthotic.  I tell clients to use the new orthotic one hour a day in the morning and one hour in the afternoon.  Every day increase the hour by another hour.  By the end of the week you should be wearing the orthotic all day without any discomfort.  Do not start running with the orthotic in the runner and/or cleats until you are wearing them all day and they feel good. 

One of the reasons an orthotic may not fit properly is that the heel of the orthotic raises the heel and when you are walking it feels like the heel is slipping out of the orthotic.  There are orthotics that minimize this effect.  This is extremely important in soccer shoes because soccer shoes are notorious for not having any support whatsoever in the shoe.  If the heel feels like it is coming out of the shoe with every step the athlete will stop using the orthotic.  In our clinic we manufacture the orthotic so that the heel is not forced out of the shoe. 

Make sure you are totally satisfied with your orthotic before the return date is over from your provider.  

ISN'T A SPRAINED ANKLE A SPRAINED ANKLE

AND WHAT IS THE BIG DEAL?

Recently I was presented with a seventeen year old male soccer player that sprained his dominant ankle in a soccer game.  Unfortunately the player had sprained the ankle over five months prior to seeing me.  Although the player did seek and attend therapy from another therapist immediately following the incident, the player found the recovery process stalled and there had been no marked progress in his functional ability.

A quick review of the anatomy of the ankle is required so that we can discuss the problem in more depth.  First, the ankle is made up of a number of bones in the ankle and foot area.  Some of the important bones are the calcaneus, (which you step on when your heel hits the ground), the talus (which sits cradled on top of the calcaneus and has a dome on the top of it); the main lower leg bones, the tibia which is the main bone in the shin, and the fibula, which is the bone on the outside of the lower leg. 

These bones are held together by ligaments.  If the ligaments get stretched the medical community calls it a sprain.  Ligament sprains are usually classified into three areas: 

                Grade 1:  a mild sprain of the ligament; they can take 7 to 10 days to

                            recover.

                Grade 2:  a moderate sprain of the ligament; they can take four to six

                            weeks to recover.

                Grade 3:  a severe ankle sprain of the ligament; they can take six to

                             twelve weeks to recover.  These sprains sometimes require

                             surgical intervention.

The ankle can be sprained in a number of different directions but the most common is when the ankle is twisted so that the outside ligaments are stretched.  Typically the ligaments damaged are the anterior talo-fibular ligament (ATFL - running from the end of the fibula to the talus); the calcaneal fibular ligament (CFL - running from the fibula to the calcaneus); and the post tib-fib ligament.  The majority of ankle sprains will heal properly with the correct treatment and the athlete can resume their activities.

Occasionally during the assessment of a sprained ankle another injury is missed.  During the action of the sprain, the talus bone can move slightly forward in its anatomical position creating an impingement.  The altered position of the talus then does not allow the ankle to be dorsiflexed (meaning the ability of the foot to be moved toward the knee).  This is significant in everyday function because normal gait is restricted and altered.  The individual cannot go up and down stairs properly.  For the athlete further functional restrictions are observed.  The athlete cannot squat with the heel staying on the ground.  They have problems doing heel raises and jumping.  Ankle movement and function are significantly restricted especially compared to the non-injured leg.  A manual physiotherapist should be able to assess the mal-alignment, and treatment should be manipulation of the talo-crual joint.  Almost immediate resolution is seen.  Depending on how long the joint has been compromised, the ankle joint may continue to feel stiff, but the impingement should abate quite quickly.

A further complication in the acute ankle sprain, 2%-6% of cases are transchondral fractures of the talar dome (Oster, 2010).  This means that the top part of the talus has a compression type fracture.  The normal blood supply to the bone is damaged.  It can lead to aseptic (no infection) necrosis meaning the bone can literally crumble.  This is obviously a serious matter if not investigated properly.  It is a complicated medical scenario so suffice to say at this time that the talar dome fracture is a serious matter and should be investigated properly with more imaging, using either an MRI or CT scan.

A regular X-ray will not pick up either the subtle movement of the talus or a talar dome fracture.  If the player continues to have persistent pain in the ankle, cannot do functional activities like jump, run and/or squat, and has point tenderness on the inside of the front of the ankle further investigation is warranted.

The player that came into my office luckily only had the talus moved forward.  A simple manipulation corrected the mal-alignment and then normal return to play protocol was followed including proprioception, strengthening, stretching, slow introduction to function doing shuffles, grapevine, running backwards, pivoting, and quick turns prior to letting him train with his team.

So, yes, a sprained ankle is a sprained ankle and the player should be returned to his activity MOST of the time.  Unfortunately, too many times a different and correct diagnosis is missed and the athlete suffers by not playing for a long time.  Why are the aforementioned injuries misdiagnosed?  Because the practitioner doesn't know that they can occur or the practitioner forgets to check for them.

Remember, a talar dome fracture can lead to not only the end of a soccer career, but the end of an athletic career.  Make sure you get all sprains assessed by a sports medicine practitioner and take the time to heal properly before rushing back to the field.

As a coach or parent, don't tell the player to walk it off and get back on the field as quickly as possible!  Many times the athlete knows his body best and can tell if something is amiss.  Listen and believe what they are telling you!  Often those coaches and parents that take the time to listen to their athletes are the most successful because the relationship is built on trust and respect.

References

Ewing, J.W. Arthroscopic management of transchondral talar dome fractures and anterior impingement lesions of the ankle joint.  Clinical Sports Med. 10:677-687, 1991

Loomer, R.  Fisher, C.  Lloyd-Smith, R.  Sisler, J.  Cooney, T.  Osteochondral lesions of the talus.  Am. J. Sports Med.  21:13-19, 1993

Oster, Jeffrey A.  Talar Dome Fracture.  MyFootShop.com.  www.myfootshop.com/detail.asp?condition=talar%20dome%20fracture