What percentage of all ankle sprains are on the lateral side?


Ankle region - lateral - MS Clip artThere are approximately 25,000 people in the US who get ankle sprains per day.  Ankle sprains are the most common type of sports injury accounting for approximately 50% of all athletic injuries.  Of these, approximately 80% of them are lateral ankle sprains (on the outside of the ankle).

A sprain is when a ligament gets damaged (as opposed to a strain where tendons or muscles are the primary tissue damaged).  A ligament is a band of connective tissue that connects one bone to another bone.  Sprains are broken into 3 different categories.

  • Category 1 – A mild sprain with some swelling and stretching of the ligament
  • Category 2 – A moderate sprain with 1-99% of the ligament ruptured
  • Category 3 – A severe sprain with complete rupture of the ligament.

Why do most of the ankle sprains happen on the lateral side?  A little background first.  Joints can broadly be categorized as being held together in one of 3 major ways.  Primarily by: 1) bones; 2) muscles or 3) ligaments.  The ankle is held together primarily by ligaments.

There is a major difference in the strength of the ligaments on the medial (middle) side of the ankle compared to the lateral side.  The medial ligament is a broad solid triangle of connective tissue called the deltoid ligament.  The lateral side of the ankle has primarily 3 relatively small strands of ligaments.  The relatively poor ligament strength on the lateral side of the ankle is responsible for the much higher percentage of sprains taking place on the that side.

Which of these 3 lateral ankle ligaments is most commonly sprained?  This is determined by an additional factor that has to do with the shape of the bones.  The ankle joint is formed by the distal ends of the tibia and fibula (the lower leg bones) together making a ‘U’ shaped notch where the talus (upper foot bone) fits into.  The talus surface that fits into the notched tibia/fibula is not the same width throughout the foot’s range of motion.  It is widest and fits most snugly when the foot is in the standing position.  When the foot is pointed down, the articular surface of the talus that fits into the notch is more narrow and fits loosely.

This result in the ankle joint being relatively wobbly when the foot is pointed.  Common activities that result in this more unstable position happen when the foot is in front of the body and just making contact with the ground during the gait cycle.  This gives rise to the very common scenario of someone twisting and spraining their lateral ankle when they are running and their foot lands on an uneven surface or rock and twists to the outside.  The ligament that takes the brunt of this damaging twist is the anterior (towards the toes) of the 3 lateral ankle ligaments.

Seminar Intensive At Your Facility


Happy PeopleThe Diagnosis Foundation (DxF) has a new intensive seminar program we want you to know about.  The DxF is offering to come to your facility and train your staff to test individual muscles for strength.  Additional details on the seminar content is located below.

Seminar Intensive – Weekend

  • Location: The DxF will do the training at your facility in the Long Island, Metro NY area
  • Attendance: 1-13 people – staff, clients, friends  (6’x8′ space required for every 2 people to do the hands on portion of the program)
  • Schedule: The training is a total of 13 hours (6.5 hours per day in one weekend, Saturday & Sunday)
  • Price: Flat introductory pricing of $1300 for the weekend.Same price if 1 attends, or 13 attends. If you have the maximum of 13 in attendance, that works out to $100 per person or almost 80% off our regular price.  This introductory pricing is available through Friday, December 13, 2013.

– or –

Seminar Intensive – Weekdays

  • Location: The DxF will do the training at your facility in the Long Island, Metro NY area
  • Attendance: At least 4 people – staff, clients, friends (some experience with anatomy recommended) Maximum attendance is only limited by your available space to do the hands on portion of the program (6’x8′ for every 2 people)
  • Schedule: The training to fit your needs (12 hours total, split between 2-4 days) This allows you to train your staff after hours or during off peak times.
  • Price: $450 ea.  With every 5 paid seminar attendees at your site, you will receive one seminar admission free.  This works out to: 5 X $450 + 1 free is the same as 6 at $375
  • Contact us – to check available dates and schedule your seminar: Info@DxFoundation.org

– or –

Seminar Intensive – At our facility

  • Location: Miller Place, NY (Just east of Port Jefferson on the north shore of Long Island)
  • Attendance: 1 to a maximum of 6 per seminar
  • Schedule: Next Intensive – February 1 & 2, Saturday & Sunday from 9 am – 4:30 pm
  • Price: Early bird registration – $350 up until January 17, $400 up until January 31, $450 at the door

Content: This 32 hour seminar will cover the anatomy, bio-mechanics, physiology, procedures and legal environment to perform 13 key manual muscle strength tests* in the lower limbs.  Time will be allotted for Q & A as well as practicing the muscle tests.

This is the same educational content offered in the DxF’s 4 day Educational Seminar or our 4 week online self study course, but given at a faster pace.  Because of this pace, we are recommending this program for people who have some knowledge of exercise training or anatomy.  This program will be ideal for your staff and more knowledgeable clients.

Certification: The Seminar Intensive includes the educational content only.  It does NOT include the written, practical or applied certification exams.  The certification exams may be purchased separately if desired.

For additional information or to schedule your sessions: Info@DxFoundation.org

*Muscle tests included in this seminar:

  • Biceps Femoris – Short head
  • Gluteus Maximus – Femoral head
  • Gluteus Maximus – Tibial head
  • Tibialis anterior
  • Tibialis posterior
  • Fibularis longus
  • Fibularis brevis
  • Rectus femoris
  • Tensor Fascia Latae
  • Psoas major
  • Gracilis
  • Pectineus
  • Gluteus medius

More Info:

Seminar Intensive – Balanced Muscle Strength testing: Legs
Even pros have muscle strength imbalances
What can cause muscle strength imbalances?
My muscle strength test is abnormal, what next?
Manual Muscle Strength Testing: Validity & Reliability
Seminar Intensive – Millers Place, NY
Online Self Study Course – $100
Online Certification Course – $300
4 day Education Seminar – $1000
5 day Certification Seminar – $1125
“Of these 36 [professional] players, 23 still showed significant muscular imbalance (64%). New trends in rational training could focus more on the risk of imbalance…”  Scandinavian Journal of Medicine & Science in Sports

Manual Muscle Strength Testing: Validity & Reliability


Glute Med - anterior view - half bodyManual muscle strength testing has been around at least since 1915 with over 6 textbooks on the topic currently in publication. Let’s first define exactly what we are talking about when we describe manual muscle strength testing for this article.

Muscle testing falls broadly into 2 major categories. One category uses testing to measure strength based upon the functional capacity of the muscle and the directly affiliated nerves. This method has been used for many decades by a wide range of practitioners, trainers, therapists, etc. The other category utilizes muscle testing as a method of gaining insights into remote areas of the body, biochemistry or even other people. This second method of utilizing muscle testing is affiliated with the field of Applied Kinesiology.  This article is addressing the first category of measuring direct muscle strength.

Muscle testing may be done using equipment, manual methods or a hybrid of the two. State of the art testing where documentation is required for insurance or legal cases typically involves sophisticated equipment (i.e. Cybex, Biodex). While muscle strength testing with this type of equipment can be extremely accurate, it tends to be limited in the number of different muscles that can be measured and takes extensive amounts of time and money to perform.

Manual muscle testing for strength utilizes the examiner’s senses to evaluate how much strength the subject is capable of producing with each test. Accuracy suffers to some degree because of this and results are recorded in a semi-quantative manner (i.e. 0-100%) rather than in pounds of force. On the plus side, manual testing offers a much broader range of muscles that can be measured and can be done in a much quicker time frame and lower cost.

Hybrid systems utilize devices that the examiner holds in their hand to measure the peak force that subjects can exert with their muscles. These hybrid systems are somewhere in between the sophisticated systems and purely manual methods regarding the number of different muscles that can be tested and the accuracy of the results, time and cost.

Research has been extensive on manual muscle strength testing (MMST) as well as technology assisted manual testing methods, a small sample is included here.  (1, 2, 3, 4, 5) These finding support the idea that MMST has good reliability and validity for patients with neuromusculoskeletal dysfunction. These studies demonstrate good external and internal validity, and 12 randomized controlled trials (RCTs)  show that MMST findings were not dependent upon examiner bias.  Accuracy results vary from a low in the 70% range variability between examiners to as high as the 90% range.

1 – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847521/
2 – http://www.ncbi.nlm.nih.gov/pubmed/16585903
3 – http://www.ncbi.nlm.nih.gov/pubmed/21572637
4 – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259988/?tool=pmcentrez&rendertype=abstract
5 – http://www.ncbi.nlm.nih.gov/pubmed/17999004

Weak Fibularis Longus muscle leads to…


Peroneus longus - BP3DWhen the Fibularis Longus is weak, what kinds of performance and health issues can you get?  Let’s look at Fibularis Longus (FL) anatomy, actions, measurement methods along with the implications weak FL strength can have on your athletic performance and health.

Note: The Fibularis Longus is also known as the Peroneus Longus muscle.  The fibularis longus terminology has an advantage when learning anatomy in that it indicates the muscle is on the fibula side of the lower leg.

Anatomy – The FL is located on the lateral side (outer side or side with the fibula) of the lower leg and is superficial (towards the skin).  The top of the muscle attaches to the upper 2/3 of the fibula and the deep connective tissue between the tibia & fibula.  The muscle runs down the lateral side of the calf, connects to its’ long round tendon which runs behind the lateral ankle.  From there, the tendon crosses to the opposite side of the bottom of the foot.  The path of the tendon is on the plantar (bottom) side of the foot traveling on a diagonal from behind the lateral ankle towards the peak of the long arch.   There it attaches to the base of the 1st metatarsal and 1st cuneiform bones.

Action – The main action of this muscle is to plantar flex (point) your foot and at the same time, evert it (twist towards the outside).  This can be summarized as, “pointing your foot down and out”.

Diagnosis – Weakness in the FL can be determined with manual muscle strength testing, careful observation of ankle alignment during walking, running and at rest and other tests. Supporting information can be gained through a detailed history as well as physical examination for neurological, vascular and orthopedic signs.  Measurement of FL ranges of motion and muscle strength are available with specialized equipment when required for more detailed examinations, insurance purposes or research.

Functional Implications – When the FL muscle is weak, you will not have the strength you should in the following situations. 1) lateral ankle stability, 2) lateral movements of the body to the opposite side, 3) lateral movements of the foot to the same side.  With a weak FL, all of the following activities will not be as effective as they could be.

1)  Lateral Ankle stability – Because of the shape of the bones in the ankle regions, the ankle is most unstable when the foot is plantar flexed.  This means that you cannot rely as much on bone or ligament strength to maintain stability. The FL along with it’s smaller neighbor Fibularis Brevis are the only muscles that support the lateral ankle when the foot is in plantar flexion.  Having adequate strength in the FL is thus critical in any activity that requires maintaining ankle stability.  For example, running over rough terrain, sticking a landing in gymnastics or ‘holding an edge’ when snow skiing.  This will also be a critical factors for seniors who have balance issues and are looking to prevent traumatic falls.

2) Lateral movement of the body to the opposite side –  Any sport that includes movement of the body laterally will have degraded performance with a weak FL.  Let’s clarify which type of lateral movement will be impaired with this example – the right FL will assist in moving your body to the left side.

The FL does not function in a purely lateral motion.  It simultaneously includes plantar flexion.  This compound motion can be used for both acceleration and deceleration movements that include a diagonal component to the opposite side.

  • Acceleration Forward – When in the ‘toe off’ gait phase with your right leg behind your body, the right FL will assist in accelerating you forward on the diagonal to the left.
  • Acceleration Backward – From a normal standing position, the right FL will assist with accelerating your body backwards and towards the left.  An example of this motion would be a basketball player jumping backward and to the left side for a lateral fadeaway shot at the basket.
  • Deceleration Forward – When moving forward and your right leg is coming into ‘heel strike’, the FL will assist you in deceleration or putting on the breaks with some additional movement towards the left side.  For example – this would happen in a situation where a football runner decelerates quickly and moves to the left to evade a tackler.
  • Deceleration Backwards – If you are moving backward and your right leg is coming into ‘toe strike’ behind you, the FL will assist you in decelerating while also giving you some lateral movement to the left.  An example of this would be a hockey player skating backward and trying to slow down while also changing the angle of backward movement more to the left side.

 3) Lateral movement of the foot to the same side – Sports that use the FL for this function include soccer players kicking a ball with their outside forefoot.

Injury Susceptibility – In addition to performance degradation, athletes with weak FL muscles, will be susceptible to increased rates of injury due to ankle instability.  As mentioned earlier, the ankle is particularly unstable when in plantar flexion (the foot is pointed down).  In addition,  the ligaments on the lateral ankle are much weaker than on the medial side.  This combination of factors makes lateral ankle sprains when the foot is pointed, the most common form of ankle sprain.

An example of the classic ankle sprain is the runner who is landing on their foot and there is a rock under the medial side.  The foot will be pointed and unstable and it will roll to the outside.  If the FL is not strong enough, the sudden weight put on the FL will cause a strain (tearing some muscle fibers).  As the joint continues to roll laterally, unprotected by an adequate FL, weight will eventually be thrust on the relatively weak lateral ankle ligaments resulting in a partial or complete sprain (ligament tear).

Chronic Weakness – With a classic lateral ankle sprain, both the FL and the lateral ankle ligaments are damaged.  Rather frequently, therapy is only oriented to recovery of the ligament.  The joint is immobilized or supported with athletic tape, rigid or semi-rigid device until the ligaments can take weight bearing without difficulty.  Rehabilitating the FL with specific exercises to increase strength of the damaged tissue is frequently necessary to prevent a chronic weakness of the FL and increased susceptibility to recurring ankle sprains, instability and  performance degradation.

Learn how to test for muscle strength imbalances with education certification courses offered by the Diagnosis Foundation.  Then you can help identify muscle weakness early, when correction takes minimal effort.

How to eat organic for less?


Grapes on grapevine, close-up.If you read the research, you know that organic is better for you. it provides less exposure to toxins and more nutrients. More nutrients means more flavor, more flavor means you eat less. Here is an idea. We found a discount “food barn” that buys produce from local markets. The produce is organic and it has been rotated out of the stock on the shelf because maybe the life of the fruit / veggie is limited (2-5 days). We bought 40 lbs of organic bananas for $6 to store in our office freezer to make smoothies!

We’ve been using this supply for 2 months and we are still going strong! Share your cost cutting ideas with us.

How many skeletal muscles does the body have?



The body has more than 650 muscles. From the smallest, the stapedius muscle (1) in the inner ear, to the largest, gluteus maximus. (2)  This does not include muscles that do not attach to bones.  Examples of non-skeletal muscles would include the muscles in the gastro-intestinal tract, blood vessels or urinary system.

Some factors to consider for maximizing your muscular health are:

  • Do your muscles have the appropriate balance of strength compared to the same muscle on the opposite side of the body when paired?
  • For joints that have more than one muscle involved, what is the relative balance of strength?
  • Is the length of all the muscles involved in any specific joint appropriate?  For example, The strength of all the muscles controlling the shoulder joint may all be appropriate, but due to excessive stretching in certain directions, the resting ‘neutral’ position of the shoulder may not be correct.
  • Timing – when doing various activities, multiple muscles may need to fire with specific strengths in very tightly controlled sequences.  If the timing or strength of firing is off, the joints will not be controlled properly resulting in inefficiencies, damage or injuries.
  • More factors to consider include: speed of firing, ranges of motion, independence of action, neurological control and endurance.

With musculo-skeletal conditions being the second most common reason for office visits to doctors, there is plenty of room for each of us to improve our muscle awareness and the factors that could be involved for biomechanical health.  Let’s all commit to learning a bit more about our bodies every day.

  • How many of your muscles can you name?
  • How many of these do you know any performance measure for (strength, length, speed, etc.)?



Screening at Commack Ambulance Corps 5 K Run – Aug. 24


Commack Ambulance 5K Logo

The Diagnosis Foundation will be exhibiting and performing balanced muscle strength screenings at the Commack Ambulance Corps, 5 K Run.  This event is open to the public and the Health Fair / DxF Screening is free.

When: The events will take place on Saturday, August 24, 2013

Where: Sawmill Intermediate School 103 New Highway, Commack NY 11725

Registration Closing Date: Friday, August 23, 2013 @ 6:00 am

Activities include:

  • DxF Free Health & Fitness Screening: Balanced Muscle Strength testing of 12 muscles in the legs.  Designed to improve runner’s athletic performance, decrease injuries and prevent certain forms of osteoarthritis.
  • 5K Run
  • Awards

This event is to raise money to benefit the volunteer members of the Commack Volunteer Ambulance Corps. All proceeds will go to benefit the membership.


For additional info: