Ice or Heat? …Or neither?
Probably one of the most commonly asked questions we get in the clinic. Which one should you use? For how long and when? What’s better for acute injury, chronic pain or even acute on chronic episodes?
If this is a question that puzzles you then read on. It’s actually a hot (pun intended) debate among a lot of health professionals, so advice given can often be vague as there can be a lot of reasons that determine what treatment might be right for you. Factors may include the cause, location, type of injury and how recently you’ve injured yourself.
There’s a bit of science behind the inflammatory response and understanding why your body is going through these different phases of inflammation and healing is really important for how we decide what management is necessary. This process helps guide our understanding of what we should actually consider, particularly when talking about acute injury management.
Immediately after a soft tissue injury occurs, the body swells the damaged area quickly to immobilize it and stop you from using it so that repair can begin. If there is a muscle, ligament or tendon that has been torn or damaged, there may also be bleeding and swelling – this is your body starting to try to heal itself.
If you suffer an acute injury that involves soft tissue damage like the types just mentioned, it usually comes with an acute onset of pain and swelling. This is the time where traditionally we have been told to always apply ice immediately after the incident or what you may remember as the RICE rule – Rest, Ice, Compression and Elevation. This protocol has long thought to be best for managing acute injury and controlling swelling by minimizing damage to surrounding tissues.
BUT there’s been some recent evidence that actually doesn’t recommend either heat OR ice for the management of acute soft tissue injuries, e.g. an acute ankle sprain.
A recent paper published by Dubois & Esculier, 2020 speaks about a PEACE + LOVE principle instead. Sounds a bit hippy hey? But it actually makes a lot of sense, let me explain more…
Yes, ice or cryotherapy (cold therapy) can help with immediate pain relief BUT this study shows that applying ice can actually impair tissue healing and regeneration in the short term based on the fact that applying ice during the acute inflammatory phase actually inhibits this process and the delivery of all the good things the tissues need when they are injured.
Every medical professional loves a good acronym and this one focuses on the stages of recovery. PEACE refers to immediate care of an acute injury and continues into the act of LOVE.
Applying the concept of PEACE and LOVE highlights the importance of educating patients and addressing psychosocial factors that are such an important part of recovery. Additionally, the paper discusses that while anti-inflammatories are beneficial for minimising pain and increasing function, they may have a potentially harmful effect on what is our body’s optimal healing process to aid tissue repair. So for management of acute soft tissue injuries, they may actually not be recommended at all.
The article goes on to explain that “despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft tissue injuries. Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibers, which may lead to impaired tissue regeneration and redundant collagen synthesis.” (Dubois & Esculair, 2020).
Now, that’s a lot of big words, but the general gist of that is that the inflammatory process is actually integral to our body’s healing process and the traditional use of ice and anti-inflamms can actually delay and compromise overall healing. This is why it’s important to be guided by what our body is doing at the time of injury and learn to listen to the clues that it’s telling us about what we should do to assist this process.
This theory highlights the importance of taking a more active approach to healing and recovery, which is so important for long term tissue healing and rehabilitation. Looking after your body, listening to what it’s telling you, being guided by your physiotherapist and allowing nature to play its course. Gradual progressive overload, activity that is safe for you and your lifestyle and remaining positive about injuries is so important to a comprehensive recovery and potentially even assist with avoiding re-injury.
Now, all this to say – I still think that the use of heat and ice can play a role in injury management. In the clinic I still see a bunch of reasons where hot and or cold therapy is very useful.
Here are a few take home messages around when heat or ice might be considered helpful.
- Immediately post injury ice can be used as an analgesic and is an excellent pain remedy for post-operative pain rather than forcing you to reach for pharmaceutical options which can have a whole range of side effects. But bear in mind that recent evidence surrounding acute soft tissue injuries (think ankle sprain) suggests that its use should be limited or may not be necessary at all.
- Muscle tightness or spasm can be treated with heat packs or heat therapy even in the use of a long hot shower. For example, headache and neck spasms or tightness can be treated nicely with the use of a heat pack to help lessen the activity of trigger points. These remedies can also be very effective for mid and lower back spasm pain. Heat is excellent at settling muscle spasm and reducing trigger points to help you move and feel better.
- Heat therapy is not a warm up! If you’re prone to lower back pain or muscle tightness – make sure you have a proper active and dynamic warm up to increase blood flow throughout the body before you exercise to alleviate muscle spasm. This can include dynamic stretching or going for a light jog or cycle.
- Having an accurate diagnosis by a health professional to determine what actual structure is the cause or source of pain is really important to making sure your injury is managed correctly. Get assessed properly by your physio, don’t just rely on Dr google!
Confused? I’m not surprised. Best practice is to call us and have a chat about what is going to be right for you and your specific injury to avoid any question marks.
Discogenic lower back pain is the most common source. The key things to know about discs and discogenic back pain are:
• Discs hate LOADED flexion and excessive compression (increased forces)
• Leads to loss of disc height and degenerative discs
• Discs love movement
• Disc injuries usually happen after a long period (months, years) of incorrect load and then there is an incident (lifting, bending etc.)
• This injury did not cause the whole injury but finally tipped the disc over the edge to fail or become symptomatic – the straw that broke the camel’s back
To rehab lower back pain or a lower back injury effectively we need to address 3 factors: MOBILITY, STABILITY and STRENGTH.
A large cause of lower back pain/ache/soreness is stiffness (joints) and tightness (soft tissues / connective tissue). This is common in desk workers and non-exercisers. If you are not consistently moving your spine through its full range, it will stiffen and tighten up. A stiff / tight back aches. A stiff / tight back is vulnerable to injury. Hence why ensuring adequate lumbar mobility is so important.
Basic lumbar mobility program:
1. Lumbar flexion knees to chest
2. Lumbar rotations knees side to side
3. Lumbar rotation stretch leg over
4. Cat / camel
5. Lumbar extensions (McKenzie's)
6. Child’s pose
7. Standing roll downs into full extensions (flexion to extension)
8. Slump neural sliders
MOBILTIY PROGRAM INSTRUCTIONS:
• 30 secs of each movement/stretch (<5 min regime!)
• Should be done minimum once a day if stiff, tight, injured, or have a sitting based job
• Can do more (longer duration of each movement/stretch and > 1/day. You can’t overdo this regime!)
• Three times per week is a good amount for spinal mobility maintenance and injury prevention
• Mobility extra’s include glut stretches (especially hip rotator’s), hip flexor stretches, hamstring stretches, foam rolling / self-muscle releases / self-trigger point
CORE AND LOWER BACK STABILITY:
Most people are too weak! People with back pain usually have:
• Deconditioned and atrophied (shrunken) muscles
• Weak core
• Weak gluts
• Weak lower back muscles
Your core and gluts protect your spine and help offload your spine, hence why it is so important to rehab and strengthen and condition them.
An effective lower back program must include addressing the anterior core, the lateral core, the posterior core and the gluteal muscles (maximus and medius predominantly).
CORE STABILITY PROGRAM INSTRUCTIONS:
• 3 days per week ideally
• 1 or 2 days is still better than none!
• Can get your core session done in 15 minutes – not a big commitment
• Can do an incredibly effective core program with little or no equipment!
Abdominals should be trained isometrically (static contractions). Planks and side planks are a great start, while unilateral farmer carries and paloff press variations are ideal and more functional.
The gluteal muscles are absolutely crucial and are often ignored in a lower back or core program.
GLUTEUS MEDIUS EXAMPLES:
• Beginner exercises (clams, side lying leg lifts, band spreads in crook lying variations)
• Glut med side planks + top leg lifts
• Standing hip abduction (band) with hip hitch
• Tim’s glut med exercise
• Half kneel hip abduction into ball
GLUTEUS MAXIMUS EXAMPLES:
• Single leg dead lifts (supported)
• Single leg hip thrusts (isometrics then isotonics)
• Single leg sit to stands
• Step ups (90 degrees ideally)
• Double leg dead lifts and double leg hip thrusts options too, but single leg versions much better for core stability
Note: ABDOMINALS (trunk flexors and trunk rotators) are important also holistically, but we will not focus on them in this blog post. They are more advanced, especially important for athletes.
Abdominals is the trunk, not the core (as we usually mean when we refer to core). Abdominals/trunk is more strength, rather than stability. Trunk Flexor exercise examples include sit up variations and reverse sit up variations, whilst trunk rotator exercises include cable chops (multi-directional), Russian twists and med ball throws.
Below is an example for an effective core program (1 WEEK), with instructions below:
1. Anterior core: dead bugs
2. Lateral core: band paloff press (kneeling
3. Posterior core: reverse lumbar extensions
4. Glut med: glut med side planks
5. Glut max: single leg sit to stands
• Choose X1 glut exercise and X2 core exercises
• Do 3 sets TO FATIGUE of each, slowly and with control
• Complete three days a week, alternating the exercises chosen so you cover everything
• Mobility program performed pre-core program
SPECIAL NOTES TO CONSIDER WITH A LOWER BACK PROGRAM:
• Avoid sitting too long!
• Avoid bad postures
• Exercise (especially CARDIO) – increased body temperate and sweating is great for joint and soft tissue ‘loosening’
• Adequate sleep (more decompression)
• Lose weight (less compression)
Having a healthy lumbar spine, being pain free and resistant to injury can be summarized by:
• Get/stay mobile (DO MOBILITY)
• Get stable and strong (DO CORE/GLUT/LUMBAR CONDITIONING)
• Limit sustained postures (ESPECIALLY SITTING)
• Get moving (EXERCISE)
Come into the clinic to be put on a specific and individualised lower back program now so you never have to deal with back pain again.
Whether you are person who is planning on starting running for the first time, returning to running after a long lay-off, planning on increasing your running mileage, someone who has dealt with multiple issues/injuries associated with your running or you just wants to get better/more efficient at running, then a musculoskeletal screening is something you should consider.
A musculoskeletal screening adapted for runners involves certain range of movement, stability and strength (capacity) tests to clear an individual for a graduated running program. The screening will help determine if it is
a) safe to start running (or increase mileage etc.) and if
b) there is anything to address prior to starting running, or incorporate alongside to prevent injury.
A foot posture analysis is also a part of the screening process, as optimal foot posture and footwear is a crucial factor in running. A patient will be recommended the ideal running shoes for their foot posture type (e.g. Brooks Adrenaline GTS for flatter foot type), and prefabricated or custom orthotics may also be recommended. If a full gait scan is required, we can do that right here at Physio Fitness.
The following table includes the basics of appropriate running technique, including the errors to avoid and exercises to correct any incorrect technique flaws.
INCORRECT OR ERROR
EXERCISE(S) TO CORRECT
Upright vertical running posture
Trap bar carries
Video & practice
Shorter stride length
Video & practice
Mid foot strike
Rear foot strike
Video & Practice
Vertical tibia (shin)
at ground contact
No vertical tibia
(either forward slant or backward)
Video & Practice
Active arms (more energy efficient)
Minimal arm movement
Minimal trunk rotation
Excessive trunk rotation
Running with stick held
Anti-rotation core stability exercises (plank + arm reach/shoulder taps;
Hip lock position - level pelvis – glut medius
and minimus working effectively
Hip drop position – sagging pelvis
Hip hitch variations Glut med strengthening
Space/gap between knees (knees don’t touch during running)
Knees knocking/touching during running
Glut med strengthening
Practice concentrating on maintaining small gap between knees
Short ground contact time
Longer ground contact time
Practice Plyo exercises
SPRINTING: Increased hip flexion – thigh height (knee’s high)
Practice hip flexor strength exercises hip flexion ROM exercises
The graded approach to running is the recommended progressions to a running program to allow the body to adapt to the new loads and minimise the chance of overuse injuries to the tissues (stress fractures, tendinopathies etc.).
We utilise the 10% rule here. It is recommended to only increase total weekly distance (km’s) AND total session distance (km’s) by a maximum of 10% each week. Anything above this you will greatly increase your risk of injury and breaking down during the training process. It helps to work backwards from an event date to plan out your running progressions using this rule (and determining if you have enough time to prepare for the event safely!).
For beginners, running on alternate days is best. You can then move on to 2 days on, 1 day off as able. Advanced runners can do a 3 days on, 1 day off running program. Beginners should start on grass and flat surfaces, and progress to roads/trails and hills as appropriate.
Beginners should start with run/walk intervals. A good starting point is 1:2 walk/run e.g. 30s run/60s walk intervals. You then progress to 1:1 and then 2:1 interval before eventually progressing to all running (no walking). My recommended starting session for beginners is 2km or 15mins, and then progress 5-10% each week (session distance and total weekly distance).
When more of an intermediate runner, you can start to introduce some higher speed running. Fartlek running (jog/surge intervals) is perfect for this. Similar to the run/walk intervals for beginners I would start with a 1:2 jog/surge interval. You can then decrease the work:rest ratio as able, increase the speed of the effort/surge as able and increase the length/distance of the surges as able.
For more advanced runners – mix it up – you can’t just do steady state running if you want to progress – incorporate interval running, sprint work, hill work etc. – get different energy systems working. Continue also to build total running loads – and incorporate more advanced progressions/periodization’s e.g. 3 weeks’ heavy build, 1-week light. Different cardio stimulus’ can be utilised on rest days, such as cycling, swimming, upper limb ergo or sports.
INJURY PREVENTION (MOBILITY, STABILITY AND STRENGTH)
Mobility crucial for running includes adequate ankle dorsiflexion, adequate hip extension, full knee extension and adequate trunk mobility (namely rotation and extension).
Strength is CRUCIAL for not only injury prevention but also performance gains in runners.
As I tell all my runners, if you are not doing strengthening to complement your running you will break down and get injured.
The glutes, calves and core are the most important areas to strengthen for injury prevention. Training programs for runners MUST consist of a significant proportion of single leg compound exercises (e.g. step ups – best strength exercise for runners), and strength programs should be done at least 2 days per week to be effective.
The gluteus maximus is important for adequate hip extension and force production. Exercises to strengthen include 90-degree step ups, single leg hip thrusts, single leg dead lifts and single leg sit to stands. The gluteus medius is crucial for the hip lock position (HIP STABILITY) as mentioned above. Exercises to strengthen include glut biased side plank variations, band hip abduction in standing, hip abduction into a Swiss ball in half kneeling and single leg hip hinging into a Swiss ball against the wall variations.
Strengthening the calves should begin with basic strength/endurance (bodyweight, single leg) and must be trained through full ankle range e.g. single leg calf raises over the edge of a step. Progression to a calf strength focus (weighted calf raises) is advised. Both the soleus (bent knee calf raises – 20-30 degrees optimal) and the gastrocnemius (straight knee calf raises) should be addressed. Calf training should then progress to plyometric exercises (progressing from simple hopping variations to more advanced drop jumps from a high height).
Abdominals should be trained isometrically (static contractions). Planks and side planks are a great start, while unilateral farmer carries and paloff press variations are ideal and more functional.
For sprinters, eccentric hamstring strength is crucial to prevent hamstring injury. Nordics and single leg RDL’s are recommended.
Maintenance and extras are an important part of the puzzle, and include mobility/ROM exercises, stretching, foam rolling, self-trigger point, physio, massage and injury prevention/maintenance programs. Also remember that optimal recovery, sleep, hydration and nutrition are important.
If you are injured – come and see me! I will get you on the right rehab program and return to running program.
We can also do a full running assessment – this will involve running on the treadmill (including breaking down slow motion video from different angles) and identifying any technique errors. We will then see if they are correctable on the spot and practice running on the treadmill incorporating the technique adjustments (and re-video and watch back for visual feedback). Exercises to correct errors not immediately changeable will then be taught and implemented.
Groin pain is a common issue in people who participate in a running based change of direction sport, and even more prevalent if kicking is also involved.
When we talk about the ‘groin’ we are usually referring to the adductor muscle group and their tendon attachments around the pelvis. Groin pain can also be caused by the hip joint, the lumbar spine and the hip flexor muscle group.
This article will focus on adductor related groin pain (the most common cause of groin pain). Whilst acute adductor muscle and tendon strains/tears are common, this article will focus on the more prevalent adductor tendinopathy.
Adductor tendinopathy refers to the overload (either acute or chronic) of the adductor tendon(s) leading to micro breakdown of the tendon structure itself, pain and loss of function, and occasionally accompanied by inflammation.
Overload typically occurs due to an increase in tendon load over the proceeding few day/weeks (walking, running, change of direction, kicking, sports) that occurred too quickly over too short a time period, not allowing the tendon to adapt to the spike in loading as it would if the increases were more gradual.
When presenting with an acute reactive adductor tendinopathy, first and foremost we will get you to rest from all aggravating activities, usually for about 7 days. During this period, we want to unload or offload the tendon as much as possible. If inflammation is present ice and anti-inflammatory gels/medications will also be used. A detailed history of your loading activities will also be taken to determine why the overload occurred, so we can address this going forward in your rehab.
During this rest period we can immediately start addressing the contributing factors of why this overload tendinopathy occurred.
From a muscle control and strength standpoint, an adductor tendinopathy occurs not necessarily because the adductors are too weak (although this can be the case) but rather that the antagonist muscle group (the hip abductors – glut medius/minimus) are too weak and not functioning effectively to stabilize the hip and pelvis properly, leading to the adductor muscle group working too hard and having to do too much to make up for this – leading to the overload.
Balance around the hip and pelvis needs to be optimal in order to successful cut, change direction, sprint and kick without overloading certain tissues and leading to injury. The hip adduction-hip abduction agonist-antagonist pairing needs to be working together and each doing their role effectively. In adductor tendinopathy – this is not usually the case.
So immediately we need to test and determine hip abductor function (activation, control, capacity/endurance and strength). We then need to rehab and strengthen the hip abductors to correct this imbalance, and help reduce the load on the adductor tendon(s).
The glut medius is one of the most commonly weak muscles in the body – yet is so crucial for hip and pelvis stability, particularly in runners – even more so in change of direction running/sports – and is the muscles responsible for the all-important hip lock position in running. A weak and poorly functioning glut med will contribute to not only groin issues, but knee, hip and lumbar spine as well.
Exercises to target this muscle group will include side planks (glut med version), banded hip abduction in standing with hip hitch, half kneeling hip abduction isometrics with a Swiss ball against the wall and single leg hip hinge variations to name a few.
It is important to strengthen the glut med both in hip extension and hip flexion (which is often overlooked). It is also important to progress to rehab of the glut med in standing, which is functional and relevant to the muscles true role in standing/running/change of direction.
For groin injury rehab we want the patient to be ‘single leg strong’ – meaning we want them to be stable and strong when on one leg – so the majority of rehab exercises should reflect this. End stage rehab will involve single leg multi-directional hop and stick exercises to train this.
We also want to address and rehab the other stabilizers of the hip and pelvis – the hip extensors (namely glut max), the hip flexors (namely psoas) and the core (abdominals). We need all of these muscles groups functioning effectively to again unload the adductors so they don’t have to do so much work.
To strengthen the hip extensors, we will utilize 90-degree step ups, single leg dead lifts, single leg RDLs, single leg hip thrusts and single leg sit-stands. Notice these are all single leg!
To strengthen the hip flexors, we will focus on the psoas (inner range hip flexor strength), utilizing progressions of isometric contractions of hip flexion in inner range, progressing from supine to single leg standing.
The core plays a huge role in stabilizing the hip and pelvis, and a poor functioning core means the adductor muscles will have to work extra hard to take over the stabilizing load – leading to breakdown and tendinopathy.
We will stabilize the core making sure we address the anterior core, lateral core and total core with ‘anti-core’ exercises. Examples include plank variations, dead bug variations, roll outs, flexion isometric holds, side planks, lateral isometric holds, paloff press variations, unilateral farmer carry variations. Standing/split stance paloff presses and multi-directional unilateral farmer carries will be the end stage exercise and most relevant to our sporting goals.
In most acute cases WE DON’T HAVE TO DO ANY ISOLATION ADDUCTOR STRENGTHENING. The adductors are already working too hard and are overloaded – they aren’t weak – they are overloaded - it will be detrimental to add more load to the tendons. Instead we strengthen the antagonist muscles (the hip abductors) and the other hip-pelvis synergists (hip extensors, hip flexors, abdominals) and let the adductors settle down.
In some acute cases, we will need to strengthen the adductors themselves too, as their weakness and poor function led or contributed to the overload and tendinopathy. In chronic cases we will definitely have to strengthen the adductors themselves, as the tendon(s) have degredated (broken down) and degenerated. To rehab the adductor tendons, we will start with long isometric contractions (30-45s holds) – in the form of ball squeezes in multiple hip positions, progressing to standing hip adduction isometrics (band/ball) and Copenhagen adductor isometrics. End stage adductor rehab will involve isotonic Copenhagen adductor exercises and isotonic weighted hip adduction.
When certain adductor testing is pain free (e.g. adductor squeeze testing) and strength numbers are looking better (e.g. adductor / abductor strength using our electronic manual muscle testing dyno – comparing left leg to right and the patient progress from initial injury assessment) – we begin a return to running and sport program, as well as a return to kicking program if required.
This will progress as such:
- Straight line submaximal running
- Straight line maximal running (sprinting)
- Sub maximal change of direction, cutting and agility
- Maximum pace change or direction, cutting and agility
And for kicking:
- Stationary sub maximal straight line kicking (building distance as able)
- On the run sub maximal straight line kicking (building distance as able)
- Sub maximal kicking around body (start stationary progress to on the run)
- Stationary maximal distance straight line kicking
- On the run maximal distance straight line kicking
- Maximal kicking around the body (start stationary progress to on the run)
For the strength program to be effective, it needs to be completed minimum 3 days per week. Some exercises (particularly tendon exercises) may need to be completed daily. In the end stages of rehab, the goal has to be maximal strength – so the patient will be progressing to the 3-5 RM rep ranges.
The running and kicking programs should not be done on consecutive days. The rest day in between will allow tissue recovery and adaptation.
When cleared for return to sport, a maintenance program will be put into place 1-2 times per week to prevent injury recurrence.
To facilitate the rehab process manual treatments in the clinic will help the recovery. These will include adductor muscle soft tissue releases +/- dry needling, hip joint and lumbar spine mobilisations, and other hip muscle soft tissue releases and stretching.
If you have a groin injury – book in to see one of the physios at Physio Fitness now. Your physio will accurately assess and diagnose the issue, and will then guide you through your rehab – progressing you through your strength program, your return to running program and guide your return to sport.
Lateral ankle sprains are one of the most common injuries that people encounter in their lifetime. Whilst profoundly common, their management may appear simple however ankle sprains can actually be notoriously difficult to treat. A recent systematic review (Doherty et al, 2016) found that 40% of first time lateral ankle sprains develop into chronic ankle instability within 1 year. The need for you to identify what an ankle sprain is, how bad it is and when to see the physio is highly important due to the potential long term consequences of these injuries.
Lateral ankle sprains are the most commonly suffered ankle injuries and often occur during sports such as soccer, basketball, netball or even a night on the dance floor. There are four main ligaments that often are injured in a lateral (inversion) ankle injury. These are your ATFL, CFL, PTFL and PITL. The ATFL runs from the end of your fibular to the talus and prevents the foot from moving too far into inversion, hence why this ligament is commonly injured if you roll over on your foot, another player or even a tree root. The combination of forwards momentum and forceful outward movement under the weight of your body exposes the ligament to a high degree of tension and causes the fibres to rupture.
A true inversion injury (think: rolling your ankle over the ledge of a gutter) involves lateral movement of the ankle without forwards movement and will injure your CFL. If it is quite a traumatic injury this can even cause an avulsion fracture where the origin of the ligament pulls some bone away from the end of your fibular. With big antero-lateral sprains, it is not uncommon to injure multiple ligaments.
All ligament sprains, irrelevant of the grade of injury, infers a tear or rupture of some or all of the fibers of the ligaments in the ankle. This ranges from grade 1 (partial fibre disruption) through to grade 3 depending on the amount of ligament rupture. A grade 3 tear suggests complete disruption to the fibres and in severe cases can require surgical reconstruction.
Depending on the extent of the injury, all ankle sprains develop acute swelling and pain, muscle guarding and stiffness. Sometimes you may notice bruising appear on the outside or near the bottom of your foot and swelling around the lateral part of your ankle. This can be accompanied by a reduced ability to bear load through your foot and a reduced ability to move your ankle freely through the normal range of movement.
At your initial consultation following your ankle injury, firstly your physiotherapist will assess the extent of your injury, as well as determining whether or not you may need any imaging to accompany your diagnosis. It is also important to be educated on the use of the RICE principle or the potential use of non-steroidal anti-inflammatories to aid your recovery.
One thing that is required throughout your ankle injury rehabilitation is learning about ‘proprioception’. Proprioception is the ability of the brain to receive positive messages and helps the brain to understand what position your ankle may be in so as to help adjust a certain position or angles. Learning how to control this and training your ankle to determine what it needs to do to reposition itself and prevent re-injury makes this component of your rehabilitation highly important and cannot be missed with ankle sprains due to common risk of potential re-injury.
The first phase of rehabilitation involves soft tissue treatment, joint mobilization and taping or possibly even immobilization in a boot to settle the swelling, decrease the pain, stabilize the joint and allow you to return to normal walking gait. It’s important that you see your physio regularly during this stage and is not uncommon to need to see your physio a couple times in the first few weeks to help get your swelling under control and commence some gentle strengthening and range of motion exercises to kick start your rehab.
The second stage focuses on continuing to increase the range of motion in your ankle where you will be able to progress to more advanced and regular strengthening exercises, stretching and balance exercises. The third stage is focused at ongoing strengthening and injury prevention exercises, as well as returning to plyometric, running, hopping and more sports specific rehabilitation to help prevent further injury or instability you may otherwise encounter. If you’re planning to return to sport, a key component to your rehab is performing multi-directional and lateral single leg hopping exercises on a variety of surfaces before returning to play or even running. One thing your physiotherapist will assess is your ability to hop AND land without stumbling before you are able to return to your sport. It is important that these components are assessed and your physiotherapist properly observes this criteria – relying on time alone is not adequate for a proper recovery.
1. See your physio ASAP! Whether or not you believe it to be a “simple” sprain doesn’t mean that it is, you don’t want to become part of the 40% that develop chronic ankle instability after an ankle injury. One of the big factors that contributes to patients developing chronic instability is premature return to sport and not seeking medical attention.
2. Complete your rehab! It’s important to complete at least a 6 week strengthening program tailored to your individual needs and addressing the strength, range of motion and loss of proprioception components. Don’t just stop doing your rehab because you “feel better” or you’re not experiencing pain anymore.
3. Strapping and taping plays a key part of rehab, not only may it help you to feel more stable or comfortable putting weight on your ankle and returning to exercise, it plays a huge role in helping manage swelling and reduces the likelihood of you doing any more damage to your ankle. Taping can be useful in both the acute injury and the return to sport phase.
Got an ankle sprain issue that needs assessment and a rehab program?
The Achilles tendon is the attachment connecting your calf muscles to your calcaneus (heel bone).
Achilles tendon pain can be of an acute nature (such as strains, tears, reactive tendinopathies and paratendon inflammation/synovitis) or of a chronic nature (degenerative tendinopathies), and can affect anyone from elite athletes, to non-exercisers or weekend warriors, of any age.
The most common cause of Achilles pain is an Achilles tendinopathy: an overload of the Achilles tendon leading to micro breakdown of the tendon structure itself, occasionally accompanied by inflammation.
Overload typically occurs due to an increase in tendon load over the proceeding few day/weeks (walking, running, jumping, sports) that occurred too quickly over too short a time period, not allowing the tendon to adapt to the spike in loading as it would if the increases were more gradual.
When presenting with an acute reactive Achilles tendinopathy, first and foremost we will get you to rest from all aggravating activities, usually for about 7 days. During this period, we want to unload or offload the tendon as much as possible, so we may include putting heel raises in your shoes or utilizing taping techniques. If inflammation is present ice and anti-inflammatory gels/medications will also be used. A detailed history of your loading activities will also be taken to determine why the overload occurred, so we can address this going forward in your rehab.
When the acute pain and inflammation (if present) has settled (usually day 4-8), we will start loading the tendon.
This will begin with isometrics (static contractions) – single leg if able or double leg if single is too painful – we need to get you on one leg as soon as possible to isolate the tendon.
A normal application of isometrics would be 5 sets of 45s holds, with 30-45s rest periods, either once or twice a day.
A combination of straight knee isometrics and bent knee (20-30 degrees) will be used to bias different calf muscles.
With tendon rehab you ideally want to feel the tendon “activated” and 1-2/10 pain maximum is also acceptable.
We would then progress to doing weighted isometrics, either holding a kettlebell/dumbbell or using a barbell (ideally in a smith machine). With heavy weighted isometrics the length of static holds can go down to as low as 5-10s holds, with a 1:1 work-rest ratio.
When the tendon is tolerating isometric load well we transition into isotonics (through range calf raises). We start just from the floor, but progress to doing the calf raises over the edge of a step so the tendon can work through a full range. We start the isotonics body weight and again progress to completing them weighted.
With bodyweight calf raises, we would begin with 4 sets of maximum reps (to fatigue) with a tempo of 1:1:3 (that means 1 second up, 1 second hold at the top, then at least a 3 second slow lower (eccentric)).
We would progress to heavy weight single leg calf raises over a step, progressing to 5 sets of 3-5 reps with the same tempo (heavy, strength focus).
Once we progress from isometrics to isotonics, initially we would still prescribe daily completion, but once we progress to heavier and weighted it will most likely be every second day, to allow a day of recovery. It is important to remember to complete both straight knee calf raises (gastrocnemius bias) and bent knee calf raises (soleus bias) during the rehab process. Mix it up – do one-day straight knee, then the next day bent knee.
At some point throughout the strengthening process it will be appropriate to begin plyometric exercise. Tendons are basically a spring, and function with a very fast stretch-shortening cycle (energy absorption – energy storage – energy release), so we have to train them and rehab them specifically this way.
This would begin with fast calf raises, where you will complete normal calf raises as quickly as possible (with control). When fast calf raises are pain free we transition to simple hopping exercises (starting double leg and progressing to single leg), focusing on short ground contact times and a quick spring action.
This can be progressed from hopping on the spot, to hopping forwards/backwards/sideways, and increasing the time of the hopping set and the intensity of the hops (higher, longer). A good starting point for the first plyo sessions would be 3 sets of 30 secs. All plyo work must be pain free during and after, and appropriate recovery is needed so plyo should only be completed twice a week initially, and with 2 days’ rest in between sessions.
Some physios would split the plyo process up and start with energy absorption exercises (such as landing and sticking on one leg from stepping off a box). Then energy release exercises (such as single leg box jumps or horizontal bounds landing two feet) and then put it all together with stepping off a box and then immediately springing into a vertical jump.
Return to running is allowed when the patient can single leg hop for 30s pain free (during and after). Running should be done on non-consecutive days, and will progress from sub-maximal straight line jogging to eventually fast speeds and sprinting. Change of direction and cutting running will begin as planned and sub maximal and also progress to full speed and unplanned (reactive).
Putting this all together (the strengthening, the plyometrics, and the return to running) is the job of the physio and he/she will guide you through the process and progress you when ready and appropriate. Tendon programs tend to fail due to incorrect loading (either too much or too little) and incorrect progressions (too quick or too slow). We will perfect this process for you and guide you on this journey.
Eventually you will be cleared to return to full and normal sport, running and activities – and will usually have an injury prevention maintenance program to continue doing once a week ongoing (if needed).
We will facilitate the rehab process with soft tissue therapy to the calf muscles and Achilles tendon, ankle and foot joint mobilizations, strengthening other contributing muscles and addressing your foot posture issues (with either appropriate footwear or custom orthotics) as well as addressing any other contributing factors.
Got an achilles tendon issue that needs assessment and a rehab program?