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 TWO: KNEE

Part two of load related adolescent conditions focuses on the knee.

Osgood-Schlatters Disease

 What?

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

How?

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). It can also be related to growth spurts which puts increased tension through the muscles and therefore tendons.

 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)

-       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 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.

Relative Energy Deficiency in Sport (RED-S)

Are you unable to recover between training sessions? Experiencing severe wide-spread muscle ache/DOMS? As a female athlete, has your menstruation ever been affected by your training? These can all be signs of energy deficiencies and overtraining. Our blog explores what energy deficiency is, how to identify it and how to treat it.  

What is RED-S? 

Relative Energy Deficiency in Sport (or RED-S) is due to low energy availability in athletes. This means the fuel going into the body from food is less than the energy burnt during exercise. This energy balance should be at least equal and is additional to the normal calories consumed during the day. When energy input is at a deficit, RED-S can have significant impact on many body systems, affecting both injury risk and performance. 

RED-S used to be known as the ‘female athlete triad,’ terminology which is no longer used as it affects ALL athletes. The most well-known consequences of poor energy availability are bone stress injury and female athletes losing their period. These are both extreme consequences of RED-S, however there are much earlier signs and symptoms which are lesser known. 

Signs and Symptoms 

·      Poor sporting performance 

·      Inability to recovery between sessions

·      Poor wound healing 

·      Regular cold and flu sickness

·      Irregular/cessation of menstruation/periods (see below; ‘The female athlete’)

·      Poor bone health/osteopenia/bone stress response

·      Mood changes 

·      Iron deficiency 

·      Arrythmias (in severe cases)

Why does it matter? 

1.     Adverse effect on performance 

·      Quicker onset of fatigue from less energy available to skeletal muscles

·      Reduction in muscle strength/size due to impaired testosterone production and compromised neuromuscular control  

·      Impaired recovery increasing the risk of overtraining 

2.     Impact on health and wellbeing 

·      Increased the risk of chronic fatigue 

·      Low energy availability decreases the ability to heal from injury. Strains, sprains, cuts and bone injuries will take longer to heal

·      Impaired growth and development from inadequate cell turnover

The good news is most effects of RED-S are reversible if picked up early.

Athletes are often worried increasing food intake can result in weight gain. This is not the case for most athletes. Nutritionists and sports science professionals understand the energy demands of sport and ensure the balance between energy input and output is correct. 

The female athlete

1.     Menstruation 

If an athlete has low energy availability, their body is unable to produce normal levels of hormones. This can affect the menstrual cycle in female athletes. Periods may become irregular, or even cease altogether. Although the female menstrual cycle is variable between individuals, an individual’s cycle should be quite consistent. Irregularity or cessation of periods for longer than 6 months, or not getting a period by 16 years of age should be reviewed by a doctor. 

2.     Contraception 

Female athletes may be advised the oral contraceptive pill can treat symptoms and normalise their menstrual cycle. The combined pill produces a synthetic estrogen the body can not process and therefore does not assist with improving bone health. This can mask hormonal problems, without assisting in bone health. Athletes using contraception that contains estrogen may also be screened for risk factors of RED-S. Athletes using contraception that alters the normal production of a period (e.g. Mirena, Implanon) must also be monitored for RED-S symptoms.

How can physio help?

Physios can help review your training program and lifestyle to assess energy availability. If an athlete is at significant risk of RED-S, a Sports Physician should be involved to identify any hormonal/nutritional deficiencies and directly address them. This is commonly done through a blood test. 

After any nutritional deficits have been addressed, a physio can help modify training loads and aid with recovery techniques.

Who else can help? 

Sports doctor – Vital for initial diagnosis and hormonal/nutritional testing. Depending on severity, medical intervention may be needed (e.g. iron infusion)

Nutritionist – Eat the right food… and enough food, is vital for good energy availability   

Strength and conditioning coach – Clever programming results in efficient training and decreases the risk of overtraining. 

Low Back Pain Myths

There is a lot of information out there on low back pain and injuries. Some of which is very useful but on the other hand there is a lot of misinformation which can sometimes lead us in the wrong direction. In this blog we will look to debunk some of the most common low back pain myths!

Myth # 1 : I Should brace my core or I will get pain

This is a very common thought and is a big reason why people seek help for their low back.  Although we have previously thought bracing can help relieve symptoms it can in fact increase the forces going through the back and in some cases lead to pain. The muscles around the trunk play an import role in movement and stability but trying to actively brace these muscles can often lead to stiffness and inefficient movements. The body is clever, our trunk muscles will naturally contract and work when required to assist in tasks such as lifting.

Myth # 2: My low back pain is cause by my back/pelvis being out

One of the most common myths when it comes to low back pain. The back is extremely strong and robust and without serious trauma or force the back and pelvis does not go ‘out’. Manual therapy techniques such as manipulations and adjustments DO NOT put these structures back in to place but they can however provide pain relief which is helpful in the short term.

Myth # 3: I have a disc bulge and degeneration and that is causing my pain

Disc bulges and degeneration are very common and have a high occurrence rate amongst people who don’t have low back pain. We consider these changes to be age related and are not necessarily linked to pain.  Approximately 30% of people in their 20’s will have a disc bulge in the absence of low back pain and this percentage goes up approximately 10% for every decade in life. Further to that disc bulges and protrusions have shown to recover on imaging over time. So, it is likely that a disc bulge that you may have previously had is no longer there!

Myth # 4 I need to stand and sit in “good” posture, or I will get pain

There is no such thing as good or correct posture! Despite what we have previously thought and what we may have been told as kids. Research has showed us that there is no direct link to how we sit and stand and pain. Instead, it is recommended to find a posture that you are comfortable with. This may differ from person to person but that is okay. Of course, it is always recommended to keep moving, so taking regular breaks to move around may help reduce the occurrence of discomfort from prolonged positions.

Myth # 5 Bending your back when lifting is bad for your back and you should lift with my knees

The spine holds some very important structures, and it would be a big design flaw if the back was not robust and strong to protect them. In fact, it is one of the strongest parts of the body and can handle large forces. When trained correctly the spine can comfortably handle loads in positions of lifting, squatting and twisting. We are often told to avoid bending the back when lifting however this can often create problems such as inefficient movements and fear avoidance.  Like all activities, we need to exposure our body to them for us to get better at it!

 Our physiotherapists at East Vic Park Physiotherapy can help answer all your low back related questions. If you would like more information or help with your low back do not hesitate to get in touch!

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. 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

1.     Maughan R, Burke LM, Dvorak J et al 2018 IOC consensus statement: dietary supplements and the high-performance athlete. British Journal of Sports Medicine; 52 418-419. doi: 10.1136/bjsports-2018-099199

Busting Running Myths

Are you a seasoned runner or just starting out? Training for your first marathon or just enjoy your Sunday jog? Check out these commonly assumed running myths to know what is and isn’t important for improving performance and reducing injury!

Myth #1

‘The wrong shoe type can cause injury’

• There is some largely subjective and unreliable evidence claiming barefoot running reduced injury by 2.6x compared to running in shoes

• More recent research shows runners who change from a ‘bulkier’ shoe to a minimalistic shoe have a huge varied response in how their running style is affected from this change (with no correlation to injury)

• There is a common belief that shoes should be fitted for a person’s foot type (i.e. pronated feet require more arch support). There is actually no evidence that this type of shoe ‘prescription’ affects performance or injury risk 

Myth #2

‘Changing running style or becoming a forefoot runner is more efficient and reduces injury’

• Forefoot strikers place more force through their ankles and calves, while rearfoot (heel) strikers place more force through their knees and hips

• Despite the differing biomechanics, no running style has proved to enhance performance or reduce injury risk

• There are large variations in the running styles of national 10K runners, with zero correlation to injury or finishing position

• The biomechanical changes that occur when transitioning between running styles changes force distribution to certain muscles and joints, in fact INCREASING injury risk due to this shift in load

• Forcing a running style that feels unnatural uses more energy when you run 

Myth #3

‘Running will damage your knees’

• Evidence is continuing to prove recreational runners are less likely to develop knee osteoarthritis (OA) than non-runners. It appears elite athletes who compete at an international level have the same risk of developing knee OA as non-runners.

• Although further evidence is needed for a conclusive answer, a recent study has shown running does not speed the progression of existing OA and may even help to reduce symptoms. 

• There is strong evidence to suggest resistance training reduces the risk of OA, and slows progression of existing OA

Myth #4

‘You will get sore/injured if you don’t stretch’ 

• Static stretching post run has no positive or negative influence on delayed onset muscle soreness, injury risk or running performance. That being said, as there are no detrimental effects and it can psychologically help runners ‘relax’ after a big training, stretching is still warranted if it feels beneficial for you.

• It is well proven that sleep is one of the best forms of recovery. Athletes who sleep for less than 8 hours increase their injury risk by 1.7x compared to those getting 8 hours or more. 

• Re-fuelling your body with appropriate food will provide your cells with adequate nutrients to recover and grow muscle tissue. Low GI carbohydrates gives your body sustainable energy while you run, and High GI carbohydrates and protein are necessary for filling energy stores and muscle growth

• An active warm-up including dynamic stretching (eg walking lunges, leg swings) and easy jogging is commonly used prior to exercise, but has not been proven to have an effect on injury risk.

Myth #5

‘The only thing that will improve running, is more running!’

• The biggest injury predictor for runners is overload (doing too much too quickly). Total running load or volume should increase by no more than 10% per week to give your body time to recover and adapt.

• Twice weekly strength training has been shown to improve performance, improve fitness or running efficiency and reduce injury risk.

• There is no benefit to running performance by training low weight, high rep endurance exercises, nor circuit training.

• Have a look at our ‘Basic Guide to Resistance Training’ blog for an explanation between different types of gym training

What does this all mean? 

• The number one biggest predictor of injury is a significant load increase of more than 10% per week (Running too much too quickly)

• Choose a shoe you are comfortable in – there are more effective strategies to help your running than changing shoes 

• The body is adaptable and resilient, and there is no ‘perfect’ running style

• Well thought out recovery (diet, sleep) is one of the most effective ways of reducing injury 

• Twice weekly strength training will reduce your injury risk and improve your running performance. 

Our physiotherapists at East Vic Park Physiotherapy can answer all your running questions and can help review your running program to get you the best possible results

Injury Prevention: Part ONE – Groin Injuries

Prevention is the best cure - Desiderius Erasmus

Prevention of an injury can be difficult as injury occurrence is usually multi-modal. Extensive research has gone into the development of programs designed to address contributing factors of common injuries. Two common injury sites in sport are; groin and hamstring and both have been the subject of research articles investigating the efficacy of specific exercise intervention on prevention of injury.  

 GROIN

Groin injuries are a common occurrence in change of direction sports like soccer, basketball (e.g Lebron James recent injury) and Australian rules football. With the highest paid player in soccer earning $111 million per year, you can see why prevention of these injuries becomes very important. 

 Haroy et al (2017) looked at the inclusion of the Copenhagen exercise in the FIFA 11+ program (used as a warm up for soccer players) on improving hip adduction strength. 

The Copenhagen Adductor (CA) exercise is a partner exercise where the player lies on the side with one forearm as support on the floor and the other arm placed along the body. The upper leg is held at approximately hip height of the partner, who holds the leg with one arm supporting the ankle and the other supporting the knee (position A in figure 1). The player then raises the body from the field and the lower leg is adducted so that the feet touch each other and the body is in a straight line (position B in figure 1). The body is then lowered halfway to the ground while the foot of the lower leg is lowered so that it just touches the floor without using it for support. It is performed on both sides. 

Figure 1 The Copenhagen Adduction exercise. A start/end-position. B mid-position. 

The article found that the CA exercise delivered in the below protocol (figure 2) resulted in an increase in hip adduction strength and as this is a risk factor for groin injuries, should be included in the FIFA 11+ to try to reduce the incidences of these injuries. 

 Figure 2 The prescription parameters for the CA exercise.

The CA is a fairly safe and easy exercise to self- integrate into the pre-existing FIFA 11+ protocol. However, even with the diligent performance of the protocol, groin injuries can still occur. It is always best to be assessed by a physiotherapist to ascertain a correct diagnosis so you can receive the best treatment possible for your specific condition. Here at East Vic Park Physiotherapy, our physiotherapists are very experienced in assessing and treating groin pain. Additionally, if you would like to know more about the CA exercise or the FIFA 11+ program then click the link at the top of the webpage to book an appointment or call us on 9361 3777. Below is a quick link to review:

https://www.fifamedicinediploma.com/lessons/prevention-fifa-11/