Sprained Ankle Management

Lateral Ankle Sprain

Ankle sprains remain the most common lower extremity injury in all of sports.  From the minor “tweak” of the ankle to the high ankle sprain, the range of symptoms and the limitations vary greatly.  The challenging factor with ankle sprains remains the ongoing vulnerability of the ankle joint for years after a sprain because of the resulting ligament instability so common after a significant injury.

The term “sprain” refers to an injury that involves damaging a ligament.  Ligaments connect bones to bones while tendons connect muscles to bones.  Ligaments are common stabilizers of joints, often embedded within a capsules surrounding most of the joints in the body.  The ligaments in a normal ankle provide static stability to the bones of the lower legs and hindfoot.

A ligament sprain can be as simple as a minor stretch or as complex as a complete disruption or tearing of the ligament fibers that give stability to a joint.

Lateral Ankle Sprain

With a lateral ankle sprain, commonly called an inversion sprain, occurs, a majority of the ligament damage takes place along the lateral or outside of the ankle joint.  These ligaments include the following ligaments:

1.  Anterior Talofibular Ligament (ATF) – located in front of the outer distal Fibula (shin) bone.

2.  Calcaneofibular Ligament – Connects the fibula (shin) to the heel bone

3.  Posterior Talofibular Ligament (PTF) – located behind the outer distal Fibula (shin) bone.

High Ankle Sprain

Often we read about elite athletes with an ankle sprain that forces the athlete to be out of competition for 2-6 weeks.  Immediately, questions arise as to why anyone would miss so much time with “just an ankle sprain”?  In most cases, the reason is that the athlete has suffered a high ankle sprain.  The high ankle sprain is one of the most frustrating and difficult injuries for an athlete to recover from during a season.  This injury is even more difficult to overcome when the athlete is involved in what I refer to as a “stop and go sport” where rapid changing of direction is required.

With a high ankle sprain or interosseous ankle sprain, most of the damage is found in the anterior ankle and distal shin area.  These structures include the following:

  1. Interosseous Membrane – located between the two bones of the distal shin.
  2. Anterior Distal Tibiofibula Ligament – located at the front of the distal two bones of the shin just above the ankle joint.

Additional damage to the surrounding bone, tendon, capsule and joint surfaces can result from any ankle sprain.  A serious ankle sprain can result in complete ruptures of the lateral and anterior ankle ligamentous structures including the capsule.  Ankle joint dislocations and fracture often occur.  I suffered such an injury while in college resulting in two surgeries and four months of rehabilitation.

Signs and Symptoms of a Lateral Ankle Sprain

The signs and symptoms for a lateral ankle sprain will vary based upon the grade or significance of the ligament damage.  Sprained ankles are graded from 1 to 3 based upon their laxity or the ligament looseness.

Grade 1 Lateral Ankle Sprain:

  • Minor stretching of the lateral ankle ligaments.
  • Minimal joint instability with a firm end-feel or tautness of the ligaments when stressed.
  • Mild pain.
  • Minimal swelling around the bone on the outside of the ankle.
  • Mild joint stiffness with walking or running.

Grade 2 Lateral Ankle Sprain:

  • Moderate stretching and tearing of the lateral ankle ligaments.
  • Moderate joint instability with a firm end-feel or tautness of the ligaments when stressed.
  • Moderate to severe pain and difficulty walking.
  • Moderate swelling on the outside, front and back of the ankle.
  • Significant stiffness of the ankle and mid-foot.
  • Moderate bruising of the lateral ankle and mid-foot.

Grade 3 Lateral Ankle Sprain:

  • Complete tearing of the lateral ankle ligaments.
  • Significant joint instability with a soft end-feel or tautness of the ligaments when stressed.
  • Significant pain.
  • Significant swelling throughout the outside, front and back of the ankle and mid-foot.
  • Significant bruising of the lateral ankle and mid-foot.

Treating a Lateral Ankle Sprain

  • Rest the distal leg with Ice, Compression and Elevation (RICE).
  • Ice is a valuable tool for a fast recovery.  Ice bags on the outside and inside of the ankle joint for 15 minutes is a good way to reduce the swelling and pain.  The best way to aggressively ice the entire ankle/foot/distal shin area is to place the ankle into an ice bucket for 10 minutes.  A rubber glove or insulated sock covering only the toes will significantly help make the ice bucket more tolerable.
  • Depending upon the grade of the sprain, limitations in the weight bearing status may be necessary.  The use of a walking boot and/or crutches will prove to be helpful to allow for a daily reduction of the symptoms while still performing normal activities of daily living. (ADL’s)
  • Easy range of motion (ROM) with elevation can be started in a painfree range.  This motion should only be in the upward (dorsi flexion) and downward (plantar flexion) directions to avoid stretching any damaged ligaments located on the outer ankle joint.
  • Compression when weight bearing and with activities is very helpful to control swelling and pain in the ankle joint and surrounding tissue.  Compression with rest will be helpful for acute sprains.
  • Massage to the arch, ankle joint, Achilles and calf will help reduce the swelling and enhance blood flow the injured tissue.
  • Bike riding with compression can be started early.
  • Manually resisted strengthening exercises can be started when the swelling is reduced by 50%.  Starting with resisted upward (dorsi flexion) and outward (eversion) movements while avoiding inward (inversion) stretches.  Typically this inversion motion was the mechanism of injury resulting in ligament damage to the outside of the ankle.
  • Slant board can be initiated when stretching of the calf and posterior ankle joint is comfortable.  Include calf strengthening heel raises when tolerable.
  • Balance activities are great drills for the final stages of treatment to prepare you to return to your sport.
  • Sports specific activities can be started when strength is at least 75% and the swelling is not significantly increasing with activities.
  • Having your ankle joint taped by a certified athletic trainer is the smart way to minimize your chances of re-injuring your ankle.

Questions a Pro Athlete Would Ask

A smart professional athlete with an ankle sprain who wants to safely return to his/her sport will ask his sports medicine specialist the following questions:

  1. What grade is my ankle sprain?
  2. Do I need an x-ray to rule-out a fracture?
  3. What do I need to accomplish with my rehab to be able to safely return to my sport?
  4. Do you recommend that I have my ankle joints taped or braced when I return to my sport?

Sports Medicine Tips for a Sprained Ankle

Avoid the Bum Ankle – Trust me: a chronically loose ankle can ruin your confidence and your game.  So many have a “bum ankle” that rolls over just walking across the yard or stepping off a curb.  Treat your ankle sprain right now will keep your ligaments tight and keep you from becoming a “bum” down the road.

Flexible Calves and Achilles Are Key – If your calves and Achilles remain loose, your ankle will have great range of motion and function normally.

Compression is Your Friend – Wearing compression on the ankle joint and distal calves will help maintain the congruity of the lower leg long after the sprain has healed.

Back to Basics – Other then Michael Jordon, none of us where born with sneakers on our feet.  Get out of those hard shoes and spend more time barefoot.  It will strengthen your arches, foot muscles and ankle ligaments.

Knee Therapy: Sports’ Best Kept Secret

One of the most common questions that I’m asked is:  “With a sports-related injury, when do I use ice and when should I apply heat?”

ICE THERAPY the best kept secret in sports medicine, period!

All the fancy machines and cool rehab techniques may get all the hype.  But if you ask the elite athletes with a knee injury what helps them maintain their body and assist their recovery the most, they will tell you that some form of ice therapy is vital.

Personally, my best training partners when it comes to athletic injuries is ice therapy.  I often use ice to help me control soft tissue pain and supercharge my recovery.

Knee Surgery Recovery is Enhanced With Ice

Recovering from any type of knee surgery is not easy.  Unless you have the unique skill of a gymnast, you won’t be able to walk around on your hands all day.  With the painful and lengthy rehab work that needs to be done with most knee injuries, you’re creating additional swelling and pain in the joint on a daily basis.  Knee surgery recovery starts with pain control to allow you to increase your range of motion (ROM), increase your strength and to restore your function.  Ice therapy is the trick to making that happen as soon as you wake up from your surgery.

It’s not a coincidence most successful knee orthopedic surgeons apply a cold therapy device to their patient’s knees before they even leave the operating room!  What does that tell you?

Injury prevention is an important motivator for me as the founder of this website and I’m sure it is the same for you.  Ice therapy should become a part of your injury prevention plan.

There are many myths and questions in the battle of ice versus heat…so today I am going to shed some light on the truth about ice.  I’ll discuss the benefits of heat therapy in upcoming blog writings.

How to Use Ice in Knee Therapy

Three Benefits of Ice

  1. It’s a lot easier to keep a joint from swelling than it is to reduce the swelling of an inflamed injury.
  2. Icing will quickly relieve knee pain by blocking pain receptors’ feedback to the brain.
  3. Ice will significantly minimize the likelihood that the injury will swell which can actually reduce your recovery time by 50%!

How Does Your Knee Respond to Ice?

  • It decreases inflammation.
  • It moderately reduces circulation to an area which will drastically decrease the rate of tissue swelling. (In contrast, applying heat to an acute injury is like turning on a drippy faucet.  It speeds up blood flow which can quickly INCREASE tissue swelling.)
  • It slows down the metabolism of the injury site which will reduce the body’s normal inflammatory process.
  • It decreases pain.

How Should I Include Ice in my Knee Therapy?

  • Ice the injury and the surrounding tissue, not just at the site of the injury.  For example, if your injury is on the right side of your knee, ice all the way around the knee instead of just on the injured side.
  • Try to ice the knee injury while elevating the body part.
  • Ideally ice with compression.

Methods of icing:

  • Submerge in ice water – the most aggressive and effective way to ice.
  • Ice Bags
  • Ice Massage
  • Frozen Vegetables

How Long Should I Ice My Knee?

  • Ice Massage – 10 minutes
  • Ice Bath, Ice Bag/Veggies – 15 minutes

Ice Massage Made Easy:

Fill a paper cup almost to the top with water and place in the freezer.  Once frozen, peel away most of the cup and massage with the exposed ice.

Common myths about icing

  • “Ice hurts.” Toughen up!  It’s not going to kill you.  Besides, you’ll get used to it.  To minimize your pain when icing the entire leg, keep the distal extremity being iced warm.  One way to do this is to put a rubber glove or bag over the toes when submerging the body part in ice.
  • “I might get frostbite.” The likelihood of frostbite is pretty rare–especially when you are only icing for 15 minutes or less.  However, if you have a circulatory pathology like diabetes or are being medically treated for chronically swollen extremities, consult your doctor before implementing this type of ice therapy.
  • “It’s been more than 72 hours since my injury, so it’s time to switch to heat?” If the injured area feels warm, it needs ice, regardless of the time frame.  So if the injury site feels warm and inflamed, apply ice, even if it’s been more than 72 hours.

The bottom line is simple:  If you want to stay active and continue to challenge yourself as an athlete, ICE THERAPY needs be included in your knee therapy plan.  If you’re pondering the eternal question: “To use ice or heat?”  ICE is always the safe selection.

Osgood Schlatters: Managing Youth Patella Pain

Painful Osgood Schlatters Disease

He has this huge bump below his knee, his doctor says he’ll grow out of it but it hurts him all the time.  What should we do?’ his mother said, frustratingly seeking an answer.

Following a fund raising golf tournament recently a good friend of mine came to me looking for a clear answer for a strange injury with a bizarre name.  Her athletic teenager had an overly large bony lump just below his right knee.  He was 16 years old, still growing and she was understandingly concerned about her son’s knee.

Osgood Schlatters Disease is an orthopedic disorder that results in an enlarged tibial tuberosity just below the front of the knee.  The tibial tuberosity is the lower attachment of the patella tendon.  Because of the excessive forces generated by the quadriceps (muscles located in the front of the thigh) muscles, the load is transferred to the patella (kneecap) and directly to the tibial tubercle on the tibia (shin bone).

Patella injuries are usually a mechanical injury.  In a simplistic manner, when these muscles are contracted, the forces are applied to the tibial tuberosity and the knee is extended.  That’s the easy part.

A growth plate is typically a location at the end of most long bones.   At a growth plate, a cartilaginous ring allows for the growth of the bone.

Chondromalacia is commonly associated with many types of patella injuries.

Here comes the interesting part…..a growth plate is located at the tibial tuberosity.  Therefore, when an active teenager creates excessive forces at the knee with activities such as jumping, squatting, running, trauma,…etc., the rate and the direction of the growth at that tibial growth plate can easily be altered.  Hence, the bump gets larger and more painful.

Patella injuries are successful resolved when addressed promptly. With an early onset of Osgood Schlatters, if the young athlete rests the area for 2-4 weeks and avoids the specific sports activities that worsen his pain, his symptoms will resolve themselves.

Osgood Schlatters and chondromalacia are similar in the fact that when these conditions occur, the athlete is typically predisposed to having symptoms in the future.  With Osgood Schlatters, when the athlete stops growing and his growth plates mature or “close”, the athlete has much less problems with the injury other than the cosmetic appearance and mechanical issues of an enlarged tibial tubercle.

Suggestions to Alleviate Osgood Schlatters Pain

  1. See his doctor to clearly diagnose this problem and to “rule out the bad stuff.”
  2. Ice his knee after every workout and competition.
  3. Become a flexibility machine.  My advice on flexibility: start young and stick to it.
  4. Avoid aggressive leg strengthening exercises and agility work whenever possible.
  5. Rest the knees.  A little rest now will help him avoid missing large chunks of time later.

I think this young man will do well if he follows this advice.  The Osgood Schlatters will quiet down in time.  Meanwhile, the enlarged tibial tubercle will probably not return to its normal size.

As with most sports injuries, the earlier you address the problem the quicker they quiet down.  Being smart now will ensure that you will be active and healthy later!