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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Running Injuries: Can I train through?

Authored by Donna Withers – Physiotherapist @ Bureta

This is a common question we get asked. As a runner it is always our goal to be running one hundred percent pain free. Unfortunately in reality this is often not the case as many runners are constantly dealing with a niggle whether it be a slight pain in the knee to a tight calf or a niggling hamstring. These small niggles and aches often don’t bother us enough to need to take time out from running but do stop training from being enjoyable.

There are a wide range of running injuries that are common complaints amongst the running population. These range from severe injuries which require a lot of time off to mild aches that can come and go. You can reduce the risk of needing to take too much time off with how you go about managing your injury. Taking the time to seek treatment and getting a treatment plan that focuses on the causative and underlying factors and developing a long term management plan for prevention which often includes strengthening, stretching and regular maintenance through the use of a roller and massage can significantly reduce time off.

An example of a very common running injury is Patellofemoral Syndrome also known as “runners knee” this is the irritation of the cartilage on the underside of your knee cap. This is commonly seen in runners who don’t have good biomechanics with loading/running. This can be caused by a number of factors i.e. weakness of the quads, gluts, hips or poor foot control/overpronation (rolling in). By focusing on the correct strength exercises which improve biomechanics and therefore reduce the loading of your knee training can be continued by reducing intensity and cross training.

Prevention is always the key whether you have an injury or you are just looking to avoid one your physiotherapist at Bureta can assess your biomechanics and work with you to develop a management plan to keep you out on the track. See our previous blog on some tips for running injury prevention. Remember the best injury cure is injury prevention – happy running!!

Is your stretching program putting you at risk?

Stretching – Recent research shows us a number of factors that affect when, why and for how long we stretch.

The latest research suggests that general stretching prior to exercise does not prevent injuries- in fact traditional static stretching (where a muscle is held on stretch for a period of time) has been shown to decrease muscle contraction for 20mins post stretch- adversely affecting muscle performance.
Dynamic stretching has been shown to be much more effective at preparing the body for exercise. Dynamic stretching is about preparing the body for sport and involves movement to end range to put stretch on tissues. This type of stretch signals to the body that we are preparing for action and has been more effective at preparing the body for exercise.
Traditional static stretching can be useful after exercise to prevent post exercise soreness
Talk to our team of Physiotherapists to devise the most appropriate dynamic stretching program prior to your exercise – this can benefit the weekend warrior going for a run, surf or cycle etc, right up to the elite sports people that we look after.

Those people with specific injuries may need to stretch these areas in order to prevent them causing further problems
Physiotherapist uses stretching and joint mobilisation to gain range of movement in strutcures that have lost range. This can be either a joint, or your soft tissues (muscles/ connective tissue/ ligaments)

Running into pain? What are Shin splints

Kate Niederer – Physiotherapist at Bureta Physio explains

As the days get longer, lighter and warmer, many of us shift our attention to the great outdoors and getting moving in time for summer. Often we go gung ho in a running regime, which is great for cardio fitness but our body tissues which have been in hibernation over winter, aren’t quite ready for the increase in load and this can set us up for a number of over load issues. Shin splints being one of them.

Shin splints is a generic term for any pain at the front of shin. The most common is medial pain (inside shin). This pain is caused by bone stress, inflammation at the insertion of the muscle into the shin bone and/or an increase in muscle compartment pressure.

Generally an overload issue caused by:

footwear
training surfaces
increase volume/load of training
biomechanics
running technique

The muscle involved (tibialis posterior) attaches into the bone along the length of the shin. When this muscle is overloaded or works to hard, it pulls on the bone causing an inflammatory reaction. With continued loading, the outer layer of the bone can pull away and if the load continues, can develop into a stress fracture – this is why it is so important to get it treated as soon as symptoms present!

The goal of treatment is too reduce pain/inflammation/compartment pressure by limiting the amount the muscle pulls on the bone. We look above and below the injury site to find WHY the muscle is pulling on the bone.

Causes:

rigid foot – decreased shock absorption
over pronation -> medial muscles work harder and longer from lengthened position -> muscle fatigues ->decreased shock absorption -> chronic traction of muscle on bone -> inflammation -> stress #/compartment syndrome
tight calf muscles
ankle instability from previous sprains
poor glut and core control

Specific investigation is required to determine the exact cause of pain and therefore the treatment required. There are many treatment options available but which is most effective for you will be dependent on the CAUSE of muscle stress.

Treatment options that we can help with include:

Ice massage
Rest
Managing training load, talking to coach/physio, pain-free cross-training
calf stretching/rolling (plantarfascia and calf)
massage/trigger point/acupuncture/Dry needling
Footwear/orthotics/strapping
Running analysis, running drills
Strengthening programme – usually targeting gluts/core to improve control lower down chain. A Muscle Balance Assessment can be useful to determine muscle imbalances

If you get onto it quickly, this issue can resolve quickly, otherwise, if a stress fracture develops, it can take much longer (up to months of rest (no running)) to settle.

If you do have any of these symptoms, try some of these remedies, otherwise come and see one of the excellent physios here at Bureta (we specialise in biomechanical analysis and treatment of overload issues) so we can work together to get it settled sooner rather than later! And remember, if you are starting an exercise programme coming into summer, build in to it to allow your muscles time to adapt or have a chat to us about the safest way to start your fitness regime.

Don’t forget your exercise recovery is just important as the training you do

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So many times in the Physiotherapy practice we get our clients asking how to improve performance, but commonly recovery is hugely overlooked. Marcel Gyde – Physiotherapist @ Bureta Physio takes you through some of the basics of exercise recovery to making sure you get the most out of your training.

You put the hard work in so now reap the rewards and recover well

Successful exercise and sport has a basis of quality training set around duration, frequency and intensity, with an important ingredient of recovery, as a means to adapt, improve and capitalise on training. All to often in physiotherapy we see many athletes suffering conditions related to fatigue, conditions of strain that can be avoided through successful exercise recovery programmes and tips.

HYDRATION – recovery and hydration begins before sport and exercise takes place, temperature and intensity are important aspects to consider, 1% loss of body water effects VO2 max output, increases heart rate and decreases alertness. For 20 minutes of exercise 300 ml of fluid needs to be consumed pre-event. Post event 1 litre of fluid for every kilogram of weight lost during event, measuring pre and post event can help with this equation. Electrolytes and recovery drinks can form important nutrient recoveries for the body, which is best 30 minutes post event, when muscles uptake of glycogen is at its optimum. A 4:1 carbohydrate to protein ratio is best for replenishment of glycogen stores and muscle repair, many recovery drinks fit this bill, as does low fat chocolate milk as a cheaper easy option.

FOOD – High quality carbohydrates are essential in optimal recovery, 7-12grams per kilogram of body weight is necessary to replenish muscle glycogen stores. An easy snack that contains 50 grams of carbs is 2 slices of toast with banana and 1 tablespoon of peanut butter. High quality protein is essential for muscle repair, 15-25 grams of protein should be consumed one hour post event. A favourite meal post exercise is pasta with chicken and vegetables which covers all the essential carbs, proteins and fat.

MUSCLE RECOVERY – Compression garments can aid in minimising tissue swelling, promote blood flow back to the heart and help with lactic acid recovery. There are several clothing brands now on the market but make sure the garment is tight but not constricting.
Static stretching post event can increase blood flow to muscles, improve range of motion and speed up recovery and promote injury prevention. It’s important to only stretch warm muscles, and the muscles you have used in your exercise or sport. Stretch slowly with no bouncing, and breath through stretches not holding breath, current time frames of 45 seconds to a minute for each stretch, re potions dependant on tightness and previous effort.
Ice baths are beneficial, they cause blood vessels to constrict, forcing out blood with waste products, such as lactic acid, from the muscles. No more than 10minutes of ice bath, I usually use a cold pool and for 5-10 minutes, followed by a warm shower to further promote circulation, but usually only on the heavier training days.
Massage can aid in flushing blood in and out of muscles and joints, aiding in reducing waste product stagnation, improving circulation, helping injury prevention and reducing muscle tightness and imbalances. Oboe rollers are becoming very popular and can be performed by yourself, which saves the cost of massage therapists, as well as not burdening partners with this arduous chore.
Active recovery can be another solution to good recovery, Low Intensity activity boosts circulation which removes lactic acids and promotes faster recovery, a talking pace with minimal exertion is paramount to this modality of recovery.

SLEEP – a good nights sleep, plus little nana naps are essential to good recovery, the body releases growth hormones and testosterone which aid in muscle repair and weight loss, as well as boosting immune system. It’s also a time for your brain to rest, your body to heal and repair post exercise. If it’s a nana nap on the cards, 45 minutes of sleep is optimal for physiological benefits to take place.

So there is the exercise recovery plan, hopefully a few good ideas in there to help your body into its next great sporting effort. Marcel Gyde

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