Ankle distorsion part IV; When can players participate in games/matches again?

A very knowledgeable physiotherapist named Richard Dahan lectures widely on the topic of return to practice and games. His vast experience and knowledge has created what he calls The Rehab Staircase. The last step of The Rehab staircase is a whole weeks participation in regular training, and only after this step the athlete is approved for game playing.

This is an excellent rule; for the speed, intensity and the increased mental and physical stress affects the players. To be able to perform well, the player must be able to trust his/her body to actually play; this also reduces the risk of injury if we know the player can perform fully without being hindered by the foot.

Should this rule apply in all cases? And to all ages?

This can be discussed till the end of time. What do we need to take into consideration?

Age? Obviously. A youth player who isn’t finished growing and still can’t control the body from the start, should definitely not enter the playing field.  Still, a lot of players feel the pressure to participate even thought the foot is hurting, maybe due to this player being an important player, or the star of the team.

Level? Is it the playoffs for a senior team where the player has 20 years of experience and a sports career - then maybe it's not that bad. The player knows his/her body, and can adapt the movements to a foot that doesn’t feel completely well yet. They are, after all, paid for this job. But what if it ultimately leads to osteoarthritis of the ankle? Is it still OK to expect them to play?

As you can imagine, it is not easy to make decisions or generalize, it must be decided individually.

So, what could happen then?

If the ankle isn’t ready to be loaded, even if it’s minimally damaged, the healing will be affected. The swelling never goes down properly and the foot remains stiff and with reduced mobility compared to the other foot for a very long time. Does that matter if you can still play sports, walk, and so on? Yes, it does, because stiffness = less spring in the joint = other structures such as the Achilles tendon becomes more loaded, as all movements are shortened. Other joints are affected as well, the knee for example experiences greater load - so also the tendons around it.

The player is also exposed to danger; doing sports with an unsteady foot can lead to falling or movements that weren’t planned. This can cause damage to other joints. What if that ankle injury that wasn’t allowed to recover will lead to ankle osteoarthritis at age of 40? (You can’t replace the ankle joint as easy as the knee or hip joint.) Another scenario is that after a few years not being able to run or jump any longer due to a painful ankle which no one can find a reason to?

Sad scenario ... And still; this is "just" an ankle sprain.

All of you who work in the club teams, national teams, and so on - you have no easy job ...

Ankle distorsions part III; How to rehabilitate the foot? And when can the athlete return to sports?

The rehabilitation will take the time it needs. The injury will determine the time needed to regain normal function. If it’s a very small injury, active rest a couple of days can be enough. During this time the ankle should of course be trained, but also swimming, bicycling and strength training of the rest of the body should be performed – to keep the physical level. A more severe injury can take up to several weeks, and if really bad; several months, in case or surgery for example.

The goal is to regain full mobility and then gradually increase the load and resistance. That is, beginning with very easy movements without weight or load (just actively pumping the foot up and down, and working side-side), then adding gait training (walking forward, backward, rolling of the foot etc). Start with balance training as soon as the you can put your full weight on 1 leg, and start easy by just standing on the floor and move on to more challenging exercises when possible.

To increase strength you need resistance training of the foot; this is done for example by training the foot in different directions with a rubber band, and with heel raises for example. And then move on adding agility training, jumping, and so on. The amount of swelling determines which level or phase you start your rehabilitation.

When can players participate in regular training again?
In the perfect world of sports, there should of course be no swelling or pain in the foot and ankle during everyday life, with the same range of motion in both ankles, i.e. normal mobility. But for sports medicin professionals - functional testing must be performed! Namely; running forward and backward, running sideways, running in an 8-figure, jumps and landings - even landing on one foot in balance - and performing hard decelerations... The player must pass the functional tests without pain and cheating - i.e. trying to relieve the injured side. 
Although the foot isn't completely healed, for it can take a very long time for tendons and ligaments to heal, the foot is still functionally stable (normalised balance and near-muscular coordination). Put on an ankle orthotics and get back to regular training.
To avoid re-inury, studies have shown that the athlete still needs to continue with rehabilitation a few weeks (ankle strength, balance and so on). This is due to the muscles and nerves that take time to learn and maintain proper cooperation again after an injury.

Repeated injuries can lead to unnecessary complications in the future, which can be difficult to get rid of. Make sure to use a proper ankle orthotics that allows enough mobility in flexion and extension for running and jumping, but keeps the ankle stabile side-ways. You really shouldn't slack with that!

When can players participate in matches/games again? That's the fourth and last topic in the ankle distorsion series.

Ankle distorsions part II; How to know the severity of the ankle injury?

Start with finding out if the player can take a number of steps after the injury. If the answer is yes, no need for an X-ray directly. However, the foot must be wrapped tightly directly – compression is the most important treatment in the acute stage – and then wrapped medium to hard after 20 minutes. The foot may not be unwrapped the first 48 hours at all. If a sports medicine knowledgeable physical therapist / chiropractor / doctor is on site; he or she should also palpate the foot and check the areas that are common for fractures to exclude that possibility.

After 4-7 days you can test the foot for anatomical stability - ie testing the ligaments. You can check the skin for bleeding earlier – that provides you information on whether the injured ligaments and joint capsule could be ruptured. Unfortunately, examination of anatomical stability before these 4-7 days does not give reliable results.

If reduced mobility and joint-play is found, that would make me suspect the possibility of swelling in the joint, which, if the athlete is unlucky, could depend on a blow to the cartilage inside the ankle joint. Increased pressure on the joint will of course aggravate the pain and prolong the healing, and the ability to start running and jumping will take much longer. In this case, the foot should be X-rayed to rule out small bone chips loose in the area (but not acute - better if a few days pass, as the damage is usually more visible on x-ray).

How should the foot be rehabilitated? And how long is the rehabilitation? When can the athlete return to normal training and play games again? Information and discussion on this topic in the coming posts!

Ankle distorsions part I; what exactly is an ankle distorsion?

A Swedish doctor named Per Renström, with a specialty in the subject of ankle injuries, lectured on the topic in the Sports Medicine course I most recently participated in. He was up to date on the latest research in the area; there is some research, but mainly on the general population. Some information about this;

• Ankle sprains is still one of the most common injuries athletes encounter - does not matter if you are into recreational sports or an elite athlete.
• Functional training of the ankle is a successful rehabilitation. But studies have shown that about 20% have residual problems after rehabilitation.
• In addition to these 20%, many people do not take care of their ankle sprains, or do not go through the whole rehabilitation.

A common sight of a quite severe
injury that wasn't taken care of
immediately.

I will focus on the more common kind of the distortion – the lateral distortion (outside of the ankle).

However, an ankle sprain is not so bad...!? Must I rehabilitate it? You just jump in and continue to play / train, right...? Well, not always, depends on how much has been damaged - and if the player still has the good function of the foot. I’ll return to the subject of good function later. There is a risk of greater damage, and the damage which already occurred could worsen - and when the swelling is allowed to expand, the healing time is much longer. (If you haven’t read the post, "Take care of your acute injuries!", I advise you to do so).

An ankle sprain is simply a dislocation, where the person often steps down with the whole weight on one foot that is entirely on the side. The trauma this causes depends on the force directed downward and how long it lasts. One can step a little crooked, but get the foot back to the normal position quickly - not such a big trauma, but if you land on the foot when it is in the wrong position - major trauma.

The damage occurs then on several tissues;

1. There are two exterior ligaments that can be damaged, if the trauma is great, often both ligaments are damaged - which of course provides greater anatomical instability. If unlucky and the tear is from the ligaments’ attachments to the bone; small bone fragments can detach and cause pain until found and removed or resolved/decomposed by the body.
2. Inside the ligaments, we have a joint capsule. This joint capsule encloses the entire ankle joint from all sides, encloses the lower legs and covers down to the bone parts in foot. The joint capsule could be damaged and stretched - and if there is a discoloration of the foot, it has also often been torn.
3. The ankle consists of several joint surfaces. Above all, it is the top that can be affected. The upper ankle joint consists of three parts; the two lower legs that create a dome, and the Talus. When the foot is situated laterally, the Talus hits the dome roof above in two different places. It can be a gentle force so that it does not create a big reaction in the ankle and cartilage, but it can also be a nasty blow that damages the cartilage, and can (although it is quite rare) cause a tiny sliver detachment of Talus’ edge.
4. Dislocation of the Fibularis muscles tendons, which lifts the foot outward, and are functionally stabilizers of the foot laterally. The tendons starts sliding over the outer malleolus instead of being stuck behind the ankle - which both hurts and degrades the functional stability.
5. Many more things can happen, but som more unusual than the last two points. Among other things, one can encounter syndesmosis injury inte the lower leg, avulsion fractures in the foot, compression injury to the inside of the foot, nerve damage / irritation on the outside of the foot due to the stretching.

Bony parts of the upper ankle
joint.

How do you know the severity of the injury, and when the athlete can return to sports? Well, that is not easy, but I'll do my best to go through it in the next post... 

Why all the exercises?

Why do the patients always get so much homework in form of exercises from us physiotherapists? I mean, they're already in pain, and then we make them work as well...

Well, there’s a pretty simple explanation to that… When somebody seeks the help of a Physio it’s usually one of these three reasons:

Somebody fell and got injured acutely; while doing sports, in everyday life, in traffic etc. I.e. some sort of accident,

Because of surgery to some part of the body due to injury,

Or because of pain, without any trauma.

In the first two cases most people understand that you need exercises to rehabilitate the injured body part due to loss of function, strength and stability (these changes depend of course on the severity of the injury and time spent before rehab is begun). These negative changes (or adaptions) depend on inactivity, time for healing and reduced loading (one protects the injured area by resting and avoidance of using it normally).

But in the third case; you seek help because of pain, for example in the back, without any real reason for the pain. Suddenly you’re in pain, or perhaps the pain has crept on you and slowly increased. Why not just get a treatment that reduces the pain? I mean, there’s obviously nothing wrong since you haven’t experiences an injury, right?

No, that’s not really the case… There’s always a reason for pain, you don’t suddenly experience pain in the back for no reason at all. No matter if the pain is due to a disc or a nerve, or pain without any real anatomical change or degeneration. I’ve tried to explain the concept of imbalance surrounding a joint in previous posts. This concept is true to all joints, even those in the spine. So where does the pain come from? If nothing is really injured – why does it hurt? And why do one have to go through all those exercises? Imbalance in the muscles, or in the range of motion will also result in pain – therefore we have to find the reason for the pain.

Let’s continue using the spine as an example. It consists of 7 cervical vertebras (neck part), 12 thoracical (upper back part) and normally 5 lumbar vertebras (lower back part). All of these vertebras consist of the vertebral body and joints to upper and lower vertebra. These joints enable movement between the vertebras. Now imagine that the mobility is limited between two vertebras for some reason – the body will compensate through using too much mobility (hypermobile) in another level of the spine. What then to do if this is a part of the reason for the pain? The physiotherapist can help you increase the mobility in the stiff part; there are many different techniques for that, but at the same time you have to stabilize the hypermobile part.

Often this kind of thing problem affects many different levels or parts of the spine, not just in one place between two vertebras – although that also happens. When suffering from such an imbalance for a long time, often with a bad posture, static work, maybe also training repetitively without variation, the muscles will become affected with stiffness in the stiff joint-areas, weakness in the hypermobile areas, over activity in some muscles and instability in the smaller deeper muscles. This will lead to pain, and in the future; to degeneration of disks, joints, etc.

What about the exercises then… Well, the physio cannot do all the work for you, unfortunately for you. The therapist helping you stretch 2/week will not give you a permanency in the shortened and tightened muscles – you have to stretch basically daily, atleast 4-5 times/week to achieve a lasting change. The physio cannot strengthen the weak stabilizing or inactive muscles for you – YOU have to activate and train them your self, etc. Therefore, my friends, we physiotherapists will always give you exercises to work on…

Sure, we can help ease the pain – but it doesn’t help in the long run; the reason for the pain is still there. It’ll only lead to the return of the pain within a near future, and you’ll have to start over from scratch. In my opinion, that feels a bit irresponsible and in the end, it's a waste of time, for both of us...
When I finish treating a patient, I usually say; I hope I don't see you again - at least not for same reason... ;)
Take care of your self!

Do you have a good posture? A discussion about postures

My generation wasn’t as nagged at about "straighten up the back" or "walk with a straight back" as previous generations were. On those days children and adolescents were told even in school to correct threir posture. Good or bad to avoid the nagging? Perhaps mostly bad. Why? Because today, I see even worse postures in the next generation youngsters; that might be due to us nagging too little about their postures.

The famous slouchy
posture, check your friends,
family etc, I promise you*ll
see it!

The strange armé 
posture

Oh yes, you've seen a lot of youths sitting like this. Even if I
 have good  mobility, I'll never be able to achieve the same 
degree of flexion of the back as they can after years of 
stretching their ligaments and muscles in this C-shape...

“Straighten up your back!”; is it the right way to express one self? If I have a patient and ask him to straighten up, I see most often a strange form of military posture where people pull in their stomachs, push out their chests and lean the upper body backward. That's not really what we want to achieve when talking about the importance of good posture ... A good posture involves placing the body segments on top of each other in balance with as little energy expenditure as possible, which puts the joints in neutral position, and that means happy and healthy joints. Easy? Yes, for a child of 2-8 years. They are experts at this. Then we go slowly downhill; especially when we hit the teens; because of too much sitting. And usually at this age children begin to specialize in sports and train too much homogeneous patterns of movement, or playing computer games, playing with iPads, smartphones, etc. The worst thing we can do with our bodies in the subject of posture is to sit most of the day.

How do I instruct a patient to correct their posture? I always start from the bottom:

• Feet; rock back and forth on your feet a couple of times, and find the center of gravity directly in front of the ankle of the foot - but make sure you have good contact with the floor in the following three points; the base of the big and little toe and on the middle of the heel.
• Knees; tighten your thighs and push your knees back, then relax and bend your knees very slightly. Repeat a few times, and then find a middle position - where you feel that your knees are loose and thigh rests on the lower leg without having to contract your muscles.
• The pelvis; this is difficult for many! Tilt the pelvis a little backwards (ie round the lower back) and then tilt the pelvis forward (ie, arch your lower back - like a duck). Repeat a few times and then try to find a middle position with a slight lordosis of the lumbar spine without having to press the pelvis in any direction. You should have a neutral lordosis as we call it.
• Rib Cage and shoulders; inhale and push up the chest - breathe out and sink down. Repeat a few times. When you finish try to find a slight lift of the sternum.
• Shoulders; do a couple of big circles with your shoulder – lift up ventrally and down dorsally. Relax your shoulders after finishing down dorsally.
• Neck and head; Elongate your neck from the spine, push the most prominent part of your head upwards without tilting it back - tuck your chin in a bit and keep your eyes on the horisontal level.

See the movie about correcting the posture here!

Once you found the position, imagine that you lift the entire spine from the pelvis. I once heard a yoga teacher instruct the position of the spine in a poetic way; imagine that the spine and its vertebras are like a string with pearls, and that you stretch the string so that the beads are pulled upward. Beautiful way to express posture correction on.

But unfortunately this is not enough for everyone. As I have in previous blog posts pointed out that today's society with certain type of training methods (pumping up certain muscles), the sitting desk work where we have arms in front of us at a desk for several hours / days etc has altered the anatomy around the joints. A pull toward the stronger muscles is now created. It may also be that certain muscles are shortened or too active and it gets too hard to try to keep the joints in neutral position with the fatigued or weak muscle on the other side. A relatively simple example:

Chest muscles have a tendency to become strong, short and overactive compared to the back muscles. Think of all the guys who want to pump up the breasts, you know how their posture looks... But the muscles are not strong, short and overactive just by improper training, but also of our everyday movements and positions; example what we therapists hate – sitting office work. I can try to instruct that person in the correct posture, but if the chest muscles pull the shoulders constant, the person cannot assume a correct posture more than a few minutes, or maybe even less. It’s too much work, hence one must also work on getting the body into balance. And this applies not only to the torso, it’s equally important for the muscles of the trunk, pelvis and hips, as well as around the neck.

Therefore, I cannot in this blog solve the problem for everyone with bad posture, but for those who do not have so many problems with stiffnesses or weaknesses can work on their posture as instructed above.

For the others; for God's sake, start a more balanced life! Book an appointment with a physiotherapist or the likes and work on your physical problems...!

Well, those are my thoughts anyway :)