People tend to protect their foot/ankle injuries excessively for a day or so after which they brush it off as minor (“It was just my ankle but its OK now”) injury. If you take nothing more from this piece, please remember: Ankle and foot injuries are NOT MINOR!

For many years, people were taught to treat an acute ankle/foot injury by keeping weight off it, doing the standard RICE (Rest, Ice, Compression, Elevation) principles and strengthening the ankle once it is pain free by using a resistance band. Who knows why it was seen as important to be able to pull a dangling foot to either side as rehabilitation?

Things have certainly changed since then! The major change came in when someone pointed out that the foot’s biomechanics are altered significantly when it is in a weight bearing position. We want to be able to use the foot again as normal (which involves weight-bearing more than 90% of the time) so… lets rehabilitate it in a weight bearing position!

The guidelines for ankle injuries now call for pain-free use as soon as possible (not to be rested). It should also be protected enough to allow optimal function by wearing a lace-up brace for 12 months after the injury-no matter how ‘minor’ the injury was. Further generals tips include the need for full “dorsiflexion” and Talus “adduction” range of movement. Without these two, you are fighting a losing battle.The chance of re-injury is still around 30% at the moment and also roughly 30% of people will not recover to their previous level of function These figures should drop as more people receive correct rehabilitation.

After suffering a foot or ankle injury, there are a number of things that should be assessed. Firstly your Physiotherapist will need to rule out a fracture (The Ottawa ankle rules contain good guidelines). Following that, in the next 3-4 days, your therapist will establish a diagnosis. The history of the injury, which includes the mechanism, is incredibly important and so is the way your ankle has responded since the injury (bruising, swelling, shape, bony tilts, toe positions and the way you walk.) Hard, gel-like swelling within 24hrs indicates that there may be neural involvement and pain aggravated mainly during single leg squatting means that there could be cartilage damage in the joint. Both of these injuries will need an extended healing and rehabilitation period. There are also a number of clinical tests that can help to establish the diagnosis.

The clinical grading used for these injuries are: I: Niggling pain and the inability to run, II: A positive anterior drawer’s test and limping, III: Inability to bear weight but no fractures.

The objective tests used to establish what the starting point for rehabilitation are done with the eyes closed and special attention will be given to the shape/position of the foot as well as the alignment of the rest of the body.

The most important thing with ankle rehab is that the patient must be committed throughout the process and needs to focus 100% when doing the exercises. Most other rehab exercises can be done while thinking of other things. NOT the foot or the ankle!

Have you ever tried to spread your toes? To lift your arch using only the muscles in your foot? To contract a single, specific muscle in your foot like you would your biceps? We were never taught to do these things yet we expect our feet to do it while we are running around on a sports field or climbing stairs in high heels. This is the reason why ankle rehab can still fail today even with ‘doing’ the correct exercises and this is why commitment and concentration are so important.

Rehab guidelines:

Active ankle rehab takes 6-10 weeks and return to normal exercise/function could happen in 6-8 weeks providing that the patient is fully committed as discussed above. All exercises need to be done in front of a mirror to increase feedback to the patient. Hip and knee stability are as important as the local ankle stability and compensations on the opposite side must be avoided from the start.

Find the amount of support needed to walk pain free from day 1! If this means that you need to wear a moon boot and use a crutch or 2 then do it. By bearing some weight from the very start (vs having your foot dangle in the air between 2 crutches) you are speeding up you recovery already. Naturally, you need to reduce the support (and bear full, pain-free weight as soon as possible) as your injury heals. Taking this into account, old RICE principle has been changed to a POLICE principle which is Protect, Optimal Loading, Ice, Compression and Elevation. If you still have pain even without bearing weight on the injured side, you should take pain killers and anti-inflammatory medication as needed.

BUT the jury is still out on any use of ice and anti-inflammatory medication so try to keep both of those to a minimum until we know where to draw that line…

What are the causes and symptoms of High ankle sprain?

The most common cause of this type of injury would be when your foot is planted on the ground and then an excessive outwards twisting of your foot occurs, like what commonly happens with football tackles!  The symptoms include feeling pain both when you walk and above the ankle, particularly when you rotate the foot in an outward motion. From a visual perspective, there is usually clear bruising and swelling above the ankle, or the ‘High ankle’ area.

Knowing this is my injury what is my best course of action…and what can I expect?

You can, without referral from a doctor directly contact your Physiotherapist, as they are the experts in the treatment and rehabilitation of such injuries. A Physiotherapist, with a special interest in sports injuries, would usually have the greatest expertise in this area. If they suspect a high ankle sprain or Syndesmosis injury they may recommend a ‘mortise’ view on X-ray, CT scan or MRI to confirm the diagnosis. Patients with a high ankle sprain with or without a fracture may at first not bear weight and this will slowly be progressed depending on healing. Normal rehabilitation rules will apply as for normal ankle sprains but would only commence 2 to 4 weeks later. The treatment of Syndesmosis injury is extensive, but the sooner it commences the better the recovery time, so contact us as soon as any such injury occurs and we’ll assist to get you back out there again!

When the muscle that supports the arch of your foot weakens, through modern life and the wearing of shoes, this can increase the likelihood of Bunions forming.

What are the symptoms of Bunions?

The primary symptom is the bulging bump outside the base of the big toe, but other symptoms are: swelling, redness and pain around the big toe joint; corns and calluses which develop where the first and second toes overlap; intermittent or persistent pain and restricted movement of the big toe.

What are the causes of Bunions?

Bunions result from complex biomechanical changes in the feet and shoes (particularly tight-fitting shoes with high heels and narrow toe boxes) that restrict the feet. Because wearing shoes isn’t exactly natural and they limit foot and toe activity, our feet and in particular, the toes, tend to chronically lack exercise. Just walking barefoot regularly can be beneficial to Bunion sufferers.

The slope of the foot bed of high heel shoes put the feet at a disadvantage and makes them more susceptible to strain. It causes the front of the foot to bear your weight which makes the forefoot widen. A narrow toe box exacerbates the problem by causing the toes to squeeze together and be at an angle, straining the big toe in particular.

Injuries to the foot and poor arch control leading to flat feet or overpronation can also cause Bunions.

What is my best course of action?

Consult your Physiotherapist directly who, after a comprehensive examination, will embark on a treatment program which typically targets:

• Pain relief, minimising swelling and injury protection
• Restoration of normal foot and ankle ROM and muscle length
• Restoration of muscle strength and control through prescription of exercises to correct the foot biomechanics – this starts from day 1 and should be made a priority
• Restoration of full function and prevention of recurrences – Your rehabilitation program will be tailored to achieve your own functional goals. Depending on your needs at this point, you may be fitted with off the shelf inner soles, or referred to a Podiatrist for custom made orthotics.

Bunions can be corrected to the point where you forget they were ever there! And more importantly, they are preventable in the first place – so contact us today to embark on a program that will lead to a pain free and bunion free future!

DOMS is one variety of muscle damage caused by exercise but is typically nothing sinister; the other occurs during and immediately after exercise and this is ‘acute muscle soreness’.

What are the symptoms of DOMS?

Apart from short term loss of muscle strength, reduced range of motion and possible swelling of the muscles, the most significant symptom of DOMS is a dull muscular ache. Passive stretching increases the symptoms, which explains the feeling of stiffness.

What are the causes of DOMS?

The primary cause of DOMS is muscle strains or ‘Myofibril tears.’ Small scale damage results in an inflammatory response with intramuscular fluid and electrolyte shifts. Blood tests can confirm this micro-trauma though the detection of markers like ‘creatine kinase’ and ‘lactic dehydrogenase’.

Muscle strength, motions and functions are impaired in someone experiencing DOMS due to swelling, altered muscle firing patterns and pain.

How do I know if I have DOMS or an injury?

Innocent soreness (as in the case of DOMS) is a tender, tired or burning feeling, usually an achy, stiff or tight feeling, typically occurring bilaterally and has a delayed onset.

An injury on the other hand causes deep, sharp, stabbing pains, typically only on one side and starts less than a day after activity, if not during. These are the signs that there may be a more serious injury and one should not assume that it’s just DOMS. Additionally, an injury will typically last longer than just a few days. General soreness from DOMS should peak at 24 to 48 hours after activity and last only up to 3 days. If symptoms are not subsiding after that, something more serious is possible.

What is my best course of action?

DOMS responds well to light activity of a similar nature to that which cause it …E.G. if you’re stiff from running, taking a leisurely walk should help. If symptoms linger beyond 3 days, or if any improvement seems negligible, schedule an appointment directly with your Physiotherapist, as you may be suffering DOMS or an injury. Try to remember what could have caused your pain and what it feels like, as this can help in your diagnosis. Contact us to ascertain the specifics of your condition and create an individualised plan to get you back on track with advice on how to avoid DOMS going forward.

What are the symptoms of Fibromyalgia?

Each individual can experience different symptoms, but the most common are:

• Fatigue that is disproportionate to the level of the individual’s activity and sleep
• Stiffness, tenderness and a high level of pain in the muscles and joints
• Anxiety, depression and possible bowel function problems
• Poor sleep patterns or waking after long bouts of sleep, but still feeling tired all day.
• Poor memory and alertness. A ‘foggy’ feeling in the brain.

The symptoms of Fibromyalgia are cyclical and each symptom can create the onset of another. The typical cycle would be:

An injury or disease leads to limited physical activity – which leads to muscular tension or stiffness – leading to stress/depression/anxiety – which leads to poor sleep – leading to pain – which leads to disease etc …and so the cycle will resume and continue. Breaking this cycle is essential to the recovery of a Fibromyalgia patient.

What are the causes of Fibromyalgia?

Far more prevalent in women than in men, there is really no known cause of this disease. It is extremely difficult to diagnose and treat, as it is neither an inflammatory, degenerative, nor an auto-immune disease.

What is known is that Fibromyalgia appears to manifest itself after:

• A stressful event like a motor accident or the death of a loved one
• A traumatic injury
• Repetitive poor sleeping patterns
• The sudden onset of an unexpected or chronic illness like Lupus or Rheumatoid arthritis

What is my best course of action?

Alleviating any of the symptoms of Fibromyalgia, even temporarily, can enable the sufferer to break the chain of symptoms and experience some relief or potentially break the cycle altogether.

Because it is difficult to diagnose and other conditions like an underactive thyroid, Vitamin D deficiency, or Rheumatoid arthritis can mimic this disease, extensive testing by a doctor or Rheumatologist may be necessary to eventually establish that you have Fibromyalgia.

Through alleviation of the pain, even for a few days, your Physiotherapist can assist you in finding, starting and maintaining comfortable and regular exercises, in addition to providing guidance on sleeping more comfortably. The combination of a reduction in pain, improved sleep and regular exercise provides a massive leap towards snowballing back in the right direction. Contact us for advice, referral to the correct specialist if necessary and positive treatment of this complex, yet but not necessarily incurable, disease. 

What is a ‘Ligament sprain’, as opposed to rupture?

To elaborate a little, ‘Ligament sprain’ occurs when its inelastic fibres are stretched through too great a range and tearing of the ligament takes place. The tear can be just a few fibres and classed as mild or grade I, but when classed as severe or grade III, a complete ‘rupture’ of the ligament has taken place, leading to joint instability.

How do ligament sprains happen?

The most common type of sprain is a sprained ankle, usually occurring amongst runners and sports people in general but it could happen to anyone. To give an example, in the USA alone, 25 000 ankle sprains occur daily. A runner going over a curb, catching the foot and twisting the ankle is a typical example. Knee and ankle sprains also happen in stopping and turning sports like hockey or soccer or in baseball where a player slides into the plate and twists the knee. The whipping arm action of the baseball pitcher and swing of the Golfer can also cause shoulder and elbow sprains and thumb, finger and wrist sprains happen in sports like skiing where one falls with an outstretched palm, or netball and cricket through catching injuries.

What are the symptoms of sprains?

Pain, inflammation and bruising are all common signs and symptoms of a sprain. At the time of injury, you may hear or feel a “pop” in your joint. With a mild ankle sprain, the pain may not be too intense and you may just have a limited ability to move the affected joint, but with a ruptured ankle ligament one may not be able to bear any weight on the foot.

What is my best course of action?

Mild sprains can sometimes be successfully managed at home with relative rest, compression and elevation but if the symptoms aren’t improving significantly each day over any 3 consecutive days, it’s likely that the management at that time is not sufficient. For your own peace of mind, to assure that the treatment is being correctly administered and to reduce the recovery time, it is advisable to consult a Physiotherapist directly to get started on the correct rehabilitation program, in addition to the management of your symptoms. It is essential to contact your Physiotherapist if you can’t walk more than a few steps, move the affected joint, or if you feel any numbness in the injured area. Severe sprains or ruptures may even require surgery, but you can save time and money if you contact us first, as Physiotherapists are the specialist for this type of injury, trained to have you back in action ASAP and refer immediately should that be required.

The more common types of musculoskeletal pain are lower back pain (LBP), whiplash, headaches, tendonitis (tendon inflammation), myalgia (muscle pain) and fractures. These could result from trauma, repeated movements, sports/exercise, poor posture or being immobilised (keeping still) for a prolonged period of time.

The symptoms differ from person to person and depend greatly on the cause and the duration of the injury. Common symptoms include: Pain that is aggravated by movement and remains after movement; Stiffness or aching with or without any movement; Sharp, stabbing pain with movement that resolves greatly after movement; Fatigue, Sleep disturbances or the inability to get comfortable; Burning sensations and Twitching.

My rule of thumb for any musculoskeletal pain is to have an assessment and treatment done by a Physiotherapist if you have not seen a drastic improvement within 3 days of the onset of the pain. Patients commonly try to cope by using medication and only turn to Physiotherapy after a few months having tried numerous remedies (or trying to ignore the pain). The problem here is that even an acute injury has then become chronic. The muscles have tightened more, the joints have sustained further damage while moving differently (in an attempt to avoid the pain during function) and the medication has not only cost a lot (while simply hiding your symptoms), but they have usually also started damaging your stomach lining.

The effect of all this is that you may have problems with ulcers, you have spent money and you have had no actual healing of the injury. In fact, the injury has most probably progressed and the number of treatments you may need to help the injury heal is now substantially more.

Very few people know just how simple it could be to rid you of the niggles you deal with on a daily basis. AND in South Africa, you do not even need a referral from your GP as Physiotherapists are first-line practitioners which means that we can assess, diagnose and treat the problem while being fully aware of other possible conditions outside the scope of Physiotherapy for which we will refer you to the relevant practitioner if need be.

Treatments for musculoskeletal pain may include splinting, rest, heat or icing, myofacial release, joint mobilisations or manipulations, dry needling, strengthening/conditioning/stretching exercises and anti-inflammatory/muscle relaxing medications. These treatments will vary depending on the findings on assessment, your diagnosis and the nature of the condition.

1. Discomfort that disappears through warming up
2. Discomfort that disappears when warming up, but re-occurs at the end of the activity
3. Pain or discomfort that occurs and worsens during any activity
4. Pain or discomfort that is there all the time.

Stages 1 and 2 allow for moderate continuation of activities/training (while starting rehabilitation with your physiotherapist to combat the cause), but in stage 3 or 4, aggravating activities/training should immediately cease and your Physiotherapist consulted to assess the injury and begin a rehabilitation program in conjunction with treatment to reduce pain and promote healing. Merely resting is rarely a solution and may not only delay your recovery but could in fact set you back further.

What are the common symptoms of Overuse injuries?

Symptoms are not always picked up in the beginning, because the first symptoms of stiffness and soreness for example, can disappear during warm ups. Other symptoms are swelling, redness, feeling warm to the touch and if the part is just not functioning well. The strongest symptom of overuse though, is when pain is experienced during an activity and continues even beyond cessation of such activity.

What Causes Overuse Injuries?

Repetitive usage itself is not necessarily harmful, but Overuse injuries can occur when combined with some of the following:

• Incorrect training, techniques, or equipment in the case of sports injuries.
• Simply not having sufficient endurance or muscular strength.
• Poor core stability and inflexibility.
• When strong tight muscles work against weak stretched muscles, this causes muscle imbalance.
• Any Misalignment or Biomechanical issues – like flat feet for example.

How can I try to prevent Overuse injuries?

The most common cause of Overuse injuries is incorrect training or preparation, so here are some helpful tips for prevention…

• Warm-ups with dynamic stretching before and cool-downs with static stretches after training are essential.
• Correct equipment (like the handle size of your bat or racquet) and footwear can make a big difference.
• Correct technique and slow building of intensity (max 10/% per week).
• Pain is a warning that there is a problem – Be aware of what your body is telling you AND LISTEN TO IT!

Remember that early identification and treatment will allow you to continue your activity, so contact your Physiotherapist as soon as any warning symptoms appear. We can not only identify the cause of your pain/discomfort but assist in correcting any poor biomechanics while addressing the symptoms, allowing you to say goodbye to your overuse injury!

In which areas of the body do Pinched nerves most commonly occur?

Although you can pinch a nerve anywhere in the body, it is more likely to happen where the space around the nerve is limited, as is the case in the Carpal tunnel, a tunnel through which the nerve passes in front of the wrist. So, this is the area where the commonly known ‘Carpal tunnel syndrome’ occurs.

The most common however and best known pinched nerve is the Sciatic nerve, situated in the lower back. A symptom of ’Sciatica’ is referred pain in the leg, and could result from pressure due to an Arthritic spur, a ligament injury or disc problems.

If there is pain in the arm, weakness or altered reflexes, it is possible that you have a pinched nerve in the neck, the second most common area of occurrence. The medical term for Pinched nerve in the neck is ‘Cervical Radiculopathy’ and be warned that it can be far reaching and deceptive. Some conditions diagnosed as Carpel tunnel syndrome and Tennis elbow for example, turn out to originate from pinched nerves in the neck.

How do I know I have a Pinched nerve….and need to see my Physiotherapist?

Pinching of your nerve can result in a combination of nerve pain, sensory loss, muscle weakness or altered reflexes…and possibly even loss of bladder or bowel control, depending on the function of the affected nerve. Whenever there is this reduction in or loss of power, it is essential to have an assessment ASAP as this often indicates true nerve involvement! Short of this scary scenario, if you have discomfort and you merely suspect some nerve involvement, physiotherapy should still be your first stop to address the situation.

Rest assured though that in the hands of an experienced physiotherapist, the cause and symptoms accompanying pinched nerves can be greatly alleviated if not totally resolved. Contact us for advice or a consultation.