You're making like Dr. J, driving hard to the basket, when all of a sudden, you zig when you should have zagged. Your ankle rolls under you like a possum playing dead. The game stops, but you bravely shrug off the pain and continue on. Later that day, you take off your shoe and find your ankle extremely angry. It is red, swollen, warm, and in no mood to do any work, such as supporting your body weight. You are definitely on the "DL" for tomorrow's game, but what about next week? What about that mountain hike you promised you'd go on in three weeks? Don't fret. By following a few simple rules, and being patient and smart, you can return to your previous form faster than you think.
Generally, sprains are graded I, II and III (III is the worst kind of sprain). Since the majority of ankle sprains are grades I and II, only those will be discussed here.
A grade I, or mild, sprain is characterized by some tearing or stretching of fibers of the ligament (a tough band of connective tissue). The fibers have not been extended too far so there is no looseness in the ligament. Also there is minimal internal hemorrhaging (bleeding) and no residual instability or unsteadiness in the ankle when it is healed. Grade I sprains require, on the average, about 12 days to heal. A grade II, or moderate sprain is a full tear of the ligament with mild instability. Unlike a grade I, the ligaments in a grade II have been stretch beyond their limits, so there is also a slight reduction in function and strength. Grade II sprains require approximately two to six weeks before you can return to your previous slam-dunking, crossover-dribbling and shot-blocking form.
Ligaments
Ligaments are bands of tough tissue that connect bones together. The most commonly injured ligament is the anterior talofibular ligament (ATFL), located on the lateral side (or outside) of your ankle. When your foot turns inward excessively, the ATFL can be stretched beyond its normal limits, resulting in a sprain.
Ligaments have three jobs. First, they provide proprioceptive information for joint function. Proprioception is the ability to sense the position, location and movement of body parts. In other words, my sense of proprioception allows me to know that my right arm is hanging along the right side of my body, without having to see it. Ligaments, along with joint capsules, are able to gather this information and transmit it to the brain, so you know where your joint is in relation to your body. If a ligament is damaged, the correct information may not be getting to your brain, and your arm or ankle may not be exactly where you think they are. To continue the example from above, even though my right arm is hanging along my right side, if my proprioception is abnormal, I may actually think my arm is over my head. A second job of ligaments is to prevent excessive motion within the joint, stabilizing and strengthening it. The third job of ankle ligaments is to act as guides to direct motion.
Lateral ankle sprains are the most frequent injury sustained by athletes. They result from the foot inverting and then twisting medially (to the inside) while the lower leg remains steady. In fact, more than 90 percent of all ankle sprains are like this and are categorized as inversion sprains.
Acute phase (one week after injury)
Mourn your loss of playing time quickly because early treatment will have you back to the court in no time. Immediately after the injury, you are in what is known as the acute phase of healing. Swelling and warmth are present, and there is pain no matter what you do. At this point, it is best to follow the acronym PRICE: Protection, Rest, Ice, Compression and Elevation.
Health
Your primary goal now is to limit the amount of swelling in order to accelerate the healing process. Protect the ankle with a functional brace such as an Air Cast, which prevents excessive movement as well as a compressive force to counter the swelling. An elastic bandage can supply some added compression. Stay off your feet and elevate your foot while keeping it iced. Cold causes nearby blood vessels to constrict, reducing blood flow and swelling in the area. A bag of frozen peas makes an inexpensive, reusable ice alternative. Make sure you keep the foot elevated and positioned so that your ankle is as close to a 90-degree angle as you are allowed by the pain and swelling. This helps keep joint swelling at a minimum and reduces the amount of tension on the injured ligaments.
Subacute phase (one to three weeks after injury)
The next phase is known as the subacute phase. You know you're there because the &hotness" and local swelling subsides, though the ankle may still look as big as a grapefruit. Range of motion is still abnormal. There is still pain when you try to put weight on your foot or walk, but to a lesser degree. In the acute phase, we talked about protection and rest. Now is the time for motion. Prolonged immobilization is harmful to the damaged ligaments and muscles. It is extremely important to get that ankle moving again. This reduces atrophy (muscle weakening or wasting), maintains range of motion and reduces the chance of scar tissue forming.
Early joint motion also stimulates healing of torn ligaments. Ankle pumps are a good rehab exercise. Start by pointing your toes away from your body, then pulling them toward you (point and flex). Work only within a range of motion that feels comfortable. Later, you can add side-to-side exercise by moving your foot from the inner edge to the outer, again in the pain-free range. Isometric exercise is a type of exercise where you contract a muscle without actual moving the body parts involved. It is another option for strengthening the ankle joint.
Retraining your ankle
Remember proprioception? You need to start to retrain your sense of joint position. The real purpose of this training is to improve your ability to handle the type of movement that caused the injury in the first place. Start by simply practicing standing on one foot. You can also work on gentle stretching of the Achilles tendon by using a towel or band around the ball of your foot and slowly pulling the towel or band around the ankle up. Again, any movements should be done only in the comfortable, pain-free range. If you cannot walk normally, use a cane or crutches until you are able.
When you can stand normally without pain and can walk without a limp, it is time to progress to the next phase of your rehab. (Can you hear the squeak of sneakers on the court?) Although you may still have pain while running or jumping, what you want to do now is regain the strength and range of motion that has been lost. Resistance training for each ankle muscle group can be performed using rubber tubing or bands, free weights or weight machines. By strengthening each muscle group you will improve your ankle's range of motion and how it reacts to sudden changes in directions. Start with light resistance, and slowly build up as your strength and endurance improve.
You also want to continue your proprioceptive training, progressing eventually to standing on one foot on a soft surface, like a pillow. If available, a balance or wobble board is an excellent training tool. Also, it is important to stretch the areas around the ankle, like the calf muscles and Achilles tendon.
The last phase is really a &functional-training& phase. Activities should mimic the movements you'll do while on the field or in the game. All should be pain and symptom-free. Continue with regular strength and proprioceptive training.
Reinjury Precautions
The biggest concern as anyone returns from an injury is the chance of a repeat. With an ankle sprain, people need to avoid moving the ankle in the opposite direction towards the inverted position Chances are that the joint is a little less stable after coming off the &DL&. Is there a need for extra support? This is an individual decision, and there is no guarantee that taping or bracing will prevent further injuries. Studies have shown that ankle taping is effective in restricting ankle motion and decreases the incidence of ankle sprains. However, tape can loosen in as little as 10 minutes, and there goes your stabilization. Also, tape is not easy to apply to your own ankle.
Braces that minimize side-to-side motion in the ankle are an alternative, and they could potentially cut the risk of injuring the ligaments on the outside of the ankle. You may say that wearing a bulky brace on your ankle will slow you down, but studies have shown that they don't seem to hinder normal athletic performance.
Although high-top sneakers may provide proprioceptive input and add additional support, a study performed on basketball players showed no relationship between high-top (or low-top)sneakers and the incidence of injury.
Conclusion
Sprains may recur due to:
- healing of the ligaments in a non-90-degree angle and not following PRICE
- weakness due to scar tissue
- weakness of the evertor muscles (muscles that work in the opposite direction to the initially injured ligament)
- loss of proprioception in the ligament
But the consequences listed above can be avoided with an early and thorough treatment program. To reiterate what was said above, start early and remember the PRICE is right. Initiate motion early and progress according to your tolerance, but be smart and monitor the amount of pain and swelling. If it's your first bad sprain, it's a good idea to see an orthopedist. An orthopedist can x-ray the injury, prescribe an anti-inflammatory if needed, and refer you to a physical therapist. For a severe sprain, it is always best to consult an orthopedist and/or physical therapist who can assist you in proper rehabilitation techniques and exercises. Injury time can be increased if rehab is done improperly. Also, if you need any other help or the ankle is not healing like you feel it should, it is a good idea to see an orthopedist for further consultation.
