Ankle Rehab: Are You Treating The Wrong Thing?
Posted By: Andy Barker
The ankle is meant to be a relatively simple joint.
It has one degree of freedom and only allows the movements of dorsiflexion and plantar-flexion.
The ligaments, bones and muscle anatomy around the ankle are simple in nature and much less complicated than joints like the shoulder or the neck.
So, why is it that even simple ankle cases sometimes struggle to get back to full fitness?
I’m sure you’ve had those patients that you struggle to restore ankle range of movement or get rid of that block or pain with ankle movement, despite how much hands-on treatment or rehab you do.
It used to baffle me as a New Grad.
I couldn’t quite grasp why such a simple joint was sometimes so tricky to fix up.
That’s until I learnt how to assess the ankle using a really simple test…
And how to use the results of this test to tell me exactly what to treat and what rehab to give my patients and athletes.
It stopped me wasting my time and efforts on methods that would never improve range of movement, because I was no longer treating the wrong thing!
I’ll show you this simple test in this blog so you know exactly where to start with your patients and you do NOT end up just trying to treat everything…
Crossing your fingers, hoping something will work…
So you can give your patients exactly the right treatments and rehab they actually need, to help you get quick, positive patient results with any ankle injury.
Identify The Actual Problem
The problem I had, and so many New Grads have that come to me struggling with tricky ankle cases, is that it is unclear what the actual problem is.
I’m not talking about a diagnosis here, but referring specifically to what is causing a patients lack of movement.
Before we get to that…
I want to talk about how to test ankle range of movement.
The ankle is a weight bearing joint, so it makes sense to test it like that.
So why is it that many therapists just assess dorsiflexion and plantar-flexion on the bed?
Ankle specialists and consultant surgeons do the exact same.
I have been to see many world leading ankle surgeons with some of the players I have worked with in the past and I have never seen a standing ankle range of movement test conducted.
They look at movement on the bed and it looks great.
Yet I tested their standing range of movement earlier that day at the training ground and it was 50% of that on their unaffected ankle.
I’m not saying don’t test on the bed.
But also test in a weight bearing position.
The only exception might be with an acute or severe injury whereby weight-bearing is not feasible or too painful for the patient.
Where Is The Problem
The standing ankle assessment or ‘knee to wall’ assessment is easy.
Just instruct your patient to stand facing a wall.
Then keeping their foot flat, drive their knee over their toes straight forward towards the wall.
If they can touch the wall with their knee, move the foot further back.
If they can not touch the wall with their knee, move the foot closer to the wall.
You are trying to find the point your patient can touch the wall with their knee, whilst still keeping their heel in contact with the floor.
This is maximal weight-bearing dorsiflexion.
Firstly you want to see if their is a restriction and you can measure this range (use a ruler on the floor) then compare this to the other ankle.
This is key and will help you determine what to do next.
When at end of range ankle dorsiflexion your patient will report either a restriction in the front of the ankle or a stretch in the back.
A restriction in the front of the ankle relates to a restriction in the ankle joint.
A restriction in the back of the ankle relates to a restriction in the soft tissue structures of the posterior lower leg like the gastrocnemius, soleus and achilles.
This is gold-dust.
This is telling you what to do next.
Quite simply…
If you have a restriction in the front, its the joint, so treat the joint.
If your patient feels a restriction in the back, it’s a soft tissue problem, so treat those tissues.
A patient with a joint based problem that is given calf soft tissue treatment or calf stretching will NOT improve.
In the same way, a patient with a soft tissue problem given joint mobility treatment or mobility exercises won’t respond.
Because you are treating the wrong thing!
You are using treatment techniques and giving exercises to fix the wrong problem.
What If They Feel A Restriction In The Front AND The Back?
Usually it’s one or the other.
Sometimes a patient will feel some restriction in both, but the front or the back, usually feels more restricted.
Whichever feels most restricted, treat that.
Less commonly, your patient might feel they have an equal restriction in both the front and the back of the ankle.
In this case, do this…
Spend a few minutes (and only a few minutes) treating the joint (e.g. joint mobilisations or mobilisation with movement) and then re-test standing range of movement.
If this improve symptoms stick with this and continue your treatments and prescribe joint based rehab, like a simple ankle mobilisation exercise.
If having done the joint mobility work, it doesn’t improve symptoms, spend a few minutes treating the calf muscles and then retest.
If this helps then continue with this and prescribe calf exercises like stretching or self soft tissue release.
The ankle is NOT as complicated as it may seem.
I greatly overcomplicated it as a New Grad…
And so many New Grads I speak to do exactly the same.
Follow these tips to ensure you don’t make the same mistakes and waste your and your patients time and efforts on the wrong treatments and rehab, which will never (how ever long you try) improve their symptoms.
Key Take-Aways
Identify The Actual Problem: Test ankle range of movement on the bed AND in a weight-bearing position (knee to wall assessment).
Where Is The Problem: As well as noting a difference in range of movement, it is key to determine where your patient feels this restriction (front – joint; back – calf muscles)
What If They Feel A Restriction In The Front & Back? Treat one area (joint or calf) then retest. If it improves symptoms stick with that, if it doesn’t, treat the other area.
Andy Barker
The New Grad Physio Mentor
PS. Do you sometimes struggle with ankles?
Is it a challenge to dampen down ankle pain and restore a patients range of movement?
Or maybe you struggle to know when to progress your patients and know when they are ready for that next step in their rehab?
If so, let me know.
I’m making a special webinar I recorded recently ‘Ankle Assessments Made Easy’ available for the first 25 therapists that get in touch.
Contact me at andy@newgradphysio.com with the subject ‘FREE Webinar’ and I’ll send over the link.