The Dreaded "High" Ankle Sprain

http://www.youtube.com/watch?v=ILYi9SIag5o&feature=colike

We hear about it all the time in our favorite sports.  Rather than “it’s just a sprain” and he/she will be back soon, the term “high ankle sprain” gets mentioned and you know the athlete is out for an extended period of time.

Recently, Adrian Peterson, arguably the best pure running back in professional American football was the victim of such an injury.  And, uh-oh, it’s going to be awhile to get back in the game.

So what’s a high ankle sprain?  What’s the mechanism and why does it take so much longer to recover from?  Check out my "Ask the Doctor" segment from Cal-Hi Sports (noted above) and read below!

Usually with a sprain the ankle is inverted.  The toes roll inward, the outer ankle moves outward.  The lateral (outer) ligaments connecting the talus and calcaneus bones to the fibula bone may be sprained or completely torn.

In general, with a high ankle sprain, the ankle gets twisted the other way.  The inner ankle ligament complex (the deltoid ligament) may be stretched, and the talus pushes up against the lateral malleolus on the outer part of the ankle.  This puts a stretch on the ligaments binding the outer fibula bone to the main tibia bone.  A stretching or tearing of these ligaments is termed a “high-ankle” sprain.

The rehab from these sprains generally takes much longer than a typical ankle sprain.  These ligaments take a lot of stress with weightbearing and need sufficient time to rest prior to starting any major weightbearing rehab.  Oftentimes, immobilization with a walking boot or cast can be helpful, followed by a structured rehab program.  But return to play generally takes 4-8 weeks with the high ankle sprain vs. the 1-4 weeks with a more typical lateral ankle sprain.

In the case of Adrian Peterson, the injury looked relatively minor but he has missed a lot of time so far.  This is particularly problematic for athletes who need to do a lot of quick change of directions.  Look to see him back soon with plenty of tape on that ankle.

The Achilles Tendon Tear

When the Philadelphia Phillies were eliminated from the playoffs last month, they not only had to leave the field as losers, but their star slugger, Ryan Howard, had to limp off with a torn Achilles tendon on the last out of the game.

His quote afterwards was very telling.  “It felt like my bat came around and hit the back of my Achilles, “ he told reporters after the game.  “I tried to run and felt a pop and it felt like the whole thing was on fire.  ... like I was literally on a flat tire.  I tried to get to get up, but I couldn’t go.”

A very typical history given by the weekend warrior as well who feels the “pop” or “shot” to the back of the Achilles tendon when it gives way for no apparent reason.  “I turned around thinking someone had kicked me” is what I hear a lot of.  While it can happen at any age, most patients are over 30.

What happens in this sudden, non-contact injury?  How can someone be running hard one second, then all of a sudden be clutching his leg when he wasn’t touched?

This YouTube video of David Beckham and rupturing his Achilles tendon and accompanying analysis in March, 2010 demonstrates it well-

In layman’s terms, the tendon snaps when the calf muscle contracts while the ankle is dorsiflexed (foot extended toward the front of the leg) suddenly.  The tendon gives way many times with the feeling of a pop.

While non-operative treatment by casting the foot with toes pointed down can work, in general, most patients and surgeons opt for operative repair, to ensure that the tendon will heal in a tight, functional position and decrease the chance of re-rupture. 

Rehabilitation generally involves a brief period of immobilization followed by careful, systematic increase in range of motion and eventually strengthening.  Because the calf muscle and associated Achilles tendon is so vital to proper gait and running, it is important to get as close to full strength as possible.  The process, however, can take from 8 months to a year to get back to “normal”.  

So if your favorite pro (or weekend warrior) tears his/her Achilles tendon, don’t expect them back till next season.  This one’s a season ender!

Plantar Fasciitis- A Real Pain in the Heel

It’s seen in men and women; the elderly and the young; the athlete and couch potato.  So what is it and what to do?

Lately, Antonio Gates, the future Hall of Fame tight end for the San Diego Chargers, has been felled by this common, yet potentially complex problem.  Having already missed several games near the end of last season, he now has missed several more games so far this year!

The plantar fascia is a band of tissue starting at the base of the heel and splaying out, like the branches of a tree, toward the toes.  It is made of collagen fibers similar to a tendon and helps support the arch.  So it takes significant strain all day long.

Most of us over 30 have felt some of its symptoms at the bottom of the heel.  The pain is usually worse first thing in the morning with the first steps of the day or after one has been sitting for some time and then stands up.  As the sufferer “warms up” the pain dulls down, but may not go away completely.  Surprisingly, the symptoms are generally self-limited and go away on their own.  The big question is when?  For some, it may be just a few days.  But for others, it may be as long as a year!

A plantar fascia tear can occur, with the fascia’s attachment to the heel tearing away completely.  While this may actually stimulate healing, this can take a long time and requires extended immobilization.

The pathology seems to be an area usually near the origin of the plantar fascia at the heel that has micro-tears with inflammation.  This can occasionally end up with a poorly organized scar tissue deposition in the area leading to chronic problems.  Generally, treatment is non-operative.  Non-steroidal anti-inflammatories (NSAIDS), stretches of the plantar fascia and Achilles tendon, night splints (for prolonged stretching while asleep), and custom orthotics to support the arch and plantar fascia can be quite helpful.

Steroid shots to the area of pain can provide quick relief by acting as an anti-inflammatory right to the site of the pain.  But there is a possibility that they may actually prevent true recovery by decreasing the inflammation needed for healing, causing atrophy and tearing of the plantar fascia.  Platelet-rich plasma (PRP), drawn from the patient’s own blood, may be a safer and more effective option to stimulate true healing but more research is needed before it should be used routinely.

Surgery involves a partial release of the plantar fascia using a small scope and knife blade, essentially injuring the area to stimulate healing.  However, this too can have side effects, and should be a last option.

So what happened to Antonio Gates last year and now this year?  There has not been much information put out in the press other than “foot pain”.  But it is clear this is more complicated than a standard case of plantar fasciitis.

He was having trouble early last season, while recovering from a left toe injury.  This was probably putting increased pressure on his right foot.  In October of last year it was reported he had a plantar fascia tear, which can be difficult to recover from. 

Sometimes, when the plantar fascia is completely torn (or cut on purpose in surgery) there is a subtle arch drop that leads to a troublesome pain on the outer aspect of the foot (lateral column syndrome).  This pain may take up to six weeks to resolve in a walking boot.  I suspect this may have happened to him.

He tried playing through it, but was shut down in December and rested it through the offseason.  It has been reported that he has now torn the scar tissue and is probably out another couple of weeks.

In a high-level athlete like Gates, it may be something that comes and goes for the rest of his life.  “It’s the worst feeling in the world,” Gates had said last year.  “Sometimes you feel your career is coming to an end!”  

The Troublesome Hamstring

We’ve all seen our favorite player pull up as she breaks away a layup or runs down a drop shot.  The player grabs the back of the thigh and limps off to the side to receive “treatment” for the dreaded hamstring strain.  You know it will hobble her for the rest of the match and it’ll be a constant annoyance for the rest of the tournament.

Recently, in American pro football, Arian Foster and Miles Austin are the latest big name hamstring tears to hit the mainstream media.  Foster’s decision to even tweet a picture from his MRI scan speaks to the annoyance of this injury.  But how bad could it be?  There’s no talk of surgery on these tears, right?

So what are the hamstring muscle and how to prevent such an annoying injury?  What are the potential treatments?

Unfortunately, hamstring injuries occur in all age groups and are quite common.  They strike athletes of all sorts, from tennis players to track sprinters to footballers (the beautiful game- soccer, Australian-rules, and American).  This group of three muscles in the back of the thigh bends your knee.  They function quite a bit with any locomotion.  The strain/pull/tear occurs when the muscles are suddenly stretched when sprinting and lunging as the knee straightens and hip flexes.

In an injury to this area, there can be an intramuscular tear or a tear of the tendon attachment to the pelvis at the lower buttock.  It’s a bad one when you look at the back of your thigh that night and you see a dark blue bruise!

Prevention revolves around proper warm up, consistently stretching the hamstring (not right before you start exercising, but after you warm up and after you cool down), keeping your hamstring strong to balance against the powerful quadriceps on the front side of the thigh, and being gradual in increasing your exercise regimen.  Staying warm during workouts/exercise by wearing bicycle shorts may be helpful.

Treatment is rarely surgical and generally performed only for severe tears of the tendon off of its attachment to the pelvis in high-level athletes.

Initial treatment includes ice, elevation and compression.  After 1-2 weeks, as the injured area is scarring in, stretching and careful progression of strengthening exercises occurs. 

Re-injury after a hamstring strain is generally more severe and has a longer recovery time.  Sorry, Adrian Foster and Miles Austin fans (both re-tears from training camp injuries)!  I wouldn’t be surprised if the team doc tries some new invasive measures like platelet-rich plasma (PRP) injections (injecting the player’s own platelets and growth factors to the area of tear) to help stimulate quicker healing.  That’s a topic for another time.

Until the next injury…