Essentially, the ankle consists of three bones, the tibia, fibula and talus, all held together by thick fibrous ligaments. The bottom parts of the tibia and fibula (shin bones) join together and surround the talus in such a way that it is able to rock forwards and back while providing stability and restricting the side-to-side movements.
The ligaments holding the tibia and fibula together are large and thick, forming a syndesmosis. An injury to this area is known as a high ankle sprain.
How do they happen?
A high ankle sprain can occur when your lower leg twists inwards while your foot is planted on the ground. The foot is typically pushed back and rotated outwards, putting excess pressure on the ligaments that hold the lower leg bones (tibia and fibula) together. This force can cause the syndesmosis to tear resulting in a gapping of the two bones, which can lead to significant instability of the ankle. This can happen simply from a fall, but more commonly while playing sports that involve running and jumping. This is also a common injury for downhill skiers. You are often unable to walk on your toes after this type of injury.
What is the difference between a high and a low ankle sprain?
A "normal" or low ankle sprain is a tear of the ligaments connecting the ankle to the foot, a syndesmosis tear (between the bottom of the tibia and fibula) is called a “high” ankle sprain. High ankle sprains are much less common than lower ankle sprains, accounting for only 1-11% of all ankle injuries. It can initially be difficult to tell the two injuries apart. To complicate things, a fracture of the ankle will also have similar symptoms. Your physiotherapist has a set of physical tests they can perform if they suspect a high ankle sprain. Ultimately imaging such as X-Rays or an MRI may be required to confirm the diagnosis.
Why does correct diagnosis matter?
High ankle sprains can take up to two times longer to heal than normal ankle sprains and require more immediate attention. Syndesmosis tears that are left untreated can result in chronic instability and pain, making them vulnerable to further injury in the future. Furthermore, if the separation of the tibia and fibula is severe enough, early surgery to fixate the injury with a screw or a "tightrope" to pull them back together may be required.
What is the treatment?
As mentioned, severe and unstable tears may require surgery, but most syndesmosis tears will need to be put into a supportive boot for around 4-6 weeks. Following this period a graduated rehabilitation program of strengthening, mobilization, balance, control and agility will need to be commenced before your ankle will be back to its pre-injury level of function. This can take up to 6 months in some cases.
What is the labrum of the shoulder?
The shoulder is a remarkably mobile joint, however this flexibility comes with the cost of less stability. The glenohumeral joint, where the upper arm meets with the shoulder blade is a ball and socket type joint. The surface area of the ‘socket’ part of the joint (the glenoid fossa) is much smaller than the ball part of the joint (the head of the humerus). A fibro-cartilaginous ring called a labrum surrounds the edge of the glenoid fossa which acts to increase both the depth and width of the fossa.
This labrum provides increased stability and is also the attachment for a part of the biceps muscle via a long tendon. The labrum can provide flexibility and stability that a larger glenoid fossa might not be able to, however being a soft structure it is prone to tearing which can be problematic.
What causes the labrum to tear?
The most common way the labrum is torn is through a fall onto an outstretched arm or through repetitive overhead activities such as throwing or painting, as the repeated stress on the labrum can cause it to weaken and tear.
Suspected labral tears can be diagnosed in a clinic by your physiotherapist through a series of tests, however, an MRI is usually required to fully confirm the presence of a labral tear. Labral tears are classified into different grades, which are determined by their location and severity. This grading is used as a guide to help determine the correct treatment.
What are the symptoms of a labral tear?
A labral tear is often associated with other injuries, such as a rotator cuff tear, which can make the clinical picture a little confusing. Commonly there will be pain in the shoulder that is difficult to pinpoint and the pain will be aggravated by overhead and behind the back activities.
Severe labral tears can lead to instability and can also be related to dislocations of the shoulder.
How Can Physiotherapy Help?
The severity and grade of the labral tear will guide treatment. Smaller tears can be treated with physiotherapy that is aimed at increasing strength and control of the shoulder. Other tears may require surgical repair after which physiotherapy is an important part of treatment to rehabilitate the shoulder.
The shoulder is a fascinating joint with incredible flexibility. It is connected to the body via a complex system of muscles and ligaments. Most of the other joints in the body are very stable, thanks to the structure of the bones and ligaments surrounding them. However, the shoulder has so much movement and flexibility that stability is reduced to allow for this. Unfortunately, this increased flexibility means that the shoulder is more vulnerable to joint dislocations.
What is a dislocation and how does it happen?
As the name suggests, a dislocated shoulder is where the head of the upper arm moves out of its normal anatomical position to sit outside of the shoulder socket (the glenoid).
Some people have more flexible Joints than others and will, unfortunately, have joints that move out of position without much force. Other people might never dislocate their shoulders unless they experience a traumatic injury that forces it out of place. The shoulder can dislocate in many different directions, the most common being anterior or forwards. This usually occurs when the arm is raised and forced backward in a ‘stop sign’ position.
What to do if this happens
The first time a shoulder dislocates is usually the most serious. If the shoulder doesn’t just go back in by itself (spontaneous relocation), then someone will need to help to put it back in. This needs to be done by a professional as they must be able to assess what type of dislocation has occurred, and an X-ray may need to be taken before the relocation happens.
A small fracture can also occur as the shoulder is being put into place, which is why it is so important to have a professional perform the procedure with X-Ray guidance if necessary.
How can physiotherapy help?
Following a dislocation, your physiotherapist can advise on how to allow the best healing for the shoulder. It is essential to keep the shoulder protected for a period to allow any damaged structures to heal as well as they can.
After this, a muscle strengthening and stabilization program can begin. This is aimed at helping the muscles around the shoulder to provide optimum stability and prevent future dislocations.
The information in this article is not a replacement for proper medical advice. Always see a medical professional for an assessment of your condition.
What is it?
Shoulder instability is a term used to describe a weakness in the structures of the shoulder that keep the joint stable, which can lead to dislocation. As one of the most mobile joints in the body, the shoulder maintains stability through a balance of support between the dynamic structures (muscles and tendons) and static structures (ligaments and joint shape).
Shoulder instability most often occurs in one of two directions, anterior (forward) or posterior (backwards). Anterior instability or dislocations are more common than posterior.
What are the symptoms?
The most noticeable symptom of shoulder instability is dislocation or subluxation of the joint. This is often accompanied by pain, clicking sensations, a feeling of instability and in some cases weakness, and pins and needles in the arm. Many patients report a feeling of apprehension or instability, as if ‘something is not quite right’. Posterior instability can also cause reduced range of movement and might mimic other common shoulder conditions, which need to be ruled out first.
How does it happen?
Shoulder instability can be classified as traumatic, occurring after an injury or atraumatic, where the shoulder is exceptionally flexible and prone to dislocations from everyday forces. Instability can also occur from chronic overuse where the shoulder joint is damaged slowly over time.
Traumatic shoulder instability is the most common form. Often the joint is dislocated by a strong force and damaged, leaving it more unstable and vulnerable to future dislocations. Rugby and football players are commonly affected. However, dislocations can occur in the general public from something as simple as falling onto an outstretched hand.
How can physiotherapy help?
Shoulder instability is a complex condition and each person will have a different combination of causes and structural deficiencies. Physiotherapists are trained to identify issues of coordination, control and strength that may be contributing to instability and provide an extensive rehabilitation program. For some patients, surgery is recommended to help restore some static stability to the joint. However, this is not the best pathway for everyone. If surgery is indicated, a full rehabilitation program is recommended post-operatively for the best possible outcome.
Helping patients to understand and manage their condition is an essential part of recovery. Physiotherapy is usually recommended as the first line of treatment before surgery and can have excellent outcomes, with or without going under the knife.