The Curious Case of the Wiggles

Wow, that was a very nice response to the scapula winging video!  Great comments and discussions by many.  I read each and every one of your comments throughout the week, thanks for participating.  There were a ton of great comments.  There are probably 100’s of things we can discuss, but I wanted to share my general focus.

If you haven’t read the original post, please go back and take a peak at my original shoulder overhead elevation assessment post and read all the great comments.  Here is the video again:

General Comments

  • assessing overhead arm elevationI would first comment and state that this is one quick video in a long series of assessments.  I chose overhead elevation because it was simple and reproducible  and showed a bunch of interesting things!  I start my assessment off by simple asking them to raise their arms over head.  That is it.  No other instructions.  I feel that it is important to assess how “they” want to move, not how “I” want them to move.  This is important to assess and often missed as we want to stick everyone in a “system.”  I like systems, they enhance re-test reliability, but sometimes they decrease validity.  
  • A test like overhead elevation in the sagittal plane, such as in this video, assumes two thing: Symmetry and Neutrality.  I don’t think either of these exist.  So it is inherently flawed.  Think about it, if his scapulae are off, then doesn’t that mean his glenoid is off?  Then technically the “sagittal” plane is just in relation to the ground, not to his body.
  • There is also a “chicken and the egg” concept here.  Did his pain create the dysfunctional movement or vice versa?  Unfortunately in retrospect we’ll never know.  Taking this into consideration I don’t think it is fair to assume that anything we are seeing is the “cause” of his pain.  Essentially it is all just the summation of where we are today.
  • I noticed many people wanted to comment on specific muscles being “tight,” “long,” “short,” “weak,” etc.  Remember all we know here is that he has a movement dysfunction.  I think it is appropriate to suggest these may be true, but you will need to take the next step and assess these assumptions.  I wouldn’t just jump in and treat based on assumptions.
  • I should also comment on the marks on his back.  One relevant, the other not so relevant.  The circles are cupping marks.  He is seeing another provider that performs this as part of his maintenance program while swimming in addition to massage etc, not for treatment of his symptoms.   However, the horizontal marks on his low back are relevant.  Those are stretch marks.  More on this later…

Static Scapula Position

  • I have commented on this before in my article on Myths of Scapula Exercises, but I don’t put a lot of emphasis on resting static scapular position.  Realistically, the scapula sits on the ribs, so it’s resting static posture is likely more a reflexion of rib and thorax position that scapular position.  I prefer to look at scapular dynamic movement quality.
  • Interestingly, you can see his dynamic concentric control of his scapulae doesn’t seem as bad as you would think based on his static resting position, especially as he gets high into elevation:

static and dynamic scapula position

The Head Wiggle and Scapula Wing

  • The first thing that really stuck out to me was his head wiggle.  I bet you missed it the first time!  A very interesting movement pattern.  In retrospect, you can find him shift his neck in this fashion quite a bit while observing him moving around and performing activities, even just talking to you sometimes.  It is not limited to just overhead elevation in the sagittal plane.  
  • We can’t really separate this from his winging scapula, they go together.  It sure looks like the head wiggles when the scapula wiggles.
  • To me, this looks like the levator scapula pulling the head with a complete lack of opposition from the lower trapezius and serratus anterior.  His head goes into side bend to the left and extension.  This is the cervical responsibility of the levator.  However, his scapula also shoots up into elevation and downward rotation.  This is my biggest indicator that levator is the one acting.  There could be more involved, like SCM, but I’m focusing on levator.
  • There is obviously some winging and lack of opposition of the levator by the traps and serratus.  This is really obvious on eccentric lower.  He also does not have a painful arc during this movement.  He is not shifting away from pain.

scapula winging

  • So while the levator may be causing the head wiggle, it sure looks like the serratus and lower trap are not doing their job and creating the scapula wiggle.
  • See how everything plays together?

 

The Elbow Wiggle

  • Many people picked up on the elbow wiggle, good work!
  • I don’t think this is really an elbow issue.  If you watch closely he keeps his hand in the same position.  He essentially fixes his hand on an imaginary sagittal plane track.  To me his shoulder and scapula want to move into adduction and internal rotation with the beginning of his scapula winging about to occur.  I feel like his glenoid may be the one the is not stabilized.  Since we have forced him to perform a strict overhead assessment in the sagittal plane, he is keeping his hand fixed and his elbow has to hyperextend to not allow his hand to horizontal adduct.  Again, just shows some of the flaws of assessments like this.

elbow compensation

  • So while this may be glenohumeral instability, I think it is still just the scapula as it occurs during the eccentric lowering and he has almost no ability to control winging.  And again, he does not have a painful arc.
  • This really illustrates a general point that I tend to make about humans in general, but even more so on high level athletes.  We are excellent at getting from point A to point B.  It’s all about how we get there.  Unfortunately the overhead elevation assessment uses an internal cue to “raise your hand up in front of you.”  Perhaps it would be better to give an external cue like “reach up and touch the ceiling.”

 

Thoracolumbar Flexion

  • So taking away all the interesting things happening from the scaps up, I also notice some interesting thoracolumbar compensations.  Remember, this client is a swimmer, and a high level swimmer.  Is it me or does his left latissimus look too small for a swimmer?
  • I mentioned earlier the stretch marks on his lower back.  When he tries to pull down with his arms with any resistance, his movement compensation was to go into a large amount of thoracolumbar flexion, which is a compensatory movement for the inability to extend his arms against resistance.  His lumbar paraspinals show hypertrophy.  So while this could be poor core control, I feel that may be too simplistic.  He goes into thoracolumbar flexion with minimal resistance.  Seems more compensatory rather than poor patterning.  In the photos below, that is not just paraspinal hypertrophy, that is also flexion:

latissimus

  • In looking at the photos above, see how he moves into thoracolumbar flexion?  These are fairly recent photos.  Here are a couple of photos from two months prior.  You can really see the thoracolumbar flexion compensation.  But also notice the dramatic increase in body composition in 2 months.  He put on 15 pounds of muscle mass in a 2-month program designed specifically for him:

thoracolumbar compensation

  • One thing I mentioned was that he feels symptoms with prolonged swimming.  He actually fatigues out well before his fellow swimmers.  Feels strong and swims well, then hits a wall quickly from 10-20 minutes in the pool, while everyone else is in there for 60-120 minutes without complaints.  While he looks a lot better.  There are still some muscles that are not coming back as expected, and he is still fatiguing out in the pool and feeling generalized symptoms.
  • This really makes me think a nerve issue that is just not allowing proper muscle function, and/or the fact that he is essentially swimming with his accessory muscles like his teres major and deltoids.  This is something we need to explore further.
  • I read some comments that taking him out of the pool and assessing him on dry land may not be the most valid assessment.  However, I would imagine that this thoracolumbar flexion occurs during every stroke in the pool as his lat is trying to pull through the water.  This is something else we need to explore further.

 

Great thoughts, comments, and discussions on this video everyone!  Thanks for participating.  We obviously still have some work to do to try to find out how exactly what is going on and how we can best help this client.  I’ll be sure to post an update if we gather any new information.

 

 

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Assessing Overhead Arm Elevation

assessing overhead arm elevationOne of the many things I look at during my comprehensive assessment process is the movement quality of raising your arms overhead.  The information you gather on the person’s ability to perform such a basic task is often invaluable when designing someone’s rehab or training program.

[box type=”note” icon=”none”]UPDATE: I have posted my follow up of this article breaking down the scapular winging.[/box]

I have a video below of a recent assessment I performed.  This is an interesting case and something I wanted to share.  However, I want to try something completely different for this week’s post, let’s try to make this interactive!  I am going to post a video below.  Use the comments section, either on this website or using the Facebook comments section below, to tell me what you see and what you think is going on in this video.

I’ll be upfront, there are no wrong answers, just what you see!  And there are a decent amount of things to see in this one video, so don’t be shy.

I will give you a little history.  Patient is a competitor high school swimmer with insidious onset of bilateral generalized shoulder discomfort and fatigue in the pool after prolonged swimming.  Mostly posterior in nature but not specific.  Exam obviously reveals generalized laxity you would expect with a swimmer, however no significant structural pathology detected.

 

Comment below and let me know what you see and what may be going on in the video – remember there are a lot of things to see, so don’t be shy – there are no wrong answers!  I fully expect people to see things that I missed.  I’ll give everyone a couple of days to join in and then on Wednesday I will post and update and discuss more about what I saw, so check back here later in the week as well.

Hopefully this interactive post experiment goes well.  If you like this type of post, please join in and let me know in your comment, and share this with your friends to get more discussion going!

 [box type=”note” icon=”none”]UPDATE: I have posted my follow up of this article breaking down the scapular winging.[/box]

 

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5 Principles of Treating the Stiff Shoulder

5 Principles of Treating the Stiff Shoulder

The latest webinar recording for Inner Circle members is now available below.

5 Principles of Treating the Stiff Shoulder

This month’s Inner Circle webinars discussed several principles of treating the stiff shoulder.  We’ll cover:

  • The several types of “stiff shoulders”
  • Are we seeing shoulder stiffness more than we realize?
  • How to completely understand the anatomy and biomechanics of the glenohumeral capsule
  • Know when to push motion (and when not to!)
  • What should people with stiff shoulders do at home between sessions

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Internal Impingement – What it is and How to Diagnose

Internal Impingement

The latest webinar recording for Inner Circle members is now available below.

Internal Impingement – What it is and How to Diagnose

This month’s Inner Circle webinars discussed a one of the most requested topics to date and featured a TON of people online live!  We’ll cover:

  • What is internal impingement?
  • The difference between internal and subacromial impingement
  • Anatomical, biomechanical, and pathological reasons for developing internal impingement
  • What do athlete’s that have internal impingement feel?
  • The #1 test to perform to diagnose internal impingement
  • What else you should look for on examination to develop the best treatment program

The topic is so big, I need to break it down into 2 parts.  This first part will cover the etiology and diagnosis.  I will follow this up in the upcoming months with an entire webinar dedicated to how to treat internal impingement.

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

 

 

Integrating the FMS into Group Training

Integrating the FMS into Group Training

I have a pretty special post today that includes an interview of Steve Long, one of the co-founders of Smart Group Training, discussing how to integrate the FMS in group training.  More exciting, Steve was willing to give an exclusive discount on their Smart Group Training Assessment product for my readers only!

Steve and I have been chatting about stuff for a little bit and I was really impressed with how he and Jared Woolever created the Smart Group Training system.  As a physical therapist, I have always felt that one of the draw backs of the group training format was the lack of individualization.  Steve and Jared have essentially systemized an approach that solves this problem!

I have watched their latest DVD and definitely recommend it, especially with the special discount for my readers.

 

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MR: Tell us what exactly is Smart Group Training and what made you want to create SGT?

SL: “That is a really great question actually. Smart Group Training is many things really. It’s a training system, an educational website, educational products, workshops, etc, but more importantly it’s a movement. It’s a movement towards increasing the quality of group fitness training, and a movement towards increasing the communication between trainers, strength coaches, and clinicians.

Myself and business partner Jared Woolever had been doing 1 on 1 and semi private training for many years when we decided to open up “bootcamp classes”.  We knew there were a lot of great benefits for clients mainly the price and atmosphere, but the quality of training was just not as good as semi private.

We knew from that point, that we had to either cut bootcamp or make it just as quality as semi private training. We dedicated ourselves to creating the best group training system available, and that is how Smart Group Training was born.  We just didn’t know at the time, what it would really end up becoming.

Our first product, Smart Group Training Volume 1 – Screening and Corrective Exercise, came about because so many people were asking us about our training systems, and how we incorporated the FMS into bootcamps. We created the product for our friends, and it has started to explode.”

 

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MR: The corner-stone of the SGT system is the FMS.  I like how you integrate a system to customize the large group training programs.  Since you have probably seen 1000’s of FMS scores over the years, what do you tend to find are the most common deficits you see?

SL: “It probably won’t surprise you to find out that we see a lot more mobility issues with men, and more stability issues with women. So we find that a lot of the men start with 1’s on the Active Straight Leg Raise and Shoulder Mobility. We will typically see women start with 1’s on the Rotary Stability, Trunk Stability Push Up and the Deep Squat.

Almost everyone starts with a 1 in the following:

  • Active Straight Leg Raise
  • Shoulder Mobility
  • Rotary Stability
  • Trunk Stability Push up

These are the foundational movements that we spend the most time working on by far. These movements must be cleared before moving on to the functional movements like lunging, stepping, and squatting.”

 

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MR: What are your top corrective strategies to address these common findings? 

SL: “The biggest thing is to make sure that people stop doing exercises or actions that could make it worse. Then we give them a corrective exercise strategy to correct the pattern. We find the weakest link on the FMS Hierarchy and attack that pattern with corrective exercise. We have the client do 1 or 2 exercises. Those exercises should be done pre workout, during the workout, and 1-2 times per day outside of training sessions. Some examples of exercises we use to correct the bottom four are:

  • ASLR: Pelvic tilts, pelvis repositioning, Leg lowering progressions, toe touch progressions
  • SM: Breathing, ribcage repositioning, reachbacks, cat cow, wall slides
  • RS: Rolling, bird dog progressions
  • TSPU: Elevated push ups, band assisted pushups”

 

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MR: In your experience how long does it take to start seeing improvements in your clients’ FMS scores?

SL: “Our goal is to see changes in the first session. That’s definitely not always the case, but many times it is. Typically we want to have each movement limitation cleared within a few weeks at the most. If it takes longer than that we refer out.  The screen usually points you to the right spot to make sure that we are correcting in the right order. Most people who have issues with the correctives not working are not following the hierarchy.

For example, sometimes one set of leg lowering will clear a clients ASLR deficiency forever, and sometimes they have pathology that caused it to never be a 2 or 3.  Generally speaking however, it usually takes a couple of weeks.”

 

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MR: What kind of carryover do you see in your clients’ general fitness goals by individualizing their programs and developing corrective strategies based on the FMS? 

SL:“They blast through plateaus! Clearing movement dysfunctions allows the clients to do things they couldn’t do before, it keeps them injury free, and a lot of times takes people out of a “high threshold life” which lowers cortisol and helps with fat loss. Moving good and feeling good, are huge for general population, and the FMS helps us with that.”

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MR: When will we be seeing more SGT products?

SL: “We have so much great stuff coming out this year. I can’t even begin to explain how excited both Jared and myself are to get this stuff out!  We have asked thousands of trainers, PT, chiros, and strength coaches what they need, and we are producing it. We have close to TEN great products coming out this year.

A lot of the stuff that we are doing this year is based around program design and giving people “done for you” programs that you can use immediately.

Over the next few months, keep an eye out for:

  • Group Training University: Basically and MBA on starting and running a group training business.
  • SGT 365: This is an entire year of done for you group training program design based on the FMS, and SGT training systems.

These are our next two products that will be available over the next few months, but like I said, we have a lot of great stuff coming out all year-long. Check out our blog, and get on our newsletter list to stay up to date with everything that Smart Group Training is doing”.
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Special $50 Discount for My Readers

Steve and Jared were nice enough to give me a special discount code for my readers to get $50 off their Smart Group Training Assessments DVD program.  Click the link or image below and be sure enter coupon code MR50 in the shopping cart to receive $50 off.  This is a limited time offer for this week only!  The discount ends at the end of the day Sunday.

Smart Group Training

Click here to purchase Smart Group Training Assessment DVD for $50 OFF

 

Steve Long NSCA, FMS, USAW, IYCA, TPI, HKC, KBA

Steve has made quite a name for himself in the fitness industry, achieving many awards and acknowledgements for his accomplishments. He has trained a variety of clients ranging from ages 6 to 80 in 8+ years in the fitness and performance industry. He assists clients in many aspects of health, fitness, weight loss, performance training, nutrition, and more. Steve is known for his practical approach to training and blending the many benefits of corrective exercise into highly metabolic conditioning and fat loss programs. Among other things, Steve specializes in functional fat loss, sports performance, golf fitness, injury prevention/post rehabilitation, kettlebell training, and lifestyle coaching. Steve has been mentored by, and continues to learn from the best professionals in the industry, bringing the most cutting edge programs to his clients and fitness trainers worldwide.

Learn more at SmartGroupTraining.com.

 

 

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Shoulder Adaptations Over the Course of a Baseball Season

Today’s guest post by Chris Beardsley is a review of a recent study looking at the changes in shoulder joint range-of-motion that baseball players experience over the course of a season.  A timely post as the MLB season winds down.

 

The Study

Shoulder Adaptations Among Pitchers and Position Players Over the Course of a Competitive Baseball Season, by Laudner, Lynall and Meister, in Clinical Journal of Sports Medicine, 2012 [Pubmed]

 

Background

Baseball position players typically play daily during game season and while pitchers throw in games less frequently, they often throw on their rest days. Consequently, upper extremity injuries are common in baseball players, particularly among pitchers. And despite advances in both rehabilitation knowledge and surgical technology, the trend for such injuries appears to be increasing.

Researchers investigating upper extremity injuries in baseball players have previously reported alterations in shoulder function such as posterior shoulder tightness and scapular dyskinesis, both of which have been associated with a variety of shoulder pathologies.

 

What did the researchers do?

The researchers wanted to investigate whether posterior shoulder tightness and scapular position change over the course of a competitive baseball season in both baseball pitchers and in position players. So they recruited 16 asymptomatic, professional baseball pitchers and 16 asymptomatic, professional baseball position players. Neither group had any history of upper extremity injury in the last 6 months nor any history of upper extremity surgery.

The researchers measured scapular upward rotation and glenohumeral range of motion (ROM) using a digital inclinometer. They measured glenohumeral horizontal adduction ROM with the subjects supine on a table and the shoulder in 90 degrees of abduction and flexion with the scapula stabilized using a posterior force into the table. They measured bilateral glenohumeral internal rotation ROM in a similar set-up: in the supine position with the shoulder in 90 degrees of abduction and flexion and the scapula stabilized using a posterior force into the table.

The researchers measured bilateral forward scapular posture with the subjects standing against a wall and used the double-square method to establish the distance between the wall and the acromion of the scapula. They recorded the difference between the throwing and non-throwing arms for analysis. Finally, they measured scapular upward rotation of the throwing arm in a resting position as well as in the scapular plane at 60, 90, and 120 degrees of humeral elevation.

The researchers performed these measurements at two points in time: at the baseball players’ initial physical examination during spring training and within the final week of their competitive season.

 

What happened?

Glenohumeral horizontal adduction ROM

The researchers found that were no significant differences in the changes to glenohumeral horizontal adduction ROM between pitchers and position players over the course of the season. However, there was a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by a reduction in the ROM of the pitchers.

 Glenohumeral adduction ROM

 

Bilateral internal rotation ROM

The researchers found that were no significant differences in the changes in bilateral internal rotation ROM between the pitchers and the position players over the course of the season. However, there was again a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by a reduction in the ROM of the pitchers.

Bilateral glenohumeral internal rotation

 

Bilateral difference in forward scapular posture

The researchers did not note any significant differences in the changes to the bilateral difference of forward scapular posture between the pitchers and the position players over the course of the season. However, there was a trend for the pitchers to start the season with a greater ROM than position players, while the ROM at the end of the season was similar in both groups of players. This was caused by an increase in the ROM of the position players.

Bilateral difference in forward scapular posture

 

Scapular upward rotation

The researchers found that the pitchers displayed significantly lower increases in scapular upward rotation at 60 and 90 degrees of humeral elevation compared with the position players as a result of the baseball season. However, this appeared to result from the pitchers starting the season with a higher level of upward rotation and both groups finishing the season with similar degrees of upward rotation.

Scapular upward rotation

 

What did the researchers conclude?

The researchers concluded that pitchers developed significantly less scapular upward rotation at 60 and 90 degrees of humeral elevation over the course of a competitive baseball season compared with position players. The researchers propose that the increase in scapular upward rotation displayed by the position players may be a beneficial adaptation geared towards reducing their injury risk.

The researchers suggest that the absence of a similar increase in pitchers may make them more susceptible to shoulder injuries. However, it is important to note that the pitchers started the season displaying significantly greater levels of scapular upward rotation and the season only serves to bring the position players up to a similar level. An alternative interpretation of the results is therefore that the pitchers already have such adaptations, beneficial or not, and that the season’s activities bring the position players up to a similar level. Whether these adaptations are genetically determined or acquired over time is unclear.

Indeed, the researchers note that since posterior shoulder tightness causes the humerus to translate upwards into the subacromial space, it is possible that athletes perform increased scapular upward rotation in order to elevate the acromion and increase the available subacromial space. Therefore, it is possible that the adaptive process that was observed in this study in the position players was done for this reason and it is also possible that the pitchers did not require this adaptation, having sufficient subacromial space already.

 

Limitations

This study was clearly limited by the small sample size that precluded the observation of several large differences in the measured variables between position players and pitchers over the course of the season.

 

Key Points

Pitchers develop significantly less scapular upward rotation at 60 and 90 degrees of humeral elevation over the course of a competitive baseball season compared with position players. However, the increase in scapular upward rotation observed in the position players only brings their total amount of movement in line with the pitchers, who begin the season with a greater degree of upward rotation.

 

Mike’s Thoughts

Thanks Chris, I thought you did a great job summarizing this nice article.  Studies like this are extremely challenging to perform, more so than you would think.  There is inherently an issue with control over the course of a season.  Did every pitch the exact same amount of innings and games?  Did they all throw with the same velocity?  Since this is a ROM study, did they all stretch exactly the same and with the same exact frequency all season?

The answer to all of these questions is, “of course not.”  This is what makes this so challenging, we can only take the means of a large group and try to draw conclusions.  I do caution readers to take information like this with a grain of salt.

As my readers know, I work in baseball everyday, yet I seldom discuss baseball on this website.  I am not in a position that I can share all I have learned (yet at least!), but I can tell you that we have studied very similar trends as this study.  Players will loose motion over the course of a season, similar to what we showed acutely after one outing (see here and here).  The acute ROM changes can become cumulative over the course of a season.  However, a proper stretching program can maintain normal ROM over the course of a season.

 

About the author

Chris BeardsleyChris Beardsley is a co-founder of Strength and Conditioning Research, a monthly publication that summarizes the latest fitness research for strength and sports coaches, personal trainers, and physical therapists. Chris also writes a regular blog in which he reviews some of the latest developments in biomechanics.

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If you enjoyed this post, then you’ll love Strength and Conditioning Research, a monthly publication that summarizes recent journal publications just like this post.  Don’t let the name fool you, there are a ton of research reviews for rehabilitation as well.  Chris does an awesome job summarizing a ton of great articles every month.  I am a proud subscriber because it helps me stay current and I can read it on my iPad when I am on the go.  Learn more about Strength and Conditioning Research.

 

 

 

 

 

 

High Ankle Sprains

As football season is upon us, we often hear the term “high ankle sprain” used by announcers and in the media. This guest article from Trevor Winnegge will help to explain this orthopedic diagnosis, etiology, diagnostics and treatment.

 

What is a high ankle sprain?

High Ankle SprainA high ankle sprain, or syndesmotic sprain, occurs when there is an injury to the distal tibiofibular syndesmosis.  Injury to the syndesmosis can occur to any or all of the following structures: anterior tibiofibular ligament; posterior tibiofibular ligament, including its superficial and deep (transverse) components; interosseous ligament; and interosseous membrane.(1)  All of these ligaments function to stabilize the ankle mortise and prevent it from splaying, or widening, during the demand of gait, running, cutting, and sports. (Photo from Wikipedia)

 

Mechanism of High Ankle Sprain Injuries

While trauma to the ankle in any position has potential to injure the syndesmosis, ankle external rotation and forced dorsiflexion are the two most common injury mechanisms.  Normally, the talus is positioned between the medial and lateral malleoli and is unable to rotate substantially. However, with a great enough force to the forefoot, the talus is forced to rotate laterally, thereby pushing the fibula externally away from the tibia, widening the mortise. This type of injury is often seen in football and skiing.

Typically, dorsiflexion causes the interosseous ligament to become taut. However, since the anterior aspect of the dome of the talus is wider than the posterior aspect, the wider portion of the talus pushes or wedges the malleoli apart during extreme dorsiflexion. This mechanism of injury is more common in running and jumping sports. High ankle sprains can occur isolated, can involve fracture of the fibula or medial malleolus, or tears of the lateral talofibular and medial deltoid ligaments.(2)  High ankle sprains occur in up to 15% of all ankle sprain injuries.

 

Clinical Examination

High Ankle Sprain Spring TestHigh ankle sprains cause significant pain in the ankle and lower leg. All weight bearing and gait will be painful, if possible at all. There is usually a significant amount of bruising, however, there is typically NOT a lot of edema. Pain with any rotation of the foot, or dorsiflexion will be painful. Palpation to the ankle mortise and syndesmosis will be painful to palpation.  Compression of the tibia and fibula above the ankle joint will result in pain at the syndesmosis.

A “Squeeze test” can be performed as a clinical test of syndesmotic instability. This is a simple, moderately reliable test where the examiner squeezes the proximal calf of the patient. A positive test occurs when this maneuver causes distal syndesmotic pain.(3)

 

Diagnostic Imaging

Plain film Xrays are useful in ruling out fractures, but may be negative in an isolated high ankle sprain. Stress Xrays are most useful, where the foot is stressed into external rotation or dorsiflexion.  This will show a widening of the ankle mortise. MRI/CT Scan can confirm the diagnosis and document severity of the injury.

 

Treatment of High Ankle Sprains

Treatment of high ankle sprains depends on the severity of the injury. Conservative care can be used to treat minimal to moderate injuries. Treatment may consist of a walking boot or nonweightbearing cast for anywhere from 1-4 weeks. Most athletes will return to sports in 6 weeks but many remain symptomatic for up to 6 months.  A general rule of thumb, though not set in stone, is that the higher up the leg symptoms go, the larger the severity and longer the injury will take to heal.

High Ankle Sprain FixationSevere injury often requires surgical fixation. While wire and sutures are sometimes used, many doctors use 1-2 syndesmotic screws for fixation of the distal tibia and fibula, which allows for bony fixation to allow soft tissue scarring and healing. After fixation, weight bearing is surgeon specific.  Some feel early weight bearing will transfer force through the screw, leading to breakage of the hardware and/or disruption of the syndesmosis. Sometimes, the hardware is removed prior to weight bearing, at anywhere from 2-4 months post operative.

Physical therapy for both conservative and non-operative care consists of range of motion, strength, stability and functional training to allow progression back to sports or activity.  It is important to remember that this is can be a severe injury and healing times are much longer than a typical lateral ankle sprain, despite the lack of edema.(4,5)

 

References

  1. Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
  2. Norkus S, Floyd R. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Athl Train. 2001 Jan-Mar; 36(1): 68– 73.
  3. Alonso A et al. Clinical tests for Ankle Syndesmosis Injury: Reliability and prediction of return to function. JOSPT. 1998, 27 (4): 276-284.
  4. Press CM et al. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep. 2009 Sep-Oct;8(5):228-33.
  5. Schepers, T. To retain or remove the syndesmotic screw: a review of the literature. Arch Orthop Trauma Surg. 2011 July; 131(7): 879–883.

 

About the Author

Trevor WinneggeTrevor Winnegge PT,DPT,MS,OCS,CSCS  has been practicing PT for over 11 years. He graduated from Northeastern University with a Bachelors in PT and a Master of Science Degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he treats many orthopedic conditions in addition to high ankle sprains.

The One Thing We Need to Do With Everyone

I am often asked by students or people attending one of my seminars, “what is the one thing you do that you find works the best.”  What a loaded question!  I wish it were that simple that I could teach everyone just one magic technique.  I have been reflecting on this question for several months, planning on writing a post to provide an answer.  I took me sometime to figure out how I wanted to answer the question, but I think I might have an answer

 

The One Things I Do That Works the Best

The one thing that I would say that I do that works “the best” is probably something we should all be doing with everyone.  It’s not a stretch, it’s not an exercise, it’s not the latest fad in equipment, and it’s not the lastest manual technique.  It’s actually so simple, that it took me awhile to figure it out.  It is assessing and Reassessing.

A proper assessment and reassessement is by far the best thing we can do for every patient and client we encounter.  This is really the key to understanding each individual, what they need, and what works for them.   Everything should start with a proper assessment and then after treament or training, reassess!  Do it every time you work with that person and even multiple times a session.

[quote]Ask them, “what is your primary complaint?”  Assess it.  Quantify it.  Treat it.  Reassess it.[/quote]

This simple concept can have many meanings.  At the simplest level, imagine if you were working with a weight loss client and didn’t assess their body weight.  How would you know what was or wasn’t working?  How would you know how much improvement that client has made?

For the clinician, we have many evaluation and assessment tools – range of motion, joint mobility, strength, flexibility, and many many more.  But these measurements are irrelevant to the patient.  They don’t really care if they gained 10 degrees of motion.  They simply want to feel better and move better.

OK, your shoulder hurts.  When does it hurt?  What can you do to recreate that pain?  Great – you just established a baseline that you can reassess.  Don’t get me wrong, you still want to take objective measure, but you now have a real life baseline assessment that the patient can feel.

This is why tools like the FMS and SFMA are valuable – systematic methods of assessing movement.  This is especially true in the fitness fields, where assessments are even more limited.  Quantify the quality and feel of movement to assess changes.

FMS

Ultimately, this is going to always lead to better outcomes – instead of just applying treatment or exercise and hoping it works, assess what really works and adjust as needed.

 

Assess and Reassess

How do you apply this?  The wrong way would be to just start working on someone that complains “my back hurts.”  “Well, hop up and let’s start throwing some massage techniques and exercises at it.”  In this example, there was no assessment, just treatment, so what do you reassess?  Pain?  That is not always the best assessment.

Maybe a better way would be to assess when and how the back hurts.  What movements bother you?  What can’t you do?  Now, provide care to that person and reassess what you just observed.  Simple, yet a powerful message when a person stands up and says, “wow, I can now touch my toes, that really worked!”

Here is an example of a recent patient I evaluated with complaints of left sided diffuse mid thoracic and rib pain.  I provided a comprehensive evaluation, but I will just cut to the chase and outline the important details.  His primary complaint was pain.  I could of just started trying to treat the area to reduce sympotms and essentially “chase the pain.”  However,  my primary focus was on his limited multisegmental rotation to the left.

Multisegmental rotation doesn’t tell us enough, so I dug deeper.  He had a moderate loss of thoracic rotation to the left.  I could of stopped here as the location of his symptoms were in this area, but I again dug deeper.  I was fine with his hip mobility.  However, I found that his pelvis was shifted with a left anterior tilt, causing his entire pelvis and SI joint to rotate to the right.  Subsequently, his lumbar spine was orientated slightly to the right, meaning his “neutral” was actually rotated to the right slightly, causing what looked like limited rotation to the left.

Thoracic Spine Mobility ExercisesWith my assessment in hand, I went to work.  First, I wanted to start at the thoracic spine to see what the precentage of invovlement may have been.  I worked on soft tissue, joint mobility, and few thoracic mobilization corrective exercises.  Reassessment at this point showed a fairly large improvement of thoracic rotation to the left.  I could of again stopped here, but I also wanted to check multisegmental rotation to the left, which only showed approzimately a 50% improvement in rotation to the left.

If I just stopped here, I would have restored half of his dysfunction, and I bet he would have slipped right back to where he started.

I next went to the pelvis and with a few exercises and manual techniques improved his pelvic alignment.  Reassessment of thoracic rotation and multisegmental rotation showed normal symmetrical movement, and naturally a reduction in his complaints of pain.

That is the power of assessing and reassessing.  Not just once, but multiple times in one session so that I can narrow down the effectiveness of each technique as best as possible.

 

The Power of Reassessment

That was a pretty good example of how I really narrowed down and enhanced by treatments by assessing and reassessing.  To summarize some of the key points:

  • Helps you individualize and find what works.  This is the no-brainer concept, to see if there was an immediate improvement that can be directly correlated to what you just did to the person.
  • Helps you find out what doesn’t work!  Don’t underestimate this one.  By properly assessing and reassessing you also find out what doesn’t work, which is just as valuable so you can shift gears and try another approach.
  • This is also diagnostic.  By assessing what does and doesn’t work you may also narrow down the exact dysfunction.  Perhaps their limited thoracic rotation is related to soft tissue changes rather than joint mobility.
  • Helps buy in.  Lastly, but probably most importantly, assessing and reassessing helps build buy in, confidence, and compliance from the person.  They will see immediate benefit in what you do.

 

That is probably what I would consider the one thing that we all need to do with every patient or client we see – assess and reassess, what do you think?

 

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