Chronic ankle instability is the recurring giving way of the ankle, often developing after repeated ankle sprains. The ankle is one of the most traumatized parts of the body. Sport injuries of the ankle account for 10-30% of all sport injuries. Ankle sprains are very common making up a high percentage of those injuries. Ankle injuries have a high recurrence rate of spraining the ankle again. When someone sprains their ankle, the ligaments can be stretched or torn. This can affect a person’s ability to balance, if not rehabilitated efficiently the lack of proprioception can increase the likelihood of spraining the ankle again. Every time the ankle is sprained it causes further weakening of the ligaments. This weakening creates more instability through the ankle. When chronic ankle instability occurs, the ankle often gives way with activities like walking but can also happen when you are just standing. This instability can lead to other problems within the ankle.
Symptoms and Diagnosis
Someone who has chronic ankle instability may experience:
Ankle repetitively “rolling”, especially on uneven surfaces or during sports activities
Ongoing discomfort and swelling of the ankle
Pain
A feeling of being unstable or wobbly
To diagnose chronic ankle instability a health care practitioner will ask you a few questions about previous ankle injuries and what symptoms you are experiencing. They will then assess the range of movement of the ankle, look for signs of swelling and examine the surrounding muscles and tissues for tenderness. Further investigation might include getting some imaging such as X-rays or MRI scans done.
Treatment for Chronic Instability
The treatment of chronic instability depends on;
what is found during the examination
he individual’s circumstances.
There are both non-surgical and surgical treatment options. Non-surgical treatment options may include:
Physical therapy: This can involve a hands on treatment of the foot, ankle and leg as well as prescribing exercises to strengthen the ankle, improve balance and retrain the muscles.
Taping or bracing to provide extra support and prevent the ankle from rolling
Medication prescribed can help to reduce pain and inflammation
In some cases, surgery is the choice of treatment. This will depend on the degree of instability and usually when all conservative treatment options have been exhausted. Surgery often involves both ankle stabilization as well as an arthroscopy to assess the integrity of the ankle joint. Following the surgery, rehabilitation and physical therapy is still essential in order to build strength, improve balance and retrain the muscles of the ankle.
Need help with a recurrent chronic ankle issue?
Seeing one of Our Osteopaths is a good place to start.
Written by Osteopath – Dr Belicia Ralph.
Belicia works from our Brisbane City Eagle Street Clinic Monday – Friday. You can make an appointment to see Bel online
What is pain? What happens when pain does not go away?
Pain is one of many responses from the brain when it has received enough danger messages from one part of the body.
Let’s take a common injury:
You just cut your finger. So what’s happening?
1. Danger receptors in your finger send danger (or ‘fire’) messages up towards your spinal cord and then onto your brain. These messages travel through your nerves.
2. The brain (aka the big boss/computer) analyses, processes all the information received from the finger area as well as going through your memory of similar past events (that happened to you or to someone you know).
3. At the same time, it analyses information from outside your body, receiving messages from your vision and hearing, to know whether you are in a safe environment.
Why does it do that? Because in the unlikely event a tiger just happened to be behind you when you cut your finger, you would obviously need to escape first, and only once you’re safe would it make sense to start worrying about the finger. So the brain would release some adrenaline to help decrease the danger messages or even stop them for long enough for you to get to a safe place.
4. If your life is not in any immediate danger and there are enough danger (‘fire’) messages going to the brain, one of the response will be that you feel pain in your finger.
There will also be other responses, such as your immune system kicking in to start the healing process, muscles reactions, etc..
5. As the wound heals with time, there will be less and less danger (‘fire’) messages going to the brain. Therefore the pain decreases until it’s fully gone.
*However, sometimes pain levels are not proportional to the tissue damage (think about a paper cut, ouch!) but also it does not always equal damage*
How is that possible?
That’s because pain is there as a PROTECTOR, it can be a response to BOTH ACTUAL threat and PERCEIVED threat. It will feel the same either way, pain is pain. It is there so you can get out of a situation your brain perceives as dangerous or threatening to its wellbeing, whether it really is or not.
So, this is what happens with what we call “Acute Pain” or pain that has been present for less than 3 months.
The medical body considers that most injuries will be healed to their best ability within 3 to 6 months. For example, it ‘only’ takes about 6 weeks for a fractured bone to heal.
But what happens when my pain persists beyond this timeframe?
We don’t always know why some people’s pain persists once all the tissues have been healed, but we do know that it happens in around 20% of cases.
Going back to our finger analogy, the danger (‘fire’) messages from the finger always travel up the same road (the nerves).
Before the injury, you could say that the road wasn’t used a lot, it was a single lane
dirt road, with danger messages travelling through from time to time. For example when the finger was slightly touching a hot surface.
However, when pain stays for a while, there are sustained danger (‘fire’) messages travelling through that same road, meaning the road gets busier and busier.
So the old single lane dirt road has to be upgraded to a 2 lanes dirt road, then later on to a 2 lanes sealed road to then upgrade to a fancy 4 lanes sealed road and so on it goes.
The more danger messages travel to the brain, the more road upgrades have to be made by the brain. That is called central sensitisation.
Your brain is so smart, it learns to be more aware of that finger, more protective of it and more sensitised to any messages.
Your nervous system becomes wound up.
So what can I do to help the road go back to a good old single lane dirt road (and reduce the sensitisation)?
There are many things that can help reduce the danger/fire but be aware that there also are things that can increase it.
Danger/fire reducers (aka buckets of water):
They help secrete endorphins, which helps decrease the danger messages
ANY meaningful activites to YOU. That is things that you LIKE doing, things that bring you JOY, that make you PROUD, give you a sense of ACHIEVEMENT. Be it calling a friend or family member, playing with or petting your pet (or any pet, really), looking at photo albums of good memories, helping others, gardening, volunteering, working, etc..
Pain education. Because it reduces fear of the pain, improves your understanding of what is happening in your body, gives you some power back over your it.
Relaxation/Mindfulness techniques. Because it helps soothe your nervous system.
Sleep management. If you have issues with insomnia or pain at night, get help from a professional to work out how to improve it.
Medication. See your GP or a pain specialist to review your pain medication. What to take, when to take it, how many pills, for how long. Be aware that strong analgesics including opioids can get addictive with regular use and a tolerance can develop, meaning you will need higher doses as time goes by for the same effectiveness on pain. On the long term, opioids use can even create MORE pain. The evidence does not really support their use for chronic pain. There are other alternatives, discuss it with your GP.
Goal setting and Pacing plan to achieve these goals. Think about what you used to do before the pain started and that you would like to go back to or do more of without having a flare up. It can be about work/vocational related activities, social/family related activities, leisure/sport related activities or even domestic/personal activities. Find a practitioner with chronic pain specific knowledge/education to help you work out a pacing plan to achieve your goals and get you the tools to get there.
Danger/fire increasers (aka buckets of petrol):
These are stressors that induce the release of cortisol, which increases the danger messages
Negative thoughts, concerns, fears about the pain
Pain/recovery expectations (for example, my friend had low back pain 3 years ago and never got better, is this going to happen to me too?)
Grief, anger, depression, anxiety, etc .. Belief that pain always equals damage Fear avoidance behaviours of certain movements/activities
These can be worked on with the help of your healthcare practitioners, psychologists or ACT/CBT trained professionals. They will give you reassurance about what is happening regarding your pain, but also tools to use during difficult situations and day to day stresses.
It may look overwhelming. Know that you don’t have to do all of these steps in one go. Choose one, do some research about it, note your questions down and start your journey back to recovery. The other steps will slowly follow, at your own pace.
Here are some great resources to dig deeper into pain, chronic pain, mindfulness:
Can you believe it is the start of a new decade too!?! All these new things often coincide with giving us a prompt to consider new goals and plans for the future which is great!! So what are your 2020 goals?
(Here at MOVE) We/the team love helping people achieve their goals! We are particularly well equipped to help you with your physical goals (and breaking down some of those barriers that may be holding you back). Get us in your corner and supporting you achieve your goals.
Why get us helping out??
Because many of the practitioners have experienced firsthand the influx of clients about 3-4 weeks into a New Year who went too hard and fast and end up not being able to continue with their plan (and possibly have done this ourselves).
First – ask yourself the question why? Why is your goal important to you? By having a clear why you can better formulate some of the finer details of your goal. For example if you want to lose weight is it to look good in the photos at your cousins wedding, or to create a long term healthier lifestyle change? Both goals have their place but will greatly change the how in achieving it.
The how to go about your goal is very specific to you rather than go all out, is a gradual change more likely to work? With that said though there are some of us who need commit 100% to a change and the gradual approach will not work. Again, understanding your own why will help you adhere no matter which how is best for you.
In terms of the physical body –we do know that a gradual change in load allows our tissues to adapt to new loads which increases the tissue tolerance to further load and decreases the risk of injury. A helpful rule is the “Rule of 3”. Start with the particular level of exercise eg going to the gym once per week stick with it for 3 repeats. If there are no adverse issues you are ready to progress. This is a simplified example and would vary greatly depending upon your own starting point and previous experience.
If you need help – feel free to reach out to our team. We have Osteopaths, Physiotherapists, Pilates Instructors and Massage therapists that can help. And remember you don’t have to wait until the start of a new year, or new week to start making some changes. We are here to help you out whenever you are ready.
This article was written by our Physiotherapist and Exercise Physiologist Glenda Walters. Glenda works from both the Brisbane City and New Farm Clinics.
To make an appointment to see Glenda please click here
Are you familiar with videos that circulate social media showing someone ‘cracking” joints or the spine? But what makes that satisfying sound and what does it achieve? Seeing an Osteopath will often combine various techniques tailored to you and your pain, one of which may include a spinal manipulation. The technique has been around for over 2000 years. It involves a quick thrust to a joint over a very short amplitude, thus the name high velocity thrust (HVT). Manipulation is also another name for an ‘adjustment’,
What is the crack?
Osteopaths, Physiotherapists and also Chiropractors can use this technique for treating neck and back pain. Manipulation is often also associated with an audible ‘crack’ or ‘click’ (which often feels very satisfying) and can be applied to various joints in the body. Contrary to the old wives’ tale, there is no evidence to suggest that this technique can cause arthritis, which I’m sure many parents have told their children, probably to stop them clicking their fingers at the dinner table. In fact, Dr Donald Unger spent 60 years cracking only the knuckles of his left hand. At the end of which, there was no degenerative differences or ailments. For this research he was awarded an Ig Nobel Prize in 2009.
Another outdated belief is that the click is produced by bone rubbing on bone. Again, this is not correct. The sound happens within the synovial fluid of a joint (a lubricant within the joint capsule which reduces friction). There is no contact between adjacent bones. This click happens when the joint slightly separates, creating gas filled cavities or air bubbles which then rapidly dissipate.
Does this technique realign your bones or put them back in place?
This is the oldest theory of spinal manipulation and not very accurate. Osteopaths use manipulations every day with various patients, the myth that spinal manipulations crack your bones back in place is only a myth. Practitioners did once believe they were ‘putting the bone back in place’, which is believable with the relief that often follows. In my clinical experience, patients who think their bones need popping back in are often suffering from acute back pain with associated muscle spasm or a restricted joint of the spine, of which manual therapy can help. Don’t worry, your bones won’t pop out!
(Evans, 2002)Evans, D. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), pp.251-262
Muscle injury, what can you do? When should I see an Osteopath about muscle strain? Being a sportsman (an average one at best), I suffered various sporting injuries. Iould now say put myself alongside Daniel Sturridge for being so injury prone. I’ve pulled hamstrings, had tendonitis in both knees, dislocated shoulders and damaged ligaments in my left ankle, alongside other niggles. Being young and naïve about pain/injuries can greatly impact your future in sports and the time spent on the sideline or sitting at home whilst your friends play football (speaking from experience).
The importance of resting an injury and not rushing back to play sports is paramount. As tempting as it may be to play in a cup game for school/college and think 75% fitness will be ok, you won’t play at your best. You’ll more than likely set yourself back another few weeks. As an Osteopath, we want to provide the best information and treatment plans to avoid injuries/speed up recovery time and give people participating in sport the information they need to be as safe as possible.
The most commonly injured muscles in athletes are the hamstring and groin. This following advice can be applied to any muscle, here is a summary of the important steps to take immediately following an injury…
M.I.C.E
Mobilise – If able, try to weight bear on the injured leg in a controlled manner. This is especially in the first few hours following an injury, avoiding any sudden movements or over stretching. This will aid muscle fibre regeneration and reduce scar tissue forming.
Ice – Apply cold to the affected area for the first 48 hours following injury. Do so for 10-15 minutes up to every hour if you can. If using ice such as frozen peas, wrap them in a tea towel to prevent burning the skin. The results in significantly less tissue bleeding caused by the injury and will help reduce the pain.
Compression and Elevation – A compression bandage and elevating the leg will result in less swelling. Too much swelling can cause additional pain.
Should you stretch the injured muscle?
No! The injury has occurred due to the muscle fibres being overstretched and torn. Imaging shows that a tear in a muscle takes around 7-10 days to ‘bridge the gap’ created by the tear. The muscle should not be stretched before this takes place. Instead of stretching in the early phases of healing, maintain movements within a pain free range to avoid further damage to the injured site.
What if you don’t rest/repair?
Various factors can influence the rate of repair, including age, diet and obviously the severity of the injury. It is vital that sufficient time is given for the muscle strain to repair. If you don’t, you could be looking at very annoying, long-term repetitive injury. Inflammation is a key component of repair. It can last between 2 days to several weeks, again depending on the severity of the injury. However, if not given chance to repair this inflammation can become chronic. This is when scar tissue forms. Instead of healthy, elastic muscle fibres being regenerated, a rigid, weaker tissue is formed which is very difficult to break down and predisposes future muscle strains. You don’t have to be an athlete to pull a muscle. You might tweak a hamstring running for a bus and just can’t seem to shake it off.
A rehabilitation programme should always be tailored to you and your activity. If you are struggling with a muscle strain/repetitive injury get in touch with us to see an Osteopath about muscle strain.
(M.Ost)Garg, K., Corona, B. and Walters, T. (2015). Therapeutic strategies for preventing skeletal muscle fibrosis after injury. Frontiers in Pharmacology, 6.Neidlinger-Wilke, C., Grood, E., Claes, L. and Brand, R. (2002). Fibroblast orientation to stretch begins within three hours. Journal of Orthopaedic Research,20(5), pp.953-956.
