Rehab of Ankle Sprains


Ankle
Sprains are one of the most common sporting injuries, and often are relatively
quick solve and recover from - a little bit of patience and discipline can do
the trick. However, this isn’t always the case. I regularly see patients who
complain of having sprained their ankle (to various degrees of severity)
several months previous to seeing me. They have usually rested and iced
initially, then done some basic rehab exercises and slowly begun to re
introduce their normal exercise routine, but not without problems. They often
complain of chronic stiffness, the ankle aching after exercise, pain around the
contours of the foot, and sometimes pain within the joint itself. In some cases
I have experienced, this may be 12 months after the original injury.

For me, the
main thing that often seems to be missed in these cases is Range of Motion
(ROM) throughout the rehab. In any musculoskeletal injury, ROM is key to
regaining a joints original function. For some reason though, in ankles, it
seems to be missed out regularly. People often rest until pain subsides, and
most of the movement returns, then they may do some strengthening exercises (in
some cases, ALOT of strengthening exercises), and gradually start to build up
their activity again. However, this misses out a key stage, which is re-gaining
FULL ROM as quickly as possible. During the initial resting period (which may
be up to 3-4 weeks for a grade II, or post-cast in a grade III),

After this
point, strengthening should be done regularly and gradually. This is something
I will discuss in another blog, but in this one, I want to focus on the thing
people forget.

At first,
regaining ROM can be as simple as sitting on a chair with your feet off the
ground and simply pointing your toes, then bringing them up towards your knee.
Compare this to the other ankle, if similar, move onto rolling your ankle on
and over a football or similar. Roll it left and right, forwards and backwards,
and in a big circular pattern.

If this
becomes as easy to do as the other side. Then move to ROM exercise using a
resistance band. Wrap the band around a fixed location and around your foot.
Pointing and bending the foot as far as you can against the resistance band.
This can be with eversion and inversion as well (keep heel on the ground and
point the foot left and then right.)

You would
then move onto weight bearing ROM exercises. Such as a knee-wall stretch. Stand in front of a wall and set your foot on
the ground with toes touching the wall. Keeping your heel on the floor, try to
get your knee to touch the wall. If this is easy, bring the toes back a few mm
and repeat. When you find a distance that is challenging, stay at that distance
and repeat the bend 20 times. This is again easily comparable to the other
ankle.

All the
above exercises are extremely simple and straight forward. However, these are
the things that often aren’t done following ankle sprains and even breaks.
Regaining early ROM will always increase your chances of making a quick and
effective recovery. So don’t ignore them. Wolfe et al (2001), is a literature
review study that well demonstrates this.

Getting
early treatment from a trained professional is also another great way to ensure
early ROM is increased. This study shows how use of mobilisation can improve
ankle ROM in sub-acute sprains (Collins et al, 2004).

Al

References:

Collins, N., Teys, P. and Vicenzino, B., 2004. The initial
effects of a Mulligan’s mobilization with movement technique on dorsiflexion
and pain in subacute ankle sprains. Manual
therapy
9(2),
pp.77-82.

Wolfe, M.W., Uhl, T.L., Mattacola, C.G. and McCluskey, L.C.,
2001. Management of ankle sprains. American
family physician
63(1),
pp.93-104.


The ITB and Runners

**The ITB and Runners:**

Runners often experience pain in the Illiotibial band. They also often complain of hip or knee pain which can be linked to the ITB and even more commonly, complain of‘tight’ ITBs.

**Anatomy:**

The Illiotibial Band is an extension of the tendon of Tensor Fascia Lata \(TFL\) It runs the length of the femur on the lateral side of the leg and inserts at the knee onto the lateral patella and onto a notch on the tibia. Illiotibial Band Syndrome \(ITBS\) is one of the most common causes of knee pain in runners and is responsible for 12% of all running related pain \(Taunton et al, 2002\)

It is caused by excessive friction between the ITB and the lateral femoral epicondyle, which it must pass in order to attach at the knee.There is also a bursa present at this site, which sits between the femoral epicondyle and the ITB. This can also become inflamed due the extra friction caused by a tight ITB and so can cause further pain.

Conservative treatment of ITBS would involve ice to reduce any inflammation but would also involve lengthening of the ITB in order to reduce the friction present at the knee. Stretching, however of the ITB is often unsuccessful, as the ITB is not a muscle and therefore does not contain stretch receptors. This stops people being aware of when they are putting this structure on a stretch and so it can often be in effective. It is there for every important to bear this in mind and when stretching the ITB, focus on the anatomy of the structure and not on how it feels. Stretches could include:

**One Leg Crossed behind the Other**: This involves crossing one leg behind the other and continuing to face forwards. You can further this stretch by bending the knee of the supporting leg and sliding the stretched leg further from the body and holding onto to something for support. It is important to keep the hips and torso facing forwards though. **Foam Roller:** Use a foam roller to roll directly over thelength of the IT band. Take your feet off the floor to increase the effect: **Resistance band stretch:** Lying on your back use a resistance band to pull the leg into a hamstring stretch then slowly move the leg over the other one and turn the foot as inwards as possible against the band. If you do suffer from ITB pain, it is also important to compare the strength of your abduction to the other side. Frederickson et al\(2000\) conducted a study on 54 runners and found that hip abduction was weaker on the affected leg for all participants with Illiotibial band pain syndrome\(ITBPS\) and that pain reduced with direct strengthening of the abductors.

Another symptom often associated with the ITB is pain over the greater trochanter \(hip bone\). This can again be caused by friction over the area due to tightness in the ITB or snapping of the TFL/ITB tendon over the greater trochanter. Conservative self-treatment of this condition would be much the same as with the knee pain and would involve the use of ice and lengthening of the surrounding structures.

As a runner, the demands on the ITB are very high, therefore it is important to take good care of this structure and maintain as much length as possible. If you do ever experience pain in either the lateral hip or knee, both abductor strength and ITB length should be addressed immediately. Lengthening of the quadriceps and hamstrings would also be advised in order to make quicker progress. Remember, however that ITBPS is most commonly associated with OVERUSE and therefore a look at your training diary would be worthwhile. Too many miles in un-supportive shoes or a rapid increase in mileage are two of the most common causes of short term ITBPS!!!

**References:** Fredericson M, Cookingham CL, Chaudhari AM,Dowdell BC, Oestreicher N, Sahrmann SA. \(2000\). Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clinical Journal of Sport Medicine. 10. \(3\). 169-175

Taunton, J.E., Ryan, M.B., Clement, D.B., McKenzie, D.C.,Lloyd-Smith, D.R., Zumbo, B.D., \(2002\). A retrospective case–control analysis of 2002 running injuries. British Journal of Sports Medicine 36 \(2\), 95–101. United Health, Kent. \(2012\).Knee Pain – Cyclists and Runners. Availible at: http://unitedhealthkent.com/2012/07/knee-pain-cyclists-and-runners/


Stretching

**Stretching:**

Im sure most people reading this do some form of stretching on a regular basis, whether during warm ups, cool downs, or maybe in front of the TV at night, however I often get asked what kind of stretching is best for runners, how much they should do etc… There is lots of varied advice regarding stretching, but I will try to keep this specific to running, and particularly endurance running.

A lot of runners have a tendency to do a lot of flexibility work on one particular area,calves being a very popular one, but then neglect other muscle groups, saying“its only my calves that get tight” However there are two reasons why this can be less effective, the first being that without targeting the flexibility of other muscle groups, you fail to address other problems that are contributing to specific tightness in the first place. In the above example it may be that stiffness around the lumbar spine could be contributing to chronic tightness in the calves.

The other reason this specific stretching of one muscle group can be a problem is because it is done spontaneously and may only last 2-3 minutes, some times less. This gives no time to increase the blood supply or to warm the tissue up at all, so the length reached during the stretch, and therefore the overall lengthening effect are both minimised. However, if you were spend 20-30 minutes stretching a variety of muscle groups, the overall lengthening effect on all of those muscle groups would be increased. The same goes for during a warm up, although the desired effect may not be lengthening this time, and the stretches may be completely different, the warm up effect would be increased if all the major running muscle groups were targeted rather than just the calves or glutes.

Many athletes use stretching along side other techniques such as foam trolling for injury prevention. A review of the literature around this subject by McHughand Cosgrave \(2009\) found that stretching, done separately from warm ups and training, in specific stretching bouts, has been shown to decrease the incidence of muscle tears when training. They also found, however, that short static stretches as part of a warm up, have no correlation to the incidence of overuse injuries at all. In fact, at distances of 1500m and less, there is a lot of evidence to support no static stretches during a warm up at all. This is because, in the short term, static stretching reduces the compliance of the muscle tendon unit. It is less significant in longer distances such as 5km and above though as a compliant muscle tendon unit is of less importance in these events, due to their more aerobic/endurance based nature.

Taking this into account, it would be advisable for endurance runners to spend around 20 minutes a day working on general flexibility of all major muscle groups including, gluteals, quadriceps, hamstrings, adductors, calves and the lower back. When doing this kind of stretching session, 30 seconds and above for each stretch will help encourage as much lengthening as possible. Example stretches may include:

  • Lie on your back with arms spread and bring one knee to 90 degrees. Let that knee fall over the other leg to the ground whilst keeping both shoulders flat. You can take it further by turning to face away from the knee and by using a hand to push the knee further towards the ground. This stretch is great for the glutes and for getting a good twist through the lumbar spine and torso:
  • Start in a kneeling position and sit back onto your heels. Then stretch the arms out as far in front as you can reach. Hold for thirty seconds before taking a big breath of air in and trying to stretch the hands even further. This is great for the lumbar and thoracic spine:
  • Use a carpeted surface or a mat to get the knee as close to a wall as possible. Use the other leg to support you up against the wall with the knee bent to the acutest angle possible. If struggling, then bring the knee further from the wall. Hold for at least thirty seconds each side. Make sure the supporting leg is straight and not bent past 90 degrees. This is great for increasing the length of the quads:
  • Use a towel or resistance band to wrap around the foot. Then lie back and raise the leg as far as you can, keeping it straight. You can then use the towel to pull on the foot and increase the stretch through your hamstrings. You can also move the towel to the ball of the foot to make it more calf-specific or you can pull the leg from side to side to change the angle of the stretch. Great for calves and hamstrings and made better when you use the different angles:
  • Perform a straight arm plank position and then push your hips up and backwards so that your body forms an ark. Walk the hands back slightly and push the heels towards the ground. This is a pose called the downward dog that is used a lot in yoga and is great for calf and hamstring flexibility. It can easily be varied by treading the heels or raising one leg into the air as well:

    The above are just a few examples of stretches that you could include in a flexibility program, but grouping them together in one session will most definitely be more beneficial to the runner seeking either injury prevention or improved performance.

    As I have already mentioned, the evidence for static stretches during a warm up is somewhat contradicting. There is more evidence to suggest that for shorter distances \(up to a mile\), it may even be detrimental to performance. Therefore, a lot of people will only use dynamic stretches in their warm up. However, every human responds differently,and if static stretches as part of a warm up have been useful to you in the past, then there is no need for you to change that. I have never read a study where 100% of subjects suffered diminished performances from static stretching,as not every subject responds the same!

    It is important to mention also that when suffering form a specific injury, the above theories may not necessarily apply. It would be best to perform the specific exercises or rehab given by your physio.

    References:

    M. P.McHugh, C. H. Cosgrave. \(2010\). To stretch or not to stretch: **The role of stretching in injury prevention and performance**. Scand J Med Sci Sports: 20:169–181

    WitvrouwE, Mahieu N, Danneels L, McNair. \(2004\). **Stretching and Injury Prevention: An Obscure Relationship.** 2004 - Volume 34 - Issue 7 - pp443-449