One of the most common injuries in all of athletics, ankle sprains claim fame in soccer, football, dance, tennis and just about any other sporting event you can think of! If you have been a victim of this not so fun injury, you know just how annoying it can be getting back to your sport pain-free. Before I discuss some of the best, most common treatments for this injury, let’s first look at some of the anatomy and mechanisms behind what occurs in an ankle sprain.
There are several classifications of ankle sprains. Inversion, eversion and high ankle sprains are the three common mechanisms for injury and combinations of high ankle sprains with inversion/eversion mechanisms occur as well. As seen in the photos, different ligaments are effected as the direction during injury of the foot and ankle changes. Instead of going into the boring specifics of what structures are effected, I am going to discuss treatment immediately following injury and the weeks following.
When an MLB or NBA player rolls their ankle and has a sprain, most of the time there is an immediate 6 week period on the DL. Depending on the time of the season and the age of player, this time period lengthen or shorten accordingly. The reason I bring this up is because this is always the time line that should be used with young kids who get an injury during their sport. When the body does not go through a full rehab schedule, the likelihood of re-injury goes through the roof! This is because in the last few weeks of return to play, the focus is on proprioceptive work. Proprioception is a fancy term that describes the bodies ability to recognize where each joint, muscle and body part is in space. It allows us to have balance, change direction quickly without injury and properly activate our muscles during various activities. This is the most important step for injury prevention even before an ankle sprain has occurred!
Immediately following an ankle sprain, the athlete should first be examined to determine any instability in the area. By performing several orthopedic exams and stressing the ligaments in different directions, the practitioner would be able to tell if surgery is needed due to an extreme injury. While this is not common, it can occur. The more common, mild sprain is treated the same no matter the direction. Rest. Ice. Compression. Elevation. RICE is an acronym recognized by most sports physicians as one of the best rules of thumb to go by in the first few days following injury. Now, while I think this concept is
extremely important, I use the first 2 steps a little differently.
Rest. Pretty easy concept, but one of the most difficult especially for those who love their sport and wish to return as soon as possible. The biggest difference I use with my patients here is the fact that I want them using the ankle, just backing off of their sport. The sooner they are able to return to full weight baring walking, the better. I do not want them baby-ing the injury during walking gait because that will move up the chain and effect other tissues in the hips and lower back. The other thing I have my patients do is keep it moving while they are not doing much. Doing pain-free ankle circles while watching TV or writing the alphabet in the air with their big toe under the desk during class. As we keep motion in the ankle, the inflammation is able to be controlled and blood flow is constantly being pumped to the area without being stagnant for too long.
Ice. The rule with ice and heat is pretty black and white. 48 hours following injury should be ice then after that heat. I do agree with this, but there are other ways to use this that are better for injury. Meaning there should be a little gray area in between the transition when both are used. With ankle sprains, my favorite way to ice the bumpy, odd shaped joint is with an ice bath. Grab a 5 gallon bucket and fill it with some ice and water then put your entire foot in. After a couple minutes has past and the ankle is numb, I will add in writing the alphabet with the ankle or small circles. This keeps the joint moving and is an awesome way to help reduce some of the inflammation. I normally will only tell patients to do this for about 15 minutes a few times per day, but it is the easiest way to effectively get to the entire area. The other good way to ice a difficult area is to put ice in a gallon bag and add some water to the ice. The bag will form better to the ankle and you will notice it is much more effective.
Compression. Elevation. Both of these are used to limit the amount of inflammation to the area. It is why athletes leave their shoe on following an injury and why you see them almost immediately have their foot propped on something. Inflammation is good to a certain extent, but when too much builds in one area, range of motion is limited and pain also begins to occur. I will use compression in something as easy as an ace bandaged for the few days following injury. This will limit the range of motion enough to not aggravate tissues and offer a little more support to the joint. Once the inflammation has been controlled, the compression will be taken off in order to restrengthen the injured muscles. Elevation is also good for an ankle sprain because it assists the flow of blood back to the heart and lymphatic drainage. If at work or school, simply put a chair or stool in front of you to rest your foot on. While at home, simply use a pillow to elevate your foot just above the hip, especially important in bed.
Once pain and swelling is reduced, the next step is getting back all of the range of motion. When an injury occurs in a ligament, new fibers are replaced in a random pattern. This leads to scar tissue and fascial restrictions which may limit range of motion. In the office, I use a few tools plus my hands in order to pin and stretch muscles to reduce some of these restrictions and promote the fibers to run in a smooth, parallel fashion. Many of the exercises used to promote range of motion are also helping to activate some of the fine muscles that were injured during the sprain.
To further promote proper healing, strengthening exercises become extremely important. Many times I will start patients on an easy regimen that can be performed anywhere. Including writing the alphabet with the foot, patient will also be sent home with essentric calf raises, soleus calf raises, foot activation exercises and foot gripping exercises depending on the case.
Simply strengthening muscles however is not prevention enough. As discussed before, one of the most important aspects of treatment following an ankle sprain is the proprioception aspect. With the many joints found in the foot and ankle, balance and feedback allowing the brain to know where each of these joints is in space is extremely important for preventing further injury. Once the first and second stages of recovery are met, many athletes will return to play too early. Many of the exercises used for proprioception retraining are simple and can be implemented for the first few weeks after sport is reintroduced. My favorite is just a simple one legged balance test in a quarter squat or athletic position. Holding this position for 30 seconds to a minute then closing the eyes and repeat a 30 second hold is enough to start with. Then we add in an uneven surface like a towel or wobble board and repeat the same exercise. As we stress balance with both eyes open and eyes closed, the brain is required to retrain the balance receptors in the joint without relying on sight for feedback.
The other awesome exercise for prevention in general that I give to many patients is the star pattern. Standing on 1 foot with equal pressure between the front and back of the foot, reach the other foot as far forward, to the side, in a diagonal to the back then across the front and back of the standing leg creating a star like pattern. This exercise was shown in a video on my Facebook page. This exercise again can be performed eyes open or eyes closed and an uneven surface can also be added to make this more difficult.
These two simple exercises can be the difference between having repeated ankle sprains for life and properly rehabing an original injury to ensure your risk is tremendously reduced. That is a bet I will take any day! Who wants to keep having pain and tweaking your ankle every time you try to return to your sport? I know I definitely do not!
Question? Comments? Want to schedule a consultation? Call the office at 704-845-0777 and ask for Dr. Kylie. I am happy to help and offer free consultations to answer any questions you may have about yourself or your child. These exercises are awesome for prevention for high school and college athletes and I have seen awesome results with them.
Until next week,