Common Conditions

Anterior Pelvic Tilt

Symptoms, Common Causes and Treatments

Understanding Anteriorly Pelvic Tilt (APT)

Anteriorly pelvic tilt is a movement performed on the pelvis where it tilts to the front. Posterior pelvic tilt is the opposite movement where the pelvis tilts towards the back. The range of anterior and posterior tilts are 13.0 ± 4.9°, and 8.9 ± 4.5° respectively. In standing, the pelvis is normally tilted anteriorly for about 7 to 13 degrees.

Symptoms

At the time of injury, pain around the ankle would be the most significant symptom that could prevent playing. An audible pop might indicate a more severe injury to the ligament. The following symptoms would start within 1-2 hours following the injury:

Swelling: usually around the bony landmark of the ankle. Extensive swelling up the leg or down to the foot indicates more severe injury to the ankle;
Bruising: usually occurring around the ankle and down to the foot and another sign for a more severe injury;
Restricted ankle movement: twisting (inverting or everting) would usually be the most painful movement to perform after ankle sprains;
Limp: the patient would need to limp when walking due to pain when weight-bearing and restricted ankle range of motion.

Types of Ankle Sprains

Lateral ankle sprain

This is the most common type of ankle sprain, which takes place when the foot lands in an inverted position (sole of the foot turning inwards). This might tear or rupture the ligaments on the lateral (outside) side of the ankle, including the ATFL (anterior talofibular ligament), CFL (calcaneofibular ligament) and PTFL (posterior talofibular ligament). Grades of ligament tears are classified as follows:

- Grade 1: ligament was strained with no laxity, projected to recover in 1-2 weeks;
- Grade 2: ligament was partially torn with laxity, projected to recover in 3-4 weeks approximately;
- Grade 3: ligament was fully ruptured. The recovery is estimated for over 6 weeks depending on the need for orthopaedic intervention and the involvement of other injured structures.

Medial ankle sprain

This is much less common than lateral ankle sprains. It happens when the foot lands everted (sole turning outwards), injuring the ligaments on the medial (inside) side of the ankle, also known as the deltoid ligament. The grading system would be similar to lateral ankle sprains as above.

High ankle sprain

Also known as a syndesmosis injury, it is described when the ligaments (AITFL & PITFL, anterior and posterior inferior tibiofibular ligaments respectively) in the high ankle are damaged when the foot is everted and dorsiflexed (toes pointing up). Apart from the high ankle ligaments, the syndesmosis, which is a thick fibrous tissue connecting the fibula and tibia, is torn and stretched out. The stability of the ankle would be significantly compromised at this point so the recovery would take longer.

Ottawa Ankle Rules

This is a set of principles used to determine the need for an X-ray to rule out fractures or other bony injuries at the time of the injury. If any of the following symptoms is present, it is advised that an X-ray should be performed to check for bony injuries:

Inability to weight-bear and walk for 4 steps immediately;
Tenderness to touch around any of the 4 bony landmarks shown on the diagram

Management (acute stage)

Professional Treatments

After the bony injuries have been ruled out, it is advised that the patient should commence physiotherapy as soon as possible for symptomatic relief and swelling control. Treatment during the acute phase might include the following:

Electrical Modalities: ultrasound therapy, interferential therapy, and high energy inductive therapy are commonly used modalities for swelling control and pain relief;
Dry Needling: acupuncture around the injured sites could help with pain relief and swelling control;
Manual Therapy: soft tissue therapy can be performed on muscles surrounding the ankle, such as the soleus, gastrocnemius, and plantar foot muscles for promote overall mobility;
Gait Aid Prescription: depending on the severity of the injury, the patient might require crutches to aid walking in the first few days to offload the injured ankle. For high ankle sprains or the more serious ankle sprains, a camboot might also be fitted to immobilize the ankle for protection;
Exercise Therapy: early mobility is highly important for swelling control. Light mobility exercises performed on pilates reformer or with a soft resistance band could reduce joint stiffness and aid recovery.

MANAGEMENT (LATER STAGE)

As the acute pain and swelling subside, the individual then enters the next phase of rehabilitation which focuses on mobility, strength, proprioception and a range of other functional parameters for higher occupational or recreational needs. The rehabilitation might include the following:

Proprioception Training

It is highly imperative that the individual needs to sense the position of the ankle and properly reposition if required. Dynamic balances are given on unstable surfaces such as foam or wobble board to enhance the proprioception of the ankle.

Specific Strengthening

For those with recurrent ankle sprains or chronic ankle instability, there might be predisposing muscle weakness that have contributed to the current injury. For long-term ankle health and performance, the underlying weakness needs to be identified and addressed prior to return to sports.

Taping or Bracing

Depending on the functional needs, taping skills might be taught to individuals who need short-term immobilisation during sports for protection. Ankle braces could also be fitted for similar purposes.

Conclusion

Ankle sprains are highly prevalent with an alarmingly high recurrent rate. Studies have shown that a high proportion of individuals who suffered ankle sprains might develop chronic ankle instability. Therefore, every ankle sprain should be properly and fully rehabilitated before returning to sports.

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