Deltoid Ligament Sprain? No! It's the Tibialis Posterior

R tibilais posterior

A patient who came in to see me yesterday was diagnosed with a deltoid ligament sprain in his left ankle. He had seen a doctor who referred him to a surgeon. An MRI was ordered, but all came back normal. The surgeon referred him for physiotherapy to treat his deltoid ligament.

L deltoid ligament from Dr R LaPrade JBJS

Here's what the patient told me. He was training for the Ironman 70.3 triathlon in Cebu, Philippines on August 7th, 2022. He had done a lot of  *'brick' training prior to the pain in his left ankle. Triathletes will know that *'brick' workouts are cycling followed by running straight after dismounting to simulate race conditions. One day before the race he felt a sharp left calf pain. As a result, he had to walk the whole run (21.1 km) during his race. Thereafter, after returning to Singapore, the inside part of his left ankle started hurting.

I assessed his ankle joint and his ankle proproception and both were good. No tenderness over the deltoid (inner) and outer ankle ligaments. There was however some tenderness behind his left medial malleolus (that bone sticking out at the inside ankle region) and definitely along his tibalis posterior muscle. Much more than his right ride. 

Single-leg heel raise (SLHR) test ability on the left elicited pain too. Bingo! For the physiotherapists and clinicians reading this, you may already know what is wrong with my patient. He had a problem with his left tibialis posterior. Yes, the same tibialis posterior muscle that can cause the dreaded shin splints and your arches to "collapse". Definitely not a deltoid ligament sprain in his case.

The SLHR test was described by a study (Ross et al, 2021) as one of 4 clinical tests to find out if a patient has tibialis posterior tendinopathy. The other 3 are; pain on tendon palpation, swelling around the tendon and pain and/or weakness with tibialis posterior muscle contraction.

My patient was happy to know that he can resume running after I treated him. 

Reference

Ross, MH, Smith MD, Mellor R  et al (2021). Clinical Tests Of Tibilailis Posterior Tendinopathy: Are They Reliable, And How Are They Reflected In Structural Changes On Imaging? J Orthop Sports Phys Ther. 51(5): 253-260. DOI: 10.2519/jospt.2019.9707

Picture by Ezisports.com.au

*Brick training- short form for bike-run-in-combination. Perhaps also because it was name after a world champion duathlete and surgeon Dr Matt Brick who came up with the term whem he described his bike-run and run-bike training sessions while training for a duathlon race

Will Training When You're Tired Make You A Better Athlete?

Who says I can't lift when I'm tired? Picture from The Pit

My two boys share the same bed with my wife and I. Two nights ago at about 3 am, the younger one's diapers malfunctioned and leaked. I had to help my wife remove the soiled mattress covers while my older kid snored through it all. 

It took me a very long time before I fell asleep again, probably at about 5 am. I was soon awakened by my older boy telling me that he needed to pee ..... 

Needless to say, my wife and I were sleep deprived and tired.

Training when you're tired can be tricky. There's also some evidence to suggest that it increases your risk of injury. Especially since energy levels are depleted and you become slower in your reaction and decision making time. This will probably also impact your ability to perform.

Approached properly, training while tired may actually make you a better athlete suggested exercise physiologist Darren Paul and colleagues in their study. They found that training when you're tired can result in better maintenance of strength and improved postural control.

And not only endurance athletes can benefit from pushing past fatigue during training. 

Soccer players in their research who performed strength or balance exercises at the end of their training sessions (rather than at the beginning) were not as affected by fatigue during their matches.

When you train through fatigue and you learn to push through something difficult, it definitely gives you confidence. It's definitely empowering and shows you that you can do more than you likely thought you could.

Here are some personal suggestions as to how you can train while fatigued without getting hurt in the process and improve your performance.

Always focus on your form. Good form and technique has to always come first regardless of whether you're tired or not. If you need to push through fatigue while training, do it while maintaining proper form. If you're going too hard or too fast but not having good form and technique then you need to slow down. That will minimise your risk of injury. 

Some marathoners I've treated will often do a shorter steady paced run the day before their long run. They may run 10 km at their marathon race pace the day before their long run. They will then have some level of fatigue and glycogen depletion from the previous day's run to simulate fatigue setting in later in a race while doing their long run.

While I was still training for triathlons, brick workouts were the norm. Meaning we often stack workouts on top of each other (like stacking bricks). We often practise short but very quick running after a bike training session which forces our legs to adapt quickly. 

Training through fatigue also mean you do not do three days of interval-like running in a row. If you do that you're definitely walking down the path to injury or illness. You are training through fatigue to gain fitness and to get stronger as a result of that stress. So you definitely need to factor in appropriate or even extra recovery to help your body recover and adapt. Only then can you emerge stronger.

zzzzz ....

So my wife went for a run that morning while I was out walking and putting my son to sleep. I didn't exercise that morning but I managed to run home after I ended work at Physio Solutions that evening.

Reference

Paul D, Narciss G et al (2014). Injury Prevention In Football. Time to Consider Training Under Fatigue? Aspetar Sports Med J. p 578-581. See the article here.