Introduction
According to Yoo (2015), ankle joints are critical in full mobilization for both the young and the elderly people since it bears the whole weight of the body. Like most of the other joints in the human body, the ankle joint is prone to sprains and fracture risks. The leading causes of ankle fracture or strains include falls, twisting injuries, very rigorous exercises, and sports. The risks can be exacerbated by obesity, diabetes, osteoporosis, smoking, previous falls, and low mineral bone density (Landrum et al., 2008; Lin et al., 2006; Yoo, 2015). Young males are at higher risk of ankle fracture compared to young females due to differences in the level of endangering activities (Kato et al., 2010), while women are more vulnerable to the fractures than male due to the high osteoporosis risk at the postmenopausal period (Petersen et al. 2011). The joints are formed by three bones (tibia, fibula, and talus). Joint fractures may involve one, two, or all the three bones. Painter et al. (2015) point out that the more the bones involved, the harder it may be for it to heal. Nevertheless, the fractures healable if amicable treatments are administered, as pointed out in Tom’s case. This report will present the choice of interventions made by seven physiotherapists in order to help a patient with the treatment of ankle stiffness. The aim of the report is to analyse whether or not exercises such as stretching, strengthening, heel raise and proprioceptive exercises have the potential of effectively alleviating ankle stiffness.
Different studies have been conducted examining approaches for the treatment injuries. An observational experiment study conducted by McNair & Stanley (1996) involving 24 participants (12 males and 12 females) sought to evaluate the effectiveness of stretching and jogging exercises in ankle joint stiffness treatment. The participants were from mixed age, height, and weight groups, which enhanced the experiment setting matching that of the natural environment. The participants were subjected to jogging exercises, soleus muscle stretching exercises or both. An analysis of the results proved jogging to be more efficient compared to stretching with a covariance of P˂ 0.05; however, a combination of both the exercises ascertained to be much better than by using only either.
In another study, Moseley et al. (2006) conducted a randomized control study involving 150 patients with plantar flexion contracture of the ankle joint fracture immobilization. They estimated plantar flexion contracture to occur at a rate of 77% following removal of the cast, but rate decreases to 22% two years post cast removal with effective physical therapy. The patients engaged in a four-week intervention program where they were subjected to exercise and short duration (6 minutes) passive stretch, or exercise and long-duration (30 minutes) passive stretch. After the four weeks, the results from 139 subjects who completed the study showed no significance different between those who engaged in exercise only and those with exercise and passive stretching intervention. It was concluded that passive stretching has an insignificant impact on correcting plantar flexion contracture that causes ankle joint stiffness.
Ankle joint stiffness arises due to effects of joint immobilisation, which is often a medical-surgical strategy for allowing the joint to heal with minimal disruption; hence, improving bones union (Moseley et al., 2005). The stiffness is associated with contractures that develop during the healing process as a compensatory mechanism of immobilized joint (Yoo, 2015). Factors attributed to increased instances of ankle joint stiffness include prolonged immobilization; fear of secondary joint fracture; weak joint union; painful ankle joint that limits joint involvement; poor wound healing causing scarring; and ankle joint swelling/oedema caused by compartment syndrome (Young et al. 2013).
Lin et al. (2006) designed a randomised control study evaluating the impact of passive joint mobilization on reducing ankle joint stiffness. The primary goal of the study was assessing the effectiveness of incorporating passive joint mobilisation techniques in standard exercise programs in treatment to ankle fractures. The study involved 90 participants, who were subjected to receive interventions, categorized into two groups. The first group was received standardized physiotherapy, while the second group was received manual therapy. The finding of the study validated a positive correlation between pre and post joint immobilisation techniques and standard exercises. In respect to Davies’ case, his treatment combines mobilisation and physical exercises in the walking cast, which proved to be effective. The results of the study are applicable in Tom Davies’ situation; both standard exercises and manual therapies can be used to correct the stiffness in his knee. The group that was subjected to exercises and joint mobilisation healed faster than those exposed exercises exclusively.
In a more related study involving 11 patients, manual manipulation was discovered to have significant statistical and clinical benefit on correcting joint stiffness (Painter et al. 2015). The result concurred with findings from Moseley et al. (2006), a study which nullified any statistical significance of subjecting patient with ankle joint stiffness to passive joint manipulation. Results from Landrum et al. (2008) study seems to contradict Moseley et al. concerning joint manipulation exercises. The study evaluated the effectiveness of anterior-to-posterior talocrural joint mobilizations (A-PTJM) on improving dorsiflexion range of motion.
The findings indicated that after a single bout of the intervention, the patients demonstrated improved dorsiflexion and reduced stiffness. The conclusions of these studies suggest that Davies can either be subjected to manual manipulation techniques to ease the stiffness. In a rather similar study, Kato et al. (2010) evaluated the impact of stretching exercises on improving dorsiflexion among seven patients with ankle joint stiffness. The finding showed improvements noted on dorsiflexion following stretching exercises were due to tendon elongation, but no due to changes in muscle length. These results indicate that stiffness of the ankle joint is because of tendon contracture rather than muscle contracture following a period of the joint immobilization. The results advocated for the use of stretching exercises in correcting ankle stiffness hence Davies’ physiotherapists can simultaneously use manual manipulation.
The findings suggest that the probable cause of the weakness in Davies’ muscle can be due to a muscle contracture while the stiffness in the joint is as a result of tendon contracture. The contractures both can be managed by use of joint mobilisation methods and exercises. Some of the proposed exercises for strengthening and enhancing ankle mobility include theraband exercises, heel raises on both feet, single foot, with affected foot on the ground and unaffected on a chair and standing on a step with the affected foot (Lin et al. 2006). The exercises can help Davies manage the muscle weakness and joint stiffness.
Young et al. (2013) conducted a systematic review study of twenty-three studies with a total participant pool of 734 who were exposed to interventions aimed at improving ankle joint dorsiflexion. Some of the responses reported in these studies included static stretching, diathermy, ice compression, warm-up, and heel raise exercises. All these interventions were observed to have significant improvement. To add to the responses above, Yoo (2015) evaluated the benefits of using the unstable inclined board on both active and passive flexion exercises on a patient with ankle joint flexion. The interventions included using a wooden board and an air-cushioned inclined board. The results indicated that active stretching exercises improved dorsiflexion. The studies amplify the effectiveness of stretching which when correlated to Davies’ case feasible results are anticipated. The therapist’s strategies have literature support hence have a high probability of yielding the best results.
Ankle joint stiffness limits the ease and immediacy in resuming to fully utilization of the ankle joint. Therefore, it is critical for a physiotherapist to embark on exercises and rehabilitation practices that aim at improving the patient’s ankle joint involvement (Painter et al. 2015). Several exercises are at physiotherapists’ disposals as well as individual patients (Davies), all aim at facilitating efficient management of ankle joint stiffness and related complications.
Beckenkamp et al. (2011) evaluated educational practices aiming at empowering the patient on aspects of managing ankle joint stiffness. The study focused on evaluating the comparative effectiveness of advice and rehabilitation exercises. The study enrolled 342 patients, who were divided into two groups, one received advice session on a measure of reducing pain, enhancing mobility and maintaining adequate range of motion while the other group received standardized physiotherapy rehabilitation exercises lasting for four weeks. The results of this study are yet to be released, but the researchers hypothesized rehabilitation to be more effective than advice. Beckenkamp et al.’s results recommend rehabilitation rather than letting the patients undertake the techniques on their own. Therefore, Davies shall need to conduct rehabilitation sessions in which he will carry out the exercises with his therapists concurrently. He has a higher chance of coming out of the mobility incapacitation faster than otherwise.
Methods
Seven students were presented with a case of a twenty-year-old semi-professional footballer who suffered fractured ankle that was managed through cast immobilization. The students participated in Exercise in Rehabilitation module (HEM11). After completely healing effectively, Tom Davies is with some notable ankle joint weakness three weeks post cast removal, but he is free from pain. The seven students involved in the study were to come up with two mobility rehabilitation approaches for helping Tom to regain ankle strength subsequently facilitating ease resumption to his sporting activity. Students were made to understand that every proposed plan needed justification and good support. Every student had to explain the strategies, the aims, how the approaches would be prescribed to the client and the accompanying home advice. The chosen practices are presented in Figures 1 and 2.
For purposes of ensuring the student understood their preferred rehabilitation strategies, the students were asked to note the procedures down, and then presented the strategies in a video length 10 minutes. For ethical purposes, the students were expected to obtain a written consent, which together with the written exercises of choice and the video presentation were made available to the module team and other participating students. The module team analysed the data presented in both the video and the write-up parts. The findings were to be compared with the existing literature regarding the most appropriate exercises to recommend for Tom recovery through the stiff ankle joint.
Results
The student selected a myriad of ankle stiffness rehabilitation activities that were anticipated to be the most amicable and efficient in expediting Tom’s recovery from ankle joint stiffness. Eight options were selected as presented in Table 1. Physiotherapists highlighted supportive purpose for their selected exercises of choice. The techniques are some of the joint mobilization approaches aimed at increase ankle dorsiflexion range of motion (ROM) and alleviate joint stiffness after immobilization. The table blow also indicates the preference level of the physiotherapists on different techniques. Single leg stands technique was the most preferred in reducing muscle weakness and ankle rigidness.
Physiotherapists highlighted supportive purpose for their selected activities of choice. In all the fourteen interventions proposed, increasing muscle strength/power was reported in nine out of the fourteen interventions suggested by the seven therapists. Exercises that were targeted improving muscle strength, power, and endurance included bilateral progressing to a single leg, one leg proprioceptive standing, heel raise, single leg stand, one leg balance, and strengthening exercises. Most of the students considered having strong ankle joint muscles to ease of joint tenderness. The home messages given to the client by the different therapist’s sort to reduce risk of exposing the ankle joint from further injuries, augmenting the exercises the client is already taking, and those aimed to maintain consistency on ankle joint mobility
| Exercise | Frequency | |
| Single leg stand | 4 | |
| Single leg proprioceptive | 2 | |
| Heel Raise | 2 | |
| Strengthening Exercises | 2 | |
| Single leg balances on board | 1 | |
| Stretching exercises | 1 | |
| Balance exercises | 1 | |
| Bike exercise | 1 |
Table 1: Frequencies for the chosen exercises
Figure 2: Diagram for the Selected Exercises
Discussion
The study focused on evaluating the effectiveness of various practices used in physiotherapy rehabilitation of for ankle joint stiffness (See figure 1). As reported in the study by Lin et al. (2010), ankle joint fracture is a common condition across all ages. The client in case study evaluated in this study was aged 20 years, with the main contributor of ankle fracture being activeness in sports. This is one of the risk factors, which Petersen (2011) claimed to be a major risk factor for ankle fracture among young males. Therapists have selected different methods for addressing ankle joint stiffness, but the variability in the methods demonstrate the flexibility and openness in the manner through which an individual can choose to address correct ankle joint stiffness.
One of the most chosen tasks by the involved therapists was the single leg standing, which was attributed to aims of attaining muscle strength and power, enhancing ankle joint endurance, and improving the joint range of motion. Kato et al., (2010); McNair & Stanley (1996); and Petersen et al., (2013), identify these associated benefits in the study. Single leg stand was considered the most simple ankle mobility exercise, as the motion of the ankle, depends on the restriction of joint and its muscles. A patient can manage the activity by just standing on their toes while slightly inclining the unaffected and moving the affected leg. Patients can perform the technique easily and quickly even on their own. The patient should try it at least five times. The single leg proprioceptive can further advance the single leg stand. It can be done in multiple ways; standing on one leg with either open or closed eyes with wide arms, folded arms, or arms by side. The exercise creates sensitivity in the patient when trying to move the ankle while on a single foot. Proprioception based approaches are aimed at reinforcing the connection between the physical and psychological rehabilitation process (Petersen et al., 2013)
According to Petersen et al. (2013), the bilateral approach is best suited for patients in their initial phase of ankle joint mobilisation. The client gradually progresses to single leg use as s/he gains confidence and endurance, which are some of the major objectives indicated by the student proposing to employ this strategy. In Tom’s case, the fracture is on one leg, which means he can use the unaffected leg for support and as he gains the confidence to use the affected leg. The advice given to the client are aimed at preventing the client from refraining from the utilization of the affected leg, in particular among those customers who wholly depend on the affected limb (Yoo, 2015).
Heel raise is another strategy that the students considered a favourable approach in managing ankle joint stiffness. In a study by Young et al. (2013), heel lift was recorded a standard mean difference of between 0.70 and 0.77 with a confidence level of 95%. This score indicates a significant benefit of using heel rising as an approach to correcting ankle stiffness. Both heel raise and standing on one leg are also attributed with increased possibility of overcoming activity limitation, fear of leg use, and reducing activity impairment (Petersen et al., 2013; Young et al., 2013). Heel raise is used to predict and enhance motion. Heel raises on both feet done by placing the fractured foot on the step while the unaffected foot stepping from the ground to the stage, back and forth. They enhance ankle flexibility as well as enlightening the muscles.
Stretch exercises and strength exercises are also part of the methods that were chosen by the students. The literature evaluated highlighted stretch exercises as critical in improving joint stiffness, but also hinted on the importance of active stretching exercises over passive exercises (Kato et al., 2010; Moseley et al., 2005). The stretching exercises reported in the case study by the students are well differentiated as either active or passive stretching. Strengthening exercises were proposed to be undertaken as much the patient allows the patient. A loop resistance band should be placed around the injured ankle and held at the ends; the foot is pushing back and forth slowly returning it t the resting place for at least 10-20 steps and three sets.
Weight bearing and balance techniques help to ensure the stiffness is reduced by exposing the foot on various balancing parameters. Balance exercises are similar to the single led stand only that aims more on the stability of the foot than motion. Bike exercises enhance the mobility of the foot by minimising ankle stiffness, while cycling, the tendons, and the muscles stretch slowing reducing the stiffness. Once soft cycles are attained with no pain at all, then the muscle weakness and ankle stiffness have been managed. Bike exercises were less preferred as they are not readily available to many patients and may lead to dislocation if vigorous before effective healing. However, the students differentiated whether the exercises were active or passive since passive are less effective than active.
A notable exercise from the literature is manual manipulation, which according to Painter et al. (2015) is an effective way of both enhancing lower limb functionality and ankle stiffness correction. The statistical score after four weeks of manual therapy of a patient with stable ankle fracture based on Lower Extremity Functional Scale indicated a mean change of 21.9 points with a statistical score P= .001. However, none of the students considered this a favourable approach for Tom, which could be due to lack of the exercise existence awareness. The students should be encouraged to read broadly for other available exercises other than relying heavily on single leg raise, heel raise, stretch exercises, and single leg proprioception exercises. In summary, the selected exercises seem to be in agreement with the existing literature on the effectiveness of the exercises on resolving ankle joint stiffness. However, the fact that the student never had the chance to implement their selected practices and gather the data may affect the conclusiveness of the discussion regarding therapists’ success in implementing the exercises.
Limitation of the Study / clinical implications
One of the notable limitations of the study is the small sample size (seven physiotherapists). The small sample size offers an inadequate representation of the survey population, thus, reducing the possibility of valid generalization of the results obtained. The fact that the student therapists offered different exercises of their preferences reduces the ability to give a sound comparison of the on basis of individual capability to execute the exercise. In essence, implementation of these practices is subject to interferences from therapist capacity, client’s characteristics, and resources availability.
Another limitation that proved to be critical was the limited familiarity of the therapists with literature. Most of the respondents had insufficient knowledge of literature with which they were to use to support the techniques they proposed. One technique may have proved or is every effective every time the therapists has used by may have some limitations evaluated in literature. The findings thus have elements of bias and inconclusiveness as data extensively depended on the respondent’s judgment rather than both professional perspective, experience, and results of research. The study also had a limited scope, being based on an athlete (Davies, football player), it should also have interviewed footballer who has healed from such complication and compares their perceptive with that of the therapists. Football club therapists and coaches also have a better understanding of the effectiveness of each method in the treatment of stiffness.
Conclusion
In conclusion, having realized ankle stiffness is a common problem for all populations suffering ankle joint injuries, it is critical to employ the most efficient approaches to correcting ankle joint stiffness. The student options were among the commonly used exercises in correcting ankle joint stiffness and although none of the methods is arguably the definite answer, making available evidence should inform the right choice. Tom can benefit from a combination of mobility rehabilitation exercises, but the selected option should be convenient and feasible for both Tom and the therapist. From the findings and the discussion, the goal of the selected physiotherapy exercise should aim at attaining muscle strength, achieving ankle joint endurance, overcoming a range of motion limitations, ensuring Tom resume his sporting activities being stronger and more informed on risk management. Therefore, the exercises that may be the best fit for him include single leg stand, active stretching activities, and manual manipulation of the ankle joint. The exercises, which were chosen by the students, are substantially similar to the literature. However, it should be noted that the success of these practices is highly reliant on the client-therapist relationship, client commitment, and the ability of the therapist to motivate the client and implement the practice effectively.
References
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Appendices
Figure 2: Frequencies of Reported Purposes for the Selected Exercises
