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How To Avoid Chronic Ankle Sprains

Ankle sprains are a common injury for a majority of sports but the highest incidence rates are found with basketball, volleyball, soccer, baseball and gymnastics.  Depending on the severity, you could be out of the game for as little as 1 week to 8 weeks or more.

In order to ensure proper recovery from an ankle sprain, let me take you through an 8-step return to play overview for an ankle sprain to help you avoid continuously turning your ankle and suffering from chronically a ‘weak’ ankle.

A laterally sprained ankle occurs when one or more of the ligaments on the outer side of your ankle are
torn. If a sprain is not treated properly, you can have long-term problems. This is the most common
type of ankle sprain (typically known as an inversion sprain).

Step 1 Immediate Treatment
P.I.E.R.
Pressure – reduces the swelling in the area and gives support.
Ice- slows down the inflammatory process. (Dr. Keith would disagree with me on this here…)
Elevation – helps reduce swelling and gets blood flowing to the heart (increase venous return).
Rest or Restricted Activity – prevents unwanted movement at the ankle.
Next step is to go for therapy /clinical rehab.

Step 2 Clinical Assessment
At the clinic the initial assessment entails a case history, postural assessment, gait assessment and
functional testing of the ankle joint.  The case history includes a variety of questions related to how and when the sprain occurred, where it hurts, what makes it worse/better and past history of ankle injuries.

Next if possible, the therapist will have walk or have you stand. Following this the therapist will test your
range of motion. He /she will see if you can move the foot up or down and side to side. They will then
test your strength and possibly do a few more tests.

Step 3 Protection Phase
Initial treatment may include modalities like ultrasound, laser and PIER to help with swelling, muscle
setting exercises and pain free active range of motion exercises like moving the ankle up (dorsiflexion)
and to the outside (eversion). These need to be done in a clinic setting with a home program to do away
from the clinic when not being treated.  In this phase the focus is to decrease, remove swelling and maintain the current range of motion at the ankle.

Step 4 Controlled Motion Phase
In this phase the goal is to regain normal range of motion, flexibility and the introduction to weight bearing and balance exercises.  Stretching the calf muscle and actively moving the ankle in all directions.

At this point if the ankle is supported the athlete may get on stationary bike and do 30-45 minutes of
work to maintain a basic level of fitness.

Step 5 Return to Function Phase
In this phase the goal is to integrate total body strength and power exercises such as lunges, squats, single and double hops / jumps in different directions and agility exercises that mimic the movements on the sports field such as stop starts and change of direction.
This phase also includes appropriate aerobic training to reach pre-sport fitness levels. Ideally this should
be ground based; however this may be done a bike.
At this point the athlete may be braced or taped depending on the severity of the injury.
It is in this phase that the athlete may return to the field / ice to do isolated agility drills, stop starts and
change of direction.

Step 6 Field / Ice / Court Training 1 – (This may happen at the same time as Step 5 in the clinic.)
Dynamic Warm up, individual game skills, specific aerobic fitness training. For example if you are a hockey player most shifts are 30 to 45 seconds with about minute and half to three minute rest. You want mimic your work to rest timing as though you are in game.

Step 7 Non – Contact Practice
Work with your team for plays, drills; however there is no contact

Step 8 Full Contact Practice
In this step you are fully engaged as though you were in game.

Game Time
If you have been successful in the previous steps you are now ready to participate in a game.

Your friendly neighbourhood Athletic Therapist!

Michael Wolfe Grafstein

B.Ph.Ed, RMT, R.Kin, SMT(C), CAT(C)

Is A Cortisone Shot The Answer To Your Shoulder Pain?

Cortisone shots are frequently prescribed by medical doctors if you have been suffering with prolonged pain in your back, knees or shoulders.  Is it the best way to manage your pain?  A recent study in the Annals of Internal Medicine, August 2014, compared a one year outcome of steroid injection to physical therapy for shoulder impingement syndrome.  Both groups showed the same pain level and disability improvement after 1 year (approximately 50% improvement).  But 60% of the injection group had to return to their primary care doctor after 1 year as compared to 37% of the physical therapy group.  Also, the injection group were more likely to need more injections or physical therapy after 1 year.

Case Study – 60 Year Old Male Triathlete

Here is a case study of a successful recovery of one of my patients. Let me tell you and it was not always this way. I was successful in facilitating this rehabilitation for two main reasons: 1. Patient compliance with exercise and  2. I changed my way of treating shoulders.

Initial Assessment:
The patient was not able to lift his arm to the side past 90 degrees (shoulder level) without having pain and moving his head forward. It was difficult for him to wave without having pain or major discomfort.  Even putting a sweater or even a T-shirt on caused pain and discomfort.  Not only did he have difficulty raising his arm to the side but he also had difficulty raising his arm forward.  When I looked at his posture I saw slight forward head carriage and rounded shoulders.

Treatment:
I treated this patient over a five to six week time period. Specific manual techniques were performed on the following muscles to help to increase muscle length: medial and lateral rotators of the shoulder joint, the trapezius muscle along with some of the neck muscles.
The deltoid muscle, the biceps muscle and triceps muscle were also treated manually. I treat these muscles because I find if left untreated, there is still a lingering restricted range of motion.  I also treated the subclavius muscle which lies directly underneath the collar bone and attaches to the ribs.
I have found treating this area very beneficial with increasing range of motion at the shoulder.

Exercises:
To complement this treatment, I gave very specific postural exercises for this patient to do at home. Muscle setting exercises are the base for any recovery from shoulder issues for me. Although simple in nature they do take time to master; however the benefits are phenomenal.
This simple exercises are performed by lowering the shoulder and shoulder blade, then bringing the shoulder blades together. This causes the front to open up which decreases the sense of “tightness”.
He was required to complete three sets of ten repetitions, holding for three seconds at a time.
My patient was and is still very compliant with these exercises and feels significantly better since starting them.

Outcome:
Putting on clothes and waving to family and friends are no longer a problem!  He is extremely pleased with the results as he thought he would have to live with the pain for the rest of his life.  And he went on to compete in a triathlon without feeling restricted in his shoulder during swimming.  All this without resorting to a cortisone injection which would have only masked the pain temporarily but would not have addressed the underlying muscular issues contributing to the actual problem.

Your friendly neighbourhood Athletic Therapist!

Michael Wolfe Grafstein

B.Ph.Ed, RMT, R.Kin, SMT(C), CAT(C)

Your Knee Pain Is Coming From Your Foot and Hip!

Now that I have your attention you may want to read on. If you answer yes to any one of these questions there is a very good chance your knee pain is a symptom of something else that is weak or tight or flat.

Do you have pain when jogging?

Do you have knee pain when going up stairs?

Do you have knee pain from jumping?

Do you have knee pain when you play sports?

Chances are that if you answered ‘yes’ to any of these questions then your pain is either an indirect or direct response from something else in your body that is not working functionally or mechanically.

So you may be asking yourself now, “What is actually causing my knee pain?”

In my experience in assessing and treating knee injuries for the past 25 years, knee pain arises from either muscle issues at your hip or problems with your feet.

The knee joint is like a hinge. It is the midpoint between the hip and the foot. Anything that happens to either the foot or the hip will have a direct effect on the knee.

If you have flat feet there is very good chance that right now you suffer from knee pain unless you wear inserts or orthotics in your shoes. Without the inserts the foot becomes flat when you walk. This causes the knee to turn in more which leads to more load on the knee joint.

To correct this inserts or orthotics give support to the foot minimizing the flattening of the arch of the foot when you take a step. Sometimes this all you that you need to correct this problem.

Next, if the muscles at your hip are weak that will lead the thigh bone to rotate inward more causing more force on the knee joint. This may lead several areas of pain at the knee:

  1. Pain on the inside of the knee
  2. Pain on the underside of the knee cap (Chondromalacia patella)
  3. Pain below the knee (Patellar tendonitis)
  4. Swelling behind the knee (Housemaid’s knee)
  5. Pain above the knee (Jumpers knee)

What is the solution?

As with most injuries I put you through a full assessment that includes both postural observation and gait analysis followed by specific testing at the ankle knee and hip.

Once this testing is completed I create both a clinical plan and a home exercise program. The home exercise program focus is on exercises that strengthen weak muscles and lengthens shortened muscles.

If you truly want to get rid of this knee pain I would suggest that you make the time to do your “homework” on a daily consistent basis. Exercises may include the “clamshell” and/or the “monster walk”.

Be aware that any treatment that solely focuses directly on the knee may give you short term relief but not resolve your knee pain long term.

Your friendly neighbourhood Athletic Therapist!

Michael Wolfe Grafstein

B.Ph.Ed, RMT, R.Kin, SMT(C), CAT(C)