Ouch! Swelling and bruising after a twisted ankle indicates a Grade 2 injury which can take 6 weeks to heal.

Twisted or rolled over your ankle?  OUCH! It can be very painful and swollen. What is an ankle sprain and how does

one treat it?  Ankle sprains are one of the most common injuries that we treat at BOOST PHYSIO in North West London. If you have gone over on your ankle and want to know what to do, then read on. Laura Harman, Senior Physiotherapist at BOOST PHYSIO, explains the anatomy of ankle sprains and treatment including useful exercises you can do at home.

Anatomy of the ankle

The ankle is a complex structure made up of 3 different joints:

1) Talocrural joint (ankle joint)

The talocrural joint is what most people think of as the “true” ankle joint. It is made up of three bones; the tibia on the inside, the fibular on the outside and the talus underneath. This joint allow the up and down movement of the foot (dorsiflexion and plantarflexion)

2) Subtalar joint

The subtalar joint sits below the talocrural joint and is made up of the talus and the calcaneus. This joint allows the inward and outwards movement of the foot (inversion and eversion). The main role of this joint is to allow the foot to adjust to uneven ground.

Ice compression treatment is used soon after a sprain to reduce swelling

3) Inferior tibiofibular joint

The inferior tibiofibular joint is the joint between the ends of the tibia and fibula. Although there is minimal movement of this joint, it is important for stability of the ankle.

In addition to the joint, there are many muscles and tendons in the ankle that allow it to move in various directions. There are also numerous ligaments that provide the foot and ankle with stability.

The main ligaments for the ankle are:

1. Lateral collateral ligament – attaches the fibula to the calcaneus and provides stability to the outside of the ankle joint.
2. Deltoid ligament – attaches the tibia to the talus and calcaneus and provides stability to the inside of the ankle joint.

What is an ankle sprain?

An ankle sprain is a very common injury. It can occur during sporting or everyday activities.  An ankle sprain is injury to the ligaments of the ankle. Ligaments are elastic band type structures that support and stabilise joints. During normal movements the ligaments stretch to allow us to move. When a ligament is stretched too far it results in an ankle sprain. Ankle sprains are essentially overstretching or partial tearing of the ligaments. In severe cases, the ligament can completely rupture. There are different types of sprain depending on the severity of the injury:

Grade 1 – Tearing of a few ligament fibres

Grade 2 – Tearing of a considerable portion of the ligament fibres

Grade 3 – Complete tear of the ligament

Ultrasound and electrotherapy for sprained ankle to speed up healing

Ankle sprains occur when the foot is rolled inwards or outwards, beyond it’s normal range of motion. This can happen in a number of ways, some of which are listed below:

a)      Running or walking on uneven ground

b)      Slipping off the edge of a curb or step

c)       Jumping and landing awkwardly

d)      Loosing your balance whilst wearing high heels.

The lateral ankle ligaments are much weaker than the medial deltoid ligament. As a result, inversion injuries were the foot rolls inwards are far more common that eversion injuries were the foot rolls outwards.

Treatment of ankle sprains

The most important period following an ankle sprain is within the first 48-72 hours. In this time it is important to follow the PRICE principles. PRICE helps to limit the bleeding and subsequent swelling that cause pain and joint stiffness.

Protection  – Protect the ankle from further damage.

REST – Reduce activity to help decrease bleeding and swelling. This can be achieved using crutches.

Later stages we use mobilisation techniques to restore full flexibility to the ankle

ICE – Primarily used to decrease tissue metabolism in the early stages of the injury.

Compression – Decreases bleeding and therefore swelling. This is usually achieved using a compression bandage.

Elevation –helps to decrease the build up of fluid.

After the first 48-72 hours, you can begin to gradually put more weight through the ankle and start some basic ankle exercises (follow this link to view an example of early phase exercises for ankle sprains). It is important to carry out these exercises in order to prevent joint stiffness.

In order to promote the healing process of the ankle, other treatments can be used such as massage and ultrasound .

Once the pain starts to settle, it is important to strengthen the muscles surrounding the ankle before returning to any sporting activity in order to prevent future injuries.

The usual healing time for an ankle sprain is 4-6 weeks.

Rehab exercise is needed to ensure full strength and balance is returned to the injured ankle

Gaitscan computerised pressure plate and gait analysis system

ligaments and 38 muscles! The foot is in contact with the ground for about 0.8 of a second when walking and 0.25 of a second while running! That’s alot going on with each and every step! 

When examining and assessing patients with foot, ankle and even knee pain looking at the mechanics of the feet is essential.  BOOST PHYSIO has invested in a GAITSCAN system to better enable us to examine our patients’ gait and walking.

The GAITSCAN system is a sophisiticated pressure plate with over 4000 sensors that is connected to a computer system.  When we perform a GAITSCAN gait analysis our patient walks over the pressure plate which takes over 300 readings every second and feeds this to our computer system generating a very detailed report.  The report shows us and our patient where most pressure is occuring under their feet, if the foot alignment is correct, we can even look  the pressure under each of the toes!

If you are having persistent foot, ankle or even knee pain GAITSCAN analysis will help your physiotherapist to identify the role of faulty mechanics in your feet and ankles.  This can be addressed in a number of ways- often corrective remedial exercises will be prescribed for you.  Call us to book a GAITSCAN appointment now on 020 82017788.  GAITSCAN assessment is discounted to £48 when you pay immediately on the day, otherwise it is charged at our standard rate of £55.  As this is a physiotherapy assessment it is fully covered by most health insurance policies.

In certain cases it may be advisable to invest in a pair of prescription customised orthotics (innersoles) to improve the foot mechanics and to relieve the pain.  Your GAITSCAN data is sent to the GAITSCAN Lab in Canada where the scan data and prescription is used to produce your customised prescription orthotic to help correct and improve your foot function.

We love the easy way out- why walk when you can take the car, why cook supper when you can get take-aways, why do sit-ups when you can use electrical pads on your stomach muscles and now: why exercise when you can wear shoes that exercise for you!

Whoever invents the way to exercise without exercising will be a rich person- it sounds like a dream come true! All the benefits of exercising- firmer muscles, leaner body, healthier lifestyle- without any of the effort required- sweating on the treadmill, bouncing around at Zumba, pedalling away at a spinning class.  

What amazes me is that many highly inteligent people do not see through the marketting hype and are taken in by the alluring promises of firmer glutes and calves and leaner bodies simply by wearing different shoes. 

I guess you can hear that I am skeptical about these claims, certainly many of these shoes can indeed be very comfortable.  Some do benefit certain foot problems and assist in activating better posture.  But if it is a firmer bottom, a leaner waist, or a better bounce in your stride that you are after- it is what you do with your feet and shoes that is much more important than which shoes you are wearing. 

So wear comfortable, well supported lace up trainers and go walking at a brisk pace so that you begin breathing harder

The BOOST Blogger- Steven Berkman, Head Physiotherapist at BOOST PHYSIO, Hendon NW4

and you feel your body getting warmer.  Build up gradually to a 30minute brisk walk at least 3 times a week and progress to doing so 5 times a week.  Not only will this tone your glutes, quads, calves but it will also burn more calories, help keep blood pressure under control and assist with diabetes prevention.  Invest in shoe for sports- definitely, invest in costly shoes that claim to get you fitter quicker- use your common sense!

www.boostphysio.com

Mr Fares Haddad- leading knee and hip surgeon

Considering having hip or knee surgery?  Make sure you read my interview with top London knee and hip surgeon Mr Fares Haddad.  During Consultant Q&A I ask Fares questions that are on my patients’ minds about his field of hip and knee surgery. If you want to know about latest advances, “lubricating” injections for the knee and more, then please read on.

At BOOST PHYSIO we’ve enjoyed rehabilitating many of Fares’ patients over the years following hip and knee operations and I’ve also had the benefit of watching Fares perform various knee operations-hence we highly recommend him to our patients. If you want to read Fares’ impressive biography and CV follow this link to his website, but in brief Fares Haddad is a Hip and Knee Reconstructive Surgeon at University College Hospitals, The Princess Grace Hospital and the Wellington Hospital.  He is Divisional Clinical Director of Surgical Specialties at UCH, and Director of the Institute of Sport, Exercise and Health at University College London.  Clearly an expert in his field!

Q: Fares, you are well known for being one of a few surgeons to perform key hole surgery for hip problems. Which patients do you find benefit the most from this procedure?
A:  Hip arthroscopy is a procedure that has expanded dramatically over the last ten years. The indications have become much clearer. The most successful interventions are in cases where there are isolated labral tears or when patients present in the early phases of femorocetabular impingement (FAI) before the joint is irrevocably damaged. FAI is a condition where the bones of the hip joint develop in such a way that the patient can function relatively normally, and often very athletically, but where abnormal contact between the femur and pelvis damages the hip. These are typically in sporting individuals who either suffer an acute injury, the labral tear, or get the insidious onset of symptoms through activity such as running, cycling or football. Plain x-ray imaging and MRI scan gives us most of the information we need although CT scanning is occasionally necessary to look at the bony anatomy. By dealing with the primary bony impingement as well as the problems within joint we decrease symptoms and hopefully also prevent recurrence and further progression of the problem in future. 

Q:  What does the future hold for technological developments in treatments for arthritic hip and knee joints?
A:  The management of early arthritis of the hip and knee is progressing at an impressive rate. Technical developments will focus in the first instance on prevention thus by replacing the damaged menisci and the damaged joint surface and injured ligaments. The new work on partial resurfacing of joints with novel materials such as Oxinium is very exciting. New work also on customising joint replacement will change the face of the management of arthritis giving us joint replacements that are much more functional and geared to high end activity such as sports. 
 
Q:  Which sports do you believe are suitable for patients following total hip replacement surgery?
A:  Following a hip replacement operation, we encourage our patients to get back to normal day to day activity within 6 weeks. All non impact sports such as long distance walking, gym exercises, swimming, doubles tennis and golf are encouraged. It is perfectly feasible for patients to play singles tennis or indeed in certain circumstances squash and many of our patients do get back to running but it is important for the patients to realise that there is a tension between the amount of impact activity that they do and the wear that they will cause to their new joint. 

Q:  How effective do you find “lubricating” injections are for arthritic knees?

A:  Our experience of the Hyaluronic acid lubricating injections for knee and hip arthritis has been mixed. There are some patients who have an extremely good response that lasts up to six months. There are others who do not respond at all. It is very difficult to predict. My personal experience is that those patients have dry knees without effusions tend to respond better to Hyaluronic acid therapy whereas those with effusions can respond to aspiration and injection but do so for a shorter period of time.  These are nevertheless interesting therapies which we must continue to pursue both in our athletic population when we often use them after surgery and also in the arthritic population.

I hope that you have found this Consultant Q&A interesting, if you wish to discuss any issues regarding your hip or knee condition with myself or one of my physios, please do not hesitate to contact us, you can call the clinic in Hendon, NW London on 020 82017788 or email us at info@boostphysio.com 

The BOOST Blogger- Steven Berkman

Regards… The Boost Blogger, Steven Berkman

We tend to use it most often post-operatively. For example following total knee replacement, ACL reconstruction surgery, key hole surgery to the knee and post-meniscectomy. For ankle injuries we use Cryocuff to bring down swelling after torn ligaments, fractures and surgery (eg following bunion surgery, achilles tendon repair surgery etc).

What exactly is the Cryocuff system? There are various garments used for the different body parts- ie ankle, knee etc. These are applied by your physiotherapist to the affected area and the the garment is filled with iced water! As the garment fills with the iced water it begins to compress the affected area.

You should be familiar with the acronym RICE which is used in physiotherapy treatment and injury management: Rest, Ice, Compression, Elevation. Cryocuff treatment forms a crucial part of the ice and compression of the RICE regime.

Boost Physio in Hendon will apply and use this treatment when appropriate.

If you don’t know what UGG foot is, I’ll fill you in quickly. Ugg type boots may look very comfy and cosy and good for you, but they don’t support your feet. If you have dropped arches, pronate (that’s when your foot rolls inwards while walking) or very flat footed- wearing ugg type boots for long periods can be very painful and harmful for your feet and ankles. As our patient discovered…

She lives in her Uggs and in flat flip flop sandals. As her foot and ankle pain developed she thought she ought to wear her Uggs more, because she thought they were so good for you. Wrong- they were a big part of her problem.

She finally saw my article after months of trouble- diagnosed herself- but it was too late. She has had to have an operation to repair the tibialis posterior tendon in her foot and ankle because it had been over stretched and torn. A problem that would have been prevented if she’d been wearing better shoes instead of her Uggs and flip flops all the time.

Following excellent surgery and physiotherapy at BOOST PHYSIO she is on her road to recovery.

The achilles tendon is the very strong and tough sinew that attaches that big calf muscle (gastrocnemius and soleus) to the calcaneus (heel bone).  Ruptures (where the tendon snaps completely) of the achilles tendon are a common injury in over 35 year olds, making David Beckham a prime candidate for a rupture.  It is a common injury it football, but also in tennis, squash and basketball due to the explosive push-off (and also in fathers and sons races at school sports day as a good friend of mine will testify).

So what is the treatment- well it aint gonna grow back by itself- so surgery it is.  I’ve personally diagnosed and sent for surgery 4 cases of ruptured achilles tendon that have been missed by GPs.  The surgery stitches the tendon together and then usually involves immobilising the leg from the below the knee down to the toes for 6 weeks.  Then is the slow process of physiotherapy to recover the movement and strength.  Like I said 6 months out of sport at least. 

One of my patients had surgery in Israel for a ruptured achilles tendon which was very successful- this involved a per-cutaneus stitching of the tendon.  Per-cutaneus is where there is only a very small hole made in the skin, rather than a big incission to perform the traditional operation.  This led to much quicker rehab and recovery time- reduced by approximately 1/3.  I suspect that in David Beckham’s case a traditional procedure will be performed (probably today) because it is critical that the tendon is repaired very strongly and this may not be the case with the per-cutaneus procedure.

So in short David Beckham will not be able to attend the world cup in my opinion.

Steven Berkman- the Boost Blogger

The BOOST Blogger- Steven Berkman

How good are Crocs for you?

 While they score low on style, Crocs actually score very high on being anatomically moulded with correct support being provided for the foot and hence ankle.  Not only this, but the very material that Crocs are made of are excellent for shock absorption and minimizing stresses and strains to the feet and ankles. 

The whole issue about shoes is that they should help to support the structure and mechanics of the foot and of course be comfortable and reduce shock being transmitted through the foot.  Crocs do this well, UGGs do this poorly.  

Looking at the inside of a Croc it is easy to see that it has has a contoured surface with arch support and a good heel cup that nestles your heel bone.  This heel cup and arch support help to maintain the mechanical alignment of the foot, ankle and knee.  In particular they minimise pronation, which is the movement that occurs in the foot when the foot rolls from the outside of the heel to the front of the big toe,  pronation can stress the ankle and knee joints and muscles. 

Could UGG type boots be bad for you?

UGG type boots however support the foot very poorly, they do not provide enough support to the heel bone (calcaneus) and the sole of the shoe does not have sufficient arch support.  For someone who is flat footed these shoes (along with shoes like ballet pumps) can be a big problem as they stress the sole of the foot, can lead to ankle and even knee pain. In children whose feet are still developing and growing particular care must be taken.