John (that’s not his real name) is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all, Let alone the type of running required to play competitive soccer against younger men. John’s left leg is riddled with arthritis.
John’s arthritic left leg is an anomaly because the whole rest of his body is extremely strong, mobile and healthy for its age.
To understand a left leg like Johns, you have to view it in its context. John’s whole body is exceptionally mobile and healthy for his age, he has the look of a lifelong athlete and all-around strongman because that’s what he is. No part of him is 30 years old any more. But he has no signs of stiffness or weakness anywhere in his arms, spine, or right leg. His overall mobility is excellent for his age, hence in part, the long soccer career.
John’s left leg is another story. It has advanced osteoarthritis in every major joint. His knee, hip and ankle are all severely arthritic. They stand in complete contrast to the rest of his body which is not even mildly arthritic, let alone suffering from advanced cartilage loss. He has had four separate arthroscopic surgeries at different times. All on joints in his left leg.
It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.
Computerised gait analysis measures the distribution of weight in each foot during walking and running in great detail. It then compares the left with the right to establish whether there is a gait insufficiency or asymmetry compared with the normal population. Essentially, it’s a dynamic postural analysis of the lower limb.
Gait analysis of John’s left leg reveals a catastrophic degree of pronation (arch collapse) with every step. While John’s healthy leg only exhibits the slightest amount of pronation (the amount he was born with). The pronation reveals that his gluteal muscles have wasted away to nothing on his arthritic side. His knee, ankle and hip all collapse inwards with every step – Millions of times yearly on the same side as all the arthritis.
Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough.
It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.
Computerised gait analysis measures the distribution of weight in each foot during walking and running in great detail. It then compares the left with the right to establish whether there is a gait insufficiency or asymmetry compared with the normal population. Essentially, it’s a dynamic postural analysis of the lower limb.
Gait analysis of John’s left leg reveals a catastrophic degree of pronation (arch collapse) with every step. While John’s healthy leg only exhibits the slightest amount of pronation (the amount he was born with). The pronation reveals that his gluteal muscles have wasted away to nothing on his arthritic side. His knee, ankle and hip all collapse inwards with every step – Millions of times yearly on the same side as all the arthritis.
Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough.
When John was 16 years old, the full weight of an adolescent rugby scrum collapsed onto his left ankle. The resulting sprain was so bad that he was on crutches for five months. He confesses that his ankle never felt the same again. He also recalls that he sustained two further bad sprains during his late teens and early 20s. Mystery solved.
The joint trauma, scar tissue and muscle wasting left in the wake of the ankle sprain left John with a severely unstable foot and ankle. And if you have an unstable ankle, you have an unstable leg, foundations being what they are. The chronic instability caused chronic wear and tear, not only in the ankle but also in the knee and hip. Yet it was more than three decades before John started to really feel the longer-term impact his ankle injury would have on the hip and knee.
As for John playing masters football on such a severely compromised leg, that was easily attributable to a combination of innate athleticism and sheer belligerence. Despite this, once he had seen the results of his gait analysis and finally understood why his left leg was so compromised, he played the last two matches of the season. Finally, he retired—instead, choosing to pursue general exercises and rehab to prevent further unnecessary joint degeneration. He had never connected the ankle sprains with the arthritis he had in that leg, nor had any of his previous healthcare providers.
Despite the common and somewhat irrefutable nature of case studies like John’s ankle, there is still some scholarly debate over the true prevalence of joint degeneration after injury; because the current data is far from conclusive. Yet there is so much data, clinically, statistically and anecdotally, there is a consensus about there at least being some level of correlation. And arthritis aside, there is certainly no doubt about the high prevalence of further pain and injuries after ankle sprains and the like.
A study published in the Journal of Athletic Training in 2019 highlighted what countless clinicians have known for a long time. Up to 70% of people who sustain an acute ankle sprain develop some level of residual physical disability in that leg. This study highlights the devastating potential of ankle sprains; and also the fact that we struggle to effectively rehab even the most straightforward musculoskeletal injuries.
We need to do a better job of injury care if we are going to conquer the pandemic of chronic pain we live in at this point in history. Unrehabilitated injuries and complex injuries contribute significantly to the pain burden. Walking must always come before running, individually and collectively. So, if we can’t get to grips with the humble ankle sprain, what chance do we have of conquering back pain, complex PTSD-associated pains and an opioid epidemic?
Improved injury management is as much a mindset as it is a set of rehab approaches.
If we adopt a mindset where we assume that all but the most extreme injury events have something to reveal about the integrity of our musculoskeletal chains, we have made a giant step towards better care of injuries, complex injuries and complex pain.
If we adopt a mindset where we assume that the injuries seen on scans and x-rays are just the tip of the injury iceberg; and that other more subtle but significant soft tissue injuries play out ‘under the medical radar’. A world of injury and pain healing approaches opens up to us.
If we adopt a mindset where we are willing to give our painful and ‘injury-prone’ body parts the kind of long-term attention we give our teeth, we will have made another quantum leap towards preventing long-term pain and disability.
Once we have made this small handful of shifts in our belief structure around injuries and rehabilitation, we become open to proper use of the full injury and pain rehabilitation toolkit, in which the techniques and approaches are often surprisingly straightforward. Just like flossing your teeth daily and seeing a hygienist twice a year is straightforward.
Pain is a symptom. Symptoms are the feedback that the body generates when it faces problems with its delicate internal balance (homeostasis). Without symptoms like pain, thirst, nausea and fevers, it would be very difficult for us to maintain a healthy body in the same way that it would be hard to drive a car safely with no dashboard display.
John is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all, Let alone the type of running required to play competitive soccer against younger men.
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