Physiotherapy Blog

What is Parkinson’s Disease?

Parkinson’s Disease is a progressive neurodegenerative disorder which effects movement and slowly progresses over time. Parkinson’s Disease effects the brain networks which control movement. The low levels of brain Dopamine results in a loss of communication between the higher brain structures (the cortex) and the deep brain structures (the basal ganglia). The higher brain structures are where you think and plan a movement and the deeper brain structures are where those thoughts are translated into a movement. In Parkinson’s Disease there is a miscommunication between the intention of movement and the actual execution of the movement. 

Common Symptoms:

1. Slow movement
2. Tremor
3. Rigidity and stiffness
4. Slow, shuffle gait with smaller steps
5. Difficulty turning and changing direction
6. Difficulty regulating the size or speed of a movement
7. Changes in posture 
8. Freezing – inability to finish a movement or a sensation that the feet are stuck on the ground while walking
9. Poor balance
10. Cramping
11. Speech and swallowing issues
12. Memory changes
13. Decreased special awareness and depth perception

Benefits of exercise:

Research has shown that exercise is beneficial in managing Parkinson’s Disease. There is no cure for Parkinson’s, however research has shown that aside from medication exercise is the most important treatment in slowing the progression, maintaining quality of life and helping the brain to be able to compensate for the changes that occur as a result of Parkinson’s disease.

Benefits of exercise include:

• Improved balance, gait and reduced number of falls
• Improved flexibility 
• Improved endurance
• Improved decision making
• Improved movement planning
• Reduced freezing while walking
• Improved cognition 

What type of exercise?

• Aerobic exercise: To improve endurance and oxygen efficiency 
• Skill based exercise: To improve motor planning and help the brain to learn to compensate for the effects of Parkinson’s Disease
• Strength and resistance training: To improve general strength 
• Balance exercise: To improve balance and reduce risk of falls
• Movements with external feedback: Research on exercise and neuroplasticity shows that when a new skill is learned, the brain is learning the movement and creating a new pattern in the brain. External feedback helps to reinforce these patterns and helps the brain learn new ways of performing a task which doesn’t involve the effected area of the brain. 

Written by Ashley Holliday – Physiotherapist

Benign Paroxysmal Positional Vertigo is a condition that physiotherapists are able to help with.

Vertigo is the cause of 45-54% of people who experience dizziness!

There are various causes for vertigo-like symptoms. It is important to have a thorough examination by your GP to rule out any other issues which may be causing your symptoms.

SYMPTOMS

– Dizziness that lasts under one minute with head movements, there may be recurring episodes of dizziness over days or weeks, but each episode is quite short

– Sudden onset of symptoms

– nausea and vomiting may occur

– Symptoms tend to settle once you are in a different position

WHAT CAUSES IT?

BPPV is when the tiny particles in the inner ear (in the semicircular canals) are disturbed and the brain receives the incorrect message of movement. Usually the inner ear can detect movement, the message that the head is moving is sent to the brain and you are able to move without a spinning sensation. When the brain does not receive the correct information from the inner ear, the brain will sense movement when you’re not actually moving anymore. This usually settles in under 30 seconds, until the head is moved again.

WHAT CAN YOU DO ABOUT IT?

Often the symptoms will eventually settle on their own, but it will settle much quicker with intervention

– The GP may prescribe motion sickness medication to help with nausea

PHYSIOTHERAPY: Physiotherapists are trained in specific manoeuvres to help settle the particles back to where they are meant to be. Following this, you will be guided through some home exercises to help. Usually this takes 1-2 sessions to resolve and you would expect to continue the home exercises until you are symptom free for 24 hours.

*DO NOT DRIVE YOURSELF to your physio appointment, make sure you have someone to drive you home as treatment may cause some nausea for a short period of time.

TIPS FOR HOME CARE:

– Avoid positions that provoke symptoms, this includes putting your head back, looking upwards or turning too quickly – it is advised not to go to the hairdresser or dentist while symptoms are present as this involves putting your head back, which will likely bring on symptoms.

– Sleep with an extra pillow to raise the head slightly

– Avoid sleeping on the side that causes your dizziness

– Get up slowly in the morning and allow time to sit on the edge of the bed before standing up

– Do not drive until symptoms have completely resolved

Written by Ashley Holliday

PHYSIOTHERAPIST

Osteoporosis is a condition of low bone density causing weak and brittle bones. Normally the bone regenerates and continually renews as old bone is removed. In osteoporosis the old bone is being removed at a faster rate than the new bone is able to replace it, leaving the bones weaker and thinner.

• From approximately 30 years old the body starts to break down old bone faster than it replaces it.
• Women around the age of 45-55 or during/after menopause can lose bone denity quicker due to hormonal changes.
• Men tend to lose bone density slower as there is less hormonal changes, however once Men reach 65-70 years old, they tend to have a reduction in bone density at the same rate as women.

Symptoms:

There often is no symptoms and people often don’t know they have osteoporosis until they break a bone or have a bone density test. Fractures are the main symptom, however in some cases there may be joint pain present.
In severe cases fractures of the bones can occur from minor incidences including falls, strongly coughing or sneezing and direct trauma to an effected bone.

Causes/Risk factors:

• Hyperthyroidism
• Long term use of steroid medication such as prednisone or cortisone
• Hereditary
• Poor nutrition and inactivity
• Age
• Gender

What can you do?

There are some things you can control and others you can’t (Such as your age, family history and gender). Your doctor will likely prescribe medication or injections to improve bone density. Some lifestyle changes you can implement include:

• Diet changes: Increase calcium and vitamin D intake
• Weight bearing exercises

Weight bearing exercises are great for strengthening the bones. It is important to include weight bearing exercises for the arms/upper limbs as well as the legs. Walking is a great form of weight-bearnig exercise as well as resistance training. Swimming and cycling will NOT improve bone density as these activities are great for offloading painful and stiff joints but do not involve weight-bearing.

• Stop smoking
• Balance exercise program
  We know that bone density starts to decrease from 30 years old and so does our balance. Ideally it is recommended to start balance training from 30 years old, however the good news is, your balance can improve at any age. The better you balance is, the less likely you are to fall.

How can physio help?

Physiotherapists are trained to give advice and help you with appropriate exercises to help with managing osteoporosis. There may be no cure, but we can help you remain strong and active and prevent falls as much as possible!

Written by Ashley Holliday

Physiotherapist

Swimming is a much loved sport in Australia with a high level of participation of people of all ages, from athletes training for meets, triathletes working on their swim leg or the everyday person following the black line for some low impact exercise. 

There are many benefits to swimming including it being low impact, great for the cardiorespiratory system and great for overall strength and coordination. Swimming however, involves a lot of overhead movement which can be problematic on the shoulders.

WHY DOES SWIMMING CAUSE INCREASED LOAD ON THE SHOULDERS?

1.     Repetitive 

Swimming involves repetitive overhead movement, the arms are continually rotating and reaching overhead. The incidence of competitive swimmers with shoulder pain is 50-70%. Athletes can be training across two training sessions per day on most days of the week. Competitive swimming also does not have an “off season” which also increases the repetitive load. 

2.     Rotator cuff imbalances 

Swimmers may develop an imbalance between their internal rotation (Rotating the shoulder inwards) and external rotation (Rotating the shoulder outwards). Swimmers often are stronger with internal rotation as this is developed through pulling through the water (in freestyle, butterfly and breastroke). Swimmers that do a lot of backstroke often have improved external rotation.

3.     Shoulder laxity

Swimmers are often hypermobile (increased joint laxity/flexibility of the ligaments). Hypermobility of the shoulders is beneficial in achieving the range of motion required to swim efficiently. Although hypermobility helps performance it can cause unwanted stress on the shoulder as the ligaments are repetitively on increased stretch. 

4.     Increased need for flexibility

To swim efficiently swimmers need a lot of movement and flexibility. To achieve the streamline position, a high elbow catch and good clearance of the water, swimmers need a lot of thoracic extension, particularly butterflyers and breastrokers. Backstrokers need a lot of shoulder external rotation and thoracic rotation in order to swim with correct technique. If the swimmer does not have adequate movement around these areas, this will increase the demand on the shoulders.

RECOVERING FROM SHOULDER INJURIES

The process of recovering/rehabilitation following swimming related shoulder pain should include addressing the muscle imbalances and issues with range of motion as well as other factors such as training loads and swimming technique.

Depending on the specific injury, overhead movements may need to be avoided for a short period of time to let the pain settle. During this time the swimmer can keep up fitness through kicking and drills with the arms by the sides. The swimmer may be able to tolerate some level of overhead training, however the intensity and duration may need to decrease for a short period of time. During this time the swimmer can be working on muscle imbalances, range of motion issues, joint control and general fitness either in the water or during dryland training. 

The key is to manage these injures and keep the swimmer fit and strong while working on recovering from the injury and rehabilitation to ensure the injury doesn’t continue to come back!

Written by Ashley Holliday – Physiotherapist

That annoying pain around your neck, shoulder and down your arm that you can’t find the source of! It may be Thoracic Outlet Syndrome!

Signs and Symptoms:

• Pain in the base of the neck/1^st rib (Just below the collar bone)
• Pain in the arm when lifting the arm above your head
• Pins and needles and numbness may be present down the arm – usually into the 4^th and 5^th finger 
• Pain in the shoulder or down the arm when carrying things on your shoulder
• Increase symptoms after use of the arm
• Fatigue and arm/hand weakness (may be present)
• Often pain is worse at night
• Discolouration and swelling (If there is vascular compression – This is rare but more serious)

What is it?

Thoracic outlet syndrome is compression of nerves and possibly blood vessels as they pass over the first rib. 

Neurogenic Thoracic Outlet Syndrome: The most common, when the Brachial Plexus (bundle of nerves) is compressed.

Venous or Arterial Thoracic Outlet Syndrome: Rare but more serious, this is when the Subclavian Vein or Subclavian Artery is compressed.

What causes it?

There are a number of structures that may be contributing to compression at the first rib, this is why it is difficult to diagnose. What is causing it for one person may be different to what is causing it for another person. Thorough assessment is crucial for effective management. 

Potential sites for compression include:

• Muscles: Scalenes and pectorals 
• Bones: Some people have a cervical rib (An extra rib attached at the neck which can get in the way of the nerves and blood vessels – This can be seen on X-Ray
• Mechanics of the scapula or rib dysfunction: If the scapula is not upwardly rotating correctly, the scapula can be dumping downwards which can put extra pressure on the neural structures. There can also be dysfunction at the ribs which can also increase the pressure.

*Any one, or a combination of these things can be contributing to the issue. 

How can Physiotherapy help?

• Assessment and identification of the cause of the problem is key!
• Addressing postural habits
• Addressing muscle imbalances
• Mobilising the neural system 

Written by Ashley Holliday

Physiotherapist

What is Lateral Epicondylalgia?

 Lateral Epicondylalgia is an overuse/degenerative soft tissue injury caused by over use of the wrist extensor muscles, most commonly extensor radialis brevis which’s primary role is to stabilise the wrist to allow hand and finger movement. The wrist extensors attach onto the bony prominence on the outside of the elbow (Lateral epicondyle) this attachment site becomes irritated and the tendon starts to undergo degenerative changes. 

Symptoms?

The pain is generally localised to the lateral epicondyle without radiating pain into any other area. Pain is reproduced by gripping, wrist extension, middle finger extension and rotating into pronation (Palm down). Over time without management, the radial nerve may become irritated in the radial tunnel which may present with pain turning the hand into supination (Palm up) and pain may radiate into the upper forearm. 

What causes Lateral Epicondylalgia?

 There is often a history of overuse (one episode or repetitive trauma), the pain then increases gradually following this episode. The injury is usually developing before the onset of pain if the injury is caused by repetitive trauma however the pain may present as a sudden onset. 

What to do?

 Tendons need optimal load in or order to remain healthy. An injured tendon needs a balance between resting to unload the irritated tendon and exercising the tendon to strengthen and repair it. Optimal load will be different depending on your strength, the activities you are accustomed to and how long the injury has been present. Optimal load is the amount of load the elbow can tolerate without bringing on pain, the amount of load tolerated will increase as the tendon strengthens and repairs. 

When and how to rest the elbow?

 If the onset of pain is recent and sudden, 6 weeks of avoiding aggravating activities may be enough to settle the pain down however if the pain has been present for more than 6 weeks of there is no reduction in pain, physiotherapy treatment and gradual loading exercises may be required. 

Activity modification to unload the lateral elbow 

• Reduce aggravating activities such as excessive gripping and rotating the wrist 

• Reduce manual labour if possible 

• Hold things close to your body with your elbows bent 

• Tennis elbow straps can be useful when doing aggravating activities to re-distribute the load onto the forearm, however should not be worn for extended periods of time to avoid irritating the area around the strap 

• Isometric exercises (as seen below) are useful in reducing pain as they have an analgesic effect. 

When and how to load the elbow?

• Loading exercises should start if initially resting the elbow has not settled the pain or if the pain has been reoccurring for 6 weeks or more 

• Tendons require load to be able to heal, if the tendon is completely rested the pain will return once normal activities commence (note: as the tendon heals it will cope with more load) 

• All loading exercises should be completely pain free (unlike lower limb tendons) 

• Loading starts with isometric contractions and self-mobilisation techniques (see below) and gradually progress to eccentric strengthening as pain allows 

Physiotherapy Treatment

Initially:

• Physiotherapy manual therapy around the elbow joint and soft tissue release of the forearm muscles 

• Dry needling of the wrist extensor muscles may be useful in reducing increased muscle tension 

• Anti-inflammatories and ice to reduce inflammation 

• Tennis elbow strap for when aggravating activities are unavoidable 

• Exercises to gradually load the tendon

Following initial treatment your physiotherapist will guide you through a series of progressive loading exercises to ensure you build up strength in the elbow and can safely return to your regular activities without flaring up the injury.

 

Written by Ashley Holliday

Physiotherapist

What is the Temporomandibular Joint?

The jaw! is a synovial joint (Therefore can become inflamed) it has 3 supporting ligaments, a fibrocartilage disc (meniscus), joint space filled with synovial fluid and many muscles which control movement

Movements of the Temporomandibular joint

Movements:

• Depression (opening)
• Elevation (closing)
• Protrustion (Jaw coming forwards)
• Retraction (jaw coming back to rest)
• Small amount of lateral movement

Symptoms of Temporomandibular Dysfunction (TMD)

• Pain around the jaw or referred into the ear, behind the eye or into the head (headache)
• Ringing in the ear or dizziness
• Referred pain into the neck
• Clicking or locking of the jaw and limitation in movement

Causes of Temporomandibular Dysfunction

• Teeth grinding or clenching – puts increased wear on the cartilage (disc). There should always be several millimeters between back molars when jaw is at rest
• Habitual chewing, only chewing on one side or nail biting
• Postural habits 
• Trauma to the facial bones
• Stress and tension
• Dental problems (E.g. braces may have caused gradual trauma)

Temporomandibular joint and the Cervical Spine

• Closely linked, C1 is located just behind the disc of the jaw
• Suboccipital tension (Tension in the back of the head) and Temporomandibular pain are often seen together
• Headaches from the suboccipital region can refer into the jaw and vice versa

Treatment of the Temporomandibular Joint

• Treatment of the cervical spine may be required
• Adjustments to posture
• Soft tissue releases of the jaw muscles
• Habitual changes

Jaw warnings:

• Chew on both sides
• Avoid chewing too hard or very chewy foods
• Relax the jaw to avoid clenching when stressed
• Avoid lying on your side to sleep (the side you lay on will be tighter)
• Consider a night splint if you grind your teeth
• Self release techniques (As taught by your physiotherapist)

Written by Ashley Holliday

Physiotherapist

Osteoarthritis (OA) is often referred to as “wear and tear” arthritis. OA can affect joints due to uneven or excessive loading, resulting in the lining of the joint (cartilage) wearing away and causing more force through the bones (Hence the term “bone on bone”). 

• Over 3.1 million Australians suffer from Osteoarthritis
• 53% of the population over 75 suffer from increased disability due to osteoarthritis
• Osteoarthritis is more common in females

Causes of knee Osteoarthritis

• Repetitive strain injuries can lead to early onset of Osteoarthritis – E.g. constant stress on the knee could be from excessive kneeling, squatting or heavy lifting
• Previous injury such as ACL rupture of meniscus damage
• Being overweight – progression of Osteoarthritis is more rapid in people who are overweight
• Genetic disposition – abnormal structure of the shape of the bones
• Rheumatoid arthritis – you may develop secondary Osteoarthritis

Treatment options of knee Osteoarthritis

While knee Osteoarthritis is often a degenerative and an irreversible process, functional improvement and pain control are reasonable goals. Earlier treatment intervention may improve the odds of preserving joint integrity and function for years and possibly prolong or reduce the need for joint replacement surgery.

Treatment may include some of the following:

• Unloading the painful structures by taping or bracing
• Stabilising the unstable patella (Knee cap) through specific exercises
• Restore dynamic balance of the quadricep muscles to support the knee joint
• Improve lower limb mechanics, working on flexibility of the hips and gluteal strength
• Decrease swelling
• Reconditioning program
• Hydrotherapy (strengthening the knee without weight bearing)
• Orthotic therapy to correct lower limb alignment
• Weight loss – According to a study by S P Messeir “For every kilogram of weight loss there is 4kg less load through the knee for every step”

Other treatments may include:

• NSAID’s
• Diet and nutrition 
• Joint injections

When conservative treatment isn’t enough and the joint is too damaged you may need an orthopedic review to consider joint replacement surgery.

What is the aim of physiotherapy treatment?

The aim of physiotherapy treatment is to reduce the pain and stiffness at the knee joint by improving the loading through the joint. Waiting for knee replacement surgery is not the only option. The first principle in management of OA is to slow the progression of the disease and improve functional capacity. This can be done through a combination of physio, exercise, weight loss and the use of anti-inflammatory pain medication.

Written by Ashley Holliday

Physiotherapist

What is the Sacroilliac Joint?

The Sacroilliac joint is the joint which connects the Illiac bones of the pelvis and the sacrum (Triangular bone which becomes the tail bone). The sacrum sits directly below the lumbar spine and the sacroiliac joints are to the right and left of the lumbar spine.

Statistically 85% of the population will suffer from low back/pelvic pain at some stage in their life and 18-30% of chronic low back pain has the sacroiliac joint as the pain generator.

How does the Sacroiliac Joint get injured?

• Pregnancy related injuries
• Fall directly onto the coccyx (Tail bone)
• Fall onto one knee
• Traction injuries E.g one leg pulled by leg rope while surfing
• Repetitive trauma E.g excessive pelvic tilting motions in sports

What are the common symptoms associated with Sacroilliac Joint Dysfunction?

• Pain over the sacroiliac joint
• Pain with prolonged sitting or standing
• Buttocks pain
• Coccyx pain (Tail bone)
• Neural symptoms down the back or side of the leg – This may be very similar to disc related symptoms
• Pain and aching in the surrounding muscles – The gluteals, legs, hips, low back and ribs
• Pain at the front of the hip

Following an injury the body starts to respond with compensatory strategies…

After an acute injury the body goes into protective mode and stiffens up in attempt to protect the injury. Within 3 days the core stabilisers (Transverse abdominus and Lumbar Multifidus) are inhibited and stop working effectively. If this is addressed quickly, you should return to a “normal” movement pattern as the acute pain settles back down.

If this isn’t addressed early or a significant injury is sustained and takes much longer to settle down the body starts to compensate for this by overusing the surrounding muscles. The muscles that are often overused are the gluteals, legs, hips and back leading to overuse and altered movement patterns.

How can Sacroilliac Joint injuries be diagnosed?

Sacroilliac Joint dysfunction can be difficult to diagnose and is often misdiagnosed. Statistically it takes 2 years to be diagnosed after the initial injury as the body generally can compensate well using the surrounding muscles for approximately 2 years, until the pain starts to present more specifically around the sacroiliac joint.

Sacroilliac Joint Dysfunction is difficult to identify on scans. MRI and CT scans may detect irritation or inflammation around the Sacroiliac Joint however cannot determine dysfunction. The diagnosed is made based on a series of clinical tests.

If the pain is not coming from the Sacroilliac joint, what else could it be?

• Referred pain from the lumbar spine
• Pelvic pain due to issues with the internal organs such as the bladder, bowel or intestines

How can physiotherapy help Sacroilliac Joint Dysfunction?

Physiotherapy can help in identifying the abnormal compensation strategies you are using and help re-train lumbopelvic control to ensure you are using the correct stabiliser muscles and not overusing the surrounding muscles.

Physiotherapy treatment can help ease the symptoms through various treatments such as:

• Soft tissue release
• Taping or sacroiliac joint belts (if appropriate)
• Dry needling
• Muscle energy techniques
• Specific exercises

More importantly the physiotherapist will work towards underlying cause of the pain through identifying incorrect movement patterns, muscle imbalances or activities that may be contributing to the pain. The physiotherapist will work with you in addressing these issues and treating the source of the pain as well as the symptoms.

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Written by Ashley Holliday

Physiotherapist

What is a Lateral Ankle Sprain?

An injury that occurs from rolling the ankle inwards (inversion injury), injuring the ligaments on the outside of the ankle. The role of these ligaments is to prevent excessive ankle movements in an inwards and downwards direction. If the ankle is forced beyond what these ligaments can withstand these ligaments will sustain an injury.

Mechanism of injury: 

Two most common mechanisms: 

1. Landing on uneven surface (someone’s foot, pot hole, off the edge or gutter, high heels etc.) 
2. Pushing off laterally during cutting or changing direction maneuver in sport 

What structures are likely to be involved? 

There are 3 main ligaments on the outside of the ankle (ATFL, CFL, PTFL) these ligaments may be sprained during an inversion injury. There may also be involvement of the deltoid ligament on the medial (inside) of the ankle in some cases.

An Avulsion fracture may also occur. This occurs when the ligament pulls off a fragment of the fibula bone (Which it attaches to) during the injury.

Ruling out fractures:

Ligament injuries do not show up on X-Ray however if a fracture is suspected an X-Ray should be considered. To determine whether an X-Ray is needed we follow the Ottawa ankle rules.  

Ottawa Ankle Rules:

1. Tenderness from lateral or medial from tip of the posterior part, 6 cm up from the lateral malleolus 

2. Tenderness over base of 5th Metatarsal 

3. Tenderness over the Navicular 

4. Cannot immediately weight-bear or cannot currently weight-bear

Recovery Time

 Returning to every day activities will vary depending on severity. It is important to return to daily activities as soon as possible. Below are the estimated timeframes for returning to sporting/higher stress activities.

– Grade 1: 2-4 weeks 

– Grade 2: 4-6 weeks 

– Grade 3: 6-8 weeks (Avulsion fractures will take longer) 

Initial Management

 Treatment days 0-3 

48-72 hours 

PRICER:

Protect, Relative rest, Ice, Compression, Elevate, Referral 

– Protect the ankle from excessive inward ankle movement – Taping or bracing 

– Relative rest: Daily activities should be as normal as possible, when the ankle becomes uncomfortable then have a rest 

– Ice: 15-20 mins regularly throughout the day if the ankle is swollen and bruised 

– Compression: tubigrip, elastic bandage, tape for compression 

– Elevation: Above the heart level 

– Referral to physio or X-Ray 

Rehabilitation

20% of acute ankle sprains lead to chronic instability, therefore rehabilitation is very important. Reoccurrence of ankle sprains are most likely within the first 12 months following the initial injury. Rehabilitation reduces the risk of re-injuring the ankle.

Rehabilitation should include range of motion, strength, balance, proprioception and return to activities/function.

Range of motion 

• Address Range of motion, this may be limited by swelling, stiffness or soft tissue) 

• Movement will help with swelling and regaining motion of the ankle 

• Muscle tone increases as a response to limit excessive movement, but we want to limit some of that muscle tone. 

• In the early stages is using dry needling may be useful as it decreases muscle tone without increasing inflammation

• Physiotherapists can also do some mobilization and manual therapy around the ankle joint to help improve range of motion and help get you walking as normally as possible 

Strength 

• The most common strength deficit is usually from the peroneal muscles (Outside of the lower leg)

• Peroneals often also get strained during an inversion injury 

• The peroneals become overtoned with protective muscle spasm, we need to activate a normal peroneal contraction and decrease some of the excess tone 

Balance 

• Balance training should start as soon as possible (in first week if able to) as soon as it is comfortable to do so (Can be in the first week – This may start with balancing for 2-5 mins/day and have a rest when it becomes uncomfortable)

• Start with single leg stance, slight knee flexion (Soft knee – so that glutes and quads can be incorporated for better balance) 

• Progress to more advanced balance exercises

Function 

• You want to walk as normally as possible so the brain knows the normal walking pattern so you don’t get stuck with an altered walking pattern 

• Taping or bracing can help in the early stages 

• Try to avoid limping 

• Heel raises in the shoes for a short time can help limit the amount you have to pull your foot back while walking which may make walking slightly more comfortable. 

After the initial/acute phase: 

Once you get past the acute phase of the injury it is important to continue with rehab and strengthening the ankle to prevent chronic ankle instability in the future. This may include extensive balance exercises and strengthening exercises.

Written by Ashley Holliday

Physiotherapist