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The importance of restoring balance to the grading system

Athletes returning to activity too soon after a severe ankle sprain may be at risk for longer-term ankle instability. The good news is research supports the use of foot orthotics to improve balance-a key component for preventing permanent ankle damage. This may happen when descending stairs, walking on uneven surfaces, or being tackled in a football game. The stresses from a sudden forceful pedal inversion and the loss of balance result in damage to some of the lateral ankle ligaments.

Among the lateral collateral ligaments, the anterior and posterior talofibular ligaments and the calcaneofibular ligament are most vulnerable in a sprain and may be attenuated or torn in an acute incident. There are several systems that classify acute ankle sprain. Grade II represents a partial ligament tear with moderate edema, a significant limp, and reduced ability to walk without assistance. In Grade III there is a complete tear, severe edema, and no ability to bear weight.

Initiating weight bearing soon after an injury can reduce swelling and help improve and speed healing.

The ankle joint is more stable when it is dorsiflexed, whereas a non-weight bearing resting foot will naturally tend to plantarflex. In more serious cases the patient could be fitted with a CAM walker to begin immediate, protected weight bearing. The importance of restoring balance to the grading system partial touch down will compress the ankle joint and stimulate muscle action. While encouraging early weight bearing, it is also important to rest the foot at least until the pain and edema begin to lessen.

There is a necessary balance between encouraging early mobilization and protecting the patient from pain. Periodically icing the ankle will help reduce swelling, improve circulation, and aid recovery. Wrapping the ankle assists in controlling edema, which has the advantage of enhancing ROM. It may also allow for earlier weight bearing and some pain reduction. Early mobilization and aggressive rehabilitation: Early intervention speeds healing and, in the long term, may reduce recurrence.

This will include non-weight bearing exercises such as plantarflexion and dorsiflexion, inversion and eversion, and toe curls. Eventually balance training and restoring proprioception and postural control are the best defense against a recurrence. Unfortunately, ample evidence suggests that protocols are sometimes rushed after an acute sprain, even though ruptured ligaments need up to six months to repair.

Poor initial treatment in the acute phase and other factors such as age can lead to this debilitating condition. The resulting chronic instability may be considered functional or mechanical. Functional instability refers to neuromuscular or proprioceptive deficits diminishing control of the talocrural joint. This is the recurring chronic condition in which the ankle seems weaker and is more easily sprained. Mechanical instability describes a loss of the intrinsic stability of the ankle.

This may occur from overstretched ligaments that become lax after a significant sprain. It can also indicate restricted range of motion ROM in the ankle or foot joints. The effects of these instabilities overlap and a combination of both is believed to be at work in recurring ankle injuries.

LATERAL ANKLE INSTABILITY

The Neuromuscular System Neuromuscular control of the ankle, which affects functional stability, has four major components: In the ankle, this sense is gained primarily from afferent sensory nerve terminals in muscles and tendons, and mechanoreceptors in the capsule and ligaments.

Feedback from the surrounding skin and tendons also provides vital information, which explains why interventions such as ankle taping or wearing high-top shoes can be beneficial for preventing injuries. The efferent motor loop also plays its part.

The primary evertors of the foot are the peroneal muscles; they act eccentrically against inversion. Damage to the peroneals can weaken them and delay muscle reaction time. This allows an imbalance to develop before a corrective response is initiated. As a result, physical therapy is an important aspect of any rehabilitation program to restore strength and essential muscle cues regarding position. Postural control is the ability to maintain or restore a state of balance in any posture or activity; loss of this control is a factor in chronic ankle instability.

The sole of the foot plays a critical role in providing feedback on balance and sway. There are three distinct types of mechanoreceptors on the plantar surface that respond to pressure and inform the central nervous system, which then activates muscles in the lower leg.

Properly designed foot orthotics can enhance these pressure sensor systems and provide clear signals to the body. The neuromuscular system is a dynamic stabilizer of the ankle joint, but its action is complex, interdependent, and not well understood.

In one study, researchers applied an anesthetic block to the critical anterior talofibular ligament and then tested for proprioception and balance. In another study, researchers provided posted prefabricated orthotics to half of the cohort and measured postural control. Biomechanics of the Foot Another key factor in ankle stability is the mechanical operation of the the importance of restoring balance to the grading system and ankle. The talus sits at the junction of the lower leg and foot, playing a vital role in the operation of each.

It has no muscular attachments and is affected by both axial rotation of the leg and frontal plane pronation or supination of the foot. This motion transfer between the leg and foot is referred to as movement coupling. In essence, when the lower leg rotates internally the foot will pronate.

This is a stable position for the foot. Likewise, rotating the leg externally induces supination of the foot.

  • In the past it was thought that holding the foot in a vertical position was best, and as a result, many foot orthotics were extrinsically posted to neutral;
  • As previously mentioned, sulcus posting can be applied to reduce internal compensations and rebalance the forefoot;
  • The resulting chronic instability may be considered functional or mechanical;
  • Feedback from the surrounding skin and tendons also provides vital information, which explains why interventions such as ankle taping or wearing high-top shoes can be beneficial for preventing injuries;
  • It can also indicate restricted range of motion ROM in the ankle or foot joints.

Supination includes plantarflexion and inversion, which are considered less stable. Oftentimes the trigger event leading to an ankle sprain, such as landing from a jump, transmits torque from the supinated foot to the lower leg.

Due to the movement coupling, sudden supination of the foot translates to rapid external rotation of the leg, damaging the lateral collateral ligaments. The Role of Foot Orthotics If forefoot alignment is one of the mechanical factors contributing to ankle sprain, then custom foot orthotics can be used to address the imbalance.

When the weight bearing foot is inverted, pressure along the lateral border will usually be increased. Rather than just push the foot medially with a lateral wall, the use of posting under the forefoot, distal to the metatarsal heads, can rebalance forces. For example, in the case of a forefoot valgus, consider using a lateral wedge from the fifth to the third metatarsal extending it to the sulcus.

In both cases you are rebalancing, attempting to evert the forefoot and bring it closer to a neutral position. In combating chronic ankle sprains, it appears that the role of foot orthotics is to improve body position and allow greater ROM.

In the past it was thought that holding the foot in a vertical position was best, and as a result, many foot orthotics were extrinsically posted to neutral.

Whether the patient pronated or supinated, rearfoot posts were prescribed.

Restore the Balance: Personal, Social & Global Resilience

With current understanding of the importance of postural control and the pressure sensors on the plantar foot, the role of orthotics has changed. The goal now is to provide ROM while engaging the sensor systems, which may allow sufficient time for the body to react when it senses sudden imbalance.

This is supported by a 2012 study that provides preliminary evidence that custom foot orthotics can improve balance in older adults. Use of an intrinsically balanced semirigid shell with a deep heel cup will improve plantar contact and give good mechanical support without blocking motion.

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Medial support and full-length cushion top covers have the advantage of activating sensors along the entire sole. Most of these orthotics should not have a rearfoot post as this restricts motion of the subtalar joint. As previously mentioned, sulcus posting can be applied to reduce internal compensations and rebalance the forefoot. Physical therapy is an important part of rehabilitation to prevent long-term, recurring problems.

Muscle strengthening, stretching, and proprioceptive and balance training will improve the overall function of the neuromuscular system, restoring balance and control. Wearing lace-up ankle braces has also shown a reduced incidence of sprains among athletes.

Studies indicate there is no clear benefit to early surgery, so it is often best to aggressively treat the condition using conservative measures before choosing to undergo an operation. Ankle function and associated injury prevention is a rich topic; a 2007 review by Douglas Richie Jr.

References De Carlo, M. Evaluation of ankle joint proprioception following injection of the anterior talofibular ligament. Randomized clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet. Effects of foot orthoses on balance in older adults. Effects of foot orthoses on patients with chronic ankle instability.