terça-feira, 26 de maio de 2015

Sprained Ankle

Tissues commonly affected

Keywords; sprained ankle, chiropractic help.

Lower leg injuries often occur when there is weakness of one or more muscles on the side of the lower leg, commonly one of the Peroneus muscles. Normally these muscles should prevents the ankle from twisting, most commonly inwards, called inversion.

The talus bone moves mainly in one mode, called dorsi and plantar flexion; up and down. When an ankle is sprained, the bone subluxates within its socket, see below, causing jamming. This is what causes the severe, sharp pain of a sprain.

The talus may remain partly locked for years, if not correctly freed with the appropriate adjustment, changing the whole movement pattern of the foot, knee and hip. At chiropractic coalface 2 you can read about how the Dutch national marathon champion had to stop running because of knee pain that was directly caused by an untreated ankle sprain.

The talus sits on top of the calcaneus, or heel bone, in what is known as the subtalar joint. Can you also see the ankle mortice in the pictures below?

There are so many bones and joints, with so much pain potential.

The joint or, ankle mortise, as it is called, is formed between two leg bones, the tibia and the fibula and the talus.

The talus fits snugly into a socket formed by the tibia and the fibula, moving like a hinge and allowing the foot to move up and down, supported by an array of ligaments.

Trauma is probably the most common cause of ankle joint pain, but other conditions like a flat foot, or an arthritic hip that change the gait could also be a factor.

Very serious injuries can happen to this complex as you can read about in this ankle joint pain casefile.

The more common fractures are of the ends of the long bones, the tibia and fibula. However, fracture can occur of any of the ankle bones.

Whenever there's enough force to break a bone, assume that there have been torn ligaments too.

How reliable are xrays? A missed fracture can have terrible consequences for the ankle. Scroll down for this case of avascular necrosis.

Careful correction of any ankle mortise and subtalar joint subuxations is a very important, and oft neglected, part of the successful treatment of a sprained ankle.

Ankle mortise and Subtalar joints

LIGAMENTS

There are ligaments on both sides of the ankle that hold the bones together. They give the joint stability. They connect bones together while tendons connect muscles to the osseous structures.

In an inversion sprained ankle, the most common injury, usually it is the ligaments on the outer side that are stretched and occasionally ruptured. Bruising is a sign that there has been some tearing of the tissues.

Should that correction of the subluxations in the ankle not be done, it leads to vital changes to the biomechanics of the foot. This is usually the underlying cause of chronic pain, plantar myofascitis and more difficult to predict changes in the knees, hips and spine.

Yes, that arthritic knee may be the result of an old ankle injury that wasn't properly cared for.

An ankle guard may be useful during the healing phase of the damaged ligaments. Research shows that small movements of the joint, rather than total immobilization as in a cast, for example, promotes faster healing in the treatment of a sprained lower limb.

The trend today is towards a boot that limits movement, provides pressure to reduce swelling, but can be removed for icing, bathing and gentle non weight bearing exercises.

Crutches may be vital for a period in a serious injury. However, keep the ankle mobile and moving, gently if it's swollen and sore, by doing the alphabet exercises. Soon something coming up on YouTube for you, but for the moment just wriggle the joint about whilst you are sitting.

A strong recommendation; if you know your ankle is not getting better, get a scan. Fractures of the one of the tarsal bones lurk and are often missed on plain xrays, sometimes with very serious consequences.

Muscles of the ankle

There are also many tendons that cross the ankle to move the foot and the toes. Tendons connect muscle to bone, enabling you to move your foot.

The muscles usually affected lie on the outer side of the lower leg. There are three of them called the peronei group, plus a few others, mainly for moving the toes.

The contraction of Peroneus Brevis may be so sudden and severe, in attempting to prevent inversion ankle sprain, that it ruptures off its attachment to the bone. This is called a Jones fracture and immobilisation in a cast is essential.

Sprained Ankle Treatment @ Chiropractic Help

Displaced bones are often associated with sprained ankle, usually the Talus bone, the Calcaneus bone and the Cuboid bone. Correction of these subluxations is an essential part of the treatment of a sprained ankle. For more about the immobilisation arthritis that comes from uncorrected subluxations.

The ankle ligaments may be associated with ankle sprain, with stretching and possible tearing of these ligaments. Swelling and bruising are common findings. Rupture is uncommon.

Muscle and tendon sprain may also occur. The achilles tendon and the muscle on the outer part of the leg are most frequently involved in ankle sprain.

Less commonly, bones may be fractured in a sprained ankle. Most usually the knobby on the outer side of the ankle (the lateral maleolus) and the end of a bone on the side of the foot may be involved. They are the attachments for the ligaments and tendons of the ankle which are often stronger than the bone itself (aka an avulsion fracture ). Immobilisation is then essential, and occasionally a pin or plate may be necessary if a fracture has occurred in your ankle sprain. It doesn't take much imagination to guess this is a job for a good orthopaedic surgeon ...

There is some interesting research that magnetic care may help in the healing of ankle fractures and sprained ankle.

ANKLE SPRAIN TREATMENT

ICE should immediately be applied after a sprain of the ankle. This can best be done with an ice block immediately over the effected painful area.

COMPRESSION may be important if it starts to swell. This is done with a compression bandage which should be professionally applied, but needs to be loosened regularly to allow movement of the joint (which has been shown to promote healing) and so that ice can be applied.
ELEVATION is necessary if more extreme swelling occurs.

X-RAY

CHIROPRACTIC HELP management of this very painful condition is particularly successful because it addresses subluxation of bones that usually occurs, and looks for the underlying cause which may be in the low back or sacro-iliac joint. Remember, it is the weakness of a muscle that allows the ankle to invert and sprain.
REHABILITATION of the ankle is essential. For more aboutankle exercises ,

LIGAMENTS

Gentle stretching of sprained ligaments is important. The alphabet ankle exercises are equally effective for your ligaments.

"If it's not fun, it's not worth doing. And it doesn't have to be silly. It can be hard work and it can be edgy. It can be a lot of things. But it can also be fun."

Robert Redford

Muscles

An ankle sprain often strains muscles and their tendons. Most particularly the muscles on the side of your lower leg (called the Peronei; there are three, Longus, Brevis and Tertius) together with the gastrocnemius and its Achilles tendon.

To exercise the Peronei, lie on the floor and hook your kapot bicycle tube over your foot, and the other end over some fixed point on the other side of your foot. Start by pulling the toes towards your head against the pull of the tube, then do it an an angle. They are difficult muscles to stretch without putting undue stress on the injured joints.

To exercise the Gastrocnemius mucles (and its oft forgotten companion, the Soleus, the cause of Shin Splints stand on a hard floor, go up on your toes. Start using both feet together, gradually putting more weight on the injured foot. Do this regularly through the day.

To make it more difficult, stand on the balls of your feet on a step. Go up on your toes, and then sink deep, before flexing your ankle again. Do it with the ankle guard on to begin.

These are simple and effective ankle exercises, things you can do for yourself. They cost nothing, just a little time and discipline! Otherwise you will be visiting your chiropractor endlessly! Saving you time, saving you money ...

To stretch the Achilles, stand with your injured leg about a metre from a wall. Put the other foot forwards. Reaching forwards, keeping your heel on the ground, stretch the achilles,

first with the knee straight, and
then slightly bent.

You won't be able to do this if the talus is still fixated - you will get sharp pain, deep within the ankle. First have the joint adjusted.

Buy yourself a wobble board to do proprioception training after an ankle injury. Start with sports shoes to give the ankle support, but graduate as soon as possible to bare feet when doing your ankle exercises.

Walking

Walking is of course the best of your outdoor ankle exercises. Normally we would suggest that you don't walk on tarmac or concrete, but in this instance it is recommended. That ankle can turn again VERY easily if the ankle ligaments have been torn. So do it on a level surface, with your ankle support and good shoes.

Neck/cervical manipulation

Things I Have Learned: Don't Adjust My Neck!

By Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM

The patient came into my office with obvious back problems. He was leaning to the side with his hand on his hip; the classic antalgic posture. My staff quickly helped him check in so we could get him in the back and evaluate his condition.

After the formalities of paperwork, we got down to business.

As we talked, he explained how he had twisted his back working in the yard over the weekend and couldn't take the spasms anymore. He also commented that he had experienced similar problems before and that chiropractic had always helped - that's how he ended up in my office. During the course of my examination, I performed some basic orthopedic checks on his neck. He stopped me and noted an additional history of neck pain. Then he stated that he didn't want his neck adjusted, because he had heard how dangerous that could be.

Let that sink in a minute - a previous chiropractic patient who was afraid of having his neck worked on, not because of a bad experience, but because of what he had heard somewhere else along the way.

The dangers of cervical manipulation have certainly helped in the campaign against chiropractic. The negative propaganda put out by various groups plays on patients' fears and is very difficult to overcome. Most patients equate neck manipulation with karate moves they saw in a Chuck Norris movie on TV. Many medical doctors have not been educated enough to know that good chiropractic care involves more than a violent twisting of the head just to make the neck crack. Clearly the neck is the most exposed and susceptible part of the spine, even when it is not injured. It takes a tremendous amount of trust on behalf of the patient to lay his or her neck in your hands so you can "spin their head around." When dealing with any patient, proper evaluation of the neck is critical. Most chiropractors I know are great adjusters and their patients have great respect for their skill. However, skill alone is not adequate. You must be able to objectively show there is a problem that needs to be corrected, and be able to define that problem in terminology another doctor, insurance company or attorney can understand.

Standard of care dictates that a patient's complaints must be evaluated locally (the area of complaint) and globally (any related or affected structures). In today's medical-legal climate, you must be aware of how one area of the body can affect another. In previous articles, I discussed how irritation in the neck can cause hand and wrist problems¹ and how the neck and lower back will compensate for each other.² Therefore, when a patient presents with any spinal complaint, it is reasonable to perform a full-spine exam.

My basic evaluation of the neck is not complicated; I can run through it in a matter of seconds. However, the tests I use give me great insight into what is going on.

DeJerine's. This is more of a question than a formal test, and should be done during every new-patient exam. Just ask if the patient has increased pain or radicular symptoms with coughing, sneezing or bearing down. An increase in pain is positive and indicates an obstruction of the flow of spinal fluid, usually due to discal injury. The location of the pain with this irritation can help identify the involved nerve root and the site of the problem.
George's. This is the classic test for cerebrovascular insufficiency. You have every reason to make sure you perform this test on each of your patients, even if you are not treating the neck. The first part of the test is simple auscultation for bruits over the supraclavicular fossa. Then have the patient rotate their head to the side and look up behind them. Watch for any ischemic reactions (i.e, eyes twitching, dizziness). If any of these findings are positive, the patient is at risk for a stroke. It doesn't mean you can't treat them, but you need to be very aware of their condition and treat conservatively.³
Cervical Foraminal Compression. With the patient seated, gently push down on the top of the head. Pain is a positive finding, but must be further investigated. If pain is produced, have the patient rotate toward the side of pain and again gently push down. Localized pain suggests foraminal encroachment, while radicular pain indicates pressure on the nerve root.⁴ Sharp local pain suggests facet irritation. Variations of this maneuver include Jackson's and Spurling's.
Cervical Distraction. This is a great follow-up test to help differentiate your findings from the compression test. Gently lift the patient's head using your palms or forearms on the occiput and hold traction for 30-60 seconds. A positive finding can be increased or decreased pain. Increased pain suggests myospasm. Decreased pain, either localized or radicular, indicates IVF compromise or facet irritation. Your diagnosis may be further confirmed if the patient's symptoms return when the weight of the head is returned to the neck.
Shoulder Depressor. While supporting the patient's head erect with one hand, apply downward pressure to the same shoulder. Increased or reproduced pain indicates that adhesions have formed around the dural sleeve, nerve root or joint capsule.
Soto-Hall. With the patient lying supine, flex the head and neck. As you bring traction into the spine, pain will be produced at the level of injury. This is a great screening maneuver for subluxation, sprain/strain and meningeal irritation, but if you have positive findings (pain anywhere along the spine) you must follow up with additional testing at the level of pain. Also, watch for the knees to buckle, as in Kernig's, as this is a red flag for meningitis.
Rust's Sign. This is not so much a test as an observation. If the patient is using one or both hands to support the head, this is a sign of severe instability. This is often seen with acute muscle spasm or subluxation, but also may indicate fracture.
Bakody. This is another observation. If a patient notes that raising his or her arm decreases the pain in the neck on that side, this suggests traction or compression on the lower trunks of the brachial plexus. In more severe cases, the patient actually may find it more comfortable to keep their hand on their head, as dropping the arm is too painful. Evan's text also notes that the more difficult it is for the patient to lower the arm, the more difficult the condition will be to treat conservatively.⁵

These are a few quick basic tests that can give you a quick understanding of what structures in the neck are irritated, and where the irritation lies. Certainly there is a lot more you can add in. Palpation is critical; there is no good orthopedic test just for trigger points. Basic neurologic testing is also necessary (if there is paresthesia in the C5 dermatome, you know what nerve root is irritated). Finally, it must be noted that neck pain and headache - particularly migraine - can be an indicator of a vertebral artery dissection. Symptoms related to CVA frequently include unilateral, unprompted posterior cervical pain of acute onset. These symptoms may precede stroke by several days and must be considered important warning signs.⁶ The absence of orthopedic findings in a patient with recent, insidious onset headache also should be considered a red flag.

So, what have I learned? Even when there is no neck pain, make it a habit to check the neck; you may pick up on an associated or referred problem. This will make your documentation easier; it will give you good information to explain your findings to the patient, and it helps you justify your treatment. Sure, it takes a few extra moments, but the extra information is well worth the effort.

References

Briggs DR. Things I have learned: beyond the carpal tunnel. Dynamic Chiropractic, Feb. 13, 2006. www.chiroweb.com/archives/24/04/17.html.
Briggs DR. Things I have learned: the short leg dilemma. Dynamic Chiropractic, Feb. 26, 2005. www.chiroweb.com/archives/23/05/16.html.
Bovee ML. The Essentials of the Orthopedic & Neurological Examination. Davenport, IA: Palmer College, 1977.
Evans RC. Illustrated Essentials in Orthopedic Physical Assessment. St. Louis, MO: Mosby, 1994.
Ibid
Kier AL, McCarthy PW. Cerebrovascular accident without chiropractic manipulation: a case report. Journal of Manipulative and Physiological Therapeutics, May 2006;29:4.