Watch Your Step: Ankle Sprains
Sometimes my GRIP articles spring forth from questions people ask or issues brought up during conversation. Yesterday, my last two patients hobbled in with foot injuries. As soon as I got through taping up the second one, I had my inspiration.
We are experiencing global warming – the real one that we call “spring.” Many people are getting outside to do yard work and exercise, maybe releasing all that pent-up energy from the cold weather months. Athletic injuries are on the way.
It is very easy to turn an ankle to the inside when walking, jogging, or turning. The bony architecture of the foot is such that the inside of the ankle (where the arch is) is more stable than the outside. Consequently, 85% of ankle sprains happen on the outside aspect of the ankle. These are called “inversion sprains” because in this position, the ankle is said to be inverted as it turns inward. This is the most common injury among joggers.
Most ankle sprains affect a 3-ligament complex that fastens bones together in the lower part of the ankle and respond to conservative care and rest. A more serious injury is the “high ankle sprain” that affects the connective tissue that holds the two bones in the lower leg together, and this one might require a little surgery. Football fans will be familiar with these terms because they are prominent in the weekly injury reports.
Ankle sprains may also injure more than just ligaments. Other connective tissue and muscle may also be injured. Fracture of the bones in the foot and lower leg should also be ruled out. Extension of injury to these tissues will also complicate treatment and recovery.
When I see a foot injury, I get a history of how it happened so that I can understand the physics of the injury. This helps me predict what kind of injury exists and what I may need to do about it. I observe how someone can walk and whether they can put weight on it. I look for swelling, discoloration, whether the patient can move the foot on command, and I look at the range of active motion to assess for limitations.
There are three kinds of sprains that we might see. A first-degree sprain has minimal tearing, some swelling, but you can walk on it. A second-degree sprain has moderate tearing of ligaments, and is more painful. You would not want to walk on this. A third-degree sprain has complete tearing of connective tissue, and you will see a significant decrease in active motion. You would be unable to walk on this one.
When there is swelling, I proceed to x-ray, obtaining front side and oblique views. If there is a fracture, I will stabilize the ankle with tape or splint, elevate, ice, and find a good orthopedist for a direct and urgent referral.
If there is no fracture, we then need to decide whether this is a first-degree, second-degree, or third-degree sprain. If it is a third-degree sprain, we go straight to the orthopedist. We will treat first and second degree sprains conservatively, and get an orthopedic opinion on the latter when it appears warranted.
When you think about the physics involved with an ankle sprain, you may logically conclude that you cannot sprain ligaments without first displacing bones. This would happen before ligaments are stretched and injured. Where bones are displaced, they may misalign. Therefore, our first concern is to put the bones of the foot and ankle back where they belong. Frequently when we adjust these joints, pain reduction is significant and immediate. It also facilitates healing of sprain ligaments when we put the bones to which they attach back in their rightful position.
After adjusting the misalignments in the foot, we will frequently use some form of physiotherapy to reduce swelling and pain. Ultrasound, electrotherapy, and even laser treatment are excellent tools to use. Reduction of pain and swelling leads to better motion, and the faster we can restore normal motion, the larger quantum leaps we can make toward complete recovery.
I use athletic taping to stabilize the foot in the opposite direction from the sprain. This will allow motion, but will stabilize the joint and allowed the ligaments to rest and heal. I have splinting supplies if the condition warrants it, but I like to facilitate motion as much as possible to keep swelling controlled and minimize the possibility of blood clots.
In the first few days, we will encourage rest, ice, compression, and elevation (RICE) to promote healing. Anyone with an injured lower extremity has an increased risk for a fall, so we typically provide either crutches or a walker for short-term stabilization and safety.
I have been privileged to serve a number of athletes in my career, ranging from young children to the senior athletes at Sun City Peachtree. I have seen golfers, cheerleaders, marathon runners, and even some professional athletes along the way.
There are some seasonal injuries we have come to expect, such as the ankle sprains of ballerinas in November. Typically, my assignment is to get an injured ankle ready for solo work in the Nutcracker with less than a week to go. I love challenges.
So, if you get off on the wrong foot, so to speak, get it assessed quickly. You do not want to walk on an injured foot and make it worse. Aggressive conservative care (chiropractic adjustment and physiotherapy) can drastically shorten the healing time for this kind of athletic injury.