Lisfranc Injuries

Lisfranc joint injuries are the second most common foot injury in athletes, yet are often missed or misdiagnosed.¹ Lisfranc (midfoot) injuries refer to bony or ligamentous compromise of the tarsometatarsal and intercuneiform joint complex. The Lisfranc ligament connects the plantar portion of the medial cuneiform to the base of the second metatarsal.² Without proper treatment, a chronic Lisfranc injury may lead to longitudinal arch collapse, abduction of the forefoot, and midfoot arthritis.³ Physical therapy can help individuals regain functional mobility and return to sport or activities.

Mechanism of Injury

High-energy: Forced hyper-plantarflexion with a valgus/varus component. Example: Car accident, crush injury or fall from a height.

Low-energy: Forced hyper-plantarflexion of the midfoot with an axial load through the foot.  Example: Competitive sports or a ground level fall.

The midfoot injury may involve the ligament, bone, or a combination of both.

Signs and Symptoms

Bruising and swelling over the plantar surface of the midfoot, pain with palpation over the midfoot for up to five days after injury, pain with weight-bearing that is typically exacerbated with heel raises.¹

Non-operative Treatment

Stable injuries (partial sprains and extra-articular fractures) are treated non-operatively. Typically an immobilization boot is worn for up to 6 weeks, gentle range of motion exercises are performed, and weight-bearing is progressed as tolerated.² Treatment focuses on restoration of a normal gait pattern and proprioceptive training.¹

Operative Technique

Unstable or displaced injuries of the midfoot require surgical management. Open reduction and internal fixation (ORIF) with transarticular screw fixation has been the gold standard. Traditional screws are typically removed at 4 months.³ However, ORIF with primary arthrodesis has become more popular as it’s been associated with a lower reoperation rate for hardware removal compared to ORIF alone.²

Post-operative management

Post-operative patients are initially placed in a non-weight bearing cast and progress to a walking boot. Full weight bearing is initiated by the 8th week postoperatively.¹ Athletes may transition from a walking boot into a stiff-soled athletic shoe with a semirigid orthotic device or an athletic shoe with a graphite insole added for stiffness.³

 Blog Post written by Kathleen Hank, DPT.  At the time of publishing Kathleen was in her Sports Ortho Clinical with me at Catz Physical Therapy.

References:

1. Lorenz DS, Beauchamp C. Functional progression and return to sport criteria for a high school football player following surgery for a Lisfranc injury. Int J Sports Phys Ther. 2013;8(2):162-171.
2. Clare MP. Lisfranc injuries. Curr Rev Musculoskelet Med. 2017;10(1):81-85. doi:10.1007/s12178-017-9387-6.
3. Haytmanek Jr. CT, Clanton TO. Ligamentous Lisfranc injuries in the athlete. Oper Tech Sports Med. 2014;22(4):313-320.

 

ACL Rehab – Finding The Right Physical Therapist Matters

By Wesley Wang, DPT

In my opinion, not every physical therapist is qualified to treat ACLs from start to finish. While this statement may ruffle some feathers, let me present you with an analogy that may help put things in perspective. If your car starts having issues, do you take it to just any average mechanic or try to find the best one for your specific type of car? If you’re looking to improve your skills in a specific sport, do you hire an average coach or try to find a specific one for your specific sport? While these examples aren’t perfect, recovering from ACL surgery is a lengthy process and finding the right therapist can significantly improve outcomes.

There are many components that need to be addressed in physical therapy to ensure full recovery.  Research provides detailed guidelines on specific factors including range of motion, strength, movement assessments and return-to-sport testing which should all consistently be addressed to ensure athletes are safe to go back to sports. These seemingly minor details can significantly decrease second ACL injuries which are reported to be approximately 1 in every 4 to 5 patients. (1,3)  Coming back to the mechanic example, would you want a mechanic who wasn’t detail oriented examining your car? Would you want a coach who didn’t use the latest methods to optimize your training sessions?

The entire ACL recovery process takes approximately 9-12 months and sometimes even longer. Research tells us that nine months is the minimum recovery time after surgery and returning too early increases the risk of a second ACL injury. (2) There is simply too much to address in ACL rehabilitation and returning to sports too early is just not worth the risk.

There are two major components of ACL rehabilitation, strength and neuromuscular control. Limb asymmetries which includes range of motion and strength are pivotal for optimal recovery. One of the primary foundations of ACL rehabilitation is achieving full range of motion. For example, if the knee can’t fully extend (straighten), it makes it extremely difficult for the quadriceps to regain full strength. Obtaining greater than 90% quadricep strength and a hamstring-to-quad ratio of at least 85% (compared to the non-operated knee) have been shown to significantly decrease second ACL injuries. (1,2)

Dynamic neuromuscular control involves how the athlete is able to control their body when performing tasks such as balancing, jumping and landing. When performing these tasks, the athlete should be able to demonstrate proper control of their trunk, hips, and knee. For example, when landing on the surgical knee (once it’s safe to do so of course), there should be minimal upper body movement such as the trunk swaying from side to side or the hips twisting and minimal knee movement particularly into valgus (inward). (1,3) Return-to-sport tests identify deficiencies and one study found that successfully completing return-to-sport criteria reduces re-injuries by 32.5%. (2)

Additionally, physical therapists should have knowledge of various exercises to consistently challenge patients in their recovery process which includes both strength and dynamic control. This is a big issue in rehab as I’ve heard from many patients that they weren’t challenged in their previous physical therapy facilities and instead repetitively performed simple exercises. Athletes should be challenged in every physical therapy session or we are doing our athletes a disservice.

Finding the right physical therapist for ACL recovery is absolutely necessary to safely return to sports. The physical therapist should utilize up-to-date research and be able to properly progress and challenge patients to significantly improve outcomes following ACL surgery.

 Blog post written by Wesley Wang, DPT.  Wesley practices in Rockville MD at Healthy Baller Sports Medicine.  He is a go-to resource for ACL & sports rehab info, find him on Instagram @wesleywang.dpt

References

1. Hewitt T, Di Stasi S, Myer G. Current Concepts for Injury Prevention in Athletes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2013 Jan: 41(1): 216-224
2. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg M. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Deleware-Oslo ACL cohort study. British Journal of Sports Medicine. 2016 May.
3. Wiggins AJ,Grandhi RK, Schneider DK, Stanfiel D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul:44(7):1861-76.

The Influence of Hormone Levels on ACL Laxity: Are We Missing a Piece of the Puzzle?

By Steph Allen, DPT, OCS

How many of you out there have torn or know someone who has torn their ACL? How many of you, or the ones you know, are female? Have you/they injured the ACL multiple times? How many have injured BOTH knees one or more times?

If we go with what research statistics have shown, there are likely a large number of you that answered “yes,” “two or more times,” “most are female,” or “both right and left knees.” These are common responses we hear. Not super promising.

The thing is, we seem to know so much about the anatomy of the ACL, injury mechanisms, risk factors, and potential prevention. However, injury rates are not improving, and females remain [continue to be] at a much higher risk of both initial injury and of reinjury.

Frankly, I think we are missing something here, people!

Let’s first take a look at what we DO know, based on years of scientific research:

1. ACL injuries are often non-contact in nature
2. ACL injuries are 2-6 times more likely in females than in males
3. Re-injury and injury to the opposite side are all too common
4. Rates of return to high level/previous levels of sport are low
5. Injury prevention programs are starting to take better shape, and it is more widely accepted that a focus on jump/land technique and neuromuscular control is essential
6. Around puberty, females tend to show a decrease in strength and power and generally poorer LE control and mechanics with jump and land, as well as cutting tasks, as compared to their male peers

This is all extremely helpful, and should be taken into account with all athletes and patients. BUT, I’d like to hop outside of the box for a sec (with pristine control, of course) and explore a possible “X” factor in this conundrum…

I want to look more closely at the impact that hormones have on the ligament complex and how this differs in males vs. females. We have done a great job with researching risk factors, and developing solid injury prevention/risk reduction programs for athletes. However, the sex disparity in ACL injury is still significant.

So let’s dive in a bit with the sparknotes of the research that has been done regarding hormonal influences on ligament laxity…

WHAT THEY DID: They took ACL’s, exposed them to the various hormones present during different phases of the menstrual cycle and measured “laxity” via tensile strength (resistance to pull).

WHAT THEY FOUND: Greatest laxity resulted when the ACL was exposed to Estradiol, which is at its peak in ovulatory phase (10-14 day mark). They also noted increased laxity when it was exposed to relaxin (another hormone floating around during the cycle). AND… they found these exposures to have profound effects on tissue remodeling. [NOTE: due to variability between individuals, it is difficult to assign highest risk to one phase].

Alright, that’s cool. But, how does this work? How can these hormones actually make the ligament more lax?

Here is the mind blow…There are hormone RECEPTORS ON THE ACL!!

When the hormones bind to the ligament, this can affect gene expression and collagen metabolism in a way that can influence the characteristics of the ACL and other soft tissues around it. (*This is key- it is not just the ACL that is affected- it is ALL the soft tissues).

A bit more about why collagen matters: In tendon tissue; collagen accounts for approximately 60–85% of the dry mass of the extracellular matrix (mostly type I collagen). Tiny collagen fibrils group together within the tendon and form “functional fibers”, whose purpose is the transmission of force between muscle and bone. This is HUGE! If the metabolism/cellular turnover and production of the tissue that is largely involved in force transmission at a joint is being affected, this could be a big contributor to the problem of overall joint stability and injury risk.

 

Okay so enough of the cell and biology stuff, let’s take a step back and look at the bigger picture. Let’s take into account movement patterns and neuromuscular control, which we all know is MAJORLY important, both in risk reduction and post-injury rehab/return to sport.

Park et al. found increased loads during cutting tasks in females during their cycle. The most common non contact MOI is deceleration with a quick change in direction, such as a plant and twist that occurs with cutting in sport. In biomechanical terms,  this is combined valgus with tibial IR, putting the ACL on high tension (great explanation in the @cvasps podcast with Tim Hewitt- click here or see references below). These two things, combined with the fact that we now have reason to believe that hormones can increase ligament laxity, may just be what is creating the perfect storm for ACL injury in females…

Lower tissue tolerance/greater tissue laxity + Game type speed and force on ligament with cut/jump/land + physical/mental fatigue and poor mechanics = Tissue failure

Oh man, so what in the world can we do about this? You might argue, hey, we can’t control something such as the menstrual cycle; it’s part of every healthy female’s life. And I can’t disagree with that. However, I cannot, and WILL NOT believe that there are not some actions we can take to combat these biological constants.

First and foremost, let’s make risk reduction/injury prevention programs more of the norm in youth athletics and let’s start these programs EARLY. Thompson-Kolesar et al. found that pre-adolescent female soccer players demonstrated greater improvement in double leg jump tasks after participating in an injury prevention warm up program than did older adolescent females. So if we can reach these kids before skeletal maturity and while they are still learning motor patterns for the first time, we can be more confident that they are able to control their sports specific movements even when they are fatigued or the movements are unplanned.

Second, let’s keep encouraging females to get really strong for their sport, thereby making it “cool” and more socially accepted during teenage years when being cool is as important as breathing oxygen. Thompson-Kolesar et al. also found that the rapid bone growth that occurs in adolescence correlates with an increase in muscle power and strength in males, but corresponds with a decrease in strength and dynamic knee stability in females. So now we have a larger human and larger bones to support, coupled with less of an ability to produce force and decreased neuromuscular control. Yuck. Let’s get ahead of this and address BOTH the strength and motor control deficits that seem to poke their heads out during puberty and adolescence.

Third, let’s stop burning the candle at both ends. This part may be a bit on the opinion end of the spectrum, but I think many would agree. So many young athletes, especially elites, are training SO much and training a single sport. Under-recovery and repeated motor patterns without exposure to movement variability is also a piece of the problem puzzle, if you ask me. I am an advocate of proper recovery and promoting multi-sport participation, regardless of age.

Lastly, let’s please make the conversation surrounding the menstrual cycle as it pertains to training less taboo, more the norm, and a bit more influential. Sex differences in injury cannot be fully explained by strength or motor control alone. There is something else to this! If there is a way we can combat the influence of hormones on ligament laxity and overall injury risk, ultimately leveling the playing field (literally and figuratively), then let’s do it! I think this warrants a deeper dive into research and investigating longer term data so that we can actually solve this puzzle and get these injury and reinjury rates under control.

I hope this piece sparks some interest and discussion, and results in more people asking outside of the box questions. Our athletes, patients, and clients deserve it. Let’s go!

 Blog Post written by Steph Allen, DPT, OCS. Steph has a particular passion for ACL research and rehabilitation and hopes to be instrumental in making positive changes, both in in post op rehab and risk reduction programs.

I asked Steph to write on this topic after hearing her Interview on the CVASPS Podcast, click here to listen. This is an important topic if you have daughters involved in sports, or if you coach, train & rehab female athletes.

Steph is on staff at Boston PT & Wellness in Medford MA. You can find her on Instagram @stephallen.dpt

 Resources:

CVASPS Podcast with Tim Hewitt: https://www.youtube.com/watch?v=dC7zU0fvhnI

Thompson-Kolesar JA, Gatewood CT, Tran AA, Silder A, Shultz R, Delp SL, Dragoo JL. Age Influences Biomechanical Changes After Participation in an Anterior Cruciate Ligament Injury Prevention Program. Am J Sports Med. 2018 Mar;46(3):598-606. Doi: 10.1177/0363546517744313. Epub 2017 Dec 27. PubMed PMID: 29281799.

Von Rosen P, Kottorp A, Fridén C, Frohm A, Heijne A. Young, talented and injured: Injury perceptions, experiences and consequences in adolescent elite athletes. Eur J Sport Sci. 2018 Mar 3:1-10. Doi: 10.1080/17461391.2018.1440009. [Epub ahead of print] PubMed PMID: 29504456.

Leblanc DR, Schneider M, Angele P, Vollmer G, Docheva D. The effect of estrogen on tendon and ligament metabolism and function. J Steroid Biochem Mol Biol. 2017 Sep;172:106-116. doi: 10.1016/j.jsbmb.2017.06.008. Epub 2017 Jun 16. Review. PubMed PMID: 28629994.

Park SK, Stefanyshyn DJ, Ramage B, Hart DA, Ronsky JL. Relationship between knee joint laxity and knee joint mechanics during the menstrual cycle. Br J Sports Med. 2009 Mar;43(3):174-9. doi: 10.1136/bjsm.2008.049270. Epub 2008 Aug 26. PubMed PMID: 18728055.

 

 

 

High vs Low Ankle Sprains

By Grant Uyemura, DPT

High ankle sprains are more common in high impact sports and usually occur when the
foot is forced into external rotation with a planted, dorsiflexed foot. This mechanism of injury will cause the talus to widen the ankle mortise which can injure or tear the syndesmosis. The syndesmosis is made up of the anterior inferior tibiofibular ligament, interosseous ligament, interosseous membrane, posterior inferior tibiofibular ligament, and transverse ligament.

Lateral ankle sprains also known as inversion sprains are the most common orthopedic
injury and account for 85% of all ankle injuries. Lateral ankle sprains usually happen when the foot is point down, plantarflexed and rolls inward. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are the most common ligaments to get injured during a lateral ankle sprain.

High ankle sprains will take longer to heal and are more likely to create long-term
dysfunction compared to lateral ankle sprains. However, high ankle sprains are less common than lateral ankle sprains. Both injuries can be treated through physical therapy with conservative treatments.

The first phase will be protecting the joint while minimize pain, inflammation, weakness, and loss of motion.

The second phase will focus on normalizing joint mobility, strength, neuromuscular control, and return to activities of daily living.

The last phase will prepare the athlete for return to sport activities.

Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. Williams GN, Allen EJ. Rehabilitation of Syndesmotic (High) Ankle Sprains. Sport Heal A Multidiscip Approach. 2010;2(6):460-470. doi:10.1177/1941738110384573.

2. Hunt K. J, Phisitkul, P Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. Journal of the American Academy of Orthopaedic Surgeons. .
2015;23(11):661-673. doi:10.5435/jaaos-d- 13-00135

3. Albin, S. Rehabilitation of the Athlete Following Ligamentous Injury. Oral Presentation at: 12 th Annual CU Sports Medicine Fall Symposium. Meeting; September 22. 2017; Boulder,
CO.

Concussion: When Can I Return to Sport?

By Grant Uyemura, DPT Student

A concussion is a mild traumatic brain injury (TBI) that occurs when a head impact jars or shakes the brain inside the skull. This can damage neural pathways, which can lead to neurological disturbances. Symptoms can affect your physical, cognitive, behavioral, and emotional well-being.

Physical signs such as headaches, dizziness, sleep disturbances, nausea, vomiting, noise & light sensitivity, loss of consciousness.

Cognitive signs are confusion, slow reaction time, memory problems, poor judgement, inability to focus.

Behavioral changes may be confrontational demeanor, explosive temper fearfulness, impatient, hypervigilance.

Emotional changes such as depression, agitation, irritability, anxiety, and frequent mood changes man also be experienced. 90% of diagnosed concussions do not involve loss of consciousness, so it is important to understand common signs and symptoms.

Return to Sport Stages

Following a concussion, it is recommended to rest for 24-48 hours before starting stage
1 of the return to sport protocol. If the athlete is able to complete the stage without concussion related symptoms, then they can progress to the next stage. There should be at least 24 hours for each step of the progression. At minimum, it would take athletes 1 week to proceed through the full rehabilitation protocol before returning to play.

 Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5 th  international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017- 097699

2. Parker M, Lecture presented: Mild Traumatic Brain Injury, How to Identify and Treat
Concussions with Compassion at the University of Saint Augustine for Health Sciences, San Marcos, CA.

What is Femoroacetabular Impingment?

By Grant Uyemura, DPT Student

Femoroacetabular Impingement (FAI) is abnormal contact between the femoral head and acetabulum, which can cause hip pain, labrum, and/or cartilage damage. There are three different types of FAI’s: Cam, Pincer, and mixed. Cam impingement lesions are more prevalent in younger males than in females. Pincer lesions are more common in middle aged, active women.1 A study by Tannast et al. found that 86% of patients have a combination of both cam and pincer impingement.2

Types of FAI

Cam: Aspherical femoral head tries to fit into a spherical socket. Can cause chondrolabral junction separation due to shearing force.

Pincer: Over coverage of acetabulum socket, can cause labrum crushing and degeneration/ ossification.

Mixed: Combination of cam and pincer deformities.
Clinical Presentation

• Anterior or anterolateral hip/groin pain

• Stiffness

• Painful hip flexion past 90º and internal rotation

• Pain with prolonged sitting

What Physical Therapy can do?

The goal of physical therapy is to increase range of motion, increase strength, and decrease pain in order to maximize function and return to your prior level of function. Surgery should only be considered when conservative treatments do not control symptoms or functional limitations are unacceptable.4

 Blog post written by Grant Uyemura, DPT Student from University of St. Augustine. At the time of publishing Grant was in a clinical rotation with me at Catz PTI.

References:

1. ​Kuhns BD, Weber AE, Levy DM, Wuerz TH. The Natural History of Femoroacetabular Impingement. Front Surg. 2015;2(November):1-7. doi:10.3389/fsurg.2015.00058.

2. ​Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: Radiographic diagnosis – What the radiologist should know. Am J Roentgenol. 2007;188(6):1540-1552. doi:10.2214/AJR.06.0921.

3. ​Stephanie Pun, MD, Deepak Kumar, PT, PhD, and Nancy E. Lane M. Femoroacetabular Impingement. Nih. 2016;67(1):17-27. doi:10.1002/art.38887.Femoroacetabular.

4. ​Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. J Orthop Sport Phys Ther. 2014;44(6):A1-A32. doi:10.2519/jospt.2014.0302.

 

 

 

Is Your Lack of Ankle Mobility Increasing Your Risk for Knee Injury?

 Follow Chris Butler Sports PT

By Ashley Pena, DPT Student

 According to the NCAA Injury Surveillance system, knee internal derangements accounted for the highest percentage of more severe injuries sustained by college athletes (44.1% in games and 25.5% in practices) and approximately 70% of all game and practice injuries affected the lower extremities. As a result of these studies, much thought has gone into what factors contribute to this in an attempt to prevent, or rehabilitate these injuries while decreasing pain and improving performance. Although there are many factors which have been found to contribute such as muscle weakness, body type, training factors and others, little thought is given to the ankle joint unless it is giving the athlete pain.

When a person lacks dorsiflexion range of motion, often times compensations begin to manifest such as excessive pronation or “fallen arch”,  hip external rotation or “out-toeing” during walking, or lack of knee flexion with landing, all of which can increase the valgus forces on the knee and decrease shock absorption which can place a person more at risk for ACL injury, meniscus injury, or collateral ligament strains. In a systematic literature review done by Mason-McKay et. al, strong evidence was found that a restriction in DF ROM alters landing mechanics with specific studies reporting that altered frontal plane ankle motion (inversion and eversion), reduced sagittal knee excursion, and greater peak knee valgus.

 Blog Post written by Ashley Pena, DPT Student from Cal State Northridge.  Ashley is currently in her final clinical rotation with me at Catz PTI.

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❗️4th Student of the year❗️ Welcome Ashley, from my alma mater Cal State Northridge. Continuing with the BFR hazing. Stay tuned for some 💻blog posts from her soon. #CSUN @ashpena3r

A post shared by Chris Butler, MPT, CSCS (@cbutlersportspt) on Jun 13, 2017 at 12:18pm PDT

Sources:

1. Arendt E, Dick R. Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer. The American Journal of Sports Medicine. 1995;23(6):694-701.
2. Dick RM, Putukian M. Descriptive Epidemiology of Collegiate Women’s Soccer Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2002–2003. Journal of Athletic Training. 2007;42(2):278-285.
3. Kerr ZY, Marshall SW. College Sports–Related Injuries — United States, 2009–10 Through 2013–14 Academic Years. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a2.htm. Published December 11, 2015. Accessed June 5, 2017.
4. Mason-Mackay A, Whatman C, Reid D. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport. 2017;20(5):451-458. doi:10.1016/j.jsams.2015.06.006.
5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Llyod-Smith DF, Zumbo BD.  A retrospective case-control analysis of 2002 running injuries.  Br J Sports Med 2002; 36: 95-101.