Treatment Objectives Goals And Of Lateral Ankle Instability - Podiatry M
CME /BIOMECHANICS & ORTHOTICSGoals andObjectivesTreatmentof Lateral AnkleInstabilityAfter completing this CME,the reader should be able to:1) Recognize the causal factors that lead to lateral ankleinstability.Proper diagnosis and treatment will leadto the best clinical outcomes.2) Understand the relationship of lateral ankle instabilityto chronic ankle sprains.BY John McNerney, DPM3) Appreciate the value ofearly conservative intervention4) Be familiar with the diagnosis, treatments, and procedures which will result in thebest clinical outcomes.Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Continuing Medical Education by the Council on Podiatric Medical Education.You may enroll: 1) on a per issue basis (at 25.00 per topic) or 2) per year, for the special rate of 195 (you save 55).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also takethis and other exams on the Internet at www.podiatrym.com/cme.If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earnedcredits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake thetest at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 144. Other than thoseentities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will beacceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use itsbest efforts to ensure the widest acceptance of this program possible.This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal ofthis program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscriptsby noted authors and researchers. If you have any questions or comments about this program, you can write or call us at:Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@podiatrym.com.Following this article, an answer sheet and full set of instructions are provided (pg. 144).—EditorLateral ankle sprains or“sprained ankles” areamong the most commonlower extremity injuriestreated in a sports podiatrist’s office. 30% of all sport injuries involve the ankle and 15-20%are sprains.1 On any given day, oneperson in 10,000 sustains an anklewww.podiatrym.comsprain.1 Ankle sprains are more common in younger patients (ages 1535) and comprise the most commontime-lost injury in sports.1The lateral ankle ligaments consist of the anterior talo-fibular (ATF),calcaneo-fibular (CF), and the posterior talo-fibular ligaments (PTF)(Figure 1). The inferior anterior ti-bio-fibular ligament (AntTF) is alsoa major stabilizing component of theankle and is often injured in a lateralankle sprain, especially when torqueis combined with lateral imbalance(Figure 1).2The peroneal tendons act as activestabilizers for the lateral ankle, and areContinued on page 136SEPTEMBER 2015 PODIATRY MANAGEMENT135
g nin atiouBiomechanics & orthoticstin ducnEolC icaedone or more of the laterAnkle Instability (from page 135)M136commonly injured (Figure 2).2 Syndesmotic sprains (high ankle sprains)involving the AntTF ligaments are themost debilitating injuries and requirelonger treatment times for resolution.3In general, a lateral ankle sprain involves the ATF, CF and PTF (less common), but the AntTF and peronealscan also be involved.2In severe injuries, the Achilles’,styloid process of the 5th metatarsal, anterior process of the calcaneus,tibia, fibula, and the cuboid and/ornavicular articulations may also beaffected.2Injury to the lateral ankle mayoccur acutely (like stepping in adeep hole) or chronically (repeatedsub-maximal sprains like repeatedly tripping on a small pebble). In anacute sprain, an inversion stress commonly caused by uneven terrain orpoor balance causes rapid foot andankle supination. This inversion stressmay be accentuated by structural(lower extremity varus) or posturalimbalance (poor proprioception).The net effect is stress on thelateral ankle ligaments that may besufficient to stretch, attenuate or tearFigure 1:Top—MARKER in Light Blue Anterior InferiorTibio-Fibular Ligament (Ant.Tib.Fib.):Green Anterior Talofibular Ligament (ATF):Yellow Calcaneofibular Ligament:Red Posterior tibiofibular ligament (PTF)bottom—MARKER in White Deltoid ligamental ligaments. While initial treatment of acuteor chronic injuries maybe similar, long-term sequelae can occur due toimproper or truncatedtreatment.4Chronic AnkleInstabilityChronic ankle instability is often the resultof an acute injury thatwas not treated properlyin the acute stage. Agemay also play a part. Aswe mature, the cumulative stress on the lateral ligaments combinedwith deterioration of theindividual’s ability tobalance and have proper proprioception canpredispose one to lateralankle overload.4While poor treatment is often the causeof chronic ankle problems, about 10-30% ofsprains become chronicdespite early and propertreatment.3Figure 2: The lateral side of the ankle showing the peroneal tendons(most notably seen the peroneus brevis) that act to stabilize theankle against inversion sprains and are often injured in the process.Loss of peroneal strength is a key factor in lateral ankle instability.Figure 3: A picture of a severe sprain of the lateral ankle about 24hours old. A compressive bandage and ice bags had been used.Note the severe ecchymosis in the heel and ankle and the edema ofthe leg, ankle, and foot. Treatment should be started immediatelyand consist of PRICE, An acronym for protected weight-bearing,relative rest, ice, compression and elevation. A home program maybe complemented by physical therapy at an outside facility.Diagnosis andSymptoms of theAcute Ankle SprainWhen examining an acute sprain,the physician should obtain a goodhistory regarding the mechanism ofinjury. Was it due to outside forces(a tackle, a hole, a bad shoe, etc.), ordid it seem to occur without provocation (a poor step or loss of balance,etc.)? Physical examination shouldinclude searching for any edema, eccymosis, redness, hematoma or otherphysical signs of injury over the lateral ligaments or appurtenant structures (Figure 3).The ability to weight-bear is important from both a diagnostic andtreatment perspective. 5 Inability tobear any weight usually portends amore serious injury. Patients may beable to weight-bear with a significantlimp, a mild limp, without a limp, orsustain a toe-toe gait, depending onthe severity of the injury.The Ottawa rules for ankle injurySEPTEMBER 2015 PODIATRY MANAGEMENTstate that diagnostic x-rays are requiredonly when the patient cannot walk atleast four steps, or if there is pain inthe malleolar area or common sites offracture following a sprain.1 Range ofmotion (ROM) should be assessed. Thequality of motion can be fully restricted, to having no apparent restriction.There may be no pain until the endROM, or pain throughout the range.Gradation of Acute Ankle SprainsThe first step in treatment of anacute sprain is assessing the grade ofinjury. Historically, two systems havebeen used, but they are commonlycombined into one.5 The West Pointand Chapman systems both grade ona one to three scale (Figure 4).Some clinicians feel that physical assessment has severe limitationsand suggest adding physical testing asContinued on page 137www.podiatrym.com
nng ioui atin cnt EduCo icaledMBiomechanics & orthoticsAnkle Instability (from page 136)well. The anterior drawer test can beperformed with or without an x-ray.To perform this test, a hand is placedover the anterior aspect of the tibiawhile another cups the heel bone. Theexaminer then pushes backward onthe tibia while pulling forward on thecalcaneus. Anterior migration of thetalus, with or without “clicking”, isconsidered a positive sign.A variation of this test measuresthe anterior migration of the talus onx-ray. A 5mm anterior shift from aresting to stress view is consideredpositive. Talar tilt is another physicaltest deemed important by some clinicians. It is performed while stabilizingthe tibia just above the malleoli andgripping the heel bone from below.The hand on the calcaneus then places an inversion stress on the anklewhile the tibia is stabilized. Laxityof the lateral ligaments will allow increased inversion of the ankle joint.Radiographically, a talar tilt(measured by an angle formed bylines parallel to the inferior surfaceof the tibia to the superior surface ofthe talus) of 10 degrees or more is asignificant finding.Hopkinson’s SignHopkinson’s sign can be used toassess syndesmotic ankle sprains. 6The clinician stabilizes the tibiaabove the malleoli with one handand the calcaneus plantarly with theother. A rotational twist is applied byturning the hands in opposite direction simultaneously. A positive signis excessive motion and pain in theankle mortice or lateral fibula. Thereare many other tests that can be usedto assess ankle injuries. The testsabove are the most commonly usedand clinically significant.Treatment of Acute SprainsOnce the injury has been assessed and graded, treatment canedema, and inability to standto subside. Early mobilization of an injury has long beena hallmark of treatment in sportsmedicine. 5 Time has proven its efficacy and it now has become thestandard of care for most patients.The question of how long an injuryshould be rested depends on manyfactors. Most authorities agree thatweight-bearing should be encouragedas soon as practical.Hopkinson’s sign can be usedto assess syndesmotic ankle sprains.begin. The pneumonic PRICE isa good way to remember the keypoints of treatment.P stands for protectedweight-bearing. This may be as simple as wearing a good shoe, to theuse of crutches or walking boots.It has been shown that early protected weight-bearing shortens disability and speeds the healing process. Extended periods of rest allowsedema to persist, limits circulation,produces poorer quality of scar tissue, and can lead to decreased ROMand poor proprioception.7R stands for rest. Few disputethat in more severe injuries rest maybe needed initially to allow the pain,Figure 4:Combined West Point andChapman GradingGrade 1 No tear: minimal edema and almost full ability to weight bearwithout assistanceGrade 2 Partial tear: moderate edema and weight bearing with asignificant limp with or without assistanceGrade 3 Complete tear severe edema and no ability to weight bearwithout assistanceI stands for ice. Control ofedema is essential to allow healingto progress as rapidly as it should. Asimple method can be the use of anice bag or bath. An Ace bandage,Unna boot, Jobst compression, orhands-on physical therapy can all besuccessful.5,7 Alternately, eschewingmodalities that warm tissue such asheating pads, hot packs, ultrasound,etc. are discouraged.C stands for compression. Control of edema is very important. Significant edema can prevent propercirculation, decrease needed ROM,limit the ability to weight-bear andincrease pain. Ice and early gentlecompression help the body to launchthe “healing cascade” that encourages collagen formation (Figure 5).E stands for early mobilizationand early aggressive rehabilitation.Early mobilization has been shown toform stronger and more elastic scarsdue to faster and higher quality collagen formation.5,7 Early and aggressivephysical therapy with emphasis onstrength, flexibility, and proprioceptive training protocols speed healingand help prevent recurrence.4,5,7Functional Ankle InstabilityIn 1965, M.A.R. Freeman broughtattention to the role of functional instability as both a cause and effect ofsevere ankle sprains.4 While not thefirst to notice that ankle instabilityContinued on page 138www.podiatrym.comSEPTEMBER 2015 PODIATRY MANAGEMENT137
g nin atiouBiomechanics & orthoticstin ducnEolC icaedmore lax the ligamentsAnkle Instability (from page 137)M138often followed a significant sprain,he emphasized that structural imbalance together with proprioceptive deficiency often combined to enhancelateral ankle instability. This was especially true in chronic ankle sprains.A high arched or cavus foot isoften implicated (Figure 6). Structural imbalances such as tibia or sub-talar varum, rigid or plantarflexed 1stray, and loss of ankle or sub-talarjoint (STJ) motion were well knownin contributing to chronic sprains.5,7The role of mechanoreceptorsin the ankle capsule was less obvious. Freeman suggested that severeor chronic sprain of the ankle withconcomitant damage to the anklecapsule and mechanoreceptors oftenleads to loss in proprioception. 4 Astretched out capsule might fail toinitiate enough pressure to triggerthe position sense organs. This couldlead to delayed response in triggeringproprioception.In essence, the ankle joint wouldbe past its balance point before proprioception was triggered. The moreoften the ankle was “sprained”, theFigure 6: Structural deformities in the lower leg,ankle, and foot may accentuate proprioceptiveloss and can contribute to lateral sprain. Biomechanical factors like the cavus (high arched) foottype above cause lateral overload (supination)and strain on the lateral stabilizers of the ankle.Strengthening the peroneals, balance training,stretching, proper shoe selection, and use of laterally stable orthotics can lessen lateral overloadand help prevent sprains.and the slower the response. This could resultin the tendency towardchronic sprain. If we accept this as we should,then treatment of anyankle sprain should include balance or proprioceptive training in addition to strength and flexibility protocols and PRICE.A simple home exercise for balance can be themodified Romberg’s test(Figure 7).Figure 5: Part of aggressive early treatment of an ankle sprainis the control of edema. PRICE is an acronym used to describethis. The “C” refers to compression or wrapping of the ankle (asshown above). Wrapping helps to support, control eccymosis,reduce edema, reduce pain, and allow earlier weight-bearing.A simple home exercise for balance can bethe modified Romberg’s test.Delayed, Improper or InadequateTreatment of Ankle SprainsThe early and aggressive treatment of an acute sprain is essentialin the prevention of chronic ankle instability.4,5,7,8 It is commonly held thatthis treatment includes the proprioceptive protocols above, combinedwith strength and flexibility training. Loss of strength and guarding inthe peroneal muscles, especially theperoneus longus (PL) and peroneusbrevis (PB), is a common sequel toankle sprain.5,7,8This is underscored by the common finding of splits, tears, or scarsin these structures on MRIs of theankle.7 These findings are seen evenin routine MRIs not taken to assessankle sprains. Home remedies usinga tension or resistance band andeversion of the foot and ankle helpstrengthen the ankle (Figure 8).Physical therapy with the use ofresistive bands, isokinetic machines,or even isotonic contracture againstthe therapist’s hand to inhibit eversion is a common rehabilitative tool.Flexibility of the calf must be re-established following injury to theankle.5,7,8 In both acute and chronicsprains, the perceived ankle instability is countered by the patient tonically contracting the gastrocsoleusmuscle to offload the injury. The imbalance that ensues needs to be addressed to ensure full ankle mobility.SEPTEMBER 2015 PODIATRY MANAGEMENTActive wall stretch of the calf isolating each leg and holding understretch for 10 seconds with the anklestraight, then bent, repeated 10 timesis a good home exercise. Physicaltherapy may employ active, passive,or proprioceptive neurofacilitativestretch (PNF) to achieve this goal.Balance training should be instituted as soon as possible. The “modified Romberg’s” balance test (Figure7) can be used at home or in therapy,but therapy usually includes the useof a balance board or proprioceptiveplatform as well. When we are dealing with athletes with ankle instability, sport-specific training and the useof a brace are sometimes requiredas a return to sport protocol. Otherancillary measures to prevent spraininclude emphasis on the use of properly constructed shoes and foot orthotics (Figure 9).The Need for Surgical Interventionfor Ankle InstabilityA common misconception aboutankle instability is that surgical correction is commonly needed andprovides better stability with fewersequelae. This has NEVER been thecase. Brostrom (1964-6) outlined thetreatment of lateral ankle sprains ina series of articles culminating in1966.9 Despite years of controversy,his research has consistently beenContinued on page 139www.podiatrym.com
nng ioui atin cnt EduCo icaledMBiomechanics & orthoticsAnkle Instability (from page 138)shown to be correct and remains thestandard of care. Summarizing hisresearch, ankle sprains of any magnitude are best treated by early mobilization and protected weight-bearing.In acute injury where conservative protocols fail, Brostrom showedthat delayed secondary ligament repair yielded the same functional results as early primary repair.9 Manyresearchers since have noted a 1030% recurrence of sprain, regardlessof method of treatment.2,8,10 A prospective study of 146 patients with GradeIII sprains were treated with early protected weight-bearing and showed return to activity six weeks earlier thana group that underwent surgery.8 Nodifference was noted between groupsin re-injury rate or joint laxity seen instress x-rays at the two-year mark.Chronic ankle instability and/orpain is seen in 10-30% of sprains.2,8,10This instability can be mechanical,structural, or positional (poor biomechanics, lower leg alignment orbalance problems). It is importantto note that there is no correlationbetween mechanical/structural andfunctional instability. They can existapart or together. Rehabilitation is thepreferred route of treatment. It hasbeen shown that the combination ofFigure 8: A key element in treatment and prevention of chronic ankle instability is strengthof the peroneus longus and brevis muscles. Patients can be taught home use of a tension or resistance band to accomplish this goal. Aggressivephysical therapy protocols will commonly useresistance on specially designed machines.www.podiatrym.comFigure 7: The modified Romberg’s testshown above can beused to test for proprioceptive deficiency AND/OR rehabilitate an unstableankle. The patientis asked to stand onthe affected ankleand balance. Failureto maintain balancefor 5 seconds withthe eyes open isindicative of proprioceptive loss. Tobuild balance, havethe patient standin a door frame for5 seconds. Whenthis is possible, add5 second intervalsuntil it is able to bedone for 30 seconds. Progress to5-30 seconds witheyes closed. Thedoor frame preventsinjury, and increasingtime builds balance.peroneal strength, proprioception, and the useof properly constructed orthotics can control most chronic problems. 10 Surgery shouldbe reserved for those patientswho have at least six months ofproper rehabilitation, and wheresymptoms persist and cause theinability to perform normal activities of daily living.Surgery to CorrectRecalcitrant LateralInstabilityWhen it has been determined that conservative treatment is insufficient to controllateral instability, surgery isoften a last resort.The procedure that is chosen is often the key to a successful surgical result. TheGould modification of Brostrom’s original imbricationprocedure is considered bymany to be the “gold stan-A common misconception about ankle instabilityis that surgical correction is commonly needed andprovides better stability with fewer sequelae.Figure 9: Use of properly constructed shoes andfoot orthotic devices (FODs) can reduce themorbidity of chronic instability. Shoes that resisttorque and have a stable midfoot, among otherfeatures, lessen lateral instability. Non-rigid, laterally posted FODs can help to control biomechanically unstable feet.dard”. 11,12 For this procedure to besuccessful, the injured lateral ligaments must have sufficient lengthand strength after injury to allowplication without undue tension.When the damage to the lateral ligaments causes the tissue to looklike the end of a mop, or where notenough viable tissue exists to allowanastamosis, reconstruction of theligament may be necessary.11,12There are a myriad of procedures designed for this purpose.Watson-Jones described a procedurewhere the full peroneus brevis tendon was passed through the fibulaand neck of the talus to supplantthe normal ligament. 11 Lee’s modification recommended only passingthe tendon through the fibula beforesuturing.11Elmslie suggested a full graftsplit into halves, one put throughContinued on page 140SEPTEMBER 2015 PODIATRY MANAGEMENT139
g nin atiouBiomechanics & orthoticstin ducnEolC icaedAnkle Instability (from page 139)Syndesmotic AnkleMthe fibula, the other attached tothe heel bone. 11 Chrisman-Snookused a split graft. One half remainedin place, the other half went throughthe fibula and was sutured into theheel bone.11 Evan’s procedure seemsto be in vogue today. He suggesteda full graft that went from anteriorto posterior through the fibula (theopposite direction of most other procedures) and then was sutured tothe fibula.11,12There is no reliable evidence thatany one procedure is better than an-SprainAbout 10% ofankle injuries involvethe inferior anteriortibio-fibular syndesmotic ligaments (Ant.TF). This injury is oftentermed a “high ankle”sprain. The mechanism of injury involvesankle plantar flexion,and lateral stress as ina normal “sprain”, butis complicated by rotational stress as well.13Figure 11: Severe or chronic lateral instability or syndesmotic injuriesoften leave radiographic evidence behind. Calcification interosseouslyor peri-crurally on radiographs can help confirm previous injury. Thecalcification on the talar head and neck and anterior surface of thetibia on the above radiograph are indicative of repeated trauma.Chronic ankle instability is usually the result of poorlytimed or inadequate treatment of an acute sprain.140other in re-establishing ankle stability. It has been said by some thatmany of the lateral ankle stabilization procedures work because theyproduce scar formation over the lateral ankle. The scar acts to limit abnormal motion and triggers a morerapid proprioceptive response. Whilelogical, this has never been proven.In cases where tissue is not viable,surgery has failed, or the imbalanceis too severe, ankle implantation orfusion may be considered.This results in an injury that is moresevere. Lateral sprains commonly result in .04 games and 1.1 practices missed on average, while “highankle” sprains result in 1.4 gamesand 7.3 practices missed.13,14 Physicalsigns and symptoms:The physical signs above areoften evaluated along with diagnostic tests such as x-rays (commonlynegative) which initially sometimesshow interosseous calcification; orankle spurring six months to oneFigure 10:Signs of Syndesmotic Sprain( ) Kleiger sign (pain on external rotational stress of foot on ankle)( ) “thump” test (pain when the plantar aspect of the calcaneus is struck smartlyby the examiners fist)( ) Hopkinson’s squeeze sign (pain in ankle or leg when squeezing the fibulaagainst the tibia)– Pain at or above the ankle mortise on palpation or compression– Swelling over the anterior or posterior lateral ankle– Pain anterior or posterior in the ankle on ROMyear post-injury (Figure 11). An MRIis a better diagnostic tool, especiallyimmediately post-injury. It can evaluate both bone and soft tissue trauma(Figure 12).13,14Generalized Ligamentous LaxityThe presence of generalized ligamentous laxity (GLL) is commonlyoverlooked in evaluating soft tissuedeformity or injury to the foot. Thisis a mistake that can have seriousrepercussions. When an individualwith GLL has a soft tissue injury oris about to undergo a soft tissue surgery, it is good practice to evaluatethe individual’s joint hypermobility. Individuals with high GLL scoresare more prone to recurrent injuryor return of deformity post-rehabilitation or surgery when positional(soft tissue) corrections are done inlieu of structural (boney) correction.The reader is referred to the Contompasis method of evaluation as described by McNerney and Johnston.15In essence, it evaluates six points oflaxity. A short synopsis is containedbelow:Sprain with FractureWhile it is beyond the scopeof this paper to delve deeply intoankle fractures involving the ligaments, a brief discussion is warranted. About 1-2% of the most troublesome sport injuries involve anklefracture.16 Treatment depends on thetype, severity, and timing of treatment. There are many classificationsystems to guide treatment. Olderclassification systems may still haveContinued on page 141SEPTEMBER 2015 PODIATRY MANAGEMENTwww.podiatrym.com
nng ioui atin cnt EduCo icaledMBiomechanics & orthoticsAnkle Instability (from page 140)some validity, and newer systems areoften complicated.Danis-Weber classifies ankle fractures according to the level of fibular fracture to the ankle mortise,Lauge-Hansen by the mechanism ofinjury.17 One could describe a fractureas being above, below, or at the levelof the ankle mortise, according toDanis-Weber. Lauge-Hansen woulddescribe the fracture by describingthe foot position and motion of theleg at the time of injury. Examplesare supination with external rotation(SER), supination with adduction(SAD), or pronation with adduction(PAD), to name a few.17Fracture classification is necessary not only to facilitate proper treatment, but to help predictpossible sequelae. Addenda to theabove fracture classification systemsas well as many new systems arein vogue. The reader is encouragedto explore them in greater depth,where warranted.Shoe and Orthotic DesignLateral ankle instability can beenhanced by proper shoe selectionor the use of foot orthotic devices(FODs). Conversely, improperly chosen shoes or poorly designed FODscan make instability harder to control. Shoes designed for lateral instability generally incorporate someor all the following design features(Figure 14)18: 3/4 high top cut is superior tobelow-ankle at ankle stabilization; Full high top adds NO extra stability over 3/4 high cut style; Resistance in the heel counteris required; Torsional stability through themidsole is essential (Figure 14); Shoe should bend easilythrough the forefoot; Shoe should bend or collapseminimally through the arch; Cleated shoes must have cleatsthroughout the arch (not just in theheel and forefoot) (Figure 14); Cleated shoes should have reinforced arch in the midfoot; Cushioning throughout the shoeshould be compliant but not “bottomout” to create instability.www.podiatrym.comFigure 12: Magnetic Resonance Imaging (MRI)is better than x-ray at accessing soft tissuedamage. The image above shows damage tothe Achilles tendon, a common ancillary injuryin chronic ankle instability of the ankle.Just as shoes can help stability,properly designed FODs can help footsupport and guidance. When there isa structural imbalance in the lowerextremity, FODs designedto lessen foot supination canprotect against lateral overload.Orthotics designed for this purposemight include the following modifications (Figure 15): A deeper heel cup of 18 mm orhigher (normal is 14-16 mm.); Increased lateral forefoot posting (valgus wedge or post); A lateral clip (extension of thelateral heel cup to the 5th metahead); Full arch contour—do not allowlab to arch fill or lower the arch; Use semi-rigid or semi-flexiblematerials to prevent arch avoidanceor reflex over-supination generallyassociated with harder materials; Make all forefoot support extend to the toe sulcus to support thefoot throughout the push-off phaseof gait (Root-style FODs are not as effective in late stance because the postends behind the metaheads); Use minimal heel lift. Liftingthe heel supinates the foot and results in greater lateral instability;Continued on page 142Figure 13:Evaluation of GeneralizedLigamentous Laxity151) Thumb to wrist-flex the wrist and try to pull the thumb down to touchthe fore arm. Normal thumb barely touches forearm2) 5th metacarpal extension- with the hand on a supportive surfacetry to pull the 5th metacarpal backward on the hand. Normal a90 degree ankle of finger to hand, more than 90 degrees is ( )3) Elbow hyperextension try to extend the elbow as far backward as possible.Normal the elbow extends to 180 degrees or straight (not beyond)4) Knee hyperextension try to hyperextend the knee. Normal is the knee at 180degrees or straight (no genu recurvatum)5) Palms to floor Bend at the trunk with the knees locked. Normal One shouldbe able to touch fingertips to the ground. (not the wrists or palms)6) Calcaneal valgus View the calcaneus from behind. Normal the perpendicular bisector of the heel should not form a valgusangle to the lower leg.SEPTEMBER 2015 PODIATRY MANAGEMENT141
g nin atiouBiomechanicstin ducnEolC icaedAnkle Instability (from page 141)M Minimal to neutral rearfoot varus posts to decrease lateraloff-loading; FODs made over a plaster castwith accurate rearfoot to forefootmeasurements; good arch contourand minimal alterations in the fabrication by the lab work best.142SummaryLateral ankle instability canbe a sequela to ankle injury, evenwhen proper treatment is timely. Inmany cases, treatment of a sprainis delayed, inadequate, or neglected completely. An estimated 10-30%of individuals who sustain an anklesprain fall into that category. Propertreatment must involve not only theweakened structures but also the impaired proprioception. Chronic ankleinstability is usually the result ofpoorly timed or inadequate treatmentof an acute sprain.The most common mistakes areinadequate strength training for theperoneals, failure to regain adequateROM, neglec
stabilizers for the lateral ankle, and are L ateral ankle sprains or "sprained ankles" are among the most common lower extremity injuries treated in a sports podia-trist's office. 30% of all sport inju-ries involve the ankle and 15-20% are sprains.1 On any given day, one person in 10,000 sustains an ankle sprain.1 Ankle sprains are more com-
can establish goals and objectives. The last section provides a template to document specific goals and objectives. Instructions Review the guidelines to identify goals and objectives for EHR implementation. Use the template provided in section 7 to document specific goals and objectives
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CONNECTICUT STATE DEPARTMENT OF EDUCATION STUDENT LEARNING GOALS/OBJECTIVES 2014 A Handbook for Administrators and Teachers To guide the process for developing high-quality goals/objectives to improve student learning . CONNECTICUT STATE DEPARTMENT OF EDUCATION . Including Sample Student Learning Goals/Objectives . August 6, 2014
The sequence of treatment processes through which wastewater passes is usually characterized as: 1. Preliminary treatment 2. Primary treatment 3. Secondary treatment 4. Tertiary treatment This discussion is an introduction to advanced treatment methods and processes. Advanced treatment is primarily a tertiary treatment.
The sequence of treatment processes through which wastewater passes is usually characterized as: 1. Preliminary treatment 2. Primary treatment 3. Secondary treatment 4. Tertiary treatment This discussion is an introduction to advanced treatment methods and processes. Advanced treatment is primarily a tertiary treatment.
