If only I knew…
About Ankle Sprains
An overview of the facts about recurrent ankle sprains
By Marie-Catherine Bruno, BScPT, Cped(C).
It seems unavoidable: every year, you sprain your ankle running through the woods. Have you ever thought that maybe there is a way to change this scenario? A way to give it a better ending? Did you know that 85-90% of untreated ankle sprains will be recurrent, but that you can bring those numbers down to only 35% when you treat the first occurence? Hum, you may want to reconsider following your doctor’s advice of simply going home and icing your sprained ankle a few times…
An ankle sprain usually occurs when the foot is plantarflexed (toes pointing down), and inverted (toes in). In other words, you literally go over your ankle. There are 3 major ligaments on the lateral side of the ankle: the anterior and the posterior talofibular ligaments (ATFL and PTFL), and the calcaneofibular ligament (CFL). The most common one to sprain is the ATFL simply because of the mechanics and the limited support at the anterior portion of the ankle.
Sprains can be classified on a 3 level scale, according to the severity of the injury (that same system is valid for any ligament in your body). A minor tear or simple overstretch would be a 1st degree sprain. A complete rupture is a 3rd degree sprain. Anything in between is a 2nd degree sprain. You can recover up to 100% from a 1st or 2nd degree sprain, but 3rd degree sprains usually leave residual symptoms (osteoarthritis, hypermobile joint…).
So what should you do with a fresh ankle sprain? Well, if you think you did it really bad (let’s say you weight 250 lbs and you happened to fall on it), then there is a chance you could have a small fracture, so don’t hesitate to get it X-rayed. If on the other hand you feel like you simply went over it, you can still put weight on it but it hurts a bit, don’t waste any time going to the hospital. Instead, go home (avoid walking on it if possible), wet a thin towel (something like a dish cloth), fill it with crushed ice or with a bag of frozen corn, and apply to the painful area for a good 15 minutes. Do so every 2-3 hours for the first 24 hours. This will limit the extent of the damage by keeping the swelling down. In between ice application, use the RICE principle: Rest, Ice, Compression and Elevation. Avoid standing up as much as possible, (because when you stand up, the fluid in your body is under the effect of gravity – remember Newton- and l wants to go down into your ankle). Even better, keep your foot elevated (at night, pillows underneath the foot of the bed will give you just enough elevation to sleep painfree).You can also do some pumping exercise by continuously bending and extending your toes, especially useful when the foot is elevated.
Use a tensor bandage. Always start it from your toes and work your way up (it will push the fluid away from your ankle and towards your heart, the main pump). It should be tight enough to stop the fluid from going down into your ankle (if your toes turn blue, loosen up a bit!). Take it off at night but put it back on first thing in the morning, even BEFORE you put your foot down to get off the bed. DO NOT walk on it for the first 24 hours – it will only make it worse. Get yourself some crutches, and use them until you can walk without a limp. You can upgrade to a cane if you want, but make sure you are using it properly: on the opposite side from the injured ankle (I know it seems wrong, but trust me that is way better for unloading the injured joint).
After 24 hours
Has the swelling gone down by at least 50%? If not, go to a physical therapist, you need some professional help. Is there any bruising? If so, also go to a physical therapist, even if the swelling has gone down – bruising means internal bleeding, and that requires in dept assessment.
In the event that all of the above is clear, let’s just say that you are one lucky orienteer! But the game is not over yet, you still have some serious work to do! Keep up the RICE regiment for another 2-3 days or until the swelling is about 75% gone. The battle still isn’t won. Your ligament will take up to 3-4 weeks to heal completely, so this means be careful (read “no orienteering at all for at least 3 weeks”). During this period of healing ou will now need to exercise it a bit:
- strengthening (get out your good old bike inner tube and attach it to the leg of a sturdy table. Tie the other end to your foot and practice those 3 movements: pull the foot towards you – aka dorsiflexion – pull the foot in – aka inversion – and pull the foot out – eversion. Do sets of 15-20 or to fatigue.)
- movement (draw the alphabet with your big toe)
- proprioception (the most important part of the rehab - discussed below)
These exercises will make you recover completely, and will also help to prevent recurrence.
Proprioception – or your ticket to a recurrence-free summer!
This is the part that you may not be so familiar with. The purpose of it is to train your ligaments to react fast again, making it the most important part of your rehabilitation. Remember how in the previous article you learned that ligaments hold bones together. Not only do they hold bones together, but they also control part of your balance by sending messages to your muscles (via the brain), telling them how to react to maintain your balance or to prevent excessive movement. After a sprain, your ligaments need to be retrained. A simple way of doing so is to stand on your affected leg and try to hold your balance. You will probably notice at first that your injured foot is much more wobbly. This will get better as you practice it. Perform for about 30 seconds to 2 minutes, 3 times a day.
When you get good at it (no more sway or only very little), you want to make it more challenging and work your way up towards running in the forest again. Different ways of increasing the challenge include using a softer and more unstable surface (a cushion or pillow, very soft carpet, grass…), or by moving your arms around (try to throw a ball up in the air and catch it back), or by closing your eyes (make sure you have walls or furniture close by to hang on to quickly). After you master this last challenge, you are ready for the last challenge: jumping and trying to land on your foot as stable as possible – no wobble accepted!
You are only ready to go back to your sport when you can land a jump on your affected leg with no sway, no pain, and a smile on your face!
You can follow this whole recipe for old recurrent sprains, but unfortunately, once a ligament has been stretched and not taken care of, it will never go back to its original length – thus the importance of treating the first sprain (and all subsequent ones) religiously.