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.

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.

Common Adolescent Conditions – Part One: Ankle

This topic seems somewhat timely given these particular injuries are normally load related.

As discussed in my previous blog about Load Management, the last 6 months have played havoc with people’s Acute Chronic Workload Ratio and children/adolescents are no exception. 

The conditions I will be discussing are usually related to a big spike in activity which has been the case this year with most sporting organisations eager to recommence their seasons. These spikes will be somewhat amplified in young athletes who participate in multiple sports or who are already specialising in their chosen sport which can mean numerous training sessions/games per week.

 Sever’s Disease

 What?

An irritation of the insertion of the Achilles into the calcaneus. This differs from adult Achilles tendinopathy due to the immaturity of the adolescent skeleton which means it affects the actively remodelling trabecular metaphyseal bone.

How?

As mentioned previously, it is usually due to the area’s inability to deal with an increase in activity (particularly activity that uses that area eg running or jumping sports).

 When?

More common in boys and usually between the ages of 10-15 compared with girls which is usually between the ages of 8-13.

How does it resolve?

Usually self resolves with time (6-24 months) however the reason it’s best to seek treatment/advice is due to the pain that accompanies the condition which can affect sports performance and most importantly day to day activities. 

What is the treatment?

The main focus of treatment is to reduce pain levels. This can be done in a few different ways including:

-       Manual therapy (eg muscle massage)

-       Heel raises for footwear to offload the tendon

-       Taping to offload the tendon

-       Exercises to strengthen key areas 

-       Implementation of load management strategies (eg RPE scale)

-       Advice regarding recovery (eg icing)

The main takeaways about the condition are:

-       The adolescent will grow out of it

-       It can still be quite painful however so there should be a focus on pain relief

-       Load management with guidance from a physiotherapist can allow the continued participation in sport without compromising day to day function 

If you would like your injury reviewed by one of our physiotherapists, then don’t hesitate to book an appointment. All of our physiotherapists specialise in sport and have had extensive experience with adolescent athletes.

Achilles Tendinopathy - What you need to know

What is a tendinopathy?

Tendinopathy simply means that the tendon has failed to adapt to loading, doing “too much, too soon”. 

Whether you have increased your load by volume, intensity or frequency… this amount was greater than the tendons capacity to cope and recover.

Load > Capacity

How did I get an Achilles Tendinopathy?

 You may be more prone to a tendinopathy if you are a…

o   Running / jumping / landing athlete i.e. distance running, basketball, AFL and netball.

o   Weekend warrior who over exercises on weekends and under trains during the week.

o   Older person with a history of poorly rehabilitated and/or grumbly tendon.

Where does it hurt?

Do you pinch your heel and feel your pain? 

People tend to have a very specific site that is the source of their symptoms and can put their finger right on it.

Do I need a scan of my Achilles?

No.

In 90% of cases this should be easily diagnosed by your physiotherapist or sports physician. If you aren’t getting results with your treatment and rehab then you may be referred for a scan.

What should I avoid doing?

-       Don’t rest

Staying off it completely will only increase the time it takes to rehabilitate the tendon.

-       Don’t stretch/massage the tendon

Stretching and massaging the tendon won’t get it stronger. Muscle massage however, is ok. Stretch may feel good temporarily, however can make the tendon more irritable.

-       Don’t train through high levels of pain

Low or mild discomfort can be ok during activity, but if you are still sore 24-72 hours later then you have done too much, too quickly.

 I’ve been having physio and not getting better, what should I do?

Ask yourself;

-       ‘Do I have the correct loading amount in my work out?’

… not too much or too little.

-       ‘Am I sticking to the program?’

… over committing/loading or too many days between rehab sessions won’t help the tendon to strengthen and repair.

 If you’re doing all these things right then discuss with your health practitioner where to go to next.

What’s the best treatment for Achilles Tendinopathy?

Best practice for tendon health is a combination of…

-       Regular progressive loading, and

-       Pain monitoring

-       A short period of staying off the grumpy tendon may also be necessary.

-       Your GP or health professional will be able to advise regarding anti-inflammatory use. 

Speak to your physiotherapist who will assess and prescribe the optimum amount and intensity of exercises for you.

Author: Peter Gangemi - Master of Physiotherapy

PREHAB: TAKING CONTROL OF YOUR RECOVERY

Optimising recovery from surgery:

Regardless of what it’s for, surgery can be scary and overwhelming. It is normal to feel a sense of helplessness or feeling as if you don’t have control over the end outcome. However, it is important to understand that you play the single most important role in the outcome of your recovery and it starts long before you meet with your surgeon. Preparing your body and mind for what you are about to encounter is an important aspect of recovery and creates good habits for your post-surgery rehabilitation.

How do you do this, you ask?

We call this Prehab

Prehab is a programme designed to prevent injuries before they actually occur. This can be applied to anyone or any injury however in the context of surgery it is you taking an active approach to prepare yourself physically and mentally for what you are about to go through. It plays a massive part in giving you the power to control the success of your upcoming surgery.

Why should you do Prehab?

Numerous studies have shown that patients who participate in Prehab have significantly better outcomes than those who do not. Those who undergo prehab generally have quicker recovery times, return to sport faster, have less complications and are generally more satisfied with their end outcome.

Does this apply to me?

Prehab is highly recommended for anyone planning to undertake or has been referred for surgery. Research has shown Prehab to be effective in enhancing recovery for patients undergoing total hip and knee replacements, ACL reconstructions, shoulder surgery such as rotator cuff repairs and lower back surgery.

What does it involve and how long for?

Ideally, undergoing 6-12 weeks of Prehab prior to surgery will optimise post-surgical outcomes. In most situations this is not possible due to availability with your surgeon. This does not mean that Prehab won’t help be helpful for you. As they say, something is better than nothing and there are still many meaningful benefits to be gained with only 2 weeks of preparation.

5 reasons to Prehab:

1.     Get control of your pain:

 A prehab program should give you the tools to minimise pain. Reducing pain early will enable normal muscle activity and put you in a good head space leading up to surgery.

2.     Get in optimal physical shape:

Through a specific exercise program, you can improve muscle strength, flexibility, balance and coordination which has shown to optimise and speed up the recovery process post-surgery. Additionally, improving general fitness and wellbeing has many added benefits such as weight loss and improving mental resilience which is extremely important to recovery.

3.     Create good habits and kick the bad habits

Firstly, creating good habits beforehand will make your life so much easier once you have been discharged from hospital. Good habits start with getting in a healthy exercise regime This extends to healthy sleep, nutrition and lifestyle habits which your physiotherapist and health practitioners can guide you on.

Conversely, bad habits will have the opposite effect, so you can imagine the importance in changing these prior to surgery.

4.     Manage anxiety/stress

It is completely normal to feel anxious or stressed prior to surgery. In addition to physically preparing yourself you must also get yourself in the right headspace. Prehab will help mentally prepare you by getting you in a good mindset for the upcoming rehabilitation process. It will also teach you appropriate coping strategies to deal with pain and stress associated with the injury.

5.     Speed up your recovery and reduce post-operative complications

Prehab sets you up for a successful recovery leading to quicker recovery and return to sport times. It also reduces the risk of common complications associated with surgery.

Please feel free to contact our team at East Vic Park Physio on 9361 3777 if you have any questions or would like to find out if Prehab is appropriate for you.

THE IMPORTANCE OF MUSCULOSKELETAL SCREENING

Finals time for most winter sports is fast approaching and from a physiotherapy perspective this is the time of year that we see a spike in sporting injuries. A lot of these injuries tend to be to parts of the body that have some sort of deficit, be it strength, length or control. It is quite hard to be able to identify these areas yourself and even physiotherapists would find it hard to accurate identify these deficits purely through observation.

This is why screening is so widely utilised for athletes from amateur to elite. Screening usually involves a battery of tests that give objective measurements that are then compared to the normal values for an athlete in a specific sport. Screening can also involve questionnaires that focus on general health and previous injury history.

An article by Sanders, Blackburn and Boucher (2013), looked at the use of pre-participation physicals (PPE) for athletic participation. They found PPE’s to be useful, comprehensive and cost effective. They explained that PPE’s can be modified to meet the major objectives of identification of athletes at risk.

An article by Maffey and Emery (2006) looked at the ability of pre-participation examinations to contribute to identifying risk factors for injury. They found limited evidence for examinations in terms of the ability to reduce injury rates among athletes. However, they were effective in the identification of previous injury (such as ankle sprains) and providing appropriate prevention strategies (such as balance training). From this it has been shown to reduce the risk of recurrent injury. It may also be useful in identifying known risk factors which can be addressed by specific injury prevention interventions.

An example of a screening measure that is typically used in screening protocols includes a knee to wall test (KTW). This test is used for ankle dorsiflexion as well as soleus muscle length (one of your calf muscles). The test is performed using a ruler which is placed perpendicular to a wall with no skirting board. The athlete puts their foot flat on the ground next to the ruler and as far from the wall as possible as long as their knee is touching the wall. Distance from the wall to the end of the big toe is noted by looking at the ruler. An example of a normal distance for netball players is greater than 15cm on each side.

Here at East Vic Park Physiotherapy we have developed a number of specific musculoskeletal screens for a variety of sports including netball, running, swimming and throwing sports. They comprehensively identify the key risk factors that are seen in injuries sustained in each sport. If you are interested in preventing injury for the upcoming sports season, then contact the clinic on 9361 3777 and book your screening appointment today!

Plantar fasciitis

WHAT IS IT?

Plantar fasciitis Is a very common cause of heel pain. It can be quite debilitating and can last for months if not addressed. Typically, pain will be felt on the inside of the heel and arch. Pain can be sharp or achy. There can be a small amount of swelling over the medial heel as well as tenderness to touch. Mornings are worse, with it usually taking anywhere from 2-3 minutes to an hour for the stiffness and pain to reduce.

POSSIBLE CAUSES

·         Change in load eg Running/jumping

·         Change in footwear

·         Change in activity surface eg. Hard surface

·         Acute trauma eg. Stepping on a rock

 SCANS

Sometimes your GP will refer you for a scan of the affected area. Most likely it will be an x-ray or an ultrasound. This may show that there are heel spurs or “tears” in the plantar fascia. Although it can be good to confirm the diagnosis, scans can sometimes be detrimental as it may cause people to become worried about their condition. Scan results can also correlate poorly with symptoms an example being that people with heel spurs on x-ray don’t necessarily develop Plantar fasciitis.

TREATMENT OPTIONS

·         Soft tissue release

·         Joint mobilisations

·         Taping techniques

·         Orthotics

·         Exercise program (Physiotherapist prescribed)

·         Load management plan (Physiotherapist prescribed)

LOAD MANAGEMENT

Load management is about controlling how much you use the particularly area on a day to day basis. Usually when an area becomes painful, its load capacity (ability to tolerate load) is reduced so it becomes overloaded quicker than normal. This means that even normal tasks or activities like walking or standing can cause it to become more painful and swollen. 

One of the ways to improve the capacity is to progressively build up the amount that you use that area. This can be done with a specific structured exercise program (physiotherapist prescribed) that is made more difficult over a period of time. It is normal for rehabilitation to be painful, you cannot improve load tolerance without causing some discomfort.

The best way to monitor improvement is by recording morning pain (rating it out of 10, 10 is worst, 0 is nothing). It is normal to have ongoing morning stiffness even after pain has completely disappeared.

DIFFERENTIAL DIAGNOSIS

Sometimes Plantar fasciitis might not be the cause of heel or foot pain. It is important to see a physiotherapist to get an accurate diagnosis. Other causes of heel pain are below:

·         Plantar or Calcaneal Nerve pain

·         S1 radiculopathy

·         Stress fracture

·         Tarsal tunnel syndrome

·         Fractures

·         Retrocalcaneal bursitis

·         Spondyloarthropathies

·         Cancer (osteoid osteoma)

TIPS FOR PAIN FLARE UPS

·         Try to avoid walking around in bare feet

·         Using ice over the sore area can give temporary relief

·         Stretching it may be uncomfortable so roll a golf ball/tennis ball under the foot instead to release tight muscles

·         Pain relief or anti-inflammatory medication can be helpful but ask your pharmacist for advice

·         See your physiotherapist for a progressive loading program

UNDERSTANDING PAIN

An excellent video on what our understanding of pain currently is and in particular the complexities of chronic pain.