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.

 

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.

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.

Lateral ankle sprains (LAS) are one of the most common sports injuries. As a result they have a high economic burden with direct and indirect costs associated with the injury.

 

From a clinical point of view, the problem with LAS is that there is a very high recurrence rate and 20% of the general population and 30-50% of the athletic population will go on to suffer from chronic ankle symptoms (pain, swelling and instability); also known as chronic ankle instability (Gribble et al., 2016, Attenborough et al., 2015 & Tanen et al., 2014). It is believed that contributing factors to the development of chronic ankle instability are:

 

1) Very few will seek medical attention for primary LAS

2) Most people prematurely return to sport; when their pain is absent.

 

The good news is that a recent systematic review and meta-anaylsis showed that there are 2 very simple things that can be done to reduce the chances of a primary LAS developing into chronic ankle instability (Doherty et al., 2016). These are:

 

1) Exercise Therapy: Exercise therapy when performed in high doses (>900mins) significantly reduced the chances of recurrent LAS by 42%. Furthermore, exercise therapy significantly improved function following primary LAS.

– 900mins sounds like a lot, but when broken down is very achievable:

– 5x30mins per week = 150mins per week

– 150mins per week x 6 weeks = 900mins

 

2) Bracing/Taping: Significantly reduced the risk of recurrent LAS by 62%. It is currently recommended that a brace be worn on the injured ankle, or that it is taped for every game or training session for at least 6 months following the initial LAS.

 

Take home messages:

 

1) Ankle sprains are not so simple, and they need to be respected.

2) The absence of pain does not mean that you’re ready to return to sport. The subtle losses of strength, ROM, proprioception and balance do not magically re-appear once your pain has gone.

3) Make sure you COMPLETE your rehab; 6 weeks of regular strength, balance, stretching, plyometrics and agility should be considered a non-negotiable part of the rehab plan.

4) Ensure that you brace or tape your ankle for training and games for at least 6 months following your sprain.

5) Like every injury, the decision to return to sport following a LAS should be based on performance criteria such as strength, balance and hop tests rather than time-alone or the absence of pain.

Patellar Tendinopathy is most commonly characterised by pain localised to the inferior pole of the knee cap and load related pain which increases the demand on the knee extensors.

Risk factors include being 15-30 years old, males are affected more than females, involvement in jump/lunging sports and training loads.

Pathology occurs because there is an ↑ tenocyte numbers, ↑ ground substance, swelling, matrix degeneration and neovascular growth.

Presentation is generally pain localised to the inferior pole of the patella, load related pain (knee extensors). Regional findings sometimes present with wasting of quads, foot issues, ↓ hamstring/ quad flexibility and ↓ dorsi flexion.

Imaging generally doesn’t confirm patellar tendon pain but can exclude other diagnosis’ such as bursitis or fat pad irritation for example.

Management of Patellar Tendinopathy

• Eccentric Exercises may be too aggressive when there is high irritability, and there is little data that leads to better outcomes.
• Heavy slow resistance exercises demonstrated similar improvements to eccentric exercises in pain and function, with the benefit of higher patient satisfaction scores.
• The focus of treatment is to develop tolerance of the tendon, muscle and kinetic chain. progressive criteria is based on pain, strength and function.
• Initial load modifications aims at reducing pain with a focus on ↓ high load energy storage tasks. Modify : Volume and frequency
• Progress loading based on pain monitoring with a 5/10 during exercise.

**********24 hour response test **********

At the same time each day the client does a single leg squat to 90 degrees and compares the pain to baseline scores. If pain is higher than the previous days it means the previous days load has not been tolerated well.

Bottom line ……..

1) Calm it down and build it back up

2) Some pain is acceptable during exercise but symptoms should resolve quickly after exercise and should not progressively worsen over the course of the rehab program.

Do: Choose Low-Impact Exercises
Low-impact aerobic exercises such as walking, biking, and swimming are considered joint-friendly. They help build strength around the affected joints and keep them aligned and functioning properly.

Knee braces are supports to be worn when you have pain in your knee. Some people use them to prevent knee injuries during sports. Braces are made from combinations of metal, foam, plastic, or elastic material and straps.

Scientific research hasn’t given a clear answer but there are different reasons for their use.ellness

– Functional braces

These give support to knees that have been injured in the past. Clients often wear them after a major injury has healed. They stabilize the knee and control motion to prevent another injury.

– Rehabilitative braces

These are usually used for a period of weeks right after an injury or surgery. They keep the knee stable but still allow limited movement while it is healing. Some specialists haven’t seen a benefit from these braces and no longer recommend them.

– Unloader braces

These are designed to relieve pain in people who have arthritis in their knees. They shift the weight (“unload” it) from the damaged area of the knee to a stronger area.

– Prophylactic braces

These are designed to protect knees from injuries during contact sports such as football. They have become popular among athletes. Research has not proven that they work, but studies are ongoing.

 

– Knee sleeves

These are not technically braces, but they are the most common type of knee support. They are designed to provide compression around the knee joint. This helps support the knee, and can control pain and swelling.

Things to consider

– Companies that make knee braces claim that their products work well. Scientific studies have not completely agreed. Some physios are afraid that knee braces may actually increase the number of knee injuries in athletes. But many people who wear knee braces feel that they help.

– Knee braces are the least important part of preventing knee injuries or healing after an injury. Good strength and flexibility are much more important. You should focus on stretching the muscles around your knee, strengthening your leg, and improving your techniques.

– Make changes in activity intensity or training schedules little by little, to limit knee stress.

– Researchers are trying to learn more about how well knee braces really work and when it’s best to use them.

What indicates conservative or surgical management pathways?

The main clinical issue currently is the lack of research regarding the efficacy of arthroscopic meniscal repairs compared to a conservative approach (Englund, Roemer, Hayashi, Crema, & Guermazi, 2012).

There is minimal literature regarding clinical prediction rules or protocols which indicate surgery rather than conservative management. There are multiple articles displaying the benefits of physiotherapy following meniscectomy, however only two articles exist (that I’m aware of) comparing surgical and conservative management following meniscal tears.

Herrlin and associates (2007) analysed a group of 90 individuals with degenerative medial meniscus tears, half receiving arthroscopy and supervised exercise program while the remaining individuals received only the exercise program. The exercise program consisted of twice-weekly sessions for eight weeks, consisting of stationary bicycle, calf and quadriceps strengthening, lunges, stairs, leg press, balance training and knee stretching, enhanced by a similar home exercise program. At eight weeks and six months follow-up both groups improved in VAS scores, knee function measures and satisfaction measures, with no significant difference between groups. This article is a landmark paper as it justifies an eight week targeted exercise program, compiled and delivered by a physiotherapist, is as effective as a surgical procedure (Herrlin et al., 2007). Using literature, we can validate our treatment is more cost-effective, time-effective and provides less risk for the patient.

 

 

A more recent study by Katz and colleagues (2013) randomly assigned 351 individuals, aged 45 years or older with meniscus tears and mild to moderate osteoarthritis evident on imaging, into a surgical group (who then received physiotherapy) and a physiotherapy group (with individuals able to receive surgery if indicated or chosen by the patient). The physiotherapy group consisted of a standardised program (addressing range of motion, muscle strength, aerobic capacity, proprioception and balance) where exercises were individually progressed as the patient’s objective measures improved. The WOMAC Index was used as the primary outcome measure, assessed at baseline, 3, 6 and 12 months post-intervention. There was no significant difference between groups at 6 months, however 30% of individuals in the physiotherapy group underwent surgery within 6 months (Katz et al, 2013). Although this appears less enchanting than the Herrlin study, 70% of individuals had full return to function without requiring surgery. We are still able to justify the efficacy of physiotherapy as a valid alternative to surgical intervention, with only 30% requesting surgery.

A case report by Stensrud and colleagues (2012) provided a twelve week neuromuscular and strengthening program, progressing to single leg exercises, which also produced these positive results, however the physiotherapy group was compared to control rather than an arthroscopy group.

We must remember that Herrlin’s study looked only at degenerative meniscal tears, with traumatic injuries being excluded. Katz’s study does not dictate whether the tears were traumatic or degenerative, so extrapolation to treating traumatic meniscus tears is difficult. With traumatic tears, the severity ranges from mild pain to severe pain and locking or restricted knee range. Brukner & Khan (2012) state a locked knee requires immediate arthroscopy. However, the majority of patients present with moderate pain and mechanical symptoms, with some catching rather than true locking. The management for these patients must be made considering the patient’s signs and symptoms, work and sporting demands, timeframes, financial status and MRI findings.

Patients who appear to respond best to arthroscopy present with increasing pain, some locking and/or catching and have a displaced meniscus tear on MRI (Suter et al., 2009).

 

Certain therapists are more conservative in their approach and will try three to six weeks of conservative management, monitoring symptoms. If no improvements occur they will be referred for a surgical consultation. This greatly depends on sporting and work timelines, if a deadline is looming and surgery can return a player to function faster, surgery may be indicated. However, with greater knowledge of bone oedema and osteoarthritis secondary to trauma, therapists are trending towards a more conservative approach.