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Winter Running and Training Tip: Reducing off season hamstring injury

By: John Fiore, PT
Sapphire Physical Therapy

The sun appeared today and the thermometer reached 40 degrees Fahrenheit (ed. note: this was written last week!). Warmer temperatures and sp ring racing commitments result in a rapid increase in running intensity and distance. Winter legs accustomed to skiing and indoor gym workouts lack the repetitive loading rates which occur while running. Avoid a hamstring injury by avoiding the temptation to rapidly increase your running speed and-or mileage without proper training. A useful concept is Training Load Versus Tissue Capacity. Strength training and progressive tissue loading-specific exercises should be included in regular winter workouts to build hamstring tissue load capacity as we transition from winter sports back to road and trail running miles.

The hamstring is an important and complex, two-joint (crosses both the hip and the knee joints) muscle group used in running. While hamstring pulls and strains are common in runners and often healed with rest, proximal hamstring overuse injuries and traumatic hamstring muscle pulls can be painful and difficult to treat with rest alone. Repetitive micro-trauma in the hamstring attachment at the ischial tuberosity of the pelvis may result in tendinopathy (acute tendinitis or chronic tendinosis) and pain. While proper diagnostic testing is key (clinical testing by an experienced physical therapist or by a sports orthopedic physician), insufficient or improper treatment of proximal hamstring tendinosis may result in a season-ending injury. As with most running injuries, gradually increasing training volume and tissue loading is great way to reduce injury risk.

The hamstring is comprised of three muscles. All three hamstring muscles originate on the ischial tuberosity of the pelvis. The semimembranosus and semitendinosus muscles attach on the medial side of the lower leg (tibia) below the knee. The biceps femoris attaches on the lateral side of the lower leg (tibia) below the knee. The hamstring muscle group works in opposition to the quadriceps muscles. When you are flying down a hill at full speed, quads pounding and quads burning, the hamstrings act as the “brakes” to prevent knee hyperextension and to initiate the push-off phase of running.

The hamstring’s primary function is to flex or bend the knee. The hamstring’s secondary function is to aid in extending the hip. Because the hamstring crosses both the hip joint and the knee joint, it is a key muscle in the running stride.

Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are stronger and more prepared to manage the repetitive loading associated with running fast on flats and descending hills at speed (see exercise examples below). Core strength addressing lower abdominal, hip, gluteal, and lumbar stabilizers in a functional manner will reduce the demand on muscles such as the hamstring. Hamstring-specific strengthening with progressive loading will reduce overuse and associated tissue micro-trauma which leads to injury.

In order to quantify hamstring function, a 2D video running analysis may be indicated to determine how you as an individual run. Are you using your gluteus maximus to extend your hip, or is the hamstring acting as the primary mover? Are you over-striding and placing increased tension through the hamstring? A 2D video running analysis is a useful way to detect additional underlying running compensations in the clinic which may influence running biomechanics and resulting hamstring tissue loading.

Finally, do not forget self-care such as adequate recovery, sleep, hamstring release techniques, and eccentric hamstring exercises throughout the year to maximize your tissue load capacity. The exercises listed below are for example only. I recommend seeing a physical therapist to develop an effective hamstring-specific loading exercise program suited to your unique strengths, underlying weaknesses, and running goals. Call or email John and the PT staff at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or john@sapphirept.com).

Hamstring Loading Exercises to Increase Tissue Load Capacity:

1. Glut Bridging Progression: Contract your glutes (glute max) together and hold the contraction and lift into a bridge position, holding for 5 seconds. Slowly return to starting position and repeat for one minute. Further challenge yourself by repeating glut bridging exercise with the addition of single leg marching or single leg bridging without allowing your pelvis to drop. Additional progression includes the addition of a Swiss Ball beneath your heels.

2. Step-downs: Stand on a box or step (begin with a 4-inch box and progress to taller box over time) with a pole for balance assistance as needed. Step down slowly while maintaining alignment through the pelvis, knee, and foot. Increase hamstring loading by landing further forward and by increasing the box or step height. Practice landing quietly “like a cat” to decrease impact loading.

3. Quadruped Plank: Add a single leg lift (hip extension) while maintaining a level back-pelvis. May be modified by resting on your forearms.

4. Eccentric Hamstring Treadmill Stepping: Set treadmill to the slowest speed. Face backward on the treadmill and hold the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The exercising leg (the right leg shown) is placed on the belt. Slowly resist the forward motion of the belt with one leg as the belt moves. The exercising leg then is moved back to the starting point by flexing the knee and extending the hip.

5. Forward Glider Disc Lunge: Stand with exercising foot on a glider disk (use poles or counter support as needed). Slowly slide foot of exercising leg forward and slowly allow your knee so straighten slightly (do not fully extend your knee or you may do the splits) while avoiding excess hamstring tension. Return to original position and repeat.

6. Nordic Hamstring Curls: Kneel in an upright posture and have a second person hold your lower legs and ankles against the ground (or you may hook your heels beneath a stationary bar). Place hands in front of body and slowly lower towards the floor as shown without excessive hamstring tension. Slowly return to starting tall kneeling position.

Photo: http://prohealthphysio.com.au/exercises/nordic-hamstring-curl/
References:
1. Cushman, D.; Rho, M., Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2015, 45 (7), 557-562.
2. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.

3. Finding the balance photo: https://blogs.bmj.com/bjsm/2016/04/11/balancing-training-load-and-tissue-capacity/

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Practical Winter Running Tip: Protecting Your Feet from Potential Traction Mishap

By John Fiore, PT
Sapphire Physical Therapy

Icy and snow-packed roads and trails synonymous with winter in Montana are here. While Missoula runners often trade running shoes for ski boots, January marks the beginning of training for the 2019 running season. Runners have numerous ways to transform running shoes into traction beasts to tame the worst winter running conditions. Traction can be added via sheet metal screws, Due North traction devices, or Kahtoola Microspikes. While all of these options will dramatically improve traction, they also place increased stress on the foot. Protecting your feet from the focal pressure points secondary to running shoe traction devices will increase winter running enjoyment and reduce foot injury.

Ice is as firm as concrete. Add wire and metal traction devices between and icy surface and the foot and the stage is set for metatarsalgia. The term metatarsalgia is used to describe “pain in the metatarsal bone(s) of the foot. The metatarsals are located in the forefoot between the bones of the midfoot and toes. Metatarsals are long, slender bones which function to absorb impact and allow the foot to accommodate to uneven surfaces. When a metatarsal becomes irritated due to high, repetitive impact, a bone inflammatory response occurs. Reducing impact, pressure, and weight bearing will reduce metatarsalgia symptoms. A simple rock plate can be made at home to reduce the risk of developing metatarsalgia secondary to running with winter traction devices. Below are several photos and a description of how to make any pair of running shoes into a pair of metatarsalgia-proof winter running beasts.

Materials:

  • Flexible cutting board (purchased for $4.99 at Ace Hardware)
  • Sharpie pen
  • Scissors
  • Running shoes
  • Traction device (Kahtoola Microspikes used for example)

 

Step One:

  • Remove running shoe insoles and place on flexible cutting board
  • Trace insole on flexible cutting board using Sharpie pen
  • Cut out new rock plate with scissors

                             

 

Step Two:

  • Trim rock plate as needed to fit inside running shoes
  • Insert rock plate in running shoes
  • Place insoles back in running shoes on top of rock plate

 

Step Three:

  • Put running shoes on and attach Kahtoola Microspikes
  • Enjoy winter running without associated metatarsalgia pain

 

                          

Proximal Hamstring Pain in Runners

By:  John Fiore, PT

The hamstring is an important and complex muscle group used in running. While minor hamstring pulls and strains are fairly common in runners, proximal hamstring overuse injuries can be very debilitating. Repetitive micro-trauma in the hamstring attachment site (ischial tuberosity of the pelvis) may result in proximal hamstring tendinopathy (acute tendinitis or chronic tendinosis). While proper diagnostic testing is key (clinical testing by an experienced physical therapist, real-time ultrasound by a sports physician), insufficient or incorrect treatment of proximal hamstring tendinosis can shut a runner down for months.  

Understanding the hamstring musculature is the first step.  Unlike most muscles in the human body, the hamstring crosses two joints (hip and knee) and plays a role in two distinct movements. The hamstring’s primary function is to flex or bend the knee. If your knee bends, you can thank your hamstring for its work. The hamstring’s secondary function is to aid in extending the hip. Because the hamstring crosses both the hip joint and the knee joint, it is a key muscle in the running stride.  Understanding the hamstring is the first step in preventing and treating hamstring related running injuries.

The hamstring is comprised of three muscles. All three hamstring muscles originate on the ischial tuberosity of the pelvis. The semimembranosus and semitendinosus muscles attach on the medial side of the lower leg (tibia) below the knee.  The biceps femoris attaches on the lateral side of the lower leg (tibia) below the knee.The hamstring muscle group works in opposition to the quadriceps muscles. When you are flying down a hill at full speed, quads pounding and quads burning, the hamstrings act as the “brakes” to prevent knee hyperextension and to initiate the push-off phase of running.

Once diagnosed with a series of clinical tests by your PT which place tension on the hamstring origin or attachment, establishing a proper treatment progression is crucial. Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are strong and more prepared to check the power of the quadriceps while running. Core strength addressing lower abdominal, hip, gluteal, and lumbar strength in a functional manner will complement hamstring-specific strengthening to reduce overuse associated tissue micro-trauma.

Decreasing pain is only one component of a proximal hamstring injury prevention and treatment plan.  Strengthening the hamstring in a manner consistent with running is key in preventing injury recurrence. You can go to the gym five days a week and do hamstring curls to strengthen your hamstrings but continue to have pain while running. The key to effective treatment lies in understanding the hamstring’s role while running. A video running analysis is a helpful way to detect underlying running compensations and cadence which may influence running stride which increases hamstring stress.

A qualified physical therapist skilled at applying pain-relieving modalities, integrated dry needling, deep tissue release-mobilization, muscle energy techniques to balance pelvis symmetry, active release techniques, and contract-relax techniques will address pain and tissue restriction in the hamstring secondary to overuse. An eccentric hamstring strengthening program based on your pain, compensations, and goals will build tensile strength in your hamstring and tendinous attachments. Ruling out underlying pathology (such as lumbar spine referred pain) is important as well. Finally, do not forget to roll, release your hamstrings to decrease muscle and tendon tension. A few exercise examples are illustrated below, but see a qualified physical therapist to rule out underlying injuries,  referred pain, and for the gradual addition of strengthening exercises when appropriate. Call or email John, Holly, or Jesse at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or john@sapphirept.com).

Proximal Hamstring and Core Exercises:

  1. Quadruped plank: May be modified by resting on your forearms. Do not allow your lumbar spine to extend or low back to sway-collapse.
  2. Side lying glut isolation: Press into the wall with your heel and maintain a neutral pelvis position.
  3. Quadruped hip extension: Contract the glut of your involved leg prior to extending your hip to decrease hamstring compensation.

  4. Glut bridging: Contract your gluts (glut max) together and hold the contraction as you raise into a bridge position and hold for 5 seconds.  Slowly return to starting position and repeat for one minute. Further challenge yourself by repeating glut bridging exercise with the addition of single leg marching without allowing your pelvis to drop.

  5. Eccentric hamstring-strengthening exercise using the treadmill: The treadmill is turned on to a slow speed with the individual facing backward on the treadmill while holding on to the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The involved leg (the right leg shown) is extended at the hip while keeping the knee mostly extended, and the individual is instructed to resist the forward motion of the belt with the leg as the belt moves. The involved leg then is moved back to the starting point by flexing the knee and extending the hip.  Continue for one minute.

  6. TRX hamstring curls: Lie on your back with heels hooked in TRX loops. Contract your glutes and raise your hips-pelvis off the ground. Slowly bend your knees and slowly return to a straight-knee position. Lower hips-pelvis to the floor and repeat.

Photo: www.strengthperformance.com

 

References:

  1. Cushman, D.; Rho, M., Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2015, 45 (7), 557-562.
  2. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.

 

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Winter Off Season Training: Gaining Fitness, Strength, and Durability

As snow begins to accumulate in the mountains surrounding Missoula, many runners long for the warm and sunny days we have become accustomed to over the past several months. Winter, however, provides a crucial opportunity to improve your overall health as a distance runner. Repeating the cycle of training-racing-recovering over several months takes a toll on the body. Consider complimenting your winter running with one of the many winter sports available to Montanans. Not only is winter cross training therapeutic, but it is fun as well. Introducing new movement patterns and loads will allow your bones, muscles and connective tissue to rebuild, providing long-term durability for the 2019 running season. Fitness is comprised of strength, mobility, aerobic conditioning, and power. While running is required to gain running fitness, it is important to gain strength, mobility, aerobic conditioning, and power to maximize running fitness. Winter is the time to train your weaknesses, not your strengths.

 

Strength training should be part of every off season plan for runners. A 2010 research article in the Journal of Orthopedic Sports Physical Therapy showed a correlation between impaired muscular control of the hip, pelvis, and trunk and increased knee pain in runners (Powers C. J Orthop Sports Phys Ther 2010;40(2):42-51. doi:10.2519/jospt.2010.3337). A strength training program aimed at providing functional stabilization of the hip and pelvis in multiple planes is, therefore, a vital part of any off season strengthening program. As we grow older, muscle strength becomes more important as we lose approximately 1% of our muscle mass every year. More importantly, the decline in muscle strength declines at a rate 3-times greater (Goodpaster, B.H., et al., The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2006. 61(10): p. 1059-1064. https://www.ncbi.nlm.nih.gov/pubmed/17077199). Body weight strengthening is important if you are new to weight training or have a history of joint issues. To build muscle strength and durability, however, resistance training (bands, free weights, kettle bells) is necessary. Care should be taken to seek advice of a physical therapist or a personal trainer to assess your strength training technique. One muscle group many runners overlook are the calves (gastroc-soleus muscles). 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 (DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.). Performing calf raises-drops and single leg hops will target the calves. Remember to slow down during weight training repetitions to maximize strengthening benefits. Two to three strength training sessions per week will compliment your winter outdoor activities.

 

Mobility becomes more elusive as we age. Runners are particularly vulnerable to stiffness in the knee, hip, and ankle joints as we move in only one plane. Addressing mobility restrictions with the help of a physical therapist will decrease your osteoarthritis risk and improve your running efficiency. Winter is the time to attend a yoga class, seek stretching advice, and have your running stride analyzed to decrease joint loading to promote joint health.

 

Aerobic conditioning requires consistent work. Experience has taught me that maintaining a base level of cardiovascular fitness in the offseason reduces the need to play “fitness catch-up” in preparation for spring running and racing. Building your aerobic engine to carry you up climbs both short and long requires specified training. High intensity intervals are never fun, but mixing it up the means by which you subject yourself to intervals reduces burn-out. Nordic skiing intervals, skinning (backcountry or ski mountaineering set-up) intervals, power hiking intervals, and cyclocross racing are great ways to disguise intervals in a fun and novel activity. One to two longer running or snow hiking workouts in your aerobic threshold range will build or maintain your aerobic fitness.

 

Photo courtesy of stretchcoach.com

Power is achieved through explosive movements such as plyometric exercises and through interval training. Short intervals included in a workout 1-2 times per week will provide the acceleration a summer of long miles has taken away. Utilize a watch timer and heart rate monitor to gauge effort. Plyometric exercises include a loading phase followed by a propulsive unloading phase. Plyometric exercises should not be done when sore or injured, and an adequate level of strength is necessary to perform correctly. Again, seek advice from a physical therapist or personal trainer prior to adding power training to your off season program.

 

Motivation becomes challenging as the daylight hours shrink and the temperatures drop. To avoid runner’s burnout, reduce your winter mileage and intensity and shift your focus on the exercise suggestions outlined above. Embrace the season and find an outside activity or sport which is intriguing. I discovered backcountry skiing and randonee or ski mountaineering two years ago. A January-March Thursday night race series (Rando Radness) at Montana Snowbowl which is organized by Mike Foote attracts skiers of all ages and abilities in a fun, social atmosphere. The winter days of riding my bike on a trainer indoors are long gone.

 

Durability will reduce injury risk by preparing your body for the demands of the running season. Overall fitness (strength, mobility, aerobic conditioning, power) combined with reasonable training volume increases and adequate recovery determine one’s long-term running durability. The off season is the time to build running durability as distance running and racing have a catabolic (breaks down tissue) effect on body tissues. Make the coming winter a season full of adventure, recovery, rebuilding, and fun.
John Fiore, PT

Fitness and Aging: Filtering Through Facts and Misinformation

True: Aging impacts my health and fitness. False: Maintaining fitness is not possible since I am over 40 or 50 or 60 or 70 years old. A September 2018 article in Readers Digest listed 13 exercises one should avoid if he or she is 50 years old. Yes, this caught my attention as I endorse every one of the 13 exercises if done correctly. While I do not consider Readers Digest as a credible source for exercise and fitness news, I will list the 13 exercises, all of which have benefits if done correctly:
1.Running Stairs
2.Spin Classes
3.High Intensity Interval Training
4.Hot Yoga
5.Push-ups
6.Squats with Weight
7.Bench Press
8.Burpees
9.Pull-ups
10.Crunches
11.Dead Lifts
12.Jumping Lunges
13.Sprints
The degree to which fitness is impacted by aging is based on physiology, genetics, medical history, exercise choices, and lifestyle choices. The largest factor influencing fitness as one ages (insert your definition of what “aging” represents), however, is lifestyle choices.Physiological changes associated with aging include a change in cardiac function (i.e. Max heart rate, cardiac output), a decrease in lean muscle mass, a decrease in strength, a
decrease in flexibility, a decrease in connective tissue elasticity, and a decrease in bone density. Genetics also plays a large role in the physiological cards we are dealt at an early age. Joint stiffness in the spine may be virtually absent to some, while others may develop a more limiting genetic form of spinal degeneration such as ankylosing spondylitis (HLA-B27). 1 Prior medical history and orthopedic injuries (joint and ligament injuries, fracture history, overuse injury history, bone density baseline) should guide the degree of impact your body will tolerate during exercise. But what about the factors each and every one of us can influence regardless of our genetics? How is one to sort through the conflicting information available on the subject of fitness and aging? Understanding your present fitness, fitness goals, and recognizing your past and present medical issues will guide lifestyle fitness choices to allow you to maintain fitness for years to come.
As a physical therapist and an endurance athlete, I view proper exercise as the most effective way to positively influence fitness with age. I quantify this statement with the words proper exercise because many factors determine how well your body will respond to certain exercises. Running is a relatively high impact form of exercise. If done correctly (efficiently and following a consistent, gradual training program), however, running may be tolerated well into one’s 60s and 70s. Exercise consistency is crucial for life-long fitness. Regular exercise (3 days per week minimum with 5 days per week preferred) must address the areas of fitness most impacted by age. Strength training must be included as physiology has shown a decrease in lean muscle mass and strength naturally occurring with age. Speed must be included as our fast twitch (speed) muscle fibers are replaced by slow twitch (endurance)muscle fibers with age. Flexibility training must be included to promote joint health and reduce osteoarthritis, and cardiovascular exercise must be included for circulatory health and to maintain a healthy body weight. To reduce joint-related pain, minimize impact loading and vary your workout routine accordingly.
So what is the magic exercise? What is the key to fitness with age? Where do I buy the DVD or infomercial product to give me life-long fitness? No single exercise exists which combines all of these necessary components into one activity. Training, therefore, begins with finding an exercise form you enjoy (i.e. running, cycling, swimming, skiing). The next step is to develop a functional strength training program (with the help of a qualified physical therapist or trainer) aimed at improving your power and efficiency. Add to your
strengthening program a dynamic stretching program to insure healthy joint motion and mobility. Mix up your workouts to decrease the adaptation effect created in the body when you run the same 4-mile loop every day. Finally, have an annual physical to make sure your heart is healthy, your blood levels are within normal limits, and your cholesterol and blood pressure are normal.
Fitness beyond the 20s and 30s has many faces. From the person who has just been told by their physician to lose weight and reduce their blood pressure to the 60-year old athlete who defies both years and gravity, fitness in the second half of life does not have to be elusive. Life
experiences, life choices, environmental factors, genetics, and dedication to health and fitness all impact our fitness later in life. Call Sapphire PT to find out more about how you can realistically attain your fitness goals at any age.
1 Brown MA et al. Clin Exp Rheumatology; 2002. 20: S43-S49.

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.