So You Wrenched Your Ankle (part II)

Part 1 - what to look for right away.
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You have rested, iced, and elevated your bum ankle for a few days or weeks, depending on the situation. It's likely still swollen, but you're at the point where you can bear weight on it. You need to get moving again. The first thing is to try some light stretching of the ankle to recover dorsiflexion.

Place a belt or towel under the ball of the foot and pull back to apply more stretch.

Make sure the feet are "aiming" STRAIGHT toward the wall, not flared out.

You MAY need a little help

As mentioned in part one, look for pinching when the ankle is stretched in this manner, or with real life movements like squatting or walking down steps. If the motion feels blocked and there's pinching toward the front of the ankle rather than a pulling/stretching feeling in the back of the calf and ankle, you probably should be evaluated by professional. This is a very common, stubborn problem after an ankle sprain that won't show up on an X-ray.

A skilled doc, trainer, or (yes) PT should be able to determine if there's excessive laxity (the ankle ligaments have been overstretched or torn) that would warrant further imaging or a period of immobilization. They can also perform a trial of manipulations aimed at restoring normal spacing between the top foot bone (the talus) and the lower leg bones (the tibia and fibula). 

Take dorsiflexion seriously. Lacking this movement causes you to unconsciously shift strain to other areas on the same leg or to the other leg. Chronic ankle dysfunction can be particularly hard on the knee and low back, and researchers have measure differences in joint movements and muscle activation all the way up into the trunk.

The reccurance rate for ankle sprains is somewhere between 50 to 70%; pretty horrible numbers. My friends and I have definitely walked hobbled down this road. Exercises and braces are your first steps toward better...steps.

A word on exercise

This is one time when exercises I like to make fun of are actually called for. In the weeks to months after ankle (or knee) sprain, you should be working on balance and controlled movement on both stable and unstable surfaces. We won't get into the specifics of exercise progression right now, but here's a quick screen for sprained ankles:

The intermediate phase of ankle (and knee) rehab is one time when goofy squats and reaches on unstable surfaces are actually beneficial and I shouldn't make fun of you for doing it. Unless, well, yeah, this guy.

-Try to balance on one leg with your eyes closed - no wrapping the "up" leg behind the balancing leg.
-Try to do a full toe raise on one foot - no holding onto anything with your hands. 
-Try to stand on an 8 to 10-inch step and lightly tap the "good" heel forward on the floor - don't transfer your weight, just lightly touch the floor.
-Do a deep squat with your feet straight ahead and heels staying glued to the floor and your knees staying over your toes and your chest staying up without a forward trunk lean. 

Compare your injured side to the "good" side. People often feel wobbly on their injured side, or have to use different movement strategies due to weakness and inflexibility.

A word on bracing and shoes

The absolute BEST device for stability when you need stability, and explosive movement when you need explosive movement, is a primed and efficient nervous system! The best way to shut down all your lower leg muscles and hinder the ability of the brain to fine tune movement is to lock the foot in a concrete block of a shoe and brace/tape your ankles.

Many studies have examined the performance effects of wearing ankle braces. Although there's some conflicting findings in this area, recent work from the Division of Orthopedic Surgery at the University of Utah (and a few others) showed that ankle braces do decrease vertical jump height, broad jump distance, and maximum sprint velocity.

Other studies specifically address the price your body pays for increased ankle stability. Braces and tape at the ankle allow for less movement and sensory feedback from that joint, removing a large part of the shock absorption system of the leg. This leads to measurable increases in shear strain and torque (twisting strain) at the knee. Protection of the ankle may cost you at the knee, over time.

We do need to reach a balanced perspective, however. Sometimes athletes need to get back to the game sooner than later; before their ankle is completely recovered. Many sports involve hard cuts on uneven terrain and/or lanky athletes jumping and landing all over each other. In that instance, braces and tape just plain make sense. They may be the lesser of two evils.

The athlete that makes a living out-running, out-jumping, and "out-cutting" people should consider taping or bracing WITH an end-point in mind - maybe three to six months as they rehab in controlled environments. If taking a few percent from sprinting or jumping performance really doesn't mean that much, brace or tape for nine months to a year. But there should be an end in mind, for the sake of your knees, hips, and back. 

Surgery is sometimes needed. Rarely. I have a few specific stories on this for anybody who wants to hear, but this is already too long. Maybe a part 3 or maybe not.

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1 comment:

  1. Great article! You do a fantastic job of covering the entire spectrum of an ankle sprain.

    In the bracing and shoes section, you recommend a "less is more" approach to braces. I agree, but you seem to focus on athletes and their needs for braces. In the case of an ankle grade II sprain on a non-athlete, when would you recommend for a patient to start gradually going brace-less? (end of phase II, after mastering certain exercises, when pain/inflammation/bruising disappears, etc..)

    In a sense, I'm asking when the risk of re-injury is low and optimal future performance benefit is high enough to warrant taking off a brace.