Self Treatment of Ankle Sprains

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What follows is information that may prove helpful to any triathlete who sustains an ankle sprain.

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Tracy Ray, MD Member AMSSM

Ankle injuries are a very common part of sports and activity. Ankle sprains can be nothing more than a temporary inconvenience if treated properly in the early stages. What follows is information that may prove helpful to any triathlete who sustains an ankle sprain. Immediate treatment, accurate diagnosis and adequate rehabilitation will allow the athlete to return to training and activity rapidly.

The RICE method
Almost all ankle injuries should first undergo the RICE method. Immediate attention to an ankle sprain should include rest, ice, compression, and elevation. Rest may include total immobilization of the joint for a short period of time, but often it simply means allowing activity or weight bearing that does not cause pain.

Ice is an excellent means to decrease the amount of swelling and inflammation that can take place in an ankle once the ligaments are sprained. In the first 24-48 hours, ice can be used as much as 20 minutes every hour. Crushed ice in a bag that molds nicely around the contours of the ankle is advisable. It is also recommended that a thin layer of cloth be placed between the ice and the skin.

'C' is for compression, which in the acute setting usually means tape or an ace wrap. The compression should be snugly fit to the ankle, but not so tight that it causes numbness or tingling in the toes. Elevation is also key in the acute setting. If at all possible, the ankle should be placed in a position above the level of the heart to provide the greatest potential for diminishing swelling.

Rehabilitation
Many athletes try to return to activity prior to full rehabilitation of an ankle sprain. While it is true that most athletes recover relatively quickly from these injuries, it is not uncommon for these “minor injuries” to become chronic problems. The physiology of complete soft tissue healing can continue for 6 months even though you have returned to sports. Proper rehabilitative care must be received to insure that all the physical deficiencies are addressed.

The traditional treatment of ankle sprains has focused on the following objectives: reducing pain and swelling; restoring joint range of motion and muscular flexibility; increasing muscular strength and endurance. After the initial RICE method has been used and swelling and pain of the injury are much reduced, the other aspects of rehab can be initiated. Range of motion exercises such as spelling the alphabet with the big toe in the carpet can be utilized to return normal motion to the ankle. Gentle stretching can then follow this technique. It is not uncommon for an ankle sprain to cause a great deal of tightness in the Achilles, or heel chord. Stretching this structure can be accomplished at first with the use of a towel around the toes and ball of the foot, and then progressing to the use of body weight to stretch out the Achilles. This more advanced technique of stretching the heel chord is accomplished by leaning into the wall with the involved heel planted on the ground. This is done both with the knee bent and with the knee straight to address both components of the muscles connected to the heel chord. More leaning will lead to increased tension in the calf in the Achilles area. These stretches should be held to a count of 30 and done in a set of 10 several times during the day.

A note on stretching: studies have indicated that short bouts of intermittent stretching prior to activity probably do not prevent injury or increase flexibility. However, benefit has been shown with flexibility programs that are done daily and for longer periods of time. A stretch of the muscle and tendon should be held for at least a count of 30. It is likely that very little progress would be appreciated unless these bouts of stretching included at least 10 reps done once or twice each day.

Initial strengthening exercise usually includes the use of rubber band material or surgical tubing to provide resistance to the motion of the ankle. The rubber band or tubing can be tied to the leg of a table and wrapping the material around the most distal part of the foot allows resistance in all ranges of motion of the ankle. Once the athlete is able to perform these techniques with surgical tubing, they can move to their own body weight by doing calf raises either on a flat surface or with their heels dropping over the edge of a step. Once the athlete can perform these strengthening and stretching techniques fully, he/she is ready to progress to more functional exercises. In recent years more emphasis has been placed on dynamic/functional strengthening and rehab techniques. These techniques often utilize a single-leg stance to help with balance and a neuromuscular feedback system known as proprioception. Much of this therapy is best facilitated with a Sports Physical Therapist using cushioned or uneven surfaces as well as therapy balls and sports cords. Once balance and stability have been improved, the final step in rehab would include balancing techniques with single-leg hops or jumps in multiple planes.

Return to Play Progression
As pain and swelling allow and as therapy demonstrates increased strength, range of motion and balance, the athlete can begin to return to some sport specific activities, beginning with a light jog. Progress can be made toward running, sprinting, cutting and jumping as pain allows. The activity can become more complicated as determined by rehab and pain.

Prevention
A functional ankle brace may be necessary to allow more rapid progression back to activity. These braces can also be continued to possibly diminish the risk of reinjury with heavier activities. Any athlete who has sustained an ankle sprain is at risk to re-sprain or injure the ankle, even with adequate rehab. Therefore, common sense measures such as training on level surfaces and keeping the training area free from debris are important.

Summary
Simple ankle injuries can become chronic and recurrent injuries if not addressed adequately. Some of the interventions as listed above are recommended. A trained sports physician should evaluate worrisome injuries initially. Also “minor” injuries that do not respond to the above treatment plan should be evaluated as well. “Find-A-Doc” link on AMSSM is a good resource for physicians in your area.

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date: March 20, 2005