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PrintHow to prevent ankle sprains from happening … again
Have you ever wondered that maybe there is a way to change this?
Did you know that 85-90% of untreated ankle sprains will be recurrent, but with correct management after the first occurrence those number of cases can be brought down to only 35%?
What happens in an ankle sprain? Which structures are involved?
As a result of continued rolling, turning or instability of the ankle, the ability to make rapid adjustments in the position of the foot on uneven surfaces (proprioception) becomes limited. If this happens, the likelihood of a more severe ankle sprain occurring increases.
A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to completely torn ligaments where the ankle can be quite loose.
The common diagnosis for pain on the outer side of the ankle is an inversion sprain. This usually occurs when the foot lands in an awkward manner and rolls inwards, creating stress on the outside ligaments. When this stress is severe enough, an ankle sprain occurs.
There are three major ligaments attached to the outside of the ankle: the anterior and the posterior talofibular ligaments (ATFL and PTFL), and the calcaneofibular ligament (CFL). The ATFL is the most common ligament to sprain due to the mechanics and the limited support at the front of the ankle.
The other type of ankle sprain is an eversion sprain for pain on the inner side of the ankle. This happens when the foot is twisted outwards. The inner ligament, called the deltoid ligament, is over-stretched.
What can I do after spraining my ankle?
If you are unable to put weight or walk on it, you may have a small fracture. It is advisable for you to get it X-rayed. However, if you feel like you simply rolled over the ankle and putting weight on it hurts a little, apply RICE (Rest, Ice, Compression and Elevation) immediately. Head home and avoid walking on it as much as possible. Fill a wet thin towel with crushed ice or with a bag of frozen peas, and apply to the painful area for 10-15 minutes. Do not apply ice directly to your skin for more than five (5) minutes as it can cause cold-burns. Keep this up every 2-3 hours for the first 48 hours. This will help to minimize pain and control swelling in the area, limiting the extent of damage to the ankle.
For the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Make sure it is tight enough to stop the swelling from going down into your ankle but not enough to make your toes turn blue. However, remember to take it off at night but put it back on even before you leave your bed. Keep your foot elevated at night by placing pillows underneath the affected foot to give you just enough elevation to sleep pain-free. Foot pumping exercises (continuously bending and pointing your foot out) are also especially useful when the foot is elevated to help push the fluid away from you and back to your heart. Strictly adhere to the RICE regiment for another 2-3 days or until the swelling is about 75% gone.
How do I prevent a recurrence?
If this is not the first time you have sprained the ankle, the bad news is that once a ligament has been overstretched and not taken care of, it loosens and will never go back to its original length. Not only do ligaments hold bones together, but they also part of your balance-control system by sending messages to your muscles (via the brain), telling them how to react to maintain your balance and prevent excessive movement
The basic philosophy of any rehabilitation programme is to retrained your ligaments to sense and send the required balance signals and strengthen the muscles. This restores and improves the balance around your ankle to help prevent recurring sprains and protect it from the stresses of everyday life.
A physiotherapy rehabilitation treatment programme may include:
1. Therapeutic ultrasound would be administered to promote healing and decrease in pain.
2. Soft tissue massage to aid lymphatic drainage and remove any residual swelling.
3. Individualised exercise programme which may include:
a. Calf stretch alphabet exercises – moving the ankle in multiple directions by drawing alphabets in lowercase and uppercase motions.
b. Isometric strengthening exercises, such as pushing against an immovable object (e.g. wall or floor) or with the unaffected foot, can begin.
c. Balancing exercises such as standing on your affected leg and try to hold your balance. You will probably notice at first that your injured foot is much more wobbly, which will get better with practice.
Finally, your physiotherapist would also work closely with you to plan a proper activity based training programme to get you back to sport or normal daily activities. You can follow this whole recipe for old recurrent sprains.
Tennis Elbow Video
Have you ever wondered how Tennis Elbow occurs? If yes, click on the animation below to know more.
If you like getting your neck ‘cracked’ or thinking about it, you should know about VBI
It is not uncommon to find people in Singapore that enjoy a good crack of the neck once a while. It was particularly special way to end a hair-cut in the good old days at now-almost-extinct indian barber shops. There are also those who pop in to some massage or "chinese-sensei" shops that do these 'bone-cracking' service.
Some do it because they enjoy the loose-ness of the neck area. Others do it because they were informed that it is good maintenance to do so to keep the neck loose.
But often they are not aware of the serious risk that they face. The risk of Vertebrobasilar insufficiency (VBI), or vertebral basilar ischemia to be exact. VBI is temporary reduction in the blood flow to the back of the brain.
In other words a stroke.
Mechanical causes of VBI
VBI like other forms of stroke can be caused by blood clots, narrowing of the vessel from cholesterol or any other reasons for a reduce blood flow through the artery. A less common cause is mechanical forces, particularly in the neck region, that apply pressure on the verterbral arteries or in the worse case scenario, severe it. Particularly when the neck is cracked at its end of range. The danger lies if the technique is poor and not precise, i.e. many cracks rather than just the one intended. This puts a lot of sheer or traction force on the artery, possibly leading to tears or occlusion of the blood vessels. See diagram for more details on the anatomy.
Also to note, that the 'cracking' or manipulation in this article refers to the manipulation of the neck. It is generally consider safe to manipulate the thoracic or lumbar spine, that's the mid and lower back. Before manipulating the cervical spine, the practitioner should first perform a test for VBI symptoms.
How often does VBI result from manipulation?
It has been difficult to accurately determine the incident rate of Vertebrobasilar Accidents (VBA) due to under reporting. One study reviewing published literature found an incident rate that ranged from 1 per 20,000 patients to 1 per 1-million cervical manipulations1. To get a sense of these numbers, in 2009 for air travel in the US, there was 0.0036 accidents per 1 million miles flown and 2.55 accidents per 1 million flight departures2.
Regardless of the actual incident rate, one should be clear about the risk and that cervical manipulation should be applied selectively. Cervical manipulation has a place in the specific treatment of neck related condition3. But often it is useful to bear in mind that there are alternative approaches to treatment that may be more effective over the long term but not as easing in the immediate short-term.
Anecdotally, there appears to be an increasing trend amongst senior experienced therapist to minimise the use of cervical manipulation in favour of other treatment approaches.
Reference
- Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. J Fam Pract. 1996; 42: 475–480.[Medline]
- Table 6. Accidents, Fatalities, and Rates, 1990 through 2009, for U.S. Air Carriers Operating Under 14 CFR 121, Scheduled Service (Airlines) NSTB Aviataion Accident Statistics
- Use of high and low velocity cervical manipulative therapy procedures by Australian manipulative physiotherapists, G. Jull, Australian Journal of Physiotherapy 2002 Vol. 48: 189-193
- Ernst E (January 2002). "Spinal manipulation: its safety is uncertain". CMAJ 166 (1): 40–1
What kind of taping do I need?
A commonality in all three taping techniques is that taping in itself is thought to enhance the proprioception or kinaesthetic feedback. This improved feedback enables the muscles to “fire” more appropriately as postulated in the earlier activation of VMO when a lateral tracking patella in clients with patello-femoral joint pain, is taped in a more neutral position. Another benefit of improved feedback can also enhance the awareness of the joint position so that a feed forward action of muscle contraction can occur prior to a re-injury. An example would be placing a simple piece of rigid tape on the outer side of an ankle while getting them to balance on a wobble board. The strip of tape would provide the information that inversion is occurring, hence the peroneal muscles would be activated to prevent this movement, averting a re-injury.
Restrictive taping: What and When
Restrictive taping as the name suggest, is to restrict range of motion of a particular joint. This can be for one direction or multi direction, depending on the direction and degree of instability. This type of taping is used to protect unstable joints, where repeated or severe ligament damage has resulted in the stretching of the ligaments and/or joint capsule, thus leading to joint laxity. In such cases, an elastic brace will not provide enough support as the brace “gives” and will not limit the joint from moving into the unstable range.
Restrictive taping is most commonly used when the athlete is recovering from a ligament or muscle strain. The tape acts as an external support to prevent the joint from going into the end range of the movement that would cause pain. The most common areas that this form of taping is used are ankle, shoulder and knees.
Kinesio Taping
Kinesio taping was popularized in the 2008 Olympics where a lot of the swimmers, runners and jumpers were having these colorful and fancy looking tapes pasted on them. Some even thought that it was a fashion statement. However, the real history of Kinesio taping started in Japan, some 25years ago by Dr Kenzo Kase. The method of taping uses a uniquely designed and patented tape for the treatment of muscular disorders and lymphedema reduction. The use of the tape was to assist and give support to prevent over contraction of the muscle or to help decrease swelling. This enables the tape to help speed up the rate of healing for injured muscles.
Functional fascial taping (FFT)
Functional fascial taping was developed by Ron Alexander, an Australian remdial massage therapist who worked with the Australian ballet. Whilst he found the restrictive taping useful in preventing the recurrence in injury, it was not functional for his ballerinas as they required a full range of movement of their injured joints/muscles to perform their dance. Hence, FFT was created to allow the continuation of functional range and activity without pain. Most musculoskeletal conditions are multifactorial in nature, and pain can be a hurdle in a successful rehabilitation. FFT provides physiotherapists with another tool to manage their clients’ pain and increase compliance.
Essentially, FFT affects the connective tissues. When tape is applied, it applies a sustained load on to the fascia in a direction that allows the muscles under the fascia to glide better. This has been observed on ultrasound. The direction of tape applied is guided by the direction of load that reduces the pain. Anecdotally, it is also found that if the tape is applied appropriately, pain disappears and the range of motion increases with the functional activity. The latter is likely due to the increase muscle gliding with FFT. As with many techniques, the physiological reasons for their effects are still largely unknown although research is still being done.
FFT can be applied on any area of the body and does not need to be on a joint. FFT has been greatly applied in dance medicine but in recent years have migrated to be extensively used in the area of sports. However, the usage of FFT has been generally limited to rehabilitation where pain would inhibit the proper activation of muscles. Though such techniques have been employed to help athletes go about their sport with no pain, it is not recommended for frequent use as it doesn’t solve the problem.
Conclusion
Taping is a great adjunct to getting us back to sports if applied properly. However, please discuss with your therapist whether you are ready to get back to sports following your injury. It’s always safer to complete your rehabilitation and taping can be used to slowly give you the confidence to get back to sports.
Reference:
- Gary B Wilkerson. Biomechanical and neuromuscular effects of ankle taping and bracing. Journal of Athletic training 2002;37(4): 436-445
- Gilleard W, Mc Connell J, Parsons D. The effect of patella taping on the onset of vastus medialis obliques and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 1998; 78:25-32
- McConnell J. The management of chondromalacia patellae: a long term solution. Aust J Physio 1986; 32: 215-23
- Bockrath K, Wooden C, Worrell, et al. Effects of patellar taping on patellar position and perceived pain. Med Sci Sports Exerc 1993; 25: 989-92
- Abstracts accepted at the Fascia Research Congress
- Functional Fascial Taping real time ultrasound investigation
- Functional Fascial Taping for lower back pain: a case report
- Efficacy of Functional Fascial Taping for the treatment of non-specific low back pain
The Human Body as Subway Map
Which posture type are you?
What are the different types of posture and the possible musculoskeletal issues?
Before knowing what are the different types of postures. We need to know what ideal alignment that many people envy about. If there is a plumb line dropping from head to toe, a straight line can be drawn down from the just below the ear (mastoid process), shoulder (acromion), lumbar 3th vertebral body, hip (greater trochanter) and lastly at the front of the bony ankle protrusion (anterior malleolus).
The three main types of bad postures are flat back, kyphosis/lordosis and sway back.
| Types of posture | Alignment | Tight/ overactive muscles | Inhibited/ weaken muscles | Possible musculoskeletal issues |
|---|---|---|---|---|
| Flat back | Forward head posture ↓ Thoracic kyphosis (hunch forward) ↓ Lumbar lordosis (Reduce curve at the spine) Neutral to Posterior (pelvis rotating backward) Hips resting in increased extension Knees hyperextended |
|
| Pain or discomfort in prolong sitting, bending, driving Other common conditions include: Degenerated disc Herniated disc |
| Kyhosis/ Lordosis | Forward head posture ↑ Thoracic Kyphosis (increase C shape of upper back) ↑ Lumbar Lordosis ↑ Anterior pelvic tilt (forward rotation of pelvis) Slightly Hyperextended knee |
|
| Pain/ discomfort during prolong standing, walking, lying face down) |
| Sway back | Forward head posture ↑ Thoracic Kyphosis ↓ Lumbar Lordosis ↑ Hip extension Hyperextended knee Forward translation of the pelvis Neutral/ posterior pelvic tilt |
|
| Pain/ discomfort during Prolonged sitting , driving, bending, cycling Or during Prolonged standing, walking downhill, reaching overhead. |
What to do next?
After knowing what muscles are tight and inhibited, the next step is to carry out appropriate exercises to release the tight muscles and strengthen the inhibited muscles, sometimes it is also necessary to release the stiff joints to achieve better mobility of the joints. If all of the above, it would be easier to retrain the body into the ideal posture.
Weak muscles lead to bad posture. So why doesn’t a gym workout help?
Weak muscles lead to bad posture. So why doesn't a gym workout help? If you have chronic back or neck problems, you almost certainly have bad posture, though it may not be certain which came first. Nevertheless, you will often hear (or get) advice that you need to strengthen your postural muscle and correct your posture.
And after months of hard work at the gym with weights and cable machines, you feel slightly better but you still slouch now and then. Why didn't it work fully for perfect posture ALL the time?
Muscles Types
The reason gym workouts fail to completely correct and support your posture all the time, is that it simply did not target all the relevant muscles – the stability muscles. And it was the wrong type of training for some of the muscles – gym works targets the power muscles. And muscles exercises alone isn't enough – postural awareness is also required.
What are the different types of muscles and why does the differences matter?
We tend to think of muscles as simply muscles but in fact, there are broadly two basic muscle types - striated muscles (that includes those postural muscles) and smooth muscles.
- Striated muscles are your skeletal muscles. Muscles that you usually think of such as your bicep muscle or calf muscle.Your heart muscle is also a type of striated muscle but stands distinct from the rest of the skeletal muscle.
- Smooth muscles are usually involuntary muscle that blends in other tissue type to form say your bladder or intestines.
Longer weaker, Shorter stronger
One key difference between striated and smooth muscles is that the strength of the striated muscle weakens the further it is stretched apart. So the same muscle, at say, 10cm length will exert a lot of more force at both ends as it contracts then if the same muscle is stretch to, say, 20cm. More specifically the strength of the muscle is a function of the area of its cross-section – the fatter, the strong the muscle.
Smooth muscle is different is this respect. It doesn't lose its strength as it gets stretched out. An important feature to have with a full bladder or stomach.
So now we know that skeletal muscle, a type of striated muscle, is weaker when it is stretched and stronger when it is shortened. What does this mean to people with bad posture?
It means that one of the key things to do to strengthen weak posture muscles it to shorten the lengthened ones and lengthen the shortened ones. That is get your posture right to strengthen the key postural muscles and to release to the overly tight/strong muscles that is pulling you out of the right posture.
Sustaining good posture and strengthening the postural muscles is further confused by how we think about muscle strengthening programmes. To build strong muscles, we generally think about more repetitions, heavier weights and repeat as required. This works if we are talking about big power muscles such as your biceps and thigh muscles. Postural muscles have a higher percentage of Type I (slow twitch) fibres. These are fibres that are designed for endurance, not power.
This means for slow twitch fibres, a better type of exercises is one where we use lower load threshold and holding it for longer periods of time. Again, it sounds exactly like holding the right posture for prolonged periods of time (with proper rest periods in between) will improve your posture over time.
When a movement is loaded with too heavy a load, the fast twitch (Type II) muscle fibres take over.This is one of the reason why lower load exercises like pilates and yoga are better for people with low back problems than heavy workouts at the gym.
| Fiber Type | Type I fibers | Type II a fibers | Type II x fibers | Type II b fibers |
|---|---|---|---|---|
| Contraction time | Slow | Moderately Fast | Fast | Very fast |
| Size of motor neuron | Small | Medium | Large | Very large |
| Resistance to fatigue | High | Fairly high | Intermediate | Low |
| Activity Used for | Aerobic | Long-term anaerobic | Short-term anaerobic | Short-term anaerobic |
| Maximum duration of use | Hours | <30 minutes | <5 minutes | <1 minute |
| Power produced | Low | Medium | High | Very high |
| Mitochondrial density | High | High | Medium | Low |
| Capillary density | High | Intermediate | Low | Low |
| Oxidative capacity | High | High | Intermediate | Low |
| Glycolytic capacity | Low | High | High | High |
| Major storage fuel | Triglycerides | Creatine phosphate, glycogen | Creatine phosphate, glycogen | Creatine phosphate, glycogen |
| Myosin heavy chain, human genes | MYH7 | MYH2 | MYH1 | MYH4 |
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