A case study on the ankle

A friend of mine stepped off of a surfboard into some water she did not know the height of.  She rolled her ankle into eversion. This is where the outside of the ankle rolls outward.  This is unusual because the inside of the ankle usually rolls inward with an ankle injury.  For about a year her ankle has been quite sore limiting her in running on the beach, riding a bike, and running on the road.  Her outside ankle region/big toe region are sore with standing, walking, riding a bike and running.  Her ankle feels stiff and pulling on it gives her relief.

She had an X-ray and there was no fracture. An MRI showed the talus had inflammation. She had a stem cell injection and it seemed to improve the feeling of the inside of the ankle by about 50%.  That is cutting edge technology for a treatment.  That stem cell injection can differentiate cells into whatever cells are needed for tissue repair and healing.  She had ultrasound treatment from a physical therapist and some manual stretching and exercises for the foot- it helped but her insurance ran out and she needed a home exercise program.

Upon examination the salient findings are:

  • Both feet had moderate to maximal pronation at midstance of walking.
  • Left foot dorsiflexion was limited to 5 degrees, normal is 20 degrees
  • Flexor hallicus longus weakness significant/big toe flexor muscle ( a major stabilizer of the arch and 1st ray (big toe bone region)
  • Posterior tibialis region signficantly weak (the muscle that helps the foot in and down and helps stabilize the arch in walking)
  • Palpation of the outside of the ankle minor pain at talus laterally


Her treatment impairments would be summarized:

Compression injury to talus due to eversion injury of foot first metatarsal joint pain

  • Insoles and huge arched shoes (Asix or Brooks)
  • Calf stretching aggressively- When one area of the body is really tight commonly another area of the body will have to move more to achieve the desired movement of the body– so for this patient there was tightness of the capsular tissue and limited her dorsiflexion or upward movement of the ankle. This is a problem because now there was more movement at the first ray and it was a bit hypermobile and the flexor hallicus muscle was weak/and there was pain at the big toe region
  • Husband distraction of ankle and aggressive PROM stretching and distraction at the same time
  • Strengthening of the posterior tibialis with theraband aggressively
  • Strengthening of the posterior tibialis in standing and eccentrically going down slowly with calf raises

Image result for spenco arch support image

This is a picture of Spenco arch supports that can be bought for about 25 dollars


Image result for standing calf stretch with wedge image

Calf stretch with wedge 3 x 60 seconds 3 x a day 6 to 8 weeks

Image result for posterior tibialis strengthening theraband image

Posterior tibialis strengthening down and in resistance with band 3 x 15 2 x a day 8 weeks

Image result for standing heel raise exercise image

Up with the heels, down slowly 3 sets 15 x 4 x a week 8 weeks for posterior tibialis (calf too)

Image result for big toe flexor theraband strengthening image

big toe flexion exercise with resistance 3 sets 10 x 4 x a week 8 weeks- you could consider this 1st ray or part of the big toe bone a truss support for the whole foot




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