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Ask the PT: Ankle instability

Physical Therapy near Westchester County

Hello WSPT,

I live near your Bronx location on Bainbridge Avenue and I’ve suffered from Sinus Tarsi Syndrome and Subtalar Joint instability for the last 6 months. What can I do to increase the stability of my subtalar? It all started with a lateral ankle sprain that happened over at Bronx Park. Any advice would be greatly appreciated.

Thanks in advance!
George

Thank you George,

Sinus tarsi syndrome (STS) is a clinical entity characterized by persistent anterolateral ankle pain secondary to traumatic injuries to the ankle. STS develops from excessive motions of the subtalar joint that results in subtalar joint synovitis and infiltration of fibrotic tissue into the sinus tarsi space. What does this all mean? In simple terms, STS is pain and swelling on the outside of the foot and ankle from inflammation and scar tissue as a result of one or multiple ankle sprains.

As you mentioned, you have sprained the affected ankle several months ago at Bronx Park, and from the information you’ve provided, it sounds as if the ankle has not completely healed and now you have resulting instability, swelling, pain, etc. So, to begin, an ankle or foot sprain is a partial or complete tear of the ligaments that hold the bones of the foot to the bones of the lower leg. The most common injury in this area is an Anterior Talo-Fibular Ligament (ATFL) sprain. This happens when you roll your ankle – like when stepping off a curb awkwardly or stepping on another player’s foot in basketball.

Ligamentous injuries of the ankle are classified into the following 3 categories, depending on the extent of damage to the ligaments:[1, 2, 3, 4, 5]
Grade I is an injury without macroscopic tears. No mechanical instability is noted. Pain and tenderness is minimal.
Grade II is a partial tear. Moderate pain and tenderness is present. Mild to moderate joint instability may be present.
Grade III is a complete tear. Severe pain and tenderness, inability to bear weight, and significant joint instability are noted.
Depending on the extent of your initial injury, your activity level prior to and since the injury, and many other factors, healing time can vary. In some cases, the dysfunction becomes chronic and leads to more complicated presentations such as STS.

Swelling or inflammation is often our body’s response to instability. Excess fluid will collect in the area of an unstable joint in an effort to provide stability in the absence of ligamentous support. This cycle of instability, inflammation and pain typically will continue until a joint is allowed to properly heal.

Patients come in all shapes, sizes, and personality types. It’s impossible to get some patients up off the couch except to grab a giant soda. The other extreme is patients that won’t rest or stop doing the activity that caused their problem in the first place. Rehabilitation is about doing the right amount of activity that puts some stress on the affected area, but not too much that it continues to irritate the healing injury. Physical Therapists are experts at gauging that balance. Physical Therapists are also excellent at manually facilitating the drainage of ankle inflammation with retrograde massage and mobilizing scar tissue.

A local Bronx Physical Therapist, like myself, would also provide you with stabilization exercises that likely would include a progression of static balance exercises up to plyometrics and higher level functional stability exercises. If you cannot already, but you can tolerate the weight, practice simply standing on your affected foot with the other foot off the ground. Hold onto something stable if you need to and gradually progress to 1 or 2 fingers and down to none. Once you can maintain single leg stance without hand support for 5 seconds, you can attempt more advanced exercises such as lunges, marching and lateral walking.

In addition to standing exercises, neuromuscular re-education with an elastic resistance band can be very helpful in building ankle stability. Gentle resisted ankle movements can help teach your ankle stabilizing muscles to fire properly. Using a light band (we start with yellow or red Therabands at WSPT), wrap it around the outside of your foot, holding the band with your opposite hand, use your lateral ankle muscles to pull your foot in the direction of your pinky toe. Once you build up to 3 sets of 10, you can use a stronger resistance band the next session.

Stretching and mobility are also critical to proper ankle rehab. Even if you feel unstable, you may be tight in some areas, limiting your progress. Like other joints, the ratio of length to tension of the soft tissue around the ankle are critical to proper balance and function. Due to our mostly sedentary lifestyles, most of us have posterior ankle tightening. Heel cord stretches benefit most people and rarely lead to a problem.

If any of these exercises are painful, it’s important that you stop and possibly take a step back in your progress. Remember, these are only rough guidelines. I highly recommend having a Physical Therapist examine you and prescribing a custom plan for you.

Lastly, taping, bracing and proper footwear can help tremendously in the rehab process. By providing some necessary support and a sense of where your foot is in space, the appropriate brace can be extremely helpful. Kinesio Taping can relieve some of the inflammation you’ve been experiencing. Good shoes may make all the difference. Have a Physical Therapist recommend what’s best for you.

Despite what you’ve been through, the good news here is that ankle sprains and STS typically heal very well if treated properly. See a professional and get back to your normal life. Westchester Square Physical Therapy has three convenient locations in the Bronx and Yonkers.

Thanks for asking,

Daniel Seidler, PT

Brage ME, Colville MR, Early JS. Ankle and foot: trauma. In: Beaty JH, ed. Orthopaedic Knowledge Update 6. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:597-612.
Breitenseher MJ. [Injury of the ankle joint ligaments] [German]. Radiologe. Mar 2007;47(3):216-23.[Medline].
Rubin A. Ankle ligament sprains. In: Sallis RE, Massimino F, eds. American College of Sports Medicine’s Essentials of Sports Medicine. New York, NY: Churchill Livingstone; 1996:450-2.
Schepsis AA. Ligamentous injuries of the ankle. In: Yablon IG, Segal D, Leach RE, eds. Ankle Injuries. New York, NY: Churchill Livingstone; 1983:193-208.
Scranton PE. Ankle and foot: trauma. In: Fitzgerald RH Jr, ed. Orthopaedic Knowledge Update 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1987:447-54.

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