Doctor's Corner

Ankle Injuries: Step, Step,
Miss a Step ... Twist

Welcome to Doctor’s Corner, a new regular feature on Outsports. This feature is designed to give athletes--whether competitive or weekend warriors--practical advice on staying healthy and staving off injury. If you have any questions, suggestions or other concerns please feel free to Dr. Gloin directly

By Dr. Matthew Gloin
Outsports.com

The Most Valuable Player for the 2003 Gay Flag Football Tournament is ....  Please, come on down to receive your award! 

In your exuberance to receive the trophy that you have wanted to win ever since you began to play, you sprint out of your seat and down the aisle towards the stage.  But, before the feeling of excitement even has a chance to settle you find yourself sprawled out on the floor in excruciating pain, as you miscalculated the last step and turned your ankle.  Undoubtedly, there should be someone in the audience who can provide some insight on how to treat a sprained ankle.  However, in a situation like this where your pride is on the line it may be best if you pick yourself up, get your trophy and then slip away from the crowd and call your doctor. 

The ankle is a joint that has caused millions to suffer, from professional athletes to professional accountants.  An ankle sprain can occur with a sudden twist during a basketball game, a misstep off a curb or any number of scenarios that cause the foot to land in an awkward position.  When this misstep occurs muscles can fail to function properly, allowing the ankle joint to move further than it normally would allow.  If the force is significant, ligaments connecting the foot to the anklebones can stretch or tear, resulting in a sprain.  Typically, you can then anticipate sharp pain with swelling and bruising that may extend from your ankle into your foot.  Sprains can heal with proper care and steps can be taken to reduce the risk of re-injury.  

The lateral (outside part) ankle sprain is a common injury.  Such sprains make up about 10% of all injuries treated in emergency rooms and 15% of all sports injuries.  The lateral ankle complex consists of three major ligaments, which are tissues that connect bone to bone:  the anterior talofibular ligament (ATF), the calcaneofibular ligament (CF) and the posterior talofibular ligament (PTF).  All of these soft tissue structures are vulnerable depending on the direction of force.   

Ankle sprains are classified into three categories.   

Grade 1

Ligaments are stretched with some tearing on the microscopic level.  There is mild localized swelling and tenderness but little to no loss of function.  Estimated time required for recovery is 2-10 days. 

Grade 2

Partial tearing of the ligaments occurs with moderate swelling, bruising and pain.  There is a moderate loss of function that may require you to stay off your feet for a few days.  Estimated time required for recovery is 10-30 days. 

Grade 3

A complete rupture of the ligaments with severe diffuse swelling, pain and hemorrhage (bleeding inside the tissues).  The most severe sprain, a Grade 3 causes total loss of function with slow rehabilitation.  Patient prefers crutches to weight bearing.  Estimated time required for recovery is 1-5 months. 

Rehabilitation of the sprained ankle is accomplished with the following steps: 

1. Examination and X-ray:

Your doctor examines the affected ankle and determines if an x-ray is warranted.  Uncomplicated Grade 1 and 2 sprains can typically be managed safely without x-rays.  If a ruptured ligament is found, referral for surgery will likely be recommended. 

2.  Adjustment/Manipulation:

If you have a doctor of chiropractic managing your ankle he will want to restore proper motion to the joints where the trauma has occurred.  A chiropractic adjustment is typically performed once swelling has subsided and should not be painful.  The benefits of the adjustment are alleviation of symptoms and faster and improved healing.  The doctor of chiropractic typically couples the adjustment with other rehabilitation activities. 

3.  PRICE:

The PRICE method is a standard care solution for the rehabilitation of sprained ankles.  

a) Protection: Your doctor may recommend a splint or custom-made orthotic to help stabilize the ankle. 

b) Rest: Stay off your feet!  Some rest and immobilization is needed during the first few days for recuperation. 

c) Ice: Twenty minutes on, twenty minutes off for the first couple of days or until swelling has substantially decreased.   

d) Compression:  Wrap the injured ankle with an elastic bandage to keep it compressed during the healing process. 

e) Elevation: Elevate the ankle higher than the heart for maximum benefit.  Elevation decreases blood flow into already damaged and bleeding tissues.

 4. Prevention:

You can take steps to ensure that you won’t suffer from an additional ankle sprain.  It is important to avoid “running ahead” of the healing process, so follow your doctor’s directions fully.  Many reinjuries of the ankle come from asking for maximum performance of the joint too soon.   The pain and swelling associated with ankle sprains often goes away before the ligaments are healed and this leads the patient to believe that they are ready to return to usual activity when they actually are not.   

An ongoing exercise program may be implemented to help rebuild and strengthen the muscles and ligaments surrounding the ankle.  Your doctor may recommend daily exercises to promote range of motion in the ankle.  These exercises may include resistance exercises with tubing and wooden “wobble” boards for balance.  It is also common for your doctor to recommend custom-made flexible orthotics to provide a firm foundation for your feet and to promote long term healing.  Below is a sample ankle sprain/strain rehabilitation program. 

Figure 1	Figure 2	Figure 3	Figure 4	Figure 5
Click images for larger view

Exercises

 1)

• Motion exercises should be started immediately
• Do each exercise while seated in a chair
• Proceed slowly, letting pain be your guide
• Each exercise should be done 10 times and repeat 3 times a day

Cross your legs with your injured leg on top.  Draw the alphabet in capital letters with your big toe. (See Figure 1)
Extend your injured leg and slowly point your toes forward, then slowly point your toes toward the ceiling. (See Figures 2 and 3)

2)

• Strength exercises should be started when your ankle will permit the movement
• Proceed slowly, letting pain be your guide
• Do each exercise 10 times and repeat 3 times a day

Toe Raise 1- stand on both feet, holding a chair or wall for balance.  Slowly move up and down on the toes of both feet. (See Figure 4)
Toe Raise 2- slowly move up and down on the toes of your injured foot.

3)
“Wobble”/Balance Boards retrain the muscles, ligaments and joints and when used often can dramatically reduce the rate of re-injury. (See Figure 5) 

Progress to next level of difficulty with the “wobble” board when you are able to perform the prior level consistently for greater than 30 seconds.

 I) Balancing with both feet on the board

             II) Both feet eyes closed

             III) Both feet, eyes open tilt board forward then to neutral then backwards

          IV) Repeat III with eyes closed        

V) One leg (non-injured side) eyes open

          VI) One leg (injured side) eyes open

          VII) Repeat steps V and VI eyes closed 

Turning your ankle can be a dreadful experience.  Aggressively manage the problem in the beginning and the painful incident should be limited to a brief inconvenience.  The next time you “come on down” badly on your ankle, you will now know what you must do to ensure that the show will go on! 

Always consult with a doctor for diagnosis and treatment recommendations prior to beginning any self-therapy on your own.

Other health columns:

• Heat vs. Ice
• Stretching myths and facts

Photos by Brent Mullins / Outsports.com