We are spilling the tea.....
Oh, you don't know what that means? Don't worry! Neither did I until my 18-year old cousin filled me in on this new slang. Spilling the tea is getting the scoop, letting the cat out of the bag, telling that juicy secret and we are here for it.
What are we spilling the tea on you ask? One of the most common and problematic orthopedic issues. Any guesses? Let's start with a little history. I spent almost six years living in Las Vegas. During that time, I worked part-time as a physical therapist for Cirque Du Soleil. What a blast! When I tell others about this experience the response is unanimous, "Oh I bet they really need PT!" And yes, they absolutely need therapy. Any guesses on the most problematic injury? I bet you are thinking lumbar instability from our contortionists, or labral tears from trapeze artists, or even ACL tears from trampoline artists. While all of those injuries occur frequently, good old fashioned ankle sprains lingered for months on many of our performers. And I'm not talking about rare eversion deltoid ligament sprains, these were inversion sprains.
Many therapists know we've added on to the age old acronym RICE to also include movement. Therapists expertly rehab patients through acute and sub-acute stages of ankle sprains. But how about those chronic sprains that continue to cause pain with plyometrics, running, and deep squatting?
Well let's spill that tea!
Chronic ankle sprains, especially on elite or high performing athletes, require a more in-depth look at biomechanics of the foot and ankle. Range of motion can appear full and equal bilaterally without normal talo-crural mechanics. Are you checking talo-crural swing in sitting? Are you seeing that last bit of external rotation in full dorsiflexion? These minute motions keep basketball players from forceful and explosive push off and cause pain in landing for gymnasts. But the loss also keeps moms from fully squatting to tie their toddlers shoes. The point, there is more to evaluate than what first meets the eye and dysfunction from the talo-crural joint effects everyone, not just athletes. Let's talk about the cuboid bone. Remember that little guy? Man can he cause some pain! When picturing the biomechanics of common inversion injuries keep in mind that the cuboid is often forcefully internally rotated. Patients complain of pain in the lateral foot, some say they feel like something is poking the outside of the foot causing them to pronate more during gait. Over pronation stretches and stresses plantar fascia which is a whole other post. The point, address these issues early. What about pain in the heel after full talo-crural swing resolves? Check the sub-talar joint. Is the calcaneus still stuck in inversion from the initial injury or is it compensating with loss of inversion to accommodate other joint dysfunction caused from trauma? Make sure the fibula mechanics are good for the inferior and superior joint. The fibula takes a big hit with ankle sprains.
So you've found faulty mechanics, now what? I'll list a few of my favorite tips and tricks for each of the joints listed.
Talo-crural: mobilization with movement. Have the patient step forward with involved leg into a lunge position. Pull the inferior tib-fib complex anteriorly as the patient lunges forward. Repeat 20-30 times as tolerated.
Cuboid: cuboid whip manipulation. Patient is standing holding onto table or chair for support. Stand on uninvolved leg and bend the knee of the involved ankle. Dorsiflex the foot as you push the cuboid forward. Make sure the patient is relaxed as you quickly "whip" the cuboid anteriorly into eversion.
Sub-talar: prone calcaneal distraction. Have patient lay in prone. Pull the calcaneus away from their head. Grade 4 mobilizations as tolerated for three minutes. Great for pain relief!
Tibio-fibular: muscle energy technique. Find limitations of superior joint first. Look for a loss of anterior-lateral or posterior-medial glide. For loss of anterior glide use ankle dorsiflexors to pull forward for five seconds followed by anterior-lateral mobilization. For loss of posterior glide use ankle plantar flexors to pull the fibula posterior-medial for five seconds followed by mobilization.
We love to share our favorite treatment tips and hope they help you with problematic patients. We would love to hear your thoughts and some of your favorite treatment techniques. Reach out to us below!
