Your First Visit to Physical Therapy

On your first visit, your physical therapist will want to gather some more information about the history of your ankle problem. You may be given a questionnaire that helps you tell about the day-to-day problems you are having with your ankle. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your physical therapist gauge how much pain you have now and how your pain changes once you've had treatment. Your physical therapist will probably ask some more questions about your ankle problem to begin zeroing in on the source and location of your pain and to know what will be needed to help relieve it. Here are some questions your physical therapist may ask you:

• How long have you had ankle pain?
• Where do you feel the pain? 
• What makes the pain better or worse?
• How do your symptoms affect your daily activities? 
• Do you have pain in your lower leg, knee, or hip? 
• Does your ankle swell?
• Does your ankle ever feel like it's going to give out?
• Do you have any numbness or tingling?

Physical Therapy Evaluation

Once all this information has been gathered, your condition will be evaluated.

Posture:
Your physical therapist will begin by checking your overall posture, including your foot and leg alignment. Imbalances in the position of your foot and leg can put extra pressure on your ankle. If alignment is a problem, your therapist may take some measurements to see if a special shoe insert, or orthotic, will be needed to take away the pressure and pain.

Observation:
Your therapist will note if there is any swelling in or around the ankle joint. If so, measurements will be taken to get an idea of how much swelling is present. Volumetric testing is done by placing your foot and lower leg in a container of water and measuring how much water is displaced. The results of each ankle and leg are compared. Another way to measure swelling is to use a tape measure and compare several measurements around one ankle and then the other. These measurements can be rechecked later on to get an idea if the swelling is going away.

Gait analysis:
By watching you walk back and forth, your therapist can see if how you walk may be linked with your condition. Even subtle changes in your stride, foot and knee position, or hip movement can create problems like ITB syndrome. Range of motion (ROM): Next, your physical therapist will check the ROM in your ankle. This is a measurement of how far you can move your ankle in different directions. Ankle movements include bending the ankle up and down (dorsiflexion/plantarflexion) as well as in and out (inversion/eversion). Your therapist may also want to get an idea of how other joints around the ankle are moving, including the lower leg, knee, and possibly even your hip. Your ROM is written down to compare how much improvement you are making with the treatments.

Strength:
Your therapist will then test the strength of your muscles. You'll be asked to hold against resistance as your therapist tests the muscles around the ankle. Other areas that may be checked include the muscles of the knee and hip. These measurements are compared to your other leg. Weakness in key muscles of the leg or ankle will be addressed with a strengthening program. Trained muscles can help control your sore ankle, which eases pain and keeps the joint healthy for as long as possible.

Manual Examination:
You may be given a manual examination of the muscles and joints of the ankle. Your physical therapist will carefully move your ankle in different positions to make sure that the joints are moving smoothly. This will help guide treatment to the areas that are tight (called a hypomobility) or where the joint may have been injured and is moving too much (called a hypermobility). Your physical therapist will also look at the flexibility of the muscles and tendons around your ankle. This type of exam can help guide your therapist to know where your soreness is coming from and which type of treatment will help you the most.

Palpation:
The evaluation usually ends with palpation. Palpation is when your physical therapist feels the soft tissues around the joint. This is done to check the skin for changes in temperature, areas of soreness, and whether you have swelling. Palpation is also done to find whether there are tender points or spasm in the muscles around the ankle. This can help your therapist get a good idea about which treatments will help you the most.

Treatment Plan:
Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. The plan also lists the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.

Physical Therapy Treatment

Your therapist may choose from one or more of the following tools, or modalities, to help control the symptoms caused by ankle osteoarthritis:

Heat:
Heat makes blood vessels get larger, called vasodilation. This action helps to flush away chemicals that are making your ankle hurt. It also helps to bring in nutrients and oxygen which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm water whirlpool or bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin doesn't overheat and burn. It's also not a good idea to sleep with an electric hot pad at night.

Ultrasound:
An ultrasound machine produces high frequency sound waves that are directed toward the sore area. Passing through the body's tissues, these waves vibrate molecules. This causes friction and warmth as the sound passes through the tissue. The rest of the sound changes to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are a way for your therapist to reach tissues that are over two inches below the surface of your skin.

Phoresis:
This means to "carry or transmit." There are two methods that therapists can use to transmit substances across the skin. Phonophoresis uses the high frequency sound waves of ultrasound to "push" a steroid medication (cortisone) through the skin. Iontophoresis uses a small machine that produces a mild electrical charge, which is used to carry medicine, usually a steroid, through the skin. The steroid is a very strong anti-inflammatory medication that actually stops the pain-causing chemical reaction within the cells of the sore tissue in your body. Either type of phoresis may be used in place of a cortisone injection.

Electrical Stimulation:
This treatment stimulates nerves by sending an electrical current gently through your skin. Some people say it feels like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. This procedure is based on the Gate Theory which says that when you feel a sensation other than pain, like rubbing, massage, or even a mild electrical impulse, your spinal column will actually "close the gate" and not let pain impulses pass to the brain. In the case of electrical stimulation, the electrical impulses speed their way across the skin and on to the central nervous system much faster than pain. By getting there first, the electrical information "closes the gate" to pain, blocking its passage to the brain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort. Other settings on the machine can be used to help your body release endorphins. These are natural chemicals formed within your body that behave like a strong drug in reducing the perception of pain for up to eight hours at a time.

Soft Tissue Mobilization/Massage:
Physical therapists are trained in many different forms of massage and mobilization when treating the neck. Massage has been shown to calm pain and spasm by helping muscles relax, by bringing in a fresh supply of oxygen and nutrient-rich blood, and by flushing the area of chemical irritants that come from inflammation. Soft tissue treatments can help tight muscles relax, getting them back to a normal length. This will help you begin to move with less pain and greater ease.

Joint Mobilization:
These are graded pressures and movements that are done by skilled physical therapists. Gentle graded pressures help lubricate joint surfaces, easing stiffness and helping you begin moving with less pain. Pain that is left unchecked can quickly escalate to an uncomfortable "cycle of pain and muscle guarding." In other words, the pain can make your muscles go into spasm, in which your muscles try to guard the sore joints, keeping you from wanting to move your ankle at all. When movement stops, your brain gets an uninterupted flow of pain sensation. Ouch! This leads to a cycle of even more muscle spasm and pain because your muscles try to "protect" you from painful movement. By applying gentle pressures, or mobilizations, your therapist will begin to halt the flow of pain information, which helps muscles relax. Once your muscles begin to relax, you will begin to feel other sensations than pain. As your pain eases, more vigorous grades of mobilization may be used to lengthen tissues around the joint helping restore better movement in your ankle.

Topical Agents:
Certain topical ointments (such as Capsaicin(r)) have been shown to ease pain by blocking chemicals that cause pain.

Improving Range of Motion:
When movement of a joint is limited, pain and other problems may worsen. Improving ankle movement can help keep the joint surfaces healthy, while helping to control soreness. Getting more motion can give you the relief you need to do your day-to-day activities. If you don't have full range of motion, your therapist has several ways to get more movement in the ankle. Your therapist can use graded joint mobilization, manual stretching, and select exercises. Active movement and stretching either as part of a home or pool therapy program can also be helpful.

Strengthening:
In the early stages, strengthening may be done by using isometric exercise. These are exercises where the muscles around the joint are worked, but the joint stays in one position. Isometrics help restore strength while protecting you from further pain and irritation. As your muscles gain strength, you may notice less pain while experiencing a sense of ease with walking and other activities.

Joint Protection:
These are ways to give your joint the edge it needs to stay healthy for as long as possible.

Muscular Control:
Sometimes the ankle gets an extra jolt when you suddenly miss a stair or stub your toe. Untrained leg muscles are slow to respond in protecting the ankle joint, and these jolting forces can do more damage to the softer bone under the cartilage. A trained muscle will generate force quickly. Conditioning exercises help ankle and leg muscles generate forces more quickly, preparing them to act as shock absorbers to protect your ankle joint.

Shock Absorption:
A good pair of shoes will also help reduce shock. If walking is one of your primary exercises, choose a soft walking surface like cinder or grass. Avoid cemented or other hard surfaces. Limit your walking speed, especially if you find that increasing your walking speed irritates your ankle pain. Other types of exercise that prevent high impact on your joints include stationary biking and swimming.

Walking Aids:
In cases of severe pain or joint wear and tear, you may need to use a cane or walker until your condition is stabilized. Using a walking aid can take some of the pressure off the ankle joint, protecting it from undue stress and strain.

Alignment:
When the leg and ankle are not properly aligned, you may be getting extra pressure around the foot and ankle. In these cases, a special shoe insert, or orthotic, can help relieve pressure and pain. Sometimes a small heel lift or cushion can be placed in your shoe to limit pressure on a stiff ankle joint, helping you to enjoy walking longer distances without a limp.

Daily activities: Here are some helpful hints to use during the day to limit strain on your ankle.

• Avoid standing for greater than 10 minutes; instead take frequent rests.
• Use a heel or shoe cushion when standing or walking on hard surfaces.
• Limit stair climbing; take the elevator, escalator, or ramp.
• Avoid bending and squatting by storing items at waist level. Or use a reacher.
• Park close to your destination.

Exercise Progression:
Your exercise program will be advanced cautiously to include strengthening, balance, endurance, and other exercises that mimic your daily activities. Your program will address key muscle groups of the hips, thighs, calves, and foot. You will be trained in exercises that help stabilize and control the ankle. Other exercises can be used to simulate day-to-day activities like raising up on your toes, stepping off a curb, or descending a ramp. Specific exercises may also be used to simulate your work or hobby demands.

Daily Exercise:
Your joint surfaces can remain healthier by consistently working your ankle through a full range of motion and using safe, load-bearing exercises. Do exercises as prescribed to keep the hip, knee, and ankle muscles strong. Avoid pain by exercising with pain-free movements, by limiting walking speeds, and by not overdoing it. If you feel pain, you may need to back off and do gentle range of motion and isometric exercises.

General Fitness:
The Surgeon General recommends that everyone get at least 30 minutes of moderate activity a day for as many as seven days a week. Along with reducing the risk of heart disease, lowering stress, managing body weight, and prolonging life, a general fitness program can also assist you in managing ankle osteoarthritis. Moderate activity can include walking, swimming, stationary biking, or low impact aerobics. Before undertaking such a program, consult your physician.

Long-term management: Here are some long-term solutions to help manage your ankle condition:

• Control pain and inflammation with heat, cold, and medication (as prescribed by your doctor).
• Reduce shock by using a walking aid, wearing good shoes, choosing soft surfaces, and keeping the leg muscles conditioned for unexpected stresses.
• Exercise often to maintain range of motion, strength, and cardiovascular fitness.
• Use a shoe orthotic in cases where leg and foot alignment is a problem.
• Take precautions with daily activities to avoid stressing the ankle.

Home Program:
Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will give you some ideas to help take care of any more soreness at home. You'll be given some ways to keep working on the range of motion and strength too. Before you are done with physical therapy, more measurements will be taken to see how well you're doing now compared to when you first started in therapy.