"Just an Ankle Sprain..."

Let's talk about ankle sprains.

I've recently had a few patients come through the clinic with ankle sprains that needed to be evaluated.  It's basketball season!  My first question to any new patient is usually "what brings you into physical therapy today?" Any of my fellow PTs also experience teenagers coming in and answering this question with "just an ankle sprain?" They usually shrug while they say it and sigh in exasperation, maybe even a hint of an eye roll.  It's a completely different presentation from the kid in a sling who broke their arm and tells you all about the huge tree they were climbing or the other kids who were on the monkey bars when they slipped and who got the teacher for help and whether or not they cried. It's a different presentation from someone who just tore their ACL and feels like the future of their sport seems impossible - or at best a million years way.  Those are real injuries, right?  A broken arm or a torn ACL are a big deal... but an ankle sprain is no big thing, they think.

From a physical therapist perspective, an ankle sprain is a bit of a double-edged sword.  On the one hand, they're pretty easy to evaluate and they overall recover fairly quickly - at least back to baseline function.  On the other hand, they usually feel really good long before they have made an effort to reduce the risk factors that contributed to their injury in the first place.  Said another way, sometimes these athletes feel like they're back to normal, but normal is at risk for getting injured again.  As a physical therapist, I sometimes have to convince these patients that just because they feel like they should be playing their sport without any restrictions, it doesn't mean physical therapy or strength training has ended.

So who says this?  Sometimes it's a young athlete who wants to look tough after an injury that shouldn't seem like a big deal. Sometimes it's an athlete who really didn't have that much pain a day or two after the injury but couldn't get into physical therapy so they're almost back to playing sports.  These athletes have already gone to practice but their coach won't let them play in a game until someone clears them, so they come in for their first visit hoping that I'll be the one to do that.  This very rarely happens, though I won't say never. Sometimes they've noticed that half of their teammates have had the same injury and it's really common.  When you're at physical therapy and your teammates are there with you, something could be very wrong with your team training program. 

Here's why it is, in fact, a big deal:

Ankle sprains are really common.  In my graduate thesis that surveyed 246 high-level women's basketball players about their injury history, 70% had experienced an ankle sprain.  So not only are they really common - but athletes also recover from them and get back to playing their sport at a high level.  You can sprain your ankle and recover in such a short period of time that it would be possible to experience the same injury repeatedly throughout a season or career, though with each subsequent injury, the recovery is generally longer and the tissue damage gets worse.

When someone sprains their ankle, about 40% of the time, the ankle becomes chronically unstable.  According to this 2017 paper by Miklovic et al, this chronic instability affects range of motion, strength, movement patterns, and postural control.  Basically your nervous system recognizes that something has occurred and tries to protect you by moving in different ways.  An unstable ankle can get better with strengthening and balance - though it doesn't generally go back to it's original state.  The other way an unstable ankle gets better is through surgery... which is what happened to me.

The BIGGEST RISK FACTOR for an injury is a previous injury.  (Sorry PTs who have heard this before!  The general population just doesn't know this is a fact!) So if 70% of athletes on your team are having ankle sprains, that means 70% of athletes on your team are at risk for another injury and next time it may be another ankle sprain, or it could potentially be something that takes them off the field or court for a much longer duration.

Here are three key concepts with regard to ankle sprains that are really important for you to know if you're an athlete or a parent of a youth athlete or a youth sports coach or a person with an ankle - because these happen to non-athletes, too!:

First: When an ankle sprain occurs, it can be classified into one of three grades. This grading system is used for all sprains and strains in the body, but we're talking specifically about the ankle today.  There are many references that outline this, so here's one:

Grade I: the ankle feels stable, you can probably walk on it, there likely isn't any bruising but maybe some swelling.  There may not be any damage or a few ligament fibers are injured, which is painful, but these generally recover very quickly in about 1-2 weeks and often they are not treated in physical therapy.  In my opinion, this is a mistake!  Get it checked, get a home exercise program, and reduce risk of re-injury particularly when you're only missing a short period of time from sports or activities.

Grade II: the ankle probably has a little bit of bruising and swelling, it's painful to walk on, and may or may not feel unstable.  Usually people with a grade II sprain are given crutches and sometimes a boot for a short period of time.  There is partial tearing of a ligament with this injury.  These take a little longer to recover, more like 4-6 weeks.  These are more frequently seen in the PT clinic, but still many people don't come get treated for these until they've had multiple episodes.  Again, I believe this is a mistake. 

Grade III: the ankle will have much more bruising, usually also going into the foot and lots of swelling.  Generally you won't be able to walk with this and there is full rupture of a ligament or more than one ligament.  Sometimes these are also accompanied by fractures to the ankle bones, so these people typicall need XRAYS to determine the severity of their injury. These are the injuries that get a boot and crutches for a longer period of time.  The ankle feels unstable, even after the extended period of immobilization.  Generally these do not require surgery but take closer to 6-12 weeks for full recovery and almost always are recommended to have physical therapy.

(Of course - recovery times vary and it depends on the anatomical structures involved in the injury.)

Second: It seems pretty obvious to some, but in case you haven't noticed, in a standing  sport, the foot is the first place that the body interacts with the environment. The foot strikes the ground and that interaction directs human movement.  When I treat patients in the clinic with pain in their low back - I must choose to treat them from the ground moving upwards or from their head moving downwards.  Sometimes the symptoms are driven from above- othertimes from below - and sometimes the symptoms are sandwiched between dysfunctions and you treat from both directions.  When it comes to the foot - there isn't really anything to consider below it because that's the ground.  I of course need to make sure the toes are all moving, but overwhelmingly, when you are looking at someone who experienced an ankle sprain, you're going to treat the ankle injury and give focus higher up the chain to the hip which controls the leg in space.

After an ankle sprain occurs, the most common deficits to the athlete following the injury are: Limited dorsiflexion ROM, decreased balance/proprioception, decreased strength which translates into decreased power to push off or jump.  This is a long list of things that are affected from "just an ankle sprain."  So if you play a sport in which you jump, after an ankle sprain you're likely jumping differently than beforehand.  And squatting differently.  And walking differently.  And rebounding differently. And pushing off of first base differently... got the idea?  Your movement changes after the injury - and physical therapy helps guide you to exercises that will improve this.  Moving differently may not be a problem - but it might contribute to your risk for another injury.

If you just treat these deficits and don't consider what could have been going on BEFORE the injury, you might entirely miss the need to assess and strengthen their hips and the way they move as a whole unit.  The body moves as a whole and needs to be treated as a whole.

Third: What you can do about it:
I've previously written about injury prevention programs.  Ideally everyone would do a better job of preventing ankle sprains from happening in the first place. Here's where I've written about those in the past for ACL injuries as well as this post using dynamic warm ups as a way to incoporate injury prevention into daily practices.  Start with a program for everyone on your team and find a physical therapist in your area to screen your athletes for risk factors and then get individualized exercises to add in for each person.  There is evidence available showing that injury prevention programs help reduce ankle sprains.

If you are a parent to an athlete who experiences an ankle sprain or a youth coach who has an athlete experience this injury, SEND THE KID TO PHYSICAL THERAPY!  Once the injury occurs, get them screened, get them a home exercise program that you incorporate for all your athletes.  They will probably benefit from some mobility work, some strengthening to their ankle, hips, and core, some training on how to move with control, and some balance exercises.  If I've said it before, I've said it a million times: Injury Prevention = Performance Enhancement. 

Don't end up like me, in the photo above, having had so many ankle sprains that I did nothing about and ultimately ending up in the operating room.  Prevent things from getting worse, and Get PT 1st.  It might even make you a better athlete!

Warm Up Like You Mean It

Photo Credit: Seattle Pediatric Sports Medicine
I'm front-right, and I need to work on my landing.

High school and college basketball season is here!!!!!! (YAY!) I'm so fortunate to have many friends who coach or work in high school and intercollegiate athletics.  This post is for all of you.  It's tinted towards basketball, but it could apply to any sport. 

Working in pediatric sports medicine, I notice clusters of injuries which coincide with the change in sports seasons.  This is, of course, a generalization, but it seems that there are patterns. Some examples: shoulder overuse injuries in swim and baseball season, concussions as football gets underway, "shin splints" in cross country runners who may have ramped up too quickly, and ankle sprains with soccer and basketball.

So now that the sports seasons are changing and I'm expecting to start seeing basketball players in the clinic, I thought it was time to hop on my soap box suggesting the use of a dynamic warm-up as an injury prevention tool. It has recently come to my attention that some of the local high schools are so overbooked on their gym time that the athletes are expected to warm-up on their own before they're allowed access to the court.  The team does not warm up together unless the captain organizes the group beforehand.  To me, that means it isn't mandatory.  It isn't a priority.  If teams only get 2 hours of on-court time per day, they'll use the time to focus on sport-specific activities, no time wasted on preparing their bodies.  I get it, but I don't approve.  I think you might end up with a team that knows a few extra plays, but you also might have a few more injured players on the bench.  Is it worth it?  There's quite a lot of research on the benefit of ACL injury prevention programs, including the 2018 National Athletic Trainer's Association Position Statement written by an awesome group including my mentor, Dr. Lindsay DiStefano, which can be found here.  (That paper includes the components you should include in your injury prevention program... no worries ... they're going to be briefly summarized below.)

I've previously mentioned that an injury prevention program is the same thing as a performance enhancement program here.  Most of these programs are targeting prevention of ACL injuries, but there is no reason to believe they couldn't help prevent other injuries, as well.  The Seattle Pediatric Sports Medicine Group's ACL Injury Prevention Program and the FIFA 11+ programs were both designed to be used as a dynamic warm-up.  Note that I'm using three different names for the same thing: Dynamic warm-up, if used properly, is the same thing as an injury prevention program, which is the same thing as performance enhancement.  (There are many other programs out there, but these are the two I'm most familiar with and have seen teams use most frequently. Ignore that they're set on a soccer field... it doesn't matter!). 

Let's back up for a moment.  What is a dynamic warm-up?  A dynamic warm-up is a progressive increase in the intensity of exercise placed at the beginning of a training session to prepare the body for the work it will do.  It targets increasing the cardiovascular system and getting the blood flowing as well as progressively increasing the use of the musculo-skeletal system and the nervous system to optimize the body for movement.  There are numerous publications that recommend doing this for a variety of reasons.  Like this article for injury prevention, and this one to optimize power. You've probably learned that you shouldn't skip meals leading up to Thanksgiving Dinner (though many people wrongly think this means more room for extra desserts, you're better off having some breakfast earlier in the day and regular eating the day before.  You're welcome.)  Why would you go from sitting in school all day long to sprinting up and down the basketball court without preparing your body?

Great, so now that we've determined that you're going to include a warm-up in your teams' practices and before games, why not decide how to design the warm-up for optimal performance?  This really can't be just about going through the motions.  It needs to be intentional.  It needs to be focused.  This is a great opportunity to develop a plan that team captains can lead early in the season so you can help teach individuals who might need more help with some of the movement patterns.

No more sitting in a circle stretching and chatting about last night's episode of Grey's Anatomy. Focused, purposeful movement.  There are SO MANY activities you can include if you're not able or willing to use one of the programs already designed for you due to the amount of time they may take.  I urge you to consider one of those programs, but alternatively, take the components from those programs and use them interchangeably.  If you structure your practices so you know what things you're going to work on, you can also structure your warm-ups so you know what you're going to work on in that time. What good is running a play for your shooter if they're not yet getting off the floor with their jumps?  What good is spending an hour teaching your team how to get a pass into the post if your center doesn't understand the benefit of getting low (in their squat pattern) to back down their defender and take it to the hole.  I'll say it one more time for the people in the back, injury prevention IS performance enhancement and a dynamic warm-up is an easy way to fit this into your daily routine.  If you help develop your athletes into just that - better athletes - they'll have more skills available to them to apply to whatever sport they're playing.

Components you should consider using in your warm-up.
1) mobility/flexibility (walking stretches)
2) strength (of the hips and core as well as the upper body) which can be done using:
3) movement patterns (squat, lunge)
4) jumping (plyometrics)
5) balance
6) agility (cutting/change of direction)
According to the NATA position statement, you should be using at least 3 of the above categories.  The prepared programs use all of them.

I don't have data to support this claim, but in general, I would say that most of the injured teenage girl athletes I see in the clinic do not jump or land in an "optimal fashion".  They're generally strong, but need to be stronger for the demands of the sport they're playing.  They often can't squat without falling over and I don't think I've seen any who can control a single leg squat.  As a coach, if you don't know how to teach these things to your players or why they're important, you could ask a local physical therapist to come in and screen your athletes and give you some pointers.  Or call me and we can chat about them!  Seriously... any time.  If this post prevents one high school basketball player from injury, I'll be happy.  Or if this post changes the way a coach organizes their practice to include more of the above components, I'll be elated.

As a reminder -
Every jump shot is, in fact, a jump and a landing.
Most rebounds are, in fact, a jump and a landing.
Jump-landings are, in fact, related to the squat.  If you do it on one leg, it's more related to a single-leg squat.
Defensive stance and the "triple threat" position are, in fact, related to the squat.
If you are standing on one leg for any reason - landing from a rebound, trying to save a ball from going out of bounds - you need to be able to balance.  Most teenagers can easily stand on one foot on a firm surface and balance steadily without a problem.  But if they have had an ankle sprain, it gets much more difficult.  If they're turning their head - like they would for an outlet pass or to avoid a defender - it gets much more difficult.

I'll go back to the discussion of getting the high school girls into the weight room another day, but for now, strength training could be as simple as a few sets of squats and a few lengths of the court with walking lunges and a few side planks - all with body weight - to focus on movement patterns and strengthening.  That could easily be a huge part of their warm-up before playing basketball.  (If you're preparing for a strength training workout, the dynamic warm-up should more closely mimic the motions of the exercises to be completed, but for a sports practice, there's a ton of variety available that will be relevant and beneficial). 

Last thought on these warm-ups.  Something that makes my mind go nutty is watching a team practice where they spend a good 15 minutes warming up, and then the coach has them circle up and stand still to discuss the upcoming practice, ultimately cooling them back down.  Prepare your team's mindset before the warm-up so you can transition right from the warm-up into business.  You can't avoid it during games when you substitute a player from the bench and they've been sitting for the whole first half.  That player is cold and has to use the game to warm up. Hopefully the energy of the game has kept the blood pumping a bit.  Hopefully they do some jumping up and down on the sidelines when your team makes a great play, to keep them warmer.  But on a daily practice routine, you can keep them warm and ready to go.

Any questions?  Let me know if I can help.
Here's to a great basketball season with zero injuries for your team.  And lots of offensive rebounds.  Those are my favorite.

(Go Cheshire Rams! Go UConn Huskies!)

Palm Trees and Tennis

Today I'm out of town on a quick adventure to the Bay Area of California for a UConn Athletics event, but while I was in town, I decided to walk around Stanford University.  I've never been to this campus and I always like to check out basketball arenas when I get a chance, but unfortunately, Maples Pavilion was closed.  I was so looking forward to a photo with the court wearing UConn attire, but I guess I'll have to come back for a game. 

On Stanford's Campus

Anyways, the campus is gorgeous and the sun was shining.  There are palm trees (and awesome Mexican food), something Seattle and Connecticut are both lacking.  I came upon the Taube Family Tennis Stadium, got in a few stairs to move around after my morning sitting in an airport from flight cancellations causing lots of waiting around.  Then the women's tennis team walked out to start their practice.  Opportunity!!!

I haven’t spent much time watching tennis live - a few matches in high school to support some friends and occasionally on TV when the big names are playing.  Beyond that, I've also only played a few times, so I'd be lying if I said I know much about this sport.  But I love to watch how people move and I have treated patients who played tennis so it's always good to consider the demands of different activities on the body and where injuries might potentially come from. Here's what I observed watching the first 15 minutes of their practice: 

First - I watched their dynamic warm-up.  I've recently been becoming an even bigger fan of the dynamic warm-up in my own training and also with my patient care.  I will admit that sometimes it becomes fairly routine and I'm not always creative - but sometimes the children I'm working with just need to get their heart rate elevated, get their bodies moving, and get some dynamic balance activities in before some more intensive loading.  I strongly believe that a warm-up has a functional purpose of getting you transitioned from the day to day tasks into the mindset of "I'm about to get to work" and also should serve as a primer for the movement patterns that are going to follow it.  It's also a good chance to include some rehabilitation activities or "activation" exercises, so when the tennis players started taking out their resistance bands to complete most of the "Thrower's Ten," my heart smiled. Shoulder Care in Tennis! I LOVE THIS!  They also put on sunscreen... which I appreciated.  Safety first Cardinal. 

Second - I was surprised to observe that all their players used two hands in their backhand stroke. I know I've seen players do this, but I didn't think it was used so commonly and for some reason it made me immediately Google if Serena and Venus Williams did the same.  I found this article which goes into detail about Serena's which is considered to be an old-school (traditional) back swing with an "unorthodox" stance and a "text book" follow through.  I guess Stanford's crew is not only on top of their prep work, but also on their use of two hands with the backhand stroke.  Photos popped up with Venus also using both hands.  Then I Googled Raphael Nadal and Andy Roddick- also using two hands.  Apparently I just thought everyone used one hand... and I was wrong. Ya learn something new every day.

I came across this article that discusses numerous hand grips for backhand in tennis and talks about how it mostly falls on player preference and the preference is usually based on where the most power can be elicited. It summarized 5 different grips!  There are pros and cons to each one, but the use of two hands adds stability and strength and can influence the spin on the ball.  Neat! 

All this reading helped me to consider one more thing that was easily apparent during their volleying warm-ups I observed but that I often don't think about: timing.  I've previously read a few articles about the timing of the shoulders and hips with baseball pitchers so this concept wasn't new, but watching how they let the ball come to them and timing the swing and how they ramped up their distances from the net and the speeds of the ball was really neat and gave me some things to think about. 

Back to the sunshine... hope I run into Coach VanDerVeer!

ACL Injuries

Of course ACL Injury would be an early topic of conversation on the Blog.  After watching several friends tear their ACL and rehab for months on end to get back to the basketball court, I applied to PT School with the intent of learning how to contribute to ACL injury prevention.  There's tons of research saying how common ACL injury is, particularly in women's sports, and there are also numerous programs available working to prevent it.

But there are also countless sports teams and sporting organizations that don't implement any of these practices.  It's a little bit shocking to me since an injury prevention program could equally be called a performance enhancement program.  Some of these programs have published research showing they decrease risk in injury - but they could easily be assessed differently.  For example - complete the program for 6 weeks and compare maximal strength in a squat and it would be expected that these athletes would improve.  They'll have increased motor control and core stability from the program translating into functional testing.  I guess there's a study to be had there. The way to teach your body to move to avoid injury is the same way to move to be an all around better athlete.

As a component of my graduate school research, I surveyed 35 athletic trainers and strength/conditioning coaches working with women's basketball teams at the Division I and WNBA levels.  In my unpublished data, I asked these individuals if they implemented any injury prevention techniques with their athletes: Twenty three out of the thirty five said yes. That's 66%. Two thirds.  So... what exactly are they doing if not focused on improving performance.. and at this elite level?!  No look at a younger population, such as middle school, where overall the coaches don't have specific training on how to improve human body movement.  How can this group possibly implement programs when they aren't trained in how to use them properly?

Even more startling than the providers who answered that they were not incorporating these routines into their athlete's programs the results of the next question.  When asked what sort of measures were implemented to specifically prevent ACL injury, every single answer was different and not one of them utilized an organized injury prevention program.  So everyone is trying to do it their own way, based on whatever they've learned in the past.

Last night the Seattle Pediatric Sports Medicine ACL Injury Prevention Task Force met to plan implementation stages of their new program.  It was inspiring to see physicians, physical therapists, and athletic trainers brainstorming ways to prevent injury in the kids of our region.  Their intentions are great.  The program is comprehensive.  I'm concerned for the potential obstacles the group will face as far as resources to implement the program and coaching buy-in.  I'm also optimistic that they can sell the program as a combination of injury prevention AND performance enhancer.

The program, once it has been well learned, is 4 components that takes about 15 minutes to complete.  It is intended to be the daily warm-up for practices and games - but could be split into parts if needed.  Videos of each component are available on the website, and each activity has proper mechanics that need to be adhered to and properly trained.  Untrained coaches simply printing the program and trying to teach it to teams won't provide the proper mechanics.  Basically - we need to teach sports team coaches how their players should be moving, so they can help guide them through this process.

Preliminary implementation of the program has had athlete feedback that they feel stronger and move better.  The detractor from coaches is that it takes 15 minutes of their valuable practice time - but in comparison - is a warm-up of arbitrary jogging and sprints without proper body control really making these players better at their sport?

As I see it, there are two primary goals here: 1) Get these athletes moving in a purposeful manner on a routine basis because kids need to learn how to move properly and 2) Educate coaches and parents so that they can help improve the way their athletes are moving to prevent injury.

Here's the outline of the program. Ultimately it gets the blood flowing so the team is ready to participate in practice when they're done.  Interestingly, it similarly mirrors several components of a post-op ACL Injury Rehabilitation Program in many ways.

1) Dynamic Mobility: 
Open/Close Gate, Forward Jog, Side Lunges, Backwards Jog, Cradle Walk, High Skips, Quad Stretch with Reach, Carioca, Butt Kickers, Lateral Shuffle with High Knees, Lunge with Rotation, Inch Worms

2) Strength:
Rotating Side Planks to Prone Planks, T's, Double Leg Squat, Single Leg Kick Stand Squat, Double Leg Squat Jumps

3)Motor Control:
Single Leg Deceleration, L Hops, Diagonal Hops

4) Agility
Partner Jump Bump, Diagonal Backwards Shuffle, Cone Weaving, Bounding

Check out the program if you're interested and reach out if you have a group that would benefit from being trained to participate and I'll help get it set up.

Abby