How to identify and treat a high ankle sprain or syndesmosis injury

If you’re a fan of AFL, NRL, Netball, Basketball or NFL, chances are the word ‘syndesmosis’ is one you’ve heard a lot of in the last few years. Syndesmosis injuries have been on the rise in contact sports in recent years as games are played faster by bigger and more agile players.

Your ankle is a complex hinge joint between the bones of the lower leg  and a bone of the foot and allows your foot to bend upwards (dorsiflexion) and downwards (plantarflexion). Because of the number of ligaments, muscles and tendons in the ankle region and the volume and variation in the tasks we complete on our feet, the ankle is one of the most commonly injured musculoskeletal zones treated by physiotherapists.[1]

What is a high ankle sprain?

The anterior talofibular ligament (ATFL), the posterior talofibular ligament (PTFL), and the calcaneofibular ligament (CFL) make their way along the outside of the ankle. The common ankle sprain, also known as an inversion sprain usually involves injury to the ATFL and CFL and occurs when you roll your ankle.

A high ankle sprain is a little bit different and much less common than a lateral sprain and involves the syndesmosis between the lower tibia and fibula just above the ankle joint.

The syndesmosis is a fibrous joint located where the two leg bones connect together by ligaments or connective tissue and usually have very little mobility. Syndesmosis injuries may not be as common as their lateral cousins, but they are more painful and debilitating.

A sports physio will generally grade ankle sprains on a scale of 1 to 3 – mild, moderate, and severe depending on the severity of any tearing to the ankle ligaments. In most cases, x-rays are performed to rule out a fracture or dislocation accompanying the tear.

Grade 1 strain – (mild)

  • Minor tear
  • Minimal pain
  • Little of no joint instability
  • Mild pain with weight bearing activities
  • Slight loss of balance

Grade 2 strain – (moderate)

  • Some tearing of the ligament fibres
  • Moderate to severe pain
  • Moderate instability of the joint
  • Swelling and stiffness
  • Possible pain with weight bearing
  • Poor balance

Grade 3 strain – (severe)

  • Complete tear of the ligament
  • Severe pain followed by minimal pain
  • Gross instability of the joint
  • Severe swelling
  • Pain with weight bearing activities
  • Poor balance

What causes high ankle strains?

Chances are, if you play any sport requiring jumping, turning and twisting movements like AFL, football, basketball, volleyball or explosive changes of direction such as soccer, tennis and hockey then you’ve likely already suffered an ankle injury of some kind. High ankle sprains can also be caused by slightly different mechanisms such as when the weight of a tackling opponent is put onto the ankle causing inversion or dorsiflexion trauma to the syndesmosis.

What does a high ankle sprain feel like?

Compared to lateral sprains, high ankle sprains do not “look that bad” in that they do not generally cause as much bruising or swelling. This lack of in your face swelling can cause many people to be unaware of how severely they have injured themselves, until the pain sets in. High ankle sprains are usually accompanied by a pain that radiates up your leg from the ankle. Each step you take will probably be very painful, especially so if you move your foot in the same way as when the injury occurred.

How are high ankle strains treated by a physio?

Your physio will ask you to describe the movement you were performing when your injury took place and under what circumstances, assess your symptoms, and conduct an in depth physical assessment including testing the syndesmosis. High ankle strains can be tricky to manage and are best treated by a sports physio or titled musculoskeletal physio.

In the immediate aftermath of your injury it is important to use the same “RICE” protocol used for the common ankle sprain:

Rest – Keep your weight off the affected leg. The amount of rest required for healing is usually much nearly twice as long as lateral ankle sprains

Ice – Apply ice to the area for about 15-30 minutes every few hours in the first couple of days after the injury, to reduce inflammation and swelling.

Compression – Wrap the lower leg with an elastic bandage to reduce swelling, but not tight enough to cut off circulation.

Elevation – Sit or lie down with your foot elevated to a position above the level of your heart to reduce swelling and pain.

If you have suffered an ankle injury or have pain in the ankle/lower leg region it is important to seek guidance and treatment before causing further harm to the area. Don’t end up spending more time on the sidelines through not getting timely treatment.

[1] Lin CW, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010;18(1):22–28. doi:10.1179/106698110X12595770849524


Back to school tips to help children stay active and healthy

It’s that time of year again, the school holidays are over and that means heading back to school or heading to school for the first time for kids all over the Northern Beaches. The start of the school year can be filled with excitement or dread for both parents and kids. Going through booklists, getting all the right uniforms and planning getting everyone to school are all important parts of the new school year, but it can cause some other areas to be overlooked.

The start of the school year usually brings an increase in child patients in physiotherapist’s office across the Northern Beaches as a number of factors create the perfect storm for injuries and pain to arise.

Following these tips will help you and your child get through the back to school period as happy and healthy as possible.

Focus on good nutrition and hydration

Children are balls of energy at most ages, and balls of energy require the right fuel to keep them healthy and going throughout the day. Playing outside in the heat of the day dehydrates children faster than adults and without good hydration habits, kids can end up with heat stroke pretty quickly. Eating a good healthy breakfast and lunch will help your child to concentrate throughout the day as well.

Find the right backpack

Do you like the idea of carrying around an uncomfortable backpack filled with heavy objects that might as well be rocks? Try running and jumping with them on as most children do. The wrong school bags filled with heavy books and lunches are a prime cause of back pain in children and can even lead to long term damage and malformation of the bones. Usually this is due to inappropriately sized bags, not carrying the bag correctly (on one shoulder like the cool kids) and too much weight.

How do I choose the right backpack?

  • Forget good looks, put comfort and fit at the top of the priority list
  • Make sure the backpack is properly sized – no wider than your child’s chest
  • Choose a backpack with broad, padded shoulder straps

Once you’ve found the right backpack:

  • Place the heaviest items at the bottom, close to the spine for better weight distribution
  • Don’t overload the backpack – moderate weight IS NOT harmful to your child’s back
  • Don’t let your child sling the backpack over one shoulder
  • Any waist straps are there for a reason – use them!
  • Don’t wear the backpack any lower than the hollow of the lower back

Make sure your child has comfortable shoes

Good shoes for your child are just as important as getting good tyres for your car! The average kid spends over 1500 hours per year in their school shoes, running, jumping, and playing sport on hard surfaces. That’s a lot of time to be spending in shoes that are unsupportive or that are incorrectly sized for your child. Children are susceptible to ankle injuries while their bones and joints are strengthening and shin splints are no fun for anybody! Some tips to look out for when picking shoes for your child include:

  • Make sure they fit correctly – too much or too little space affects comfort and can potentially cause blisters or the foot to move too much within the shoe
  • Make sure the shoe has a firm heel counter to hold a firm support around the ankle
  • Make sure the shoe bends at the toes where the foot naturally bends to avoid extra stress underneath the foot

Limit time on electronic devices

Research shows that spending too much time on iPads, phones and other touchscreen devices could lead to the muscles and bones of young children not developing properly. A Curtin University study conducted in 2016 showed that poor neck posture with little neck movement and decreased physical activity could lead to neck pain and under-developed muscles and bones.

Outdoor games are not just a fun way for children to exercise with their friends – getting outside like the good old days, away from the iPad, will help children develop their bodies, sleep better and keep them active while also having fun. Which is the best part of being a kid!


How to treat whiplash injuries

Whiplash injuries are common. Whiplash and whiplash-associated disorders (WAD) are frequently seen in motor vehicle accidents when the head is suddenly jerked back and forth beyond its normal limits, just like a whip.

Whiplash is a vertebral dysfunction that can also be described as a sprain of the joints in the neck. While many whiplash related injuries seen by physiotherapists are a result of car accidents, whiplash can also result from forceful sporting injuries that cause similar stress to the neck joints, ligaments, muscles and discs.

Up to 75% of people involved in car accidents develop neck pain, with even minor car bumps causing enough whipping of the neck to cause painful or noticeable symptoms in the muscles and ligaments supporting the spine[1].

What are the symptoms of whiplash?

Whiplash is a complex mechanism that can cause pain in the neck, shoulders, back, head and arms. The pain may come on immediately after the accident or come on slowly afterwards and be accompanied by symptoms including[2]:

  • Headache or pain in the jaw or face
  • Pain or reduced movement in the neck
  • Pain between the shoulder blades
  • Lower back pain or stiffness
  • Irritability, Fatigue, Dizziness
  • Pain in the feet and hands
  • Nausea
  • Ringing in the ears or Blurred vision

What is the best treatment for whiplash?

Research shows that the most effective way to treat the complexity of whiplash injuries is with a combination of treatment options tailored to your individual condition.[3] Physiotherapy management with an expert in rehabilitation such as a sports physio who specialises in neck injuries or whiplash is extremely effective.

Acute treatment consists of reducing your pain and inflammation in the localised area and stabilizing your neck to prevent any further damage from occurring.  You can’t beat ice when it comes to a natural anti-inflammatory and when your neck is painful you will be wanting to ice the region regularly.

Once you begin recovery treatment with your physio, you will be given a thorough physical history, orthopaedic, neurological and spinal examination to determine the exact location and mechanism of your neck pain.  Your physio may also refer you for an X-ray, CT or MRI in order to fully assess any damage that appears to be more serious.

Whiplash sufferers tend to get the best results when there is a combination of active range of motion exercises such as gentle mobilisation, massage therapy and gentle stretching in a recovery program. Other common treatment methods for whiplash include:

  • Exercise to promote flexibility, strength and good posture
  • Fine neck muscle and proprioception retraining programs
  • Acupuncture or dry needling
  • Joint mobilisation or manipulation to loosen stiff joints
  • Soft tissue massage for short-term muscle tension relief

How long does it take to recover from whiplash?

How long is a piece of string? Just as the symptoms and severity of whiplash vary from person to person and between mechanisms of injury, so can the recovery time. Research shows that most whiplash sufferers who participate in actively guided treatment with a physio take from a few days to several months to rehabilitate[4].

There are many other non-physical factors which can impact the length of your recovery, including depression and trauma-related anxiety, so it is important to raise any additional issues with a qualified health professional to give yourself the best chance of recovery[5].

Do you have a whiplash injury?

Don’t let a whiplash injury affect your ability to work or do the things you love. Book an appointment now by choosing physiotherapy and then by choosing a time that suits you, alternatively, please call us on 02 8964 4086.

[1] Sturzenegger M. et al. (1994). Presenting symptoms and signs after whiplash injury: The influence of accident mechanisms. Neurol., 44, pp. 688–693

[2] Stace R. and Gwilym S. « Whiplash associated disorder: a review of current pain concepts. » Bone & Joint 360, vol. 4, nr. 1. 2015.

[3] Sterling M. (2014). Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy, 60, pp. 5–12

[4] Gargan MF. Et al. (1994).The rate of recovery following whiplash injury. Eur Spine J, 3, pp. 162

[5] Phillips LA. Et al. (2010). Whiplash-associated disorders: who gets depressed? Who stays depressed?. Eur. Spine J., 19(6), pp. 945-956


Rotator cuff injuries; so common that even physiotherapists get them

You can get it spiking a volleyball

You can get it painting a wall

You can get it swinging a racquet

A sore rotator cuff needs an in depth assessment

And the best in depth assessment is Fixio

You can get it rowing

You can get it mowing

You can get it any old how

As a matter of fact I’ve got it now.


Rotator cuff pain and injuries are among the most common afflictions treated by sports physios. However, rotator cuff injuries are not just treated by physiotherapists; we can also suffer them ourselves. After a particularly grueling 3 hour straight beach volleyball session, I’ve found myself in the same position as many of our patients; nursing a sore shoulder and wondering what I did to deserve that as my birthday present?!

What Is a Rotator Cuff Injury?

Your rotator cuff consists of four muscles and their tendons – the supraspinatus, infraspinatus, teres minor, and subscapularis, with each attaching to the scapula (shoulderblade) and the humerus (the upper arm bone). These muscles stabilize the shoulder joint, rotate the shoulder and come together to lift your arm above your head. All movements involving the shoulder use the rotator cuff in some way.

Rotator cuff tendinitis is one of the most common forms of rotator cuff injury and typically begins with inflammation of the supraspinatus tendon and can progress from there to affect the three other tendons. Injuries to the rotator cuff usually develop as a result of repetitive motions over time, but can also happen as a result of direct trauma; causing the tendons to tear and become damaged.

The most common signs of rotator cuff injuries are:

  • Muscle weakness in the shoulder joint
  • Functional impairments; difficulty lifting, pushing and especially overhead movements
  • Painful external/internal rotation
  • Pain may be present, located either in the anterior or lateral area of the shoulder

What are the most common rotator cuff injuries?

Due to the nature of the Rotator Cuff, location to other muscles, range of movements it is used in and connection to other sensitive areas in the shoulder, there are many different rotator cuff injuries:

  • Rotator Cuff Tears; muscle or tendon tears of varying grades
  • Rotator Cuff Tendinitis
  • Rotator Cuff Tendinopathy due to chronic irritation (ie what happens if you let your tendinitis continue!)
  • “Impingement syndrome”

What are the causes of a rotator cuff injury?

If you play sports or have a job that uses repetitive overhead arm motions, you are at a higher risk of developing a rotator cuff injury. People over age 40 and anyone with weakened shoulder muscles from inactivity are also at higher risk of a rotator cuff injury. A rotator cuff injury may be caused by:

  • A direct blow to the shoulder
  • Repetitive overhead motions of the arm; volleyball, swimming, baseball and tennis are common culprits
  • Chronic degenerative wear and tear on the tendons
  • Falling on an outstretched arm

How are rotator cuff injuries diagnosed?

Most physiotherapists will be able to accurately diagnose rotator cuff tendinitis and other injuries by performing an in-depth examination and going through your physical history. Your physio will also perform tests for tenderness near the top of the upper arm in the subacromial space and will have you gauge your pain as your arm is lifted and moved in certain ways. Pain associated with normal muscle strength in the shoulder can suggest rotator cuff tendinitis; pain with weakness may indicate a tear.

If you’ve suffered a traumatic injury or if a tear is suspected, your physio may refer you for an x-ray or MRI may be ordered.

How to reduce your chances of rotator cuff injury

The best way to prevent rotator cuff tendinitis is to avoid or limit activities that irritate the shoulder. This one is easier said than done due to how much the rotator cuff dominates the movements of the shoulder. If you have a history of rotator cuff tendinitis, avoiding aggravating activities such as repeated overhead movements can reduce the number of flare-ups.

If you play sports that involve the shoulder, you should ensure that you are using the correct technique to limit irritation as much as possible. Speak to your sports physio about having them conduct an assessment of your movements and technique in order to get a better idea of any alterations you can make in order to help you stay pain free.

You can also help to prevent or manage rotator cuff tendinitis by:

  • Stretching the shoulders during the day and before any activity
  • Using a good posture when standing, sitting, or walking
  • Resting the shoulder as soon as you feel any pain or discomfort
  • Sleeping on your back or the unaffected side
  • Taking breaks from during activities that use repetitive motions and movements

How do I treat rotator cuff pain?

During the acute phase of rotator cuff tendinitis, apply an ice pack to your shoulder for no longer than 20 minutes every hour. If you are in a lot of pain, ibuprofen may be helpful during this time as well. While you’re in the pain phase, stay away from heavy lifting and reaching out overhead as much as possible. Once you’re through the acute phase it is important to keep the shoulder moving because that can lead to frozen shoulder; a condition that causes the tissues around the shoulder shrink and reduce its range of motion.

Your physio can then begin to work with you and utilise exercises that will aim to fix problems such as stiffness and weakness and correct any other underlying causes. Sports physios are experts in the retraining of movements and activities related to your sport, work and the day to day activities that were aggravating your shoulder so that you can get back to what you were doing before the pain.

Now, back to get the ice out of the freezer!

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