Patient complaint: right Achilles pain preventing him from training and competing (sprinting). By taking a thorough history and mechanical exam, it is clear his pain is originating in his low back. When taking his verbal history, what made me suspect his spine - and not his actual Achilles tendon - is the tendon pain variability, his report of intermittent low back and calf "tightness," and his history of other lower extremity issues.
If a tendon itself is the problem it is very unlikely that it “warms up” and pain during a workout subsides. The more you stress a problematic tendon, the worse it usually gets. However, it is likely that a joint moves from a place causing pain to a harmless position as you move (“warm up”).
When we did the mechanical exam he had an obstruction to movement in his right low back and sciatic nerve tension on his right. When he initially did 10 right, single-leg calf raises, the Achilles burned starting with repetition #2. After repeatedly moving his spine into extension with pressure (about 30 repetitions), this test was much less painful. His homework was therefore spine extension in lying with belt overpressure. After a couple weeks of doing that (10 repetitions every 2 hours), we added spine bending to ensure the injury was fully healed. He was discharged at visit 4 with a prevention and maintenance program.
When people twist or roll an ankle, the common diagnosis is that the ligaments are sprained. However, the joint itself is also affected! Here, a patient who twisted her ankle is treated successfully with simple repeated movements of the ankle JOINT. Therefore, the ankle JOINT was injured, not the ligaments. She was discharged with full recovery at visit number 2.
Clinicians MUST assess joints as joints are injured far more commonly than soft tissues such as muscles, tendons, and ligaments. (I learned how to assess joints like this through my post-doctoral studies with the McKenzie Institute, not in school.) -- Laura
Tendon issues are unfortunately incorrectly diagnosed all the time. That is, issues that are not tendon problems are diagnosed as tendon problems. “Issues” and “problems” refer to tendinopathy, tendinosis, tendonitis, and tendon tears. We have hundreds of tendons in our bodies; they are pieces of tissue that connect our muscles to our bones. Those that get an unfair share of the blame are the four rotator cuff tendons in the shoulder, the two main tendon groups at the elbow, the Achilles tendon of the ankle, and the patellar tendon at the knee. This frequent misdiagnosis happens for two chief reasons.
One, tendon problems are common on images such as MRI so, in the absence of an expert clinical mechanical exam, the tendon is identified as the culprit simply because of a picture. The concern with this is that tendon problems are common on images such as MRI in people with NO pain or other symptoms. So if Sarah has a large supraspinatus tendon tear on her MRI and no shoulder pain and John has a large supraspinatus tendon tear on his MRI and does have shoulder pain, can you assert that the supraspinatus tendon tear is causing his pain? Not from that information alone, you can’t.
(Say your car starts acting funny. You open up the hood to take a quick look. You see a lot of leaves around the engine. Can you assume that the leaves are causing the problem? Or would your mechanic need to run some diagnostic tests? After all, we know that there are plenty of cars with leaves stuck under the hood that run just fine.)
The second reason for this misdiagnosing conundrum? Lack of expert clinical “mechanics.” When I first began as a physical therapist, if a patient came to me with shoulder pain (with or without an MRI report), I performed the orthopedic shoulder tests I learned in school. While there are several tests aimed at diagnosing a rotator cuff tendon problem, these tests are actually not very good. They can regularly be positive when something other than the tendon is at fault. If physical therapists, orthopedists, general practitioners, surgeons, chiropractors, athletic trainers, etc. are still basing their diagnoses (and subsequent treatment) on these tests, they are missing a lot of crucial information.
Once I learned during my post-doctoral coursework that other problems can mimic tendon problems, I began looking for these in the clinic. And, lo and behold, most of the time it is something else causing the patient’s problem. The top two problems that mimic tendon problems are misalignment in the spine joints whose nerves send signals to the area of the tendon (eg the neck) and misalignment in the extremity joint closest the tendon (eg the shoulder).
How do I diagnose a tendon problem then? These are my top two criteria:
In closing, don’t jump to conclusions based on an image or the location of pain. A lot of shoulder pain is coming from the neck or from a shoulder joint that is not sitting properly – not a rotator cuff tendon. Likewise, a lot of pain on the outside of the hip is coming from the low back or from a hip joint that is not sitting properly – not the gluteal tendon. Our bodies are beautiful in their intricacy and nuance, making my job as a mechanical therapist exciting. It is the ability to understand this nuance that makes a clinician effective at diagnosing and treating. --Laura
If your foot/ankle needs to be immobilized and/or you can't walk on it, you have a few options. There are wheelchairs and crutches, but what fewer people know about are knee walkers (aka knee scooters or knee rollers). If you have the balance to manage them, they're a great way to get around quickly. Also, they don't take up too much space and don't require a lot of arm use like crutches do. Here is an example. -- Laura
This exemplifies the importance of rehabilitating even seemingly small injuries. A kink in the system can have a big impact. -- Laura
The Hazards of Ankle Sprains
by Jane E. Brody
New York Times July 25, 2016
Many fashion-conscious women wear high heels to show off their legs. But in truth, given the extraordinarily high incidence of ankle sprains, we’d probably all be better off if we had thick stumps like an elephant’s to connect our feet to our legs.
Every day in the United States, about 28,000 people sprain an ankle. Too often the injury is dismissed as “just a sprain,” with no specific treatment and a return to full activity before it has completely healed. Fully 45 percent of all athletic injuries are ankle sprains, and players often go back into the game with little or no treatment as soon as the pain subsides.
In fact, according to the International Ankle Consortium, a global group of researchers and clinicians who study ankle injuries, 55 percent of people who sprain an ankle never seek professional treatment in the aftermath of the injury.
Yet the majority of ankle sprains are doomed to recur. That’s because they often result in a chronically unstable joint that tends to “give way,” poor balance, a distorted gait, difficulty exercising, weight gain, diminished quality of life and early arthritis. Not to mention the expense of dealing with health problems that can result from being overweight and sedentary living.
Sound scary? It should, says Phillip A. Gribble, an athletic trainer at the University of Kentucky and co-director of the International Ankle Consortium, who hopes that knowing the potential consequences of ankle injuries will prompt more people to treat them with respect and seek proper treatment. Even better, he said, would be if more people took steps to prevent injury in the first place. And that, ladies, may include leaving those spike heels in the store.
Dr. Gribble was one of several experts who recently presented the latest technical information on ankle sprains to the National Athletic Trainers’ Association meeting in Baltimore. In a study of 3,526 adults who responded to a questionnaire, more than half, or 1,843, had previously sustained an ankle injury. Those who had injured their ankles tended to weigh more, had greater limitations in their daily activities and were more likely to have cardiovascular or respiratory conditions than those who remained injury free.
While ankle sprains are most common among physically active people, especially amateur and professional sports players and dancers, the general public is hardly immune. The injury can result from walking on an uneven surface (especially while wearing high heels or platform shoes), misstepping off a curb or staircase, being pulled erratically by a dog on a leash, even playing around in the yard with children or friends.
It doesn’t take much. I know — years ago, I sustained two bad sprains, one stepping on a stick while trimming a hedge and the other missing the last step while exiting a plane in the dark. I am now extremely careful about where I walk and what I put on my feet, especially when hiking in the woods (boots are de rigueur).
Most ankle sprains result when the foot abruptly turns in under the leg so that the sole of that foot faces the opposite leg, unduly stretching the ligament on the outside of the ankle. The extent of the injury can range from a minor strain to a complete tear, and the rate and extent of healing can vary greatly.
In one report to the athletic trainers’ convention, 12 college students who had sprained an ankle still had an incompletely healed, overstretched ligament a year after the injury, which “may explain the high percentage of patients that develop chronic ankle instability,” said Tricia Hubbard-Turner of the University of North Carolina at Charlotte.
Even though fewer than half of ankle sprains receive medical attention, the injury is so common (an estimated incidence of 2.06 ankle sprains per 1,000 people a year) that it is the leading lower extremity injury that results in an emergency room visit, according to data from the National Electronic Injury Surveillance System.
As with any injury, ankle sprains are best prevented. One of the best approaches is to improve one’s balance with exercises that train the body to stay upright and maintain control in all kinds of positions. Dr. Gribble recommends spending time standing on one foot, at first on a firm surface, then with eyes closed, then on a soft surface like a pillow. As a final challenge, practice balancing on a wobble board, he said.
Muscles surrounding the ankle can be strengthened by wrapping a towel around the foot for resistance, then moving the foot up, down, in and out. Do stretching exercises that increase the flexibility of the legs, hip and torso to guard against any unanticipated awkward movements.
When participating in sports like basketball, soccer and tennis — which involve jumps or quick changes in direction that can put ankles at risk — consider taping or bracing the ankles to increase their stability.
Finally, avoid being a weekend warrior who indulges in a sport full tilt without adequate preparation. Build up gradually, practice the skills involved and make sure to keep needed muscles strong.
Should you sprain an ankle, avoid the all too common layman’s advice to “walk it off.” At a minimum, leave the game or whatever you were doing and avoid putting weight on that foot to give the injured joint adequate rest. If the injury is severe, you may need to use crutches.
If you do sprain an ankle, apply ice wrapped in a cloth for 15 to 20 minutes every two or three hours for two days, then once a day until pain and swelling are gone. Sit or lie down as much as possible with the injured ankle elevated above the hip. To further minimize swelling, wrap the ankle in an elastic bandage, starting at the toes and working up to the leg.
Seriously consider a medical consultation, especially if pain and swelling persist for more than a few days. Although in most cases, an X-ray or M.R.I. is not needed to make an accurate diagnosis, the injury could be more serious than a simple sprain. Ask about physical therapy, which can strengthen the joint and help prevent reinjury.
Most important of all, don’t rush back into activity before healing is complete and normal, pain-free range of motion has been restored. Reinjuring the ankle can result in permanent pain and disability and the health consequences noted above.
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