I sprained my ankle months ago and it still hurts?

A sprained ankle is the most common sports injury. However, it usually is easy to diagnose and will eventually always heal. Sprained ankles are expected to be back to 90% recovery within 6 weeks (This may vary depending on the degree of sprain and other associated factors). However, what if it doesn't get better? What if your symptoms have not resided by that time? Believe it or not, a simple sprained ankle can often lead to long term problems.


1) Osteochondral Lesions/Osteocondritis Dissecans of the Talus

Often when an ankle is sprained there can be a sudden loss of stability. This can cause bones within the ankle to impact or collapse into one another causing an osteochondral lesion to form. An osteocondral lesion is when the cartilage surrounding a bone is torn, crushed and in more rare causes forms a cyst. Cartilage is the cushioning our bones and joints are surrounded by to help with impact forces. With the cartilage now torn or disrupted it may break off with a small piece of bone and be wedged or displaced inside a joint.


Symptoms often include persistent pain with activity. The pain may be deep within the joint and can occur long after the pain felt from a sprained ankle has resided. The ankle may also experience catching, snapping or locking which it hasn't experienced before. There have been reports of asymptomatic cases and individuals healing spontaneously, but this is often amongst a younger population. Furthermore, these lesions can at times progress to create osteoarthritis within the ankle joint.

Do not assume you do not have this injury because you had radiographs taken. The lesions are small (2-5mm) and flake like. Furthermore, special views are commonly used to spot the injury which will often not be included in a normal series of ankle radiographs. Observe below (A & B no lesions is shown but can be seen on view C). Needless to say this injury is difficult to spot. If easily accessible an MRI should be taken as it has shown optimal diagnostic value.

Osteocondral lesion can be treated conservatively and surgically. However, there has been a lack of research to determine what factors play into the decision making process. Most children or adolescents will resolve the lesion because of their healing properties but adults often carry out the option of surgery.

2)Complex Regional Pain Syndrome/ Reflex Sympathetic Dystrophy

There is no standard definition for CRPS, as nobody has determined what causes the condition. Essentially the syndrome can be defined by its simplistic name "Complex Regional Pain". The syndrome involves a complex array of symptoms in a particular region which leads to pain. However, CRPS has a neurological component explaining the symptoms.

The cause is often attributed to the neurological system becoming confused. When someone experiences an injury the bodies nervous system reacts by producing pain, increasing swelling, changing color due to inflammation ect. However, with CRPS the nerves now are hyper-vigilant, meaning the littlest touch or activity can set of a chain reaction replicating a more serious injury. Reports have shown incidents as small as a paper-cut to cause CRPS. Simple events such as walking or putting on your socks can be interpreted by the ankles nervous system as getting hit by a hammer.

Symptoms will include pain disproportional to the event causing the symptoms originally. Light touch or the application of any form of heat or coldness may be taken as intolerable. Nerves which innervate blood vessels and sweat glands are also affected. Symptoms of this nature may will appear as excessive swelling by the ankle, changes in color, changes to the appearance of the toe nails, hair loss and even sweating when not indicated. In Addition, muscles around the ankle with time may become weakened and get smaller in appearance.

Diagnosing CRPS isn't an easy task. Radiographs, MRI and common physical examination procedures can give a good implication of a diagnosis but not always confirm. Often special imaging is carried out to assess the bodies thermo graphic patterns.

3) Ankle Impingement Syndrome

The body works on a simple concept that when a structure gets damaged it will try to repair itself. Furthermore, whenever a repetitive force or even a constant pressure is applied to a structure it will react by growing, shaping or forming a new position to compensate for this pressure. This concept is how braces work for shaping ones teeth properly.

In the ankle there are a lot of ligaments, muscles and joints. Often when repetitive trauma or strain is applied to one of these structures it will compensate similar to what was described above. Eventually the small bit of cartilage surrounding the bones or ligaments will be pulled on or experience "traction". This constant repetitive action will lead to the formation of little bone and cartilage spurs. These spurs will also occur after repetitive ankle sprains. This process is called osteophytosis.

The spurs formed can often not present any problem at all. However, occasionally bone spurs (also called "osteophytes") will "impinge" structures such as ligaments, tendons and scar tissue from past injuries.

Signs and symptoms may include an ankle which feels unstable or weak. Tenderness or a "pinching sensation" may occur when the foot is brought through flexion and extension. A painful clicking may also be observed during certain movements of the ankle. Impingement can occur in the front and back of the ankle. Usually squatting or bringing your toes towards your head will be painful in anterior impingement. Bringing your toes downward or rising on your toes will produce pain in posterior impingement.

5) Cuboid Syndrome

The cuboid is a small bone that lies on the outside of the foot. Cuboid syndrome is when this bone experiences excessive movement or a collapsing effect. The excessive movement can cause irritation of the surrounding joint capsule and ligaments or put strain on a particular muscle which attaches to the cuboid called the fibularis longus.

Up to 4% of athletes can experience cuboid syndrome with a particular high rate in ballet dancers. However, up to 6.7% of those experiencing ankle sprains can develop cuboid syndrome. When the foot is forced into this position the fibularis longus muscle experiences tension thus jamming the cuboid bone and forcing it to shift out of place.

Patients with cuboid syndrome may present with pain directly over the cuboid and radiating down the outside of the foot. Pain is often associated with a weight bearing position but can occur otherwise. Pain can be experienced with squatting or on toe off during a running gait. Weakness can often be a secondary complaint.

The good news is cuboid syndrome has been shown to be successfully treated with conservative treatment including rehab, manipulation, taping and the placement of a small felt pad under the cuboid preventing it from collapsing.

In summary, if your experiencing new symptoms after an ankle sprain get it assessed by a trained professional. The complaint may be something completely new but sprained ankles often lead to problems down the road. Assess the problem early, listen to your clinician and take precautions on your first ankle sprain to reassure these problems don't persist.

Other injuries that may occur after a sprained ankle or be confused with previous mentioned conditions are:

-Os trigonum
-Fibularis Longus Subluxation
-Sinus Tarsi Syndrome
-Osteoarthritis
-Nerve Palsy

References





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Choi WJ, Park KK, Kim BS, & Lee JW (2009). Osteochondral lesion of the talus: is there a critical defect size for poor outcome? The American journal of sports medicine, 37 (10), 1974-80 PMID: 19654429

PONTELL, D. (2008). A Clinical Approach to Complex Regional Pain Syndrome Clinics in Podiatric Medicine and Surgery, 25 (3), 361-380 DOI: 10.1016/j.cpm.2008.02.011

Jennings, J. (2005). Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1596

Orthopedic Test of The Month: The Stroke Test

Often when carrying out an examination multiple test will be performed. The checklist of orthopedic test can be endless. Multiple books and studies have been written regarding testing procedures. Furthermore, most test will have different names and variations which are open to subjective analysis. This is why research has shown the experience of the clinician to increase the diagnostic value of a test [1] Swelling is no exception to this rule.

How can you measure or grade swelling? What one deems to be significant swelling another may assess as minimal swelling. Due to this subjective nature it is often difficult for manual therapist to confirm or apply a grading system to swelling.

This Months Orthopedic Test: The Stroke Test (a.k.a Brush test, Wipe test, Bulge test)

When an injury occurs swelling will usually develop. Sever swelling outside of a joint can often be simple to see (See Pictures). However, whenever swelling occurs on a small level it can be difficult to assess and measure.

The knee joint normally holds 1-7ml of fluid within it's capsule. The stroke test has reported to show as little as 4-8ml of extra fluid within the knee. Occasionally when a knee has minimal intracapsular swelling the only observable feature is a puffy type of appearance. The patient may report a boggy sensation, an increased amount of pressure or assume a resting position of the knee. The resting position of the knee is when the knee will remain in a 15-25 degree flexed position. This position allows the knee capsule to hold the most amount of fluid and can be observed from the side of a patient while standing.

Multiple test have been purposed to measure swelling in the knee but no gold standard has been established. Measuring tape can lead to many forms of human error and subjective scrutiny. Although ultrasound and MRI have been deemed valuable ways of measuring swelling they are not always easily accessible for practitioners. Due to these reasons the stroke test can be a valuable method to not only diagnose swelling but to assess and be used in monitoring the progression of rehab exercises.

The stroke test is performed with the patient in a supine position and the knees fully extended and relaxed. The idea of the stroke test is for the examiner to create a fluid wave and displace the fluid in an area of the knee that allows the fluid to dissipate and pool. Starting at the medial tibiofemoral joint line, the examiner strokes upward 2-3 times towards the suprapatellar pouch in an attempt to move the swelling from within the joint capsule to the suprapatellar pouch. The examiner then strokes downward on the distal lateral thigh superior to the suprapatellar pouch, towards the lateral joint line. A wave of fluid may be observed along the medial side of the knee.The test can be measured in quantity on a 0-3 scale. If performing the downward stroke doesn't produce a wave of fluid a score of 0 is given. A small bulge produced with the down ward stroke is valued at 0 and a large wave 1+. If the medial fluid returns to its position without attempting a downward stroke a grade of 2+ is given and not being able to displace the fluid with an upward stroke is valued at 3+ .

The grading system has been shown to produce a high interrater reliability amongst practitioners [2]. Furthermore, the test creates a rating scale which can be used when relaying information to other professionals. In addition, creating a rating scale allows more precise measures and more specificity to be observed when researching or examining swelling of the knee.

1. David J Magee. Orthopedic Physical Assessment. 5th Ed

2. Sturgill L.P & al. Interrater reliability of a clinical scale to assess knee joint effusion. JOSPT. 2009, Vol 39, 12 845-849.

Need Another Reason To Text? How About Losing Weight?

With the rise of obesity in our society people will try almost anything to lose weight. This can include different diets, workout regiments and even surgery. The research and market exposure tackling such a topic is outstanding. However, a new study from the University of California purposes a different method to losing weight...texting?

Subjects in the study were sent 3-5 text messages a day with friendly tips and reminders on nutrition and weight control. Furthermore, calls would be carried out throughout the study to subjects by a health counselor.
Participants of the study lost on average slightly over 6lbs in 16 weeks. This was 4lbs more than those who were not texted during the study. Although 6lbs seems like a minor loss this is fairly significant considering no other adjustments were made to these people's lives.

The study purposes an interesting method of assisting people in losing weight. With the rise of child obesity and the popularity of cell phones such an idea isn't too far-fetched. New IPhone applications are always arising regarding diet tips and nutritional advice. In addition, one could use such a protocol when needing advice or motivation from their trainer which is not always present. So the next time you text your overweight friend try texting them some diet advice. Who knows........it may go over well.

Dr. Wayne Button, BSc, D.C

Patrick K, Raab F, Adams MA, Dillon L, Zabinski M, Rock CL, Griswold WG, & Norman GJ (2009). A text message-based intervention for weight loss: randomized controlled trial. Journal of medical Internet research, 11 (1) PMID: 19141433

Biking Injuries: Handlebar Palsy - Riding my bike is bad for my wrist?

It is pretty hard to walk along the canal on a nice day in Ottawa and not see a herd of bicycles pass you along the way. Biking is becoming increasingly popular in both transportation and recreational settings. In China bicycling is the number one form of urban transportation.

Due to these reasons bicycling injuries are becoming more and more common. However, most of these injuries can be avoided with just a few simple tips or minor adjustments to a bicyclist form or bike.


"Handlebar Palsy" is a term used to describe a nerve injury which occurs to bicyclist. This injury is often caused by prolonged compression or repetitive damage consistently to the Ulnar Nerve in the wrist. This nerve runs along the outside of the wrist and can carry both motor and sensory components. Depending on where the nerve gets damaged can dictate which components are corrupted. (Observe Picture).

However, the motor branch of the nerve is most commonly affected. This means pain, numbness and tingling aren't presented as symptoms. However, muscles will begin to lose their strength and function leaving bicyclist curious of why an onset of sudden hand weakness has occurred.

Signs and Symptoms

Often cases of "Handlebar Palsy" occur in individuals who have performed an excessive amount of biking. Cases have been published on people biking across the country or going on biking trips. However, there is also cases of it occurring due to an acute direct trauma.

Symptoms include unexplained weakness, clumsiness and muscle atrophy of the hand. Patients have also reported not being able to perform normal hand functions such as playing piano or using surgical equipment.

Prevention

Handlebar Palsy can often be avoided by a proper placement of one's wrist on the handlebars. Those suffering from HP will usually display a faulty grip position. This can include hyperextending the wrist which will apply tension to the nerve (Picture to the left). Furthermore, one may grip the handlebars in a position which leaves the ulnar nerve exposed to being compressed. Try gripping your handlebars with a neutral wrist and leave the outside of the hand exposed. (Picture to the right)

In addition, bicyclist should always be fitted by a professional to make sure thier seat, frame, handlebars and pedals are placed properly for them. Try adjusting your seatt to place you in a more upright manner and avoid applying pressure on your hands and wrist. Attempt to take frequent breaks whenever carrying out long bike rides. When riding constantly adjust your position on the handlebars avoiding a consistent compression point. Whenever possible one should attempt to distribute the weight along the outside of their hands rather then the center of their palms. Using bicycling gloves and soft gripping for handlebars can also help reduce the force of vibrations being transmitted to your hands. Lastly, attempt different hand and wrist stretches before going for a ride.

I think I already have this injury?

Get the possible injury assessed by a health professional. Attempt to find a professional in your area who has a specialty or interest in sports injuries. There are multiple more serious neurological conditions which can replicate this injury (ALS, MS) and shouldn't go ignored without being looked at.

Cases of handlebar palsy may take weeks to months to reside. However, bicycling should also be ceased until the nerve is given time to regenerate. This is a slow process (approx 1mm a month) and will be hindered if the nerve is still left exposed to consistent vibrations. After the injury is confirmed by testing and shown to resolve one should take precautions before returning to the bike. Strength of the muscles in the hands and wrist should be returned to full form and again the patients biking mechanics should be looked at.

In summary, multiple bike injuries can be avoided with simple precautions and changes in biomechanics. We often wear helmets to protect our head but forget about the other body parts which are crucial in our everyday life such as our hands. Dr. Wayne Button, BSc, D.C




Capitani D, & Beer S (2002). Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking. Journal of neurology, 249 (10), 1441-5 PMID: 12382163

New Ground Breaking Research on MS

New MS story--ground breaking research

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20091120/W5_liberation_091121/20091121?s_name=W5

Does Your Pelvis Move Too Much????

Form Closure vs Forced Closure and the Active SLR

Often many people wonder why the SacroIliac Joint (SIJ) is designed the way it is? The SIJ is in an area where a lot of forces are transferred from the lower body to the upper body and vice versa. Due to this reasoning one may wonder why the SIJ has such flat articulation. The SIJ is designed to deal with compressive and bending forces but not shear forces. This is why it would make more functional sense for the SIJ to be glued together.

So how does the SIJ compensate?

1. Wedged shaped sacrum stabilized by inominates

2. Not a normal smooth articular cartilage (view images)

3. Cartilage covered bony protrusions into the joint (view images)

These three mechanisms represent the SIJ's way of achieving what is called Form Closure.


But if the SIJ was molded perfectly it would have no mobility?

This is why the SIJ needs to find a perfect equilibrium between movement and stability. With the muscles, fascia and ligaments around it, the SIJ now finds a way to create what's called Force Closure. Using anatomical structures to create force and allow the SIJ to move and be stable.

How does the SIJ achieve this "SelfLocking" or "SelfBracing Mechanism"?

1. Ligaments
               - Dorsal Sacral Ligaments (Nutation=Tension)
                  -When the sacrum experiences nutation it uses the dorsal sacral ligaments like a hammock. Resting on these ligaments now creates tension and thus provides friction/stability to the SIJ. Often this ligament can be dysfunctional or tender amongst pregnant women. This relationship explains how now a more mobile pelvis has to use ligaments around it for stability.

               - Sacrotuberous Ligaments (Loading = Decreased Mobility)
                  - Studies have shown that by loading the sacrotuberous ligament mobility of the SIJ will be decreased. This ligament will become loaded by tension in the muscles that attach to it such as the Bicep Femoris, Glut Max, Piriformis and Tharacolumbar Fascia. Again this connection can be supported by the correlation of pregnant women having tight hamstrings. The hamstrings attempt to load the sacrituberous joint and work harder to keep this now mobile SIJ stable.

2. Thoracolumbar Fascia
               - Multiple muscles attach to the thoracolumbar fascia allowing it to the act as a connection point between muscles of the lower back, pelvic and proximal aspect of the lower extremities. This fascia creates stability by producing tension when these muscle contract. The Multifidus may contract and balloon up into the fascia allowing it to tighten and thus brace its surroundings.

3. Musculature Slings
               - There are multiple slings of muscles which envelope the SIJ allowing it to be stabilized. The anatomical pattern of these slings gives premise for rehabilitation to be performed on these muscles in an attempt to create SIJ stability. If one creates a rehabilitation program to strengthen these muscles the movement and pain from the SIJ may be reduced.

Three Musculature Slings

1. Longitudinal Sling 

Multifidus-Sacrum-Deep Layer of TLF-Sacrotuberous Ligaments-Bicep Femoris

2. Posterior Oblique Sling

Latissimus Dorsi-TLF-Glut Max

3. Anterior Oblique Sling

Ext Obliques-Int Obliques-Transverse Abdominus-Piriformis-Rectus Abdominus-Linea Alba-Inguinal Ligament

So what if I don't have this "Selflocking" mechanism?

Problems may occur in this area if an equilibruim is not created between stability and movement.

-This can create diminished muscle power causing muscles to have to work more towards stabilizing the SIJ and not working towards other functions.

-Secondly, this may create an imbalance between muscle function and not allow muscles to work in synergy together towards other goals like creating core strength.

-Thirdly, this can create excessive ligament tension around the SIJ.

-Lastly, this will cause an excessive amount of mobility in the SIJ similar to someone who is pregnant.

Combine all these factors and you will experience a consequence of PAIN.

Is there anything else I can do?

There are mechanisms of producing this type of forced closure that your SIJ needs.

Pregnant women often try using a maternity belt for posture. Furthermore, athletes are now using what is called "Core Shorts" and getting great results.

Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, & Mens JM (1998). Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Manual therapy, 3 (1), 12-20 PMID: 11487296

Self Diagnosis: Why you should tell your doctor what the diagnosis is

Ever look up your symptoms on the internet? Ever have a friend diagnose you with something they have had previously?

With the internet today more and more people are taking initiative to diagnose themselves.  New research shows there is some merit in telling your doctor what you believe you may have. The British Medical Journal recently published an article discussing the new phenomenon of “Self Diagnosis” or “Self Labeling”.

Reports have been made that “Self Diagnosis” can initiate a correct finding in 18% of consultations. Furthermore, the “presenting complaint” of a patient may guide the diagnosing process 70% of the time. This indicates the importance of a patient communication to their doctor. If you have multiple symptoms a diagnosis may be established by your initial complaint.

Conditions accurately diagnosed by self labeling: Urinary tract infections, recurrent uveitis, schistosomiasis and head lice.

However, don't over estimate the power of self diagnosis. Wrongful incidence of self diagnosis can occur when treatment is initiated by the patient before consulting their doctor. Women who purchase over the counter antifungal treatment with the suspicion of having an infection are a great example.  A high percentage of these women actually have a bacterial form of infection not fungal.

In addition, self diagnosis can be at times very unsafe. Cases have been reported of a heart attack being mistaken as indigestion and rectal bleeding thought to be due to haemorrhoids only to be discovered as colon cancer.

Conditions often misdiagnosed by self labeling: pregnancy, yeast infections and scabies.

So remember always consult a health professional with your problems but don’t be afraid to give them some pointers.  Dr. Wayne Button BSc, D.C

 

Ryan, M. (1979). USSR letter: Self-diagnosis. BMJ, 2 (6196), 979-980 DOI: 10.1136/bmj.2.6196.979

Carpal Tunnel Syndrome a real pain in the neck?

Often in school when we are thought the nervous system our instructors will use pretty pictures from text books.  Blue represents the L5 dermatological distribution or pink is where the median nerve travels. Although these pictures give great insight towards mapping out the nervous system they can at times be diagnostically useless. This is because they are based on the belief every nerve carries out the exact same pattern in every person. In addition, it is wrong to believe every nerve which obtains a pathology will present with similar symptoms consistently.

The nervous system is one of the most complex systems the body has to offer. Studies have shown Ulnar Nerve abnormalities in patients with Carpal Tunnel Syndrome (CTS), which is a condition involving the Median Nerve.[1] Furthermore, studies have also demonstrated a decrease in pressure of the Guyon's canal (a common site for Ulnar nerve entrapment) after Carpal Tunnel surgeries have been performed.[2]

This gives premise to the concept that nerves in one area may very well affect nerves in another area. It seems the nervous system may work as a whole and not in just different subsets of entities.  When considering this concept it doesn't surprise me that CTS has been shown to also relate to neck disorders. [3,4].

A recent study in JOSPT evaluated this relationship further. The article attempted to analyze if forward head posture (FHP) and cervical range of motion (CROM) is related to CTS or median nerve abnormalities. Subjects with CTS were compared with healthy controls. In addition, subjects were paired based on age, occupation and hand dominance. Occupations consisted of desk worker, housewife, cleaning lady and teachers.

Results indicated a significant correlation to both a reduction in CROM and increased FHP in the group with CTS. CROM differences ranged from 12-18 degrees less in those with CTS. Furthermore FHP ranged with a difference 8-9 degrees in those with CTS.

Although this correlation is an interesting finding it can not create a cause and effect relationship. The study also found these findings to not be related to pain or symptoms of CTS.

In summary, one cannot say CTS is caused by postural abnormalities of the neck. The authors suggest these findings may be due to the CTS itself. A similar example is when patients will often have an antalgic posture when herniating a disc in their back. This purposes the concept that we should explore the option of treating the neck in patients with CTS. Furthermore, if postural corrections are made in patients with FHP will this decrease the prevalence of CTS? Only one case study to date has assessed a multimodal approach to treating a patient with CTS [5]. Hopefully, the following study will promote more research into this relationship.

Ginanneschi, F., Milani, P., & Rossi, A. (2008). Anomalies of ulnar nerve conduction in different carpal tunnel syndrome stages Muscle & Nerve, 38 (3), 1155-1160 DOI: 10.1002/mus.21070

Mondelli M, Ginanneschi F, & Rossi A (2009). Evidence of improvement in distal conduction of ulnar nerve sensory fibers after carpal tunnel release. Neurosurgery, 65 (4) PMID: 19834374

Chow CS, Hung LK, Chiu CP, Lai KL, Lam LN, Ng ML, Tam KC, Wong KC, & Ho PC (2005). Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand, 10 (1), 1-5 PMID: 16106494

Reading, I. (2003). Anatomic Distribution of Sensory Symptoms in the Hand and Their Relation to Neck Pain, Psychosocial Variables, and Occupational Activities American Journal of Epidemiology, 157 (6), 524-530 DOI: 10.1093/aje/kwf225

Valente R, & Gibson H (1994). Chiropractic manipulation in carpal tunnel syndrome. Journal of manipulative and physiological therapeutics, 17 (4), 246-9 PMID: 8046280

De-la-Llave-Rincón, A. (2009). Increased Forward Head Posture and Restricted Cervical Range of Motion in Patients With Carpal Tunnel Syndrome Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.3058