(The Trainer’s Room is a regular column at Midwest Sports Fans by Denver chiropractors Dr. Niall McNally and Dr. Ihsan Erhuy, the pain and rehabilitation experts at the Mountain View Pain Center in Denver, CO.
All treatment options provided in this article should not be taken as specific advice, but rather as a general guide regarding what is typically done to treat the injury being described.
You should always consult your doctor before beginning any pain management or rehab program.)
For this article we will discuss one the most common sports related injuries, the ankle sprain. This type of injury can happen in all sports, to any player, and makes any activity nearly impossible until the pain is gone and the ankle heals.
Inversion injuries, or acute lateral ligament sprains, are the most common form of sporting injury, accounting for 40% of all injuries and up to 85% of ankle sprains, which in themselves are responsible for over 15% of all time lost from sport.
The injury occurs when the athlete lands with the foot plantar flexed and slightly inverted. This position unlocks the joint. What this means is simply rolling your ankle.
Sprained Ankle: The Ligaments, Ankle Sprain Grades, and Recovery Time
The lateral (outside) ankle ligaments are: the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The medial (inside) ankle ligaments are the deep and superficial portions of the deltoid ligament.
The most commonly sprained ankle ligament is the ATFL, followed by the CFL. An isolated CFL tear is rare, and is almost always preceded by a tear of the ATFL. These injuries are caused by running on uneven terrain, stepping in a hole, stepping on another athleteâ€™s foot during play, or landing from a jump in an unbalanced position.
A syndesmotic ankle sprain, or high ankle sprain, occurs as a result of forced external rotation of the foot or during internal rotation of the tibia on a fixed, planted foot. A common mechanism is a direct blow to the back of the ankle while the foot is externally rotated.
Classification of lateral ligamentous injuries is variable. Injuries are described as primary, secondary, or tertiary, or grade 1, 2, or 3, in order of increasing severity, as illustrated in the ankle sprain grade chart below. The grading of ankle sprains helps to guide treatment, rehabilitation, and prognosis. The ankle sprain grade is based on the number of ligaments injured, degree of ligament tearing (partial vs. complete tear), and amount of swelling and ecchymosis (bruising).
West Point Ankle Spain Grading System
|Stage 1||Stage 2||Stage 3|
|Weight Bearing Ability||Full or Partial Without Significant Pain||Difficult Without Crutches||Impossible Significant Pain|
|Ligament Pathology (ligament damage)||Ligament Stretch||Partial Tear||Complete Tear|
|Return to Sporting Activities (recovery time)||11 days||2-6 weeks||4-26 weeks|
Please note this chart provides only a rough estimate of sprain ankle recovery time. Other factors must be weighed in such as previous injuries, age, weight, health status, and your sprained ankle treatment plan to give a more exact prognosis of recovery.
Two easy tests to determine when your previously sprained ankle is stable enough to get back in the game are to stand on the ankle in question for one minute with eyes closed, or jump up and down ten times in a row. If you can perform these without pain then you should be ready for action. However, even if you can perform these tests, your ankle may still be damaged, so take caution and protect yourself. Have the sprained ankle taped or wear some form of ankle support until it has healed.
Be aware there may also be an underlying fracture as well with an ankle sprain. This could contribute to the intense pain and swelling. It is possible to fracture the malleoli, cuboid, navicular, talus, or calcaneus. This is why it is important to see your doctor for an X-ray after an injury. An MRI might be needed because some fractures do not show up on conventional X-ray; MRI is also the best way to rule out underlying ligament damage.
While most ankle sprains will heal without complication, 20% of all sprains will lead to further chronic instability. Ligaments and tendons are stretched and damaged in an ankle sprain, but with the appropriate treatments we can heal and strengthen the area. If the ankle is left to heal on its own, you run the risk of developing an unstable joint. This can leading to multiple ankle injuries and even more complications down the road.
Sprained Ankle Treatment and Rehab
Before we get into treatment, we must first understand what is happening to the ligament. In the initial injury for example, the inversion sprain, the ATFL is stretched and torn. When this occurs the area will hemorrhage and will become inflamed. The body’s natural healing process will kick in and lay down more collagen to the affected area. If the appropriate steps are taken the collagen will lay down in the correct fashion reducing scar tissue and decrease the risk of future sprains.
Sprained Ankle Treatment
Initial treatment or the acute phase (0-24 hours) of the inversion injury/simple ankle sprain follows the usual regime of protection, rest, ice, compression, and elevation (PRICE). Although a very simple step, it is commonly overlooked, creating a longer recovery process.
Ice is most beneficial immediately after the injury, as it decreases swelling and helps with pain relief. Blood flow does not decrease significantly for about 10 minutes after the application of ice (but DO NOT ice longer than 20 minutes), by which time considerable bleeding may already have occurred, so the compressive element becomes equally important as an aid to restricting hemorrhage. The ankle should be taped in the opposite fashion of the injury. This will help to shorten the stretched ligaments and begin the healing process. If sports related, the athlete should be removed from the field of play without placing weight on the joint. The limb should be elevated as soon as possible and compression applied.
After you pick yourself up off the sidelines, go see your doctor. It is important to perform the appropriate orthopedics examination to determine the ankle’s stability and if there is any other underlying tendon ruptures or fractures. The majority of ankle sprains respond well to conservative care, and surgery is generally avoided in this type of injury. However it is recommended to see a doctor and let him/her make the call. You do not want to push an unstable ankle, or you can further damage the already weakened ankle.
Many think that because the ankle was injured the best course of action is to brace it and leave it alone. However, research shows that early mobilization of the joint will stimulate collagen bundle orientation and therefore stimulate healing. At Mountain View Pain Center we recognize the importance of adjusting and restore biomechanics to the joint while applying the other therapies. It is important to work with your doctor or trainer to properly rehab the area to strengthen and prevent from further sprains.
Early sprained ankle treatment will focus on moving out the edema (swelling) of the area, which will also promote healing. At Mountain View Pain Center we perform this process in several different ways. The first is an electrotherapy called hi-volt. Hi-volt is a direct current applied to the body through pads. In this type of injury the polarity should be set to positive (acts like ice). The hi-volt treatment has several benefits for an ankle sprain. The electric current will pump out the swelling and decrease pain.
The next step we take at Mountain View Pain Center is to apply kinesio-tape to the area. This allows the healing process to continue while the patient is at home. The tape also assists in the removal of inflammation and swelling. In the first 72 hours the kinesio-tape will be applied in a fan-like fashion across the foot with two strips, one facing towards the middle of the foot and one fanning out. This will open the lymphatic channels thus allowing the edema to move out of the area.
Another great way to move out swelling is a soft tissue technique aided with a specialized instrument. This specific technique is great for breaking spasms, removing adhesions (scar tissue), and in this case pushing out swelling. Your doctor should perform this to assist the lymphatic flow in the ankle. Adding this technique to our treatment has helped patients get back on their feet much quicker.
Sprained Ankle Rehab
After the removal of the pain and swelling, the next step is to begin rehab and work to prevent future ankle sprains. We do this by therapeutic exercises designed to strengthen the injured and weakened area. We also continue the use of kinesio-tape to help support the area, as well as allowing the patient the freedom to move the ankle, while still getting the therapeutic benefits. This is done with the same technique with tape to the outside of the foot, as well as stabilization tape up the calf muscle to aid the ankle in flexion of the foot.
As mentioned in previous articles Omega fatty acids or fish oils help with inflammation in the body. Flavanoids, which give fruit their pigment, work exceptionally well with the reduction of inflammation, the increase of stabilizing collagen structures, and thus decrease pain. Collagen is a major protein in the tendons, so if you are trying to avoid future sprains, it is a good idea to take this supplement to help enforce the tendons.
Another important supplement to take for the prevention of future strains is vitamin C. Vitamin C deficiency is associated with defective formation of the tendons, making you more susceptible to an injury. (Side note: smokers are often deficient in vitamin C, so if you smoke you may be inhibiting your bodyâ€™s ability to heal itself.)
Chronic Ankle Sprains
Without the appropriate care for an ankle sprain you may develop an unstable joint. When the joint becomes unstable the risk of further and more severe ankle sprains increases drastically. From here you must address the buildup of scar tissue as well as the instability. If you find yourself suffering from a chronic ankle sprain, let us know. We can help you develop a modified treatment plan.
These are the opinions and examples of treatment plans for sprained ankles from Mountain View Pain Center. If you have any further questions or concerns feel free to contact our office or leave a comment below. Additional home exercises can be prescribed by your physician to speed up the healing process.
The Trainer’s Room is written exclusively for Midwest Sports Fans by Denver chiropractors Dr. Niall McNally and Dr. Ihsan Erhuy of the Mountain View Pain Center in Denver, CO. You can contact them by leaving a comment below or sending an email to [email protected].
Dr. Niall McNally is certified in chiropractic neurology and has a strong background in sports injuries and in the rehabilitation of common nagging athletic problems. Dr. McNally also is trained in pediatrics, orthopedics, and nutrition.
He graduated from the University of Central Oklahoma and successfully completed his Doctor of Chiropractic degree at the Parker College of Chiropractic in Dallas, TX. A very active athlete, Dr. McNally played hockey up into the junior level. In fact, it was his love for hockey, and the Colorado Avalanche, that originally gave him the idea to one day practice sports medicine and chiropractics in the area.
Dr. Ihsan Erhuy specializes in motor vehicle accident injures, back, neck, and extremity problems, as well as treating pregnant patients and children. He is certified in the Diversified, Gonstead, Thompson, Upper Cervical, Activator, Sacral Occipital, Applied Kinesiology, Soft Tissue techniques.
Originally from Adana, Turkey, Dr. Erhuy graduated from the University of Arizona and also susuccessfully completed his Doctor of Chiropractic degree, along with his bachelor of science in health and wellness, at the Parker College of Chiropractic in Dallas, TX.