【踮起腳尖痛，腳踝也會有夾擠問題？】

(這次文章內容稍長，若懶得看文字內容可直接觀看影片)

大家應該對於肩夾擠、髖夾擠這兩個名詞不陌生，但你有聽過腳踝夾擠嗎？夾擠指的是我們的骨頭過度擠壓到周遭的軟組織，可能是肌腱、韌帶或是滑液膜等等，造成疼痛或角度受限。夾擠是一個症候群，並非一個特定的病症，夾擠症候群底這個名詞底下，可能夾到的組織不同，造成的原因歧異度也非常大，造成評估上其實並不是那麼容易。腳踝夾擠雖然沒有像肩夾擠一樣有被正式分類成不同的夾擠類型，但仍能根據症狀呈現的方式跟解剖構造簡單分為前夾擠跟後夾擠，若還要再細分還會分前內側、前外側夾擠，以及後內側、後外側夾擠。

前側夾擠的症狀主要出現在腳踝背屈末端角度的時候，脛距關節 (Tibiotalar joint) 前側的組織受到擠壓。腳踝前側的有不少脂肪、滑囊組織，正常情況，這些組織會在腳踝背屈15度過後受到擠壓，但如果在遠端脛骨前側或是距骨頸有增生的骨頭的話，便可能限縮前側的空間，讓組織提早受到壓迫。如果長期在這角度下活動，就可能進一步造成慢性的發炎，或是造成關節囊韌帶的增生。除此之外，如果腳踝曾經扭過傷，造成韌帶或皺襞增厚的話，也是可能造成前側夾擠的原因之一。

雖然這些解剖構造上的變化已有多篇文章有所描述。但造成這些組織增生的原因卻仍不是很清楚。因為運動員有比較高的比例有這樣的問題，有些學者認為前側夾擠可能是因為頻繁地做出大角度的背屈，或是因為運動過程中受到的外力，讓前側軟骨邊緣反覆受到衝擊所造成。也有些學者認為，踝關節的不穩定，造成關節有不正常的微小滑動，也是一個可能造成骨質增生、或是軟組織受到夾擠的的原因。另外在比較早期的文章，一開始學者認為前側的骨質增生可能是來自於頻繁地蹠屈，牽拉到關節囊，進而造成關節處的增生，只是這樣的假設被後來的研究給推翻了。

因為前側夾擠症狀大多是在腳踝背屈的末端角度下出現，上樓梯、跑步、走上坡、爬梯還有深蹲是幾個比較容易會加劇前側疼痛的活動。若未接受妥善治療，在症狀後期可能會因為組織的增生或疼痛，造成更進一步的活動度受限、夾擠和周圍組織的傷害，再回頭限制關節活動度與功能，形成惡性循環。

後側夾擠的症狀主要出現在腳踝蹠屈到末端角度的時候，脛距關節與距跟關節後側的組織受到擠壓。後側夾擠常出現在需要頻繁把腳踝往下壓的人身上，像是芭蕾舞者、需要頻繁跳躍的運動員等等。與前側夾擠雷同，後側夾擠可能是骨質或是軟組織的夾擠，或是兩者同時存在。距骨後外側 (trigonal process) 的骨質增生是比較常被認為導致後側夾擠的原因。除此之外，頻繁的將腳板大幅度的往下踩，可能會導致後側關節囊、後下脛腓韌帶、三角韌帶的後側韌帶發炎，產生疤痕組織，進而造成組織增厚。另外我們的屈足拇長肌的肌腱經過距骨後側的內、外骨突中間的凹槽，也很容易因為過度使用，或是周遭骨質的增生，造成肌腱病變，像是肌腱或腱鞘炎的問題。

與前側夾擠的疼痛大多較為淺層、可觸摸的到相反，後側夾擠的症狀通常較為模糊，比較難有一個特定的單點疼痛，而且位置較深，通常落在阿基里斯腱底下。這也讓後側夾擠不容易和阿基里斯腱或是腓骨長肌的問題做區分。因為症狀出現在腳踝往下踩的時候，走下坡、下樓梯或是穿鞋跟較高的鞋子是幾個容易誘發症狀出現的活動。芭蕾舞者之所以比較容易出現這樣的症狀，被認為是因為需要頻繁的做出踮腳站，承重在前足的關係。

雖然影像檢查出來的骨質、軟組織的病變被認為是可能導致腳踝夾擠的原因之一，但實際上研究還是有提到，我們仍然不能光靠這些影像結果證據就判斷踝關節是否夾擠。影像檢查與我們的症狀表現之間的相關程度有限，仍需要結合其他理學檢查做綜合判斷才行。針對踝關節夾擠的介入，目前比較常見的作法仍是先採取保守治療，若在急性疼痛期，需要先避免會造成疼痛的動作，有必要的話也會使用消炎藥來控制疼痛。在非急性期，甚至是已經是慢性問題的個案，我們則需要著重在踝關節穩定、本體感覺的訓練上，畢竟前面有提到，踝關節不穩、扭傷都是可能造成夾擠的原因之一。與其他肌肉骨骼問題一樣，即使解剖構造上的異常也會被認為是造成踝關節夾擠的原因，但大多數的個案都能在不開刀的情況下有很好的進步。若有類似的狀況，一樣記得先找醫療人員的協助，避免症狀隨著時間越變越嚴重。底下的影片 (6:52) 將跟大家分享幾個簡單的踝關節穩定與本體感覺的訓練。

Impingement syndrome is a common musculoskeletal problem in shoulder and hip joints. But have you ever heard of ankle impingement? Impingement syndrome refers to abnormal contact of bony structures or soft tissue, e.g., tendon, ligament, synovial tissue, resulting in pain and restriction. Through different causes of impingement syndrome, it includes different medical signs or symptoms. Therefore, causes of impingement syndrome differ from person to person, making it more difficult to make a right diagnosis. Although ankle impingement is not officially classified into different types like shoulder impingement, researchers still sort it into anterior and posterior impingement according to anatomical structures are involved. More specifically, it can be classified into anteriomedial, anteriolateral, posteriomedial and posteriolateral impingement.

Symptoms of anterior ankle impingement are generally induced by compression of anterior margin of tibiotalar joint in terminal dorsiflexion. There are adipose and synovial tissues in the anterior joint space. Normally, these tissues are compressed after 15 degree of dorsiflexion in healthy individuals. However, if there is osteophyte at anterior distal tibia or talus neck, it will take up the space and limit ankle movement, causing early compression. This will result in chronic inflammation, synovitis, and capsuloligamentous hypertrophy. Apart from this, ankle sprain, thickened anterior tibiofibular ligament and synovial plica are also possible causative factors.

Even though structural pathologies are well described in much research, their exact etiologies are still less understood. Research showed that athletes are tend to affected by anterior impingement, and it led to hypothesis that pathologies are caused by repetitive impact injury to anterior chondral margin from hyper-dorsiflexion or direct impact during sports. Chronic ankle instability has also been hypothesized to be the causative factor of anterior impingement, because abnormal repetitive micromotion may develop bony and soft tissue lesions. In addition, early research hypothesized anterior osteophyte is caused by traction to the anterior capsule during repetitive plantar flexion, but this theory was disproved by later anatomic studies.

Anterior impingement symptom typically presents as anterior ankle pain during terminal dorsiflexion. Climbing stairs, running, walking up hills, ascending ladders and deep squat are common aggravating activities. If anterior impingement doesn’t get treated well, in the later stage, joint mobility may be further restricted due to mechanical block or pain, resulting in vicious circle.

Posterior ankle impingement symptom typically occurs in terminal plantarflexion, due to compression of tissues posterior to the tibiotalar and talocalcaneal joint. Posterior impingement tend to occur in athletes who need to plantarflex frequently, like ballet dancers, etc. Similarly, posterior impingement can result from compression of bony or soft tissue in isolation or in combination. Trigonal process of posterior talus is the most common cause of posterior impingement. Besides this, repetitive hyper-plantarflexion may cause posterior capsule, inferior tibiofibular ligament, and posterior fiber of deltoid ligament inflammation, scarring, and thickening. Lastly, tendinitis and tenosynovitis are easily found in flexor hallucis longus tendon, running between the medial and lateral posterior process of the talus. This probably results from overuse or irritation from surrounding abnormal bony tissue. The tissues mentioned above are all possible causative factors to the posterior ankle impingement.

In contrast to patients with anterior impingement pain that are accessible to palpation, posterior impingement pain is less specific, deep to the Achilles tendon. This makes it difficult to differentiate from Achilles tendon or peroneal tendon pathology. Since posterior impingement symptom is usually irritated by repetitive plantarflexion, walking downstairs, downhill running, and wearing high-heeled shoes are some common exacerbated activities to posterior impingement syndrome. Ballet dancers are commonly affected by posterior impingement syndrome due to weight bearing on forefoot in plantarflexion position over and over again.

Though osseous or soft tissues abnormality in radiography is seen to be one of the causes of ankle impingement, it doesn’t mean that we can simply blame patient’s symptom on these structural pathology. In fact, there is a limited correlation between medical image findings and our symptom. We should integrate patient’s history, physical examination, imaging studies, etc., for accurate diagnosis. Conservative treatment remains first option to manage ankle impingement. In acute stage, patient should avoid from doing provocative activities. If it is necessary, NSAIDs can be used for pain management. In chronic stage, clinicians should focus on ankle stability and proprioception training because ankle instability and sprain are both causative factors of ankle impingement. Just like other musculoskeletal disease, even though structural abnormality is thought to be a possible cause of ankle impingement, most ankle impingement cases still respond well to conservative treatment. If you have any similar medical problem, please find medical professions for help. The video below will show you some simple ways to train our ankle stability and proprioception.

參考資料：
https://pubmed.ncbi.nlm.nih.gov/27608626/
https://link.springer.com/article/10.1007/s00247-019-04459-5
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5065672/

#腳踝夾擠 #踝關節不穩 #腳踝扭傷 #本體感覺訓練 #物理治療 #ankleimingement #ankleinstability #anklesprain #proprioception #physiotherapy #hunterptworkout

「每日英文閱讀分享#010」​
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今天的文章：Abandoning Globalization Will Only Hurt U.S. Businesses，標題已經完全道盡作者的想法，但是他舉出了四點，為什麼deglobalization對於美國是有害的，一樣會把連結附在下面喔！​
（再度預告，本週會整理跟international business相關的報導一起做講解，希望可以也跟大家有些討論～）​
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回到今天的單字，​
「decouple」分享的原因，是因為用拆解的方法來看，這個字就是「不當情侶了」感覺很可愛（還是很悲傷？），卻是一個正式的商業用字。​
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動詞意思是：to ​ separate ​ two or more things or ​ activities, or to ​ become ​ separated，​
當作名詞時會變成「decoupling」意思為：a situation in which two or more activities are separated, or do not develop in the same way
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常用的動詞用法為：decouple (sth) from sth ​
例句：Europe and Japan might decouple from the United States by growing on their own, but right now they're dependent.​ --Cambridge Dictionary
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再給大家一個用於國家的例句給大家看看：Tractors that haul Mexican-made goods to American consumers must decouple from their trailers on the Mexican side.​ --Cambridge Dictionary
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或是用在公司之間：Zhang also began trying to decouple the company’s technology from China, and has pointed out that all the data on U.S. TikTok users is stored in the United States and backed up in Singapore. — Washington Post, "TikTok’s fate was shaped by a ‘knockdown, drag-out’ Oval Office brawl," 8 Aug. 2020​
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就是沒有用於分手的用法（期望落空中ＸＤ）​
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最後還是正經一點附上原文的例句：​
1. Coming on the heels of the trade war and Washington’s push to de-couple economically from China, this has brought widespread predictions of deglobalization.​
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2. They know that deglobalization of supply chains and de-coupling from China will actually reduce their ability to produce in the U.S. and compete with Chinese companies in the long run. ​
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歡迎大家與我一起養成閱讀（或發文）習慣～～

#言之有物​
#英語學習​
#商業英文​
#BusinessEnglish​
#InternationalBusiness​
#Globalization ​
#每日英文閱讀分享​
#一起來建立英文閱讀習慣吧

沒錯！我就喜歡 Ron Jeffries 的論調（軟件開發本質論作者，XP 大神之一，敏捷宣言簽署人之一）。
　
Let’s have a new rule: you don’t get to say what agile software development is, or say how to do it, if you cannot personally develop software as part of a team, in the agile style.

you can teach scrum, or kanban, or retrospectives, or being nice, or anything you’re actually good at. but you can’t teach or explain stuff you can’t even bloody do. like agile /software development/.

I just think if you've never been part of it, pretending you can teach it or coach it is pretty questionable.
　
來源：https://twitter.com/RonJeffries/status/936807106425995264
　
※ 感謝 明洋林 （Jerry Ming Yang Lin） 分享這則 2017 的 twitter
　
--
後記：
我就說了，簽署敏捷宣言的，幾乎都是技術工程底的大神，技術對他們來說已經都不是問題了，所以要用敏捷來搞定協作、價值、文化，也就是人的問題。
　　
但多少人在搞敏捷、在導敏捷，根本沒有技術能力、沒有技術含量，甚至沒有 software product development 的經驗，這些人依然可以關注在他們可以帶給團隊的價值，但就不要去假裝、去宣揚那些你根本沒經驗的名詞。
　
這也是我跟其他 coach 之間最大的差異，因為能下去動手做產品，能在跟團隊一起做產品的過程中去影響他們、引導他們，甚至指引他們。不只是 coaching, 還要時常能扮演 trainer 跟 consultant 的角色。
　
如果只有敏捷，雖可以作到持續改善、單位時間內交付最大價值的。但如果是在做一個軟體產品，那麼最終的瓶頸天花板就會被 Delivery 的能力給限制住。畢竟，我們是在做個產品，這一塊交付的本質避無可避。
　
我再強調一次，兩者有各自的關注點，也不互斥，只偏重一方，在持續改善到一個程度之後，就會碰到另一方為瓶頸點。兩者無法兼具的話，就無法發揮最大價值。
　　　
【敏捷宣言簽署人】
Kent Beck
Mike Beedle
Arie van Bennekum
Alistair Cockburn
Ward Cunningham
Martin Fowler
James Grenning
Jim Highsmith
Andrew Hunt
Ron Jeffries
Jon Kern
Brian Marick
Robert C. Martin
Steve Mellor
Ken Schwaber
Jeff Sutherland
Dave Thomas

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1【teapot 茶壺】— 名詞
South Africa has warned restaurants not to hide alcohol in teapots.

2 【die of 因某原因而去世】— 動詞片語
A renowned Chinese pianist died of Covid-19.

3【jail 監禁】- 動詞
China jails 10 Hong Kong activists for an illegal border crossing.

4【speak out 勇敢發聲】— 動詞片語（通常可能有風險甚至危險）
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簡單複習：
1）teapot 茶壺
2）die of 因某原因而去世
3）jail 監禁
4）speak out 公開表達意見
5）join forces 攜手合作

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