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I will be posting with purple tiles. I enjoy hiking, reading, music, and going to the gym. I added a picture of one of my favorite waterfall hikes.

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My Dad and Dusty the bear in his side-by-side

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I will be posting with yellow! I grew up riding ATVs with my dad in the sand dunes of SoCal. I can't wait to have the time to go check out the Oregon dunes with him someday.

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me and my mare Diva during a trail ride a couple of summers ago

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I will be posting in blue :), Some of my favorite hobbies include riding horses, hiking and making new memories with my friends, family and of course my pup wookie.

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I will be posting with red tiles. Outside of class, I have many hobbies, but a few of my favorites are hiking with my dog, reading and writing, volunteering, working out, and archery. Because I'm always finding new and fun things to do, I've gained many unique experiences, one of coolest being the picture above, when I became my undergrad university's mascot: Bucky the Beaver!

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Hi I am Jeremy, you guys all know me I think. I enjoy many hobbies including woodworking, welding, gardening, automotive, D&D, Kayaking, hiking, camping, cooking, and more. Right now I spend most of my time oustide of school with my 8 month old son Robert and wife Heidi. I will be posting in green.

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Hello, I will be using the white tile. One of my favourite hobbies is to travel with family and my loved ones. Especially going to places that have beautiful history, like Cordoba, Spain in the picture.

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Distal Lower Extremity Injury- Acute Ankle Sprain:

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Distal Lower Extremity Injury- Acute Ankle Sprain:

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Cervical Spine Injury - Whiplash: Chronic

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Cervical Spine Injury - Whiplash: Chronic

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Low-Back/Lumbar Injury - Muscle Strain: Subacute

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Low-Back/Lumbar Injury - Muscle Strain: Subacute

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Care varies depending on the type of ankle sprain, other than two movements which Sabrina posted. Ankle pumps and alphabet rehab excercises.

For the most common type of ankle sprain (lateral ankle sprain).

-Start with gentle PROM administered by the provider, 3 sets of 10 with 3-5 second holds at end range, with care taken to avoid additional damage to the injured ligament.

-The patient themself can do AROM 1-3 sets of 15 reps 3 times a day, but avoid directions that could damage the injured ligament, especially in the case of a severe sprain

- Stretching the achillies tendon can also be beneficial especially if the foot is imobilized, to maintain range of motion in the ankle.

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- Start with ankle pumps (slowly dorsi & plantarflex ankle) stopping at pain point. 10-20/hr. Discontinue if symptoms worsen.

-Spell the alphabet slowly with affected ankle, motions should be pain free. 2x/hr. Discontinue if symptoms worsen.

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The first stretch that we can perform for a lumbar strain is the child's pose. This will lengthen and relieve pain from the lumbar extensor muscles. Find a yoga mat or somewhere comfortable and kneel with your toes together and your knees hip-width apart. Reach forward and extend your hands palms down with your head resting on the mat. Close your eyes and take deep breaths. Hold this position for 30 seconds. Repeat 2 times a day. Remember to ease into the stretch as this may cause some discomfort. If symptoms worsen with this stretch, try sitting in a chair and leaning forward until a gentle stretch is felt.

The second stretch is the knee-to-chest. This stretch relieves tension in the lower back and promotes spinal flexibility. Lie on your back with both knees extended. Bring one knee up toward your chest, keeping the other leg straight. Hold for 20-30 seconds, then switch sides. Repeat 2-3 times per leg.

The last stretch is the seated forward bend. This stretches the lower back and hamstrings, which can relieve lumbar tension. Sit on the floor with your legs extended straight. Flex the feet to engage the hamstring muscles. Inhale and lift your arms over your head, and as you exhale, begin folding forward hinging at the hips. Hold onto your toes, feet, ankles, or legs, or wherever your flexibility permits. Hold for 20-30 seconds, breathing deeply. Repeat 2-3 times.

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Acute: Reduce pain and swelling, weight bear, unload and protect joints (as needed)

Rehab: Restore proper range of motion, strength, proprioception and balance = return to preinjury function and reduce the likelihood of chronic ankle instability

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-Acute phase goals are to reduce pain, protect the joint from further injury, maintain ROM, and reduce inflammation.

- Long term goals are to restore normal stride biomechanics, reduce pain, and restore ability to perform ADLs. If the patient is an athelete we would be seeking to return them to play.

-To measure these outcomes, we would assess the patient during our initial visit and followup visit using ROM, the OPS pain scale, and the PSFS. We would also observe the patient's gate and posture, noting if they limp or if they have an antalgic posture.

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For a lumbar muscle strain we will want to strengthen the core, lower back, and glutes. A very good way to do this is by doing the bridge exercise, which you start by laying on back and your knees bent with your feet and hands flat on the floor. You then will slowly lift your hips toward the ceiling by engaging your core and squeezing you glutes, and try to maintain a straight line from your shoulders to your knees. You will then hold this position for 2-3 seconds, and then slowly lower your hips back to the ground. Avoid any jerking or none smooth movements and focus on control. Aim for 10-15 reps with 2-3 sets.

Another exercise you can do to strengthen your core is the dead bug. You would do this by laying on your back with your legs bent to 90 degrees, and arms extended towards the ceiling. We will want to make sure that the core is always engaged to make sure that the low back stays against the floor. Then you will slowly lower your right arm and left leg towards the floor with your core kept tight. Then return them both to the starting position and do the same with the other side. Aim for 8-12 reps per side.

Lastly, another exercise one may do is the plank. You will start by laying face down with your elbows right under your shoulders. Then you will use this position to push your body up, keeping a straight line from your head to your toes. You can do this by making sure that your core is engages and that your glutes do not go too high or too low. Hold this position for 20-60 sec while continuing to breath. Then come back down when you are down and repeat as many times as you can. Aim to do this exercise 2X/day.

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The therapeutic goal would be to relieve pain, restore mobility, and reduce inflammation. Stretching and range of motion exercises will help to restore mobility, while the core and lower back strengthening exercises will improve stability. Proper posture, avoiding prolonged rest without movement, and adjustments will help in improving the spinal health. Lastly, sticking with an exercise routine will encourage a healthy lifestyle that will help prevent future injuries.

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A lumbar strain occurs when the muscles or tendons in the lower back are overstretched or torn due to excessive force, leading to inflammation, pain, and limited mobility. Lumbar strains are a prevalent disease in the medical field. Most patients who develop a lumbar strain are asymptomatic. However, some will continue to have chronic, disabling symptoms. Acute lumbar strains may be triggered by physical or non-physical activity. Lifting seems to be the most commonly recalled mechanism of injury.

The mechanism begins with an acute overextension or excessive load on the lumbar musculature, often caused by sudden movements, improper lifting techniques, or repetitive strain. In response to tissue damage, the body releases pro-inflammatory mediators such as prostaglandins, histamine, and cytokines, which increase vascular permeability and attract immune cells to the site of injury. The inflammation leads to localized swelling, pain, and increased sensitivity of nociceptors which end up amplifying the perception of pain. The nervous system then initiates a muscle spasm causing involuntary contractions of the surrounding musculature in hopes of preventing further injury from occurring in the affected area. Although this is a protective mechanism, it can contribute to prolonged stiffness and dysfunction in the lower back. Excessive or repeated strain can lead to fibrosis and scar tissue formation, reducing flexibility and increasing the risk of future injury.

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Continuing Education Activity

Mechanical back strain is a prevalent disease in the medical field. Most patients who develop a mechanical back strain have a benign course; however, some will continue to have chronic, disabling symptoms. While evaluation and management are usually conservative for mechanical back strains, healthcare providers must differentiate between other causes of back pain and be aware of when to search for other life-threatening etiologies. This activity reviews the etiology, epidemiology, evaluation, differential diagnoses, and treatment of mechanical back strains. It highlights the role of an interprofessional team in the treatment of patients with mechanical back strain.

Objectives:

Describe the etiology of mechanical back strain.

Outline the appropriate history, physical, and diagnostic evaluation of mechanical back strain.

Summarize the current recommendations for pharmacologic, non-pharmacologic, and invasive treatment options available for mechanical back strain.

Explain the importance of interprofessional team strategies for improving care coordination to advance the management and improve outcomes in patients with a mechanical back strain.

Access free multiple choice questions on this topic.
Introduction

Back pain is one of the most common chief complaints in the emergency department. It is also a leading cause of disability and high healthcare expenses globally, as it affects patients of all ages and backgrounds. Mechanical back strain is a subtype of back pain where the etiology is the spine, intervertebral discs, or the surrounding soft tissues. While the majority of cases of mechanical back strains that present to the emergency department can be managed conservatively, healthcare providers must be aware of the common red flags that signal more emergent causes of back pain and that are associated with high morbidity and mortality when the diagnosis is delayed.[1][2]

Etiology

Historically, references to mechanical back pain have used many other vague terms like "non-specific back pain," "lumbar strain," or "lumbago." This terminology was due to the absence of proper diagnostic methods in the past. However, more recent advances in imaging technology and a better clinical understanding of spinal anatomy and the body's innervation have allowed more accurate terminology and diagnoses, depending on the underlying cause. Hence, more specific diagnoses are made based on the etiology of mechanical back strain, which is typically due to pathology involving the spine's anatomy. While the lower back is usually affected the most, mechanical back pathology may involve any part of the bones, spinal ligaments, intervertebral discs, facet joints, spinal cord, spinal nerves, or paraspinal muscles. Common examples of pathology involving these structures include the following diseases[3]:

Epidemiology

Greater than 80% of people will suffer from low back pain during their lifetime. The global point prevalence of low back pain is 12% to 33%. There is a higher prevalence among women and people ages 40 to 80. Due to missed workdays and decreased wages, 100 to 200 billion dollars are estimated to be spent each year in the United States due to lower back pain.[2][4]

History and Physical

Obtaining a complete history and performing an in-depth physical exam is crucial to diagnosing mechanical back strains. The goal of evaluation in the acute setting is to ensure no red flags warrant more advanced imaging and surgical consultation. These red flag symptoms include fevers, involuntary weight loss, night sweats, bladder or bowel incontinence, significant trauma, frequent falls, history of cancer, anticoagulant use, chronic systemic steroid use, intravenous drug abuse, or an immunocompromised state. Physical exam red flags compromise assessing focal neurologic deficits, including weakness, ataxia, saddle anesthesia, decreased deep tendon reflexes and diminished rectal tone.[3][5]

Acute mechanical back strains may be triggered by physical or non-physical activity, with lifting being the most commonly recalled event. However, one-third of patients may not necessarily remember an inciting incident. More specific spinal pathology may have classically associated symptoms. For example, herniated discs will present with radicular pain that radiates from the lower back in L4 to S1 distribution, and pain may be reproducible to the affected side on straight leg raise. Spinal stenosis may demonstrate back pain and bilateral posterior leg pain that worsens with ambulation and spine extension but is relieved by rest and spine flexion. Patients on chronic steroids or at risk for osteoporosis are at increased risk for vertebral compression fractures even after seemingly minor trauma. Compression fractures tend to be focally tender on palpation.[1][6]

Evaluation

In the absence of the red flags discussed above, no laboratory or radiographic studies are necessary to diagnose or manage mechanical back strains in the acute setting. Inflammatory biomarkers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are useful for risk stratification of patients with risk factors for infectious spinal pathology or malignancy but have no neurologic deficits on examination. Routine imaging for mechanical back strains is not recommended, as many may have incidental abnormal findings that are unrelated to their pain. More advanced imaging is needed in trauma, failure of conservative management, worsening of symptoms, and new neurologic deficits. Plain radiographs and computed tomography are useful when suspecting fractures. However, patients with signs of spinal cord compression or red flag symptoms need magnetic resonance imaging for an accurate diagnosis.[3][5][7]

Treatment / Management

Management of mechanical back strains depends on the chronicity of symptoms, the patient's comorbidities, and the specific etiology. The American College of Physicians published an updated guideline in 2017 with recommendations regarding non-invasive options for treating low back pain. First-line nonpharmacologic therapy for acute low back pain includes spinal manipulation, acupuncture, massage, and superficial heat application, while first-line pharmacologic therapy for acute low back pain is nonsteroidal anti-inflammatory drugs and muscle relaxants. According to low-quality evidence, the use of acetaminophen and systemic corticosteroids showed no improvement of acute back pain compared to placebo. There was insufficient evidence to determine the benefits of other pharmacologic agents, such as benzodiazepines, antidepressants, antiepileptic medications, and opioids. According to the clinical policy by the American College of Emergency Physicians, opioids should not be routine pharmaceutical therapy but should be saved for those whose pain is severe or uncontrolled with other medications.[8][9]

Physical therapy is an integral component in the treatment of mechanical back pain. When initial conservative measures fail, a referral is appropriate. Studies have shown that early physical therapy intervention, when compared to the implementation of physical therapy after lower back pain was chronic, resulting in a reduction in healthcare costs, a decrease in opioid use, and a reduction in spinal surgery rates.[10][11]

For chronic low back pain, non-pharmacologic approaches were recommended as the first-line agents, including exercise, tai-chi, yoga, multidisciplinary rehabilitation, spinal manipulation, acupuncture, psychotherapy, low-level laser therapy, and electromyogram biofeedback. Nonsteroidal anti-inflammatory drugs were again the first-line pharmacologic agents recommended, followed by tramadol and duloxetine as the second-line treatments. Recommendations for opioid therapy are only if the previously mentioned therapies failed and based on an individualized decision to determine if the benefit outweighs the risk.[8]

The American Pain Society also published recommendations by a multidisciplinary panel in 2009 regarding the use of more invasive procedures for diagnostic and therapeutic purposes to treat non-radicular low back pain, radicular low back pain, and spinal stenosis. The panel emphasized the use of intensive interdisciplinary rehabilitation for chronic non-radicular low back pain, as it has similar efficacy to fusion surgery. Epidural steroid injection showed variable evidence of short-term benefit for radicular low back pain; thus, the panel recommended a shared decision-making process for the appropriate patient.

For surgical management options, standard open discectomy and microdiscectomy have a moderate short-term benefit in treating persistent, debilitating radiculopathy secondary to herniated disc disease. Similarly, decompressive laminectomy has a moderate short-term benefit in treating severe, debilitating spinal stenosis. The panel noted that these benefits tend to decrease over time, and a shared decision-making process is also appropriate in these patients before surgical intervention. Lastly, spinal cord stimulation may be an option for patients who underwent surgery for herniated disc disease but continue to have debilitating radiculopathy.[12]

Differential Diagnosis

The differential diagnoses for mechanical back strains are other nonmechanical causes of back pain. These include but are not limited to the following categories and diseases[1][5][13]:

Rheumatologic - ankylosing spondylitis, Reiter syndrome, psoriatic spondylitis, polymyalgia rheumatica

Oncologic - metastatic disease, spinal cord tumor, lymphomas, leukemia, multiple myeloma

Infectious - spinal epidural abscess, osteomyelitis, discitis

Gastrointestinal - pancreatitis, cholecystitis, bowel perforation

Vascular - aortic aneurysm, spinal epidural hematoma, aortoiliac disease

Renal - pyelonephritis, nephrolithiasis, perinephric abscess

Genitourinary - endometriosis, prostatitis, pelvic inflammatory disease

Prognosis

While most acute episodes of mechanical back pain resolve spontaneously within 12 weeks, up to one-third of patients may continue to have chronic symptoms. However, even those whose acute symptoms resolve have a 20 to 40% chance of symptom recurrence during the first year and 85% of lifetime recurrence.[2][8] Various environmental and psychosocial factors may influence the prognosis of mechanical back strains. These include a body mass index greater than 25, smoking, poor health, depression, fear avoidance, strenuous work demands, job dissatisfaction, and the presence of compensation.[1][3][6]

Complications

The possible complications of mechanical back strains depend on the specific etiology, with the most common complication being the persistence of symptoms and the development of lasting disability. Rarer physical complications include cauda equina syndrome and physical deformities. Other health complications may arise as side effects from long-term pharmacologic therapies, such as NSAID use, or more invasive therapeutic procedures, such as injections and surgeries. Many financial and social complications also exist for both the patients with chronic, disabling mechanical back pain and their employers due to lost wages and missed workdays.[1][8]

5% to 10% of adults with low back pain develop chronic pain. Recurrence of low back pain occurs in 20 to 72% of patients. In adults with low back pain severe enough to cause them to miss work, 60 to 70% return to work by 6 weeks, and 80 to 90% return by 12 weeks.

Deterrence and Patient Education

Reduction of strenuous physical requirements is the main primary prevention for mechanical back strains; however, secondary prevention rather than primary prevention is more practical due to the high prevalence of the condition. The greatest risk factor is the recurrence of a previous episode. Some interventions by employers that may aid in injury prevention are stretching exercises at the workplace, appropriate rest breaks, and ergonomic modifications. Ergonomic modifications refer to adaptations in the work environment to reduce the physical stress of the employees. Also, educating patients regarding the importance of maintaining proper posture and correct lifting techniques may aid in prevention. Other prevention techniques that patients can use aim to reduce the risk factors of having a poor prognosis, including exercising, smoking cessation, weight loss for obese patients, and resuming normal physical activity.[1][14][15][16]

Enhancing Healthcare Team Outcomes

Healthcare professionals of many specialties are involved in providing care for patients with mechanical back strains. Physicians and nurses, especially in the acute setting, must be familiar with red flag symptoms of back pain that may require more urgent interventions and possible surgical consultation. Conservative management of acute mechanical back strains after a complete assessment is reasonable as the course is usually self-limited; this includes superficial heat, nonsteroidal anti-inflammatory drugs, and muscle relaxants.[8] [Level 2]

Chronic mechanical back strains require an interprofessional team approach due to the psychosocial factors involved. Initial non-pharmacologic therapy includes exercise, interprofessional rehabilitation, manipulation, and acupuncture. First-line pharmacologic therapy is nonsteroidal anti-inflammatory drugs followed by duloxetine or tramadol as second-line therapy.[8] [Level 2] A pharmacist should review the patient's medications to ensure there are no drug interactions and that dosing is appropriate. Patients with persistent disabling chronic non-radicular low back pain may benefit from interprofessional rehabilitation, described as rehabilitation along with a psychological, social, or occupational component. Here is where an orthopedic specialty nurse can help coordinate therapy, monitor progress, answer patient questions, and inform the managing clinician if further intervention may be necessary. Patients with persistent chronic radicular pain due to herniated discs or spinal stenosis may benefit from surgical interventions.[12] [Level 1]

Mechanical back pain requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical therapists, chiropractors, and pharmacists, collaborating across disciplines to achieve optimal patient results. [Level 5]

References

1.

Casiano VE, Sarwan G, Dydyk AM, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 11, 2023. Back Pain. [ PubMed: 30844200 ]

2.

Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 09;169(3):251-8. [ PMC free article: PMC4339077 ] [ PubMed: 19204216 ]

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Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb;16(2):120-31. [ PMC free article: PMC1495170 ] [ PubMed: 11251764 ]

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15.

Shariat A, Cleland JA, Danaee M, Kargarfard M, Sangelaji B, Tamrin SBM. Effects of stretching exercise training and ergonomic modifications on musculoskeletal discomforts of office workers: a randomized controlled trial. Braz J Phys Ther. 2018 Mar-Apr;22(2):144-153. [ PMC free article: PMC5883995 ] [ PubMed: 28939263 ]

16.

Tariq RA, George JS, Ampat G, Toney-Butler TJ. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 22, 2023. Back Safety. [ PubMed: 30085608 ]

Disclosure: Moustafa El Sayed declares no relevant financial relationships with ineligible companies.

Disclosure: Avery Callahan declares no relevant financial relationships with ineligible companies.

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Back pain is one of the most common chief complaints in the emergency department. It is also a leading cause of disability and high healthcare expenses globally, as it affects patients of all ages and backgrounds. Mechanical back strain is a subtype of back pain where the etiology is the spine, intervertebral discs, or the surrounding soft tissues.

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Acute Ankle Sprain: Strengthen Calves - Heel Raises

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Acute Ankle Sprain: Strengthen Calves - Heel Raises

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Calves play a huge role in ankle stability, mobility, shock absorption, balance and support. In order to strengthen them, the patient needs to be fully weight bearing.

Heel raises progression: start with bilateral (double) heel raises with the patient holding onto something for balance and decreased load. Start with 10x 1/day. Once the patient can do 20 without pain, move to single leg heel raises (still holding onto something). Once they can do 20 of those without pain, remove the support. Next step is to perform it on a slant board or a stair which would let the heel drop into a stretch). Next would be heel walks and toe walks. The final step in the progression is heel raises with 3-4 hops.

Always make sure it isn't painful. Discomfort is okay, but if it lingers or is actually painful, the patient should stop the exercise and go back to the pain free step.

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Acute Ankle Sprain: Strengthen Intrinsic foot muscles - Toe Crunches

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Acute Ankle Sprain: Strengthen Intrinsic foot muscles - Toe Crunches

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Toe crunches with a towel are great because they can be done quite early in the treatment progression because they don't require moving the ankle and only need the patient to be 50% weight bearing. The goal is to activate and gently start to strengthen the injured tissues in the foot and ankle.

To perform: Find a comfortable spot where the feet can be flat on the floor. Put the foot about halfway onto a small towel on the floor. Keeping the heel on the ground, curl the toes to pull the towel towards you scrunching it up. Continue this motion until the you have scrunched up the whole towel and there isn't any more to pull.

Another way to start is to have them do 10 reps, 3x/day and work up to curling the whole towel. Changing towel size could also increase the difficulty as well when tolerated.

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Upper Trapezius Stretch:

How to: Sit or stand with a straight back and shoulders, while placing one arm behind in the arch of your back to help stabilize. With the other hand, gently pull your head towards one shoulder until you feel a stretch on the side of your neck. Hold this position for 15-30 seconds and repeat on the other side. repeat this process once every hour.

Benefit: The upper trapezius muscles are commonly tight after whiplash traumas; this stretch will help to decrease neck stiffness and pain caused by this agitated muscle.

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Neck isometrics (Cervical flexors and extensors):

How to: sit up straight with your back, shoulders and neck in a neutral position. Place the palm of your hand against your forehead and gently push your forehead into your hand while applying pressure back with your hand to keep your head still. Hold this for 10 seconds and then relax. Repeat this on the right and left side of your head as well as the back of your head. Repeat this about 3 times a day

Benefit: This exercise strengthens the deep muscles of the neck without exposing it to excessive motion, which is ideal for whiplash recovery.

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Goal 1: Manage Pain

Outcome Measure – OPS Scoring

CMT and STM manual therapies can effectively help treat and reduce reduce neck pain and stiffness. Applying heat and ice, along with the use of NSAIDs can also assisting in treating acute pains and improve a patients’ therapeutic outcome.

Goal 2: Increase Mobility & Flexibility

Outcome Measure – Cervical AROM/PROM Assessment

Gentle stretching and mobilization techniques can be utilized to return cervical ROM to normal limits. Such practices can also help alleviate muscular tension in the neck, shoulders and upper back and assist in reducing pain with fast, unguarded movements.

Goal 3: Improve Strength & Stability

Outcome Measure – PSFS Scoring

Strengthen the deep neck flexors and the upper back muscles via home care and rehabilitation exercises as well as conditioning core stability to help reduce overwork of the neck during ergonomic and prolong postural activities.

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The initial injury leads to micro tearing of the cervical muscles and ligaments, inflammatory responses with reduced cervical flexion, and lingering pain.

Nociceptive response from peripheral nerve irritation and central sensitization of the nervous system also occurs. As such, this level of dysfunction may also lead to decreased proprioception, which often presents symptoms of dizziness, muscle imbalances/hypertonicity, and increased ANS reactivity. Psychological speaking, anxiety and stress will increase nociception and tighten the muscles as well. All these factors add to the delay in the normal healing process.

The presentation of chronic whiplash can be highly variable. Therefore, compliance to a personalized treatment plan of manual manipulation therapies, cervical rehabilitation exercises, and nerve desensitization techniques are recommended.

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Scapular retraction (Upper back and shoulders):

How to: Sit up straight with your arms at your sides. squeeze your shoulder blades back and down as if you were trying to pinch something between them. Hold for 10 seconds then release slowly. Perform 3 sets of 10 twice a day.

Benefit: This strengthening exercise targets the muscles in the upper back and shoulders, which will help improve posture and relieve shoulder and neck tension.

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Bird-dog (Core strength/ stability):

How to: Begin on your hands and knees with a neutral spine. I would then follow the bird-dog progressions with this patient, but in this case, I will stop at raising their arm and extending the contralateral leg while maintaining a level back, pelvis and neck. I will have them hold this position for a couple of seconds and then repeat on the other side. I would like to see the patient perform 10 reps on each side 2 time a day.

Benefit: This exercise strengthens the core and the back, and promotes strength and stability of the entire spine, which can help to decrease the strain put on the neck and the upper back.

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Thoracic Extension Stretch

How to: Sit or stand up straight with your feet hip-width apart. Place your hands behind your head with your elbows to the side. Gently arch your upper back backwards by opening up your chest and bringing your elbows slightly back. Hold this for 15-30 seconds, and repeat this 3-5 times a day

Benefit: This stretch is helpful for improving spinal mobility and counteracting the rounded posture that can develop from neck pain.

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Chin Tucks:

How to: Begin by either sitting or standing with a straight back and shoulders. next, gently tuck your chin towards your chest, as if you were trying to give yourself a double chin but make sure you aren't tilting your head down too far. Hold this for 10 seconds and then return to starting position. Repeat this 10 times for a total of 3 sets/day

Benefit: This stretch will target the deep muscles in the neck and improve posture, which will decrease the stress put on the neck.

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Strengthening may not be something we have the patient do after the first visit, as loading the tissues could be painful, and we do not want to risk causing the patient more injury.

However if the patient can tolerate it we would recommend that the patient perform isometric exercises to help maintain functionality in the ankle. Or other low ankle impact exercises such as stationary cycling may be recommended.

We also would want to examine all of the biomechanics of the patient and may prescribe strengthening based on those even before giving targeted exercises for the ankle. For example if the patient sustained their injury due to an imbalance in their gate related to the hip muscles, then we could and likely would give them exercises to improve their biomechanics in order to protect them from future sprains. It is also likely that the patient will be able to perform hip exercises without pain or much risk of injury to the foot.

Generally once the patient can bear weight on the ankle, or when they enter the "subacute" phase, that is when we want to start our primary strengthening program. Generally in almost all ankle injury cases the calf muscles are a primary target for strengthening and stretching. Ankle stabilizors and intrinsic muscles of the foot.

Exercises we would recommend would include toe crunches, heel raises, and general strengthening of hip muscles. We would likely ask the patient to perform heel raises 10 reps, 3 times a day as tolerable.

After the patient is able to perform basic exercises without pain we would increase the difficulty and move into performing resisted ROM motions with the foot, proprioceptive training, and sensorymotor exercises. Specifically we would transition them to using a balance board if able or other devices which offer a slanted surface.

In the third phase of our program we would transition into having the patient run and possibly jump. If they have sport specific requirements we would transition into those activities as well. The third phase would be scaled to the abilities of the patient.

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Acute ankle sprains are common injuries amongst the general population, and they are the most common injury sustained in sports. There are three grades of sprain (I, II, and III). The severity of the sprain is related to the positioning of the foot, direction of force, and the stability of the ligamentous structures and musculature.

Grades I and II result in microscopic tears in the stabilizing ligaments of the ankle. Grade III sprains involve comprimization of the syndesmotic structions and or complete tears of the ligaments with the possibility of fractures.

Most commonly the Anterior Talofibular Ligament (ATFL), and the Calcaneofibular ligament (CFL) are sprained in the foot. These are associated with an inversion sprain/lateral ankle sprain. ATFL is the weakest ligament in the lateral complex. The Posterior Talofibular (PTFL) is the least commonly injured ligament in a lateral ankle sprain.

The Deltoid ligament is less commonly sprained as it is the strongest of the ankle ligaments. It is injured during an Eversion/medial ankle sprain.

A high ankle sprain involves injury to the ligamentus structures of the tibia and fibula at their distal end. The syndesmotic ligaments which hold them together are injured and usually involve more trauma, and can occur in conjunction with other ankle sprains. These are almost exculsively seen in sport settings given the force required for injury. Most commonly these occur during external rotation and/or ankle dorsiflexion.

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Acute Ankle Sprain - StatPearls - NCBI Bookshelf