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Spring 2019 Newsletter

Decreasing Risk of Ankle Sprain

Jesse Dupre, DPT

The human foot and ankle are complicated structures comprised of numerous small bones, joints and ligaments. The foot and ankle have to be able to adapt to different movements and accommodate types of terrain including uneven, soft, or unsteady surfaces in order to keep balanced. This important task requires a combination of muscular strength, joint mobility, and coordinated muscle function. When the foot and ankle are not able to complete this task effectively, it can result in slips, falls, and injury.

medial and lateral diagram of the ankle

Ankle sprains are common injuries, and often experienced by active individuals and athletes. Sprains occur when ligaments are tensioned forcefully, which, depending on the severity can cause stretching of the ligament, disruption or tearing some of the fibers making up the ligament, or a complete tear of the ligament in a worst case scenario. In the ankle, the ligaments that provide stability at the lateral side of the ankle and limit inversion (ankle tilting inward) are the most commonly injured, and are often injured by rolling the ankle inward.

In order to reduce the risk of ankle sprains, both strength and motor control need to be addressed. Having strong and balanced tibialis and fibularis muscles will help stabilize the ankle in a lateral direction and adequate strength at the hip in both abduction and adduction with help stabilize the entire lower extremity.

Motor control and response can be improved through proprioceptive training. This is sometimes overlooked, but has also been shown to be an important consideration in reducing the risk of ankle sprains. Proprioception refers to awareness of position or movement of the body through input to the nervous system from various types of receptors. In the case of the foot and ankle, the body can use this information to respond by activating muscles that may oppose forces acting at the ankle or adjust movement patterns appropriately. Ultimately, this results in the ability to maintain balance and decrease the risk of injury when engaging in activities like walking, running, jumping or scrambling across a boulder field. Proprioceptive training involves exercises where the body must sense and react to movement. With practice, the body becomes faster and more accurate when responding to proprioceptive input, which, in the case of the foot and ankle, assists in maintaining balance and reducing the risk of lower extremity injury while engaging in weight bearing activity.

Bosu ball exercise for the ankle, John demonstratingProprioceptive training often involves balance exercises and the use of soft or unstable surfaces. The addition of foam pads, Bosu ball, dyna disc, or rocker board ankle exercises are also good tools to train ankle proprioception. Maintaining control of the foot and ankle while performing ankle circles standing on a dyna disc or other uneven surface challenges the nervous system due to the instability and movement at the disc and the need for precise muscular response.

Active people looking to reduce the risk of ankle sprain or those becoming more active after winter, the addition of proprioceptive training could be important, especially for those who have experienced previous ankle sprains. If this applies to you or you need help identifying weaknesses and ways to improve your ankle and foot stability, contact a physical therapist for assistance.

collage of tennis shoes, bandana and bone

Sapphire PT Hosts Women’s Running Clinic

Sara Boughner, SPT

On April 6th, we had 24 women join us in the basement of Runner’s Edge for the annual Sapphire Physical Therapy Women’s Running Clinic. This diverse group of women ranged in age from 25 to 72, with some who have only started running in the past year to others who have been running for over 20 years, and training goals ranged from 5k runs to ultra-marathon races. We offered participants a well-rounded mix of information regarding overall health and longevity with running regarding nutrition, pelvic floor health, running gait analysis, and strength training all in a fun, relaxed atmosphere.

At the nutrition station, women learned about the importance of calcium intake and absorption with Vitamin D regarding bone health. We also talked about iron, thyroid function, and timing of nutrition while running.

At the women’s health station we had a lively discussion about engaging pelvic floor muscles in relation to stress incontinence, an issue experienced by 52% of female athletes.(1) Hopefully each woman left with an exercise to improve her strength.

We also fit in a qualitative running gait analysis for each attendee, which helps identify common mechanical patterns that can increase loading rates and risk for developing repetitive-use injuries. We encourage all runners to take part in one of our in-depth, on-site 2-D video running gait analyses.

We also reviewed the principles of strength training and how to incorporate it into running programs. Each woman left with a thorough understanding of how low-repetition, higher-weight exercises can benefit tissue health while running.(2)

Participants rated their overall satisfaction with the clinic at an average of 98%. All of the women identified value in each station, and one participant quoted, “Each station was fantastic. I would come back again without any changes.” We at Sapphire Physical Therapy are already looking forward to this clinic again in the future.

Thank you to our partners Burton Nutrition, Runner’s Edge, and Three Rivers Physical Therapy.

1) Bouchard, Marie, “Stress Urinary Incontinence in Collegiate Female Athletes: Prevalence and Impact” (2018). Master’s Projects and Capstones. 787. https://repository.usfca.edu/capstone/787
2) “Running Myth #1 High Repetition Strength Training Is Needed to Improve Running Performance.” La Trobe Sport and Exercise Medicine Research Centre, 7 Oct. 2018, semrc.blogs.latrobe.edu.au/running-myth-high-repetition-strength-training-needed-improve-running-performance/

Bike Fitting for Efficient Cycling

Sarah Menhennett, DPT

Spring is here and now is the time to dust off your bike and hit the roads or trails! Sapphire Physical Therapy wants to make sure you have an enjoyable, injury free cycling season.

Bikers on roadAs a repetitive activity (5000 pedal strokes per hour1), cycling can result in overuse injuries, with knee pain being the number one complaint2. As many as 25% of cyclists experience overuse knee injuries3, and other common complaints are neck pain, shoulder pain, wrist pain and/or hand numbness, low back pain, discomfort in the saddle, and foot tingling and/or numbness. The good news is that a proper bike fit may decrease or eliminate discomfort experienced while cycling and can also improve your efficiency and performance.

When you first bought your bike, you may have been sized for your bike, but does the bike actually FIT you? A bike fit performed in a physical therapy setting is not a “one size fits all” process. Although there are “ideal” measurements that we use to guide how we fit the bicycle to your body, we may make adjustments and recommendations based on your specific anatomy and limitations in mobility, as well as pain and symptoms that you experience while cycling. Some common associations between symptoms and an improper bike fit or poor bike posture include4:

  • Neck/upper back pain
    • Helmet size problem
    • Reach is too far or too low
    • Limitations in cervical or thoracic mobility
  • Shoulder pain
    • Reach is too far
    • Reach is too wide
    • Increased tension due to straight elbow reach
  • Wrist pain and/or hand numbness
    • Inappropriate hood placement
    • Gloves needed for cushioning
    • Tight or uncomfortable grip
  • Low back pain
    • Hamstring tightness
    • Limited lumbar mobility
    • Poor hip/pelvic disassociation
    • Seat position
      • too high or too far back
      • Poor tilt
    • Deficits in core strength and stability
  • Knee pain
    • Medial (Inside of Knee)
      • Toe’d out cleat alignment
      • Pedal width is too wide
      • Mobility restrictions result in rider’s knee going into a valgus (knee pointed inward) position
    • Lateral (Outside of Knee)
      • Toe’d in cleat alignment
      • Saddle is too high or too low
      • Pedal width is too narrow
      • IT band restrictions
    • Anterior (Front of Knee)
      • Saddle
        • Too low
        • Too far forward
      • Improper cleat alignment and float
    • Posterior (Back of Knee)
      • Saddle
        • Too high
        • Too far back
      • Improper cleat alignment and float
    • Foot tingling and/or numbness
      • Plantar flexed (toes pointed down) pedaling
      • Improper shoe fit

What can I expect from a PT bike fit?

There are a lot of things to address during a bike fit both on and off the bike. We ask about your cycling experience, mileage, training program (if applicable), injury history, and take a look at your equipment (bike, shoes, helmet, gloves, etc.). One of the most important things we ask about is your specific goals for the bike fit. Is it performance? Comfort? Do you have a race coming up that you want to be ready for? We then perform a physical examination looking at strength, flexibility, range of motion, and posture, focusing in on any particular pain complaints that you may have. With you on the bike, starting from the foot going up, we make adjustments at the contact points between you and the bike balancing between “ideal” alignment and individual needs. An important next step is the assessment of your posture while you ride the bike. We may take a video to show you changes you can make to optimize your cycling form. While many complaints experienced while cycling can be reduced or eliminated with a proper bike fit and adjustments to cycling form, manual therapy techniques to address soft tissue or joint restriction, specific stretches, and strengthening exercises may also be indicated to help you ride pain free.

If you are experiencing pain or discomfort while cycling or would simply like to optimize your cycling performance, call Sapphire Physical Therapy and we would be happy to help get you scheduled for a bike fit.

1 Asplund, C., & St Pierre, P. (2004). Knee pain and bicycling: fitting concepts for clinicians. The Physician and sportsmedicine, 32(4), 23-30.
2 Kotler, D. H., Babu, A. N., & Robidoux, G. (2016). Prevention, evaluation, and rehabilitation of cycling-related injury. Current sports medicine reports, 15(3), 199-206.
3 Bailey, M., Maillardet, F., & Messenger, N. (2003). Kinematics of cycling in relation to anterior knee pain and patellar tendinitis. Journal of sports sciences, 21(8), 649-657.
4 Zebell, Sadie J., Bike Fit and Assessment for Injury Prevention and Treatment, Lecture presented for Gundersen Health System Sports Physical Therapy Residency Clinic Rounds, December 8, 2017

Maximizing Strength and Support for Foot and Ankle Health

John Fiore, PT

Increasing foot and ankle strength should be a priority during the spring. Following a winter of wearing rigid ski boots and walking or running on snow and ice, our feet are deconditioned. In order to transition to running, hiking, and backpacking on uneven, rocky, steep terrain, a two-fold approach is necessary. A strength training program targeting the muscles which stabilize and support the foot and ankle will increase your durability over a variety of surfaces. Proper footwear and insoles (ranging from over the counter options to custom orthotics) will insure your foot and ankle have adequate support in a wide range of footwear or when fatigue sets in on longer outings.

A progressive calf (gastroc-soleus muscle group) loading program tailored to your abilities and goals is a great place to start. A 31% reduction in calf muscle strength naturally occurs between the ages of 20 and 60 (DeVita, et al 2016), making lower leg, Achilles, and foot injuries more common in masters-aged athletes. Strengthening the medial and lateral ankle (tibialis posterior, fibularis musculature) is important as well to improve ankle stability. The intrinsic muscles of the foot support the arch and improve foot shock absorption and must be strengthened if your feet spent time in ski boots or on the couch during the winter. It is important to have a physical therapist evaluate your unique foot and ankle function (strength, range of motion, joint mobility, tissue tension) in order to create a strengthening-loading program which is right for you. Body weight resistance exercises are not enough to adequately load the lower leg and foot. Adding external weight (load) is necessary to stress tissues (muscle, tendon, ligament, bone, fascia) in a progressive manner. Examples of a few strengthening exercises are provided below to strengthen the calf and Achilles tendon, intrinsic muscles of the arch, and the tibialis posterior muscle of the lower leg.

image of stair exercise to stretch muscles (ankle)
Heel Raise-Drop

exercise example of the arch raise stretch
Arch Raise

exercise example of tibialis posterior ankle inversion
Tibialis Posterior Ankle Inversion

Insoles and Orthotics:
In some cases, strengthening alone is not enough to allow us to increase our activity level. Whether you are a runner, walking, hiker, backpacker, or just spend a great deal of time on your feet at work, adequate support in your shoes can greatly improve your tolerance and enjoyment of spring activities.

Prior foot or ankle injury history, lack of intrinsic strength, and a unique foot structure may warrant the use of an insole or orthotic to provide the support needed to stand and move comfortably with the foot in a more neutral position. Sapphire Physical Therapy has over the counter insoles and also makes custom insoles and orthotics with a 3-day turn around (see AmFit flyer on following page). We use an Amfit 3D Digitizer to scan your foot on-site for an accurate, custom fit. The days of hard, uncomfortable, poorly-fitting insoles and orthotics are gone. Find out more on our website (www.sapphirept.com) or call Sapphire PT to find out more about custom insole and orthotic options or to discuss a foot-ankle strengthening program to meet your 2019 fitness and running goals.

DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.
McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J Sport Med. 2006; 16 (2): 149–54.