RICE & MICE: Chronic Ankle Instability

Unless you’ve been hiding under a rock, you have probably heard about the 2011 version of “Peter Forsberg’s Comeback to the NHL.” For the better part of the last decade there have been whispers and rumors about a possible comeback for Forsberg at least once in each NHL season.

Mentioning Forsberg’s name may prompt any combination three reactions from hockey fans: they love him, they hate him or they complain about the number of injuries that have plagued his career in the NHL. We are now in a point of the 2010-2011 season where people are once again speculating that this could actually be the year that he can finally overcome the bothersome right foot/ankle issue that has otherwise cut his career short.

What do you remember about Peter Forsberg’s chronic foot issue(s)? If you are anything like me, you vaguely remember that there was always an issue with his foot fitting into skates, and that multiple surgeries had failed to help or alleviate his symptoms enough to allow him to play, but ultimately, you are unsure of exactly what was wrong with his foot in the first place.

From what little information I can find, it seems that Forsberg has a ligament laxity or loose ligament issue in both of his feet and this generally can cause all kinds of injuries and chronic problems. A ligament’s main function is to hold bones together and keep the bones from being aligned improperly, so there has to be some elasticity, like a rubber band, that is strong enough to keep the bones in proper alignment yet flexible enough that they do not just tear apart when they are stressed.

This is usually a rare condition and not something that is overtly prevalent in the NHL or any professional sports, for that matter.

Ligament laxity in the ankle can cause wear and tear in parts of the ankle that wouldn’t normally experience such changes because parts of the foot that are not meant to bear weight and impact will end up stressed by bearing weight which can lead to bone spurs, stress fractures, frequent sprains of the ligaments, chronic pain and muscle imbalance in the feet and ankles from overcompensating for the deficiency in stability.

A joint that is not in proper alignment will shift one way or another before it is able to make that movement, and that extra shifting causes stress on the joint, which may lead to degeneration to the joint. Bone spurs form in areas of stress and often, bone may be broken down from “normal” weight bearing surfaces in order to build it up on the stressed areas because of the misalignment. The over compensation can lead to bursitis, hip, groin, and back problems, all of which the Forsberg has had in the past. The body will also attempt to stabilize the joint with muscle spam and pain and there is often chronic inflammation and swelling in severe cases.

The problem with ligament laxity is that it is often overlooked or misdiagnosed. If unstable ankles are not treated with physical therapy or in extreme cases, surgery, there is often much more damage to the ligaments of the joint and there may be damage to the muscles and tendons as well.

In 2002, Forsberg had a tendon repaired in his left ankle, which could be caused by the overcompensation of muscles to stabilize the joint. He had sprained that ankle in the offseason that year and mentioned in a physical that there was some “popping” felt in the joint.

His right ankle and foot have been the ongoing issue. He has tried countless orthotics, inserts and braces. When he was with the Philadelphia Flyers he had surgery on his right foot to tighten up some of the loose ligaments. At the time, even though his skate was technically a proper fit for his foot, the foot will tend to roll over within the skate boot as if he was wearing skates several sizes too big.  He had difficulty keeping his feet in his skates and that would cause balance issues. Proper balance helps prevent things like back and groin injuries.

In the short time with the Avalanche in 2008, he wore a muscle stimulation pack on his right foot in order to help stimulate muscles in his foot.

The newer treatments for ligament laxity involve prolotherapy and/or platelet rich plasma injections. These therapeutic injections can actually repair the damaged ligaments and restore them to health. Surgical repair involves identifying the loose or stretched ligaments and reinforcing them to make them tighter. Surgical reconstruction is usually needed if a surgical repair of the ligaments fails to alleviate symptoms and instability.

Tendon reconstruction of the ligaments involves stabilizing the stretched out dysfunctional ankle ligaments by securing a tendon graft through bones on the outside of the ankle, Tendons used for the graft are usually taken from a nearby tendon, a tendon that has been harvested near the knee joint, or by using a tendon from a cadaver.  The tendon graft is usually placed through the end of the fibula (the small bone of the lower leg), the talus (the ankle bone), and often the calcaneus (the heal bone).  There are a variety of ways to perform the reconstruction.  In each case the tendon is pulled tight, and secured solidly to the bone to stabilize the ankle joint.

Recovery from a tendon reconstruction involve casting an non-weight bearing for a period of approximately 6 weeks which will allow the bone to heal in the area of the grafts in order to secure them.  The rehabilitation phase focuses begins with improving ankle motion and progresses through strengthening the muscles around the ankle, regaining ankle proprioception and improving gait. Ankle bracing may be used to help reinforce the reconstruction.

Unfortunately, countless surgeries have not yet helped Peter Forsberg make a return to the NHL.

In 2009 he had yet another surgery on his right foot, which seemed to show promise. In 2010, he was able to play in the Vancouver Olympic Games, yet he just didn’t seem to have the mobility that was needed for him to make more of an impact. He is once again eyeing a comeback while currently practicing with the Avalanche. His heart is willing, but will his foot hold up?


Disclaimer: Information on found in RICE & MICE on flyersfaithful.com is not intended to be medical advice. Any information or materials posted on the web site are intended for general informational purposes only, and should not be construed as medical advice, medical opinion, diagnosis or treatment. Any information posted on the web site is NOT a substitute for medical attention. See your health-care professional for medical advice and treatment.