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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The Influence of Pelvic Position on Lower Extremity Stretching

Inner Circle Premium Content

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

 

The Influence of Pelvic Position of Lower Extremity Stretching

The below webinar will help you understand:

  • Why lower extremity stretching is essentially flawed
  • Why we aren’t always in neutral position or symmetrical
  • The influence of pelvic tilt on pelvic position
  • Simple assessments to see if you are “neutral”
  • How to adjust stretches to assure proper form and alignment
  • How to individualize lower extremity stretching based on pelvic alignment
  • What to avoid while stretching to maximize movement quality

 

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

 

Assessing and Treating Loss of Knee Extension Range of Motion

Assessing and treating loss of knee extension range of motion is an important component of rehabilitation following any knee surgery.  We recently discussed how loss of knee extension range of motion may be one of the biggest factors associated with the development of osteoarthritis following ACL reconstruction.

The purpose of this article is to review some of the many methods of assessing and treating loss of knee extension range of motion to help maximize outcomes following knee surgery or injury while minimizing long term complications.

 

Assessing Loss of Knee Extension Range of Motion

There are many ways to treat loss of range of motion in the knee, however, proper assessment of range of motion is even more important.  A certain degree of hyperextension is normal, with studies citing a mean of 5 degrees of hyperextension in males and 6 degrees in females.  Simply restoring knee range of motion to an arbitrary 0 degrees is not advantageous.

The most important factor in assessing loss of knee extension range of motion is looking at the noninvolved knee.  As simple as this sounds, this can not be overlooked as you need to establish a baseline for what is “normal” in each patient or client.

The first thing I look at is simply grasping the 1st toe with one hand to lift the foot off the table.  My proximal hand can stabilize the distal femur.  This is a quick and dirty assessment but I always recommend quantifying the available range of motion.

To accurately measure knee extension range of motion, you will need to use a towel roll of various height to assure the knee is fully hyperextended before taking a goniometric measurement.

Knee Hyperextension

Other aspects of assessment that should be performed when dealing with loss of knee extension range of motion should include patellar mobility, tibiofemoral arthrokinematics, and soft tissue restrictions.  Patellar mobility is especially important after ACL reconstruction using a patellar tendon autograft.  Any restrictions in patellar mobility can have an obvious correlation with restricted knee extension.  Scarring of the patellar tendon can restrict superior glide of the patella and full knee extension.

These assessments will help guide our manual therapy approach to restoring normal arthrokinematics and range of motion of the knee.

Documenting Knee Range of Motion

I took a poll of a large group of students coming through my clinic in the past and found that there was great confusion regarding how we document hyperextension of the knee.   Is + or – when defining a numerical value?

Let’s say that someone has a contracture and is sitting in 10 degrees of flexion and is unable to straighten their knee.  That would be +10 degrees of flexion, thus has to be -10 degrees of extension.  They are on two ends of the spectrum.

Still, using a + or – can be potentially confusing, so I have long taught my students that we should document range of motion using the A-B-C method.  Other authors, such as Dr. Shelbourne, recommend this method as well.

  • If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
  • If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.
Using the A-B-C method eliminates the potential for confusion while documenting.

Treating Loss of Knee Extension Range of Motion

There are several ways to improve knee extension range of motion, however, if a person is struggling with this motion I have found that self-stretches, low load long duration (LLLD) stretching, and range of motion devices can be superior to us cranking of a already cranky knee!  Allowing gentle, frequent, and progressive load to the knee is usually more tolerable for the person, especially those that are sore or guarded in their movements.

The intent of this article is to discuss some specific independent strategies to enhance knee extension range of motion.  Other skilled treatments should focus on patellar mobility, soft tissue mobility, and other aspects of manual therapy for the knee as needed.   However, patients will need to perform stretches at home to assure good outcomes.

 

Self Stretches for Knee Extension Range of Motion

Two of the first stretches that I give patients following surgery are simple self stretches for knee extension.  The basic version simple has the patient applying a stretch into extension by pushing their distal thigh.  The second and slightly more advanced version, has the patient press down on their distal thigh while using a towel around the foot to pull up and simultaneously stretch the hamstrings.

Knee Extension Stretch

Towel Knee Extension Stretch

Similar to how we assess knee extension range of motion, you will want to use some sort of wedge under the heel to assure that you are restoring full motion.

 

Low Load Long Duration Stretching for Knee Extension Range of Motion

For the person that is having a hard time achieving knee extension, my next line of defense is usually LLLD stretching.  Several research articles have been published showing the benefit of LLLD stretching in achieving range of motion gains.

I prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial position for me.  To perform this exercise, place a towel roll or similar item under the heel to allow full knee extension and then a comfortable weight over the distal thigh.

Low Load Long Duration Stretch Knee

The purpose of this exercise is to be gentle and to hold the stretch for several minutes.  I typically use anywhere from 6 to 12 pounds and hold the position for at least 10 minutes.  If the person is fighting against the weight, then it is too aggressive.  Lower the weight and you’ll see better results.

Don’t forget that you can apply moist heat to the knee simultaneously for even more benefit.

LLLD Knee Stretch with Heat

Devices for Knee Extension Range of Motion

I am also quick to prescribe a range of motion restoration device for people that may be struggling with range of motion or are not moving their knee enough throughout the day.  I have tried some of the dynamic splinting in the past but found that many people would rather control and hold a sustained stretch rather than have the brace apply a dynamic stretch.

The two devices I have used and enjoyed are from Joint Active System (JAS) and End Range of Motion Improvement (ERMI).

JAS Knee Brace        ERMI Knee Brace

Both devices allow the patient to apply their own tolerable LLLD stretch at home.  This is helpful as frequent movement throughout the day is always beneficial.

Personally my criteria to use these devices is usually when I perceive the person will self-limit themselves and avoid motion.  I will get a device in their hands early so that they can move their knee more at home and have a feeling that they are controlling the restoration of range of motion.  We probably resort to using these devices when it is too late and the patient is already too stiff.

 

Conclusion

These are just some of the many ways to assess and treat loss of knee extension range of motion.  Considering how important it is to restore full knee extension after knee surgery, properly assessing early signs of loss of motion and effectively treating the knee to avoid long term loss of motion is critical.

What has the Biggest Impact on Outcomes Following ACL Reconstruction Surgery?

Loss of knee extensionIt is no surprise that loss of motion is one of the biggest factors in patient satisfaction following ACL reconstruction surgery, specifically loss of knee extension.  In addition to the limitations in functional activities that occur with loss of knee extension, we have also discussed some of the risk factors of loss of motion following ACL reconstruction.

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics.

Imagine not being able to straighten your knee out.  You can’t lock out your knee for stability.  You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back.  Your quad and hamstring never get to shut off and relax.  Your patellar tendon will probably be on fire, and your patella will always be engaged and taking stress.

I can definitely see why patient satisfaction would be poor if you had long term loss of motion following ACL reconstruction!

Impact of Loss of Motion on the Development of Arthritis

In addition to poor patient satisfaction, recent research has shown that loss of motion following ACL reconstruction also results in the development of osteoarthritis.  In a recent study in AJSM, Shelbourne et al followed 780 patients for a mean of over 10 years.  They showed that of the group of patients that had normal motion on follow up examination, 29% exhibited signs of osteoarthritis on radiographs.  Conversely, 47% of the group that showed loss of motion had developed osteoarthritis.

This makes perfect sense as your arthrokinematics, center of rotation of the joint, and tibiofemoral and patellofemoral contact pressure will be altered.

How Much Loss of Extension is Significant?

More importantly, the authors also showed that even a loss of 3-5 degrees of motion had a significant impact on both patient satisfaction and the development of early arthritis.  Those subjectives that exhibited greater than a 5 degree loss of motion had an even more dramatic impact.

According to DeCarlo and Sell, the average amount of knee extension in healthy individuals is 5 degrees of hyperextension, with 95% of individuals demonstrating some amount of hyperextension in the knee.

Taking this into consideration, we should challenge the common belief that 0 degrees of knee extension is “normal.”  Individuals with 5 degrees of knee hyperextension that only restored their knee to 0 degrees of extension after ACL reconstruction surgery have a significantly greater chance of developing early osteoarthritis.

Clinical Implications

Based on these recent studies, there are bunch of clinical implications that we should all consider.  Here are just a few that I thought of right away:

  • Timing of ACL reconstruction surgery and pre-operative rehabilitation is important to settle down the knee, reduce swelling, and most importantly restore range of motion.
  • Knee extension should be restored as soon as possible after surgery, and should be one of the focuses of the initial postoperative phase
  • Even a small 3-5 degree loss of either extension of flexion range of motion has a significant impact
  • Most patients will have a certain degree of hyperextension, restoring a person to 0 degrees of knee extension is likely not enough
  • For those training post-ACL rehab clients, keep this in mind if the individual does not have full motion.  Advancing to exercises with high tibiofemoral and patellofemoral compressive and sheer forces before achieving full knee motion should be performed with caution.
  • Each patient should be assessed individually and range of motion should be restored to their unique assessment
This information also shows the importance of skilled therapy following ACL reconstruction, despite some of the studies that may show that home exercise is equally as effective.  If loss of the motion has the biggest impact on outcomes following ACL reconstruction, the development of osteoarthritis, and the subsequent health care costs, this strengthens the need for skilled manual therapy during the postopertaive rehabilitation process.

In regard to what to do with the tight person, I’ll work on a future post that discusses how I assess and treat loss of knee extension range of motion, but in the meantime I would love to hear what you think about this information and what you do with these patients.

Concussions in Sports: Part 1 – Risk and Recovery Process

Concussion in SportConcussions in sports are becoming more and more of a problem as our athletes continue to get bigger, stronger, and faster.  As our understanding of the impact of concussions continues to increase, the need for knowledge of how to manage and rehabilitate athlete’s with concussion becomes paramount.

Today’s guest post discusses Concussions in Sports from Shaun Logan, DPT.  This is part 1 of a 2 part series on Concussions in Sports that will give a brief overview of concussions and the recovery process.  This information is needed before we can even discuss how we can best manage these injuries.  (Photo from Wikipedia)

Part 2 will specifically discuss the role of physical therapy in concussion management.  If you are interested in learning more about concussions in sports, read my past article on the evaluation and treatment of concussions that includes a nice link to a Journal of Athletic Training consensus statement.

 

Concussions in Sports

Between 1.4 and 3.6 million sports and recreation-related concussions occur each year, with the majority happening at the high school level.[1] Studies estimate 10-19 percent of all athletes involved in contact sport sustain a concussion each season.[2] As concussions have become more prevalent in the every day media, with more research being conducted and information discovered every day, the role of rehab and physical therapy for concussions has been emerging.  This is something that has been discussed and practiced by few for several years, but is still relatively new to most clinicians.

 

Concussions in Sport

In the 3rd International conference on Concussion in Sport in Zurich (2009), McCory et al. defines concussion as, “A complex pathological process affecting the brain, induced by traumatic biomechanical forces.”  In general terms, a concussion is an injury to the brain that occurs when a force is transmitted to the head that causes the brain to “shake” inside of the skull resulting in injury.  This can be a direct hit to the head, face, or neck – or can be caused by a force applied elsewhere on the body that is then transmitted into the head. [3] Helmets were not made to prevent concussions, as they are unable to prevent the brain from shaking in the skull. Helmets were made to prevent skull fractures and blood vessel injury. [4]

 

Recovery from Concussion

Headaches, fogginess, confusion, and disorientation are among the most common symptoms of concussion in the first week. [4]  Generally, most concussive symptoms will subside within 7-10 days without any treatment other than rest. [1][3][4]  Therefore, most athletes completely recover within that 7-10 day time period. However, concussed athletes still need to be progressed properly and continually assessed for any symptoms that may arise with increased movement, activity, or exertion.

The accepted best practice for concussion management, recovery and eventual return to play is for the athlete to be on complete rest both physically and cognitively until symptoms are no longer worsening.  Cognitive, or mental, rest includes, but is not limited to, not participating in the following activities: watching TV, texting, reading, going to school, and being in loud crowded places. This rest period can take anywhere from a few hours to days or weeks, depending on the severity and symptoms of the concussion.

Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases. [2] This is what is known as Second Impact Syndrome.  In documented cases, when a second brain injury occurs within 3 weeks of the initial concussion (most commonly within 7-10 days) there is some form of permanent brain damage in 100% of cases, with 50% resulting in mortality. [4] (There is a small sample size of documented cases, but this is still an astounding result)

 

Post-Concussion Syndrome

Not all concussed athletes will completely recover in the 7-10 days.  Studies show only about 10% of athletes show symptoms beyond 1 week and 1-5% with symptoms for longer than a month.  The prevalence of extended symptoms for high school athletes was about double that of college athletes.  These are the athletes who require rehabilitation. [4]

Athletes who continue with signs and symptoms for more than 3 weeks are considered as having Post-Concussion Syndrome (PCS). Though there is not a concrete agreed upon definition of PCS, the World Health Organization defines PCS as: “Three or more of the following symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, or memory difficulty experienced for weeks, months, or occasionally years after a concussion”. Other symptoms would include photophobia, tinnitus (ringing in ears), visual, and balance problems. [4]

The athlete must be appropriately monitored and progressed through activities by a health care profession, such as a physical therapist or athletic trainer, to prevent mismanagement of the concussion. Mismanaging a concussion is associated with several risks. [4]

Short-term risks of mismanaging concussion include:

  • Persistence or worsening of post concussion signs and symptoms
  • Repeat concussion with post-concussion syndrome
  • Second impact syndrome

Long term Risks of mismanaging concussion include:

  • Prolonged post-concussion syndrome
  • Depression, cognitive impairment, Chronic Traumatic Encephalopathy

 

Rehabilitation and the Concussed Athlete

Current thought is once the concussed athlete is asymptomatic at rest the physical therapist and athletic trainer’s role emerges in the form of a graded program of exertion, which will be discussed later in part 2. This is true, but it is only part of what we are able to do to aid in recovery and progress towards safe return to sport.

Read on to part 2 regarding the rehabilitation following concussions in athletes.

 

References

  1. University of Pittsburg Medical Center. (2011)
  2. University of Pittsburg Medical Center. (2011)
  3. McCory P, Meeuwisse W, Johnston K, et al. (2009) Consensus Statement on Concussion in Sport: the 3rd International Conference on Concusion in Sport held in Zurich, November 2008. Br J Sports Med; 43: i76-i84
  4. Guskiewicz, K. Concussion and Postconcussive Syndrome: When to Rest, Exercise, or Return to Sport. 2010. APTA Annual Meeting, Boston, MA
  5. Wallace, B. (2011) Concussion Health: Program www.concussionhealth.com
  6. Mucha, A. Physical Therapist’s Guide to Concussion. American Physical Therapy Association. 3/24/2011
  7. Wallace, B. Concussion Management Guidelines: Balance 360. By Concussion Health. (2011)

 About the Author

Shaun LoganShaun Logan, DPT practices out of The Training Room: Sports and Orthopeadic Physical Therapy located within Velocity Sports Performance in Cherry Hill and Washington Township in South Jersey where he has recently started a concussion program. Shaun graduated from Penn State University with Bachelor of Science degree in Kinesiology: Movement Science and from Drexel University’s DPT program in 2010. When his schedule allows, he returns to Drexel University to assist in teaching orthopedics. Shaun is working towards becoming board certified in sports.

 

Assessing the Sacroiliac Joint: The Best Tests for SI Joint Pain

SI JointThe sacroilliac joint, or SI joint, is one of those challenging areas of the body that we all have to deal with from time to time.  When I learned how to assess the SI joint, I know that I felt like I didn’t have a firm grasp on the best way to test for SI joint pain.  Many of the commonly performed assessments for SI joint pain seemed to not be very reliable and sometimes not even valid.

So treatment almost sometimes became taking a shot in the dark as I never truely felt confident in my exam findings.  This led me to perform treatments and progressions of patients based on trial and error rather than because of exam findings.  (Photo from Wikipedia)

Assessing the Sacroiliac Joint

Treating this way, to me, is a huge pet peeve, so I started to research the area to gain more comfort in my SI joint examination.  I found some interesting research regarding palpation, SI joint motion, and provocative testing.  Here are some of the things that I found along that way that really helped me get better at diagnosing SI joint pain, hope it helps you too.

Palpating the SI Joint

One of the simplest methods of assess the SI joint is palpation.  However, the reliability and validity of palpating the SI joint has come into question in recent years.  Several studies have been published showing poor inter-tester reliability for static SI joint palpation, including a nice study from Holgren and Waling.

McGrath has published an interesting article, entitled “Palpation of the sacroiliac joint: an anatomical and sensory challenge” in which the concept of SI joint palpation is scrutinized.  It is an interesting paper, that certainly makes you think.  In the paper, the author describes the several layers of tissue that sit between the skin and the posterior SI joint, which is 5-7cm deep to the skin, and the inherent challenge of both reliability and validity of palpating something so deep.

Assessing SI Joint Motion and Symmetry

Assessing the amount of SI joint motion and the symmetry of the SI joint itself is a very commonly performed technique during SI joint examination.  This method of examining the SI joint is popular and accepted, despite the lack of research supporting the technique.

Based on the above information regarding palpating the SI joint, one would question the ability to palpate AND now accurately assess motion in addition.  If palpation has poor reliability, this automatically makes assessing motion difficult.

Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing.  They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests.  This is a particularly interesting article to read if you have interest in this area.

Another study from Robinson et al had similar conclusions, stating that SI joint motion palpation tests have poor inter-tester reliability.

Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability.

Thus it appears that the reliability and validity of assessing SI joint symmetry and motion may be too poor to be used clinically.  The amount of motion of the SI joint motion is extremely small, perhaps less than 2mm and 2 degrees of translation and rotation.  This makes detecting patholgoical movement extremely challenging.

However, I still think symmetry and motion assessment may be a valuable component of the SI joint examination in the case of significant malalignment and pathology, and still should be assessed.  Just realize that you are looking to “rule in” more significant pathology.  I would not “rule out” SI joint dysfunction based solely on symmetry and motion assessment.

Location of SI Joint Symptoms

Van der Wurf et al (2006) published an interesting study looking at the location of symptoms reported in patients with SI joint pain and dysfunction.  In the study, the authors performed local SI joint injections to block the patients’ pain.  The authors found that:

  • All subjects that responded to the SI joint block had symptoms located at the Fortin area (3cm horizontally by 10 cm vertically inferior to the PSIS)
  • All subjects that did NOT respond to the SI joint block had symptoms at the Tuber area (just inferolateral to the ischial tuberosity)

Again, I wouldn’t rule in or rule out SI joint dysfunction based on this alone, but it appears that if you DO have pain at the Fortin area AND do NOT have pain at the Tuber Area, you may be experiencing SI joint pain.

SI Joint Provocative Tests

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there probably isn’t one perfect SI joint provocative test that we can perform to definitively diagnose SI joint pain or dysfunction.  Basically, there is no “gold standard” such as using the Lachman test for ACL tears in the knee.

However, by performing several tests together, you can increase your sensitivity and specificity of detecting SI joint dysfunction.

Combining the two studies, there are 5 provocative tests to perform when attempting to diagnose SI joint pain:

  1. Gaenslen
  2. FABER / Patrick’s test
  3. Thigh thrust / femoral shear test
  4. ASIS distraction (supine)
  5. Sacral compression (sidelying)

Laslett et al report that the accuracy of detecting SI joint dysfunction is increased with at least 3 of the 5 tests are positive.  Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint.  Van der Wurff et al report that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire serious performed together.

It seems like performing a series of provactive SI joint tests is better than one true test in isolation, though I would specifically emphasize the thigh thrust test.  In my experience, you have to use a decent amount of force during the thigh thrust technique to avoid missing a positive provactive sign.

In an attempt to find good demonstration videos on youtube of these techniques, I came across Harrison Vaughn’s excellent videos (I mentioned Harrison in the past and recommend you also check out his website).  Great job and thanks for sharing Harrison!  These are the tests recommended by the above authors to use together:

Gaenslen Test

FABER / Patrick Test

Thigh Thrust / Femoral Shear Test

ASIS Distraction

Sacral Compression

 

The Best Tests for SI Joint Pain

I will admit that I am not a SI joint expert, so I am interested in hearing the opinion of my readers that deal with a lot of SI joint dysfunction.  It appears that palpation, symmetry, and motion testing of the SI joint may have concerns in regard to reliability and validity.

Some things to keep in mind when assess the sacroiliac joint:

  • It is difficult to palpate the deep SI joint, making reliability and validity challenging
  • The reliability of assessing symmetry, SI joint motion, and SI joint position also has poor reliability
  • Pain along the Fortin Area without pain in the Tuber Area may indicate SI joint pain
  • A series of provocative SI joint tests yields better results that performing tests in isolation, with at least 3/5 positive tests demonstrating the highest accuracy of detecting SI joint dysfunction

Based on some of the research above, we should all consider the location of symptoms and a series of provocative testing when attempting assessing the sacroilliac joint and diagnosis SI joint pain and dysfunction.

 

Core Stability From the Inside Out

The core stabilization concept keeps being a hot topic for discussions. After more than a decade of core-training frenzy there is still very little evidence that core-training actually produces any positive effects. There is no universally accepted definition of what the make-up and function of the core is.

It all started with the Transversus Abdominis and the abdominal hollowing theory, where people were instructed to pull the belly-button in towards the spine when exercising. It has since been shown that abdominal bracing (tensing the abdominal wall as if preparing for being punched in the stomach) is superior to abdominal hollowing in regards to providing stability for the lumbar spine. Abdominal bracing is good, but it is still approaching the core from the outside in. The abdominal wall is the focus of the training. Real core activation has to come from the inside out.

Definition of Core

Core Stability Model

When looking up “core” in a dictionary we get descriptions like: centre, nucleus, middle, heart and interior.

If someone refers to the core of our planet they mean the absolute centre.  When people train their core they concentrate on the outer layers of the wall equal to the crust and the mantle.

People have to stop treating the core as a hollow tube and learn how to pressurize the “centre” of the tube instead of just tensing the walls.

Core Function

How do we pressurize the “centre”?

Intra-abdominal PressureThe diaphragm contracts and pushes down into the abdominal cavity, which combined with the resistance created by the pelvic floor, and an eccentric contraction of the entire abdominal wall, increases the pressure in front of the spine. The pressure from the front is counteracted by contraction of the lumbar extensor muscles and the spine is fully stabilized.  Without proper diaphragm contraction the increased  IAP will not reach all the way down to the lower lumbar spine, where the loading is most prominent.

Diaphragm

The diaphragm is the key component to core stability. The diaphragm has to contract first and then the abdominal wall and not the other way around. A too early or too strong contraction of the abdominal wall prevents the diaphragm from descending properly and is therefore counterproductive in stabilizing the spine.

At this point I would like to present the results of two interesting MRI studies of the diaphragm by Professor Kolar and colleagues that demonstrated that the diaphragm has dual functions of respiration and stabilization.

The first study (1) demonstrated that the diaphragm has a postural function that can be voluntarily controlled and is independent upon breathing.

The second study (2) showed that the diaphragm can performed its dual functions of stabilization and respiration simultaneously. The diaphragm can perform the breathing task at a lowered position ensuring that the stabilizing pressure is maintained throughout the breathing cycles. There is a close relationship between the diaphragm and Transversus Abdominis which contributes to the respiratory and postural control.

These two studies pointed out that the activity of the diaphragm during stabilization varies greatly amongst individuals, which supports Kolar’s clinical evidence that individuals with limited capability to contract the diaphragm for stabilization have a higher risk of developing back-pain.  The simultaneous activation of the diaphragm’s dual functions is the key to proper core stabilization

It is interesting to note that in the study by Hodges and colleagues which started the core craze, it showed that not only the transversus abdominis but also the diaphragm was activated to stabilize the trunk prior to any limb movement. The transversus got all the attention and turned into the core super-star while the diaphragm got ignored.

Respiratory function of the diaphragm

During inspiration the diaphragm contracts and pushes down into the abdominal cavity which decreases the pressure in the thoracic cavity and the lungs fill up with air.

Diaphragm

The diaphragm participates in all breathing patterns whether they are ideal or dysfunctional. You cannot avoid using the diaphragm when breathing even if you try, unless there is a medical condition preventing the diaphragm from contracting. The commonly used instruction “breathe with the diaphragm“, has no value.  Chest breathing and straight belly-breathing, where only the posterior part of the diaphragm pushes downwards, are two commonly observed dysfunctional breathing patterns, which reduce both the respiratory capacity and core stabilization. In ideal diaphragm contraction the entire diaphragm pushes down into the abdominal cavity and can be observed by an expansion of the lower ribcage and the abdominal wall in all directions.

Assessing diaphragm function

Breathing AssessmentThe diaphragm’s respiratory function can be assessed sitting or lying on the back. Holding the fingers at the lower ribcage, an examiner can feel for a lateral expansion of the ribcage and activation of the postero-lateral parts of the abdominal wall.  An upward or inward movement of the ribcage is a sign of dysfunctional breathing.

Next, the subject’s ability to pressurize all the way down to the lower part of the abdominal cavity when breathing is assessed, both in laying and sitting (holding the ribcage down assists the activation) .

Proper Breathing

After that, the postural function of the diaphragm is assessed. Instruct the individual to pressurize all the way down to the bottom of the abdomen while holding their breath. The instructor should be able to feel the pressure against a hand placed at the lower abdomen.

And finally, get the person to breathe all the way down to the lower abdomen and then maintain that pressure while going through normal breathing cycles. The diaphragm is now performing its breathing function at a lower position. This is real core stabilization.

Each of these steps should be properly activated and the testing positions are excellent to use as entry-level exercises. A resistance band can be strapped around the ribcage or the lower abdomen to pressurize against. It is worth spending a fair amount of time ensuring proper activation of the core before progressing to other exercises.

Here is a video, explaining core activation from the inside out:

Once proper activation of the core is achieved, only the individual’s imagination limits the exercise progression. Planks, bird-dogs, dead-bugs would be reasonable next steps. Uni-lateral work is an inventive way of keep challenging the core.

Frequently we see discussions regarding whether to perform core-exercises before or after other exercises. After reading this I hope everybody can see that once the diaphragm is properly activated the core will be trained in all exercises and activities. Proper core-activation is fundamental and should be part of everything we do.

The ability of the core to stabilize the spine and torso is the limiting factor in all exercises. Pay close attention to the signs of proper core activation.

 

Abdominal Wall

My favourite method of determining if the core is activated is to observe the lower lateral abdominal wall.  If there are concavities the core is not properly activated. Concavities indicate a Rectus Abdominis dominant pattern.

The contour of the abdominal wall should take on a balanced, slightly rounded appearance which should be maintained throughout performing the exercise with normal respiration.

Some individuals cannot activate the diaphragm properly by themselves and I would recommend they seek assistance from a DNS or Postural Restoration Institute trained Practitioner. Practicing with faulty patterns will only reinforce the dysfunction.

Core-stabilization has to come from the inside out and is controlled via the diaphragm. I recommend anyone who is interested in improving their performance and preventing low back pain to spend the required time to properly activate the core. It is really worth it. I have had experienced Strength athletes achieve new PB’s straight after we have activated their core.

 

References:

1-   Kolar P, Neuwirth J, Sanda J, Suchanek V, Svata Z, Pivec M. Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol Res 58:383-392, 2009

2-   Kolar P, Sulc J, Kyncl M, Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Applied Physiol Aug 2010

 

About the author:

Hans LindgrenHans Lindgren is a Doctor of Chiropractic and DNS Practitioner in Brisbane, Australia.  He has a special interest in Functional Stabilization, Rehabilitation and Sports-Performance. Hans runs courses about these topics and also writes a blog on hanslindgren.com.

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