Kids sprained ankle

A sprained ankle means one or more ligaments on the outer side of your ankle were stretched or torn. Ankle sprains are one of the most common injuries in children. Ankles are made up of three bones with ligaments (tough, stretchy tissue that hold the bones together). The ligaments help stop the ankle joint from moving around too much.

Ankle sprains usually happen when there is a sudden movement or twist – often when the foot rolls over – and the ligaments are overstretched. This causes tears and bleeding (which show as bruising and swelling) around the ankle joint. These movements are more likely to happen when a person is running, jumping or quickly changing direction e.g. in sports such as basketball, netball or football. Risk factors for both include poor conditioning, fatigue, poor warm up, slippery surfaces and poorly fitting footwear.

Pain, swelling, bruising, tenderness, difficulty moving the ankle or difficulty walking are common symptoms of an ankle sprain. However,  symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

A sprained ankle can vary greatly in severity from a minor “rolled ankle” to a complete ligament rupture with or without bone tendon or muscle injury. They are graded as 1, 2 or 3 depending on the severity. If a sprained ankle is not treated properly, you could have long-term problems. Typically sprained ankle is rolled either inward (inversion sprain) or outward (eversion sprain). Inversion sprains cause pain along the outer side of the ankle and are the most common type. Pain along the inner side of the ankle may represent a more serious injury to the tendons or to the ligaments that support the arch and should always be evaluated by a doctor.

Ankle sprains happen when you overstretch or torn a ligament. Ankle sprains occur most commonly by a sudden twisting or rolling action of your ankle often on unstable irregular surfaces. The ligaments affected is determined by the direction the foot rolls. The most common ankle sprain is the ligament on the side which occurs when the foot is turned in.

Certain factors can put a person at greater risk of spraining their ankle including poor footwear, not warming up before exercising, tired muscles and playing sport, previous injury, reduced strength, poor biomechanics or poor balance receptors. You’re most likely to sprain your ankle when you have your toes on the ground and heel up (plantar flexion). This position puts your ankle’s ligaments under tension, making them vulnerable. A sudden force like landing on an uneven surface may turn your ankle inward (inversion). When this happens, one, two or three of your ligaments may be hurt.

A sprained ankle can be difficult to differentiate from a fracture (broken bone) without an x-ray. If you are unable to bear weight after this type of injury, or if there is significant swelling or deformity, you should seek medical treatment from a doctor. This may be your primary care physician, an emergency department, or an orthopaedist, depending on the severity of your injury.

Ankle sprains are very common injuries. There’s a good chance that while playing or stepping on an uneven surface you sprained your ankle–some 25,000 people do it every day.​​​

Sometimes, it is an awkward moment when you lose your balance, but the pain quickly fades away and you go on your way. But the sprain could be more severe; your ankle might swell and it might hurt too much to stand on it. If it’s a severe sprain, you might have felt a “pop” when the injury happened.

Treatment for a sprained ankle depends on the severity of the injury. Although self-care measures and over-the-counter pain medications may be all you need, a medical evaluation might be necessary to reveal how badly you’ve sprained your ankle and to determine the appropriate treatment.

Minor ankle strains/sprains require rest, ice, compression, elevation (RICE) and over-the-counter pain relievers for treatment. An ankle brace may be helpful to support the ankle while it heals.

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment.

Ankle Joint ligaments

The ankle (talocrural) joint includes two articulations—a medial joint between the tibia and talus and a lateral joint between the fibula and talus, both enclosed in one joint capsule. The malleoli of the tibia and fibula overhang the talus on each side like a cap and prevent most side-to-side motion. The ankle therefore has a more restricted range of motion than the wrist.

Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.

The ligaments of the ankle include (1) anterior and posterior tibiofibular ligaments, which bind the tibia to the fibula; (2) a multipart medial (deltoid) ligament, which binds the tibia to the foot on the medial side; and (3) a multipart lateral (collateral) ligament, which binds the fibula to the foot on the lateral side.

Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.

The ankle joint is responsible for plantarflexion and dorsiflexion of the ankle. The subtalar joint lies underneath the true ankle joint and is the articulation between the talus and calcaneus. It assists the talo-crural joint in inversion and eversion. Most ankle sprains occur from an inversion mechanism of injury (rolled in).

The calcaneal (Achilles) tendon extends from the calf muscles to the calcaneus. It plantarflexes the foot and limits dorsiflexion. Plantar flexion is limited by extensor tendons on the anterior side of the ankle and by the anterior part of the joint capsule.

The most commonly injured ligaments of the ankle are the lateral ligaments which sit on the outside of the ankle. These include the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament. The ligament on the inside of the ankle is called the deltoid ligament which is much stronger and hence more difficult to injure.

Sprains (torn ligaments and tendons) are common at the ankle, especially when the foot is suddenly inverted or everted to excess. They are painful and usually accompanied by immediate swelling. They are best treated by immobilizing the joint and reducing swelling with an ice pack, but in extreme cases may require a cast or surgery.

High ankle sprains refer to injury to the inferior tibiofibular ligaments and syndesmosis which bind the tibia (shin bone) and fibula (calf bone) together above the ankle. A high ankle sprain is a much more debilitating injury, requiring a longer recovery time.

Figure 1. Ankle joint ligaments

What is Chronic Ankle Sprains?

Once you have sprained your ankle, you may continue to sprain it if the ligaments do not have time to completely heal. It can be hard for patients to tell if a sprain has healed because even an ankle with a chronic tear can be highly functional because overlying tendons help with stability and motion.

If pain continues for more than 4 to 6 weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces and participating in sports that require cutting actions or rolling and twisting of the foot.

Abnormal proprioception—a common complication of ankle sprains—can also lead to repeat sprains. There may be imbalance and muscle weakness that causes a reinjury. If you sprain your ankle over and over again, a chronic situation may persist with instability, a sense of the ankle giving way, and chronic pain. This can also happen if you return to work, sports, or other activities before your ankle heals and is rehabilitated.

How long does a sprained ankle take to heal?

After 2 weeks, most ankle sprains and strains will feel better. Avoid strenuous exercise such as running for up to 8 weeks, as there’s a risk of further damage.

Severe ankle sprains (grade 2 and 3) and strains can take months to get back to normal.

Most importantly, successful outcomes are dependent upon patient commitment to rehabilitation exercises. Incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain. If a patient stops doing the strengthening exercises, the injured ligament(s) will weaken and put the patient at risk for continued ankle sprains.

I sprained my ankle last spring while I was running. The ankle doesn’t really hurt anymore, but it keeps ‘giving out’. What should I do?

Ankle sprains are the most common foot and ankle injury in sports. Typically, sprains occur when the foot inverts with an awkward step while running or jumping. As the foot rotates inward, the ligaments on the outside, or lateral aspect of the ankle, are stretched, causing swelling and pain. Most frequently, sprains will recover completely with rest, ice, compression, elevation and early mobilization.

In less than 10% of cases, while ankle swelling and pain improves, the ankle continues to “give out” or feel unstable. Classically, this occurs when walking on uneven ground or when stepping off of a curb. Repeated episodes of “giving out” is a condition called chronic ankle instability. Most frequently, this is a result of incomplete recovery from an acute ankle sprain that leaves the ankle with weakness and impaired postural control.

The initial treatment for chronic ankle instability is a program of structured rehabilitation with the help of a physical therapist. Exercises are aimed specifically at strengthening the peroneal tendons which run on the outside aspect of the ankle. The regimen should also include use of a balance board or similar device to work on proprioception – awareness of the position of the foot and ankle in space. Improved proprioception helps the ankle react more quickly to stresses, preventing future sprains.

After 6-8 weeks of intensive therapy, if the ankle continues to feel unstable, one might be a candidate for surgery to reconstruct the injured ankle ligaments. At this point, an MRI is helpful to identify any underlying injury such as cartilage damage at the ankle or peroneal tendon tears. Complete recovery from surgery takes at least 3 months, but patients will typically be able to return to full activity without limitation, and, most importantly, without the sensation of their ankle “giving out”.

Grades of Ankle Sprains

After the examination, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.

Some sprained ankles are minor injuries that heal with little treatment. Others can be more serious, though. The three grades of ankle sprains, based on how much damage is done to the ligaments, are (see Figure 2 below):

Figure 2. Sprained ankle grades

Grade 1 Sprain (Mild)

• This is a mild sprain where ligaments stretch slightly.
• Slight stretching and microscopic tearing of the ligament fibers
• Someone with a grade 1 sprain will feel some soreness and may notice a bit of swelling around the ankle

Grade 2 Sprain (Moderate)

• This is a moderate sprain where ligaments tear partly, making the ankle joint feel loose.
• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint
• The ankle will feel painful, and may stay swollen for a while. Putting weight on the foot can be difficult.

Grade 3 Sprain (Severe)

• This is the most severe kind of sprain, where an ankle ligament tears completely.
• Complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instability occurs
• The ankle joint will be very painful, with quite a bit of swelling. The person’s ankle will feel loose and unsteady and early on the person probably won’t be able to put any weight on the ankle.
• If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

Tell your doctor what you were doing when you sprained your ankle. He or she will examine it and may want an x-ray to make sure no bones are broken. Most ankle sprains do not require surgery, and minor sprains are best treated with a functional rehabilitation program.

If you repeatedly sprain the same ankle or feel pain for more than 4 to 6 weeks, you may have what’s called a chronic sprain. This type of lasting sprain can flare up and be made worse by activities that involve rolling or twisting the feet, like running, dancing, or playing sports.

Sprained ankle causes

A sprain occurs when your ankle is forced to move out of its normal position, which can cause one or more of the ankle’s ligaments to stretch, partially tear or tear completely.

The most common type of sprained ankle is called an inversion sprain, or lateral ligament sprain. With this type of sprain, the ankle turns so the sole of the foot is facing inwards, stretching and possibly damaging the ligaments on the outer part of the ankle.

You don’t have to be playing hard to injure an ankle: sprains can happen just from taking an awkward step or tripping on the stairs.

Causes of a sprained ankle might include:

• A fall that causes your ankle to twist
• Landing awkwardly on your foot after jumping or pivoting
• Walking or exercising on an uneven surface
• Another person stepping or landing on your foot during a sports activity, while you are running, causing your foot to twist or roll to the side
• Participating in sports that require cutting actions or rolling and twisting of the foot—such as trail running, basketball, tennis, football, and soccer.

Risk factors for sprained ankle

Factors that increase your risk of a sprained ankle include:

• Sports participation. Ankle sprains are a common sports injury, particularly in sports that require jumping, cutting action, or rolling or twisting of the foot such as basketball, tennis, football, soccer and trail running.
• Uneven surfaces. Walking or running on uneven surfaces or poor field conditions may increase the risk of an ankle sprain.
• Prior ankle injury. Once you’ve sprained your ankle or had another type of ankle injury, you’re more likely to sprain it again.
• Poor physical condition. Poor strength or flexibility in the ankles may increase the risk of a sprain when participating in sports.
• Improper shoes. Shoes that don’t fit properly or aren’t appropriate for an activity, as well as high-heeled shoes in general, make ankles more vulnerable to injury.

Sprained ankle prevention

The following tips can help you prevent a sprained ankle or a recurring sprain:

• Warm up before you exercise or play sports.
• Be careful when walking, running or working on an uneven surface.
• Use an ankle support brace or tape on a weak or previously injured ankle.
• Wear shoes that fit well and are made for your activity.
• Minimize wearing high-heeled shoes.
• Don’t play sports or participate in activities for which you are not conditioned.
• Maintain good muscle strength and flexibility.
• Slow down or stop activities when you feel pain or fatigue.
• Practice stability training, including balance exercises.

Signs and symptoms of ankle sprains

Signs and symptoms of a sprained ankle vary depending on the severity of the injury. If your child has sprained their ankle, they may have:

• Swelling, which develops in minutes or over several hours – this is caused by soft tissue damage
• Pain around the outside part of the ankle joint
• Bruising, which shows up within two to three days
• Ankle pain, especially when you bear weight on the affected foot
• Tenderness when you touch the ankle (injured ligaments will be quite tender to touch in that initial phase)
• Restricted range of motion
• Instability in the ankle
• If there is severe tearing of the ligaments, your child might also hear or feel a “pop” when the sprain occurs.
• In the cases of a severe ankle sprain, your child may have difficulty walking and may require the use of crutches to mobilize.

Symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

Sprained ankle complications

Failing to treat a sprained ankle properly, engaging in activities too soon after spraining your ankle or spraining your ankle repeatedly might lead to the following complications:

• Chronic ankle pain
• Chronic ankle joint instability
• Arthritis in the ankle joint

Kids sprained ankle diagnosis

During a physical, your doctor will examine your ankle, foot and lower leg. The doctor will touch the skin around the injury to check for points of tenderness and move your foot to check the range of motion and to understand what positions cause discomfort or pain.

Depending on how many ligaments are injured, your sprain will be classified as Grade 1, 2 or 3. In a mild sprain (grade 1), the ankle ligament simply is overstretched. More severe ankle sprains can involve partial tearing of the ankle ligament (grade 2), or complete tearing (grade 3).

If the injury is severe, your doctor may recommend one or more of the following imaging scans to rule out a broken bone or to evaluate in more detail the extent of ligament damage:

• X-ray. During an X-ray, a small amount of radiation passes through your body to produce images of the bones of the ankle. This test is good for ruling out bone fractures.
• Stress x-rays. In addition to plain X-rays, your doctor may also order stress X-rays. These scans are taken while the ankle is being pushed in different directions. Stress X-rays help to show whether the ankle is moving abnormally because of injured ligaments.
• Magnetic resonance imaging (MRI). MRIs use radio waves and a strong magnetic field to produce detailed cross-sectional or 3-D images of soft internal structures of the ankle, including ligaments. Your doctor may order an MRI if he or she suspects a very severe injury to the ligaments, damage to the cartilage or bone of the joint surface, a small bone chip, or another problem. The MRI may not be ordered until after the period of swelling and bruising resolves.
• CT scan. CT scans can reveal more detail about the bones of the joint. CT scans take X-rays from many different angles and combine them to make cross-sectional or 3-D images.
• Ultrasound. An ultrasound uses radio waves to produce real-time images. These images may help your doctor judge the condition of a ligament or tendon when the foot is in different positions.

How to treat a sprained ankle yourself

See your doctor if your child has pain and swelling in his ankle and you suspect a sprain. Self-care measures may be all you need, but talk to your doctor to discuss whether your child should have his ankle evaluated. If signs and symptoms are severe, your child may have significant damage to a ligament or a broken bone in his ankle or lower leg.

Care at home

If your child has sprained their ankle, you can care for them at home using first aid principles (the Rest, Ice, Compression, Elevation (RICE) strategy) and ankle exercises. For a Grade 1 sprained ankle, follow the R.I.C.E. guidelines to help bring down swelling and support the injury. Treatment should start immediately and continue for the next two to three days.

• Rest: rest the ankle by not walking on it and avoid activities that cause a lot of pain. If your child is having difficulty walking, crutches should be used. You can hire crutches from your local pharmacy.
• Ice: apply ice to the injured area for 10–15 minutes. Never place the ice directly on the skin because it can burn the skin – wrap the ice or ice pack in a tea towel or a pillow case. Ice the injury every two to four hours for two to three days, when your child is awake. You can make an ice pack using a plastic bag with some ice and water in it. This moulds better to the ankle joint area than ice alone. Don’t ice more than 20 minutes every 2 to 3 hours at a time to avoid frost bite.
• Compression: wrap a firm bandage that is not too tight and does not stop circulation or cause extra pain. The bandage should cover from just above the ankle right down to the foot. Do not cover the toes.
• Elevation: raise the ankle whenever possible to help reduce the swelling. For example, raise your child’s injured leg and rest it on some pillows while they are watching TV, reading or resting.

Some children will need medicine to help with the pain. In most cases, acetaminophen (paracetamol) is enough. Anti-inflammatory medications may help, but these are not suitable for every child. Ask your doctor for further advice. Always read and follow the instructions on the package for the appropriate dose of medication for your child. See our fact sheet Pain relief for children.

Figure 3. How to wrap a sprained ankle

In the first two to three days after your child’s injury, avoid:

• heat (e.g. heat packs or hot baths) – this increases blood flow and makes the swelling worse
• re-injury – protect the ankle joint from re-injury by keeping weight off it and moving carefully
• massage – this promotes blood flow and makes the swelling worse.

Swelling usually goes down with a few days.

• Take nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) can help relieve pain and reduce swelling in the ankle.
• Crutches. In most cases, swelling and pain will last from 2 to 3 days. Walking may be difficult during this time and your doctor may recommend that you use crutches as needed.
• Avoid activities that put pressure on your ankle. Don’t play sports that require running, cutting, or stopping quickly until your doc says it’s OK. Don’t hike, jog, or exercise on uneven surfaces until the ankle is properly healed.
• Do stretching and strengthening exercises. After the pain and swelling have improved, ask your doctor about an exercise program to improve your ankle’s strength and flexibility. Depending on the severity of the sprain, the doctor may recommend physical therapy to help the healing process.
• Immobilization. During the early phase of healing, it is important to support your ankle and protect it from sudden movements. For a Grade 2 sprain, a removable plastic device such as a cast-boot or air stirrup-type brace can provide support. Grade 3 sprains may require a short leg cast or cast-brace for 2 to 3 weeks.

For a Grade 2 sprained ankle, follow the R.I.C.E. guidelines and allow more time for healing. A doctor may immobilize or splint your sprained ankle.

A Grade 3 sprained ankle puts you at risk for permanent ankle instability. Rarely, surgery may be needed to repair the damage, especially in competitive athletes. For severe ankle sprains, your doctor may also consider treating you with a short leg cast for two to three weeks or a walking boot. People who sprain their ankle repeatedly may also need surgical repair to tighten their ligaments.

Doctors usually try immobilization and other treatments before recommending surgery. But if your doctor decides surgery is the best option, he or she may start with arthroscopy. This involves inserting a small camera device into the joint through a tiny cut. It allows the doctor to look inside the joint to see what’s going on — like if part of the ligament is caught in the joint or there are bone fragments in the joint — and treat it if necessary.

In very rare cases, doctors will recommend surgery to reconstruct a torn ligament. It’s unlikely that most teens will need this type of surgery for a sprained ankle, though. Your body will probably heal on its own as long as you don’t overdo it too quickly.

Not overdoing things is key when it comes to sprained ankle. So follow your doctor’s advice and don’t push yourself or feel pressure to get back into sports or other activities too soon. Sprains usually heal well, but they need time to get fully better.

Rehabilitating your sprained ankle

Every ligament injury needs rehabilitation. Otherwise, your sprained ankle might not heal completely and you might re-injure it. All ankle sprains, from mild to severe, require three phases of recovery:

• Phase 1 includes resting, protecting and reducing swelling of your injured ankle.
• Phase 2 includes restoring your ankle’s flexibility, range of motion and strength.
• Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities)—such as tennis, basketball, or football.

This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Once you can stand on your ankle again, your doctor will prescribe exercise routines to strengthen your muscles and ligaments and increase your flexibility, balance and coordination. Later, you may walk, jog and run figure eights with your ankle taped or in a supportive ankle brace.

It’s important to complete the rehabilitation program because it makes it less likely that you’ll hurt the same ankle again. If you don’t complete rehabilitation, you could suffer chronic pain, instability and arthritis in your ankle. If your ankle still hurts, it could mean that the sprained ligament has not healed right, or that some other injury also happened.

To prevent future sprained ankles, pay attention to your body’s warning signs to slow down when you feel pain or fatigue, and stay in shape with good muscle balance, flexibility and strength in your soft tissues.

Sprained ankle exercises

Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.

• Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
• Strengthening exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
• Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
• Endurance and agility exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

How to Stretch Your Ankle After A Sprain

You should perform the following stretches in stages once the initial pain and swelling have receded, usually within five to seven days. First is restoration of ankle range of motion, which should begin when you can tolerate weight bearing.

Once ankle range of motion has been almost or completely restored, you must strengthen your ankle. Along with strengthening, you should work toward a feeling of stability and comfort in your ankle, which orthopaedic foot and ankle specialists call proprioception.

Consider these home exercises when recuperating from an ankle sprain. Perform them twice per day.

• While seated, bring your ankle and foot all the way up as much as you can.
  • Do this slowly, while feeling a stretch in your calf.
  • Hold this for a count of 10.
  • Repeat 10 times.
• From the seated starting position, bring your ankle down and in.
  • Hold this inverted position for a count of 10.
  • Repeat 10 times.
• Again from the starting position, bring your ankle up and out.
  • Hold this everted position for a count of 10.
  • Repeat 10 times.
• From the starting position, point your toes down and hold this position for a count of 10.
  • Repeat 10 times.

This stretch should be done only when the pain in your ankle has significantly subsided.

• While standing on the edge of a stair, drop your ankles down and hold this stretched position for a count of 10.
  • Repeat 10 times.
• Stand 12 inches from a wall with your toes pointing toward the wall.
  • Squat down and hold this position for a count of 10.
  • Repeat 10 times.

How to Strengthen Your Ankle After a Sprain

Following an ankle sprain, strengthening exercises should be performed once you can bear weight comfortably and your range of motion is near full. There are several types of strengthening exercises. The easiest to begin with are isometric exercises that you do by pushing against a fixed object with your ankle.

Once this has been mastered, you can progress to isotonic exercises, which involve using your ankle’s range of motion against some form of resistance. The photos below show isotonic exercises performed with a resistance band, which you can get from your local therapist or a sporting goods store.

Figure 4. Sprained ankle exercises

Range of Motion

• Ankle Alphabet: Spell out each letter of the alphabet with your foot, keeping your leg still while moving at the ankle. Use the biggest movements your ankle allows to go through the whole thing, A-Z.
• Calf Stretches: As soon as you can, start stretching your calves by putting the injured leg behind you, keeping your leg straight, and leaning pushing on a wall. If you can’t tolerate standing on your injured foot, straighten your leg by propping it up on a chair, or while sitting on your bed, then use a towel to pull the ball of your foot towards you. Hold for 30 seconds and repeat 3 times.

Strengthening

• Resisted 4-Way Ankle Holds: As pain allows, use a resistance band or towel to work against while you pull your ankle as far as you can in all 4 directions: up, down, inverted (top of foot towards the outside) and everted (sole of the foot towards the outside). Hold for 10 seconds, 5 times in each direction.
• Heel Raises: Once you can bear weight on your foot, stand on the ground and slowly raise your heels off as far as you can, hold for 5 seconds then slowly lower back down. Do 3 sets of 10 reps. You can progress this by standing half-way on a stair with both heels hanging off. Allow your heels to drop below the stair as you come down, holding that position for 5 seconds before rising back up (this can be a great way to stretch your calves too). Once you’re feeling really strong, switch to just using one foot at a time, rinse and repeat.

Balance

• Single Leg Stands: Stand on one foot (once you can tolerate it) while working up to balancing for 30 seconds. If needed, stand next to a chair or wall for support. Make it even tougher by closing your eyes, then progress to standing on a pillow to destabilize you. Stand with your affected leg on a pillow. Hold this position for a count of 10. Repeat 10 times.
• Advanced Balance Training: Once you’ve mastered single leg stands, you can really get your balance on by standing on one leg (yes, again) and putting both arms straight up above your head. Now slowly bend forward at the waist (keeping your back straight) as far as you can while keeping your balance. Not so easy, right? Try bending backwards as far as you can (hands still above your head), then to the left and to the right. Finally you can slowly twist to the left and right all while keeping balanced and tight in your core.

These same exercises that you’ve used to rehab your ankle can serve to strengthen it for future protection against another sprain. Progressing to longer periods of balancing and more reps on your resisted exercises will keep you strong and in tune with your ankle for years to come.

Once you have regained the motion and strength in your ankle, you are ready for sporting activities such as gentle jogging and biking. After you feel your ankle strength is approximately 80% of your other side, then you can begin cutting or twisting sports.

Using a brace or getting your ankle wrapped during risky activities will also help prevent future ankle sprains by adding increased support to your injured ligaments, even once they’ve healed. Whether the brace is soft or hard, find something comfortable and supportive that you’re willing to use each time you lace up your sport shoes.

Surgery

In rare cases, surgery is performed when the injury doesn’t heal or the ankle remains unstable after a long period of physical therapy and rehabilitative exercise.

Surgery may be performed to:

• Repair a ligament that won’t heal
• Reconstruct a ligament with tissue from a nearby ligament or tendon

Surgical options may include:

• Arthroscopy. During arthroscopy, your doctor uses a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
  Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures. In some cases, he or she will reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.

• Immobilization. There is typically a period of immobilization following surgery for an ankle sprain. Your doctor may apply a cast or protective boot to protect the repaired or reconstructed ligament. Be sure to follow your doctor’s instructions about how long to wear the protective device; if you remove it too soon, a simple misstep can re-tear the fixed ligament.

Rehabilitation

Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

What is whiplash

Whiplash also known as neck sprain, is an injury to the muscles, tendons and other soft tissues of the neck ¹, ², ³, ⁴, ⁵. Whiplash injury is caused by a sudden and vigorous movement of the head, sideways, backwards or forwards. Any impact that causes your head to suddenly accelerate or decelerate can cause symptoms of whiplash. However, sometimes whiplash result in no injury or pain at all ⁶.

The term “whiplash” injury was first coined by Harold Crowe in 1928 to define acceleration-deceleration injuries occurring to the cervical spine or neck region ⁷. Later modified to an all-encompassing term known as whiplash-associated disorders (WAD), these clinical entities have been refined to describe any collection of neck-related symptoms following a car accident ⁸, ⁹. Whiplash-associated disorder is a globally important clinical, social, and financial problem ¹⁰.

Your neck is made up by the cervical spine, the first seven vertebrae of the back (see Figure 1 below). Areas of the vertebrae commonly affected are the intervertebral joints (the joints between each vertebrae), the intervertebral discs (the soft material that cushions one vertebrae from another), and the ligaments, muscles and nerve roots that hold the vertebrae together.

Rear collision motor vehicle crashes are the most common cause of whiplash injuries. Whiplash injuries can also occur in other situations where the body is exposed to sudden starts and stops such as contact sports like football, rugby or soccer. Neck sprain or neck strain are other terms that are used to describe whiplash injuries.

Approximately 120,000 whiplash injuries occur in the US each year. The statistics vary for different countries. It is very interesting to find that Australia was the most prolific countries on whiplash injury, and the United States ranked second. A study of drivers in collisions involving two cars found similar results in French (1997–2003) and Spanish databases (2002–2004): 12.2% were diagnosed with whiplash in France and 12.0% in Spain ¹¹. The annual economic cost of whiplash injury is estimated to be $3.9 billion in the United States ¹².

Generally, whiplash injury causes acute neck pain and stiffness within hours of the accident, however these symptoms may in some cases be delayed for several days.

Pain should resolve with treatment after several weeks, and most patients are fully recovered within three months of the injury. Some individuals may continue to suffer pain and headaches after this.

Whiplash symptoms often greatly improve or disappear within a few days to weeks. It may take longer for symptoms to completely disappear and some people experience some pain and neck stiffness for months after a whiplash injury.

More than 50% of whiplash resolve after a few weeks of treatment ¹³, ¹⁴, ¹⁵. However, approximately 30% of cases develop long-term complex pain related disability and persist for months or years ¹⁶, ¹⁵. Recovery following whiplash injury, if it is to occur, will occur for the most part within the first 3 months post injury ¹⁷. Current estimates suggest that approximately 50% of individuals will recover by 3 months post injury, whilst the remainder will experience mild to moderate long-term disability ¹⁸, ¹⁹, ²⁰. The development of chronic symptoms after whiplash injuries may also be influenced by psychological and social factors as well as with changes in the central nervous system (brain and spinal cord) ²⁰, ²¹, ²². In countries such as Lithuania and Greece, where there is no compensation culture and no formal compensation system for late whiplash-related injuries, the development of chronic symptoms following whiplash is a rare phenomenon ²³, ²⁴. This evidence suggests that the culture and expectations around whiplash, local insurance systems, and the prospect of monetary benefits are likely to play important roles in the prevalence of whiplash injuries and related claims, as well as in the recovery process ²⁵.

Common symptoms of whiplash include ²⁶:

• neck pain and tenderness
• neck stiffness and difficulty moving your head
• headaches
• muscle spasms
• pain in the shoulders and arms

Less common symptoms include pins and needles in your arms and hands, dizziness, tiredness, memory loss, poor concentration and irritability.

It can take several hours for the symptoms to develop after you injure your neck. The symptoms are often worse the day after the injury, and may continue to get worse for several days.

Whiplash injuries are commonly caused by:

• motor vehicle accidents (80% of whiplash injury cases) ²⁷, ²⁸
• a sudden blow to the head from contact sports such as rugby or boxing
• being hit on the head by a heavy object
• a slip or fall where the head is jolted or jarred.

Whiplash occurs when the neck is moved beyond its usual range of movement, which overstretches or sprains the soft tissues of the neck (tendons, muscles and ligaments). This causes pain and discomfort in the neck and shoulders and may also cause back pain.

The joints and ligaments of the neck are covered by muscles. So whiplash injury cannot be seen from the surface. This can be frustrating when your neck is painful. Imagine a sprained ankle. Immediately following a sprain, the ankle becomes bruised, swollen and painful to move.

Key points about whiplash:

• Whiplash injury is poorly understood, but usually involves the muscles, discs, nerves, and tendons in your neck.
• It is caused by the neck bending forcibly forward and then backward, or vice versa.
• Many whiplash injuries occur if you are involved in a rear-end automobile collision.
• Your healthcare provider will determine specific treatment for your whiplash.

Cervical spine anatomy

Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another. These bones connect to create a canal that protects the spinal cord.

Other parts of your spine include:

• Spinal cord and nerves. These “electrical cables” travel through the spinal canal carrying messages between your brain and muscles. Nerve roots branch out from the spinal cord through openings in the vertebrae (foramen).
• Intervertrebral disks. In between your vertebrae are flexible intervertebral disks. They act as shock absorbers when you walk or run.

Intervertebral disks are flat and round and about a half inch thick. They are made up of two components:

• Annulus fibrosus. This is the tough, flexible outer ring of the disk.
• Nucleus pulposus. This is the soft, jelly-like center of the disk.

The cervical spine is made up of the first 7 vertebrae and functions to provide mobility and stability to the head, while connecting it to the relative immobile thoracic spine (see the image below). The first 2 vertebral bodies are quite different from the rest of the cervical spine. The atlas, or C1, articulates superiorly with the occiput and inferiorly with the axis, or C2.

The atlas is ring-shaped and does not have a body, unlike the rest of the vertebrae. The body has become part of C2, and it is called the odontoid process, or dens. The atlas is made up of an anterior arch, a posterior arch, 2 lateral masses, and 2 transverse processes. The transverse foramen, through which the vertebral artery passes, is enclosed by the transverse process. On each lateral mass is a superior and inferior facet (zygapophyseal) joint. The superior articular facets are kidney-shaped, concave, and face upward and inward. These superior facets articulate with the occipital condyles, which face downward and outward. The relatively flat inferior articular facets face downward and inward to articulate with the superior facets of the axis.

The axis has a large vertebral body, which contains the fused remnant of the C1 body, the dens. The dens articulates with the anterior arch of the atlas via its anterior articular facet and is held in place by the transverse ligament. The axis is composed of a vertebral body, heavy pedicles, laminae, and transverse processes, which serve as attachment points for muscles. The axis articulates with the atlas by its superior articular facets, which are convex and face upward and outward.

The remaining cervical vertebrae, C3-C7, are similar to each other, but they are very different from C1 and C2. They each have a vertebral body, which is concave on its superior surface and convex on its inferior surface. On the superior surfaces of the bodies are raised processes or hooks called uncinate processes, which articulate with depressed areas on the inferior aspect of the superior vertebral bodies called the echancrure or anvil. These uncovertebral joints are most noticeable near the pedicles and are usually referred to as the joints of Luschka ²⁹. These joints are believed to be the result of degenerative changes in the annulus, which leads to fissuring in the annulus and the creation of the joint. The spinous processes of C3-C5 are usually bifid, in comparison to the spinous processes of C6 and C7, which are usually tapered.

The facet joints in the cervical spine are diarthrodial synovial joints with fibrous capsules. The joint capsules in the lower cervical spine are more lax compared with other areas of the spine to allow for gliding movements of the facets. The joints are inclined at 45° from the horizontal plane and angled 85° from the sagittal plane. This alignment helps to prevent excessive anterior translation and is important in weight bearing ³⁰.

The fibrous capsules are innervated by mechanoreceptors (types I, II, and III), and free nerve endings have been found in the subsynovial loose areolar and dense capsular tissues ³¹. In fact, there are more mechanoreceptors in the cervical spine than in the lumbar spine ³². This neural input from the facets may be important for proprioception and pain sensation and may modulate protective muscular reflexes that are important in preventing joint instability and degeneration.

The facet joints in the cervical spine are innervated by both the anterior and dorsal rami. The occipitoatlantal joint and atlantoaxial joint are innervated by the ventral rami of the first and second cervical spinal nerves. Two branches of the dorsal ramus of the third cervical spinal nerve innervate the C2-C3 facet joint, a communicating branch and a medial branch known as the third occipital nerve.

The remaining cervical facets, C3-C4 to C7-T1, are supplied by the dorsal rami medial branches that arise one level cephalad and caudad to the joint ³³. Therefore, each joint from C3-C4 to C7-T1 is innervated by the medial branches above and below. These medial branches send off articular branches to the facet joints as they wrap around the waists of the articular pillars.

Intervertebral discs are located between each vertebral body caudad to the axis. The discs are composed of 4 parts, including the nucleus pulposus in the middle, the annulus fibrosis surrounding the nucleus, and 2 end plates that are attached to the adjacent vertebral bodies. The discs are involved in cervical spine motion, stability, and weight bearing. The annular fibers are composed of collagenous sheets called lamellae, which are oriented 65-70° from the vertical and alternate in direction with each successive sheet. Therefore, the annular fibers are prone to injury with rotation forces because only one half of the lamellae are oriented to withstand the force in this direction ³². The middle and outer one third of the annulus is innervated by nociceptors, and phospholipase A2 has been found in the disc and may be an inflammatory mediator ³⁴.

Several ligaments of the cervical spine, which provide stability and proprioceptive feedback, are worth mentioning ³⁵. The transverse ligament, the major portion of the cruciate ligament, arises from tubercles on the atlas and stretches across its anterior ring while holding the dens against the anterior arch. A synovial cavity is located between the dens and the transverse process. This ligament allows for rotation of the atlas on the dens and is responsible for stabilizing the cervical spine during flexion, extension, and lateral bending. The transverse ligament is the most important ligament in preventing abnormal anterior translation ³⁶.

The alar ligaments run from the lateral aspects of the dens to the ipsilateral medial occipital condyles and to the ipsilateral atlas. The alar ligaments limit axial rotation and side bending. If the alar ligaments are damaged, as in a whiplash injury, the joint complex becomes hypermobile, which can lead to kinking of the vertebral arteries and stimulation of the nociceptors and mechanoreceptors. This may be associated with the typical complaints of patients with whiplash injuries such as headache, neck pain, and dizziness. The alar ligaments prevent excessive lateral and rotational motions, while allowing flexion and extension.

The anterior longitudinal ligament and the posterior longitudinal ligament are the major stabilizers of the intervertebral joints. Both ligaments are found throughout the entire length of the spine; however, the anterior longitudinal ligament is closely adhered to the discs in comparison to the posterior longitudinal ligament, and it is not well developed in the cervical spine. The anterior longitudinal ligament becomes the anterior atlantooccipital membrane at the level of the atlas, whereas the posterior longitudinal ligament merges with the tectorial membrane. Both ligaments continue onto the occiput. The posterior longitudinal ligament prevents excessive flexion and distraction ³⁷.

The supraspinous ligament, interspinous ligament, and ligamentum flavum maintain stability between the vertebral arches. The supraspinous ligament runs along the tips of the spinous processes, the interspinous ligament runs between the spinous processes, and the ligamentum flavum runs from the anterior surface of the cephalad vertebra to the posterior surface of the caudad vertebra. The interspinous ligament and especially the ligamentum flavum control for excessive flexion and anterior translation ³⁷. The ligamentum flavum also connects to and reinforces the facet joint capsules on the ventral aspect. The ligamentum nuchae is the cephalad continuation of the supraspinous ligament and has a prominent role in stabilizing the cervical spine.

Figure 1. Cervical spine

Figure 2. Cervical disc

Figure 3. Cervical facet joint (cervical zygapophyseal joint)

How do I know if I have whiplash?

Sometimes you can have no symptoms after a whiplash injury, but sometimes your symptoms can be severe. Pain from a whiplash injury often begins 6 to 12 hours after the injury. You may just feel uncomfortable on the day of the injury or accident and find that your pain, swelling and bruising increase over the following days.

Common symptoms of whiplash include:

• neck problems: pain, stiffness, swelling or tenderness
• difficulty moving your neck
• headaches, difficulty concentrating
• muscle spasms or weakness
• ‘pins and needles’, numbness or pain in your arms and hands or shoulders
• dizziness, vertigo, (a feeling you are moving or spinning) or tinnitus (ringing in your ears)
• difficulties swallowing or blurred vision

Your symptoms are likely to greatly improve or disappear within a few days to weeks. It may take longer for your symptoms to resolve completely and you might even experience some pain and neck stiffness for months after a whiplash injury.

How long does whiplash last?

Pain from a whiplash injury often begins 6 to 12 hours after the injury. Many people feel uncomfortable on the day of the injury or accident and find that pain, swelling and bruising increase over the following days.

Many people recover within a few days or weeks. For others it may take several months but sometimes it can last up to a year or more to experience substantial improvement in symptoms. Ongoing symptoms may vary in their intensity during the recovery period. This is normal.

You should see a doctor if you have had a motor vehicle accident or an injury that’s causing pain and stiffness in your neck.

The length of time it takes to recover from whiplash can vary and is very hard to predict.

Many people will feel better within a few weeks or months, but sometimes it can last up to a year or more.

Severe or prolonged pain can make it difficult to carry out daily activities and enjoy your leisure time. It may also cause problems at work and could lead to anxiety or depression.

Try to remain positive and focus on your treatment objectives. But if you do feel depressed, speak to your doctor about appropriate treatment and support.

What can I do to help my recovery?

Research has shown that it is better to try to keep doing normal daily activities as much as possible to aid recovery.

You need to take care of your neck and not expose it to unnecessary strain during the healing phase. It’s also important to regularly exercise your neck muscles. This booklet offers advice on how to care for your neck and suggests some specific exercises for your neck to help recovery.

Can I do the same activities as before?

Are there any limitations?

In the early stages of recovery, you may need to adapt some activities to care for your neck. However you should gradually resume normal activity as your neck improves (work, recreation and social).

Those who continue to work, even in a reduced capacity at first, have been shown to have a better recovery than people who take a long time off work.

An injury will cause pain. However the pain that occurs in the recovery period does not automatically mean that there is further injury. It is best to stay active and gently exercise to recover.

It may be necessary to limit some of your usual work and recreational activities in the early to mid-stage of recovery. Be adaptable – find new ways to do tasks to avoid unnecessary strain on your neck.

Whiplash causes

Whiplash injuries are commonly caused by car accidents. Whiplash can occur if your head is thrown forwards, backwards or sideways violently. For example if your neck is quickly accelerated and decelerated in a rear-end or side impact.

Common causes of whiplash include:

• road traffic accidents and collisions
• a sudden blow to the head – for example, during sports such as boxing or rugby
• a slip or fall where the head is suddenly jolted backwards
• being struck on the head by a heavy or solid object
• physical abuse or assault. Whiplash can occur if you are punched or shaken. It’s one of the injuries seen in shaken baby syndrome.

Studies with cadavers have shown the whiplash injury is the formation of the S-shaped curvature of the cervical spine which induced hyperextension on the lower end of the spine and flexion of the upper levels, which exceeds the physiologic limits of spinal mobility ³⁸. The Quebec task force (QTF) defined whiplash as bony or soft tissue injuries as a result of rear-end or side-impact in road traffic accidents, and from other injuries resulting in “an acceleration-deceleration mechanism of energy transfer to the cervical spine” ⁵. The Quebec task force proposed a classification system to define the severity of the whiplash injury. In Grade 1 the patient complains of neck pain, stiffness, or tenderness with no positive findings on physical exam. In Grade 2 the patient exhibits musculoskeletal signs including decreased range of motion and point tenderness. In Grade 3 the patient also shows neurologic signs that may include sensory deficits, decreased deep tendon reflexes, muscle weakness. Grade 4 the patient shows a fracture ⁵. Most whiplash-associated disorders are considered to be minor soft tissue-based injuries without evidence of fracture.

Whiplash signs and symptoms

The symptoms of Whiplash Injury often include pain, decreased mobility of the neck, tenderness, headaches and problems of concentration and memory.

Common symptoms of whiplash include:

• neck pain and stiffness
• swelling and tenderness in the neck
• temporary loss of movement, or reduced movement, in the neck
• headaches, most often starting at the base of the skull
• muscle spasms
• tenderness or pain in shoulder, upper back or arms
• tingling or numbness in the arms
• fatigue
• pain in the shoulders or arms.

Whiplash can also cause:

• lower back pain
• pins and needles, numbness or pain in the arms and hands (paresthesias)
• dizziness
• sleep disturbances
• tiredness and irritability
• difficulties swallowing (dysphasia)
• temporomandibular joint symptoms
• blurred vision
• memory problems
• vertigo (a feeling you are moving or spinning)
• difficulty concentrating
• irritability
• tinnitus (ringing in the ears)

Psychosocial symptoms ³⁹:

• depression
• anger
• frustration
• anxiety
• family stress
• occupational stress
• hypochondriasis (also known as health anxiety or illness anxiety disorder)
• compensation neurosis
• drug dependency
• post-traumatic stress syndrome (PTSD)
• litigation
• social isolation

You should see a doctor if you have neck pain after a car accident or after an injury.

Pain

Whiplash injury is a painful injury. As a result of the impact that caused the injury, there may be bruising or tearing of the soft tissues in the neck region, contributing to symptoms of pain. The pain of whiplash might be localized in the neck, or may also extend to the shoulders, and upper arms. Many individuals who have sustained whiplash injuries also report pain in the lower back region.

Decreased Mobility of the Neck

The uninjured neck has considerable mobility in several directions. The neck can move up and down (flexion-extension), side to side (lateral flexion) and can rotate (rotation). These movements are often restricted following a whiplash injury. There is a natural tendency for muscles to contract when the neck is painful. This contraction is the body’s way of trying to protect itself against further injury.

Tenderness of the Injured Area

Whiplash injury is considered to be an ‘overload’ injury. As a function of the excessive forces that impacted on the neck in the motor vehicle crash, elongation, bruising or tearing of the soft tissue can occur. In turn, the soft-tissue injuries can lead to inflammation and edema (e.g., swelling). Inflamed and swollen tissues are more ‘tender’ in that they are more sensitive to touch. Following a whiplash injury, areas of tenderness can include regions of the neck, shoulders and upper arms.

Headaches

Whiplash injury can also cause headaches. Headaches of whiplash injury may differ from tension or migraine headaches. Whiplash headaches, are more likely to occur at the top or the back of the head as opposed to regions around the eyes or the side of the head. Whiplash headaches can be intermittent or constant.

Memory and Concentration Problems

Individuals who have sustained whiplash injuries sometimes report problems with memory and concentration. If the head was struck during the crash that caused the whiplash injury, it is possible that the memory or concentration problems might be due to concussion. If the head was not struck, the memory and concentration problems are most likely due to the distracting effects of pain or anxiety.

Long term effects of whiplash

Most people who have whiplash injury feel better within a few weeks and don’t seem to have any lasting effects from the injury. However, some people continue to have pain for several months or years after the whiplash injury occurred.

It is difficult to predict how each person with whiplash may recover. In general, you may be more likely to have chronic pain if your first symptoms were intense, started rapidly and included:

• Severe neck pain
• More-limited range of motion
• Pain that spread to the arms

The following risk factors have been linked to a worse outcome:

• Having had whiplash before
• Older age
• Existing low back or neck pain
• A high-speed injury

Whiplash is an injury from which most individuals recover well. Studies have shown that people who are positive about recovery and resume their normal daily activities as tolerated may recover faster than those who markedly alter or markedly reduce their activity level for a period.

A small percentage of people who have a whiplash injury may develop long-term neck pain. Research is being conducted worldwide to understand why there are different recovery rates between different people. Some reasons have been identified such as age and initial severity of the pain or injury. However there is still more to be learnt.

The main symptoms of a whiplash associated disorder are neck pain and stiffness. Other symptoms such as headaches, aching in the arms or feelings of being lightheaded are common.

Symptoms may appear immediately after the incident or have a delayed onset of a few hours or days. The nature of injury and the number and severity of symptoms vary between different people.

Neck x-rays may be taken to rule out injuries such as bone fractures or dislocations. X-ray reports often state that no abnormality has been found. However, x-rays do not reveal injuries to the soft tissues of the neck (non bony parts of joints, ligaments, muscles) and x-rays do not provide information about pain levels. Normal x-rays only provide assurance that there are no major bone injuries.

Whiplash injury diagnosis

Questions about the event and your symptoms are the doctor’s first step for making a diagnosis. You also may be asked to fill out a brief form that can help your doctor understand the frequency and severity of your symptoms, as well as your ability to do normal daily tasks.

Examination

During the exam your doctor will need to touch and move your head, neck and arms. He or she will also ask you to move and perform simple tasks. This examination helps your doctor determine:

• The range of motion in your neck and shoulders
• The degree of motion that causes pain or an increase in pain
• Tenderness in the neck, shoulders or back
• Reflexes, strength and sensation in your limbs

Imaging tests

Your doctor will likely order one or more imaging tests to rule out other conditions that could be causing or contributing to neck pain. These include the following tests:

• X-rays of the neck. X-rays of the neck taken from multiple angles can identify fractures, dislocations or arthritis.
• Computerized tomography (CT). Computerized tomography (CT) is a specialized X-ray technology that can produce multiple cross-sectional images of bone and reveal details of possible bone damage.
• Magnetic resonance imaging (MRI). Magnetic resonance imaging (MRI) is a technology that uses radio waves and a magnetic field to produce detailed 3-D images. In addition to bone injuries, MRI scans can detect some soft tissue injuries, such as damage to the spinal cord, disks or ligaments.

Imaging techniques (e.g., magnetic resonance imaging or computerized tomography) and physiological methods are often unable to provide useful and unequivocal information in the instances of mild injuries ⁴⁰. In the past, the suggestion was to combine various investigation methods, such as imaging techniques and psychiatric, orthopedic, and neurological data, together with a detailed clinical history and evaluation, to draw a complete diagnostic picture of a patient and a realistic level of disability ⁴⁰. However, this kind of assessment is costly in terms of time and expenses related to the instruments, it requires the presence of specialists ⁴⁰, and, most importantly, does not necessarily exclude the presence of exaggerated symptoms.

Whiplash treatment

It is important to note that, although there are many different treatment options available for the management of whiplash injury, not all have been shown to be effective. It is also important to note that even though a certain treatment might have been shown to be effective, it might not be the right treatment for you.

The goals of whiplash treatment are to:

• Control pain
• Restore normal range of motion in your neck
• Get you back to your normal activities

It is best to have an in-depth discussion with your doctor, chiropractor or physiotherapist to determine the best treatments for the symptoms you are experiencing.

Your treatment plan will depend on the extent of your whiplash injury. Some people only need over-the-counter pain medication or nonsteroidal anti-inflammatory drugs (NSAIDs), a cervical collar, and at-home care. Others may need prescription medication (antidepressants, muscle relaxants) and specialized pain treatment in conjunction with physiotherapy or chiropractic care.

Soft foam cervical collars were once commonly used for whiplash injuries to hold the neck and head still. However, studies have shown that keeping the neck still for long periods of time can decrease muscle strength and interfere with recovery ⁴¹, ⁴², ⁴³. Still, using of a cervical collar to limit movement may help reduce pain soon after your injury, and may help you sleep at night. Recommendations for using a cervical collar vary though. Some experts suggest limiting cervical collar use to no more than 72 hours, while others say it may be worn up to three hours a day for a few weeks. Your doctor can instruct you on how to properly use the cervical collar, and for how long.

Pain management

Your doctor may recommend one or more of the following treatments to lessen pain ⁴⁴:

• Rest. Rest may be helpful during the first 24 hours after injury, but prolonged bed rest may delay recovery.
• Ice or heat. Apply ice or heat to the neck for 15 minutes up to six times a day.
• Over-the-counter pain medications. Over-the-counter pain relievers, such as acetaminophen (Tylenol, others) and ibuprofen (Advil, Motrin IB, others), often can control mild to moderate whiplash pain.
• Prescription painkillers. People with more-severe pain may benefit from short-term treatment with prescription pain relievers.
• Muscle relaxants. These drugs may control pain and help restore normal sleep if pain prevents you from sleeping well at night.
• Injections. An injection of lidocaine (Xylocaine) — a numbing medicine — into painful muscle areas may be used to decrease pain so that you can do physical therapy.

Individuals at high-risk of non-recovery should receive referral to a specialist clinician with expertise in the management of whiplash associated disorder ⁴⁵, ⁶.

How to treat whiplash

A number of treatments have been developed to manage the symptoms of whiplash injury. Some of the more common treatments described below include ⁴⁶:

• Advice to remain active
• Education
• Medication
• Physiotherapy
• Treatment of Mental Health Problems

Advice to Remain Active

Many doctor’s and physiotherapists will recommend to their patients that they try to remain as active as possible during the recovery period. While such advice might not appear to be much of a treatment, the advice is nevertheless a critical element in ensuring optimum recovery.

When people are injured and are experiencing pain and discomfort, there is a tendency to reduce one’s participation in important activities of daily life. As a result of pain or discomfort, individuals might reduce their participation in family or home activities, in recreational activities and individuals might also discontinue their occupational activities.

Reducing activity sometimes feels like the right thing to do because it is associated with a reduction in pain. But there lies the trap. Activity reduction is probably the worst thing to do in the management of a whiplash injury. While activity reduction might reduce pain and discomfort in the short term, in the long term, activity reduction will likely lead to more severe pain, and more severe disability.

Muscles need to move to remain healthy. Individuals who discontinue the important activities of their daily lives, or individuals who spend excessive time resting or lying down will actually recover more slowly. Slowing down a little bit makes sense during the initial days of recovery, but lying down or bed rest should be avoided. Remaining active is the best formula for optimal recovery.

Medication

The two most frequently prescribed medications for whiplash injury are anti-inflammatories and painkillers ⁴⁷. Following a whiplash injury, the soft-tissues of the neck and shoulders can become inflamed. Inflammation often leads to increased stiffness and pain. Anti-inflammatories reduce swelling of the injured soft tissues, and reduce pain as well. Inflammation is typically only present in the first few weeks following injury so anti-inflammatories tend not be used for long term pain management.

There are two main types of painkillers (analgesics) that might be prescribed for pain caused by whiplash injury. There are non-steroidal analgesics such as aspirin or paracetamol (acetaminophen), and there are opiate analgesics such as codeine. Painkillers can be useful treatments to manage the pain of whiplash injury in the short term, but long-term use is typically not recommended. Long-term use of acetaminophen (paracetamol) can cause stress on liver function. Long-term use of opiate analgesics can lead to gastro-intestinal problems, and of even more concern, these medications can lead to problems of addiction.

Education

It is becoming increasingly clear that education is an important element of the management of whiplash injury. A doctor or a physiotherapist might choose to spend some time explaining to a patient exactly what whiplash is and describe the pros and cons of different treatments.

One of the benefits of education is that it can help reduce anxiety. The experience of severe pain and symptoms of stiffness and headaches can be alarming. The injured person might think, ‘there must be something seriously wrong with my neck’, ‘if it hurts this much, there must be a lot of damage’, ‘when I move, it hurts more, so I should probably not move’. Thoughts like these will create anxiety or fear. In turn, anxiety and fear will lead the person to discontinue even more of their activities.

The doctor or physiotherapist might wish to educate the injured person about why he or she is experiencing a lot of pain, to explain that the symptoms of whiplash will recover over time, and to explain the importance of remaining as active as possible.

The doctor or physiotherapist might also wish to educate the injured person about the relation between pain and injury severity. We often assume that if the pain is severe, this must mean that the injury is severe. But with whiplash injury that is not the case. The pain of whiplash can be very severe, but that does not mean that severe or irreparable damage has been done to the neck. The majority of whiplash injuries are not considered ‘medically serious’; the pain might be initially severe, but the pain dissipates over time.

Exercise

Your doctor will likely prescribe a series of stretching and movement exercises for you to do at home. These exercises can help restore range of motion in your neck and get you back to your normal activities ⁴⁸, ⁴⁹, ⁵⁰. Applying moist heat to the painful area or taking a warm shower may be recommended before exercise.

Exercises may include (see more below):

• Rotating your neck in both directions
• Tilting your head side to side
• Bending your neck toward your chest
• Rolling your shoulders

Physical therapy

Physical therapy is another commonly used approach to treating whiplash injury. If you have ongoing whiplash pain or need assistance with range-of-motion exercises, your doctor may recommend that you see a physical therapist. A physical therapist might use a variety of treatment techniques to manage the symptoms of whiplash. Initially, the physiotherapist might use modalities such as manual therapy or ice to reduce the swelling and inflammation of the injured areas. The physical therapist will also provide the injured person with exercises to improve or maintain the movement in their neck as well as strength and control of the muscles in their neck and upper body and to restore normal movement. This in turn will help increase the person’s tolerance for participation in household, recreational and occupational activities.

As the injured person begins to be more physically active, it sometimes happens that their pain and discomfort might increase. This increase in pain is usually caused by engaging muscles that have remained inactive or immobile for extended periods of time. The pain associated with increasing activity is temporary and will usually subside in a day or two.

In some cases, transcutaneous electrical nerve stimulation (TENS) may be used. TENS applies a mild electric current to the skin. Limited research suggests this treatment may temporarily ease neck pain and improve muscle strength.

The number of physical therapy sessions needed will vary from person to person. Your physical therapist can also create a personalized exercise routine that you can do at home.

Treatment of Mental Well Being

Some individuals with whiplash injuries might develop symptoms of a mental health problem. The most common mental health problems associated with whiplash injury include depression, anxiety and post-traumatic stress symptoms. If an injured person is experiencing troubling symptoms of depression, anxiety or post-traumatic symptoms, the doctor might consider prescribing medication such as an anti-depressant or anti-anxiety medication. Since the presence of symptoms of a mental health problem can slow the rate of recovery following whiplash injury, these medications can play an important role in the successful management of whiplash injury.

If you have developed symptoms of a mental health problem following your whiplash injury, your doctor might also consider a referral to a mental health professional such as a psychologist or a social worker. Psychologists and social workers can provide counselling or psychotherapy that can be useful in managing some of the mental health consequences of whiplash injury. Your doctor can familiarize you with the mental health services that are available in your community.

Alternative medicine

There are many other types of treatments that have been tried to treat whiplash pain, but research about how well they work is limited ⁵¹, ⁵², ⁵³, ⁵⁴, ⁵⁵. Some of these include manipulation, acupuncture, electrical nerve stimulation, traction, biofeedback, ultrasound among many others ⁵⁶, ⁵⁷.

• Acupuncture. Acupuncture involves inserting ultrafine needles through specific areas on your skin. It may offer some relief from neck pain.
• Chiropractic care. A chiropractor performs joint manipulation techniques. There is some evidence that chiropractic care may provide pain relief when paired with exercise or physical therapy.
• Neck massage. Neck massage may provide short-term relief of neck pain from whiplash injury.
• Mind-body therapies. Exercises that incorporate gentle movements and a focus on breathing and mindfulness, such as tai chi, qi gong and yoga, may help ease pain and stiffness.

It is difficult to make strong statements about the utility of these treatments since so little research has examined whether they are effective. Injured individuals who are slow to recover might reach a level of desperation where they are willing to try anything. It is important to remember that unless a treatment has been shown to be effective in a clinical trial, there is always the possibility that the treatment might not be helpful, or could actually worsen the condition. Before starting any treatment for your whiplash injury, it is best to discuss with a doctor or medical specialist the treatment options that are most appropriate for your condition.

Home remedies for whiplash injury

You are your own best resource in the recovery process. Managing yourself is a key part to stopping the discomfort that you are experiencing. Staying active is important. Do as many of your normal activities as possible. Some more vigorous activities that place undue stresses on your neck may need to be avoided in the early stages of recovery.

However, better recovery has been found in individuals who continue a healthy active routine after a whiplash injury. This goes for your general health as well as that of your neck.

Plan gradual increases in activity and exercise levels so that you can successfully return to full participation in your regular activities, hobbies or sports.

Continue or resume working

Those who continue to work, even in a reduced capacity at first, have been shown to have a better recovery than people who take a long time off work. It may be necessary to change some work routines for a while.

You may wish to talk to your employer or health care practitioner regarding ways to modify your particular work tasks and environment if difficulties continue.

Keeping a good relationship with your employer and co-workers is helpful in the recovery process. Talk to your employer openly and frequently.

During times of high work load or busy periods, it is important to let colleagues and supervisors know that you may need extra time or help to meet deadlines. Don’t be afraid to ask for help. You may be in a position to return the favor at some time.

Maintain the flexibility and muscle support of your neck

An exercise program that is specific to the neck and upper back will greatly benefit your recovery. The exercise program in this booklet will help you regain normal neck movement and function.

The exercises are also designed to ensure that your neck receives proper support from the muscles.

Perform daily activities in a strain-free way

Thinking about how you do your work and recreational activities can avoid unnecessary strain on your neck, reduce pain and positively assist recovery.

Be aware of neck positions and postures at work and home

Keeping your spine in a good position is important in everyday activities as well as during the exercises.

The positions in which you work and relax each day have a great impact on the health of your spine. It is easy to compensate and allow yourself to develop poor postural habits. You will need to be consciously aware of postures and positions when you are performing tasks at home and work.

Postural correction exercise

Correct your posture by gently growing tall from the lower back and pelvic region (see Figure 1 below).

Gently raise your pelvis up out of a slumped position.

Next, reposition your shoulder blades so they draw back and across your rib cage (towards the center of your spine). This needs only minimal effort.

Gently lift the base of your skull off the top of your neck. This takes the weight of your head off your neck and stimulates the muscles to work.

Hold the position for at least 10 seconds. Repeat frequently during the day (e.g. three or four times an hour).

Perform this exercise when sitting, standing or while walking, at work and at home.

Figure 4. Whiplash injury exercises

Range of motion exercises

For each of the following exercises, complete 5-10 repetitions in each direction.

Neck rotation exercise

Assume the correct postural position. Gently turn your head to the left, looking where you are going to see over your shoulder as much as possible.

You may find it easier to have a target on the wall to focus on.

With each repetition, try to go a little further in that direction. Perform the same exercise to the right side.

Figure 5. Neck rotation exercise

Neck side bending exercise

Assume the correct postural position. Start with your head centered and gently bring your right ear down towards your right shoulder. You may feel a normal stretch of the muscles on the side of your neck. The exercise should be pain-free. Perform this exercise on the left side.

Figure 6. Neck side bending exercise

Forward and backward bending

Assume the correct postural position.

Figure 7. Neck forward and backward bending exercise

Exercises to retrain muscle control

Head nod and holding exercise

This is an important exercise to retrain the deep neck muscles of the front of your neck for pain relief and muscle control.

Lie on your back with knees bent without a pillow under your head and neck.

A. If this is not comfortable, place a small, folded towel under your head for support.

B. Start by looking up at a point on the ceiling. Then with your eyes, look at a spot on the wall just above your knees. Feel the back of your head slide up the bed as you perform a slow and gentle nod as if you were indicating ‘yes’.

While doing the exercise, place your hand gently on the front of the neck to feel the superficial muscles. Make sure they stay soft and relaxed when doing the head nod movement. Stop at the point you sense the muscles are beginning to harden, but keep looking down with your eyes.

Hold the position for 10 seconds and then relax. Look up to a point on the ceiling to resume the starting position. Repeat the exercise 10 times.

Figure 8. Head nod and holding exercise

Head and neck exercises

These are important exercises to retrain the muscles at the back of your neck for pain relief and muscle control. There are three exercises to perform, which ensures you exercise the upper and lower regions of your neck.

Lie on your stomach, propped up on your elbows. Push through your elbows to prevent your chest from sagging between your shoulder blades.

To begin, perform each exercise five times as one set. Try to build up to three sets (and eventually three sets of 10 repetitions each). Remember to keep pushing through your elbows to keep your chest raised for the whole set. Have a rest between sets.

Figure 9. Head and neck exercises

Shoulder blade exercises

Poor muscle control around the shoulder blades can increase pain and strain on the neck. There are three exercises that you can do for your shoulder blades and arms.

This first exercise will relax and ease any tension in the muscles on top of your shoulders. It can give you pain relief.

Figure 10. Shoulder blade exercises

The second exercise helps you to improve the control of your shoulder blades while mimicking work you may do with your arms. It trains you to ease any tension in the muscles on top of your shoulders while you are using your arms.

Sit and correct your posture and draw your shoulder blades back and across your rib cage as you have already practised.

Concentrate on holding your shoulder blade position. Then move your arms:

• (A) forwards and backwards;
• (B) out to the side; and
• (C) turn your forearms outwards.

Do not lift your arms more than 30 degrees in exercises A and B (that is, about a quarter of the way up). Perform each exercise (A,B and C) five times and repeat this set three times.

When you feel confident that you can do the exercise keeping your shoulder blades gently back, hold a 250 gram can in each hand as a small weight.

Figure 11. Shoulder blade exercises part 2

The third exercise is simply raising alternate arms forward as far up as you can go. Make sure that you maintain a good posture, especially concentrating on lifting the base of your skull off the top of your neck and then as you raise your arm, keep your thumb facing upwards. Perform three sets of five left and right arm raises.

Figure 12. Shoulder blade exercises part 3

Neck isometric exercise (no movement)

Assume the correct postural position and gently raise the back of your head. Place your right hand on the right cheek. Without moving your head, turn your eyes to the right and gently push your head into your hand as if to look over your shoulder. While performing this exercise no movement occurs. Hold the muscle contraction for five seconds.

Do the exercise smoothly and gently, use only 10% effort.

Change hand position and perform the same exercise to the left side. Do five repetitions on each side.

Figure 13. Neck isometric exercise

Once your neck pain has settled, the exercises can be progressed to include strengthening exercises.

These exercises should not cause pain. Progress slowly.

Head lift exercise

The weight of your head is enough weight to lift. Start by sitting on a chair close to a wall. Rest your head back on the wall.

Slide the back of your head up the wall to nod your chin and hold it in this position. Then just take the weight of your head off the wall (your hair still touches the wall). Hold for five seconds and relax.

Start by doing three sets of two to three repetitions and gradually build up to three sets of five repetitions.

Shifting the chair a little further from the wall makes the exercise more difficult.

You can progress the exercise by moving the chair away from the wall in five centimeter stages.

Figure 14. Head lift exercise

Progression: Lie resting your head on two pillows.

Slide the back of your head up the pillow to nod your chin and hold it in this position. Then try to just lift the weight of your head until it just clears the pillow.

Hold for five seconds and relax. Start by doing three sets of two to three repetitions and gradually build up to three sets of five repetitions.

The exercise can be progressed by removing one pillow and performing the exercise in the same way.

Figure 15. Head lift exercise (progression)

Sitting

Sitting in one position for prolonged periods is not good for anyone, certainly not someone with neck pain.

Change your position

Sitting in one position for prolonged periods is not good for anyone, certainly not someone with neck pain. Keep your neck healthy and move often.

It is essential that you change your position before your neck becomes stiff or sore. Perform the postural correction exercise regularly. Stand up and move regularly, at least every hour.

Assess how you spend your day at work

Whether sitting in a motor vehicle, at a desk or computer terminal, you need to give your body a regular change of position throughout the day. Take a ‘neck break’, it can be as simple as standing up for a few moments to straighten your spine. Stand and stretch backwards gently to reverse the flexed sitting posture. A complete change of position every hour is advisable.

Working at a computer

Arrange your desk, chair and computer to avoid strain on your neck (see Figure 2). Have work materials close to you and in easy reach.

• A. Position the top of your screen slightly below eye level and directly in front of you (50-70cm or arm’s length away). There is no single monitor height suitable for everyone. Position the screen to have a comfortable viewing angle to the middle of the screen. Avoid extremes of head and neck bending (upwards or downwards).
• B. Have an adjustable chair so that you can change the height and angle of the back support. Have the chair close to the desk so you do not have to reach for the keyboard or mouse. If possible, rest your forearms on the desktop to ‘unload’ the shoulders.
• C. Desk height should allow sitting with shoulders and arms relaxed with elbows at a 90 degree angle and wrists in a neutral position. Sit with hips and knees at close to 90 degree angles. Feet should be flat on the floor or use a foot stool to achieve a comfortable position.
• D. If working from documents for prolonged periods, these should be placed on a document holder either positioned between the keyboard and monitor or at the same eye level as the screen and close to the monitor. Reading from items placed flat on the desktop may increase the strain on your neck and should be avoided. Books and documents should be elevated onto a sloped surface (e.g. an empty 2-ring folder).
• E. When using the computer mouse, keep the mouse close to the keyboard, use keyboard shortcuts instead of the mouse and alternate which hand uses the mouse.

Current research suggests that spending time standing at work (high set work station) has benefits not only for the neck and back, but also for general health (e.g. by increasing daily activity levels to help maintain healthy body weight). At home and work, try to spend time working in a standing position.

Figure 16. Working at a computer

Whiplash prognosis

Most people with whiplash get better within a few weeks by following a treatment plan that includes pain medication and exercise. However, some people have chronic neck pain and other long-lasting complications. Recovery following whiplash injury, if it is to occur, will occur for the most part within the first 3 months post injury ¹⁷. Current estimates suggest that approximately 50% of individuals will recover by 3 months post injury, whilst the remainder will experience mild to moderate long-term disability ¹⁸, ¹⁹, ²⁰.

Whiplash prognosis varies secondary to comorbidities prior to the injury, severity of whiplash-associated disorders, age, the legal environment and socioeconomic environment ⁸. Full recovery has been shown to occur in a few days to several weeks ⁵⁸. However, disability can be permanent and range from chronic pain to impaired physical function ⁵⁸. There have been inadequate studies that incorporate mitigating factors, such as socioeconomic and legal, which can impact an accurate assessment of recovery ⁸. Legal environment, prior injury, comorbidity, age, and defensive medicine all play roles in the management and outcomes ⁵⁸. In countries where there is little or no litigation, whiplash prognosis is more favorable lending that economic gain for disability may play a role in determining the patient’s reports of full recovery ⁵⁸. For example, in countries such as Lithuania and Greece, where there is no compensation culture and no formal compensation system for late whiplash-related injuries, the development of chronic symptoms following whiplash is a rare phenomenon ²³, ²⁴. This evidence suggests that the culture and expectations around whiplash, local insurance systems, and the prospect of monetary benefits are likely to play important roles in the prevalence of whiplash injuries and related claims, as well as in the recovery process ²⁵. In Germany, for instance, whiplash-associated disorders represent the most common consequence of road traffic accidents, counting approximately 20,000 cases each year and costing insurance companies more than 500 million euro annually ²⁴. Similarly, in Italy, it is estimated that the compensation for whiplash-related damages amounts to more than 2 million euro every year ⁵⁹.

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Joints in the body

Any point where two bones meet is called a joint (articulation), whether or not the bones are mobile at that interface. Joints, or articulations, link the bones of the skeletal system into a functional whole—a system that supports the body, permits effective movement, and protects the softer organs. Joints such as the shoulder, elbow, and knee are remarkable specimens of biological design—self-lubricating, almost frictionless, and able to bear heavy loads and withstand compression while executing smooth and precise movements. Yet it is equally important that other joints be less movable or even immobile. Such joints are better able to support the body and protect delicate organs. The vertebral column, for example, is only moderately mobile, for it must allow for flexibility of the torso and yet protect the delicate spinal cord and support much of the body’s weight. Bones of the cranium must protect the brain and sense organs, but need not allow for movement (except during birth); thus, they are locked together by immobile joints.

The science of joint structure, function, and dysfunction is called arthrology. The study of musculoskeletal movement is kinesiology. This is a branch of biomechanics, which deals with a broad variety of movements and mechanical processes in the body, including the physics of blood circulation, respiration, and hearing.

The name of a joint is typically derived from the names of the bones involved. For example, the atlanto–occipital joint is where the atlas meets the occipital condyles; the glenohumeral joint is where the glenoid cavity of the scapula meets the humerus; and the radioulnar joint is where the radius meets the ulna.

Joints can be classified according to the manner in which the adjacent bones are bound to each other, with corresponding differences in how freely the bones can move. Authorities differ in their classification schemes, but one common view places the joints in four major categories: bony, fibrous, cartilaginous, and synovial
joints.

Bony Joints

A bony joint, or synostosis, is an immobile joint formed when the gap between two bones ossifies and they become, in effect, a single bone. Bony joints can form by ossification of either fibrous or cartilaginous joints. An infant is born with right and left frontal and mandibular bones, for example, but these soon fuse seamlessly into a single frontal bone and mandible. In old age, some cranial sutures become obliterated by ossification and the adjacent cranial bones, such as the parietal bones, fuse. The epiphyses and diaphyses of the long bones are joined by cartilaginous joints in childhood and adolescence, and these become bony joints in early adulthood. The attachment of the first rib to the sternum also becomes a bony joint with age.

Fibrous Joints

A fibrous joint is also called a synarthrosis. It is a point at which adjacent bones are bound by collagen fibers that emerge from one bone, cross the space between them, and penetrate into the other. There are three kinds of fibrous joints: sutures, gomphoses, and syndesmoses. In sutures and gomphoses, the fibers are very short and allow for little or no movement. In syndesmoses, the fibers are longer and the attached bones are more mobile.

Figure 1. Fibrous joints

Note: (a) A suture between the parietal bones. (b) A gomphosis between a tooth and the jaw. (c) A syndesmosis between the tibia and fibula.

Sutures

Sutures are immobile or only slightly mobile fibrous joints that closely bind the bones of the skull to each other; they occur nowhere else. Sutures can be classified as serrate, lap, and plane sutures. Readers with some knowledge of woodworking may recognize that the structures and functional properties of these sutures have something in common with basic types of carpentry joints.

Serrate sutures appear as wavy lines along which the adjoining bones firmly interlock with each other by their serrated margins, like pieces of a jigsaw puzzle. Serrate sutures are analogous to a dovetail wood joint. Examples include the coronal,  sagittal, and lambdoid sutures that border the parietal bones.

Lap (squamous) sutures occur where two bones have overlapping beveled edges, like a miter joint in carpentry. On the surface, a lap suture appears as a relatively smooth (nonserrated) line. An example is the squamous suture where the temporal bone meets the sphenoid and parietal bones. The beveled edge of the temporal bone.

Plane (butt) sutures occur where two bones have straight nonoverlapping edges. The two bones merely border on each other, like two boards glued together in a butt joint. This type of joint is represented by the intermaxillary suture in the roof of the mouth.

Figure 2. Sutures joint

Gomphoses

Even though the teeth are not bones, the attachment of a tooth to its socket is classified as a joint called a gomphosis. The term refers to its similarity to a nail hammered into wood. The tooth is held firmly in place by a fibrous periodontal ligament, which consists of collagen fibers that extend from the bone matrix of the jaw into the dental tissue. The periodontal ligament allows the tooth to move or give a little under the stress of chewing. Along with associated nerve endings, this slight tooth movement allows you to sense how hard you are biting and to sense a particle of food stuck between the teeth.

Syndesmoses

A syndesmosis is a fibrous joint at which two bones are bound by relatively long collagenous fibers. The separation between the bones and length of the fibers give these joints more mobility than a suture or gomphosis has. An especially mobile syndesmosis exists between the shafts of the radius and ulna, which are joined by a broad fibrous interosseous membrane. This permits such movements as pronation and supination of the forearm. A less mobile syndesmosis is the one that binds the distal ends of the tibia and fibula together, side by side.

Cartilaginous Joints

A cartilaginous joint is also called an amphiarthrosis. In these joints, two bones are linked by cartilage. The two types of cartilaginous joints are synchondroses and symphyses.

Figure 3. Cartilaginous joints

Note: a) A synchondrosis, represented by the costal cartilage joining rib 1 to the sternum. (b) The pubic symphysis. (c) Intervertebral discs, which join adjacent vertebrae to each other by symphyses.

Synchondroses

A synchondrosis is a joint in which the bones are bound by hyaline cartilage. An example is the temporary joint between the epiphysis and diaphysis of a long  bone in a child, formed by the cartilage of the epiphyseal plate. Another is the attachment of the first rib to the sternum by a hyaline costal cartilage. The other costal cartilages are joined to the sternum by synovial joints.

Symphyses

In a symphysis, two bones are joined by fibrocartilage. One example is the pubic symphysis, in which the right and left pubic bones are joined anteriorly by the cartilaginous interpubic disc. Another is the joint between the bodies of two vertebrae, united by an intervertebral disc. The surface of each vertebral body is covered with hyaline cartilage. Between the vertebrae, this cartilage becomes infiltrated with collagen bundles to form fibrocartilage. Each intervertebral disc permits only slight movement between adjacent vertebrae, but the collective effect of all 23 discs gives the spine considerable flexibility.

Synovial Joints

The most familiar type of joint is the synovial joint, also called a diarthrosis. Ask most people to point out any joint in the body, and they are likely to point to a synovial joint such as an elbow, knee, or knuckle. Many synovial joints, like these examples, are freely mobile. Others, such as the joints between the wrist and ankle bones and between the articular processes of the vertebrae, have more limited mobility.

Synovial joints are the most structurally complex type of joint and are the type most likely to develop uncomfortable and crippling dysfunctions. They are the most important joints for such professionals as physical and occupational therapists, athletic coaches, nurses, and fitness trainers to understand well. Their mobility makes the synovial joints especially important to the quality of life. Reflect, for example, on the performance extremes of a young athlete, the decline in flexibility that comes with age, and the crippling effect of rheumatoid arthritis.

In synovial joints, the facing surfaces of the two bones are covered with articular cartilage, a layer of hyaline cartilage up to 2 or 3 mm thick. These surfaces are separated by a narrow space, the joint (articular) cavity, containing a slippery lubricant called synovial fluid. This fluid, for which the joint is named, is rich in albumin and hyaluronic acid, which give it a viscous, slippery texture similar to raw egg white. It nourishes the articular cartilages, removes their wastes, and makes movements at synovial joints almost friction-free. A connective tissue joint (articular) capsule encloses the cavity and retains the fluid. It has an outer fibrous capsule continuous with the periosteum of the adjoining bones, and an inner, cellular synovial membrane.

The synovial membrane is composed mainly of fibroblast-like cells that secrete the fluid, and is populated by macrophages that remove debris from the joint cavity. Joint capsules and ligaments are well supplied with lamellar corpuscles and other sensory nerve endings that enable the brain to monitor limb positions and joint movements.

In a few synovial joints, fibrocartilage grows inward from the joint capsule and forms a pad between the articulating bones. In the jaw (temporomandibular) joint, at both ends of the clavicle (sternoclavicular and acromioclavicular joints), and between the ulna and carpal bones, the pad crosses the entire joint capsule and is called an articular disc. In the knee, two cartilages extend inward from the left and right but do not entirely cross the joint. Each is called a meniscus because of its crescent-moon shape. These cartilages absorb shock and pressure, guide the bones across each other, improve the fit between the bones, and stabilize the joint, reducing the chance of dislocation.

Accessory structures associated with a synovial joint include tendons, ligaments, and bursae. A tendon is a strip or sheet of tough collagenous connective tissue that attaches a muscle to a bone. Tendons are often the most important structures in stabilizing a joint. A ligament is a similar tissue that attaches one bone to another.

A bursa is a fibrous sac of synovial fluid located between adjacent muscles, where a tendon passes over a bone, or between bone and skin. Bursae cushion muscles, help tendons slide more easily over the joints, and sometimes enhance the mechanical effect of a muscle by modifying the direction in which its tendon pulls. Tendon (synovial) sheaths are elongated cylindrical bursae wrapped around a tendon, seen especially in the hand and foot. They enable tendons to move back and forth more freely in such tight spaces as the wrist and ankle.

Figure 4. Synovial joint

Classes of Synovial Joints

There are six fundamental types of synovial joints, distinguished by the shapes of their articular surfaces and their degrees of freedom. We will begin by looking at these six types in simple terms, but then see that this is an imperfect classification for reasons discussed at the end. All six types can be found in the upper limb. They are listed here in descending order of mobility: one multiaxial type (ball-and-socket), three biaxial types (condylar, saddle, and plane), and two monaxial types (hinge and pivot).

1. Ball-and-socket joints. These are the shoulder and hip joints—the only multiaxial joints in the body. In both cases, one bone (the humerus or femur) has a smooth hemispherical head that fits into a cuplike socket on the other (the glenoid cavity of the scapula or the acetabulum of the hip bone).
2. Condylar (ellipsoid) joints. These joints exhibit an oval convex surface on one bone that fits into a complementary shaped depression on the other. The radiocarpal joint of the wrist and metacarpophalangeal joints at the bases of the fingers are examples. They are biaxial joints, capable of movement in two planes. To demonstrate this, hold your hand with the palm facing you. Make a fist, and these joints flex in the sagittal plane. Fan your fingers apart, and they move in the frontal plane.
3. Saddle joints. Here, both bones have a saddle-shaped surface—concave in one direction (like the front-to-rear curvature of a horse’s saddle) and convex in the other (like the left-to-right curvature of a saddle). The clearest example of this is the trapeziometacarpal joint between the trapezium of the wrist and metacarpal I at the base of the thumb. Saddle joints are biaxial. The thumb, for example, moves in a frontal plane when you spread the fingers apart, and in a sagittal plane when you move it as if to grasp a tool such as a hammer. This range of motion gives us and other primates that invaluable anatomical hallmark, the opposable thumb. Another saddle joint is the sternoclavicular joint, where the clavicle articulates with the sternum. The clavicle moves vertically in the frontal plane at this joint when you lift a suitcase, and moves horizontally in the transverse plane when you reach forward to push open a door.
4. Plane (gliding) joints. Here the bone surfaces are flat or only slightly concave and convex. The adjacent bones slide over each other and have relatively limited movement. Plane joints are found between the carpal bones of the wrist, the tarsal bones of the ankle, and the articular processes of the vertebrae. Their movements, although slight, are complex. They are usually biaxial. For example, when the head is tilted forward and back, the articular facets of the vertebrae slide anteriorly and posteriorly; when the head is tilted from side to side, the facets slide laterally. Although any one joint moves only slightly, the combined action of the many joints in the wrist, ankle, and vertebral column allows for a significant amount of overall movement.
5. Hinge joints. These are essentially monaxial joints, moving freely in one plane with very little movement in any other, like a door hinge. Some examples are the elbow, knee, and interphalangeal (finger and toe) joints. In these cases, one bone has a convex (but not hemispherical) surface, such as the trochlea of the humerus and the condyles of the femur. This fits into a concave depression on the other bone, such as the trochlear notch of the ulna and the condyles of the tibia.
6. Pivot joints. These are monaxial joints in which a bone spins on its longitudinal axis like the axle of a bicycle wheel. There are two principal examples: the atlantoaxial joint between the first two vertebrae, and the radioulnar joint at the elbow. At the atlantoaxial joint, the dens of the axis projects into the vertebral foramen of the atlas and is held against the anterior arch of the atlas by the transverse ligament. As the head rotates left and right, the skull and atlas pivot around the dens. At the radioulnar joint, the anular ligament of the ulna wraps around the neck of the radius. During pronation and supination of the forearm, the disclike radial head pivots like a wheel turning on its axle. The edge of the wheel spins against the radial notch of the ulna like a car tire spinning in snow.

Figure 5. Six types of synovial joints

Some joints cannot be easily classified into any one of these six categories. The jaw joint, for example, has some aspects of condylar, hinge, and plane joints. It clearly has an elongated condyle where it meets the temporal bone of the cranium, but it moves in a hingelike fashion when the mandible moves up and down in speaking, biting, and chewing; it glides slightly forward when the jaw juts (protracts) to take a bite; and it glides from side to side to grind food between the molars. To observe the importance of the forward glide, try to open your mouth while pushing the jaw posteriorly with the heel of your hand; it is difficult to open the mouth more than 1 or 2 cm when there is resistance to protraction of the mandible.

The knee is a classic hinge joint, but has an element of the pivot type; when we lock our knees to stand more effortlessly, the femur pivots slightly on the tibia. The humeroradial joint acts as a hinge joint when the elbow flexes and a pivot joint when the forearm pronates.

The Jaw Joint

The temporomandibular (jaw) joint (TMJ) is the articulation of the condyle of the mandible with the mandibular fossa of the temporal bone. You can feel its action by pressing your fingertips against the jaw immediately anterior to the ear while opening and closing your mouth. The synovial cavity of the TMJ is divided into superior and inferior chambers by an articular disc, which permits lateral and medial excursion of the mandible. Two ligaments support the joint. The lateral ligament prevents posterior displacement of the mandible. If the jaw receives a hard blow, this ligament normally prevents the condylar process from being  driven upward and fracturing the base of the skull. The sphenomandibular ligament on the medial side of the joint extends from the sphenoid bone to the ramus  of the mandible. A stylomandibular ligament extends from the styloid process to the angle of the mandible but is not part of the TMJ proper.

A deep yawn or other strenuous depression of the mandible can dislocate the TMJ by making the condyle pop out of the fossa and slip forward. The joint is relocated by pressing down on the molars while pushing the jaw posteriorly.

Figure 6. Temporomandibular joint (TMJ)

The Shoulder Joint

The glenohumeral (humeroscapular) joint, or shoulder joint, is where the hemispherical head of the humerus articulates with the glenoid cavity of the scapula. Together, the shoulder and elbow joints serve to position the hand for the performance of a task; without a hand, shoulder and elbow movements are almost useless. The relatively loose shoulder joint capsule and shallow glenoid cavity sacrifice joint stability for freedom of movement. The cavity, however, has a ring of fibrocartilage called the glenoid labrum around its margin, making it somewhat deeper than it looks on a dried skeleton.

The shoulder is stabilized mainly by the biceps brachii muscle on the anterior side of the arm. One of its tendons arises from the long head of the muscle, passes through the intertubercular groove of the humerus, and inserts on the superior margin of the glenoid cavity. It acts as a taut strap that presses the humeral head against the glenoid cavity. Four additional muscles help to stabilize this joint: the supraspinatus, infraspinatus, teres minor, and subscapularis. Their tendons form the rotator cuff, which is fused to the joint capsule on all sides except the inferior.

Five principal ligaments also support this joint. Three of them, called the glenohumeral ligaments, are relatively weak and sometimes absent. The other two are the coracohumeral ligament, which extends from the coracoid process of the scapula to the greater tubercle of the humerus, and the transverse humeral ligament, which extends from the greater to the lesser tubercle of the humerus and forms a tunnel housing the tendon from the long head of the biceps.

Four bursae occur at the shoulder. Their names describe their locations: the subdeltoid, subacromial, subcoracoid, and subscapular bursae. The deltoid is the large muscle that caps the shoulder, and the other bursae are named for parts of the scapula.

Figure 7. Shoulder joint

The Elbow Joint

The elbow is a hinge joint composed of two articulations: the humeroulnar joint where the trochlea of the humerus joins the trochlear notch of the ulna, and the humeroradial joint where the capitulum of the humerus meets the head of the radius. Both are enclosed in a single joint capsule. On the posterior side of the elbow, there is a prominent olecranon bursa to ease the movement of tendons over the joint. Side-to-side motions of the elbow joint are restricted by a pair of ligaments: the radial (lateral) collateral ligament and ulnar (medial) collateral ligament.

Another joint occurs in the elbow region, the proximal radioulnar joint, but it is not involved in the hinge. At this joint, the edge of the disclike head of the radius fits into the radial notch of the ulna. It is held in place by the anular ligament, which encircles the radial head and is attached at each end to the ulna. The radial head rotates like a wheel against the ulna as the forearm is pronated or supinated.

Figure 8. Elbow joint

The Hip Joint

The coxal (hip) joint is the point where the head of the femur inserts into the acetabulum of the hip bone. Because the coxal joints bear much of the body’s weight, they have deep sockets and are much more stable than the shoulder joint. The depth of the socket is somewhat greater than you see on dried bones because of a horseshoeshaped ring of fibrocartilage, the acetabular labrum, attached to its rim. Dislocations of the hip are rare, but some infants suffer congenital dislocations because the acetabulum is not deep enough to hold the head of the femur in place. If detected early, this condition can be treated with a harness, worn for 2 to 4 months, that holds the head of the femur in the proper position until the joint is stronger.

Figure 9. Hip joint

The Knee Joint

The tibiofemoral (knee) joint is the largest and most complex diarthrosis of the body. It is primarily a hinge joint, but when the knee is flexed it is also capable of slight rotation and lateral gliding. The patella and patellar ligament also articulate with the femur to form a gliding patellofemoral joint. The joint capsule encloses only the lateral and posterior aspects of the knee joint, not the anterior. The anterior aspect is covered by the patellar ligament and the lateral and medial patellar retinacula. These are extensions of the tendon of the quadriceps femoris muscle, the large anterior muscle of the thigh. The knee is stabilized mainly by the quadriceps tendon in front and the tendon of the semimembranosus muscle on the rear of the thigh. Developing strength in these muscles therefore reduces the risk of knee injury. The joint cavity contains two C-shaped cartilages called the lateral and medial menisci (singular, meniscus) joined by a transverse ligament. The menisci absorb the shock of the body weight jostling up and down on the knee and prevent the femur from rocking from side to side on the tibia.

The posterior popliteal region of the knee is supported by a complex array of extracapsular ligaments external to the joint capsule and two intracapsular ligaments within it. The extracapsular ligaments include two collateral ligaments that prevent the knee from rotating when the joint is extended—the fibular (lateral) collateral ligament and the tibial (medial) collateral ligament—and other ligaments. The two intracapsular ligaments lie deep within the joint. The synovial membrane folds around them, however, so that they are excluded from the fluid-filled synovial cavity. These ligaments cross each other in the form of an X; hence, they are called the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). These are named according to whether they attach to the anterior or posterior side of the tibia, not for their attachments to the femur. When the knee is extended, the ACL is pulled tight and prevents hyperextension. The PCL prevents the femur from sliding off the front of the tibia and prevents the tibia from being displaced backward. The ACL is one of the most common sites of knee injury.

Figure 10. Knee joint

The Ankle Joint

The talocrural (ankle) joint includes two articulations—a medial joint between the tibia and talus and a lateral joint between the fibula and talus, both enclosed in one joint capsule. The malleoli of the tibia and fibula overhang the talus on each side like a cap and prevent most side-to-side motion. The ankle therefore has a more restricted range of motion than the wrist.

The ligaments of the ankle include (1) anterior and posterior tibiofibular ligaments, which bind the tibia to the fibula; (2) a multipart medial (deltoid) ligament, which binds the tibia to the foot on the medial side; and (3) a multipart lateral (collateral) ligament, which binds the fibula to the foot on the lateral side. The calcaneal (Achilles) tendon extends from the calf muscles to the calcaneus. It plantarflexes the foot and limits dorsiflexion. Plantar flexion is limited by extensor tendons on the anterior side of the ankle and by the anterior part of the joint capsule.

Sprains (torn ligaments and tendons) are common at the ankle, especially when the foot is suddenly inverted or everted to excess. They are painful and usually accompanied by immediate swelling. They are best treated by immobilizing the joint and reducing swelling with an ice pack, but in extreme cases may require a cast or surgery.

Figure 11. Ankle joint

Pronation and Supination

Supination and pronation are known primarily as forearm movements, but see also the later discussion of foot movements.

Supination of the forearm is a movement that turns the palm to face anteriorly (in anatomical position) or palm facing up; in anatomical position, the forearm is supinated and the radius is parallel to the ulna.

Pronation is the opposite movement, causing the palm to face posteriorly or palm facing down and the radius to cross the ulna like an X. During these movements, the concave end of the disc-shaped head of the radius spins on the capitulum of the humerus, and the edge of the disc spins in the radial notch of the ulna. The ulna remains relatively stationary.

As an aid to remembering these terms, think of it this way: pronation = palm facing down; supination = palm facing up. You are prone to stand in the most comfortable position, which is with the forearm pronated. But if you were holding a bowl of soup in your palm, you would need to supinate the forearm to keep from spilling it.

The movements of supination and pronation occur through approximately 180° at the radioulnar joints. During pronation the radius rotates across the ulna and twists the forearm and hand so that the palm faces posteriorly. Supination returns the limb to the anatomical position. The axis of the movement passes through the head of the radius and the styloid process of the ulna. Supination is the more powerful movement and is produced by biceps and supinator, although biceps is ineffective when the elbow is fully extended. Pronation is produced by pronator teres and pronator quadratus. Also, when the elbow is flexed, brachioradialis rotates the forearm and returns the limb to the midposition from the extremes of supination or pronation. The head of the radius can be felt rotating about 2 cm distal to the lateral epicondyle during these movements.

Figure 1. Movements of the forearm

Note: Movements of the forearm. A. Flexion and extension at the elbow joint. B. Pronation and supination.

Figure 2. Supination and pronation of the hand

Supination and pronation of foot

The ankle joint is synovial (a type of joint which is surrounded by a thick flexible membrane forming a sac into which is secreted a viscous fluid that lubricates the joint) in type and involves the talus of the foot and the tibia and fibula of the leg (Figure 3). The ankle joint mainly allows hinge-like dorsiflexion and plantarflexion of the foot on the leg.

Figure 3. Ankle joint

Note: Ankle joint. (A) Anterior view with foot plantarflexed. (B) Schematic of joint. (C) Superior view of the talus to show the shape of the articular surface.

Figure 4. Ankle joint dorsiflexion and plantarflexion

The distal end of the fibula is firmly anchored to the larger distal end of the tibia by strong ligaments. Together, the fibula and tibia create a deep bracket-shaped socket for the upper expanded part of the body of the talus (Figure 3):

• The roof of the socket is formed by the inferior surface of the distal end of the tibia.
• The medial side of the socket is formed by the medial malleolus of the tibia.
• The longer lateral side of the socket is formed by the lateral malleolus of the fibula.

The articular surfaces are covered by hyaline cartilage. The articular part of the talus is shaped like a short half cylinder tipped onto its flat side with one end facing lateral and the other end facing medial. The curved upper surface of the half-cylinder and the two ends are covered by hyaline cartilage and fit into the bracket-shaped socket formed by the distal ends of the tibia and fibula.

When viewed from above, the articular surface of the talus (ankle joint) is much wider anteriorly than it is posteriorly. As a result, the bone fits tighter into its socket when the foot is dorsiflexed and the wider surface of the talus moves into the ankle joint than when the foot is plantarflexed and the narrower part of the talus is in the joint. The joint is therefore most stable when the foot is dorsiflexed.

The articular cavity is enclosed by a synovial membrane, which attaches around the margins of the articular surfaces, and by a fibrous membrane, which covers the synovial membrane and is also attached to the adjacent bones.

The ankle joint is stabilized by medial (deltoid) and lateral ligaments.

Medial ligament (deltoid ligament)

The medial (deltoid) ligament is large, strong (Figure 5) and triangular in shape. Its apex is attached above to the medial malleolus and its broad base is attached below to a line that extends from the tuberosity of the navicular bone in front to the medial tubercle of the talus behind.

The medial ligament is subdivided into four parts based on the inferior points of attachment:

1. The part that attaches in front to the tuberosity of the navicular and the associated margin of the plantar calcaneonavicular ligament (spring ligament), which connects the navicular bone to the sustentaculum tali of the calcaneus bone behind, is the tibionavicular part of the medial ligament.
2. The tibiocalcaneal part, which is more central, attaches to the sustentaculum tali of the calcaneus bone.
3. The posterior tibiotalar part attaches to the medial side and medial tubercle of the talus.
4. The fourth part (the anterior tibiotalar part) is deep to the tibionavicular and tibiocalcaneal parts of the medial ligament and attaches to the medial surface of the talus.

Figure 5. Ankle bones and medial ankle ligaments (medial or inner ankle view)

Lateral ankle ligament ligament

The lateral ligament of the ankle is composed of three separate ligaments , the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament (Figure 6):

1. The anterior talofibular ligament is a short ligament and attaches the anterior margin of the lateral malleolus to the adj acent region of the talus.
2. The posterior talofibular ligament runs horizontally backward and medially from the malleolar fossa on the medial side of the lateral malleolus to the posterior process of the talus.
3. The calcaneofibular ligament is attached above to the malleolar fossa on the posteromedial side of the lateral malleolus and passes posteroinferiorly to attach below to a tubercle on the lateral surface of the calcaneus.

Figure 6. Ankle bones and lateral ankle ligaments (lateral or outer ankle view)

Note: Lateral ligament of the ankle joint. (A) Lateral view. (B) Posterior view.

Intertarsal joints

The numerous synovial joints between the individual tarsal bones mainly invert, evert, supinate, and pronate the foot:

• Inversion and eversion. Inversion is turning the sole of the foot inward. Eversion is turning the whole sole of the foot outward.

• Pronation and supination, while used mainly for forearm movements, also apply to the feet but refer here to a more complex combination of movements. Pronation of the foot is a combination of dorsiflexion, eversion, and abduction—that is, the toes are elevated and turned away from the other foot and the sole is tilted away. Supination of the foot is a combination of plantar flexion, inversion, and adduction—the toes are lowered and turned toward the other foot and the sole is tilted toward it. These may seem a little difficult to visualize and perform, but they are ordinary motions in walking, running, ballet, and crossing uneven surfaces such as stepping stones. Pronation and supination allow the foot to maintain normal contact with the ground when in different stances or when standing on irregular surfaces. You can perhaps understand why these terms apply to the feet if you place the palms of your hands on a table and pretend they are your soles. Tilt your hands so the inner edge (thumb side) of each is raised from the table. This is like raising the medial (inner) edge of your foot from the ground, and as you can see, it involves a slight supination of your forearms. Resting your hands palms down on a table, your forearms are already pronated; but if you raise the outer edges of your hands (the little finger side), like pronating the feet, you will see that it involves a continuation of the pronation movement of the forearm.

Figure 7. Foot inversion and eversion

Figure 8. Intertarsal joint