In the clinic: Ankle sprains
Today we take a look at one of the most common injuries we see here at APC. Podiatrist Colin explains what’s going on in your ankle and what you should do to help it heal as soon as possible. Grab a cuppa and a biscuit and settle in for a read!
Ankle sprains are a pretty common occurrence here in clinic and we see them at an early stage but also many weeks or months later when the runner thinks that full function has not fully returned.
So what is an ankle sprain?
An ankle sprain is usually referred to as an inversion injury and this is when you ‘go over’ on your ankle. Usually on landing and you tip sideways with your foot planted on the ground. So there is a big stretch on all the structures on the outside of your ankle, foot and even leg. This can range from a big stretch and everything thinks that is just far enough and it settles down quickly and you can often carry on running and it eases off and could just feel a bit sore for a couple of days. At the other end of the scale is a major injury that could involve all the supporting ligaments and soft tissues in the ankle, foot and leg. The next level up from this is a break, usually of the bone down the outside of the leg – fibula – but that is another issue and will involve hospital care. So I am going to talk about ankle sprains – not breaks.
So you are running along and go over on your ankle. Even a big stretch often feels very painful. There is often a crack heard and a sharp shooting pain that feels hot and ‘white’. Often people say they can feel a bit sick at this point too. I often find swearing loudly at this point is really helpful. You may have fallen at the same time and so you are probably going to be feeling a bit shaken and not that great. If you have tripped off a kerb and fallen into the road your body will know what to do and you will instinctively get yourself off the road and back onto the path. But most of the time you are going to be able to take a minute to see how everything feels. If you have fallen check the rest of you to see if any other damage you need to know about. But this time everything else is ok and you can just concentrate on your ankle. It is going to be hurting – no matter how bad the damage. First thing is that you have to get from where you are back home or to A&E. I always carry a cohesive bandage as I remember a time before mobile phones and you had to take some responsibility for yourself up in the hills. These are great things to have with you (bandage not phone) as they will cover a whole range of body parts, easy to apply and will allow you get back to safety in most cases. So strap it up tight and get yourself back home so you can see what is going on.
Once you are back home and you have decided hospital is not needed (at the moment) you need to do something. First things first, a bit of anatomy and physiology information required. There are not only ligaments, tendons and bones around the ankle joint. There is a whole host of soft tissues that will be affected by an ankle sprain. So even if there is no ligament tear there will be damage to these other tissues and a big stretch can also be quite damaging. Also the body is going into overdrive to protect and repair the damage. So swelling is very useful at splinting, heat is great for speeding up the all the many chemical reactions that are going to be taking place and pain is great for keeping you sat on your bum and not wanting to stand on it. So think carefully about whacking on loads of ice, taking loads of Ibuprofen and trying to do too much too soon. All of these will have a negative effect on healing and will generally slow down the healing. But if you are in a lot of pain then take some painkillers but try and stick to paracetamol and be mindful that you will not be getting full feedback from the injury – but sleep is also important.
Ideally up to the first 72 hours you should be aiming to do as little as possible to let your body get on with doing what it is extremely good at – i.e. fixing what is damaged. Strapping, compression, taping can be really useful at this stage as the protection bit is really important. The less damage you continue to inflict on yourself at this stage the quicker this whole process is going to take. But life goes on and sitting around for 3 days being waited upon is not likely to happen to the majority of us. So be aware of what you have to do and do just that. Keep all non-essential activity down to a minimum and use ice and painkillers sparingly. If things are not feeling like they are improving quickly during these first 3 days then consider a trip to A&E to check for breaks.
Once the initial inflammatory response is starting to settle (this may be 36 hrs – you do not necessarily have to wait three days) then we need to get things moving again. Bodies get very good at being overly protective. They are also very good at making things feel as if they hurt more than they do to protect you from being silly again and going out for a run. The other important thing to be aware of is that bodies will only do just enough healing to do what it thinks you need. This is a response to the load you are putting on your body. So your body will only heal to the level of force you put on it. So if you do nothing a weak repair will occur, if you continually load it then the repair will be stronger as you are keeping your bodies repair process ticking over. This way does involve having pain for longer as you are going to be niggling away at the injury, but your activity should be going up and the pain should be manageable.
To start with try a single leg stance (cleaning teeth time), some double leg squats – holding onto work surface whilst making a cup of tea – feet shoulder width apart and bending forward from ankle and knees, not sitting down through hips, and walking. Walking is important as it is an easy exercise you can do anywhere and should not be overlooked. But walk properly, heel-toe, extend your leg out behind you, try not to hold ankle too stiff, let your upper body help drive your feet and legs. Also specific exercises for the individual muscles using a TheraBand to ensure you are working the specific muscle through its whole range of movement are useful. So at this stage it is not about strength but getting the muscles used to working again. They will have been in protection mode and we need them to start letting go and working correctly again – not over tightening. This is what happens if you push too hard too soon – muscles become stiff and tight as they need to protect the area and then they do not work correctly and a re-sprain is a common occurrence as the body has no tolerance to excessive movements. You have to use pain as a guide to how much you should be doing. Aim for a pain scale level of about 4-5 during and immediately after exercises that very quickly drops back to where you were prior to exercise, if not below. So you aggravate the injury, create a bit of an inflammatory response, let it settle as the body heals the new bit of damage, and then go again once it has settled back down. Start running with a gentle walk / run program. Do not overload the muscles too soon as they will fatigue quickly. Try to always come back thinking you could have done more, not continually thinking you have done too much. If you do too much and it is sore then let it settle down again and start with the gentle mobilisations exercises as soon as it can take it. It is important to keep moving but below the level of damage that your body can deal with. This process should take no longer than 6 weeks. By then you should be easily back to where you were before the injury and progressing well again.
If things do not seem to be progressing quickly then seek advice as there could be other damage or activity may need to be modified to address certain areas. Also hands on treatment to muscles, joints, bones and ligaments can be required to help with promoting healing, switching off guarding mechanisms and altering nerve conduction. This can be really useful if things have been going on for a couple of months and do not seem to be improving past a certain point.