Do You Need Physical Therapy for a Sprained Ankle?

Everyone has had an ankle sprain, right?  It’s no big deal, not worth having anyone look at it because it’s just going to take some time to get better on its own.  Not so fast!  Unfortunately, I don’t see as many ankle sprains as I think I should.  People either never seek help from any healthcare provider, or they go to see their doctor who gives them a brace, maybe some crutches, and tells them to ice it and stay off of it for a while.  That’s it, no instructions on when or how to return to activity.

This can set people up for re-injury or lingering pain.  When we sustain an ankle sprain, we not only have damage to the ligaments.  Sometimes during the healing process, the ankle joint stiffens up and loses some of its mobility.  In addition to the ligamentous injury, we also damage the nerve endings that tell us where our bodies are in space (proprioception).  This sets us up for an increased chance for injury in the future.  In fact, research shows that you are at a higher risk for re-injury if you have a minor (low grade) ankle sprain compared to a severe (high grade) one.  This is likely because people are more likely to be referred to physical therapy after a severe sprain and are more likely to just “walk it off” after a minor one.

The importance of physical therapy after an ankle sprain is threefold.  We help instruct you how to take care of yourself in the acute stages.  It’s not just as easy as rest and ice.  Rest, ice, compression, and elevation (RICE) are important, but so is early return to gentle movement and controlled loading of the joint.  The goal is to get the motion back as early as possible and get back to a normal walking pattern as soon as possible.  Only a physical therapist can help you through this process and avoid either pushing yourself too hard, or not hard enough.

500_F_113522658_z6QfUHAtGFGTyOP6HseQSCgvCjuynP6dSecond, and along the same lines, during the next few weeks we help people know how and when to progress themselves to the next step.  An important part of this progression is a focus on balance and proprioception.  We need to re-train those nerve endings and the body’s ability to tell where it is in space.  This is crucial to getting people back to their activities with less risk of re-injury.

Lastly, we have a battery of tests that we put people through in order to determine if/when you are ready to return to your sport or activity.  The tests we run people through depend on the activities required.

So next time you roll your ankle, don’t just “walk it off” and hope it goes away.  Seek out treatment from a physical therapist.  Your body will thank you for it!

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How Can Physical Therapy Help with Vertigo? Part Two

Your provider has diagnosed you with vertigo.  In a perfect world, they have given you a referral for physical therapy.  Unfortunately, there is a high likelihood that they haven’t.  This is probably because they don’t know what we can do for their patients.  This is when being a strong advocate for your own healthcare is important.  Vertigo can be very debilitating, but there are treatment options out there.

As physical therapists, we perform our own evaluation of the vertigo symptoms.  We determine if it is benign paroxysmal positional vertigo (BPPV) or some other type of vertigo.  If it is determined to be BPPV, we then assess which positions are causing your symptoms and which part of your inner ear is the source.

4b38c92e5969dc12322a877bfbd14138Our initial treatment is focused on what’s called canalith repositioning.  This is where different maneuvers are performed in an attempt to move the particles out of the area that causes vertigo.  The most common approach is the Epley Maneuver.  This can often be accomplished in 1-2 treatments, but it can require additional treatments.

Once the vertigo has subsided, there are additional treatments that patients may require.  Often people who have been suffering from vertigo have figured out ways to adapt in order to avoid their symptoms.  This avoidance of symptoms means limiting movement and activity.  We cannot go through life avoiding everyday movements and activities though!  The purpose of vestibular rehabilitation is to expose people to the activities they have been avoiding and re-train the vestibular system through compensatory strategies.

Our three main treatment approaches are:

Habituation – focusing on reducing the dizziness/symptoms that occur with quick head movements

Gaze Stabilization – focuses on improving vision when the head is moving

Balance Training – focuses on improving steadiness/stability and safety during activities.  These exercises should be challenging and incorporate additional challenges to mimic the patient’s activities of daily living.

Although there are many sites on the internet for self-treatment of vertigo, it is important to seek out a trained professional to avoid making symptoms worse, or risking injury.

What is Vertigo and How Can Physical Therapists Help?

There are different types of vertigo, but the most common one is called benign paroxysmal positional vertigo or BPPV.   Vertigo is different than just a feeling of dizziness.  It is a feeling that the room is spinning, or that you are spinning.  Although BPPV is benign (not life-threatening) it can cause severe nausea, vomiting, and disability.  It creates a significant increased risk of falling as well.

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With BPPV, the crystals in our inner ear are displaced and they migrate into the semicircular canals.  These canals are what sense head movement in our vestibular system, and a build-up of crystals in the canal will give our bodies a false sense of movement.  This creates a feeling of vertigo (spinning) with changes in head positions for people.  The symptoms of this type of vertigo are typically short lived but recur consistently with changes in head position.  Often, we hear our patients tell us that every time they roll on their side or put their head back when washing their hair in the shower they experience vertigo.

Unfortunately, this highly treatable condition often goes untreated and undiagnosed.  Many patients don’t realize that it can be treated, and so they don’t talk to their physician about it.  Even more unfortunate is that many physicians/providers don’t realize that there are treatment options out there.  I often determine my patient is suffering from BPPV when they are referred for something unrelated.  In the course of evaluating them, as they go to sit up from the table they experience vertigo.  Upon further questioning, a common response from them is, “my doctor gave me some medicine and told me it would just go away eventually”.

This approach to BPPV creates prolonged unnecessary suffering that can be avoided with a referral to a qualified physical therapist who has been trained in vestibular rehabilitation.  Please check in next week to find out what types of treatment we do for vertigo.

Assessing for ACL Injury Risk

We’ve established that poor jumping/landing technique is a major risk factor for an ACL injury in athletes.  So, what are the best ways to screen for this risk and how do we address it once we determine someone is at risk.

A quick and relatively easy way to assess someone is the Landing Error Scoring System (LESS) test.  During this test, the subject is evaluated from the front and the side and each error is marked for a maximum score of 17 errors.  The higher the score, the more errors in technique the person has with regards to their jumping technique.

I like to do this test when assisting with pre-participation screening for school sports.  It’s a great way to get a large number of people through in a limited amount of time.  It helps give athletes visual feedback that they have poor technique which helps get better buy-in for the recommended strengthening/training program.  Unfortunately, many of the local high school kids are not receiving these screens prior to participating in high risk sports.  In speaking with local athletic trainers, we are seeing an increase in ACL injuries among adolescents teenagers at least in my area.  I can only imagine that our statistics mirror the national statistics.

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As physical therapists, we have a number of ways that we can educate and strengthen so that the risk is decreased.  We all know that phrase, “an ounce of prevention is worth a pound of cure”.  Well, an ACL injury screening and prevention program is a perfect example of this.  When you consider how many high school students have to miss out on either a year of their sport, or even worse, the opportunity to compete at the collegiate level you realize that a few sessions with a physical therapist is well worth it.

The big question is, how do we convince both coaches and athletes of this?  Many coaches at the high school level feel that the screening and prevention exercises are just taking away from their time with the athletes.  Many athletes and their parents feel that the physical therapy sessions are too expensive and “not necessary”.

I would love to hear everyone’s thoughts on this.  How have you gotten past these barriers?  How do we educate the public about the importance of these programs?

What Types of People Are More Prone to an ACL Injury?

First off, let’s start with a basic anatomy lesson.  Your anterior cruciate ligament (ACL) is located in the knee.  It runs from the posterior (back) aspect of your femur to the anterior (front) aspect of your tibia.  Its primary function is to limit your tibia (shin bone) from moving too far forward with respect to your femur (thigh bone).  The primary mechanism for injury is a rapid change in direction, a sudden stop, or landing from a jump.  Injury can also be a result of direct contact to the knee.  We diagnose this injury with a physical ACLexam, as well as MRI.

There are a number of factors which make you more prone to sustaining an ACL injury.  Some you have control of, others you do not.  For many possible reasons, females are more prone to ACL injuries than males.  The most common sports to see this type of injury are gymnastics, basketball, and soccer.

Why females you ask?  There are a few different theories out there.

  1. The anatomy of our bodies – females have a larger angle between the center of theirQ angle knee and their pelvis.  This is called the “Q” angle and it is due to the wider shape of the female pelvis.  Females also have a narrower “V” shaped notch where the ACL sits, compared to the wider “U” shaped notch for males.  That combined with females having smaller ACLs creates increased risk as well.
  2. Hormones – the hormones released during our menstrual cycle cause the ligaments in our bodies to relax. This has been hypothesized to increase the risk of ACL injury.
  3. Neuromuscular control – females tend to land from a jump in a more upright position and less hip and knee flexion. This means they are relying more on the static/ligamentous structures of their knee to support them, rather than their muscles.  This means the muscles are not absorbing enough of the impact.  In addition to this, females have an altered muscle firing pattern when compared to men.  Men are more likely to fire their hamstrings first (which assists the ACL) and women have a higher incidence of firing their quads first which places increased strain on the ACL.

So, is there anything we can do about these things?  Tune in next week when I talk about screening tools and ways to address poor jumping/landing technique.

Should I Stretch Before or After my Workout?

One of the most common questions I get from people is whether or not they should stretch before or after they workout.  Well the answer is actually both, BUT, the type of stretching you want to do before your workout is different than the type you want to do after your workout.

Before your workout you want to do what’s called a dynamic stretch.  After your workout you want to do a static stretch.  What’s the difference you ask?  A dynamic stretch is one where you move your body through a large range of motion but you don’t hold the position.  Some examples of this are lunges, hip circles, and butt kickers.  Another term for this type of a stretch is movement prep.  Here is a link to some great examples.  In addition to doing this type of a warm up, it’s a good idea to either walk, or do your event at a lower intensity than you would during the bulk of your workout.  This will get the blood flowing to your muscles and reduce the chance of injury.

After your workout is when you want to concentrate on the traditional static stretches.  It is important to do this immediately after your workout while your muscles are still warm.  You might wonder why you don’t want to do this type of stretching before your workout.  Research has shown that following a static stretch, your muscles are actually experiencing an inhibition of the muscle’s force/power, and and decrease in the joint’s ability to sense where it is in space for up to an hour after preforming the stretch.  That means that you will have less power and are more prone to injury for up to an hour afterwards.

So, you are best off doing a light cardio warm-up combined with dynamic stretches that take the appropriate muscles through a full range of motion in order to maximize performance and minimize your risk of injury.  This approach will wake your muscles up without inhibiting their power.

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The Internet is a Dangerous Place

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The internet is full of amazing information.  I’m not sure how I got through life without it.  There are tons of sites on the internet that offer free medical advice and many of them offer home treatments for musculoskeletal problems.  What kinds of exercises you should do for your pain, injury, weakness.  What type of treatment approach you can try for your persistent aches and pains.  I see this most frequently with foot and ankle pain.  This might be because we are always on our feet and there’s not much we can do to give them a break when they hurt.  People’s desperation for a fix makes them more likely to try anything.

I recently had a patient who had “tried everything”.  She was convinced there was nothing I could do for her because she had already gone to multiple physical therapy sites on the internet.  When she listed off everything she was trying, I cringed.  Although the exercises she was doing may have been helpful at some point in her recovery, they were doing her a significant amount of harm in her current state of severe constant pain.

The problem with seeking out advice on the internet is that you never receive a thorough evaluation of the problem.  You need a skilled provider to assess and diagnose the problem and provide adequate education.  Just because a treatment worked for your sister, your friend, or your neighbor does not mean it’s the right treatment for you.

So how is my patient doing?  The one who had “tried everything”?  She is significantly better now that she has received an evaluation, but most importantly the proper education.  She now understands where she is in her recovery process, the importance of decreasing the load and stress on her tissue, and which exercises are best for her at this stage in her recovery.

If you have had pain for more than a few weeks and it’s not getting better, my advice to you is to seek out help from a professional.  The internet may not hold the answers.