Ever wonder why you keep spraining that same ankle?
A sportsman’s nightmare… a dodgy tackle, a patch of uneven ground, an awkward landing or maybe just a few too many Proseccos in your favourite pair of high heels. Whatever the cause, the outcome is usually long-lived and less than favourable for the affected party.
The most common form of ankle trauma, accounting for around 90%, is caused by rolling over the outside of the foot; this is referred to as an ‘inversion sprain’ and so, this will be the topic of discussion today. The injury is characterised as damage to the soft tissue structures and outer ligaments of the ankle – The result, an array of wonderful blues, purples and yellows, an ankle the size of a tennis ball and of course, the tedious trip to A&E dreading the thought of the next 6 weeks in plaster cast.
What’s the damage doc?
First port of call tends to be an X-ray. Every Saturday and Sunday, A&E’s across the country are flooded with members of the public hobbling in their sports kit, terrified of the prospect of a fracture.
In the majority of cases, damage is limited to soft tissue structures (ligament and tendon), however a fracture should always be considered with the following:
• Immediate and severe pain
• Bruising – especially when substantial
• Tenderness when touched
• Inability to put any weight on the injured foot
• Un-remitting and constant pain into the night
• Deformity – also consider dislocation.
*Finally, be aware, hair line fractures often won’t show up on an X-ray for 10-14 days following the onset. If symptoms persist without resolution you may wish to consider a re-evaluation.
(Your therapist will be able to advise you on the appropriate imaging. i.e. MRI, X-ray, Ultrasound.)
How long can I expect to be out?
Ligament damage, or to be more precise, the anterior talofibular ligament damage occurs when the outer aspect of the joint is taken beyond a point of which the structure can withstand; the strains can be classified between grades 1 to 3, which are based solely on the degree of trauma sustained.
Grade 1 – Only a small number of ligament fibres are torn.
Typically, the injury will result in 7 to 14 days lost from athletic activity; you can expect some mild soreness and swelling, but no instability and full function.
Grade 2 – A significant number of ligament fibres are torn.
This can result in a loss of anywhere from 2 to 6 weeks of athletic activity and symptoms tend to be slightly more severe; there is a moderate loss of function, the joint may feel unstable and swelling and bruising can occur at both the ankle and foot
Grade 3 – All lateral ligament fibres are fully ruptured
Patients can expect a loss for as few as 4 weeks from athletic activity, up to as many as 26 weeks; there will be a substantial degree of bruising and swelling, severe pain, a large degree of instability and a major loss of function
Why do I keep rolling the same ankle?
Now the majority of these injuries are unavoidable, but in some cases there may be contributing factors which lead to this turn of events: Hard grounds, insufficient warm up, poor joint mobility, inappropriate training or maybe you just slipped from a kerb… but possibly the most important is inadequate rehabilitation from a previous ankle strain.
Ever wondered why that ankle still doesn’t feel quite right? Or why it’s always the same side that you roll? I believe the answer is simple and that it comes down to something called ‘proprioception’.
Proprioception, ‘a posh name for balance’. Ligaments and tendons play a key role in providing proprioceptive feedback to our brain reminding us of our joint positioning at all time. The brain then responds by signalling to the surrounding musculature to either relax or contract to produce the desired movement.
Now when we damage these anatomical structures, we’re also damaging the proprioceptive feedback system, the end result is that there’s a glitch in the mechanism which warns us ‘careful that ankle is about to roll’. –thus, the first time you try and jog or go for a run, it doesn’t feel coordinated and you go straight back over on it. Furthermore, until we take the appropriate action to rehabilitate the ankle (even after the ligaments and soft tissue structures are adequately healed) we will continue to experience instability. Sceptical? If you’ve experienced a previous ankle trauma, take off your shoes and stand on one foot at a time – the affected side should feel unstable and ‘wobble’ as we attempt to balance.
Fortunately for us, proprioception is trainable. Tightrope walkers, gymnasts, ballerinas and dancers, their ability to balance was not just instilled within them from birth, it was a learnt behaviour, they improved it through repetition and you can improve yours too.
This is why it is believed that proprioception is one of, if not the, most important aspect of inversion sprain rehabilitation.
Rehab and management
First things first, stop that swelling!! Good old fashion RICE will do the trick
• R- Rest – avoid further damage, be sensible and rest up.
• I – Ice – cold applications regularly for the next 24 – 48 hours. 10 minutes a time
• C – Compression – apply a compression bandage immediately to reduce swelling
• E – Elevation – use a few pillow under the affected ankle to reduce inflation in the area
What we can do for you
• Assess and diagnose the degree of damage through orthopaedic examination
• Soft tissue massage to relieve muscle tension, pain and reduce local inflammation
• Joint mobilisation to improve range of movement available
• Medical acupuncture is scientifically proven to reduce muscular tension and pain
• Sports and kinesiology taping to provide support, pain relief and function
• Advise and educate on the appropriate footwear, crutches, ice, orthotics and exercise programmes aimed at strength, mobility and balance.
What YOU can do for you
Early stages, you can start as soon as the ankle will let you – Stand on one foot and balance, yes it’s that simple! And to make it even easier I suggest doing it when you’re brushing your teeth in the morning and again in the evening.
As your balance improves and your rehab becomes easier – try closing eyes, introducing upper body movement/exercise and finally, when you’re becoming a bit of a ‘proprioceptive pro’, you can advance to using the aid of a wobble board; start with two feet and then progress to just one.
The ankle joint is going to seize up, inflammation is going to set in, muscles are going to spasm and bony surfaces will approximate.
Move the foot side to side, up and down and in a circular motion. If you have family, a friend, or partner kind enough to help you, ask them to articulate the ankle within a pain free range.
Finally, use stretches aimed to lengthen the calf muscles.You can do all of these as much and as often as the pain will let you.
Begin with static/isometric exercises (resisting against a force with no movements at joint) – Thera bands, a towel, or just a solid surface such as a wall or floor will be adequate. Push the foot up, down and to each side. Hold for 10 seconds, break for 5 seconds and repeat each x 5
The next stage of rehabilitation is to advance to dynamic/isotonic exercise (working against a force with movement at targeted joint) – pushing through a resistance such as calf raises or again just by using the aid of a towel or a thera band. Slowly build up resistance in accordance to pain levels. 4 sets x 10 repetitions of each exercise will be a sufficient.
The final push
We’re almost there, but don’t jump straight into the deep end… Build up your endurance through cardiovascular activity. Swimming and cycling are ideal; they improve joint mobility, they strengthen the surrounding muscles and they do this all whilst delivering minimal load on the structures.
The final stages are functional exercises; these are aimed to engage various muscle groups, promote overall strength, proprioception, endurance and agility – lunges, squats, hopping, box jumps and stop start drills – continue until to your feel confident in your abilities to perform.
Hey presto… the ankle is strong, mobile and ready to return to your training programme. Enjoy.