Ankle Sprains - Ligaments And More

An ankle sprain refers to the tearing of the ligaments of the ankle and account for approximately 40% of all athletic injuries. 85% of ankle sprains occur on the outside (lateral side) of the ankle and are known as an inversion sprain. This is the type of injury that most runners experience when they sprain their ankles. Medial ankle sprains (along the inside of the ankle) occur less frequently and are usually caused by fractures or other traumatic events.

So, why is an inversion sprain so common? You can put it down to our lopsided anatomy! The bone on the lower outside of the ankle (the lateral malleolus - distal fibula) extends further down than the bone on the inside of the ankle (medial malleolus – fibula). This difference gives the inside of the ankle (medial side) more stability than the outside of the ankle (lateral side).

At a symptomatic level, most ankle sprains appear to resolve completely without rehabilitation. In reality, ankle sprains that have not been rehabilitated correctly are usually susceptible to further injury.

Anatomy of an Ankle Sprain

The outside (lateral side) of the ankle achieves its stability from a three-ligament complex. These three ligaments are the:

• Anterior Talofibular ligament (ATFL)

• Calcaneofibular ligament (CFL)

• Posterior Talofibular ligament (PTFL)

In an inversion sprain, the Anterior Talofibular ligament (ATFL) is the most commonly injured. Ligaments in the ankle are named according to the bones to which they connect. In this case, the Anterior Talofibular ligament connects to the talus bone of the ankle as well as to a long bone of the lower leg - the fibula. The function of the ATFL is to prevent forward (anterior) displacement of the ankle (the talus).

In a severe ankle sprain another ligament called the calcaneofibular ligament (CFL) may also be damaged. This ligament connects your heel bone (calcaneous) with the fibula. This is a stronger ligament than the ATFL, and is not damaged as easily.

Both the ATFL and the CFL are usually damaged in motions where the foot is both pointed down (plantar flexed) and rolled out (inverted). Considerable instability in the ankle can occur when both these ligaments are injured.

The posterior talofibular ligament (PTFL) is not injured very often, except when there is a complete dislocation of the ankle (talus). The PTFL is the strongest ligament in the lateral complex.

Another sprain injury that is becoming more prevalent is called a “High Ankle Sprain” (syndesmotic ligament complex). In this injury, the ligament and connective tissue between your shin bones (tibia and fibula) are torn. This is a serious injury that may require surgery to resolve.

Not Just Ligaments

An ankle sprain may also result in damage to other structures. You may also experience damage to connective tissue, tendons, muscles further up the ankle, and even to the bones (possible fractures). This is why, with a severe ankle sprain, it is important to see a medical professional who can determine exactly which structures have been injured, and then provide treatment recommendations.

Treatment of Ankle Sprain

There are a number of things you can do to treat ankle injuries.

Just After The Injury

Immediately after spraining your ankle, it is important to do everything you can to reduce the swelling in the ankle. The faster you can implement treatment, the faster you will recover. An ankle sprain injury that is addressed quickly will often resolve in short period of time. If the injury is ignored, the ankle sprain could be prolonged for extensive periods of time.

So, immediately after the injury, while still in the acute stage - use RICE - rest, ice, compress, and elevate!

• R = Rest: During this stage, it may be necessary to take all weight off of the injured ankle. In such cases, crutches are commonly used. In my opinion, it is important to quickly return to weight-bearing as soon as possible to improve healing. I have found that reintroduction of weight-bearing stresses tends to decrease recovery time. When should you do this? As soon as possible, but not too soon! Rest is also essential.

• I = ICE : See our Blog about icing. Ice for at least 20 to 30, minutes 4 to 5 times per day to reduce swelling.

• C = Compression: Compression (with an ACE wrap) reduces both swelling and bleeding. With a Grade 3 sprain, wear a brace at all times until you are able to bear weight on your ankle.

• E = Elevation: Elevating the injured area acts to reduce swelling and bleeding.

Once you have used “RICE”, it is very important to introduce motion into the ankle as soon as possible. Depending on the degree of injury, the patient could be asked to perform gentle ankle circles, or if able to do so, write the alphabet with their feet. Light calf stretching and using a stationary bicycle may also be beneficial.

If you are going to use medication (NASID’s) to reduce inflammation, be sure not to use them for more than seven days. Using anti-inflammatory medications for long periods of time inhibits tissue remodeling. See our Blog about Recommendations to Reduce Inflammation without Medication.

Manual Therapy for an Ankle Sprain

Manual therapy can make a huge difference in the recovery and prevention of an ankle sprain. By manual therapy, I am referring to techniques such as Active Release, Graston Technique, Massage Therapy, Fascial Manipulation, Manual Manipulation, and other manual procedures. In my opinion, these procedures are essential in the rehabilitation of an ankle sprain since they all act to break down and prevent scar tissue formation.

Manual therapy also speeds healing by increasing blood supply, oxygen, essential nutrients, and displace waste products that accumulate after an injury. This is especially important in treating ligaments because they generally have a very poor blood supply to begin with.

It is Important to Treat More Than Just the Ligaments

Earlier, I mentioned that there might be damage to several types of structures after an ankle sprain, especially the connective tissue, tendons, muscles, and nerves. The following is list of structures that are often injured in a lateral ankle sprain (inversion sprain).

Ligaments

• Anterior talofibular ligament (ATFL) – Most common injured structure.

• Calcaneofibular ligament (CFL) – Second most commonly injured structure.

• Posterior talofibular ligament (PTFL)

Tendons

• Peroneal tendon

o With an inversion sprain, it is common for the tendons of the peroneal muscles to be injured. It also common for the peroneal tendon to move out of its normal position (subluxate) during the recovery stage of an ankle sprain.

Muscles

• Peroneus brevis muscle – Longitudinal tears of the peroneus brevis are commonly associated with lateral ankle sprains.

• Peroneus longus muscle – These muscles often show a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a person more susceptible to future injuries.

Both muscles, evert the foot at the tarsal joint, and plantarflex the foot at the ankle.

Retinaculum

• Peroneal retinaculum -

o During a lateral ankle sprain, the foot rolls inwards with considerable force. This forceful action can tear the peroneal retinaculum. This retinaculum is a band of connective tissue that keeps the peroneal tendons in place. When a tear in the retinaculum occurs, patients will notice a snapping sensation in the lateral ankle. Conservative treatment is 4 to 6 weeks in a short leg cast. However, a severe tear of the retinaculum is not a candidate for standard manual therapy and may require corrective surgery.

Nerves

• Superficial peroneal nerve - This nerve is at risk for traction injury during a lateral ankle sprain (inversion sprain).

If you would like to more information or to purchase our books please go towww.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Iliotibial Band Syndrome (ITBS) - Part 4

Treatment of Iliotibial Band Syndrome

The first thing practitioners must do in treating Iliotibial Band Syndrome (ITBS) is to perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns. This will give them an initial hypothesis as to which structures are involved. Refer to Parts 2 and 3 of this Blog to see what muscles are involved in what actions.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area to be treated has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions (Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation).

Fascia and ITB Syndrome

When we evaluate a case of ITBS, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle, knee, and hip motion.

In the case of ITBS, some of the fascial connections we should consider are in the Lateral Line (see Anatomy Trains by Thomas Meyers).

The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.

Lateral Line

· Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae).

· The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.

· The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, and scalenes).

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating ITBS with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic ITBS problem if you do not consider, and treat, the fascial interconnections.

The key is to any therapy is to address all the structures involved in the kinetic chain.

Treatments need to be specific and based upon the individual requirements of each person. Treatment should not be a cookbook approach. Practitioners need to find the specific tissues that are restricted and physically work them back to their normal consistency.

Exercise is Essential

Often getting professional help in the way of manual therapy is essential to get a complete resolution of ITBS, but just as important is exercise. Without the right exercise program the probability of this condition returning is very high.

There are three important areas which must be addressed when prescribing exercise routines for ITBS, strength, flexibility, and balance.

Why strengthening exercises are essential:

Every time you injure yourself, your body lays down new tissue to repair itself. The new tissue is initially very fragile, thin, and easily torn or re-injured. Strength or weight training places stress upon these new tissues, causing them to go through a process of remodeling. In this process, the new tissue literally converts from one type of collagen to a different type which is up to 10 times thicker and 10 times stronger. However, this collagen conversion only occurs when you apply continued stress upon the tissue as you do in weight- and strength–training exercises.

Exercise example: Because the iliotibial band is formed from the deltoid complex, having strong balanced hips is essential for a full resolution of ITBS. One of my favorite exercises to increase hip strength is the Bulgarian Split Squat.

Why Flexibility exercises are essential:

During the regenerative or repair phase of an injury, your body creates and lays down collagen to repair the injured area. When the injured person performs the correct stretching exercises, the majority of new tissue will be laid down in the same direction as the tissue that is being repaired - thereby allowing this tissue to properly perform its function.

Exercise example: We suggest that patients combine stretching with self myofascial release (foam rollers). The following is an example of an ITB stretch, and a foam roller video you will find very useful.

Why balance exercises are essential:

Proprioceptive or balance training is a fundamental requirement that should not be ignored in Rehabilitation Therapy. Your ability to balance depends on feedback from your auditory, visual, proprioceptive (sense of body position), and vestibular systems (relating to the sense of equilibrium). All of these systems must be trained to achieve optimal results. As with all injuries your nervous system is often affected. Training these systems, ensures a greater chance of a complete recovery.

Exercise example: The follow exercise is an example of the type of exercises that we prescribe to our patients. This is the Squat - Single leg balance exercise from Core Performance.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Lateral Foot Pain - Cuboid Syndrome – Part Two

Symptoms

Patients who have cuboid syndrome often complain of lateral foot pain, or weakness in their feet. Pain from cuboid syndrome can also radiate to the front of the ankle. This pain is often more noticeable during time of exertion (toe-off portion of the gait cycle), or on impact.

The type of pain found in cuboid syndrome may not be a very good indication of this condition.Pain can be intermittent, or persistent, it can also develop suddenly or slowly over a period of time.

Diagnosis and Imaging

Upon physical examination, the patient may have pain directly over the cuboid bone (especially when pressure is applied dorsally on the plantar surface). In some cases there may be bruising, redness and swelling. Range of motion in the ankle is often limited in cuboid syndrome (dorsi and plantar flexion).

X-rays, CT scans or MRIs are of little value in the diagnosis of cuboid syndrome. The only reason an X-ray is of value in the diagnosis of this syndrome is to rule out fractures or some type of pathological condition.

Treatment

Several forms of manual therapy can be used in treating this condition. The sooner that treatment is implemented the faster the results will be.

• Manipulation: One of the most successful treatments we have found is manual manipulation. A therapist training in extremity manipulation (chiropractor, physiotherapist, podiatrist) can often reduce the pain of cuboid syndrome in a short period of time.

• Soft tissue techniques: Techniques such as Active Release, Graston, Massage Therapy, and Fascial Manipulation can also be of great help. The key is to work with all of the structures involved in the kinetic chain, not only at the site of pain.
• For example we know that the peroneus longus muscle is involved in plantar flexion of ankle, and that this greatly affects cuboid stability. A problem with the peroneus longus could create an alteration in the normal plantar flexion movement. Even though the peroneus longus is most likely involved in this injury, we cannot take it for granted that this is the only plantar flexor affected. Treatment of all plantar flexors and their antagonist muscles, the dorsi flexors, is often needed for a full resolution.
• Plantar flexors: Calf muscles (Gastrocnemius & Soleus), Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus, Peroneus Longus, Peroneus Brevis, and Plantaris.
• Dorsi flexors: Tibialis Anterior, Extensor Digitorum Longus, Extensor Hallucis Longus.
• Exercise: Exercises should focus on stretching the peroneus longus and the calf muscles.These stretches are combined with strengthening the extrinsic muscles of the foot. In addition, it is essential to perform balance exercises so that the injury does not reoccur.Please go to www.releaseyourbody.com for a specific exercise needed to rehabilitate this injury.
• Orthotics: Custom fit orthotics will help to correct abnormal pronation and supination that may be leading to cuboid syndrome.

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77:638-642.

Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am J Sports Med.1992;20:169-175.

Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment and treatment. J Orthop Sports Phys Ther. 1994;20:220-226.

Newell SG, Woodle A. Cuboid syndrome. Phys Sports Med. 1981;9:71-76.

Lateral Foot Pain - Cuboid Syndrome - Part 1

Lateral Foot Pain - Cuboid Syndrome – Part One

Cuboid syndrome is a condition that causes lateral foot pain. In forty percent of cases Cuboid syndrome is associated with lateral ankle sprains (inversion sprain). This syndrome affects the joint (capsule), ligaments, and tendons (peroneus longus tendon).

This syndrome is defined as a “minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint”. In laymen’s terms, the cuboid bone has moved from its normal position in the joint.

It is a common syndrome, but not well-recognized by practitioners. Cuboid syndrome also goes by several other names: subluxated cuboid, dropped cuboid, cuboid fault syndrome, and lateral plantar neuritis.

Anatomy/Biomechanics

The calcaneocuboid joint is a vital link in lateral foot stability. This joint is susceptible to sudden injury or chronic strain, which can cause this joint to partially dislocate or subluxate.

The cuboid bone is one of the seven tarsal bones of the foot.

• Joint Anatomy: The cuboid articulates with the fourth and fifth metatarsals forming a joint (tarsometatarsal joint). It also articulates with the heel bone (calcaneus), forming a joint (calcaneocuboid joint). On the inside (medially) the cuboid articulates with two bones (lateral cuneiform and the navicular). An alteration of the cuboid can have a considerable effect on the joint biomechanics of the foot.

If we were to view the bottom of the cuboid bone we would see a groove where the tendon of the peroneus longus muscle runs along it.

• Peroneus Anatomy: The peroneus longus muscle originates on the lateral lower leg (upper one-third of the fibula). It then runs down around the outside of the ankle (lateral malleolus) then through the grove on the bottom of the cuboid. It then inserts into the base of the first metatarsal (and cuneiform).

The peroneus longus acts as a stabilizer of the forefoot. The cuboid bone acts as a pulley which increases mechanical advantage for the peroneus longus muscle.

Causes

A single impact injury or repetitive motion can cause this syndrome to occur. Runners and dancers (especially ballet dancers) are susceptible to this injury because of the high levels of repetitive impact. In addition basketball players or racquet sport players also are susceptible due to the lateral motions required to play these sports.

If a person abnormally pronates their foot during the push off phase of gait, they will be more susceptible to a cuboid injury. Excessive pronation causes an increase in force transferred to the cuboid bone which causes instability and a resultant injury.

In part two of Cuboid Syndrome we will cover, symptoms, examination, diagnosis, and treatment.

Lateral foot pain part two...

If you would like more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)