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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.

 

  1. Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. JAAOS 2015 Nov;23(11):661-673.
  2. Mak MF, Gartner L, Pearce CJ. Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin N Am. 2013;18(2):195–214. 
  3. 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.
  4. 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 Reviews2(9), 403–409. http://doi.org/10.1302/2058-5241.2.160084
  5. 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.

Addressing Age-Related Calf Weakness

An average weekend in Missoula, Montana confirms the fact that 30 million people ran at least 50 days annually in the United States in 2012-2013. Running efficiently and injury-free, however, is more elusive. Nearly 79% of all runners experience a running injury annually. As runners age, the primary site of overuse injuries changes from the knee to the Achilles, ankle, and calf. Both observation (on the roads, trails, and in our running lab) and research correlates the increase lower leg injuries with altered running biomechanics and reduced calf muscle power measure as ground reaction (vertical) force.

Despite our best efforts to train consistently, understanding what happens to our running stride as we grow older allow us to focus our efforts on targeted lower leg strengthening to reduce injury risk and maximize running performance. A September 9, 2015 article in the New York Times brought to the forefront the work of Paul DeVita, a professor of kinesiology at East Carolina University in Greenville, N.C., and president of the American Society of Biomechanics.  Dr. DeVita’s 2016 research looked at running gait changes in a sample of 110 runners. The runners were a mix of male (54%) and female (48%) who had been injury free for at least 6 months. The age range was 23-59 years old. DeVita and his colleagues found that the older runners ran with a shorter stride length, a higher turnover (cadence) rate. The net result is a slower running pace which research has shown is due to altered running mechanics, decreased calf-lower leg muscle strength, and increased stiffness in the ankle with age. Between the ages of 20 and 60, runners typically experience a 31% reduction in ankle power, total power (ground reaction force to lift you off the ground and in a forward direction), along with a 13% decrease in stride length and running speed.

The statistics referenced above should be strong motivators to masters and young runners alike to be proactive with targeted strength training, especially in the off-season. With much of the mainstream running injury reduction focus targeted on foot strike pattern and core strength, the importance of the calf musculature (gastrocnemius, soleus) is often overlooked. Ankle stiffness predisposes one to developing further calf weakness. The calf muscle aids in initiating the push-off phase of the running stride, and plays a key role in absorbing impact as your foot hits the ground. The importance of the calf muscle in absorbing impact loads is phenomenal: 160-180 foot strikes per minute with 2.5 times your body weight plus the force of gravity exerted through each foot strike over “x” number of minutes running equals a HUGE demand placed through the foot and lower lower leg. Eccentric (resisting gravity) calf strengthening will increase the resilience and shock absorption properties of your calf musculature, while concentric (against gravity) and plyometric strengthening will increase the power generation of your calf muscle.

To summarize, DeVita’s research confirmed running stride length, speed, and lower leg muscle function decline in a linear manner with age.  Calf (gastroc-soleus muscle) and ankle strength declines with age as well.  A reduction in lower leg muscle strength (both concentric and eccentric) and ankle motion (dorsiflexion) shifts the burden of self-propulsion to our knees, hips and gluts which are already physically challenged by prolonged sitting and tight hip flexor muscles. Lower leg, foot, and Achilles tendon injuries become increasingly common in runners over forty. Gradual degradation of muscle and tendon tissue integrity and nerve innervation sets the stage for an increase in running-related overuse injuries. Stretching the calf and lower leg muscles, Active Release techniques, dynamic warm-up, and rolling are great ways to improve lower leg muscle tissue mobility. Lower leg, ankle, and foot strengthening exercises must be a part of every runner’s training program, not just those in the fourth decade of life and beyond.  Strengthening exercises should include single leg heel raises, heel drops, resisted ankle inversion, eversion, dorsiflexion, and intrinsic foot strengthening exercises (see photos).

If you have been battling a lower leg issues or would like to participate in a 2D video running analysis, call or email the running injury and biomechanics experts at Sapphire PT. Our physical therapists will not only return to pain-free running, but also reduce future injury occurrence while improving your running efficiency and performance.  Targeted strengthening and muscle-tendon tissue mobility are the keys to improving running performance at any age.

John Fiore, PT

Sapphire Physical Therapy
john@sapphirept.com
www.sapphirept.com

References:

  1. Reynolds G, Why Runners Get Slower with Age. New York Times. 2015, Sept 9.

Running U. Running USA 2014 state of the sport – part ii: running industry report http://wwwrunningusaorg/2014-running-industry-report?returnTo=annual-reports. 2014.

2. Goss DL, Gross MT. A review of mechanics and injury trends among various running styles. US Army Med Dep J. 2012; 62–71.

3. McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J Sport Med. 2006; 16 (2): 149–54.

4. DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.

5. Fukuchi RK, Stefanyshyn DJ, Stirling L, Duarte M, Ferber R. Flexibility, muscle strength and running biomechanical adaptations in older runners. Clin Biomech (Bristol, Avon). 2014; 29 (3): 304–10.

 

by John Fiore, PT

Runners are well aware of the importance of strength training to reduce injury risk. Even the most specific strengthening program will fail to produce results, however, if compensatory movement patterns are not addressed. Our modern lifestyle is filled with sitting. We sit at work, sit while driving, sit for relaxation, yet expect our hips, pelvis, and spine to function normally. Hip flexor tightness is synonymous with prolonged sitting. The psoas is in important hip flexor muscle which warrants further discussion to understand the challenge of running injury treatment and prevention.

The psoas is an important core muscle which stabilizes and moves both the lumbar spine and the lower extremity.  Collectively, the psoas and iliacus muscles are referred to as the iliopsoas muscle group. The psoas works in conjunction with the iliacus muscle.  While both the psoas and iliacus insert on the lesser trochanter of the femur (groin area), the iliacus originates in the iliac fossa and iliac crest of the pelvis and sacrum, whereas the psoas originates along the transverse processes of the lumbar spine. The primary function of the psoas muscle is to flex the hip. Secondary actions which are very important for proper lumbar spine and lower extremity function and symmetry include femoral lateral rotation, lumbar extension, and lumbar side bending. In addition, the iliacus tilts the pelvis anteriorly. Both the psoas and iliacus muscles activate unilaterally or bilaterally. Asymmetry between the right and left psoas muscles due to tightness or weakness, therefore, is an important source of one-sided low back and leg pain.  While psoas asymmetry is often overlooked, proper, targeted clinical testing must be included when thoroughly evaluating low back and extremity pain and overuse injuries.

The psoas muscle lifts the hip and leg forward when we walk, run, and climb. Overutilization of the iliopsoas can lead to postural and mechanical issues.  Without the necessary strength in the abdominals, hips, gluteal and small stabilizing lumbar (multifidi) musculature, the psoas becomes shortened, over-active, and irritated.  Gait and postural deviations may present as a laterally-rotated hip, an anteriorly tilted pelvis (unilaterally or bilaterally), or a sway back posture.  An iliopsoas-dominant athlete may develop a myriad of overuse injuries including:  psoas or groin pain, sacroiliac and low back pain, iliotibial band pain, and even knee and foot overuse injuries.

Once a psoas imbalance or overutilization issue is diagnosed, the resulting mechanical asymmetry must be addressed through manual physical therapy techniques. Targeted active release stretching, dry needling, deep tissue release, and muscle energy techniques are effective ways to restore symmetry and proper function to the right and left psoas musculature. Manual therapy alone, however will not “fix” the problem. Strengthening the antagonist musculature will allow the body to maximize efficiency of movement.

Strengthening the weak links in the modern day athlete can be difficult due to ingrained movement patterns.  Strengthening the lower abdominal and gluteal musculature, for example, reduces our reliance on the psoas to “pick up the slack” in lumbar and pelvic stabilization. Functional core strengthening involves the gluteal and abdominal musculature stabilizing in conjunction with sport-specific upper and lower extremity motions.  Sit-ups and crunches alone, however, may exacerbate the problem of tight or dominant psoas  musculature.  It is important, therefore, to include planks (prone and side positions) and single leg weight bearing core exercises to reduce habitual psoas use. Finding your lower abdominals (transversus abdominis) muscles when lifting is key to prevent the anterior pelvic tilt associated with iliacus activation as well as the lumbar sway back associate with psoas activation.  

Our modern day lifestyle of prolonged sitting and very little physical activity other than our “workouts” predisposes us to psoas muscle shortening and dominance.  Sitting inherently shortens the psoas while the antagonist muscle (gluteus maximus) is unable to function the lengthened position of sitting.  The most common area of weakness in present day athletes (based upon my empirical evidence of 24 years in practice) are the gluteus medius and gluteus maximus.  No wonder we have difficulty contracting our gluts when much of our day is spent sitting!  In addition to a physical therapy strength and postural evaluation, a video gait or running analysis will reveal muscle imbalances to address to effectively prevent and treat injuries related to a hip flexor or psoas domain state.  

Finally, for an aging athlete or individual, hip joint compression due to excessive sitting and associated psoas tightness can accelerate osteoarthritis.  Balancing proper muscle flexibility with core stabilization and strength will decrease the impacts of prolonged sitting to permit a healthy, active lifestyle for years to come.  

(John Fiore is the owner of Sapphire Physical Therapy in Missoula. You can reach him at john@sapphirept.com or 406-549-5283)

ARTICLE REFERENCES

  1. McGill,S.(2007) Low Back Disorders: evidence-based prevention and rehabilitation. 2nd ed. Human Kinetics. Champaign, IL. P 60-61, 214-217.
  2. Jones,S. Rivett,D. (2004) Clinical Reasoning for Manual Therapists. Elseier Butterworth Hinemann. New York, NY. P 261-274,
    3. Greives. Grieve’s Modern Manual Therapy. Harcourt Publishers Ltd. 19943
  3. http://www.serola.net/research-entry/iliopsoas/

Downhill Running Form and Training Techniques
John Fiore, PT

The challenges of running uphill are addressed through uphill interval training and techniques specific to climbing. Downhill running, however, is often a forgotten aspect of training. While it is true that many races are won on the unrelenting climbs, races are more often lost on the long, technical descents due to blown quads and poor technique. I do not claim to be a stellar downhill runner, but I will pass on useful training techniques founded in running biomechanics which may help you make the Swift Current cutoff time or even soar to victory at The Rut this September.

Regardless of body type or speed, the following seven training tips will improve your downhill running form and efficiency and reduce post-running soreness and injury risk.

Commit to running downhill: When the climb is over and the gradient tips downward, shift gears in your mind and body and commit to descending. Your leg musculature must now function in the lengthened position referred to as an eccentric contraction. In a lengthened position, your muscles are prone to soreness which is minimized through specified training.

Lean forward and use gravity: A common mistake many runners make is to lean back on the while descending. This “back seat” descending techniques results in higher impact loading through the heel, a shift of the center of gravity behind the body, and a higher incidence of blown quads or sliding feet. Lean forward slightly through the pelvis and trunk, using gravity to your advantage. Downhill running is often viewed as controlled free-falling and can actually be as fun as it sounds.

Descending at the Chuckanut 50k

Move your feet quickly: Cadence plays a crucial role in increasing running efficiency by reducing joint impact loading and conserving energy. Increasing your cadence (160-180 foot strikes per minute) will decrease joint impact forces, reduce muscle fatigue, and reduce the incidence of tripping on a stray rock. Try seeking out rocks to land on rather than navigating around rocks as if you are crossing a stream.

Look down the mountain and anticipate your next move: When running uphill, it is best to look a step or two ahead rather than face the entire climb head-on. In contrast, when descending, keep your eyes five to ten feet ahead of your feet and anticipate your next two steps in your mind and your legs will follow. Practice this technique on a rocky familiar descent and train your proprioception (non-visual sense of foot-leg position in space).

Relax your arms and utilize your entire body for balance: Balance becomes more of an issue running downhill at speed. Utilize your arms for balance and allow them to flail wildly while maintaining stable, strong trunk and hip musculature. Core strength and joint stabilization will pay off on the descents and it is important to utilize a regular program to achieve functional running strength.

Simulate race terrain in training: If your upcoming race includes downhill running or technical, rocky terrain, it is imperative to practice on similar terrain. Missoulians are fortunate to have a choice of rocky, steep terrain less than one hour away in any direction from town. Rocky trails abound in the Bitterroot, Rattlesnake, and Mission Mountains. Practice downhill intervals, climbing back up, and practicing a different line and varying your cadence and foot placement strategies.

Emphasize eccentric single leg training: Runners tend to focus on step ups, squats, and non-weight bearing gluteal exercises, but the secret to confident downhill running lies in eccentric single leg strengthening. Utilize single leg plyo-hops, box jumps, and even single leg box jumps onto an uneven surface such as a pad or Bosu Ball to train your body to fly down the scree and talus slopes of your favorite mountain race. For more specific questions related to downhill running training, injury treatment or prevention, call or email me at Sapphire Physical Therapy.

 

John Fiore, PT

john@sapphirept.com

www.sapphirept.com