Resolving Ankle Pain in a Rugby Player

History and Presenting Symptoms The patient is a 35->car-old male who plays rugby in an adult club on weekends. He describes recurring episodes of pain and swelling along the outside of his left ankle for the past couple of years. He presents for treatment of his lower extremity bio-mechanical faults, and would like to prevent future problems and improve his athletic performance with chiropractic care. Exam Findings Vitals. This athletic male weighs 176 lbs. which at 5" 11"" re­sults in a BMI of 24.5; he is not overweight. He is a nonsmokcr. and his blood pressure and pulse rate are at the lower end of the normal range. Posture and gait. Standing postural evaluation finds generally good alignment with intact spinal curves, but a slightly lower iliac crest on the left, which is confimied by a lower left greater trochantcr. He also demonstrates left calcaneal eversion and a low medial arch (hypcrpronation). A tendency to toe out (foot flare) on the left is noted during examination of his gait. Chiropractic evaluation. Motion palpation identifies a mild limitation in left sacroiliac motion with moderate tenderness and loss of end-range mobility. Several compensatory fixations arc identified throughout the lumbar region. Otherwise, all orthopedic and neurological testing is negative. Lower extremities. Examination of his left foot and ankle re­veals slight general swelling of Ms ankle, which is moderately tender to palpation along the outer aspect. All left ankle ranges of motion arc full and pain-free, except inversion, which is limited by tightness and localized pain along the lateral foot and ankle. Manual muscle testing finds mild weakness in the left pcroncal muscles when compared to the right side. Imaging No x-rays or other forms of musculoskclctal imaging were requested. Clinical Impression History of recurrent inversion ankle sprains associated with hyperpronation and foot instability. This is accompanied by sacroiliac joint motion restriction and compensatory lumbar fixations. Treatment Plan Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. The left navicular bone was adjusted superiorly. Support. Individually designed stabiliz­ing orthotics were provided to support the arches and decrease calcaneal eversion. and to reduce the asymmetrical biomc-chanical forces being transmitted to the spine and pelvis. Two pairs of stabilizing orthotics were ordered: one designed for his rugby shoes and the other for everyday shoe wear. Rehabilitation. He was initially instructed in daily sclf-mobili/ation and strengthen­ing procedures, which included marble pick-up and towel-scrunching exercises. After two weeks, daily strengthening of eversion and external rotation was intro­duced using clastic exercise tubing. Response to Care The spinal and pelvic adjustments were well tolerated, and this active athlete re­quired very few readjustments. His com­pliance with the stabilization and exercise recommendations was very good since he w as quite motivated to improve his perfor­mance and to prevent future injuries to his ankle. He adapted to the orthotics and wore them without difficulty. He faithfully filled out and brought in his exercise log at every visit, which provided an excellent oppor­tunity to support his home-based efforts. Within two weeks of receiving his orthotics. he completed several strenuous rugby practices without symptoms or swelling in the ankle. He described a noticeable improvement overall in his athletic performance, saying that he felt "more stable." He was released from acute care to a self-directed home exercise program after a total of eight visits over two months. Discussion This athlete had been to several doctors before this encounter. He was very frustrated by the lack of answers and recommenda­tions. His frequent and recurring inversion sprains occurred in a foot and ankle that previously had received poor medial sup­port (a low medial longitudinal arch) and an everted calcancus. Biomcchanical analysis found his left foot to be ovcrflcxible and unstable. As is often found in these types of cases, the combination of specific adjustments, individually designed orthotic support, and strengthening of the lateral ankle support musculature brought about an excellent response. This active athlete was very motivated to improve his sports performance, and he persisted with the recommended exercises. Dr. John J. Danchik. the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts Univer­sity \ ledical School and formerly chaired the U.S. Olympic Committee s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation. He can be reached at docjorjocsiiaol.com or 617-4H9-1220.