Kasey Miller

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Sprained Ankle by American Orthopaedic Foot and Ankle Society A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle. The ligaments of the ankle hold the ankle bones and joint in position. They protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot. A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers. How It Happens Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position. Mechanism of Injury If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle's soft tissue structures, you may even hear a "pop". Pain and swelling result. The amount of force determines the grade of the sprain. A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3. • Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament. • Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs. • Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs. Diagnosis See your doctor to diagnose a sprained ankle. He or she may order X-rays to make sure you don't have a broken bone in the ankle or foot. A broken bone can have similar symptoms of pain and swelling. The injured ligament may feel tender. If there is no broken bone, the doctor may be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain and bruising. The physical exam may be painful. The doctor may need to move your ankle in various ways to see which ligament has been hurt or torn. If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface itself. The doctor may order an MRI (magnetic resonance imaging) scan if he or she suspects a very severe injury to the ligaments, injury to the joint surface, a small bone chip or other problem. The MRI can make sure the diagnosis is correct. The MRI may be ordered after the period of swelling and bruising resolves. Symptoms The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint. Treatment Nonsurgical Treatment Walking may be difficult because of the swelling and pain. You may need to use crutches if walking causes pain. Usually swelling and pain will last two days to three days. Depending upon the grade of injury, the doctor may tell you to use removable plastic devices such as castboots or air splints. Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The doctor may tell you to incorporate motion early in the healing process to prevent stiffness. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion. For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation): • Rest your ankle by not walking on it. • Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction. • Compression dressings, bandages or ace-wraps immobilize and support the injured ankle. • Elevate your ankle above your heart level for 48 hours. For a Grade 2 sprain, the RICE guidelines can also be used. Allow more time for healing to occur. The doctor may also use a device to immobilize or splint the ankle. A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed. A short leg cast or a cast-brace may be used for two weeks to three weeks. Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor propriception is a major cause of repeat sprain and an unstable ankle joint. Once you are pain-free, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time. All ankle sprains recover through three phases: • Phase 1 includes resting, protecting the ankle and reducing the swelling (one week). • Phase 2 includes restoring range of motion, strength and flexibility (one week to two weeks). • Phase 3 includes gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities) such as tennis, basketball or football (weeks to months). Long-term outcome If an ankle sprain is not recognized, and is not treated with the necessary attention and care, chronic problems of pain and instability may result. Surgical Treatment Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment. Surgical options include: • Arthroscopy A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint. • Reconstruction A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.

What Are Bursitis and Tendinitis? By the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Fast Facts: Bursitis and tendinitis are both common conditions that cause swelling around muscles and bones. They occur most often in the shoulder, elbow, wrist, hip, knee, or ankle. A bursa is a small, fluid-filled sac that acts as a cushion between a bone and other moving body parts such as muscles, tendons, or skin. Bursae are found throughout the body. Bursitis occurs when a bursa becomes swollen. A tendon is a flexible band of tissue that connects muscles to bones. Tendons can be small, like those found in the hand or ankle, or large, like the Achilles tendon in the heel. Tendons help create movement by making the muscles push or pull the bones in different ways. Tendinitis is the severe swelling of a tendon. What Causes These Conditions? People get bursitis by overusing a joint. It can also be caused by direct trauma. It usually occurs at the knee or elbow. Kneeling or leaning your elbows on a hard surface for a long time can make bursitis start. Tendinitis usually occurs after repeated injury to a certain area such as the wrist or ankle. Tendons become less flexible with age and become more prone to damage. Doing the same kinds of movements every day or putting stress on joints increases the risk for both conditions. People like carpenters, gardeners, musicians, and athletes often get bursitis or tendinitis. Infection, arthritis, gout, thyroid disease, and diabetes can also cause swelling of a bursa or tendon. Both bursitis and tendinitis are more frequent the older you get. What Parts of the Body Are Affected? Tendinitis causes pain and soreness around a joint. Some common forms of tendinitis are named after the sports that increase their risk. They include tennis elbow, golfer’s elbow, pitcher’s shoulder, swimmer’s shoulder, and jumper’s knee. Tennis Elbow and Golfer’s Elbow Tennis elbow is an injury to the tendon in the outer elbow. Golfer’s elbow affects the inner tendon of the elbow. Any activity that involves a lot of wrist turning or hand gripping, such as using tools, shaking hands, or twisting, can bring on these conditions. Pain occurs near the elbow. It can also travel into the upper arm or forearm. Shoulder Tendinitis, Bursitis, and Impingement Syndrome Two types of tendinitis can affect the shoulder. Biceps tendinitis causes pain in the front or side of the shoulder. Pain may also travel down to the elbow and forearm. Raising your arm over your head may also be painful. The biceps muscle in the front of the upper arm helps secure the arm bone in the shoulder socket. It also helps control the speed of the arm during overhead movement. For example, you may feel pain when swinging a racquet or pitching a ball. Rotator cuff tendinitis causes shoulder pain at the top of the shoulder and the upper arm. Reaching, pushing, pulling, or lifting the arm above shoulder level can make the pain worse. Even lying on the painful side can worsen the problem. The rotator cuff is a group of muscles that attach the arm to the shoulder blade. This “cuff” allows the arm to lift and twist. Repeated motion of the arms can damage and wear down the tendons, muscles, and bone. Impingement syndrome is a squeezing of the rotator cuff. Jobs that require frequent overhead reaching and sports involving lots of use of the shoulder may damage the rotator cuff or bursa. Rheumatoid arthritis also can inflame the rotator cuff and result in tendinitis and bursitis. Any of these can lead to severe swelling and impingement. Knee Tendinitis or Jumper’s Knee If you overuse a tendon during activities such as dancing, bicycling, or running, it may become stretched, torn, and swollen. Trying to break a fall can also damage tendons around the kneecap. This type of injury often happens to older people whose tendons may be weaker and less flexible. Pain in the tendons around the knee is sometimes called jumper’s knee. This is because it often happens to young people who play sports like basketball. The overuse of the muscles and force of hitting the ground after a jump can strain the tendon. After repeated stress from jumping, the tendon may swell or tear. People with tendinitis of the knee may feel pain while running, jumping, or walking quickly. Knee tendinitis can increase the risk for large tears to the tendon. Achilles Tendinitis The Achilles tendon connects the calf muscle to the back of the heel. Achilles tendinitis is a common injury that makes the tendon swell, stretch, or tear. It’s usually caused by overuse. It can also result from tight or weak calf muscles. Normal aging and arthritis can also stiffen the tendon. Achilles tendon injuries can happen when climbing stairs or otherwise overworking the calf muscle. But these injuries are most common in “weekend warriors” who don’t exercise regularly or don’t take time to warm up before they do. Among athletes, most Achilles injuries seem to occur in sprinting or jumping sports. Athletes who play football, tennis, and basketball can all be affected by Achilles tendinitis. An injury almost always retires the athlete for the rest of the season. Achilles tendinitis can be a long-term condition. It can also cause what appears to be a sudden injury. When a tendon is weakened by age or overuse, trauma can cause it to rupture. These injuries can be sudden and agonizing. Diagnosis of tendinitis and bursitis begins with a medical history and physical exam. You will describe the pain and when and where the pain occurs. The doctor may ask you whether it gets better or worse during the day. Another important clue is what makes the pain go away or come back. There are other tests a doctor may use including: • Selective tissue tension test to find out which tendon is affected. • Palpation or touching specific areas of the tendon to pinpoint the swelling. • X ray to rule out arthritis or bone problems. • MRI (magnetic resonance imaging), which can show damage to both bone and soft tissue. • Anesthetic injection test to see if the pain goes away. • Taking fluid from the swollen area to rule out infection. What Kind of Health Care Professional Treats These Conditions? Your regular doctor or a physical therapist can treat most cases of tendinitis and bursitis. Cases that don’t respond to normal treatment may be referred to a specialist. How Are Bursitis and Tendinitis Treated? The focus of treatment is to heal the injured bursa or tendon. The first step is to reduce pain and swelling. This can be done with rest, tightly wrapping or elevating the affected area, or taking drugs that bring down the swelling. Aspirin, naproxen, and ibuprofen all serve that purpose. Ice may be helpful in recent, severe injuries, but is of little or no use in long-term cases. When ice is needed, an ice pack can be held on the affected area for 15 to 20 minutes every 4 to 6 hours for 3 to 5 days. A health care provider may suggest longer use of ice and a stretching program. Your health care provider may also suggest limiting activities that involve the affected joint. Support equipment may be suggested such as: • An elbow band for tennis elbow • A brace for the ankle or foot • A splint for the knee or hand. Other treatments may include: • Ultrasound, which are gentle sound-wave vibrations that warm deep tissues and improve blood flow • An electrical current that pushes a corticosteroid drug through the skin directly over the swollen bursa or tendon • Gentle stretching and strengthening exercises • Massage of the soft tissue. If there is no improvement, your doctor may inject a drug into the area around the swollen bursa or tendon. If the joint still does not improve after 6 to 12 months, the doctor may perform surgery to repair damage and relieve pressure on the tendons and bursae. If the bursitis is caused by an infection, the doctor will prescribe antibiotics. If a tendon is completely torn, surgery may be needed to repair the damage. Repairing a tendon tear requires an exercise program to restore the ability to bend and straighten the joint and to strengthen the muscles around it to prevent repeat injury. An exercise program may last 6 months. Can Bursitis and Tendinitis Be Prevented? To help prevent swelling or reduce the number of flares, you can do several things. The following list was adapted from MayoClinic.com. • Warm up or stretch before exercise. • Strengthen the muscles around the joint. • Take frequent breaks from repetitive tasks. • Cushion the affected joint with foam (knee pads, elbow pads). • Increase the gripping surface on tools by using gloves, grip tape, or other padding. • Use an oversized grip on golf clubs. • Use a two-handed backhand in tennis. • Use two hands to hold heavy tools. • Don’t sit still for long periods. • Practice good posture. • Position your body properly when doing daily tasks. • Begin new activities or exercises slowly. • If you have a history of tendinitis, consider talking to your doctor before starting a new exercise. What Are Researchers Learning? Researchers supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are studying bursitis and tendinitis in the following ways: • The role of the immune system in the inflammation of tendinitis to create better strategies for prevention and treatment. • Worksite issues that affect the onset of tendinitis and other work-related musculoskeletal disorders.

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 …


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The effectiveness of conservative treatment for patients with cervical radiculopathy

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TMJD Basics - From The TMJ Association What Are Temporomandibular Disorders? Temporomandibular Disorders (TMJD), commonly called TMJ, are a complex and poorly understood set of conditions characterized by pain in the jaw joint and surrounding tissues and limitation in jaw movements. Injury and other conditions that routinely affect other joints in the body, such as arthritis, also affect the temporomandibular joint. One or both joints may be involved and depending on the severity, can affect a person's ability to speak, eat, chew, swallow, make facial expressions, and even breathe. Also included under the heading of TMJD are conditions involving the jaw muscles. These may accompany the jaw joint problems or occur independently. They are often confused with jaw joint problems because they produce similar signs and symptoms. Comorbid (Overlapping) Conditions Researchers have found that temporomandibular disorders often occur along with other - often painful- conditions in other parts of the body, prompting studies in search of a common factor underlying them all. Among these conditions are chronic fatigue syndrome, chronic headache, endometriosis, fibromyalgia, interstitial cystitis, irritable bowel syndrome, sleep disorders, and vulvodynia. Moreover, certain medical conditions such as Ehlers-Danlose syndrome, dystonia, Lyme disease, and scleroderma may affect the temporomandibular joint. Who is Affected? Approximately 35 million people in the United States suffer from TMJ problems at any given time. While both men and women experience these disorders, the majority of those seeking treatment are women in their childbearing years. The ratio of women to men increases with the severity of symptoms, approaching 9 to 1 for patient with major limitations in jaw movements and chronic, unrelenting pain. Causes Although the cause of most of these disorders is not known, there are some known contributing factors to the development of these disorders. Among them are: • autoimmune diseases • infections • injuries to the jaw area • dental procedures • stretching of the jaw as occurs with inserting a breathing tube before surgery • various forms of arthritis Genetic, hormonal, and environmental factors can also increase the risk for TMJD. Studies have shown that a particular gene variant increases sensitivity to pain and this variant has been found to be more prevalent among TMJD patients than among the populations at large. The observation that TMJD are commonly found in women in their childbearing years has also led to research to determine the role of female sex hormones in these disorders. Environmental factors such as habitual gum chewing or sustained jaw positions may also contribute to TMJD. Diagnosis of TMJ Disorders At present, there is no widely accepted, standard diagnostic test to identify all TMJD. Because the exact cause and symptoms are not clear, identifying these disorders can be difficult and confusing. The American Association for Dental Research recommends that a diagnosis of TMJD or related orofacial pain conditions should be based primarily on information obtained from the patient's history and a clinical examination of the head and neck. In addition to a detailed history and a careful clinical examination, imaging studies of the teeth and jaws may sometimes be helpful as a diagnostic tool. These include: routine dental x-rays and panoramic radiographs, computed tomography (CT or CAT scan), Magnetic Resonance Imaging (MRI), and Scintigraphy (Bone scan). Blood tests are sometimes recommended to rule out possible medical conditions as a cause of the problem. Before undergoing any costly diagnostic test, it is always wise to get an independent opinion from another health care provider of your choice and one not associated with your current provider. Symptoms of TMJ Disorders The Pain of TMJD is often described as a dull, aching pain which comes and goes in the jaw joint and nearby areas. Some people, however, report no pain, but still have problems using their jaws. Symptoms can include: • pain in the jaw muscles • pain in the neck and shoulders • chronic headaches • jaw muscle stiffness • limited movement or locking of the jaw • ear pain, pressure • painful clicking, popping or grating in the jaw joint when opening or closing the mouth • a bite that feels "off" Less common symptoms include: ringing in the ears (tinnitus), dizziness, and vision problems. Comment, Like and Share with your Friends www.physio-therapy.cz

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Physical Therapy Modalities and Rehabilitation Techniques in the Management of Neuropathic Pain

Neuropathic pain is a significant problem because of its complex natural history, unclear etiology, and poor response to standard physical therapy …