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The Outdoor Athlete Book by Courtenay and Doug Schurman



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More Training Info > Ankle Sprains

ANKLE SPRAINS: What to Do, How to Recover, Prevention
C. Schurman 8/1/2003

Whether you are a runner, basketball player, boulderer, hiker, climber, or skier, the likelihood of suffering from an ankle sprain at some point in your active career is higher than you might think. Even people who primarily walk for exercise can experience a turned ankle simply by stepping off a curb the wrong way. What can you do if you sprain, twist, roll, or otherwise hurt your ankles? Here we address what you should do immediately to help prevent swelling, in the days following to limit atrophy in the rest of your lower body, and in the weeks afterward to return safely and quickly to your favorite outdoor activities. Remember, the advice here is not meant to replace medical attention; if you have trouble bearing any weight on your foot, have it checked out or x-rayed as it may be more serious than you realize.

WHAT IS IT?

Most simply put, a sprain is a twisting injury to the ankle. The most common type of ankle injury is a sprained (stretched or torn) talofibular ligament on the outside of the ankle, although if it’s a bad sprain you may also damage the calcaneofibular ligament. (Remember that ligaments get sprained, but muscles get strained). 80% of ankle injuries occur when you roll the foot inward, called an inversion injury, (i.e. the sole of the foot is pointing inward, causing the ligaments on the outside – lateral -- part of the ankle to be stressed). You may feel or hear a "snap" or "pop" at the moment of injury. Spraining an ankle may increase your risk of re-injury as much as 40-70% (1). But proper post-injury care, rehabilitation exercises and bracing can decrease the risk.

HOW SERIOUS IS IT?

In a mild (first degree) sprain, you may experience some pain on bearing weight, little to no stiffness and swelling, and some stretching of the ligaments. In a second-degree sprain, there may be instability of the joint, with torn ligament fibers, bruising, swelling and stiffness, and severe pain. The most serious sprain (third degree) involves complete rupture of a ligament, extreme pain at the moment of damage followed by no pain, bruising and severe amounts of swelling. Ankle sprains can occur 1) if you fall incorrectly when hopping down from a bouldering problem; 2) on uneven terrain if you’re not watching where you’re going (i.e. tree roots, cracks in pavement, curbs that are steeper than you expect, loose talus or scree terrain that gives way as you walk across it;) 3) while you are running if you’ve had a history of turned ankles; 4) landing during a sport where there are other people close to (and perhaps beneath) you – as in ultimate, soccer, basketball, lacrosse, rugby, football; and 5) dancing or walking in high heels when you’re unfamiliar with the footwear!

WHAT SHOULD I DO RIGHT AFTERWARDS?

The initial concern should be to reduce the inflammation as soon as possible by following the principles of PRICE: Protect it (with a splint or brace); Rest it (get the weight off of it completely; use crutches if necessary); Ice it within the first three days, 15-20 minutes three times a day; Compression (using a loose ACE bandage, compression brace or athletic tape can help protect the joint initially) and Elevation (higher than the heart, so while you’re lying on a couch or sitting with foot propped up on comfortable pillows placed under the heel and below the knee). During the first 24 hours, avoid hot showers, heating pads, hot tubs, heat rubs (such as Icy Hot), alcohol, and aspirin, as all of these promote blood flow to the area and can increase swelling. However, an anti-inflammatory medication, like ibuprofen, aleve, naprosyn, may help prevent further swelling. Actually, aspirin is an anti-inflammatory, like motrin, and can be used in place of an NSAID if this is better tolerated. Both can cause gastro-intestinal upset, however, so be sure to take with food.

WHEN DO I STOP ICING?

Once you’ve iced the ankle for two to three days, you will want to wear a compression brace in order to provide mild protection and support and help retain heat while the ankle begins to heal. Alternate between heat and ice (15-20 minutes each) to improve blood flow to the injured area, increasing nutrient flow and enhancing recovery. Always start with ice first to decrease inflammation. You will want to wean yourself off the crutches, brace, and other supports as quickly as possible to return to your sport.

WHAT CAN I DO AS IT HEALS?

Even in the worst case scenario (a third degree sprain) you may still be able to do abdominal exercises or seated upper body strengthening exercises that place no load through the foot; this is one time that machines might be useful in preventing lower body muscles from atrophying. If you’re recall, machines remove much of the stabilizing requirements from the body, hence allowing you to isolate muscles without integrating movements or putting any load through the spine or lower extremities. In the case of an injury to the lower extremities, this sort of training may actually be beneficial. You may also find that one-legged biking at a very low resistance will keep the cardiovascular system healthy; if you have access to an upper body ergometer (sort of like a bike for the arms) that may be an option as well. Swimming, at least initially, may be too painful for the ankle, as any leg movement will involve water pressure against the foot.

HOW DO I REHAB IT?

Alphabet

The first few days following a sprain, you can start to do simple exercises to try to increase range of motion: 1) Without any resistance, place your calf or ankle on a pillow so your foot dangles over the edge of it, and draw the alphabet with your toes. 2) Move your ankle side to side; point your toes, and pull your toes back with the leg straight, or simply draw slow circles. Do 15-20 for each several times a day, trying to increase the range of motion each time you do it. Compare to your healthy ankle to keep in mind what’s “normal” range for you. 3) Once you have close to normal range of motion with minimal pain, begin adding strengthening exercises with manual resistance (using your own hand), a surgical tube looped around the feet (as shown), or exercise band tied around a table leg. Complete 1-2 sets of 15 each every other day. Inversion, Eversion, Dorsiflexion (pulling toes back), and Plantarflexion (pointing toes) as shown.


Inversion Eversion Dorsiflexion Plantarflexion
Inversion
Eversion
Dorsiflexion
Plantarflexion

Injured ligaments can take up to 16 weeks or more to fully heal, but you can do a lot in that time to be sure that 1) you will not re-injure the ankle, and 2) you can return to your sport stronger than before. In addition to the preliminary exercises above, you’ll also want to add stretches for the Achilles tendon and calves (see www.bodyresults.com/e2shinsplints.asp for suggestions). You can wear an ankle brace to help protect the ligaments not only during recovery but also when returning to more typical sport or exercise activities. Once you can fully support your weight on each foot and can walk without limping, add proprioceptive one-leg balancing exercises such as standing still with eyes closed (two-leg and one-leg), do balance drills on a wobble board, stability disk, or foam tube if you have such devices, or barring that, simply do one-legged balance drills holding onto a medicine ball, dumbbell, or rubber band that a friend holds and pulls. You can also add 1-leg squats, step-ups and downs, and 1-leg deadlifts (www.bodyresults.com/e21-legsquat.asp).

wobble board one-legged balance
Wobble Board
One-legged Balance

WHEN CAN I RETURN TO MY SPORT?

When you have returned your range of motion to normal, have limited to no pain, and have regained your balance, it’s time to work back into lower body strengthening and higher intensity cardiovascular exercise. If you can, add a water aerobics class or swim with fins on your feet; add biking, elliptical cross training, or walking with sturdy footwear; these activities require less impact and little lateral movement in the ankles. Once you can do these activities for a week or two without discomfort, gradually return to two-legged strength exercises including deadlifts and squats, running, and hiking, first on flat terrain, then on more varied surfaces such as sand, grass, or dirt trails; and finally, include lateral shuffle drills, travel over boulder or talus fields while using trekking poles for added stability, and drills such as jogging in progressively smaller figure-8’s to improve ligament strength and agility. Add 1-leg hopping or jumping exercises if you will be doing anything involving jumping or side-to-side movements such as soccer, ultimate Frisbee, basketball, football, rugby, lacrosse, or bouldering. Dot drills are good at this point.

HOW CAN I PREVENT IT FROM HAPPENING AGAIN?

Continue to stretch the calf and heel daily, especially after any activity. Continue to include ankle and lower body strengthening 2-3 days/week. Be sure to perform single-limb balance exercises most appropriate to your sport. Initially, consider wearing an ankle brace during strenuous activity involving lateral (side-to-side) or cutting movements, and avoid jumping or dropping from heights. Since previous sprains increase your risk of re-injury, be very mindful of what you are doing when participating in higher risk activities, and do whatever you can to prevent twisting the ankle again. Keep in mind that failure to improve despite following a progressive rehabilitative program may mean that you have suffered a nerve injury, fracture, or possibly a complete tendon tear. If after a few days you are still unable to bear weight on the foot, the initial injury indicates more than an ankle sprain and should be fully evaluated by a sports medicine physician.

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