by Bridget Collier PT, DPT
The study, “Comparison of 3 Preventative Methods to Reduce the Recurrence of Ankle Inversion Sprains in Male Soccer Players” looks at 3 interventions and a control group to determine which is the most effective in preventing recurring ankle sprains.
Ankle inversion sprains are the most common injury among soccer players. This type of injury occurs when the foot is pointed and turns in. Multiple studies have found that once an individual sprains their ankle, they have an increased chance of reinjuring the same ankle.
There are three interventions that have been proven to help prevent re-current ankle sprains in previous studies; proprioceptive training, strength training, and ankle orthoses. Proprioception refers to the awareness of one’s self movement and body position and training typically includes balance activities on varying surfaces. In terms of strength training for the ankle, multiple studies have determined that strengthening the ankle evertors will help to prevent re-current ankle sprains. Ankle orthoses (ankle braces) are a commonly used device that individuals wear to prevent ankle sprains and research has supported that these can help protect the ankle during impact.
This study separated 80 male soccer players participating in a men’s league with a history of an inversion ankle sprain in the previous season with no prior history of LE injuries into 4 groups. The groups consisted of proprioceptive training, strength training of the evertors, orthoses group (using the Aircast Inc Sport Stirrup orthosis), and a control group (no treatment intervention completed). The athletes were followed for one soccer season where each group participated in about 120 games and practices combined.
This study found that one individual in the proprioceptive training group, four individuals in the strength training group, two individuals in the orthosis group and eight individuals in the control group had a re-current ankle sprains during the soccer season. Statistically, there was a significant lower incidence of ankle sprains in athletes of the proprioceptive training group compared to the control group. However, there were no statistically significant differences between either the strength training group or the orthosis group compared to the control group.
Overall, the study found that proprioceptive training is an effective intervention to reduce risk of ankle sprains when compared to no intervention in male soccer players who have suffered a prior ankle sprain. Although this study did not find significant differences between the strengthening and orthotic group compared to the control group, there is other clinical evidence that indicates that these interventions have been proven effective. This study was relatively small with a select population, so results may have been statistically significant if the study was broadened.
For more information regarding this topic or the research presented, please see the article referenced below. If you have an ankle sprain or re-current ankle sprains, the physical therapists here at Physical Therapy First will examine you and develop an individualized rehabilitation plan to help improve your symptoms. Proprioceptive and strength training will likely be incorporated into your unique program. Give us a call or visit the website to schedule an appointment!
Mohammadi, Farshid. (2007). Comparison of 3 Preventive Methods to Reduce the Recurrence of Ankle Inversion Sprains in Male Soccer Players. The American journal of sports medicine. 35. 922-6. 10.1177/0363546507299259.
Article Review by Evan Peterson PT, DPT
Over the years, there has been much discussion regarding building “core” muscle and stability. When the term “core” is used, generally the public immediately is drawn to the abdominal and trunk musculature. In this article by McKeon et al (2014), the writers discuss the importance of a different core system. They address the need for further attention to the intrinsic portion of the foot alongside the extrinsic muscle system for improved mechanics and function.
Throughout our normal gait pattern, the human foot has to go through many adjustments and adaptations to allow for the most efficient gait possible. Each phase of the gait cycle requires the different structures to stiffen or become mobile for proper energy storage and release. If the 4 intrinsic layers of the foot do not operate appropriately it may lead to unwanted deformation of the arch, which in turn, leads to a variety of problems such as plantar fasciitis, posterior tibial tendon dysfunction, medial tibial stress syndrome, and chronic lower leg pain.
The authors discuss the origin of the human foot and its development of arches defined by long and strong ligaments, an adducted great toe, shortened lateral toes, and compaction of the mid tarsal region to help prevent collapse. Apes unlike humans also lack the pronounced Achilles tendon and plantar aponeurosis designed for storing and releasing energy required for running. Humans, unlike quadruped runners, also have the additional intrinsic foot muscle system. Quadruped runners rely almost solely on passive stability from ligaments.
Due to the above-mentioned facts, McKeon et al, suggest the idea of the “foot core system” which working together provides stability and flexibility to accommodate varying surfaces and loads. The system consists of 3 different subsystems: Passive, Active, and Neural. The passive system consists of the bones of the foot which create a half dome, the plantar fascia, and ligaments of the foot. The active subsystem of the foot consists of both intrinsic and extrinsic foot musculature. The extrinsic muscles start in the lower leg and cross the ankle joint; whereas, the intrinsic are all located below the ankle joint. The intrinsics and extrinsics along with the passive system work synergistically to allow for proper foot function. The neural system accounts for the proprioceptive aspects of the plantar fascia, ligaments, joint capsules, muscles and tendons. It is proposed that the foot intrinsics play a key role in detecting quick stretches allowing for correction in foot dome posture.
Despite the evident importance of the core muscle system, currently there is no gold standard for measurement of the foot intrinsics. Most testing looks at flexion strength which does not completely isolate the intrinsic system and also does not test the person’s ability to maintain an arch. The authors suggest an intrinsic foot muscle test, which looks at the ability to maintain and the medial longitudinal arch while in single limb stance after the therapist sets the foot in subtalar neutral. The goal is to maintain the arch without excessive global muscle involvement.
To address any deficits found, it is suggested to utilize the “short foot” exercise as opposed to toe flexion exercises like the towel crunch in order to eliminate flexor hallicus longus and digitorum longus involvement. McKeon et al relate this to the idea of the abdominal draw in maneuver used for lumbopelvic core stability. It is necessary to build a strong base to allow for the other moving parts to perform correctly. Several studies, as mentioned in this article, have shown the short foot exercise to improve balance and self-reported function in those with chronic ankle instability.
Due to the importance of our foot’s core, the authors believe barefoot/minimal footwear is ideal for training the intrinsic foot musculature. Studies have shown increase in foot core muscle size while wearing barefoot shoes as well as have demonstrated improvements in balance and postural stability. The authors do not suggest this method for those with altered sensation in their feet.
The authors believe, at first adding external support to the foot in an acute injury is acceptable; however, the support should be removed as soon as possible to allow for strengthening of the foot core.
Here at Physical Therapy First, you can work with a physical therapist 1 on 1 for an examination and be instructed in the proper way to address your foot’s core.
McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2014). The foot core system: A new paradigm for understanding intrinsic foot muscle function. British Journal of Sports Medicine, 49(5), 290–290. https://doi.org/10.1136/bjsports-2013-092690
ARTICLE REVIEW by Tyler Tice PT, DPT, ATC
It is common for individuals with low back pain to also have associated hip pain and is often times challenging to determine the primary source of the pain. This article, which was recently published in the Journal of Orthopaedic and Sports Physical Therapy in December 2021, suggests the focus of rehab for concomitant hip and low back pain should be to the low back. Below is a review of the article.
Introduction: The cause of low back pain is not always clear and for individuals with hip AND low back pain makes the cause even harder to find. Clinicians will often perform interventions to both hip and back without knowing which treatment interventions are truly helping. This has potential to prolong symptoms and increase health care costs. The goal of this study was to determine the short term and long term effects of low back only treatments compared to low back and hip specific treatments.
- Participants randomized to 1 of 2 groups: low back treatment only; low back and hip treatments
- Participants and therapists not blinded due to nature of the study
- Inclusion criteria: >/= 18 years old; low back pain 2/10 or more, self reported disability >20% on ODI, and concurrent hip impairment (groin pain, reproducible hip pain, limited hip ROM and/or strength, or positive special test for hip pathology)
- Exclusion criteria: contraindications to manual therapy, recent trauma to low back, positive neurological findings, recent spine surgery, hip replacement
- 76 total participants – 39 low back only, 37 low back and hip treatment
- 11 physical therapists provided treatments with each given a video training for this study
- Primary outcome measures: ODI (Oswestry Disability Index – a patient questionnaire that measures function), NPRS pain rating scale from 0-10.
- Secondary outcome measures: Fear Avoidance Beliefs Questionnaire, Global Rating of Change, Patient Acceptable Symptoms State
- Outcomes were assessed at baseline, 2 weeks, discharge, 6 months, and 12 months (please refer to article for more information on each measure)
- Treatments: all in person sessions, frequency/duration varied with recommendation of 2-3x/week for 45-60 minute sessions
- Low back only group received treatment based on therapist discretion
- Low back and hip treatment group received additional hip treatments including 2 manual therapy interventions and 2 exercise interventions based on a predetermined set of treatments
- 8 participants lost at discharge; additional 15 participants lost at 6 months; additional 5 lost at 12 months (Coronavirus played a role on this)
- Baseline characteristics and number of visits between the two groups were similar
- Disability and Pain: no significant difference on ODI and pain scores between groups at ANY time point. Both groups pain and disability improved at time of discharge and maintained at 6 and 12 month follow up
- Fear Avoidance Beliefs Questionnaire: For WORK subscale: better scores for low back group at discharge and long term follow up; For PHYSICAL ACTIVITY: no significant difference between groups
- Global Rating of Change: Slightly better for low back only group at 2 weeks and discharge; similar between groups at 6 months and 12 months; both groups improved
- Patient Acceptable Symptom Scale: no statistically significant differences between groups at ANY time; majority of patients reported an acceptable symptom state at discharge and 6 months, which reduced in both groups at 12 months
Based on these results, adding hip interventions for people with low back and hip pain did not improve functional disability or pain outcomes. There were some significant differences in the secondary outcome measures that favored low back only treatments. These findings suggest that adding hip treatments may not be necessary and to focus the interventions to the low back.
Limitations for this study include small sample size, missing data at long term follow ups, wide confidence intervals, and therapists and participants were not blinded. Therapists were also allowed to choose treatments per their discretion which is reflective of real world clinical practice, however can cause certain biases and non-compliance in eh research setting.
“Adding treatment directed at the hips to usual low back pain care for individuals with low back pain and concurrent hip impairment did not improve disability and pain in the short or long term”
This is a well designed randomization control trial with its obvious limitations, however these limitations were hard to control for given the timing and nature of study. Based on these results, it is not necessarily a BAD thing or WRONG to perform hip interventions for these individuals with both low back and hip pain. If one of my patients have a clinical finding of a hip impairment, I think I will still address it using specific hip interventions. With saying that, we can not exclude interventions for the low back and by focusing on the low back in a rehab program may help the patient progress along more quickly. I also think this can have clinical significance when giving patients home exercise programs (HEP). Using these findings, it will be better to provide patients with 1-2 low back exercises to manage their back and hip pain instead of additional hip exercises. Patients typically have poor adherence to a HEP so it is better to consolidate their HEP to the most effective interventions using the best evidence.
If you’re one of these individuals having both low back pain with a hip impairment, give Physical Therapy First a call and we can help you out!
Burns SA, Cleland JA, Rivett DA, et al. When treating coexisting low back pain and hip impairments, focus on the back: Adding specific hip treatment does not yield additional benefits—a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(12):581-601. doi:10.2519/jospt.2021.10593
by Tyler Tice, PT, DPT, MS, ATC
I have seen multiple patients recently reporting they have developed shoulder pain and limited range of motion after receiving the flu or COVID vaccines. The cases that I have seen have varied in time of symptom onset from 2 days to 4+ weeks after receiving the vaccine and some reported developing pain and shoulder deficits in the opposite shoulder from the one they received the vaccine. This is questionable whether receiving a vaccine to shoulder musculature actually caused the pain and functional deficits, however it was worth looking into.
We are thankful to have vaccines readily available to help protect us from multiple different illnesses. During this time, a large amount of the population are receiving the COVID and flu vaccines and I wanted to highlight one possible specific orthopedic side effect from vaccine administration.
SIRVA, an acronym standing for Shoulder Injury Related to Vaccine Administration, is a potential reason for shoulder pain after injection. This occurs when a vaccine is injected into the shoulder capsule instead of the deltoid musculature, causing an inflammatory response to the shoulder. If this occurs, people may experience pain, decreased shoulder range of motion, and a temporary decrease in functional abilities. Patient diagnoses related to SIRVA may include shoulder bursitis, rotator cuff injury, and adhesive capsulitis. The only difference between SIRVA and other shoulder injuries not related to vaccines is the time of onset of pain and limited motion are usually within 48 hours after receiving a vaccine and do not improve with over the counter analgesic medications. There are no other known differences in the physical exam or with ultrasound imaging. Treatment for SIRVA is typically the same as treatment for routine inflammatory shoulder injuries.
Vaccines are intended to be administered in the deltoid muscle. When administering vaccines into the deltoid, the individual should outline the borders of the safe zone. The upper border is about 2-3 finger breadths below the acromion and the lower border is marked by the armpit. The thumb and index finger can make a “V” to outline the deltoid muscle in order to know the proper zone when injecting the needle at a 90 degree angle.
Prevalence of SIRVA is still being analyzed and there have been reports in the literature that SIRVA occurred due to multiple different types of intra-muscular vaccines. In a systematic review in 2020, 27 papers reported the accounts of SIRVA in the literature with the most common vaccine being the Influenza vaccine, most common symptoms were shoulder pain and loss of motion within 48 hours, and most common treatments were physical therapy or corticosteroid injection. Most cases reported had great outcomes. It is generally believed that SIRVA is under-reported, therefore there is likely more cases that have occurred, but it is still very uncommon.
Since this systematic review was published in 2020, there have been multiple more recent case studies reporting SIRVA in relation to the COVID vaccine. The COVID vaccine has been administered to a very large degree throughout the past year which makes sense that there will be some reported cases of SIRVA in relation to the COVID vaccine. Although this is a novel vaccine, SIRVA appears to occur due to inaccurate vaccine administration regardless of vaccine type.
SIRVA is preventable if using proper vaccine administration guidelines, however accidents do happen and there is always potential for this to occur.
In summary, incorrectly administered vaccines into shoulder musculature can cause shoulder pain and decreased shoulder functional abilities. These deficits typically present like other inflammatory shoulder conditions and people have great outcomes when seeking intervention and using physical therapy. It is encouraged that all people receive the necessary vaccines that are available to help protect against getting and spreading different illnesses.
Bancsi A, Houle SKD, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. Can Fam Physician. 2019;65(1):40-42.
Cagle PJ Jr. Shoulder Injury after Vaccination: A Systematic Review. Rev Bras Ortop (Sao Paulo). 2021;56(3):299-306. doi:10.1055/s-0040-1719086
by Nick Mattis, SPT, Ray Moore, PT
There are several aspects that go into game days when playing sports: traveling, getting suited up, pre-game warm-up, the game itself, and last but not least, the post-game recovery. This article looks into the different types of recovery strategies used in male soccer players to help them recover the fastest and most efficiently. Once competition ends, the body’s neuromuscular performance declines while in the recovery phase. The performance level often does not recover to baseline for 3-4 days after the end of the game through passive rest (1). This can be an issue as most athletes play 2-3 games per week, requiring them to be at peak levels much faster than the typical 3-4 day recovery period. Approximately how many intense intermittent actions are performed by soccer players during a match? Soccer players perform around 200 intense actions throughout a match on average. Due to this high number, it is vital for the body recovery properly.
Active vs Passive Recovery
Recovery methods fall under two different categories, active and passive. Passive strategy is quite simple and is the process of resting and relaxing without any other form of recovery. This allows the body to rest, recharge, and replenish energy storages in the muscles. In regards to active recovery, there are many different strategies used. Some of the following that were addressed in the article include: aerobic exercise, water-aerobic exercise, massage, compression garments, electrostimulation, and cold-water immersion. Which is true of the active recovery strategies that were reviewed? Active recovery techniques such as electrostimulation and aerobic exercise has been found to be more effective in the recovery process than passive rest. Which compounding factor of the players must be considered when implementing active recovery techniques? When performing the active recovery techniques there is one factor that must be considered, aerobic fitness level. This will often corelates directly to the removal of lactate as well as their adaptation to modalities.
There are a few different treatments that fall under this category. The two mainly focused on are an actual hands-on massage to sore/tired muscles and the use of a foam roller. The massage was analyzed in terms of a normoxic (muscles re-saturated with O2) as well as hypoxic (muscles deprived of O2) as would be found in high intensity activity. What effect was found for massage under hypoxic conditions compared to massage alone? Studies have shown that the massage is equally effective when comparing hypoxic and normoxic conditions. This means that the muscles are not time sensitive when receiving a massage during the recovery phase. On the other hand, foam rolling is a great way to lower blood lactate levels and speed up the recovery process. Foam rollers are inexpensive and easy to obtain and are practically a must for high intensity athletes looking to recovery faster. After strenuous activity, the muscles primarily used should be rolled to help recovery. What should be considered when implementing foam rolling to decrease perceptive muscle soreness? Rolling over sore muscles can be painful, which is why correct posture is the most important key to controlling perceived muscle soreness. Having the correct posture can reduce the amount of pain felt, while also targeting the muscle better. Overall massage is a very beneficial technique in the recovery process. What effect does massage have on blood lactate levels compared to passive recovery? Massage decreases blood lactate levels at a much faster rate than passive recovery (rest) making you feel less sore and ready to return to the field.
Compression garments are often leg or arm sleeves that are tight around the extremity and used to reduce swelling. Studies have shown using placebo and Far Infra-Red clothing that it took the participants a longer time to feel the muscle soreness, also know as delayed-onset muscle soreness (DOMS). However, this was just a perceived feeling of the clothing and not actually a decrease in any of the biomarker levels in the body. How significant have compression garments been found to attenuate exercised-induced biomarker response? The compression garments have been found to reduce the biomarker response but at a level that is deemed nonsignificant. In other words, they may help but there are better techniques for recovery.
ESTIM is a process of using electronic signals transmitted through nodes placed on the skin to the muscle to achieve a desired result. There are several uses of ESTIM, but for recovery, the purpose is to increase blood flow through the heavily exercised muscles. This allows O2 to be returned to the muscles as well has waste produced by the muscle to be removed. Which best describes the observed effect of electronic blood flow stimulation? Studies have shown that after stimulation, anaerobic exercise improved one hour after the intervention. This was deemed beneficial for athletes who compete in competitions that have several events or rounds in one day with short recovery periods in-between.
One of the most popular forms of recovery is the cold-water immersion. This has been seen primarily in terms of the “ice-bath” that many athletes hop into after an exhausting practice or game. The science supports the movement too. What effect did cooled phase change material have on recovery in elite soccer players? Cold-water immersion has found to accelerate the recovery process in the studies performed on male soccer players. However, unlike massage, there is not a broad window of time where it is found to be effective in the recovery process. What conclusion was made for the use of cold-water immersion as a recovery technique? It has found to be beneficial in the recovery of soccer players immediately after the match. Therefore, if you are unable to submerge your lower extremities for 10-15 minutes immediately after the strenuous exercise, then it often will not be beneficial in the recovery process.
Physical Therapy First
Here at Physical Therapy First, we have a team of skilled therapists who are able to assess, educate, and treat athletes in recovery from injury or regular sport activity to return them to their functional needs. Through manual techniques and other interventions discussed in this article, we can restore ROM, increase strength, and return you back to activity. We are able to educate you on the proper recovery process including how to optimize your return to sport as quickly as possible. Call today to schedule an appointment.
1) Ribeiro, João PhD1,2,3; Sarmento, Hugo PhD4; Silva, Ana F. PhD2,5,6; Clemente, Filipe M. PhD5 Practical Postexercise Recovery Strategies in Male Adult Professional Soccer Players: A Systematic Review, Strength and Conditioning Journal: April 2021 – Volume 43 – Issue 2 – p 7-22. doi: 10.1519/SSC.0000000000000582