Ankle sprains are one of the most common injuries experience by trail and mountain runners due to the steep and uneven terrain. Ankle sprains, however, are not all alike. In last month’s Runners Edge Newsletter, lateral ankle sprains were discussed. Most of the athletes treated for ankle sprains at Sapphire Physical Therapy participate in activities which involve running, jumping, sprinting, skating, or sliding into base. Many of these individuals present with some degree of high ankle sprain. This vague and general term warrants explanation for effective treatment and timely return to activities.
The anatomy of a high ankle sprain involves four main ankle ligaments (see illustration) plus one often forgotten structure: the syndesmosis or interosseous ligament. The syndesmosis ligament provides stability for the movement of the tibia and fibula as a unit over the talus bone of the ankle. Normal widening or splaying of the tibia and fibula is only 1 mm thanks to the syndesmosis ligament.
*Photo credit: Browner B, Jupiter J, Levine A, Trafton P: Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, ed 3. Philadelphia, PA, Saunders, 2003, vol 2, p 2307-2374.)
High ankle sprains are familiar to runners as well as soccer, lacrosse, and hockey players. What makes high ankle sprains difficult to diagnose and treat is the fact that most ankle sprains are minor and heal following several days of rest and conservative treatment. When the syndesmosis ligament is strained, however, pain, stiffness, and poor weighe bearing tolerance persists. When the syndesmosis ligament complex is suspected due to a high ankle sprain, specific testing should be conducted for effective treatment.
The syndesmosis ligament complex is often strained secondary to high impact, forced dorsiflexion (foot bent upward) combined with an eversion (inside of foot rolls outward) sprain. A sudden, high velocity ankle roll with impact sufficient to force the foot in an upward motion which increases the widening or splaying between the tibia and fibula bones. The deltoid ligament may or may not be involved in a high ankle eversion sprain as well. Swelling may or may not be present, and syndesmotic sprains characteristically do not get better on their own. Athletes commonly express frustration due to the fact that rest, ice, elevation, and an over-the-counter ankle brace did not allow them to return to running or sport. Sources place the frequency of ankle syndesmosis injuries at 1% to18% of all ankle sprains. In athletes and runners, however, the incidence increases to 12% to 32%.
Fractures should be ruled out in the case of a high ankle sprain. If swelling subsides within two days and weight bearing becomes pain-free, then an X-ray may not be indicated. If symptoms of swelling, pain, and difficulty weight bearing persist, then an X-ray is indicated. Magnetic resonance imaging (MRI) may be indicated if a syndesmotic injury is suspected. Research has shown X-rays to be less accurate (44% to 58% specificity) than MRI (nearly 100% specificity) in diagnosing a syndesmosis ankle sprain component. The degree of tibia-fibula gapping or splaying (positive when greater than 1 mm lateral subluxation or greater than 5 mm separation between the distal fibula and tibia) and the stability of the ankle (presence or absence of additional ankle sprains, stability, or fracture) will determine whether conservative treatment or surgery is the best course of action.
Treatment: Ankle inflammation reduction and rest, followed by progressive mobility and stability are necessary for proper ankle rehabilitation following an ankle sprain. If a fracture is present, then the treatment progression will occur secondary to fracture healing which is usually 6-8 weeks. A high ankle sprain involving the syndesmosis ligament requires stabilization for pain-free weight bearing activities prior to returning to running and sports. If the correct conservative treatment measures fail, surgery may be necessary. The treatment techniques described below, therefore, should be done only after a thorough evaluation including clinical and diagnostic testing.
Taping: Some degree of syndesmosis ligament stabilization is possible with taping. A physical therapist with experience treating high ankle sprains should apply the taping techniques described below:
The distal tibia and fibula must be taped circumferentially with a strong, non-stretch, durable tape. I use a base tape to protect the skin followed by strips of Leukotape. Pain reduction should be >50% with tape applied to allow for walking without a limp. Return to activities and exercise should occur only if taping provides pain-free weight bearing. I also utilize the Mulligan high ankle sprain taping technique to stabilize the lateral ankle ligaments and tibia-fibula joint.
Braces: A walking boot may be necessary to allow for early mobility following an ankle sprain. If pain is too great to allow for weight bearing without a walking boot one week following a high ankle sprain, diagnostic testing is warranted. A soft Velcro ankle brace (referred to as an ASO brace) will provide some ankle support but will not stabilize the syndesmosis ligament.
Range of motion, strength and balance: Pain-free ankle active range of motion is the necessary first step in treating a high ankle sprain. Once full pain-free motion is achieved, lower leg, foot, and hip strength must be evaluated and addressed. Restoring single leg balance and proprioception (positional body awareness) will reduce ankle sprain re-injury risk. Research has shown heightened ankle sprain risk in the presence of limited dorsiflexion range of motion, reduced proprioception, and decreased single leg standing balance. Restoring ankle range of motion and strength is followed by gradually adding in weight bearing static and dynamic exercises. Post-high ankle sprain rehab culminates with agility and balance drills specific to your sport or activity goals.
- Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. JAAOS 2015 Nov;23(11):661-673.
- Mak MF, Gartner L, Pearce CJ. Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin N Am. 2013;18(2):195–214.
- Waterman BR, Belmont PJ, Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39(5):992–998.
- de-las-Heras Romero, J., Alvarez, A. M. L., Sanchez, F. M., Garcia, A. P., Porcel, P. A. G., Sarabia, R. V., & Torralba, M. H. (2017). Management of syndesmotic injuries of the ankle. EFORT Open Reviews, 2(9), 403–409. http://doi.org/10.1302/2058-5241.2.160084
- Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline Br J Sports Med 2018;52:956.
John Fiore, PT
The strongest predictors of running injury include a prior history of running injury, running throughout the year without a break, and a rapid increase in running mileage of >10% per week (Br J Sports Med 2007). Identifying compensatory movement patterns through a comprehensive running evaluation identifies underlying faulty biomechanics and strength deficits.
The January partial thaw is behind us and many Missoulians are anxious to hit the roads and trails. The race season arrives early in mountain towns such as Missoula. Before ramping up your weekly running mileage, however, consider the importance of improving the efficiency with which you run. Once reserved for elite athletes and research subjects alone, state of the art running analysis is available in Missoula.
Sapphire Physical Therapy provides on-side real-time 2D running gait analysis. We are excited to share this informative, interactive, diagnostic technology with the Missoula running community. LED markers and high-speed cameras provide real-time feedback for both the runner and the physical therapist. Sapphire Physical Therapy uses the Simi Aktisys 2D system. Developed in Germany, the Simi Aktisys software records joint angles along the frontal, posterior, and sagittal (side) planes of motion as a person runs. Planes of movement and joint ankles (ankle, knee, hip, trunk) are recorded and observed as a person runs. The software analyses the measured video data and an easy to read, usable PDF report is produced for the runner and physical therapist. Utilizing 2D video running analysis during a physical therapy evaluation takes the guesswork out of determining the underlying cause of movement inefficiency and/or injury.
In addition to our 2D video running analysis system, we now offer provide a dynamic accelerometer evaluation which can be done simultaneously. Accelerometer date includes foot strike pattern, cadence, step length, impact force (measured in Gs of force), braking force, pronation angle, and pronation velocity. Asymmetries identified through accelerometer measurements are used in conjunction with visual video analysis to modulate impact forces and reduce future injury risk. Real world accelerometer data may also be collected during outdoor running session on the roads of trails. Following a run, the subject’s data can be downloaded to our computer and viewed for practical running analysis feedback.
Once a compensatory movement pattern is recorded, the runner can return to the treadmill (or roads-trails in the case of an accelerometer evaluation) and make changes in his or her running mechanics while observing themselves in real-time on the monitor screen. Individualized exercises addressing observed compensations or weaknesses address the cause of observed compensations to improve running efficiency. Walking biomechanics is fairly universal in healthy individuals, but running biomechanics is diverse and very difficult to accurately assess visually or with a hand-held video device in one plane. The Sapphire Physical Therapy staff looks forward to helping Missoula runners improve their running efficiency and determining the underlying cause of recurrent injuries.
Cost for a 2D video running analysis with accelerometer evaluation is $150. The hour-long appointment includes filming, review of video data, PDF printout, a discussion of possible compensations impacting biomechanics, and individualized exercise and treatment recommendations. Call Sapphire Physical Therapy (406-549-5283) to schedule your video running analysis or email me (email@example.com) for additional information.
John Fiore, PT
(Should runners stretch and if so how?)
John Fiore, PT
Confusion and controversy exists regarding the proper way for runners to stretch. Some runners stretch regularly while some never stretch at all. Stretching confusion originates in choosing the most effective way to stretch. Should I stretch to reduce injury risk? Will stretching help or hurt my running performance? What muscle(s) if any should I stretch? Understanding the difference between static stretching and dynamic stretching as well as when to utilize each is an important first step in developing an individualized stretching routine to meet your running goals.
Athletes generally stretch before or after training and competition because we were once told we should. Historically, stretching routines were fairly universal for athletes regardless of body type or sport. Research has shown, however, that static stretching warm-up routines actually decreases athletic performance while a dynamic stretching warm-up routine improves performance by decreasing injury risk (Perrier ET, Pavol MJ, Hoffman MA. J Strength Cond Res. 2011 Jul:25(7):1925-31 & J. Wilson, PhD; Journal of Strength and Conditioning).
Static stretches for runners include calf, hip flexor, quadriceps, and iliotibial band stretches. Typically held for at least 60-seconds, the purpose of static stretching is to increase flexibility. Static stretching targets collagen (the main component of tendons and connective tissue such as fascia) elasticity as well as muscle length. The problem with static stretching as a warm-up routine is two-fold. Increasing the length of a muscle or connective tissue in the body is a long-term commitment. Stretching statically for 60-seconds prior to a run or race will not result in long-term effects. The time to do a static stretching routine is after your run or race is over, or when your body is at rest. Static stretching requires a time commitment, but can be an effective means of reducing injury if done properly. Static stretching has an inhibitory neuromuscular effect on the body. Research has shown that a statically-stretched muscle produces less force for up to an hour following static stretching.
In contrast, dynamic stretching involves active movement of a limb (and the associated muscles and joints) associated with running prior to training and racing to prepare the body for movement. Dynamic stretching positively influences the neuromuscular component of running-specific muscles. Within the muscle-tendon junction of our lower extremities are structures called Golgi tendon organs. The Golgi tendon organs monitor muscle tension during activity and trigger the body’s protective mechanism of guarding or co-contraction to decrease injury risk. Dynamic stretching as a warm-up prior to activities such as running has been shown to inhibit the reactivity of the Golgi tendon organs. Targeted muscle contraction during dynamic stretching has a positive effect on the Golgi tendon organs. The net result of dynamic warm-up is a body with a short-term, functional increase in muscle length without the strength inhibition characteristic of static stretching.
A dynamic warm-up routine for runners should target the hips, quadriceps, hamstrings, gluteals, gastroc-soleus, intrinsic foot musculature, and upper body-torso. Dynamic warm-up is simple, requires no equipment, can be done wherever you are. To summarize, the goal of a pre-running dynamic warm-up routine include: Moving the joints, warming up the musculature for running, and decrease the body’s resistance (protective guarding) to intense or sustained activity through dynamic stretching.
John Fiore, PT
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