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So you doing some shopping with your favorite people at this new gorgeous outdoor mall, shopping bag in one hand and Starbucks in the other, when…bam…the coffee is up in the air and you are falling over yourself and onto the hard concrete. Once momentary embarrassment wears off, you realize that you are having a difficult time standing on your injured foot. You stare at your ankle and notice that it is the size of a football….did you break it?
Well…. not necessarily!
So what actually happens when you sprain your ankle?
Every day in the United States, close to 20,000 people sustain ankle sprains. The worst part is that if you have an ankle sprain, you automatically become predisposed to a repeat sprain…unless you do something about it! Though ankle sprain is considered a relatively mild injury, most people that experience them will ultimately become less active throughout their life.
In those playing sports, ankle sprains were most common soccer, volleyball, basketball, and football. These sports involve cutting and jumping, which placed lateral ankle structures at risk. If you are participating in one of these sports and have had an ankle sprain in the past, investing into a good brace can certainly prevent re-injury. Purchasing a reusable brace as opposed to taping requires a greater initial financial investment, but ultimately it is cheaper than purchasing rolls and rolls of tape.
In people who develop early ankle arthritis, the initial trauma can frequently be tracked to an earlier ankle sprain.
Lateral ankle sprains and resulting instability are very common. Just as with any injury, there is a spectrum of how badly one can get injured. The lateral ankle sprains are divided into 3 grades depending on severity and structures injured. There are 3 ligaments on the outside of the ankle holding the leg attached to the foot. These are commonly injured during a sprain. The greater the injury, the less firm the attachment is and the more instability.
When the injury occurs, the foot tends to twist inward underneath the leg. This frequently occurs when running on uneven surfaces, jumping onto uneven surface, or stepping off an elevation like a curb. Immediately after the injury, you will, of course, feel sharp pain to outside of the ankle with associated pain, swelling, bruising and weakness. Some people can walk on their injured ankle right away, while others will need assistance with moving.
The degree of injury depends on what structures are injured.
Grade1: occurs with almost every ankle sprain. Anterior talofibular ligament is partly torn with some associated swelling and pain. There is no instability
Grade 2: Anterior talofibular ligament is completely torn and calcaneofibular ligament is partly torn, bruising is observed, some instability is noted and person is unable to stand on toes.
Grade 3: both anterior talofibular and calcaneofibular ligaments are completely torn here. There is much more bruising involving lateral ankle and even heel with significant swelling, pain and laxity of the foot attachment on the leg.
Anterior drawer test and talar tilt test demonstrate this laxity.
Chronic ankle instability can be functional or mechanical in nature.
Functional instability describes a sensation of instability without actual physiological finding of such instability. People who experience this feel that they cannot trust their ankle, especially when walking barefoot and on uneven surfaces.
Mechanical instability is a true physiological instability where the motion of the ankle is greater than what should be normal.
How do people get better?
First response to injury should be to use RICE therapy (rest, ice, compression, elevation).
One should not be immobilizing the ankle for too long and functional rehabilitation should be initiated as soon as tolerable.
Rest: staying off the injured foot with the use of crutches, walker, knee rolling walker, or another modality based on your stability is essential during the first phase of healing. The body needs time to analyze the injury and deploy repair molecules to start addressing the injury.
Ice: this is the cheapest and most effective anti-inflammatory, pain reducing modality. General recommendation is to ice the ankle for 20 minutes followed by 40-minute break. Repeat 3 times. This can be done 2-3 times per day. Caution must be used here, especially in people with poor circulation and fragile skin as freeze burn can occur. It is best not to use ice directly on the skin and instead to apply it over cloth. Alternatively, one can put an ice pack behind the knee, as this is where a large blood vessel carrying the blood to the foot runs.
Compression: this is a more direct swelling reducing modality and can be very helpful with reducing pressure on the nerves around ankle that are being compressed by increased tissue fluid. In addition, compression will stabilize injured ligaments and tendons/bones and will prevent excessive motion allowing for healing. This can be achieved with the use of sports elastic bandage like ace wrap or with a more advanced modality like fracture boot. It is important to keep the foot in neutral with the ankle (about 90 degrees and also to avoid excessive inversion and eversion). This way injured structures will heal in proper alignment.
Elevation: keeping an injured extremity elevated is extremely helpful as it promotes drainage of lymphatic fluid from the injured foot and ankle. Usually, this fluid is drained by contracting leg and foot muscles but when the foot is not used, the fluid is retained and swelling is worsened. Keep the foot above the level of the heart by propping it up on pillows will help to drain the ankle area by using the force of gravity. This will also promote elimination of toxins and metabolites that are generated during the injury and repair process.
As ankle starts to improve, one can attempt exercises involving open kinetic chain activities like range of motion without placing weight on the ankle. This can be followed by low resistance exercises with stretchy rubber band like theraband to start on regaining flexibility and strength.
While non-steroidal anti-inflammatory medications may be helpful in early stages of injury, prolonged use was actually found to slow down the healing. Thus, they are probably not as helpful after first 3-5 days. Of course, caution should be utilized when using these medications because of their side effect profile including kidney injury, greater potential for bleeding and bruising, increasing blood pressure, causing and worsening stomach ulcers, worsening asthma symptoms, increased risk for heart attack and stroke.
Reaching complete recovery will take time.
I generally recommend that patient should progress from stage to stage once a simpler exercise can be performed with good technique up to 1 minute and without pain. All these exercises should first be done with the brace. Once one can do even the most difficult exercises in pain free manner, you can progress to same exercise but without the external support.
Rehab 1: Be able to “draw alphabet” with the ankle in open kinetic chain. Work on swelling reduction and range of motion. Strength exercises with theraband should be started to strengthen ankle dorsiflexors and plantarflexors as well as foot inverters and everters.
Rehab 2: Be able to stand on both feet with supportive shoes and with brace on injured ankle. Once you can stand, walking should be initiated on even surfaces to the point of first discomfort. This should be recorded and will become a baseline to build on.
Rehab 3. Add 10% in terms of distance and difficulty per week based on above established baseline. Now add balancing exercises. Be able to balance single leg stand with shoes and a brace.
Rehab 4. Be able to balance single leg stand with brace and no shoes. Continue with strengthening exercises
Rehab 5. Be able to balance single leg stand without a brace..barefoot. Continue with strengthening exercises, especially of peroneal muscles.
Rehab 6. Start exercises barefoot on wobble board or balance ball.
Remember, it’s not about speed of progress but about proper form and being pain free at each stage before progressing onto the next.
What to do if at home rehab modalities are not helping?
Formal supervised advanced physical therapy should be pursued next.
Functionally unstable ankles tend to respond better to rehabilitation activities including stability, balance and proprioception. Mechanically unstable ankles respond better to rehab activities targeting inflammation and swelling reduction (iontophoresis, phonophoresis, cryotherapy, passive range of motion) and improvements in strength of the muscles stabilizing lateral ankle (peroneus brevis and longus). Functionally unstable ankles do not get better with surgery, as there is nothing “anatomically and radiographically” abnormal with those ankles. Mechanically unstable ankles, on the other hand, do respond well to surgery, when physical therapy does not sufficiently restore normal function.
Prior to attempting any surgery, it is important to understand which structures are actually damaged beyond rehabilitation and this can be done with radiographic tests like MRI, x ray, CT scan or even musculoskeletal ultrasound. Frequently lateral ankle ligaments and lateral ankle stabilizing tendons are injured to some degree and both may need to be treated at the same time.
In addition, it is important to remember that surgical procedures to stabilize the ankle can stabilize the ankle but at expense of range of motion. Thus, you may end up with a very stable but also very stiff ankle. Depending on your expectations, hobbies, occupation etc….this stiffness may or may not be acceptable. That is why it is essential that you must share what you are hoping to continue doing physically after your surgery to ensure best possible surgical procedure selection or maybe avoiding surgery all together in light of your current and future activity demands.
A comprehensive discussion between you and your surgeon is a must!
Until next time…Happy moving!