by G. John Mullen, DPT 2011
With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return. The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle. The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday. As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination. Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.
Stat Fact: Ankle sprains in men and women whose average age was 23 had an injury rate of 10 per 1,000 hours of sports participation.
What is an ankle sprain?
An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments. These injuries are caused by running, jumping, landing on an uneven surface or awkwardly planting your foot (or tackling a quarterback in the NLF in Freeney’s case). The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot. You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them. This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined). There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments. In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.
The signs and symptoms of a sprained ankle are similar to most musculoskeletal injuries:
Pain and swelling
Stat Fact: Sprains of the lateral ankle make up 85% of all ankle sprains.
Acute Ankle Sprain:
Now that you know some basic facts about the ankle, we will discuss what to do if you have just sprained your ankle playing a pick-up game of basketball or Louisville Chugger. Most ankle sprains are Grade I (i.e. relatively benign) and will begin to feel better within a few days. To help speed up the healing process, most physicians, physical therapist and medicine men will tell you to R.I.C.E. your ankle.
Rest: For 24-48 hours after an injury, rest your ankle and allow it proper time to heal. During this time sit back, relax, watch The Office and discontinue any physical activity.
Ice: Icing can be used to decrease swelling of the injured ankle. Ice should be used for approximately 20 minutes (about the same length as an office episode…) at a time and should be used intermittently throughout the day (about 6 times). Make sure the injury site does not go numb when icing the injury. When the injury becomes numb, tissue can be damaged and more harm can be done! The type of cooling method is irrelevant, but make sure the ice pack, pack of frozen corn or cold pack covers the inflamed area. Additionally, make sure not to leave the ice on for longer than 20 minutes. The ice is used to reduce the swelling in the area. When ice is left on for longer than 20 minutes, the body begins to think that it is freezing and increases the amount of blood to the area to warm it up (thus increasing the swelling!). The take home: 20 minute on, 20 minutes off!
Compression: An ACE bandage works best, but any type of garment can be used to compress the injury site. Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done. Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).
Elevate: This is simple, keep your ankle higher than your heart…lying down is key here (for those of you trying to maintain the kung fu position with one leg in the air) and remember to keep your ankle elevated with a pillow while you sleep.
If the ankle swelling does not subside after a few days (~7 days) or if the ankle is preventing you from everyday activites, it may be necessary to see the physician or physical therapist and it is likely you have suffered a Grade II or III sprain…our hearts go out to you.
Chronic Ankle Instability/Functional Ankle Instability
Now that you’ve sprained your ankle and the pain and inflammation has gone by the wayside, you may be interested in preventing future ankle sprains. If you are a bit of a couch potato (not recommended by physicians) it is likely the sprain was a freak accident and is unlikely to occur again. On the other hand, if you are an active individual, the ankle is likely to be reaggrevated by future activities. The good news is that future ankle injury can be prevented by non-surgical options including ankle braces (orthosis), strengthening and improving balance.
Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity. This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly. If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).
Balance: Balance exercises include: single leg standing, single leg squats, single leg calf raises, etc. Any of these single leg activities helps improve your balance while strengthening your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging. A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles. Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.
Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual. Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball. One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock. I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock, and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left. Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle). Movements in all these planes of direction will greatly strengthen your ankle and improve your balance. These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult. A little TV time makes them infinitely more enjoyable.
Stat Fact: Basketball players with a history of ankle sprains were nearly five times as likely to sustain another ankle injury.
If these non-invasive interventions do not help the ankle instability, surgery may be considered. Ankle surgery is done only in the most severe cases of ankle instability and would have to be recommended to you by an experienced orthopedic surgeon.
Ankle instability and sprains can hamper one’s recreational football and basketball career, but implementing these three main sources of rehabilitation (bracing, balance, and strengthening) can get you back in action sooner and keep you there longer. Rehabilitation programs vary greatly from injury to injury and if you have chronic ankle instability it is recommended to see your physician or physical therapist to implement an individualized plan to help strengthen your ankle and get you back to 100%. Let’s hope Dwight Freeney is doing his ankle exercises (enter his long walks on the beach) and keeping that ankle elevated (for the Colts’ sake that is!).
Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. Review.
Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review. Sports Med. 2008;38(7):553-63.