Unless an ankle sprain is particularly debilitating, the treatment for this injury is usually ice and rest. Last post we explored the anatomy of the ankle and the different types of ankle sprains. Now that we've covered the basics, we're going to take a closer look the current state of treatment and then how to build on this current regimen.
Many of you may be familiar with the acronym RICE. This stands for Rest Ice Compression and Elevation. This strategy is the generally accepted method for treating inflammation after trauma like an ankle sprain. Why these four treatments? Here's why they've become the mainstay of ankle sprain treatment.
Rest: The idea of rest here means to avoid using the injured area in a way that stresses or strains the injury site. Too much stress early on can disrupt the early healing process.
Ice: Icing the area can limit bleeding, swelling and reduce pain.
Compression: The main goal of applying compression is to decrease swelling and bleeding but it also can reduce amounts of fibrin needed (a protein involved in blood clotting) which in the long run can reduce the production of scar tissue.
Elevation: Elevation means that the ankle is above the level of the heart. That means that just putting your feet up on a coffee table is not true elevation (although this is better than your feet on the ground). This lowers the pressure in the blood vessels in the ankle to limit bleeding and increase draining of the fluid sitting around the ankle. In other words it decreases swelling.
These 4 treatments collectively combat the inflammation, but there's more than just inflammation to an ankle sprain. So when treatment ends after RICE, we've stopped short of treating the whole injury. So what else happens? There are 3 significant things that happen after an ankle sprain.
- Restricted range of motion
- Changes in joint position sense
With some time and RICE, the body will do much of the work when it comes to the ligaments and muscles, but it won't do much for issues 2 & 3. Let's talk about how to treat these other two factors.
Have you ever noticed how hard it is to go down the stairs after an ankle sprain? Most commonly, the main motion that you need to descend stairs (dorsi flexion) becomes compromised. Dorsi flexion is the anatomical name for bringing your toes up toward your shin. It's the opposite of pointing your toes down to the ground. This restriction may be partly due to all the extra fluid in the ankle, but what about once your ankle is back to its normal size? Why does your ankle still feel jammed up and stiff? Remember that talus bone? Quite often after an ankle sprain, the talus shifts forward slightly. This position of the talus restricts the motion of the ankle.
A 2012 study by Michel Bekerom reported that this restriction can be observed for up to 6 months if not treated. Having a restriction in this motion isn't just annoying, it can be painful, hinder performance and decrease your safety.
- Pain: Many athletes will report a sharp pinching pain at the front of their ankle with cutting or sprinting.
- Performance: Having a restriction in motion means you can't get your foot in an optimal position for pushing off from the ground during kneeling, sprinting, cutting etc. This will most definitely affect your speed and agility.
- Safety: This compromises your safety because your may overexert other parts of your body to make up for the lack of motion in your ankle. More directly, you can't adequately absorb landing forces when landing on your foot.
Changes in Joint Position Sense:
Okay, what is joint position sense? This is also referred to as proprioception. Basically this is another sense your body has like sight, smell, hearing etc. It's your body's ability to know where it is in space without actually seeing it. For example, if you close your eyes and wave your hand, do you still know where your hand is? Yes. That's because of your joint position sense. So what would happen if you didn't know where your ankle was in space, unless you were staring at it? It would make landing from a jump a lot harder. That's exactly what happens with chronic ankle sprains. Your joint position sense is altered. This is part of the reason you're at a higher risk of ankle sprains after your first one. You're much more likely to roll your ankle if your brain is less aware of its position relative to the ground, especially if you're not on level ground - like on a soccer field.
While the RICE treatment protocol is certainly a good place to start it only affects one component of the injury, the inflammation. The latter two consequences of ankle sprains, range and proprioception, are often ignored by athletes and physicians. The problem is that restricted motion and altered position sense can leave you far more vulnerable to future injury. The good news is that there is a better way to rehab! We'll explore that next post.
References:What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? journal of athletic training Bleakley, C. M. et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ 340, c1964-c1964, 10.1136/bmj.c1964 (2010)
Bleakley, C. M., Glasgow, P. & MacAuley, D. C. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine 46, 220-221, 10.1136/bjsports-2011-090297 (2011)Bleakley, C. Supervised physiotherapy for mild or moderate ankle sprain. BMJ i5984, 10.1136/bmj.i5984 (2016)
http://physioworks.com.au/injuries-conditions-1/high-ankle-sprainKerkhoffs, G. M. et al. Diagnosis, treatment and prevention of ankle sprains: An evidence-based clinical guideline. British Journal of Sports Medicine 46, 854-860, 10.1136/bjsports-2011-090490 (2012)
Van der Wees, P. J. et al. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy 52, 27-37, 10.1016/s0004-9514(06)70059-9 (2006)
Hupperets, M. D. W., Verhagen, E. A. L. M. & Mechelen, W. v. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: Randomised controlled trial. BMJ 339, b2684-b2684, 10.1136/bmj.b2684 (2009)