Twist and Shout!

An ankle sprain is the most common injury to the foot and ankle. It accounts for 10-15% of all sports related injuries and is responsible for 7-10% of all emergency room visits each year. It results in pain and a loss of function at home, at work, and on the field.

An ankle sprain is defined as a tearing or stretching of the ligaments around the ankle. Ligaments are the tough tissues that connect the bones around a joint. Because of the anatomy of the bones in our ankle, most ankle sprains (greater than 85%) involve the ligaments on the outside of the ankle. Less commonly, the ligaments on the inside of the ankle or the syndesmotic ligaments (the ligament in between the two upper bones of the ankle, i.e. the tibia and fibula) are involved.

Most commonly, patients describe a twisting injury to their ankle where the ankle “rolled” to the outside. A basketball injury is the most common sports injury to cause an ankle sprain. Patients occasionally feel a tearing sensation or even a pop in the area of the ligament. These injuries can cause a significant amount of bruising and swelling. The more bruising and swelling that develop, the more severe the injury. These higher grade sprains often take longer to heal. Patients with weak muscles on the outside of their legs (peroneal weakness) or high arch feet are prone to having recurrent sprains. Orthotics and therapy can often minimize this risk.

Illustration of ankle spainAnkle sprains are sometimes associated with fractures in the foot or ankle. The Ottawa Ankle Rules (OAR) are the commonly used criteria for predicting which patients require xrays after suffering a twisting injury to the ankle. Radiographs are only required for those patients with (1) tenderness at the back edge or tip of the medial or lateral malleolus (the prominent bones on the inside and outside of the ankle respectively); (2) inability to bear weight (4 steps) either immediately after the injury or in the emergency room; or (3) pain at the base of the fifth metatarsal (the prominent bump on the outer border of the foot). MRI is rarely necessary to initially evaluate an ankle sprain but may be useful if the ankle sprain has not resolved with initial treatment within a reasonable amount of time.

Once an ankle sprain has been diagnosed, treatment should begin with rest, icing 20 minutes every 2-3 hours, compression with an ace wrap or brace, and elevation above the level of the heart if possible. These treatments are most important during the first 48-72 hours after the injury. Next, physical therapy is usually very effective in regaining full motion and strength in the ankle and is really extremely important in regaining full, pain free function.

Although some low grade sprains may resolve within 24-48 hours, some high grade sprains may have symptoms that can linger for 2-3 months. Luckily, most sprains resolve fully. When pain does not fully resolve despite appropriate treatment, it may be a sign of injury to another structure. Missed fractures, injuries to the tendons or cartilage, buildup of scar tissue within the joint (i.e. impingement), or continued instability in the ankle can all cause prolonged symptoms after a sprain. Many of these problems can be corrected through therapy, immobilization, bracing, orthotics, injections, or sometimes surgery.

Ankle sprains are very common injuries. Luckily, with appropriate treatment, most people will make a full recovery and be back to their full activities within a few weeks. A strong foot and ankle are the building blocks for the remainder of the legs and the body. A strong ankle should allow you to reserve doing the “Twist and shout” on the dance floor only.

Shoulder Instability

What is Shoulder Instability?

Illustration of shoulder jointThe shoulder joint is made up of two joint surfaces which are held together by ligaments and muscles. It has a ball on one side and a shallow socket on the other. The ball is formed by the upper arm bone called the humerus, and the socket is formed by the outer portion of the shoulder blade and is called the glenoid.

The ball and socket fit smoothly against one another with an outer rim of a cushioning cartilage structure called the labrum surrounding the glenoid. Illustration: End View of ScapulaBecause of the limited contact between these two structures, any loss of the normal integrity of the ligaments will result in the joint slipping out of its normal alignment into an abnormal position creating an unstable shoulder joint.

Minor damage to the capsule can result from recurrent injuries to the ligaments and may lead to mild instability (subluxation). Extensive ligament damage may result in complete dissociation of the two joint surfaces (dislocation).

Signs and Symptoms of Shoulder Instability

An unstable shoulder may cause pain, a sense of arm weakness and the perception of the shoulder slipping out and back into the joint. A complete dislocation is associated with severe pain, inability to relocate the joint, and usually requires and emergency room visit to restore the shoulder to its proper alignment. The joint may dislocate anteriorly (towards the front), inferiorly (downward), or posteriorly (towards the back).

How is Shoulder Instability Diagnosed?

The diagnosis of shoulder instability is made after obtaining an injury history, and doing a physical examination. Certain tests may reproduce some of the symptoms of instability, presenting the patient with the feeling that the joint is about to slip out. This exam differentiates instability from other sources of shoulder pain. Further details of the degree of instability may be obtained through a variety of x-rays and imaging studies.

Common Treatments for Shoulder Instability

When shoulder instability is diagnosed and there has not been a full dislocation, a vigorous rehabilitation program is designed to strengthen the supportive muscles. When the shoulder is very painful, a period of rest may be indicated combined with anti-inflammatory medications. The rehabilitation program is advanced as the patient makes progress and the joint demonstrates improved stability over time. A first time shoulder dislocation is frequently treated with rest and immobilization for a short time followed by progressive rehabilitation, based on the severity of the injury. When recurrent dislocations occur or an unstable shoulder fails to respond to conservative management, surgery may be indicated. A number of surgical techniques are used to fix shoulder instability depending on the extent and location of the injury.

Before/After Surgery Shot of Torn LabrumThe surgery is done anthroscopically using a thin camera and 1 cm incisions in the shoulder. The torn tissue is anchored back to the glenoid bone, and the stretched ligaments are tightened thereby restoring the shoulder stability. Your surgeon will advise you of the procedure most appropriate for you.

Spontaneous Shoulder Pain

As an Orthopedic Surgeon, the most common history my patients give me as to the cause of their shoulder pain is that “it just started one day”…”I woke up with it”…or I must have slept on it wrong”. Most shoulder pain or complaints do not start with a traumatic event or mishap. There is a tendency for shoulder pain to arise from unusual activities such as “spring cleaning” or “raking & bagging leafs in the fall”. The patient may notice that once the pain starts, certain activities aggravate the pain more than others. For example, women often complain that an overhead activity such as doing their hair or hooking their bra behind their back aggravates their pain. Men complain of pain when lifting weights such as military presses or incline bench presses. Jobs around the house that require overhead positioning of the arms, such as cleaning the gutters, painting the ceiling, putting up wall board, or washing windows can often aggravate. Once the pain starts, it tends to persist although it can wax & wane in severity. Almost every patient with shoulder pain will complain of pain at night or trouble sleeping. More times than not, the affected shoulder are their favorite side to sleep on. The patient noticing the pain more at night may be nothing more than the lack of other stimuli such as sound & light that would distract the patient’s attention during waking hours.

The above description and presentation is prototypical for the most common shoulder problem seen in an orthopedist’s office, called “Impingement Syndrome”. In years gone by, patients with shoulder pain were often told that they were suffering from bursitis or tendinitis. Bursitis means swelling of the subacromial bursa above the shoulder joint. Tendinitis means swelling of the muscle-tendon unit known as the rotator cuff, which is located just underneath the bursa. Impingement Syndrome encompasses both structure’s involvement i.e., bursitis plus tendinitis. Impingement Syndrome also suggests the notion of crowding or pinching of these structures when the arm is brought up into an elevated position. As these structures are pinched, they are irritated causing them to swell and take up more space. As they take up more space, they are more easily pinched with overhead activities, therefore in a sense, the problem becomes self-perpetuating. That is why I have interviewed patients that have had Impingement Syndrome for 18 months to 2 years. Repetitive pinching and irritation of the rotator cuff can lead to partial and full thickness rotator cuff tears. This is especially true with middle-age, as the blood supply to tissues becomes diminished the older one becomes. Rotator cuff tears are most often treated with surgical repair.

Treatment of Impingement Syndrome is usually effective when treated in its initial stages. Not allowing the shoulder to become stiff (Adhesive Capsulitis) is an important aspect of treatment. AntiInflammatory medications, physical therapy, and cortisone injections will eliminate the pain in the majority of cases. Impingement Syndrome does have the ability to recur or come back after successful treatment. If the pain returns quickly after, successful treatment of the pain proves resistant to non-operative treatment, there is an operation designed to help. The operation is called a Subacromial Decompression and can be done effectively with an arthroscope. The operation entails removing the offending bursa and resecting a portion of a bone called the acromion. The bursa will actually regenerate with time. The new bursa will have a bigger space to live in and is therefore less likely to get pinched. Recovery from such surgery is often in the 3-6 week range.