So You Wrenched Your Ankle...

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You slipped, got hit, or came down on an uneven surface. Your ankle twisted, things popped, bones jammed and gristle disengaged. You dropped and rolled around gritting your teeth. 

Someone assisted you back to your feet, suggesting ice and compression and it will be fine in a few days. You stood there, mostly on one leg, wondering how the first step on your blue balloon is going to be. Someone else advised you to get an X-ray. Another bystander announces that the ankle will never the same. 

You were hoping for less advice and more Advil.
You, my friend, have wrenched your ankle. Don't feel too bad - it is estimated that about 23,000 other people in the United States have wrenched an ankle on the same day.

It's probably going to be fine. But maybe not. Really.

PTs get to deal with this.

If you can bear some weight through the injured foot and it's not highly sensitive to moderate pressure to the inside or outside of the lower leg, you don't need an immediate X-ray. I've seen ridiculously huge ankles displaying all colors of the rainbow recover fairly well in a week or two. Had a few of those myself.

I've also seen simple ankle sprains go from acute pain to chronic nag in no time. Had of few of those myself. It's April and I'm just now getting over an ankle sprain in October. The truth is that until you have the pain just a bit under control and some of the swelling down, it's difficult to determine if an ankle sprain is going to cost you days or months. 

Evidence of two mistakes:
Falling off my mountain bike and getting a Soundgarden tatoo.

Since about 15% of ankle injuries involve fractures, if you can't bare much weight on it two or three days later, you should probably get an X-ray. Fractures require (at least) a period of immobilization before moving on to much of what's described below. Otherwise, it's clearly beneficial to work on a few things sooner than later.

The typical ankle wrenching causes persistent swelling. Supporting muscles and ligaments loosen. The result is vastly decreased proprioceptive (positional sense) feedback to your brain, which further weakens muscle drive as you unconsciously unload that leg. Researchers have measured altered movement patterns all the way up through the hip and trunk in people with a history of chronic ankle instability.

 The "high" ankle sprain involves separation of the lower leg bones as the talus (the top foot bone) is essentially driven up between them like a (wood) splitting iron. This injury usually has a longer recovery period and  different course of treatment than the typical inversion sprain pictured below. 

Early movement has been demonstrated to be helpful in many ways. Use common sense, of course. Don't go jumping and running around on a recently wrenched ankle. But that same ankle probably can and should be doing non weight bearing stretches and active movements that help restore mobility, decrease swelling, and add enough strain (but not too much) to stimulate a strong repair of collagen and other connective tissue. 

The typical inversion sprain.
MRI studies have shown that with even modest inversion sprains, the talus and outer ankle bone may slip forward, causing  some motions to increase and others to decrease. You're left with a predisposition to more ankle sprains and a mechanical blocking of movements needed for everyday life. 

One of the best indications of displaced ankle bones and loose ligaments is a pinching feeling in the front of the ankle when flexing the knee out over the foot (ankle dorsiflexion). If you get this anterior pinching after some of the swelling subsides, you really should see someone skilled in hands-on manipulation to address this. 
As far as how soon to start pushing the envelope with higher level exercise, I often go by how much pain and laxity (looseness) is present with ligament stress tests. If those tests cause a lot of clunking around and pain, then a more conservative pace is needed.

The only option that doesn't involve a lot of whining is to take a break, do some corrective exercise, and follow a structured progression of impact activities.

The recurrence rate for ankle sprains is anywhere from 50 to 70%. What do helpful "higher level" exercises look like? Do you need to tape, brace, or buy different shoes? Will there be more pictures of nasty, probably stinky, swollen feet? 

See part 2 for details.
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