Lateral ankle sprains – How should they be managed?

Diagnosis, Treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline – vuurberg et al., 2018.
Lateral ankle sprains, how should they be managed

Lateral (outside) ankle sprains are the most common ankle injury. Approximately 40% of all traumatic ankle injuries occur during sport, and only 50% of individuals seek medical attention.
Due to the poor attention to injury, a large population develop chronic ankle instability. 1-4 years following initial injury, 5-46% of individuals with chronic ankle instability still experience pain, 3-34% has recurrent sprains, and 33-55% report instability.
Risk Factors
Predisposing factors that increase the risk of sustaining a lateral ankle sprain compose of Intrinsic factors (patient-related), and Extrinsic factors (sport, environment).
Intrinsic risk factors
Modifiable risk factors include:
• Reduced strength around the ankle and calf
• Limited ankle mobility and range
• Poor proprioception (“the sense of the relative position of one’s own parts of the body and strength of effort being employed in movement”)
• Low cardiorespiratory endurance
• Increased BMI (Body mass index)
• Preseason deficiencies in postural control/balance e.g single leg stand
Non-modifiable risk factors include:
• Anatomical abnormalities in the ankle, knee alignment, and multiple clinical defects
Extrinsic risk factors
• Sport dependent – Highest incidence of lateral ankle sprains were found in: Basketball, indoor volleyball (landing following jumping), field sports, climbing.
• Playing surface – Natural grass vs artificial turf vs court
• Position played in sport – e.g within soccer, defenders obtain 42.3% of lateral ankle sprains in the sport.
Treatment
Below is some of the latest evidence for the best treatment options, and how we can get you back running around with the kids, or back onto the sports field.

 R.I.C.E (Rest, Ice, Compression, Elevation)
Purpose: to reduce pain and swelling, improve patient function
RICE alone as a treatment is not enough, the best evidence is to apply the RICE principles alongside with exercise therapy.

 Non-steroidal anti-inflammatory drugs (NSAID’S) – E.g Ibuprofen, naproxen, diclofenac
Purpose: to reduce pain and swelling for acute injuries
If you have any concerns in regards to medication please discuss with your doctor.
Adverse effects may include: stomach discomfort, allergic reactions, heart burn, nausea, vomiting, diarrhea and/or constipation and more.

Immobilisation
A minimum of 4 weeks in a low leg cast following an acute lateral ankle sprain results in less optimal outcomes when compared with functional support (brace, tape, tubigrip/bandage) and exercise strategies with duration of 4-6 weeks.
However recent evidence showed a short period (less than 10 days) of immobilisation with plaster cast or rigid support (brace) can be of added value in the treatment of acute lateral ligament injuries as it helps reduce pain and oedema (swelling), and improves functional outcomes

Functional support i.e ankle brace/ tape/ tubigrip
Tubigrip/compression stocking following the acute phase of treatment begins to become unhelpful as it doesn’t provide sufficient support. Therefore using a lace up brace or semi-rigid brace will provide enough ankle support
Ankle braces results in better outcome compared to rigid or K-tape
K-tape is unlikely to provide sufficient mechanical support to unstable ankles

 Exercise
Consist of neuromuscular and proprioceptive exercises
Reduce the risk of recurrent injuries by reducing ankle instability, and associated with quicker time to recovery and enhanced outcomes

 Manual mobilisations
Manual mobilisations provide short term increase in ankle range of movement and can reduce pain in lateral ankle sprains
However manual therapy in combination with exercise therapy results in better outcomes than exercises alone

 Surgical therapy
60-70% of individuals who sustain lateral ankle sprains respond well to non-surgical treatment programmes
Surgery is mainly reserved for patients who have chronic ankle instability and who have not responded to comprehensive exercise-based physio programme.

Other therapies
Other treatment options are can also be used during treatment, although please discussed with your physio if these are beneficial for you.
These including: Acupuncture, Vibration therapy, laser therapy, electrotherapy, shockwave therapy, ultrasound.

Here at Bureta Physio we can properly assess your injury and give you the appropriate recommendations to get you back into what you love doing. Call 07 576 1860 to arrange an appointment time or click here to book online

 

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Strain and sprain is not OK!

“The perfect movers, without strain and pain are under 5 year olds”

Stiffness and strain for many is part of life, indeed a modus operandi for many. But imagine if stiffness and strain equates to dysfunction, pain and harm, this forms much of our function and day. I recently attended a Integrated Movement Patterns Course to upskill on the Milicich Method where the emphasis was on non – specific neck and back pain. These methods were derived from analysing the perfect movers of this world; the few uninjured high performing individuals, who work within gravity, pain free. A small percentage are in the adult population and a high percentage are the 5 years old’s and under, the perfect movers of this world; the young who display natural movement synergies. The ability to move their centre of mass with perfect balance is part of our natural physical development, which sets the foundation for future movement.

The Milicich Method aims to facilitate these fundamental movement patterns that are still within our central nervous system and awaken them to treat strain and sprain. Diaphragm function underpins strength and function within these movement synergies undoing habits, utilising language to facilitate existing pathways. These are key to the learning process. Many people have unlearned the pro-gravity system and reprogrammed the anti-gravity system in their brain, working against gravity instead of with gravity.

One aspect of our daily lives that contributes to neck and back strain is lifting and the Milicich Method addresses this concern looking at the way 5 year old’s squat and how power lifters perform. This was instrumental in re-establishing the pro-gravity movement pattern. The natural flat foot squat (FFS) position is a movement that much of the western society has lost. The FFS that every child performs, moves the centre of mass through a vertical range of motion, and this is a very specific sequence of movement incorporating diaphragmatic breathing to engage the power chain, which gains a successful lift without strain within gravity.
If this concept of eliminating strain and sprain, re-establishing fundamental principles of movement and working within gravity is something that you would like to explore then I look forward to facilitating this learning process.

Marcel Gyde
Senior Physiotherapist

Keeping you safe on the slopes

With the snow season commencing the excitement can be as intense as the chill; but there should be some things to take into consideration before strapping on our boots and hitting the slopes. Snow sports have a high risk for serious injuries. Although most injuries are caused from unexpected and uncontrollable factors such as weather conditions, falls and collisions; these can be minimised with good preparation and safety practices.

Falls and collisions on the mountain can be traumatic and could be caused by many factors;

  • Fatigue
  • Lack of instruction
  • Using slopes unsuitable for skill level
  • Faulty or ill-fitting equipment
  • Altitude sickness
  • Dehydration
  • Being off pieste
  • Back country without knowledge and/or experience
  • Failure to observe warning/ safety signs

Here are the National Ski Areas Association Responsibility Code for Reducing Risk

  • Always stay in control
  • People ahead of you have the right of way
  • Stop in a safe place for you and others
  • Whenever starting downhill or merging, look uphill and yield
  • Use devices to help prevent runaway equipment
  • Observe signs and warnings, and keep off closed trails
  • Know how to use the lifts safely

 

Equipment Essentials

  • Wear a helmet- it can save your life!
  • Good quality goggles; essential for seeing the contouring of the ground especially in low light conditions

Recommended for beginners and those who spend significant time on the mountain

  • Knee pads
  • Elbow pads
  • Wrist guards

Vital tip! Make sure your equipment is serviced and personally fitted to your experience level, weight and height. This ensures the safety features will work as they are designed to.

 

Stay within your skill level .
Familiarise yourself with which colour slopes match with which difficulty to avoid being in a slope that is too difficult.

Before considering going off pieste ask yourself; do I have the knowledge and experience? Are the conditions safe? Am I sure where the section will end up? Do I have the knowledge and gear in case of an avalanche?

If the weather changes suddenly make sure to; keep close to the slope markers and look out for warning signs and abide by them.

Most importantly make sure you feel confident to stop and/or change direction safely and quickly in case of an emergency.

Additional tips:
Parents supervise your children ensuring they are hydrated and fed, skiing appropriate slopes for their skill level and that they are abiding by the ski code.

AVOID DRINKING ALCOHOL- this can cause loss of judgement/ balance and control which could lead to injuries to yourself and/or others.

 

How physiotherapy can help?
To enjoy the ski season to its full potential prevention of injuries is more effective than treatment. The stronger, fitter and more flexible you are, the less likely you are to injure yourself in an accident and this is how physiotherapy can help! Physiotherapy can provide you with an individualised exercise program to increase your body’s capacity to cope with the physical demands of snow sports.  The program can be tailored to your personal weaknesses /tightness whilst also taking into account any previous and/or current injuries; chronic or acute. We can take you through the appropriate warm up and cool down techniques / exercises/stretches targeting your individual needs. Furthermore we can give pointers on your technique designed for injury management and prevention. By addressing these factors we can help improve your performance on the slopes and reduce your risk of injuries.

Enjoy your time on the slopes !

Improve your sleep

Strategies to Improve quality and/or quantity of sleep

Inadequate sleep and/or poor- quality sleep affects the non-athletic and athletic population. Consequently, adequate sleep is a critical component for post exercise recovery thus effecting performance. Therefore, below we have listed strategies you can implement to enhance your sleep quality to optimise your health, work/sport performance and recovery.

Nutrition do’s and don’ts
Do’s

Consume tryptophan containing foods such as milk, meat, fish, chicken, eggs, beans, peanuts, cheese and leafy green vegetables in the evening meal to increase melatonin production.

Try including carbohydrate foods at dinner to assist with Serotonin production, e.g. potatoes, rice, pasta… this may not be ideal if overweight or working on losing fat.

Try consuming 30ml tart cherry juice in the evening to increase exogenous melatonin intake (also decreases DOMS -Delayed Onset Muscle soreness). Use in a periodised way, e.g. around high volume training or to get sleep sorted initially if in a rut or during competition.

Consume a balanced, healthy diet, including adequate wholegrains, low fat dairy foods, fruits and vegetables for magnesium and B vitamins.

Try 300-400mg Magnesium supplement prior to bed.
Don’ts

Alcohol intake prior to bedtime (fragments sleep later in the night)

Caffeine and nicotine stimulants intake prior to bedtime (individual tolerances do exist). This includes coffee, tea, energy drinks, cola, chocolate.

To be cautious of
Be conscious of food portions before bed (eating large portions of food can raise core body temperature and make it difficult to fall asleep) and fluid intake prior to bed (to minimise need to go to the bathroom).

Consume fluids with evening meal to increase absorption, then taper off;
i.e. individual fluid prescriptions may be necessary following late- night training/competition to ensure rehydration.

Aim for no more than one visit to the bathroom during the night to minimise sleep fragmentation.

Combating Stress
Use a journal to write down worries/thoughts before bed

Write a ‘to do’ list for the next day to help clear the mind

Body Temperature
Lowering core body temperature in the evening to induce drowsiness and sleep:

Skin-warming (for cool environmental conditions) – achieved through warm baths/shower/spa, hot foot baths, warm blankets or dressing gowns, wearing warm socks and woollen boots/slippers

Skin cooling (for warm environmental conditions) –achieved through cool showers, cold water immersion, appropriate use of air conditioning, light bed covers

Keep a Routine
It is critical to maintain a pre- bed routine to prime the body for sleep. This is crucial for proper sleep hygiene.

Allow 1 hour ‘the de-power hour’ to unwind before bed

Maintain a regular bed and waking time each day (entrains our internal body rhythm -circadian rhythm)

Avoid computer screens, texting, bright lights for 1-2 hours before bed (stimulates the eye). Some people may find a dimmer TV screen from a distance helps them relax.

Creating a sleep friendly environment
Keep the TV out of the bedroom.

Keep the bedroom for sleep activities only, and ensure it is quiet, dark and comfortable.

If you cannot sleep within 15 minutes of going to bed, get up again and try a different strategy. Eliminate the bedroom clock (avoids stress of ‘losing valuable sleep time/clock watching’).
Napping
Napping can be a valuable way of increasing total sleep hours. Experimenting with a 90 minute nap mid-afternoon (one full sleep cycle). Recommended for individuals during heavy training prior to competition or who are having short nights.

If insomnia is a problem, do not nap in the day. Otherwise time naps for 8 hours after rising time (2-3pm) and keep these no longer than 30 minutes.

Naps times between 30-90 minutes or longer than 90 minutes may result in temporary sleep inertia and performance impairments.

Napping 10-12 hours after morning waking time will likely disturb nocturnal sleep. Set an alarm to wake at the right time post nap.

Warm up, protecting our kids

Warmup prior to sport is one of the most under utilised tools in the fight against sporting injuries. Many of us grew up in a world where sport was primarily for fun, we played numerous sports all lasting a few months of the year and the majority of us never did this with the consideration of higher goals or a professional career in the future. We were strong, active, healthy, largely injury free kids.

The sporting landscape has changed and not necessarily for the better.  In a society with a growing obesity epidemic our sporting participation rates for children, adolescents and young adults are lower than ever and continuing to drop. Alongside this the number of moderate to severe injuries in our children and adolescents is at an all time high and continuing to rise.

Across the ditch in Australia they are suffering from what could be considered an ACL rupture “epidemic”. New research has revealed that Australia has the highest rates of ACL reconstructions in the world (200,000 reconstructions at a cost of >$140 million) and they are being reported at younger ages with some as young as seven or eight. It is not clear yet what is causing these growing rates of ACL rupture but there is spectulation that a combination of a lack of “free play”and early sports specialisation could be to blame.

Rules and restrictions on climbing trees, playing everyday lunchtime school games and too much time spent on devices is ensuring our children are functionally weaker than ever before. We see this on a daily basis with an increase in sporting injuries and on the other end of the spectrum an increase in back and neck pain as a result of a largely sedentary lifestyle from younger and younger ages.

Sports are now often year round, multiple levels of a sport are played by athletes concurrently with the load of training and competing often being higher in a week than many of our professional and semi professional adults. YET all of this is occuring on a growing skeleton. This along with the reduction in movement control and strength is creating the “perfect storm” when it comes to injuries in adolescence.

Having an impact in this landscape is challenging and at times frustrating but is a hugely rewarding area if changes can be made. We can not have the next generation of children having “40 year old knees” by the time they are 10 and we can not afford to have a generation of children ceasing to play sport as a result of injury as this has significantly detrimental greater health consequences.

 

Warmups prior to sport are almost always completed especially in team sports. Yet historically these largely consist of a jog and some static stretching which is what we completed 30 years ago. Research and time has moved on but education to the public still lacks in this area. Static stretching is not effective in the reduction of injuries and can potentially be detrimental prior to to sport due to reducing power production of the involved muscle after being stretched. It has NO place in a warmup prior to sport.

Warmups MUST be multifactorial, sport specific and include strengthening, balance and agility exercises. These will not only help prepare our children for the sport they are about to play but reduce their risk of injury and assist in enhancing their performance. Faster, stronger players who are not injured regularly will always be an asset to a team.

 

Effective warmups have been shown in research to prevent major injuries by up to 50% and all injuries by up to 30%. Research also shows us that teams that have the least injuries win the most and athletes that can complete the majority of their planned training will have a much higher chance of achieving their performance goals. IT IS TIME FOR CHANGE!  We must implement appropriate warmups across all sports from pre puberty – some would say it is negligent of us if we don’t!

 

See links below for examples of sport specific warmups for netball, rugby & football or contact us at Bureta Physio buretaphysio@xtra.co.nzor 5761860 for further information

 

http://netballnz.co.nz/useful-info/netball-smart

https://www.rugbysmart.co.nz/sportsmart-warm-up

http://fit4football.co.nz/the-11plus/11plus/

http://fit4football.co.nz/the-11plus/11plus-kids/

Hip tendinopathy problems and solutions

Aggravating movement Why does it aggravate Solution
Lying on painful side

 

Direct compression from the mattress Add a soft mattress cover eg use a spare duvet
Lying on the non-painful side Upper leg adducts, causing compression Place pillows between your knees and ankles to reduce hip adduction
‘Hip hanging” standing position Increases tension of the ITB, increases compression and may lead to abductor weakness Don’t hip hang
Sitting with legs crossed Compression from the ITB with adduction Don’t cross your legs
Sitting in low chairs Hip rests in flexed position which increases tension on your TFL muscle and your ITB increasing compression. Can cause pain on rising from sitting. Sit on a tall chair so hips are above the level of your knees
Standing on painful leg Pelvis drops on non-weightbearing side leadign to hip adduction Use some support for single leg activities – eg dressing or do in sitting
Walking (especially climbing hills or over striding) If pelvic control is poor the hip can adduct during gait causing compression and pain Stay active but stick to what you can comfortably do, avoid large hills and over- striding
Climbing stairs Pelvis drops on non-weightbearing side leading to hip adduction Hold onto hand rail for support. If servere do 1 step at a time leading with the good leg.

Back First Aid !

You’ve hurt your back – what can you do!?! This blog should help to explain what is going on and how to help yourself. Everyone is different, if you see a physiotherapy at Bureta Physiotherapy we can help make an individualised program for you.

Central low back pain –what is it?
Low back pain is very normal; in fact 80% of the population will experience low back pain some time in their life. This often resolves within 3 months, sometimes with recurrent episodes. People often don’t know why it happens and get upset as it can be very irritating and painful, restricting normal everyday activities.

Due to the mechanical pressure our low back gets exposed to, it is the most common part of our spine to get injured.  Most low back pain is caused by overstretching of ligaments and other soft tissue structures around our spine. This is often due to poor posture over a period of time. This soft tissue ‘damage’ is often easily reversible if we address the prolonged poor postures.

What can you do?

  • Don’t panic!
  • Keep moving! It is really beneficial for your back to keep active with light activity
  • Try lying on your stomach, prop yourself up onto your elbows if you are able to do this or onto extended arms
  • If you are unable to do this then you can try the rest position with feet up on a chair (see photo below)
  • Heat and pain relief can help to relieve the pain but not the underlying cause
  • Try some extensions 10x hourly (see image)– the majority of the population respond to this movement for pain relief and to restore some mobility. If this spreads pain into your leg then stop these exercises
  • Avoid aggravating postures
    – try sitting in a hard chair with a straight back, such as a dining room table chair, instead of in an arm chair
    – you can try a lumbar roll (you can source one of these from any physio at Bureta) for sitting
  • Get in to see a physio at Bureta Physiotherapy to help address some of these aggravating postures to prevent this from re-occurring. The physio can also start you on some core strengthening exercise, often seen in pilates classes, to provide some stability to your spine.

rest90

The 90/90 position as a rest position