BY ALAN GJEDSTED MD.

You've injured your ankle. Maybe it was coming down the stairs, maybe it was while you were playing basketball or running, or you were just walking and you tripped. One thing you know for certain: it HURTS! It's swelling and, perhaps, you are unable to put weight on it. You ask yourself: "Did I break my ankle, or did I just sprain it? How is this going to effect my lifestyle and plans?"

Firefox

What is an ankle sprain?
An Ankle Sprain is an injury to one or more of the ligaments of the ankle. Ligaments are the structures that connect one bone to the next, providing stability across joints. Sprains are a spectrum of injuries that range from the mildest, an overstretching of an otherwise healthy, intact, ligament, to the total tear, or rupture, of one or more of the ligaments. In the ankle there is a usual sequence of ligamentous injury. Well over 90% of all ankle sprains occur due to the foot and ankle rolling "under" the lower leg, that is "Inversion" of the ankle. Typically, this first injures the ligament on the outside-front of the ankle (the Anterior Talofibular Ligament) and the vast majority of sprains involve only this one ligament. It can either be stretched beyond its normal length, perhaps suffering some microscopic tears of a few of the fibers, or it can tear, either partially or completely. Except in the mildest of sprains, there is usually swelling, pain, discoloration and stiffness in the ankle, that seems to worsen in the minutes to hours after the fall. You may find it too painful or unstable to bear your full weight on the foot.The pain is most often localized to the front-outside of the ankle and top of the foot. Occasionally, there may be some pain on the inner side of the ankle. Less frequently, more than one ligament can be torn, causing more instability and, often, more widespread pain, swelling and bruising


What do I do first?

The basic principles of immediate care of any acute injury of this sort are: "R.I.C.E.'1 This stands for Rest (get off the injured leg), Ice (wrapped in a towel, applied to the most painful, swollen area and left in place for 20-30 minutes, every 3-4 hours), Compression (wrap in an elastic bandage, after icing), Elevation keep the injured limb elevated as much as possible to decrease both pain and swelling). If you are unable to put any weight on the ankle immediately after your fall, or if there is an obvious deformity or exposed bone, then, of course, you should seek medical attention immediately. Otherwise, you should come to be examined within the first 24-48 hours after an injury.


What should I expect at the Hospital Clinic?

When you are examined by the doctor, expect that he/she will feel the entire ankle for areas of tenderness and will gently manipulate pull and bend) the ankle to test the ligaments. It may be somewhat uncomfortable, but it is extremely important to do this exam to define the nature of the injury. If there is reason to suspect that a fracture might be present, an xray will be done of the ankle and, possibly, the foot.
After the exam, assuming there is no broken bone (fracture), the early phase of treatment will be started. This will include explaining all the RICE modalities, along with fitting you with crutches, a compressive dressing or brace and, frequently, some medication for the discomfort.



How do I make my ankle strong again?

Now you are on crutches, with your ankle wrapped and painful. You cannot believe this happened - no more running, no sports, no dancing; even doing your usual daily routine becomes difficult. You are asking yourself:
"Will I ever have a normal ankle again?" and "When will I be able to do all the things I want to do, without pain, again?".
There is no one good answer to this. Of course, the time of healing is longer the more severe the sprain. The mildest form of sprain may take only 1-2 weeks to heal and have you ready for sports again; the most severe sprains can take months to adequately heal to full strength. The torn ligament, itself, is not totally healed until 6-12 months from the time of the injury.
The most important thing to avoid during early rehabilitation of the ankle is putting it at risk of re-injury. Therefore, once you are able to walk without the crutches, you should use the ankle brace provided, until a sense of stability has returned to the injured ankle.
There are many different recommended protocols for the rehabilitation of ankle sprains. You can begin these exercises once you are sure that no further swelling is occurring, usually within 1 week.

The following is a good general plan for starting:

Early rehabilitation begins with early
RANGE OF MOTION EXERCISES, which include writing the alphabet in the air with your big toe, while supporting the calf of the leg on a pillow or chair, trying to keep the heel still. You may start this exercise as soon as the ankle stops swelling, usually within the first 1-3 days To help decrease the swelling, use ice compresses (a bag of frozen corn or peas works fine) for the first few days. After the swelling has stopped increasing and stabilizes, you can change to contrast baths, where you move the ankle/foot from hot water (100-105F), to ice water, keeping in each bath for 1-2 minutes, for a total of 15 minutes/session. Do 1-3 sessions/day. Always end with the ice bath, to prevent recurrent swelling and do your range of motion exercises while in the warm water bath. Early on, you should avoid putting the ankle into the same position that caused the injury (usually turned down and under).
After 1-2 weeks of the above active range of motion exercises, you can start
STRENGTHENING AND STRETCHING exercises. The first type is the Isometric exercises, where you take your foot and place it against an immovable object (wall, table) and, using only the muscles of the lower leg, push with the foot against the object in the three directions of function: up, down, and out and up (eversion). Contract the muscle, hold for a count of 10, then relax. There should be very little motion in the ankle itself when doing these exercises. Do at least 10-20 contractions/each muscle/set. Repeat at least 3-5 times a day for each muscle group. If you find these exercises cause pain, go back to the range of motion exercises and wait until you are able to do these without significant discomfort.
If you tolerate the Isometric type, you may go on to strengthening against an elastic resistance (Isotonic) exercise. Theraband, Surgical tubing, bungie cord, or slips of old bicycle inner tube are all fine for this. Tie a loop around the injured foot and secure the other end to something immovable. Do the same three ranges of motion against this "movable" resistance, holding for the count of 5 doing at least 10 sets/muscle, 2-3 times a day. Refer to the exercise page at the end of this text.
Once you have mastered these, you should begin doing calf strengthening by standing on your toes, holding for 5 seconds, and repeating as above.
During this active rehabilitation, you are permitted to do nonweightbearing types of exercise, such as stationary cycling and pool programs (swimming and aerobics programs). Once you have at least 75% of your normal range of motion (test against the other ankle), you can also begin doing Stairmaster, or other "ankle safe" exercises.
If you have had prior injuries to the same ankle in the past, or if you feel you have poor balance reflexes in the injured ankle, you should train using a balance board. These can be purchased at medical supply stores or easily made of a small (24 inch) round 1" plywood disc which you can place over a 10 lb. barbell weight in the center, then begin by attempting to keep all edges of the disc off the floor, standing first with both feet and, ultimately, only with the injured leg.
Once you are able to stand on the floor, standing up on of the injured limb only, your balance reflexes and strength are near normal.



When can I return to my sport?

When you have done all the above rehab exercises, are able to stand on the injured foot, for 20 seconds on the ball of the foot (on your toes), are able to do the balance board easily, and when the swelling is gone and there is no significant discomfort with everyday routine walking, you may now begin by taking walks for distance. Once you are able to walk for one mile without aggravating the pain, slow running is allowed. You should stretch first, then "walk a mile/run a mile". You may then gradually increased your mileage as desired (very slowly, no more than a 10%/week increase in mileage).
If you wish to return to a cutting, deceleration/acceleration type of sport such as tennis or basketball, you must also include running in figure-8's with large loops, then increasingly smaller loops, then running and cutting without pain or instability, before you return to these sports. Wear the support brace whenever you first begin your sport, whatever it may be. Once the ankle feels normal and stable, you may dispense with the brace.
At any point in your rehabilitation program, if you develop renewed pain and/or swelling, stop, rest, ice the swelling and return to a lower level of rehab, advancing more slowly.


When should I be rechecked?

If your ankle is not much improved within approximately 6-8 weeks, you should return and be rechecked. Occasionally there are injuries to the ankle that appear later and these will cause persistent discomfort and should be checked. If you have a question concerning whether you are ready to advance in your training/rehab, you should call the lOSA/Injury Center (202-2291), for further explanation. If you have a persistent sensation of instability or "movement" in the ankle, you should return for a re-exam.


GOOD LUCK AND GOOD EXERCISE.