Ankle Sprains Part I:  Causes, Symptoms, and Phase 1 of Rehab

 2013 Cross Country Grade III Sprain (me right- inversion sprain ) and fellow football player grade III sprain (eversion sprain)

2013 Cross Country Grade III Sprain (me right- inversion sprain ) and fellow football player grade III sprain (eversion sprain)

In general, ankle injuries make up about 17% of all running injuries, half of these account for lateral ankle sprains (1)

Many of us have experience 1 or 2 ankle sprains, others many more. I have received a few questions in regards to what else can be done aside from Ice and elevate after spraining an ankle. I am here to help provide some guidance.

1.     What is an ankle sprain ?

The actual ankle joint itself is made up of the talus bone articulating with the tibia and fibula bones. In order to keep the ankle stable, strong fibrous tissues called ligaments surround the joint. These ligaments connect the bones together, keep the bones in their proper position, and provide stability.  An ankle sprains occurs when these strong supportive ligaments get stretched beyond their limits and tear. The tears can be very minor and some tears can be quiet severe to where you will notice swelling, discoloration, experience pain, limited range, and inability to even walk.

There are 3 types of ankle sprains:

1.     Inversion ankle sprain ( the most common)

2.     Eversion ankle sprain

3.     High Ankle Sprain

An inversion ankle sprain occurs when the ankle rolls out, and foot rolls under. This type of sprain will stretch and injure the ligaments on the outside of the ankle most commonly the Anterior talofibular ligament and the calcaneofibular ligament.  It occurs more with runners who land on the outside of their foot.

An eversion sprain happens less frequently and it occurs when the ankle rolls inwards the foot outward. This type of sprain stretches and injures the ligaments on the inside of the ankle, the deltoid ligament. Many times some poor footing on uneven surfaces or rocks. It is common also so suffer an inversion sprain and as your foot tries to correct itself. 

Lastly, high ankle sprains are the least common and occur when the foot is planted on the ground and the lower leg rotates inward, or when the foot is forcefully rotated outward. This type of sprain will injure and tear the syndesmosis which is the fascia/dense tissue that connects the tibia and fibula bones  together.

There are also different classification of sprains that are categorized by grades. The grade refers to how injured the ligaments are.

Grade 1 Sprains are very mild injuries, where the ligaments demonstrates slight stretching. Meaning the integrity of the ligament is intact.

Grade 2 sprains are moderate sprains, where there is a partial tear in the ligament/s. At this level the integrity of the ligament has been compromised, when examined the ankle will feel loose or less stable.

Grade 3 sprains, are severe sprains in which there is a complete tear of the ligament. Therefore clinically the ankle will feel unstable.

 My grade III sprain progression: Day 1, Day 2, Week 2, Week 4 (2015)

My grade III sprain progression: Day 1, Day 2, Week 2, Week 4 (2015)

 2.     How Do you know you sprained your ankle?

 I know there have been times where you gingerly roll your ankle and you recover pretty well, in those circumstance you probably have not sprained anything.  When you have experienced a true ankle sprain if you will notice soreness, swelling, sometimes bruising, and the level of stiffness and weight bearing pain varies on the grade of a sprain.

For example:For grade 1 ankle sprains, you will experience some tenderness and very mild swelling. You may feel sore but it may not necessary limit your activity or you may even keep on running without any problem

A grade 2 sprains you will experience pain after rolling your ankle, and notice minor to moderate swelling immediately. You may experience minor bruising the next day and notice some soreness with weight bearing.

With grade 3 sprains, you may hear or feel a pop in the ankle, followed with pain and moderate to severe swelling immediately.  Weight bearing will be painful, and after a few minutes experience range of motion loss ( due to pain and swelling) and will notice bruising.

 

3.     What you should do after spraining your ankle- Phase 1/3

 Grades 1 Sprains

Ice it, weight bear as much as you can tolerate if painful. Studies show that there is a significant benefit to weight as compared to non weight bearing. Patient who managed to bear weight and work on their range of motion ( if noted) returned back to sportin 4.6 days. (3)

Grades 2-3 sprains:·    

 Immediately after : R.I.C.E !!! ( Rest, Ice, Compression, Elevate). For the last couple of years, icing has been a hot topic. Recent research neither supports or discredits icing. A recent article just came out (3/8/17) stating that icing does suppress inflammation and some aspect of healing, however it does not retard muscle regeneration, which has been the biggest argument for those against icing. (4) As well as the idea that inflammation is part of the healing process, and cannot have tissue remodeling without inflammation. I agree with those points, the problem is when there is too much swelling that it negatively affects function, range of motion, and increases pain. For most people, ice has been helpful.

On a personal note, I have had grade 3 sprain on both ankles, and I iced quiet frequently, along with my rehab exercises I was back jogging in 4 weeks and running in 6 weeks. So I attest to its benefits, but that is up to you!

·      Wrap the ankle with an ace wrap, or wear a compression stocking to avoid development of further swelling.

·      Weight bear at tolerated- use a lace up brace (2)

·      Once you have gained control of the swelling with elevation, day 2-3 you want to begin doing therapeutic exercises. Studies have shown a significant increase in function in patients with grade I and II sprains, and those with chronic ankle sprains with physical therapy interventions (1, 5)

PHASE 1 OF REHAB BEGINS WITH : Normalizing range of motion, and balance.     

 1. Standing Gastroc Stretch   3x 30-60 sec bouts   If weight being is painful you can do this stretch long sitting, using a belt or towel and pull your toes towards you. 

1. Standing Gastroc Stretch 

3x 30-60 sec bouts 

If weight being is painful you can do this stretch long sitting, using a belt or towel and pull your toes towards you. 

 2. Further work on range of motion with this WALL DORSIFLEXION exercises  Affected foot about 3 inches from the wall, foot straight, knee in line with toes and try to see if you can get your knee to touch the wall. DO not let the heel lift from the ground. - Hold for 5 seconds and REPEAT  x20 

2. Further work on range of motion with this WALL DORSIFLEXION exercises

Affected foot about 3 inches from the wall, foot straight, knee in line with toes and try to see if you can get your knee to touch the wall. DO not let the heel lift from the ground. - Hold for 5 seconds and REPEAT

x20 

 Single leg balance on stable surface first, then unstable.   First try on the ground, if that is easy or soon gets easy, and able to hold for 1 min, then progress to foam pad.   Goal is one min!   5 min of balance , hold for as long as you can hold. NO TRUNK SWAYING, TO KNEE INSTABILITY.   Once this gets easy then we progress to forward and lateral steps to balance. 

Single leg balance on stable surface first, then unstable. 

First try on the ground, if that is easy or soon gets easy, and able to hold for 1 min, then progress to foam pad. 

Goal is one min! 

5 min of balance , hold for as long as you can hold. NO TRUNK SWAYING, TO KNEE INSTABILITY. 

Once this gets easy then we progress to forward and lateral steps to balance. 

 Forward Step to Single Leg Balance   Step forward to single leg balance, or you can do a forward hop to balance.  Stick the landing and hold for 5-10 seconds, and Repeat x20   Trunk, hips, and knees should be stable and steady. 

Forward Step to Single Leg Balance 

Step forward to single leg balance, or you can do a forward hop to balance.

Stick the landing and hold for 5-10 seconds, and Repeat x20

Trunk, hips, and knees should be stable and steady. 

Yes strengthening will play a huge role after the acute phase (which lasts 7-14 days)

The goal in the first phase post sprains is to control the swelling, manage the pain, begin weight bearing (if painful), and begin normalizing range of motion.

A lot of runners benefit from manual treatment also, so if you do not have a physical therapist that may help you with that: stretch, foam roll as tolerated. The goal to is get the same amount of range of motion as the non-injured side.

This will take a few weeks 3-4 weeks for grade II-III sprains. Pain attention to how your body reacts to the exercises. 

I would advice to get a higher grade sprain checked out by a physical therapist. 

 

STAY TUNED FOR PHASE 2 REHAB that will be posted next week!

TRAIN SMART

RUN HAPPY,

JESSICA MENA DPT, PT, CSCS

 

1.     Bleakley CM, O’Connor SR, Tully MA, et al. E ect of accelerated rehabilitation on function after ankle sprain: randomized controlled trial. BMJ. 2010;340:c1964. http://dx.doi.org/10.1136/bmj.c1964

 

2.     Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilization for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001;121:462-471.

 

3.     Martin, R. L., Davenport T.E., Paulseth, S., Wukick D.K, Godges, J. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains: Clinical Practice Guideline Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy. 2013; 43(2)

 

4.     Singh D., Lonbani Z.B., Woodruff M.A., Parker T.J., Steck, R., Peake, J.M. Effects of Topical Icing on Inflammation Angiogenesis, Revascularization, and Myofiber Regeneration in Skeletal Muscle Following Contusion Injury. Frontiers in Physiology Journal. 2017. doi:  10.3389/fphys.2017.00093

 

 

5.     Rijn RM, van Heest JA, van der Wees P, Koes BW, Bierma-Zeinstra SM. Some bene t from physiotherapy intervention in the subgroup of patients with severe ankle sprain as determined by the ankle function score: a randomised trial. Aust J Physiother. 2009;55:107-113.

6.     Van den Bekerom, M., Struijs P.A., Blankevoort, L., Welling, L., van Dijkm N.C., Kerkhoffs, G.M. What is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the treatment of Ankle Sprain in Adults?  Journal for Athletic Training. 2012. 47 (4)