by | Aug 28, 2018

Ankle Sprains Slowing You Down?

When was the last time you rolled your ankle? The ankle sprain is such a common injury, it’s safe to say that it’s universal to the human experience! Whether you’re a trail runner or a mall walker, a rolled ankle can vary in severity from a short-lived annoyance to a serious setback. Most often, it’s one of those injuries that we just tend to ignore and ‘deal with’ – we (whether “we” is the injured person, a coach or parent, or even a doctor) often don’t take a sprain seriously or think very much about how to treat it, why it happened, and what the risk of recurrence is. So what’s really happening when you sprain your ankle, what is the best way to treat it, and how do you know when to seek medical care?

 

Ligament sprain grading by physioworks physical therapy in huntsville alabama

 

Most ‘rolled ankles’ are lateral ankle sprains. ‘Lateral’ just means that it is on the outside of your ankle. (While it’s technically possible to roll your ankle to the inside, it’s much rarer and you’re more likely to break your ankle before spraining it on the inside.) ‘Sprain’ technically means that there has been some kind of damage to the ligaments – anything from just tearing a few fibers, all the way up to a complete rupture of a ligament. Thus, a sprain can be anything from a very small injury that just causes a few minutes of mild discomfort – i.e., something you can ‘walk-off’ very quickly – all the way to up to a serious injury requiring a period of non-weight bearing and even surgery to heal. In this article, I want to address those sprains that are significant enough to cause some swelling, pain, and difficulty walking. So, serious enough to end your game or run for the day, and that you feel you need to get some ice on it.

 

What is a sprain?

The ligaments and muscles on either side of your ankle help to provide stability to your ankle as you move around. But when something causes your foot to roll too far to the outside, the lateral ligaments and muscles (the ones on the outside of your ankle) might not be strong enough to counteract that outward pressure, and they can get injured. While muscles are active structures that can contract to try to help protect your ankle as it rolls, ligaments are passive structures. That means that if your ligaments are put under too much strain (more than the both they and the muscles can counteract), they are going to tear to some degree. If you imagine a ship tied to a dock, your ligaments are like the rope holding the ship; as the boat moves away from the dock, the rope will get taught and restrict its movement; but if too much force is applied, the rope will fray and eventually break.

Because we do have muscles helping out with our ankle stability, the severity of ankle sprains can vary widely; thankfully, most are not very severe at all and don’t require any special treatment aside from a little bit of rest and TLC until they feel better. But when the sprain is bad enough to cause swelling and bruising, more careful treatment is called for. Although sprains have often been brushed off as ‘no big deal’, studies are showing that they are often more important than we give them credit for:

  • Up to 46% of patients with sprains still experience pain 1-4 years later
  • Up to 34% of patients experience recurrent sprains (i.e., having one sprain can increase your likelihood of suffering another one)
  • Up to 55% of patients report feeling instability in the ankle

Personally, I can attest that sprains and ankle stability have played a role in my own fitness and activity levels. Having suffered multiple sprains during adolescence from playing soccer, rugby, and cross-country running, I had a good number of ankle sprains which received no particular treatment; just rest and maybe ice at home. I used to fit the statistic above – suffering frequent sprains while exercising and would have described myself as having “weak” ankles. Thankfully, I have been able to improve my ankle stability with exercises. But what if I (or my parents, doctor, and/or coach) had known then what we know now? What really is the best way to treat a sprain, and how can it affect ankle stability and pain long-term?

 

How to Treat an Ankle Sprain

So what are the “right” things to do when you sprain your ankle? Most of us are familiar with the old acronym RICE: Rest, Ice, Compression, Elevate. Is that really the best thing to do?

Thankfully, updated guidelines were recently published in a consensus paper that can help us know how to keep a sprain from becoming a long-term source or pain and injury. The biggest takeaway? For long-term healing, movement, including loading, is key. Whereas “RICE” encourages us to rest a painful body part, as we’ve seen in other common injuries, an appropriate level of movement, including weight-bearing exercise, is important to promote long-term healing.

But this is where it can get tricky; you definitely don’t want to overdo it on already damaged tissues. “RICE” isn’t necessarily a bad protocol to follow immediately after an injury, but think relative rest, not absolute. So, you might need to hold off on your regular training or sports program for a bit, but you also don’t want to stay totally off your ankle. This is where I like a recent acronym POLICE: Protection, Optimum Loading, Ice, Compression, Elevation.

Immediately after a sprain, it’s a good idea to keep it moving, but you want to keep your pain level below 3, on a scale of 0 to 10; examples might be gentle ankle circles or pumps, careful walking. If you’re in a lot of pain and you can’t walk on it, that may indicate a more serious injury that calls for X-ray. (Check out this article to guidance on when to seek an X-ray for a foot injury.) At this point, “POLICE” is a good protocol to follow as it discourages total rest and instead a controlled level of activity to stimulate healing. A compressive wrap (ACE bandage or similar) or taping can help provide stability during the healing period. Over-the-counter pain medications (e.g. Tylenol, Motrin, etc) can be helpful, as long as you follow the recommended dosage and it is a medication that is safe for you to take (i.e., you aren’t taking another medication or have a condition that makes the pain medicine unsafe for you; if you are unsure consult with your doctor or pharmacist). But – be cautious with NSAIDs (e.g., Motrin/ibuprofen) as there is some evidence that they reduce inflammatory factors that are needed for tissue recovery!

This protocol is reasonable to follow for up to 5 days following the injury. If you’re feeling basically back to normal after a few days, the sprain was probably minor enough that it’s healing well on its own and you’re ok to tape and pick back up with your normal training schedule. But if you’re continuing to experience pain or feel ankle instability after a few days, it’s a good idea to get checked out by a physical therapist. As long as you don’t have a fracture, 4-5 days after injury is the ideal time to seek out an evaluation with a PT.

At your evaluation, your PT will assess the severity of the sprain by moving your foot relative to the ankle to look for excessive motion, and based on your unique biomechanics, will provide you with strength and balance exercises to support healing and correct instabilities that might lead to re-injury. A PT can also provide taping if needed. Depending on the severity, return to sport can typically begin between 3 and 6 weeks; during this time there should be continued functional exercise and the use of taping or bracing to help reduce injury risk.

Some things that have traditionally been used for sprains but aren’t particularly helpful:

  • Extended rest; this is particularly true to athletes! You really want to keep moving and keep loading the tissues to promote healing and limit the loss of load capacity
  • Ultrasound, laser, acupuncture, light, electrotherapy, shortwave, vibration therapies; there is currently no evidence to support the use of these to treat ankle sprains
  • Manual therapy/mobilization on their own; these are only thought to show benefit when combined with exercise
  • Ignoring the pain or feelings of instability and rushing back to sports

 

How Can I Prevent Future Sprains?

Even if you’ve never had a serious ankle sprain, there are several risk factors that can indicate if you are at high risk. And once you’ve suffered an ankle sprain, research tells us that you are at increased risk of suffering another one. So how can we minimize this risk and avoid sprains in the first place? The research points to several main risk factors:

  • Certain sports are higher risk, including basketball, indoor volleyball, field sports, and climbing (basically, sports that involve lots of jumping and changing direction quickly). In soccer, playing on natural grass (vs astroturf) and being a defender were risks.
  • Factors that cannot be modified but have a higher risk are: female gender (although in competition boys had a greater risk than girls!), taller people, and other anatomical abnormalities.
  • Factors that CAN be modified: limited dorsiflexion (pulling foot up towards you), reduced proprioception/balance, pre-season deficiencies in postural control.

If you’re in one of those ‘high risk’ groups, have had a previous serious sprain, or otherwise feel that you have weak ankles and are prone to sprains, the good news is that a PT can identify the biomechanical factors that might place you at risk, and help you to strengthen your leg muscles and improve your balance, to minimize your chances of suffering a serious sprain. A lot more is known now about ankle sprain injury prevention and injury treatment than in years past; this is not an injury you just have to live with – seek out a knowledgeable PT who can help you overcome old injuries and prevent future ones!

 

I am Suffering From Pain and Instability From a Previous Sprain; What Can I Do?

Maybe you’re like me – you’ve just always been prone to rolling your ankle, you were active in sports as a kid, and ankle sprains are now the ‘Achilles heel’ (no pun intended!) of your athletic pursuits. Is there any hope for overcoming pain and weakness from those old injuries?

The good news is, yes! I would recommend that you work with a PT to see whether exercise can help you to overcome that old injury. If it’s something you’ve been struggling with for a while, it may take some time for your body to respond to treatment and heal, but I have had many successes treating patients who have struggled for years with old injuries and chronic pain. In my practice, I tend to see patients less frequently and over a longer period of time than is typical in most PT clinics; rather than multiple times a week, I usually see patients every week or two (or even less frequently for established patients), spread out over several months. This approach can be particularly beneficial when dealing with an old injury, where we expect it to take some time for the body to heal.

In rare cases, it is possible that a severe sprain may not be able to heal on its own or with therapy, and ankle reconstruction surgery may be needed. However, this is not a trivial surgery, so you definitely want to give conservative treatment (PT) a good try first! If you’re concerned that you may need surgery, discuss this with your PT and they will be able to refer you on to a surgeon if needed.

I hope that helps you to make good decisions when/if you next sprain and ankle. If you want to know some more of the specifics from the research check out the toggle boxes below. Make sure you get the best treatment! Let me know if you have any questions and if I can help you!

 

Reference:

Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956.

Risk Factors
  • Limited dorsiflexion, reduced proprioception/balance, preseason deficiencies in postural control
  • It is uncertain whether higher or lower than normal BMIs increase the likelihood further
  • Sports that have a higher risk are: basketball, indoor volleyball, field sports, and climbing. In volleyball, landing after a jump was seen as a higher risk. In soccer playing on natural grass (vs astroturf) and being a defender were risks
  • Factors that cannot be modified but have a higher risk are: female gender, taller people, and other anatomical abnormalities. In competition, boys had a greater risk than girls.
RICE (Rest, Ice, Compression, Elevation)
  • Alone, this is not recommended. There is some evidence showing ice along with exercise allows significant improvement in short-term function including early weight-bearing exercise. So, RICE for 3-5 days combined with exercise is likely beneficial. BUT, don’t rest for too long as you will lose some of the capacity that the tissues of the ankle have for loading (this is especially the case with an athlete) and it will then take longer to build this back up.
Exercises
  • Should be started as soon as possible to improve joint function
  • Should be interspersed amongst sport and normal activities in recurrent sprains
  • Neuromuscular exercise programs (strength and balance) have been shown to have a preventive function.
Manual Therapy/mobilization
  • Should not be used on its own as only is thought to show benefit when combined with exercise
NSAIDs
  • Can be used to reduce pain and swelling, BUT cautions should be used as there is some evidence that they reduce inflammatory factors that are  needed for tissue recovery!
Immobilization
  • Not recommended – Less optimal outcomes, instead: Functional Support.
Functional Support
  • Use for 4-6 weeks is preferred over immobilization. Can be in the form of a brace or taping depending on preference as, but the brace is seen to give superior results and likely is less expensive over time. Kinesiotape has not been shown to have any supportive benefit.
  • Both tape and brace have potential to reduce re-injury and first-time injury
Footwear
  • No evidence to support any particular footwear. There is a greater risk of injury/reinjury in high heels!
Other therapies
  • No evidence to support ultrasound, laser, acupuncture, light, electrotherapy, shortwave, vibration therapies.
Sport Resumption
  • Should focus on muscle strength and proprioception/balance activities.
Diagnostics
  • The Ottowa ankle rules have been shown to be effective in deciding if a patient needs an x-ray or not. We have blogged about this previously.
Prognosis
  • 1–4 years, 5%–46% of patients still experience pain, 3%–34% of patients experience recurrent sprains, 33%–55% of patients report instability.
  • 40% of those treated with taping/bracing and physical rehabilitation, still experience chronic ankle instability – Suggests we do not know all that contributes to successful rehab, or it is not always done well.
  • Increased risk of chronic ankle instability is predicted by an inability to do jump landing 2 weeks after injury, continued ligament laxity at 8 weeks, and altered hip biomechanics.
  • Also, sports participation at a high level, being a young male, increased BMI, and greater body height can also increase risk.

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