Ankle Sprains in the Runner

Ankle sprains are one of the most common joint injuries runners experience. The injury can occur when one rolls over a rock, lands off a curb, or steps in a small hole or crack in the road. Usually the sprain is only mild, but on occasion it may seriously injure the ligaments or tendons surrounding the ankle joint. Management of this injury relies on early and accurate diagnosis, as well as an aggressive rehabilitation program directed toward reducing acute symptoms, maintaining ankle stability, and returning the runner to pre-injury functional level.

General Anatomy of the Ankle

The ankle is comprised of three main bones: the talus (from the foot), the fibula and tibia (from the lower leg). The three bones together form a mortise (on the top of the talus), as well as two joint areas (on the inside and outside of the ankle), sometimes called the "gutters". The ankle is surrounded by a capsule, as well as tissue (the synovium) that feed it blood and oxygen.

Some of the more important structures that hold the ankle together are the ankle ligaments.

Most ankle sprains involving the ligaments are weight bearing injuries. When a runner's foot rolls outward (supinates) and the front of the foot points downwards as he or she lands on the ground, lateral ankle sprain can be a result. It is usually this situation that causes injury to the anterior talo-fibular ligament. However, when the foot rolls inwards (pronates) and the forefoot turns outward (abducts), the ankle is subject to an injury involving the deltoid ligament that supports the inside of the ankle. This can occur when another runner steps on the back of the ankle, as at the beginning of a race, or when a runner trips and falls on the runner in front of him.

Diagnosis

When assessing an ankle sprain, your podiatrist will want to know the mechanism of injury and history of previous ankle sprains. Where the foot was located at the time of injury, "popping" sensations, whether the runner can put weight on the ankle are all important questions needing an answer. If past ankle sprains are part of the history, for example, a new acute ankle sprain can have a significant impact.

The physical examination should confirm the suspected diagnosis, based on the history of the injury. One looks for any obvious deformities of the ankle or foot, black and blue discoloration, swelling, or disruption of the skin. When crackling, extreme swelling and tenderness are present, together with a limited range of motion, one may suspect a fracture of the ankle. A feeling of disruption on either the inside or the outside of the ankle may indicate a rupture of one of the ankle ligaments.

To check for ankle instability, the runner should be evaluated while weight bearing. Manual muscle testing is also valuable when checking for ankle instability. One of the more critical tests that a runner should be able to perform before allowing resumption of activity is a "single toe raise" test. If the runner is unable to do this, one might suspect ligamentous injury or ankle instability.

X-rays help rule out fractures, "fleck fractures" inside the ankle joint, loose bodies, and/or degenerative joint disease (arthritis). Stress X-rays are taken when ligamentous rupture or ankle instability is suspected. When a stress test is taken of your ankle, don't be surprised if the same test is performed on the other ankle. This is done to compare the two ankles, particularly in cases of ligamentous laxity (loose ligaments).

In the past, more commonly, ankle arthrography has been used. This involves injecting a dye into the ankle joint as it is X-rayed. This helps determine if a rupture of a ligament or tear of the ankle capsule has occurred. However, this procedure does involve some discomfort during the injection process, and, on rare occasions, an allergy to the dye occurs.

Other diagnostic tests include computerized tomography (CT Scan) to discover injuries of the bone, and magnetic resonance imaging (MRI) to isolate and diagnose specific soft tissue injuries (ligaments, tendons, and capsule). The MRI is very specific, and gives a clear-cut view of these important structures.

Treatment

Treatment of an acute ankle injury usually begins with an aggressive physical therapy program that controls early pain and inflammation, protects the ankle joint while in motion, re-strengthens the muscles, and re-educates the sensory receptors to achieve complete functional return to running activity.

Modalities that decrease pain and control swelling include icing, electrical nerve stimulation, ultrasound, and/or iontophoresis patches. Easy, mild motion, with the limits of pain and swelling, can actually reduce the effects of inflammation. A continued passive motion (CPM) machine can be very helpful in decreasing pain and swelling.

Resumption of running activity is usually dependent on the runner's limits of pain and motion, and is begun to tolerance. As the runner improves, diagonal running can be prescribed. It is important to protect the runner with braces such as air casts, ankle braces, etc., which help to allow motion at the ankle joint under weight bearing.

Home exercise programs are very helpful for the post-ankle sprain runner. Proprioception re-education is critical for both the acute as well as the chronic ankle sprain. It may involve using a simple tilt board or more sophisticated proprioceptive training and testing devices.

For the acute grade III lateral ankle sprain, or complete deltoid tear, complete immobilization is usually recommended for at least four weeks. Afterwards, a removable cast is used to restrict motion and allow for physical therapy. If the ankle does not respond and ankle instability is diagnosed, surgical intervention may be required.

Today, ankle arthroscopy a much less invasive procedure than other surgery, allows the ligament to be stabilized with tissue anchors. This eliminates an extended period of immobilization, joint stiffness and muscle atrophy. Post-operatively, this primary ligament repair is protected for approximately a two-to three-week period of time in either a cast or removable cast boot, with daily-continued passive motion, cold therapy, and controlled exercise.

At three weeks, a simple air cast or ankle brace is applied for an additional three weeks while therapy and rehabilitation is progressing. At six weeks, these devices are used only during running and other athletic activity as a safeguard. As the runner resumes strength and proprioceptive capabilities, the devices are discontinued.

Conclusion

When an acute or chronic ankle sprain is not treated, as unfortunately is all too often the case, repeated ankle sprains may occur. Because chronic ankle injuries do not show acute inflammation even when the ankle is weak and unstable, this may set the runner up for another ankle sprain when least suspected. A successive sprain may be more severe than the first, and cause an even more significant injury.

The most important point to keep in mind when talking about ankle injuries, then, is to prevent the condition from becoming chronic or recurrent.

So the next time you roll over that stone, or land in that small hole, make sure that your simple ankle sprain is just that: "simple".

If you don't want to have a swollen ankle all the time while running, don't ignore early warning signs. If you have any doubts about its seriousness, have your podiatrist check your injury.

Martial Arts and Kickboxing Injuries

Guest Editor, Dr. Alan Ng
1994 World Kyuk Too Ki Heavyweight Bare Knuckle Champion
Second Degree Black Belt Enshin Karate
First Degree Black Belt Shidokan Karate

With the new popularity of athletic activities involving the martial arts, a variety of injuries will occur that are not seen with mainstream athletics. The diversity of the martial arts can be broken down into two different types of training. The traditional martial artist or kickboxer's training will involve a series of activities. A training session will involve stretching, basic techniques and combinations, bag and/or pad training, forms or kata, and finally sparring. A new type of training has become very popular in today's society is aerobic kickboxing otherwise known as "tae Bo". This type of training or exercise involves utilizing martial arts technique combined with traditional aerobic exercises. A class of aerobic kickboxing will combine stretching, basic techniques and combinations in an aerobic type format.

Training

The most important aspect of martial arts training or aerobic kickboxing training is that the student or participant must stretch extensively before a training session. By stretching the amount of minor soft tissue injuries such as muscle strains, tendon strains will be decreased. Stretching should be performed for a minimum of fifteen minutes before performing any kicking or punching techniques.

Injuries that can occur vary from minor injuries to severe dehabilitating injuries. When assessing aerobic kickboxing, injuries that occur are generally minor. Common podiatric related injuries when performing aerobic kickboxing are; plantar fasciitis, Achilles tendonitis, seasmoiditis, ankle sprains. When looking at traditional martial arts which involve striking pads, a heavy bag, and/or another student, the injuries become more extensive. In addition to the injuries mentioned above, traditional martial arts injuries include; fractures, hematomas, and dislocation joints and tendons.

Plantar fasciitis, or plantar fascial injuries can occur when training due to the constant pivoting and elevation of the foot while performing kicks. The mechanics of performing a front or roundhouse type kick involves the supporting leg to pivot on the ball of the foot, while the other leg is in the air striking the target. The fascial injury can occur on the supporting leg due the strain on the fascia, or a fascial injury can occur to the striking leg due to the repetitive pushing off and tightening of the fascia when beginning the kick, or when the kick is concluding which causes the kicking foot return to the ground which causes tightening of the fascia. The pain will be located at the inside of the heel and at the bottom of the heel when this type of injury occurs.

Achilles tendonitis is another common injury during martial arts training. The Achilles tendon is involved bringing the foot into position for many of the kicks, and is also responsible for the initiating motion when performing a kick. Since the amount of kicks performed in a training session can be over 500, an overuse injury to the Achilles tendon can cause a tendonitis when training.

Seasmoiditis, is another type of repetitive motion related injury. When performing kicks properly, the supporting foot is elevated onto its metatarsal heads, which allows the supporting leg to pivot. The long bone behind the big toe has two small round shaped bones underneath the head of this bone. These bones can become irritated and inflamed and cause pain just behind and under the big toe.

As with many other sports, ankle sprains are very common in martial arts training. The abundance of side-to-side motion and one limb support while kicking makes this injury a common one when training.

Basic Treatment Recommendations

With the four injuries listed above, basic treatment of resting the injury, icing the injury, and elevating the extremity should be performed. If the conditions persist after a few days of rest, ice, and elevation, further assessment should be performed by your podiatrist.

Other Injuries

With the addition of contact activities in traditional martial arts, fractures are common in the foot and ankle. Common types of fractures while training are; digital fractures, and metatarsal fractures. With these types of injuries, the pain is severe and often results in the inability to bear weight on the limb. Swelling and bruising will often accompany the fracture. If any injury is severe enough to hinder your ability to walk, and a fracture is suspected, it is recommended that you visit your podiatrist so x-rays of the area can be taken.

Hematoma formation may be the most common injury in the traditional martial artist. Hematoma is caused when the foot or leg strikes the target improperly or strikes a target which is not padded well. Objects such as bony prominences, a hard heavy bag, or even sandbags. What occurs is that by striking this object multiple vascular structures are disrupted causing bleeding inside the foot or leg. This will cause the foot to swell most commonly on the top of the foot, and the swelling causes pressure on the nervous structures which will result in pain. Hematomas can occur with or without fractures of the bones. The primary treatment for this type of injury is again rest, ice, compression, and elevation. It is very important thought to assess this injury properly. If you notice that the toes are cold, and the pain is very severe you must immediately have the injury assessed at a hospital or an urgent care center. A condition called Compartment Syndrome can occur in this area which if not treated immediately, can result in loss of your foot.

Dislocation of joints in martial arts will involve the digits the majority of the time. With traditional martial arts the training is performed without shoe gear. This allows the digits to be exposed and vulnerable to dislocation. If a digit becomes dislocated, see you podiatrist as soon as possible to avoid any long-term complications in that digit.

Tendon dislocation can also occur as a result of martial arts training. The primary tendon which can dislocate when training is the peroneal tendon which runs just behind the fibula. Often times this injury is mistaken for an ankle sprain. The characteristic of this injury is that the tendon which is usually behind the fibula will pop around the outside of the bone when the foot is pushed up. The injury will feel much like an ankle sprain. If you notice the tendon displacing in this way, or you notice that what you thought was an ankle sprain is not getting better you should see your podiatrist for further evaluation.

Conclusion

Martial arts is an excellent method of exercise and stress relief. As with any type of exercise, injuries are a common occurrence. Being able to identify the type of injury, and the proper treatment modality will allow for a faster recovery and a faster return to activity.

Metatarsal Stress Fracture

When excessive stress is placed upon the ball of the foot, a hairline break (fracture) of a long metatarsal bone may occur. This occurs most frequently to the second, third, or fourth metatarsal but can occur in any bone. Frequently, the injury is so subtle that you may not recall any specific occurrence. These fractures were at one time referred to as "March Fractures" in soldiers, who developed foot pain after long periods of marching. Stress fractures can occur during sports activities, in overweight individuals, or in those with weakened bones such as osteoporosis.

Diagnosis

A typical presentation for someone with a metatarsal stress fracture would be pain and swelling in the ball of the foot, which is most severe in the push off phase of walking. Pressing on the bones in this area of the foot will reproduce the pain. X-rays taken during the first two to three weeks after the injury often will not show any fracture. A bone scan at this stage will be much more sensitive in diagnosing the early stress fracture. The decision to order a bone scan will be up to your doctor. Often times the diagnosis can be made based upon clinical findings, thus making the bone scan unnecessary. After several weeks, an x-ray will show the signs of new bone healing in the area of the stress fracture.

Treatment

Treatment for a metatarsal stress fractures usually consists of rest, elevation, and ice initially. Sometimes a compression bandage is applied to help reduce the swelling. Frequently a post-op type of shoe or camwalker is used to prevent you from pushing off the ball of your foot, thus eliminating any additional stress while the bone is healing. Occasionally a short leg walking cast may be applied for a short period of time. Typical healing times range from 4 to 8 weeks. After the fracture is healed, special attention should be paid to using a well-padded insole or a functional orthotic in the shoes to reduce the stress in this area. For those who may have osteoporosis, bone densitometry testing should be done, and appropriate treatment initiated to prevent further weakening of the bones.

Turf Toe

Activities such as football, basketball, soccer, field hockey and lacrosse show the high incidence of injury to the great toe joint on artificial surfaces. Other non-sporting causes include change in shoe gear, limited range of motion of the great toe joint, and sometimes flat foot conditions.

Mechanism of Injury

There are two mechanisms of injury for turf toe. The most common cause is hyperextension of the great toe joint. The great toe joint is hyper-extended as the heel is raised off the ground. An external force is placed on the great toe and the soft tissue structures that support the great toe on the top are torn or ruptured.

Physical Signs and Symptoms

Symptoms of acute injury include pain, tenderness and swelling of the great toe joint. Often there is a sudden acute onset of pain during push-off phase of running. Usually, the pain is not enough to keep the athlete from physical activities or finishing a game. This causes further injury to the great toe and will dramatically increase the healing time.

Injuries to the great toe that cause turf toe are graded into three categories.

A Grade I turf toe injury is considered to be mild and the supporting soft tissue structure that encompass the great toe are only sprained or stretched. This is the most common type of injury. There is minimal swelling with mild local tenderness and usually no black and blue bruising evident.

Grade II turf toe injuries are considered moderate in severity. They present with more diffuse tenderness, swelling, restricted range of motion and usually are mildly black and blue in appearance. There is usually a partial tear of the supporting ligaments but no articular cartilage damage.

Grade III injuries are considered severe in nature because of the considerable swelling, pain on palpation, restriction of range of motion, inability to bear any weight on the injured foot and diffuse black-and-blue appearance of the great toe. There is generally tears to the joint capsule, ruptured, ligaments and possibly compression damage to the articular cartilage of the great toe.

Treatment

Treatment is usually centered on an individual basis and the severity of the injury sustained. The following are general principle guidelines for turf toe injuries. The mnemonic "RICE" can be employed. The "R" stands for rest and is the hallmark component to allow for successful healing to occur. However, this is the greatest area of noncompliance because the athlete assumes the injury to be trivial and not severe enough to miss a game or practice. The "I" represents ice, which is usually performed for the first 48-72 hours after the initial injury. Cryotherapy consists of placing the injured toe in a bucket of ice water for 15-20 minute intervals. "C" signifies compression, which is done by taping the great toe in a compression dressing or strapping. The "E" stands for equipment modification or change. For example, the use of a stiffer athletic shoe to resist motion of the great toe or the insertion of an orthotic to increase the support of the great toe.. Additionally, strapping of the great toe to limit motion may allow a highly competitive athlete to return to activities quicker. Non-steroidal anti-inflammatory drugs (NSAID) may be utilized for relief of minor pain as well as to decrease the inflammation of the injury.

Grade I injuries do well with strapping and usually only require a few days of rest. Grade II injuries should adhere to the "RICE" principles above and usually require one to two weeks of missed practices and games. Grade III injuries are more severe injuries and the healing process may take four to six weeks of recovery time from physical activities. Sometimes, Grade III turf toe injuries do not heal appropriately with conservative care and result in chronic pain and instability. Surgical reconstruction of the joint capsule, ligaments and articular cartilage may be necessary to restore proper alignment and function in these extreme cases.