Taking care of that ankle sprain

How many of you have this problem?
You've sprained your ankle weeks ago and can't seem to shake the injury. You can do tentative activity with it, but you wouldn't bet on it for that netball game, or the upcoming football trial. It just isn't coming right quick enough.

A group of researchers in Belfast have proven what seems to be physiotherapy's best kept secret: Targeted immediate exercise accelerates recovery and has been proven to shorten the time away from sport and work activities.

Chris Bleakley and friends led a study into 101 subjects who had grade one to two ankle sprains. They found that there are an estimated 5000 new cases a day of ankle sprain in the UK. Apply this percentage to New Zealand and we might see 33,000 of these injuries a year.

Just as Gordon Sumner is known as Sting, so the talo-crural joint is known on stage as the ankle. An ankle sprain is an injury to the supportive structures of this joint — its ligaments. Ligaments have to be strong enough to hold the ankle together, but have to also have some give to provide suppleness. To clarify the grades of ligament injury, here is the scheme we use in medicine: Grade 1 is the least severe, yet often more painful than you can believe. Many people recount strong nausea and extreme pain with these injuries. The ligament looks inflamed and microscopic tears have developed. It looks intact and feels to the trained hand, solid and not lax. A grade 2 is a partial tear. The ligament has most of its fibres torn but enough remain to keep a hold on the joint still. The risk is that left alone, and not rehabilitated, these can rupture and do further damage to not only ligament, but joint surfaces as well. A grade 3 is the final straw of structural integrity lost. The ligament has torn through and offers zero support or functional use. In some parts of the body you will not get repaired surgically and you can call upon muscles to support the joint instead, but you won't be the same. If you are involved in dynamic forceful activities you are more likely to receive surgical intervention.

With muscle injuries we often treat these with stretching, however ligaments don't usually need to be stretched, because this promotes laxity: An excess of mobility, also called hypermobility. If you roll your ankle a lot, then your ankle becomes hypermobile. It's then easier to roll it next time, and so on. This can be the reason for your ankle giving way or collapsing on uneven ground or in sudden change of direction. If you regularly experience giving way in your joints, you should seek the assistance of your physio who can help you re-strengthen to get the stability and performance back.

Did you know that your balance on the injured leg is drastically reduced, and that this can be retrained? If you've had an ankle sprain, and it's never come 100 per cent right, stand on that leg alone with your eyes shut. See how long you can do it for with a stopwatch. Perhaps for safety do it in a doorway or at the kitchen bench. Now compare the uninjured side. Most of you will notice it's difficult, that's a given, but what should be revealing is how much harder it is on the affected side. I would expect that anything above 15 seconds is good. Don't worry if you can't get 15 seconds. This ability can be trained, especially with eyes shut. I challenge sportspeople to achieve higher, maybe 30 seconds!

Bleakley's research split the 101 into two groups. The first group was given advice only: RICE (Rest, Ice, Compression, Elevation). The second group was immediately engaged in a movement-based exercise programme. Bleakley and co. showed clearly a difference between the two groups. The exercise group "showed short-term improvements in ankle function", proving the value of early intervention. The second group which predominantly rested, took longer to come back to full ability. They weren't at their best until the 10-week mark. By this point both groups were at similar levels of function. The moral is: if you want to get function back ASAP, get in early to your physio and get the exercises underway.

I was lucky enough to roll my ankle this year, to a grade one sprain level, so you can imagine how excited I was to be able to test out all the approaches I practise! The early movement approach is, in the beginning, hard to believe, but gradually and positively I got my ankle back.

Many brush off the ankle sprain as minor and do not seek treatment. A dangerous misconception is that "she'll be right" and it will come right by itself. To quote orthopaedic surgeon Jon Karlsson of Goteburg, Sweden: "many patients fail to progress after six weeks. These people complain of pain, recurrent giving way, swelling and impaired function. The key to successful recovery is accurate diagnosis". There are a number of possible injuries that the ankle can suffer, not just the common ankle sprain. "High Ankle Sprain" is the injury that tears the ligaments holding the shin bones together — tibia and fibula. These require more protection and care in the first week as too much movement repeatedly thwarts the body's attempts to knit the structure back together. If you think of it as just an ankle sprain you could be doing yourself a disservice as these take longer to heal and can remain problematic. If you sprain the ankle falling from a height, you could fracture the top of the talus, which is the part of the ankle the entire body weight rests on. You can see why it is critical that you get your ankle checked early on by your physiotherapist.

Careful assessment can reveal which tissues are damaged, and we can then treat accordingly.

Greg Bell is a physiotherapist practising at Bell Physiotherapy. www.bellphysio.co.nz