Bimalleolar Ankle Fracture
Bimalleolar Ankle Fracture

Bimalleolar Ankle Fracture

By Debbie Roberts , LMT
2019-5-1

Bimalleolar Ankle Fracture

By Debbie Roberts, LMT
2019-5-1

In this article we will explore how a massage therapist can help a client recover from a bimalleolar ankle fracture. We will review the function of the ankle joint, the type of modalities that you can use to help this client recover and the importance of timing for recovery.

A Case Study

Just five weeks ago I had a client come in to my practice., She was a young female golfer, who wanted help to regaining range of motion in her ankle. She had just finished physical therapy and was able to walk with a cane.  Her x-rays showed pins and anchors had been placed in both the tibia and fibula. Ankle fractures typically involve the tibia or the fibula. In this case, however, my client had a more serious injury involving the medial malleolus and the lateral malleolus, hence the name bimalleolar ankle fracture.

The injury occurred when her young dog took off suddenly, pulling her in a direction that created a significant force of rotation in the ankle that caused both a fracture to the tibia and the fibula. When both sides are injured, the ankle becomes unstable and surgery is typically required to repair the fracture.

Review of Ankle Anatomy 

There are three bones that make up the ankle joint. The tibia, also known as the shin bone; the fibular, smaller lateral bone of the lower leg; and the talus, a small bone that sits between the calcaneous and the tibia and fibula.

The talus articulates with the tibia and fibula above and with calcaneous below. Both articulate anteriorly with other tarsals. Interestingly, no muscle inserts on the talus, so it movesindirectly via the structures surrounding it.  The medial malleolus is the inside part of the tibia, the posterior malleolus is the back part of the tibia and the lateral malleolus is the end of the fibula. “Bi” means two and“Bimalleolar” means that two of the three parts or malleoli of the ankle are broken. For more detailed information about the movement of the ankle, read Anatomy of Movement by Blandine Calais-Germain.

The Recovery Process: How Massage Helps

Because there is such a wide range of injuries, people will heal from ankle fractures in a wide range of ways, too. It takes at least six weeks for the broken bones to heal, but may take longer for the involved ligaments and tendons to heal. In most cases, weight bearing is not allowed for six weeks. After six weeks, the ankle may be protected by a removable brace as it continues to heal. In my client’ss case, the damage was so extensive they had to leave her in the brace for 13 weeks.

Complications from surgery are most commonly encountered during the rehabilitation phase. Stiffness of the ankle joint or recurrent instability are both possible complications. 

As a massage therapist, you can help reduce both the stiffness and the instability. There are three main goals in doing so; 1. Restore the mobility of the joint. 2. Increasethe pliability of the restricted soft tissue; 3. Bring back proprioception, which is the unconscious perception of movement and spatial orientation arising from stimuli of the muscle, joints and ligaments receptors.

Sample Massage Protocol: My Experience with One Client:

1.      Use of heat to increase pliability of the tissue, hot towels, hot stones, and/or hydroculator packs.

2.      Initial gentle massage therapy in the direction of lymph flow.

3.      Use of the cupping machine, set at just enough suction to pick up the tissue.

4.      Use of 5 percent to 10 percent isometrics with up to eight second holds with resistance to dorsiflexion, plantarflexion, inversion and eversion to help re-establish proprioception. (For more understanding about the use of isometric training read articles on muscle energy.)

5.      Soft tissue treatment time was initially a half hour. As the client was getting better, I increased her therapy session to a half hour hour table time and half hour hour gym time. In the gym, I used a half hour of a combination of proprioceptive training, flexibility training, mobility training and strength training.  This was followed by a half hour session of hands on therapy with the above mentioned protocol. 

6.      You can’t strengthen what you can’t stabilize or move. In the gym, proprioception training should come first. An example of how to begin is to stand with the eyes open then eyes closed for ten seconds, then increase the timing. By closing the eyes, the body must now rely on its joint receptors to make spatial orientation and movement. As the client is able to progress, you can then move this same protocol to an unstable surface, such as a thick yoga mat or Theraband stability trainer. The final progression would be to have the client stand on one foot holding onto the wall for five to ten seconds at a time depending on their pain and stability levels. You then progress to taking away the wall contact points.  Have your client put both hands on the wall then count back from 10, removing one finger at a time until both hands are by their side. Repeat this exercise five times. You both hands on the wall, begin removing one finger at a time until both hands are by your side. Repeat this exercise five times. This process can take weeks as you never ever rush regaining proprioception because doing so may cause inflammation and set the client back. 

7.       We used total resistance exercise (TRX) bands around her knees to start working toward regaining her squat and lunge patterns and activating her gluteals. The hip on the side of injury had weakened.

8.      We began introducing core work in an all-fours position.

9.      We worked with the Theraband rocker board in a chair to regain dorsiflexion, then we were able to progress this to standing while holding onto the wall with ten contact points and using the rocker under one foot.

10.  We rolled the bottom of the foot with a vibration roller and spiky ball.

11.  She had daily self-care homework that she followed diligently.

Outcomes

Most people will return to normal daily activities, with the exception of sporting activities, within three to four months. The additional problem for sports is during the down time other muscles become weak up the chain, so those must be evaluated and rehabbed as well. Some studies have shown that people can still be recovering up to two years after their ankle fractures. It can take several months for them to stop limping and their foot not to turn outward under bodyweight loads. In this client’s case, she has returned to chipping a golf ball, but not a full swing. The estimated time by her physical therapist and doctor will be a full six to eight months from the time of surgery.

As massage therapists, I highly recommend obtaining your personal training certification and understanding how to progress a rehabilitation patient. I really feel the half hour rehabilitation strength, flexibility, mobility, proprioception sessions followed by a half hour hands on multiple disciplinary approach is the key to helping any patient recover faster .