Syndesmosis sprains : The high ankle injury
You may have heard various athletes suffering a high ankle sprain or injuring their syndesmosis. But what exactly is a syndesmosis injury? And how does it differ to a normal lateral ankle sprain?
The ankle syndesmosis is the joint between the distal (lowest aspect) of your tibia and fibula. It is comprised by three main supporting ligamentous structures – The Anterior inferior tibiofibular ligament, Posterior inferior Tibiofibular ligament, and interosseous membrane (see Figure 1). The role of the syndesmosis is to provide stability to the tibia and fibula and resist separation of these two bones during weightbearing tasks. It also plays a role in assisting with mobility of the ankle.
You may have heard various athletes suffering a high ankle sprain or injuring their syndesmosis. But what exactly is a syndesmosis injury? And how does it differ to a normal lateral ankle sprain?
The ankle syndesmosis is the joint between the distal (lowest aspect) of your tibia and fibula. It is comprised by three main supporting ligamentous structures – The anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous membrane (see Figure 1). The role of the syndesmosis is to provide stability to the tibia and fibula and resist separation of these two bones during weightbearing tasks. It also plays a role in assisting with mobility of the ankle.
Figure 1: Syndesmosis anatomy
How does it differ to a common ankle sprain?
Generally, a lateral ankle sprain is a result of and inversion injury and will result in an injury to the outside ligaments of your ankle (ATFL, CFL, PTFL). These ligaments are positioned slightly lower than the syndesmosis and provide stability to the true ankle joint.
Figure 2: Inversion sprain mechanism
Mechanisms of injury:
The most common mechanism for injuring your syndesmosis is a forced dorsiflexion combined with an Eversion movement. Essentially the foot/ankle moves in an upward direction and to the outside of the leg (See figure 3).
Figure 3: Syndesmosis Mechanism - Dorsiflexion + Eversion
The syndesmosis can also be injured with a typical inversion or lateral ankle sprain (Figure 2) mechanism. This usually occurs when the incident is of high force and will result with an injury to the lateral ligaments as well.
Signs and symptoms:
· Mechanism of injury consistent with a syndesmosis injury (forced dorsiflexion + Eversion)
· Pain location may extend above the ankle and into the lower shin
· Swelling may sit slightly above the cease line of the ankle joint
· Difficulty weightbearing, particularly when the foot is in dorsiflexion (knee over toe)
· Low confidence/feeling of instability
Gradings:
Grade 1: isolated injury to the AITFL
Grade 2: Injury to the AITFL and interosseous membrane
Grade 3: Injury to the AITFL, interosseous membrane and PITFL
Grade 4: Injury to the AITFL, interosseous membrane, PITFL and deltoid ligament
Immediate management:
As always if you have recently suffered an injury, please seek medical attention from your physio or doctor for accurate diagnosis and management.
If a syndesmosis injury is suspected acute management will initially involve offloading and protecting the tissues. This may be in the form of one or a combination of crutches, a cam walker (moon) boot and strapping.
Your physio or Doctor may also refer you for imaging such as an x-ray or MRI to assist with diagnosis and understanding the severity of the injury.
Following the acute period of offloading and protection a period of rehabilitation will be required to restore normal function of the foot and ankle. In more severe cases surgery may be required to stabilise the syndesmosis and therefore rehab will commence following a period of protection post-surgery.
If you have experienced an ankle sprain yourself, please book in with one of our physiotherapists for an individualised rehabiltation program.
The Rotator Cuff – Team work at its best
The rotator cuff are a group of four muscles which provide stabilisation of the shoulder (glenohumeral) joint during movement. These muscles include the supraspinatus, infraspinatus, teres minor and the subscapularis.
The rotator cuff are a group of four muscles which provide stabilisation of the shoulder (glenohumeral) joint during movement. These muscles include the supraspinatus, infraspinatus, teres minor and the subscapularis.
The supraspinatus is involved in abduction of the arm (raising to the side), infraspinatus and teres minor external rotation of the shoulder and subscapularis internal rotation of the shoulder. Although Individually these muscles act differently, they provide the combined effect in balancing forces which assist with centering the head of the humerus within the socket and providing a compressive and thus stabilising force with co-contraction when using the arm. It assists the static the shoulder ligaments and labrum to provide overall stability to the mobile joint.
The Rotator Cuff Cable and Crescent
The rotator cuff cable is a key feature of the rotator cuff. The rotator cuff cable helps protect the rotator crescent. The rotator crescent represents the insertional fibres in the shoulder of both the supraspinatus and infraspinatus. Tears occur most commonly in the rotator crescent.
This region is protected by the rotator cable, which facilitates a transfer of load if any region of the rotator crescent is damaged, provided the rotator cable remains intact, thus ongoing function of the rotator cuff.
There are many instances where people have had scans of their shoulders, shown rotator cuff tears, but haven’t had traumatic incidents. These findings are quite common in people whom are asymptomatic, but also the protective mechanism of the rotator cable permits the ongoing rotator cuff function in the presence of a tear.
The presence of a rotator cuff tear on a scan is only one element of the patient’s presentation and therefore forms only one part of the assessment findings, which must also match the Physiotherapist’s assessment physical findings before a diagnosis can be delivered.
Costochondritis - A real pain in the chest
There can be many medical reasons for chest, rib and upper back pain including heart and lung conditions, infections and trauma incidences like fractures.
However, once that has been ruled out a diagnosis to be considered is costochondritis.
The condition is classified as inflammation of the costochondral junction of the ribs (where the bone and cartilage meet) or of the costosternal joints (where the ribs connect to the chest bone). The issue is normally unilateral (one sided) but can sometimes be bilateral.
There can be many medical reasons for chest, rib and upper back pain including heart and lung conditions, infections and trauma incidences like fractures.
However, once that has been ruled out a diagnosis to be considered is costochondritis.
What?
The condition is classified as inflammation of the costochondral junction of the ribs (where the bone and cartilage meet) or of the costosternal joints (where the ribs connect to the chest bone). The issue is normally unilateral (one sided) but can sometimes be bilateral.
Signs and symptoms:
- Chest pain that can radiate into the upper chest near the shoulder, down the rib into the area under the armpit and even into the back near your shoulder blade
- Pain can be sharp with certain movements and a dull ache at rest
- Sometimes there is visible swelling over rib joints
- Neck and shoulder range can be affected
- Pain with laughing, coughing, sneezing and deep breathing
Why?
The exact reason for an individual developing inflammation of that particular area is yet to be determined. However, there are a few mechanisms that have been anecdotally found to trigger costochondritis symptoms including:
- Trauma to the area (eg. Direct fall/pressure or injury to the pec muscle)
- Intense exercise of the area
- A bout of illness with lots of coughing
Diagnosis methods
The condition is primarily diagnosed with clinical tests including:
- Palpation of the costochondral and costosternal joints (usually ribs 2-5)
- Assessment of thoracic, cervical and glenohumeral joint range
- Cough/sneeze/laugh test
- Deep breathing test
Scans would only be beneficial if you needed to rule out any of the below alternate diagnoses. Potentially a blood test would be beneficial if a multi joint inflammatory condition is suspected.
Examples of differential diagnosis
- Coronary artery disease (or other heart conditions acute or chronic)
- Pulmonary embolism or pneumothorax
- Rib fractures or subluxations
- Costovertebral sprain
- Tietze syndrome
- Pectoralis muscle injury
- Infections (e.g., pneumonia)
- Xiphoidalgia
Treatment
- A review with a physiotherapist can be helpful to accurately diagnose
- Ice over the joints or heat over the muscles
- Speak to your pharmacist regarding pain relieving medication
- Modification of aggravating activities
- Gentle massage to the neck, shoulder and chest muscles can be helpful in some cases
- Gentle stretches and strengthening exercises once the pain has reduced
If you believe you are suffering from costochondritis then book an appointment to see one of our friendly physiotherapists today!
Dietary Supplementation
The dietary supplement and health food market is massive and is continuing to grow. To gain that extra edge it is not a surprise that athletes of all backgrounds find themselves drawn to additional dietary help to improve their physical output. Unfortunately, most of the supplements on shelves are not what they are made out to be and there is no substitute for good old-fashioned hard work.
The dietary supplement and health food market is massive and is continuing to grow. To gain that extra edge it is not a surprise that athletes of all backgrounds find themselves drawn to additional dietary help to improve their physical output. Unfortunately, most of the supplements on shelves are not what they are made out to be and there is no substitute for good old-fashioned hard work. However, it is not all bad news, there are some foods and supplements that have been backed by science that can play a marginal performance enhancing role in sport and exercise.
Here we will briefly go over some of these health foods and supplements that may have a positive effect on performance directly. There are also many other dietary foods/supplements that claim to have an indirect on performance such as aiding recovery, assisting muscle development or improving immune function which we will not go into detail.
Caffeine:
One of the most commonly used supplements and widely used legal drug (in the form of coffee). There is significant scientific for caffeine as a positive performance enhancement for some athletes in range of different types of activities.
Possible benefits are improved endurance capacity such as exercise time to fatigue and time-trial activities of varying duration (5-150min). This has been shown across activities such as cycling, running, rowing and various team-sports. Improvement in performance measures such as time-trial time have shown to range from 3-7%.
How does it work?
Caffeine is a stimulant which can enhance vigilance and alertness, perception of fatigue and exertion during exercise and improve neuromuscular function. It can also stimulate an endorphin release which can assist in feelings of wellness.
A systematic review by Ganio et al (2009) has shown 3-6mg/kg of body mass consumed 60 min prior to exercise is sufficient to provide positive effects. However lower doses <3mg/kg of body mass has shown to also be effective. To put that in perspective the average cup of coffee has about 100mg of caffeine in it.
Possible side effects:
Larger doses of caffeine have shown not to further increase performance enhancement and in fact increase likelihood of negative side effects.
Possible side effects include; nausea, anxiety, insomnia and restlessness. Caffeine is also a diuretic which can increase urine flow but is small when consumed at the doses that have shown to improve performance.
Sodium Bicarbonate:
Sodium bicarbonate is a commonly occurring substance in most foods. In fact, most households will have this In their kitchen without even knowing as it is commonly known as baking soda.
How does it work?
It helps regulate PH in the blood which commonly increases in acidity during exercise. Sodium bicarbonate is naturally occurring in the body and helps buffer excess acid that accumulates during bouts of high intensity exercise. By keeping muscle PH level closer to its normal it can enhance exercise capacity.
Sodium bicarbonate has shown to enhance performance during short term, high-intensity exercise of approximately 60s in duration of approximately 2%. Improvements reduce as duration of effort exceeds 10 min.
Protocol of use:
According to the evidence various strategies of consumption have been suggested.
1. Single dose of sodium bicarbonate of 0.2-0.4 g/kg of body mass, 60-150 mins prior to exercise
2. Split dosage (i.e multiple smaller doses totalling 0.2-0.4 g/kg) over 60-180 min
3. Serial loading with 3-4 smaller doses per day for 2-4 days consecutive prior to an event
Potential side effects:
It is well established that gastro-intestinal upset can be associated with sodium bicarbonate. Therefore, may not be appropriate for some athletes or ideal consumption strategies may be person dependant.
Creatine:
Creatine is naturally occurring substance in body where it is found in the substance creatine phosphate. Its use as a supplement has grown significantly over recent times. Creatine works by aiding resynthesis rate of the phosphocreatine energy system. In short aiding the use of the energy system in the body that is utilised in short, high-intensity bouts of exercise.
In term creatine has shown to have positive effects particularly in sports that involve repeated high-intensity exercise (eg. Most team sports). it has also shown to assist in increased gains of lean mass and muscle strength and power.
Potential side effects:
No negative health effects are noted with long-term use (up to 4 years) when appropriate consumption use is followed. However, a 1-2 kg of body mass increase has shown to be a possible side effect which is primarily the result of water retention. This is an important consideration as the possible detrimental effect of increase weight gain may outweigh the positive effect of creatine.
Nitrate or Beetroot Juice:
It may seem as an odd one to add in but nitrate which is readily found in beetroot has been shown to have positive performance enhancing benefits. High nitrate rich foods include leafy green and root vegetables, including spinach, rocket, celery and of course beetroot which accounts for one highest sources of nitrate.
How does it work?
Nitrate contributes to the production of nitric oxide in the body. Nitric oxide is a vasodilator which improves blood flow and oxygen delivery to muscles. It therefore can improve the muscle efficiency in utilising oxygen and can improve the performance and energy efficiency of type 2 or fast twitch muscle fibres.
Supplementation of nitrate has been associated with improvements of 4-25 % in time to exhaustion during exercise and 1-3 % in sport specific time trial events lasting less than 40 mins.
Protocol of use:
Nitrate consumption within 2-3 hours of activity as bee associated with improved performance. Prolonged use of nitrate also appears to be beneficial and has been suggested strategy for highly trained athletes where improvements from nitrate supplementation is smaller.
Potential side effects:
There appears to be few side effects or limitations to nitrate supplementation. It is suggested that there is potential of gastro-intestinal upset and therefore suggested to be trialled in trainings before the use in competition. It also appears that performance gains and harder to obtain in highly trained athletes.
Beta-Alanine:
A naturally occurring amino acid, beta-alanine plays a role in the development of a carnosine.
How does it work?
Similar to sodium bicarbonate, carnosine acts as a acidity buffer in the muscle and therefore helps maintain an optimal PH level for muscular performance. It helps resist muscle fatigue and in term potentially assists performance.
Protocol of use:
Beta-alanine is commonly found in meat, poultry and fish and therefore most people can get enough beta-alanine through their regular diet.
Dietary supplementation however can further assist our daily intake. It is suggested a daily consumption of 65mg/kg of body mass taken in 3-4 smaller doses throughout the day.
Potential side effects:
Possible side effects include skin rashes and/or transient paraesthesia (tingling feeling in the skin) when taken with high single doses. This effect is temporary and harmless.
It should also be noted the effectiveness of supplementation appears to be harder to realise in well-trained athletes.
It should go without saying please seek professional medical advice whenever considering whether additional dietary supplementation is right for you.
If must also be noted that inadvertently consuming a known banned/prohibited substance should be risk considered when weighing up the decision to pursue dietary supplementation. Please find some useful links below which can assist in determining whether a specific product is considered banned or has gone through the necessary batch testing to determine if it is safe for consumption under the anti-doping rules.
Useful resources:
https://www.informed-sport.com/
https://www.asada.gov.au/substances/check-your-substances
SPORTS INJURY MANAGEMENT SEMINAR
Whether your sports season is heading into finals or you are about to start gearing up for the summer season ahead, the information presented will help you to perform at your best.
a FREE seminar on sports injury management presented by the Physiotherapists at East Vic Park Physiotherapy. Topics will include muscle contusion (corkie) management, post-game recovery and a practical session on strapping.
Whether your sports season is heading into finals or you are about to start gearing up for the summer season ahead, the information presented will help you to perform at your best.
Appropriate for all athletes, parents, trainers and coaches.
Food will be provided - let us know if you have any dietary requests.
Spaces are limited so call us on 9361 3777 to secure your place now.
