Jack Wilshere: Injury Analysis

Jack Wilshere

 

Injury Update

March 3rd, 2013: The BBC confirmed “Wilshere picked up the problem with his left ankle in the Gunners’ 2-1 defeat by Tottenham on 3 March. He had missed the whole of last season with an injury to his right ankle.

“He has an inflamed ankle, the other ankle to the one he injured [before],” Wenger said.

“He will be out for three weeks and will not be available against Munich and Swansea, and not for England.”

What is an inflammed ankle?

In a American study carried out in the USA in 2010 it was found that the highest rate of ankle injuries existed in 10-19 year olds. Males between 15-24 were more likely to sprain their ankles their female counterparts and 50% of injuries occurred during athletic activity (Waterman et al, 2010)

Fast facts

  • Ankle sprains account for 20-40% of all athletic injury (Sawkins etal, 2007; DiStefano et al, 2008; LeBrun and Karuse, 2010).
  • 85% inversion injuries, this is where the ankle rolls inwards and can cause stretching or tearing of the soft tissue on the lateral aspect of the ankle (Takao et al, 2005; Anderson et al, 2004; Bennyon et al, 2005).
  • The ankle is made up on two joints the talocrural joint and the subtalar joint.
  • Ligaments attach bone to bone and are made up of dense parallel bundles of collagen fibres that form a crimp. This crimp acts like a spring and allow forces to be dissipated. If the load is too great this can cause failure of the collagen fibres (tear) or a complete rupture.
  • The anterior talofibual ligament (ATFL) is the weakest ligament and usually the first to be sprained.

What are the symptoms of a sprained ankle?

  • Pain
  • Swelling
  • Stiffness   (Reid, 1992)

How do you diagnose and ankle sprain?

The subjective history is very important and as a physio you should be listening for the mechanism of injury, did the patient hear a pop, were they able to weight bear and do they have a history of ankle injury?

So why are these questions important?

Mechanism of injury gives indication of what structure may be damaged. Think in basic terms of what has been stretched/potentially ruptured?  Hearing a pop may indicate damage to a ligament. If the patient was unable to weight bear and had immediate bruising and swelling of the ankle this indicates significant trauma and Ottawa Ankle rules should be checked to assess the need for an X-Ray to rule out a fracture. People who have had previous ankle injury could be predisposed to injury due to a biomechanical abnormality or poor rehab from the first injury.

Objective assessment:

Observation, Active ROM, Passive ROM, Strength, Palpation, Ligament integrity tests.

Most ankle sprains can be diagnosed through clinical assessment. If symptoms are persisting  after 6 weeks of physiotherapy then MRI may be useful to rule out differential diagnoses such as osteochondral lesions.

(Takoa et al 2005)

Physiotherapy management

Treatment and progression should be based on scientific knowledge of the ligament’s healing process, the patient’s symptoms and the clinical assessment (Williams et al, 2007). Treatment should aim to compliment and support the stage of healing.

  • Inflammatory Phase: 24-72 hours
  • Reparative Phase 3-5 days following injury
  • Remodelling : 15-28 days following injury
  • 3 weeks : if managed correctly can regain 60% tensile strength (Banks et al, 2001)
  • 3 months : Ligament may regain original strength.

 Read more about these phases by an article written by Tim Watson, Electrotherapy Guru.

The following is a summary of a fantastic paper by Dubin et al (2011). Please read the FREE full article here..

Lateral and syndesmotic ankle sprain injuries: a narrative literature review

Acute inflammatory phase

  • Ice applied for 20mins x 4+ daily  /Cryrotherapy  = Reduces pain, oedema, hypoxic damage to tissues
  • NSAIDs, ultrasound, electrical muscle stim may help reduce inflammation.
  • Ankle pumps 10-20/hourly = increased circulation/reduced oedema.
  • Taping = Can provide mechanical support and offload injured structures.
  • Modified activity(depending on severity). Ie hydrotherapy, stationary cycling.
  • Active Release technique, muscle energy technique, transverse friction massage can be applied to the ligament to facilitate early ligament healing.

 (Dubin et al, 2011)

Reparative phase (3-5 days, collagen production intensifies 10-14 days)

  • Joint mobilisations
  • Soleus and gastroc stretches.
  • Isometric strengthening
  • Active range of movement (minimal pain eversion, dorsiflexion and plantar flexion. Pain free inversion.
  • Strengthening the peronei, tibialis anterior and extensors, and triceps surae.
  • Glut med strengthening.
  • Calf strengthening.
  • Standing proprioception training.
  • Show modification if needed.
  • Modified activity progressed gradually. When appropriate to begin running complete appropriate warm up then begin 3min run (easy intensity) then follow with 2 min walk. Build up gradually. Do not progress if increase of pain on swelling following each session of running (ie reduce training load to something that is tolerated).

 

Remodeling phase (15-28 days, 3 weeks regain 60% strength, 3 months regain 100% strength)

  • Modified training: progress to jumps, higher intensity runs, sprints.
  • Multidirectional agility drills – begin with two legs progress to single leg.
  • Progress to increase speed. (Progress as pain, comfort, stability allows)
  • Forward jumps, lateral jumps, jumps with twist, Box drills.
  • Progress to sport-specific proprioceptive drills.
  • Ladder Drills

  (Dubin et al, 2011)

A secondary thought on this article…..

Although this article gives us a good insight into  some treatments that are available, the literature used within it was not appraised for quality. Physiowizard recommends that you look at the article and read the original research to assess its quality before implementing these strategies. Anecdotal evidence from the Physiowizard team feel that when used in the right circumstances these treatments can be effective.

 

 References

Andersen T.E., Floerenes T.W., Arnason A., Bahr R. Video analysis of the mechanisms for ankle injury in football. Am J Sports Med. 2004;32(1):69S–79S. [PubMed]

Banks A.S., Downey M.S., Martin D.E., Miller S.J. Foot and ankle surgery. Lipincott Williams & Wilkins; Philadelphia: 2001. pp. 1898–1902.

Beynnon B.D., Vacek P.M., Murphy D., Alosa D., Paller D. First time inversion ankle ligament trauma.Am J Sports Med. 2005;33(10):1485–1491. [PubMed]

Brian R. Waterman, Brett D. Owens, Shaunette Davey, Michael A. Zacchilli, Philip J. Belmont, Jr.; The Epidemiology of Ankle Sprains in the United States. The Journal of Bone & Joint Surgery. 2010 Oct;92(13):2279-2284.

DiStefano L.J., Padua D.A., Brown C.N., Guskiewicz K.M. Lower extremity kinematics and ground reaction forces after prophylactic lace-up ankle bracing. J Athl Train. 2008;43(3):234–241.[PMC free article] [PubMed]

LeBrun C.T., Krause J.O. Variations in mortise anatomy. Am J Sports Med. 2005;33(6):852–855.[PubMed]

Reid D.C. Sports injury assessment and rehabilitation. Churchill Livingston Inc.; New York: 1992. pp. 215–268.

Sawkins K., Refshauge K., Kilbreath S., Raymond J. The placebo effect of ankle taping. Med Sci Sports.2007;39(5):781–787. [PubMed]

Takao M., Uchio Y., Naito K., Fukazawa I., Ochi M. Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain. Am J Sports Med. 2005;33(5):686–692. [PubMed]

Williams G.N., Jones M.H., Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med.2007;25(7):1197–1207. [PubMed]

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