Rehabilitation  of Peroneal Tendinopathy

Rehabilitation of Peroneal Tendinopathy

 

1) Strengthening

As soon as it is comfortable to do so, you should start strengthening the Peroneal muscles. Strengthening helps the collagen fibres within the tendon to realign and also helps develop the strength needed for running.

Start with isometric exercises which are static contractions. An easy way of doing this is to sit on the ground with the legs out straight on the insides of a chair. Position the front two chair legs on the outsides of the feet. Push outwards with the feet, into the chair legs so there is no movement, but the muscles are contracting. Hold for 5 seconds, rest and repeat 5-10 times initially. This should only be performed if there is no pain. If it is painful, rest and try again in a few days.

The next step on is concentric strengthening which can be achieved using rehab (resistance) bands or ankle weights. With a band, tie it in a loop and place it around the  balls of the feet. Turn both feet outwards at the same time, against the bands resistance. Always do band exercises slowly and under control, especially on the way back to the starting point. Again this should be done without pain and with low reps to start with, which can be built up every couple of days. For examples, start with 12-15 reps, build to 25.

Concentric Peroneal strengthening can be achieved with ankle weights which should be wrapped around the forefoot. Lay on your side with the foot to be worked on top and turn the foot out so the toes point towards the ceiling (keep the ankles and heels together).

The final stage of strengthening is eccentric which is the hardest type of contraction for a muscle and really important when running to slow the pronation force on the foot. This is harder to do yourself, but with a partner is pretty straightforward. Sit on the floor with both legs out straight. The partner pronates (inverts) the foot so the sole of the foot faces inwards. As they do this, you try to slow them down. Don’t resist the movement completely, but just aim to control it. The stronger you get, the harder they can push! This is really hard on the muscles and tendons so definitely start with low rep (around 8-10 initially).

2) Stretching

It’s quite difficult to stretch the Peroneal muscles so personally I don’t worry about this. If you are having massage treatment then this is going to be just as, if not more effective than stretching for this injury.

I would however, recommend stretching the calf muscles daily. This is especially important if you overpronate as tight calf muscles can contribute to this and place more strain on the Peroneal tendons.

3) Correcting Causes

Whilst the tendon is resting, this is the ideal time to look at what might have caused you to develop the condition and what you can do about it to stop it coming back.

If you haven’t had a gait analysis I would highly recommend this for Peroneal injuries as they are so closely involved with foot biomechanics. This will make sure you are wearing suitable running shoes and determine if you maybe need additional insoles or orthotics. Or, if you have been running for a long time and not had your gait reassessed in a couple of years, then it is worth getting it checked again as things can change.

If you have old trainers it may be time to replace them as the support and cushioning will have worn out. 500 kms is the rule of thumb for when to change your running shoes.

If this is all ok, take a look at your running program. Were you dramatically increasing mileage? Had you changed your route or added in more hill runs etc? Running on a road with a slant (so that one side is lower) could cause these problems.

If you’re struggling to find a reason for the injury, then I would recommend consulting a running coach to get them to look at your training plans and running technique. An experienced eye may be able to spot something you have missed.

4) Return to Running

Only return to running when completely pain free on a daily basis and once you are confident you have identified and addressed any causative factors.

Start with a very short jog (10 mins e.g.) and then have 2 days rest. Provided there is no recurrence of symptoms, then try another 10 minutes followed by another 2 days rest. If still ok, start to progress your running time, by 5 minutes at a time, running 2-3 times a week and only increasing every other run. Continue with this until you are back to your normal times / distances.

 

What is a Peroneal Tendinopathy?

What is a Peroneal Tendinopathy?

 
You have currently been training for a full marathon. In preparation for you marathon in a few months time you have been increasing your training regime more rapidly. After your most recent 10km training session at a higher intensity you have started to experience a dull pain around the back and outside of your ankle. Upon presenting to your local physio and after reviewing your symptoms it appears that you have a Peroneal Tendinopathy.
 
So what exactly is a Peroneal Tendinopathy?
 
 
Typically it has been found that individuals which undertake repetitive activities such as runners, dancers and basketball players results in an overuse injury. Irritation occurs to the Peroneal tendons (Peroneus Longus and Brevis) as a result of repeated movements at the ankle joint over a prolonged period of time. Both your Peroneus Longus and Brevis muscles assist in moving your foot in an upward and downward direction, moving the foot outwards and assisting in stabilising and balancing the foot and ankle.
 
 
Other factors, which predispose an individual to Peroneal injuries, include improper training, increase in training load, foot footwear choices and poor foot biomechanics.
 
Common symptoms one may experience includes:
-Pain around the back/ outside of the ankle joint during activity
-Swelling and tenderness behind the ankle bone
-Pain when pushing off the ball of your foot
-Pain while stretching the foot in both an upwards and downwards direction
 
The majority of Peroneal Tendinopathies tend to heal without the need for surgery. Since Tendinopathies occur as a result of overuse rest is often the best form of treatment though will often need to be used in conjunction with other forms of conservative treatments.
Here are 5 home remedies for you to reduce pain and discomfort on your ankle

Here are 5 home remedies for you to reduce pain and discomfort on your ankle

  1. Icing       
    your ankle may respond better to an alternating hot-and-cold therapy. Use two gel packs. One should apply heat for 20 minutes. Follow it with a cold pack for 20 minutes.
    Alternatively, you can  prepare ice packs. Apply the ice pack on your swelling ankle to reduce the amount of swelling will reduce your discomfort. Ensure that the ice rests directly on the swollen area. If the cold is too intense, place a small rag between the skin and the ice pack.
  2. Herbal Remedies
    Home remedies such as coconut and garlic oil help reduce pain and swelling when they soak directly into the skin. Mix 3 table spoon of coconut and garlic oil into a container and heat in the microwave for ten seconds, slightly warming the mixture. Generously massage the oil directly onto your ankle for ten minutes, allowing the oils to soak into your skin. Cabbage contains minerals and vitamins that are useful when ingested, as well as when they’re applied externally. Gather the outer layers, or leaves, of the cabbage plant. Blanch the leaves by boiling them in water and then immediately placing the leaves into a container of ice-cold water. Once the leaves have been blanched, wrap your entire foot and ankle, and allow them to rest for 30 minutes before removing.
  3. Dieting
    Changing your diet to relieve ankle pain can be effective over a longer term. If you are heavy, you may experience poor circulation and heightened stress in the ankles and other weight-bearing joints. If you are overweight and suffer from frequent strains or bone degeneration, losing weight can permanently end your ankle pain. Adding a joint supplement to your diet, such as glucosamine or chondroitin, may also help some people by protecting the ankle joint and surrounding tissue.
  4. Exercises
    Exercise is an ongoing home treatment that will serve as pain relief and prevention. To prevent future ankle injuries, and to strengthen an ankle that is already injured, range-of-motion exercises and stretches provide the most benefit. Only stretch or exercise the ankle once the pain has subsided.Range-of-motion exercises will increase the flexibility of tendons and ligaments that have tightened during an injury. Trace the alphabet with your toes, moving the ankle as much as possible throughout. Repeat at least ten times per day to strengthen your ankle and improve your flexibility.
  5. Orthopaedics treatment
    Seek for medical support if your pain still persists after trying out the suggested remedies. It is advisable to seek for professional help if your ankle pain is giving you symptoms that can be interpreted into serious health issues.
What is Proprioception / Balance of the Ankle?

What is Proprioception / Balance of the Ankle?

Proprioception is also known as the Joint Position System (JPS).  JPS is a system that allows the joints to send a continuous stream of information to the brain about muscle use, joint position and movement.  This allows us to know subconsciously where our limbs are in space without looking and it’s also the sense that produces sudden reflex actions when we sense danger.

For example, close your eyes….. do you know exactly how your hands are placed? Of course you do! That’s your proprioception at work.

Co-ordination

JPS is very important for co-ordinating all our movements and in terms of sports, where good co-ordination is crucial. Following injury to ankle joints and ligaments, the joint position receptors located within them can be damaged. This interferes with the joint position information that’s usually sent to the brain, and the messages are conveyed much slower. As a result, the joint feels unstable and odd in the sense that “you don’t completely trust it not to give way”.

Balance

Once you’ve damaged the proprioception or JPS, it can cause you to move awkwardly with decreased co-ordination in ordinary activities and in sports. Loss of JPS also affects balance and this interferes with the ability to avoid injury by quick and co-ordinated movements.

Fortunately, physiotherapists are able to re-train the JPS system with special exercises.   In some cases, injured athletes have gained a heightened JPS sense after physio treatment for an arm or leg injury and improved their performance!

Mobility

Following an ankle injury the doctor may need to immobilize it in a plaster cast to ensure the bones heal in the correct alignment.  When the plaster comes off and the doctor is satisfied that the bones are healing well, the physiotherapist takes over.

If a cast hasn’t been necessary, the physiotherapy exercises should be started as soon as possible after the injury.  This is important because the early scar tissue is still soft and can be broken down by the physiotherapist.  If you don’t get physiotherapy early on, the scar tissue becomes rigid and causes permanent restriction in the flexing and rotating movements.

Proprioception exercises

Massage, heat treatment, joint manipulation and stretching are the best way to get an injured joint back to normal mobility.  Muscle exercises fortify the muscles that control the joints and special proprioception exercises, like balancing and ankle disk training restore the nerve-muscle control.

Physiotherapy reduces your vulnerability to the same injury in the future and speeds up recovery – so you can return to your daily activities and sports in good form!

Are Ankle Braces Useful?

Are Ankle Braces Useful?

There is a lot of misinformation being circulated about ankle braces and their effect on the body and athletic performance.

Why Use a Brace or Support?

A support brace helps you by:

  • Relieving your pain
  • Resting the injured tissues by taking some of the stressful loads
  • Protecting the injured structures from further injury
  • Allowing for initial tissue healing
  • Preventing future injury by support or joint stabilisation.

 

A hinged style ankle brace that allows full up and down ankle range of motion will not weaken the joint because the brace is allowing unrestricted natural ankle motion. Hinged style ankle braces move with the ankle joint, and not against it, to protect the ankle from twisting and turning while still allowing for full natural range of motion.

A lace-up style ankle brace restricts all ankle range of motion, even up and down movements. This up and down natural ankle range of motion is not a cause of ankle injuries so there is no need to restrict it. One could argue that by restricting normal ankle range of motion you could potentially weaken the ankle, so it’s important to compare different ankle braces and choose the one that is best for your specific situation.

Wearing an ankle braces for an extended period of time will not weaken the ankle. There are no clinical studies available that support the notion that wearing ankle braces weaken the ankle.

Lace -up style ankle supports do hurt athletic performance. A recent study by the University of South Alabama concluded that wearing a lace-up ankle brace negatively affective ankle joint motion and muscle function. In other words, wearing a lace-up ankle brace reduced ankle range of motion and muscle strength in athletes thus reducing the level at which they could effectively perform.

Aren’t You Only Supposed to Wear an Ankle Brace After an Injury?

Athletes that play sports with a high incidence of ankle injuries like volleyball and basketball should wear preventative ankle bracing since there are many situations during a game where ankle injuries cannot be prevented regardless of ankle strength or athletic ability. With these sports it’s not “if” the injury will occur but “when” it will occur – think coming down on another player’s foot after jumping for a block or a rebound.

However, in other sports with less ankle injuries it’s not absolutely necessary to wear preventative ankle bracing. In those cases, it would be important to look into ankle bracing after an injury since 70% of athletes who sprain their ankle end up re-spraining that same ankle causing further damage to ankle ligaments.

5 QUESTIONS TO ASK ABOUT ANKLE SPRAINS

5 QUESTIONS TO ASK ABOUT ANKLE SPRAINS

  1. When should I see a Physio?The first reason to see a physio is to be evaluated for a fracture. Signs of a fracture include the inability to bear weight following the injury or if there is tenderness over the bony protrusions of the ankle or foot. In these situations X-rays should be performed to assess for a fracture. Another reason to seek medical advice is to reduce the risk of recurrent or chronic ankle problems. The most important risk factor for ankle sprains is a previous ankle sprain. Therefore, individuals should seek medical guidance and possibly formal rehabilitation to prevent recurrent and chronic ankle issues.
  2. How long does it usually take to get back to my activity?
    Most ankle sprains require two to six weeks to recover, but the length of time required is dependent on the severity of the injury and the activities required of the individual. Treatment involves three phases. Initially controlling inflammation, next regaining full range of motion and strength and finally regaining the muscular control and endurance required for one’s activities.
  3. What is involved in controlling inflammation?
    Initially controlling inflammation will decrease pain and swelling, and involves the following:
    – Icing (usually 10- 20 min, with at least 30 minutes in between sessions to avoid frostbite)
    – Compression (using an elastic bandage)
    – Elevation
    – Relative rest.

Depending on the severity of the injury, rest may involve a short term use of crutches or walking boot. However, it is important to note that early mobilization improves time to recovery, long-term stability and decreases swelling. Therefore one should begin protected and full weight bearing activities as soon as tolerated. Completing all phases of rehabilitation allows one to confidently return to sport and lessens the likelihood of chronic ankle issues.  In particular, rehabilitation should involve exercises to improve strength, balance and functional rehab exercises to guide one back to sport and exercise.

  1. Does wearing braces help prevent sprains?
    Wearing braces, specifically an air stirrup brace or lace-up support can be used to aid in early mobilization and to protect against re-injury following return to sport. Unfortunately, braces must be worn during all high risk activities for at least one year to have this benefit. In addition, braces do not stimulate healing or retrain one’s muscles, ligaments and reflexes to react to the stresses placed on them.
  2. How do I know when I am ready to play again?
    In general, once the individual has full movement and strength, in addition to being able to perform all sports specific activities required without pain they can return to play. One rule of thumb is the “rule of 20s” where the athlete is able to run20 yards, cut 20 times, hop on the leg 20 times, and balance with eyes closed for 20 seconds on the effected ankle without problems. However, it’s important to note that the risk of re-injury persists for up to 12 months, even after full rehabilitation. External ankle support and neuromuscular training can reduce this risk and are an important aspect of returning to play safely.
Foot Mechanics: There’s more to keep in mind than just what your feet are doing. 

Foot Mechanics: There’s more to keep in mind than just what your feet are doing. 

Running mechanics have been a hot topic of discussion – from the barefoot crazy to custom-made orthotics, it is possible to find someone who swears by ‘their’ style of running. Many running stores have treadmills with recording equipment set up to help find “the right shoe for your mechanics”.

So what is different when you have your gait analysed by a physical therapist?

A comprehensive analysis performed by a physical therapist looks at the foot mechanics in several ways — a non-weight bearing state, standing, walking, running at pace (i.e. endurance vs. sprint) and after fatigue. It is also considers more than the foot — a physical therapist will look at the knee, pelvis and low back. Arm swing may also be analyzed to tease out upper body compensations for lower body weaknesses. Let’s look at a few of these in a little more depth.

Biomechanics in a non-weight bearing foot boils down to the functionality of the multiple joints of the foot and how they interact, particularly in a dynamic state. Is your foot rigid, flexible, flat or high-arched? Does your big toe have the motion it needs for push-off? Is the main ankle joint moving correctly? What changes when the foot bears weight in standing, walking or running?

At a shoe store, runners are often evaluated while standing, walking, or jogging. Many are told they are ‘pronators.’ Pronation is a normal part of weight bearing in static and dynamic conditions. In very general terms, as a limb strikes the ground the foot must go through a phase of pronation to absorb and distribute the forces of the body. As we move through a gait cycle, the typical foot will then go through the opposite motion and supinate to act as a spring which helps propel us forward. Pronation is neither an entirely bad thing nor a single action, and pronation during walking may look different when jogging or running or when fatigued.

In part, this is where experimentation with barefoot running or transitioning to minimalist running shoes have gained popularity.  Motion control shoes are seeking in part to prevent ‘excessive’ pronation during the gait cycle. Part of the concept of barefoot running centers around what part of the foot strikes the ground first – toe, mid-foot, or heel. The common argument is that if runners move to a mid-foot strike they will be more efficient and can avoid using motion control shoes. I take a slightly different stand. Rather than forcing a mid-foot strike, runners should focus on increasing cadence (number of foot falls) and speed. As these two things increase naturally, most runners will move into a mid-foot striking pattern. I do agree that if the majority of running is done on the mid-foot, the need for motion control decreases, but is not eliminated, as most of the motion control in a shoe is toward the heel. The second consideration to keep in mind is the assumption that running is only efficient if you strike at your mid-foot, when in reality many factors determine efficiency.
When running, foot strike location in relation to the body position is a major factor in efficiency. If foot contact with the ground is made in front of the line of the body, regardless of where on the foot the contact happens, the foot will act as a break in motion. Ideal foot contact would be under the body to allow forward momentum to continue unimpeded.

Q: What does this mean for the average runner?

A:Think more about where your foot is landing and less about which part of your foot lands first.

Efficiency is also affected by hip strength and mobility, core strength, and arm swing. Runners with a mid-foot strike that translate much of that energy into up and down motion – rather than forward motion — will be less efficient than a heel striker who sends all the energy forward.

All of this is should be considered before we change the shoe platform. From a physical therapist’s perspective, no one solution exists for every foot type, body type or runner. Changing mechanics and footwear is possible and may be beneficial, however, slow and steady changes are more effective for the long term health of your body.

What is a high ankle sprain?

What is a high ankle sprain?

 

Unlike other ankle sprains, this injury is sustained to the tissue (ligaments) that connect the tibia and the fibula.  These are the bones that make up the lower leg (the inner bone being the tibia or shin and the outer being the fibula).

With common ankle sprains “low ankle sprains” the ligaments that are most often injured are the ones on the outside of the ankle.  These help to connect the fibula to the foot.  These ligaments are injured when someone “rolls” their ankle over.

In the high ankle sprain, there are several structures potentially damaged.  These include ligaments that connect the tibia to the fibula known as the tibfib ligaments, as well as a tissue called the interosseous membrane.  The severity of this injury often depends on how many of these structures are damaged.  The recovery time frame varies from 8 weeks to 6 months and this is why the high ankle sprain is so dreaded.

What are the symptoms of a high ankle sprain?

With a high ankle sprain there is often a minimum degree of swelling but unfortunately there tends to be more and longer lasting pain.  The pain that occurs with this type of sprain will usually occur when the ankle is turned outward and will be noticed above the ankle.  This tendency and the fact that the ligaments are above the ankle lead to the term “high ankle sprain.”  Most athletes are diagnosed with these injuries when their ankle sprain takes longer to recover than usual.  Clinical diagnosis is based on pain location, palpation, observation and a test known as the “squeeze test.”

How does one get a high ankle sprain?

The common mechanism of injury is sport and most often they occur during forceful twisting outward of the ankle.  This injury is more common in football, hockey, wrestling and soccer.  In these sports the opportunity to become tangled under another person is increased. The outward twisting motion of the ankle will cause the two bones to pull away from one another and tear the ligaments that connect them.

Another way to injure these ligaments is via hyperdorsiflexion – which means that the toes are forced toward the shin beyond their normal range.  This will occur when an athlete has his foot planted and falls or is pushed forward.  In either event the splaying (pulling apart) of the two bones causes the ligaments to tear.

How is a high ankle sprain treated?

  • When identified early a stable high ankle sprain is treated with a boot for the first 6 weeks.  Once the boot is removed, the real tough part of the recovery begins.  At this point, due to the immobilization, the joints from the ankle to the toes are very stiff.  The physiotherapy is key to restore the lost motion, strength, balance and of course to teach the athlete how to walk and run properly again.
  • If missed, the immobilization is usually absent and the ankle sprain is treated very similar to other sprains, but with a lot more patience, plenty of rehabilitation and there is often a need  for more caution on return to sport.  This caution is necessary because of the possibility of ongoing instability.
  • If the sprain is determined to be unstable, the bones of the lower leg require surgical stabilization usually via a screw.

Final thoughts on ankle sprains in general:

In my practice I hear from people that they “always sprain their ankle” or that it’s “just a sprain.”  I must make a point that the time to deal with any ankle injury is immediately!   There are many degrees of ankle sprain and as you have now read, many different types of ankle sprain.

Determining the injury type and severity will go a long way to ensure that your ankle recovers properly.  As well, just because the swelling is going away and the pain decreases, this does not imply that the ankle has healed properly.  Loss of range of motion, scar tissue and persistent instability are all complications of ankle sprains – even minor ones.

Strengthening the ankle joint!!

Strengthening the ankle joint!!

The ankle is a complex hinge joint that is primarily defined by the shin bone (tibia) and its meeting with the talus bone on top of the foot. There are several other bones that surround this meeting, as well as all the muscles, ligaments and tendons that make these bones moveable in several directions.
Let’s focus on how to prevent ankle pain and injury by improving the joint’s overall function.
Running and sports that involve agility are usually the cause of most ankle injuries, and these usually stem from the joint and tissues that surround it not being strong, mobile or stable enough to control the joint when asked to perform a task.
These exercises for the ankle and foot will help strengthen the joint by creating stability and mobility in the surrounding regions.
FOAM ROLL
The peroneals are a group of muscles that run down the side of the lower leg and attach between the knee and the ankle. Their respective ligaments run around the foot and ankle and can cause pain and undo tension when these muscles are tight. Using a foam roller to perform self-myofascial release therapy will help muscle release tension and, as a result, relieve the stress being placed on the attachment points in and around the foot and ankle.
STRETCH
Because the hamstrings and calf (and soleus) are the major muscles in the posterior aspect of the leg, they are primarily responsible for plantar flexion of the foot and can become tight when there is an issue of mobility in the ankle.
CREATE AN ARCH
A weak foundation is often to blame for other areas of the body becoming injured, so a good place to begin training is improving the support system. Strengthening the arches in the feet will help provide additional support to the ankle.
ENGAGE SUPPORT MUSCLES
By including dynamic movement patterns, especially when barefoot, the muscles that support the foot and ankle movement will be engaged to further improve stability of the joint.

How Do I know If I’ve Rolled My Ankle?

How Do I know If I’ve Rolled My Ankle?

An ankle sprain is a common injury. Inversion ankle sprains are the most common, making up 85% of all ankle sprains. It is know that the incidence of lateral ligament injuries is the most common amongst the sporting population and the consequence of not rehabilitating after an initial injury increases the chances of recurrence.
• Presents with history of inversion injury or forceful eversion injury to the ankle. May have previous history of ankle injuries or instability.
• May be unable to weight-bear through the limb.
• Potential description of a cold foot or parathesia
• Tenderness, swelling and bruising on the lateral side of the ankle.
• Bony tenderness, deformity or crepitus present.
• Passive inversion or plantar flexion + inversion should replicate symptoms for a lateral ligament sprain, passive eversion should replicate symptoms for a medial ligament sprain.
• Special Tests: +ve Anterior Draw, Talar Tilt or Squeeze Test
If this sounds like you have any f these symptoms please book in to see one of our physios today