Lateral ankle sprains are among some of the most common sports medicine injuries each year. We often see this injury with basketball players as we did recently with Kawhi Leonard in the NBA playoffs. However more often than not, unless its a grade III sprain, we can get our athletes back on the court or field pretty quickly. Yet it seems like this is an injury that is often prolonged because of a few critical mistakes early on in rehabilitation. Let's talk about what you can do to quickly get your athletes back in the game.
Critical Points to Consider
There are a few questions you have to ask yourself when an athlete comes in to see you. First, do they have a broken ankle? Refer to the Ottawa Ankle Rules when considering if they need an X-ray. More often than not they don't if they can walk and are not tender to touch over bony areas. Second, do they have a high ankle sprain? While less common, this does occur. Be sure to take a through subjective report to understand the mechanism of injury and previous injury history. The last thing to be sure to consider is what the athlete's practice and game schedule is like. If you can get your athlete in to see you everyday for the first few days you can do a lot of good right away to get things moving in the right direction.
The most important thing is to begin bringing down the swelling. Contrast baths, manual flushing, and elevation of the leg is typically very effective early on. However, one mistake I often see is therapists do not tape or compress the athlete after treatment to continue to improve the swelling. My favorite technique that I learned is a horseshoe technique that is great at improving swelling. Another technique you can use is squid taping with K-tape which is also effective. Lastly, if you don't have access to tape I would suggest having your athlete pick up a compressive sleeve.
The next part of rehabilitation is the ROM and strengthening part. Range of motion should start immediately as the ankle will stiffen up from the pain and swelling. Working on ROM exercises such as ankle circles, ankle pumps, and calf stretches in the beginning are fine but as the pain tolerance improves using half kneeling ankle mobilizations against a wall or manual techniques can make big differences. As far as strengthening goes, I typically like to start manually resisted ankle strengthening quite early as I can control the range of these strengthening exercises. Typically I will start by having my athlete match my pressure so it is more of an isometric contraction but will gradually open up the range. Other exercises include towel scrunches, marbles, ankle theraband, calf raises, and lots of core and glute retraining. Many research studies have shown the importance of strengthening glutes after ankle sprains and quite frankly it just makes sense to keep the body stronger above. In addition, improving work capacity early on can make the transition back to the court/field much easier. I like to get my athletes on the bike as soon as possible. If they cannot tolerate a bike I will get them going on the upper extremity bike. Lastly, working on proprioceptive balance exercises early on is important for furthering rehab. Start with just single leg balance and progress to unstable surfaces and using arm and leg drivers to change planes of motion.
1. Control swelling:
- Contrast Baths, Manual flushing, Elevation of leg, compression sleeve, K-tape, Horseshoe tape technique (favorite)
2. Range of Motion:
- Ankle pumps, Ankle circles, Baps board, Calf stretching (towel stretch, against wall, slantboard), Half kneeling ankle mobilizations against wall, Manual mobilizations, Bike for early movement or upper body bike to keep them in shape
- Ankle/Foot: Manually resisted 4 way ankle strengthening to ankle theraband to calf raises, towel scrunches, marbles. Glute and core retraining.
- Single leg balance, SL balance w/ eyes closed (stay close by), SL balance on airex, SL balance with arm and/or leg drivers to challenge further planes of motion
5. Work Capacity:
- Get them on the bike or upper extremity bike (if you have access to one) ASAP to keep them moving and in shape. AlterG is great for retraining gait and running
- Dr. Brian Schwabe, PT, DPT, SCS, CSCS
*Check out the Insider Access video on my return to sport progression & testing for ankle sprains*
A couple months ago, I did a mini-case study on one of my co-workers. As you may recall, he had pain with squatting in his left knee. Apparently, the knee had been bothering him for years, but with his recent running, the symptoms had increased. At the time, I had been able to reduce his symptoms with repeated motions to the lumbar spine and knee. While that worked for awhile, his pain significantly increased after doing a 5K a couple weeks ago. At that point, he came to me regarding to his knee pain not improving with the previously successful repeated motions, hoping for further advice.
Having no longer responded to the quick treatments based off my initial brief evaluation, I recommended my colleague go through a more structured treatment plan. He had gone to a dry needling course with no change in knee pain. I told him to focus on glute strengthening and high repetition/low load training on the shuttle press for thousands of repetitions. While he did have success with reducing his knee swelling and general pain with the shuttle press, he continued to have pain and a contralateral shift with his squat.
Last week, I had some extra time in the clinic, so I though I would mess around with some different equipment. For those of you regular followers, you may recall that about a month ago I took a visceral manipulation course. While I am still practicing the techniques each week, I thought I might try one for my colleague due to the theoretically and potentially odd effects. Being that my colleague's knee pain was on the left side, I thought I would try a stomach manipulation. I first performed a squat assessment of my colleague and he had pain and a contralateral shift. I then performed a couple stomach manipulation techniques and reassessed. During the squat immediately following the techniques, he actually fell posteriorly onto his glutes at the bottom of the squat. It sounds weird, but he actually did and he described his “orientation” being off. We then quickly reassessed and his squat was marginally improved. Having remembered that the primary effects of visceral treatment occur within 48 hours of the treatment, I again checked first thing the next day. It was completely normal and pain-free.
Now I am not saying that the stomach treatment was the needed fix for sure, as it is difficult to identify correlation with such a long time between treatment and results; however, there was definitely an interesting change after so many less successful treatments. If anything, this case makes me more intrigued to practice and begin applying the visceral manipulation techniques, so that I may better learn patterns for which to apply them.
-Dr. Chris Fox, PT, DPT, OCS
There are many jobs to advertise mentoring with few actually failing to live up to expectations. There are also different types of mentoring. Having completed a residency myself and being a residency faculty mentor, my experience has been one on one patient treatment and discussion. We problem solve various cases together and challenge each other on why we are doing what we are doing and possible alternatives. While that version of mentoring is ideal, it is unrealistic for employers to offer that regularly. Mentoring for other employers may mean journal clubs, chart audits, or case discussion with one of your co-workers. The concept of mentoring is understood in such a variety of ways that it is essential that prior to interviewing, you should make sure you understand what YOU want and what the employer is offering.
Now if the job you take doesn't offer what you are looking for, there are other avenues as well. Discussion regularly occurs on social media groups regarding cases or general topics, although, you may have to put up with some preaching occasionally on specific treatment approaches. Additionally, there are services you can pay for where you pay for an expert's time to discuss cases or whatever you want (such as Dr. E at Modern Manual Therapy). If looking for advanced treatment or assessment ideas, you can check out our Insider Access Page. For those looking for a long-term commitment to mentoring and clinical reasoning development in addition to learning advanced techniques, you can look for a program to join, such as Optim Manual Therapy's COMT program or other system based or non-system based programs. These can help to develop your clinical reasoning overall and hands-on skill. Programs like Optim, offer weekly case discussion online as part of the program. The key for you is to know what you want in mentoring, and then to go find it!
-Dr. Chris Fox, PT, DPT, OCS
This past weekend at the Optim COMT course, we were discussing squats as a form of treatment. While the squat is an excellent exercise for a variety of ailments, it is an exercise that is prone to many compensations. Combine that with pain in the knees or elsewhere, and form may be compromised even more. There are several reasons why the pain may impact the ability to squat, but tissue tension may play a role.
One of the common variations that is seen during squats is the "buttwink," otherwise known as posterior pelvic tilt and lumbar flexion. Typically we see this occur as the client nears their bottom depth of the squat. There are many possibilities as to why this may occur: lack of hip flexion, poor motor control, decreased spinal mobility/strength and more. Another possible explanation for lumbar flexion is poor quadriceps strength. As an individual with poor quad strength descends into a squat, they typically either stop early in the depth or display a compensation like lumbar flexion and forward trunk lean. To try and control the movement that the quads are insufficient to support, the body tries to rely on the passive tissue tension of the posterior chain and a shift in center of gravity anteriorly. As the "buttwink" occurs and the trunk shifts forward, the muscles, tendons, and ligaments become taut and provide a form of passive support to control the body during the motion. Over time, this may lead to injury.
So how do we fix this? There are many avenues to address this client, but strengthening the lower quarter should absolutely be considered. There are many ways to strengthen the quadriceps, and it may be tempting to avoid squats due to the client's poor form; however, the exercise can be modified to the appropriate level. Using an assistive device like a TRX or leg press can simulate the motion at less than body weight to allow proper form. There are some cases where adding a load to the individual actually improves form! Regardless, improving an individuals functional squat may be as simple as improving their strength.
-Dr. Chris Fox, PT, DPT, OCS
As graduation draws closer, good luck to all those taking the NPTE in a couple weeks. You've put in a lot of work thus far, and the reward awaits you at the other side. Keep at it! Upon starting your practice as a physical therapist, you will inevitably start looking towards what you can do next to improve upon your knowledge base and skills. There are many options out there, whether you are looking for a different perspective, new style of treatment, pain science management or something else, you will never run out of courses to pursue.
Upon graduating, I knew I wanted to pursue a residency in orthopaedic. Ideally everyone would complete residency training; however, there aren't nearly enough residencies out there to fulfill the need. A couple years ago Optim Manual Therapy Fellowship was started for situations just like this. We simulate the residency experience at a far more affordable cost, weekend courses, online assignments and weekly mentoring. Our approach is an eclectic one. We look to improve upon typical components, such as anatomy and orthopaedic knowledge, manual skills, and exercise application. However, we differentiate ourselves by the diverse treatment approach and evidence-informed decision making. While we educate our participants on standardized mobility exams, Sahrmann's Movement Impairments Syndromes, and pain science management/education/treatment, our real goal is to help develop your clinical reasoning and facilitate your practice patterns. Below is a sample lecture on Sahrmann's Movement Impairment Syndromes, but check out optimfellowship.com for more information on the program. A new cohort is starting in Dallas in just a couple months, but expect cohorts to begin in St. Louis, Scottsdale and Houston this fall!
-Dr. Chris Fox, PT, DPT, OCS
This past weekend I went to a course I previously never would have though I would attend: Visceral Manipulation 1 by the Barral Institute. When I first got into PT, my mind was very biomechanical. If there wasn't a mechanical or evidence-supported explanation for how something worked, I didn't think it was worth learning. The more I've practiced and read research developments on pain science I have come to understand that not only does the mind and nervous system play an incredible role in treatment response, but that there is so much out there we don't understand at all.
About 2 years ago, my wife was suffering from some pelvic/abdominal pain following her c-section that several doctors and PT's were unable to treat or determine the source. It was at that time she sought a visceral therapist and was back to playing soccer nearly pain-free after 3 sessions. This past summer I had developed the sensation of a lump in my throat (which was later diagnosed as GERD) that at one point was so bad I couldn't breathe while laying supine. It was about 90% improved after just a couple sessions of visceral treatment. These experiences had peaked my interest in at least learning more about the style of treatment.
On to the course. Throughout PT school, we are taught all about muscles, bones, ligaments, joints, nerves, etc., but the abdominal cavity is mostly ignored. Sure, we learn about organ function, pathology, and differential diagnosis, but how organs move is never even thought of. While there are certainly concepts that were explained that I am having a hard time wrapping my head around (motility, "listening" as an assessment, and mobilizing organs through ribs), the discussion on affecting mechanoreceptors and proprioceptors through the visceral manipulation is much more acceptable based on current research regarding manual therapy.
The biggest "sell" to me was the within class changes that occurred. Yes, we felt improved organ mobility whenever we were finished with a technique, but the bigger changes were seen elsewhere. One clinician with a significant Thomas Test deficit had almost normal motion following mobilization of her cecum. I had a drastic improvement in SLR mobility following mobilization of my sigmoid colon. We saw improved shoulder elevation mobility following liver mobilization. One clinician who had a history of rectocele and cystocele had recreation of labial and rectal pain following a stomach mobilization.
One of the aspects of research that is currently being developed by the instructor Brandi Kirk PT, PRPC, CVTP is regarding diastasis recti. She recently presented a case series poster at CSM 2017 on treating the disorder with manipulation of the mesenteric loop, root, and mesentery. In class, one of the clinicians presented with a diastasis recti of 4 finger-widths. After doing just one of the 3 treatments, the next day she had almost complete resolution of the disorder. The research has thus far shown retention a year later with no activity restrictions following discharge. Treatments like this could potentially help many to avoid surgeries. Thankfully the group at Barral Institute is working on developing higher level studies to show the potential benefits of visceral manipulation.
Overall, I would say the class is an absolute must-take for every clinician. Visceral manipulation tends to be thought of more as a joke than an actual treatment style, unfortunately. In taking this course, not only am I better able to understand the proposed theory, but also how the successful treatments may be explained by current evidence. My only complaints about the class are that evidence hasn't caught up yet (and they are working on this as we speak!) and that not enough time was given to practice each technique 10 or 20 times (we only practiced each technique once or twice due to how many techniques there were and the complexity of them). Aside from that, the potential for this practice is incredible and changes can not only be seen within treatment but continue for weeks afterwards. While I'm not confident in applying these skills today, with practice, I look forward in implementing this treatment style into my practice and experimenting with further potential. Let me know if you have any specific questions about my experience. I highly recommend this class, as I plan on taking additional visceral manipulation classes in the future.
-Dr. Chris Fox, PT, DPT, OCS
With today's research on pain science, we are moving away from pathoanatomical diagnoses. This is a wonderful development as not only does it minimize the fear of pathology in our patients, but it makes our job easier as well. That being said, it can still be easy to be drawn in excessively by the results of special tests, especially in the extremities.
This past weekend I performed an evaluation of a middle-aged patient, where the script said "bilateral shoulder impingement." Based on the location of the patient's pain and some positive impingement tests, there may have been "impingement," but anytime I see bilateral symptoms I make sure to assess a central component. I'm not saying this always means the symptoms are driven by the spine, if presenting bilaterally, but that there may be an impairment in the trunk that contributes. In this patient's case, his cervical spine had minimal dysfunction, but his thoracic spine and parascapular musculature were significantly involved. He presented with excessive thoracic kyphosis and weak mid/low traps and serratus anterior bilaterally. His RTC presented with 5/5 strength throughout bilaterally. While there are some deficits in the extremities, the primary dysfunction appears to be located more centrally.
In reality, if you are being thorough with your examination and treatment, this shouldn't be a novel concept at all. I always encourage assessing spinal mobility and proximal strength in all my patients. The key then is doing something to address the impairments found. It is not unusual for my foot/ankle patients to be doing lumbar mobility exercises or hip strengthening. We don't always know "why" a patient presented with a form of pain or disability, but we can be sure to address any strength, mobility, biopsychosocial factors with which the patient presents.
-Dr. Chris Fox, PT, DPT, OCS
I distinctly remember the first few times I performed manual therapy on the cervical spine. My hands were sweatier than normal, and I had an unusual shakiness in my fingers. For some reason, I thought everyone with cervical pain was on the verge of having upper cervical instability. While this mindset was irrational, it may have been something that was instilled in me during physical therapy school. This fear was likely due to a lack of experience with the cervical examination and techniques.
While performing a cervical spine examination may seem intimidating, it is very similar to any other body region. The main objectives should be to determine if the patient is appropriate for physical therapy and to identify the primary impairments that will have the greatest effect. The key to each evaluation is efficiently completing this process so that more time can be spent on treatment!
In many instances, the examination begins in sitting following the subjective history. Depending on the subjective information, various safety tests and measures may need to be completed. While all safety tests may not be completed on every cervical evaluation, having them accessible is important. Assuming the patient is appropriate for physical therapy, many other tests can be performed in the seated posture to assist in making the appropriate physical therapy diagnosis. For example, shoulder active range of motion should be performed to determine if this region is a pain generator or contributing to the cervical pain. Additionally, a seated upper rib mobility assessment should be performed to determine if the ribcage is contributing the one's symptoms. The complete flow of tests and measures can be seen in the picture below.
In the Efficient Examination breakout, many special tests are left off the list. Being efficient means quickly determining the painful region and identify primary impairments. The cervical examination should includes a brief assessment of the thoracic spine, cervical spine, ribcage, and upper quarter. Quickly assessing each one of these regions will help determine the true cause of the patient's symptoms. Do not be intimated by the cervical examination!
Jim Heafner PT, DPT, OCS
For those of you that follow TSPT regularly, I'm sure you are aware of my affinity for considering all 3 pillars of evidence-based practice (EBP) equally. With the push for a more research-driven approach, we are improving our foundation of what we know that works. This is excellent and should continue to be developed regularly. While it is a sign of progress, we need to remember an older phrase, "You know what you know, you know what you don't know, and you don't know what you don't know." With where research is going, we are improving our understanding of what we know and maybe even some understanding of what we don't know; however, I fear we are pushing so far away from the 3rd tier that we are purposefully blinding ourselves to it.
In regards to knowing what we know, we know that strengthening the quadriceps and glutes in those with knee pain often helps. While we know that a thoracic manipulation does help with neck pain or shoulder pain, we don't necessarily know why. The mechanism is theorized under biomechanical, neurophysiological, or biopsychosocial. The issue lies in not knowing what we don't know. A perfect example of this is voodoo type treatments like visceral manipulation. The way it is presented in most physical therapy culture is as a joke, unfortunately. The lack of research and basic understanding tends to push many away from exploring the topic. With many never considering it as a possible beneficial treatment, they ignore any possible chance of discovering the potential benefits and effectiveness of the treatment. While I do think the concept would be more accepting if it had greater research support, I do not believe we have the techniques to fully study the methods.
As I am preparing to take my first visceral manipulation course next week, I have been reading one of the textbooks for the course. A concept that was just brought up in the first couple pages was restriction in mobility of the viscera. The abdomen and thorax are typically ignored from a physical therapy education's perspective as we typically focus on muscles, bones, and joints. However, each time we bend or twist, there is force transmitted through the thorax and, thus, the organs. Is it possible that a restriction in visceral mobility can then limit motion or affect pain/disability as well? I do not know, but I look forward to developing some sort of understanding of it, so that I can at least begin to know more about what I don't know.
-Dr. Chris Fox, PT, DPT, OCS
Recently, Dr. Erson Religisio III over at Modern Manual Therapy discussed differentiating weakness versus inhibition in this post. If you take a look at the video, he finds that an inhibited muscle will test much stronger if we gradually increase resistance while applying force and the patient can then match, or at least improve. A truly weak muscle doesn't exhibit this improvement.
When completing my residency, we found neurogenic weakness through repetition testing of the muscle. That is, we would quickly test the muscle strength and re-test the strength rapidly, looking for a loss of strength. While I think both Dr. E's method and the one I learned in my residency can play a role, personally, I look at any loss of muscle activity as potential neural involvement. What is key to consider is correlating with testing other muscles and other findings as well. For example, if the gluteus medius tests weak, as does EHL and peroneal longus/brevis, we should think about L5 being involved. The difficulty comes in differentiating peripheral nerve lesions from local muscular weakness, specifically if there are few muscles innervated via that peripheral nerve.
In reality, with the power of the nervous system, I find that we can frequently alter "strength" through treating the spine or nerves. When in comes to practice, I recommend tackling it from all ends. If a patient with hip pain and weak glutes also has a deficit in lumbar mobility, I would treat both the weak glutes and limited lumbar motion. These are impairments and may or may not be contributing to the patient's dysfunction. As I always recommend, treat the impairments, but it may be fun to start playing around with testing for true weakness vs inhibition in your patients. See how that impacts your examination and treatment!
-Dr. Chris Fox, PT, DPT, OCS