On Tuesday, we discussed the symptoms of acute ankle injuries, how to determine the difference between a sprain and a fracture, and RICE therapy.  We will continue that discussion today with ankle injury rehabilitation and sub-acute ankle injuries (why your ankle has been hurting for a while).*

Ankle Injury Rehabilitation

Fractures will take months to heal, and all athletic activity should cease to allow bone healing while under continuing medical care.  For the more common situation, the ankle sprain, the severity of the sprain will dictate when to get back to training.  Physicians grade sprains depending on degree of instability:  First degree (Mild, ligaments injured but not torn), second degree (moderate, ligaments are partially torn) and third degree (severe, a ligament is completely torn).  While an exam by a qualified specialist is necessary to determine the degree of sprain, most sprains are 1st or 2nd degree; fortunately, 3rd degree sprains are much less common.  A good rule of thumb is to "let pain be your guide." If it hurts, stop! You're not ready to get back on your feet.

The pictures below show 3 simple functional rehabilitation exercises to get you back on your feet.  For a 1st or 2nd degree sprain (most sprains), you should initiate these exercises immediately.  Functional rehabilitation promotes collagen formation.  Collagen is the building block for ligament repair.  This will lead to faster healing.  The biggest mistake many people make is waiting too long to begin rehabilitation, which will actually delay healing and the ability to return to training.  If these exercises are too painful to tolerate, or you find that you are unable to perform them, you may have a 3rd degree sprain and should be evaluated by a physician before going any further.



Range of Motion:  Use an elastic band to stretch the Achilles tendon.  Another important range of motion exercise is knee bends with the heel planted on the floor.  These should be done in repetitions of five, five times per day; and the alphabet exercise, where you draw the alphabet with your toes on the ground.



Strength Exercises: After swelling has subsided and pain is controlled, you should begin strengthening exercises, starting with isometric exercises against a wall.  This is followed by isotonic exercises of each of the ankle motions: plantar-flexion (toes down), dorsi-flexion (toes up), inversion, and eversion.  Examples of isotonic eversion and plantar flexion exercises are shown.



Proprioceptive Exercise: Once strength is restored and weight-bearing is achieved, the final step in rehabilitation is proprioceptive exercise.  This refers to having a sense of your foot position in space, and being able to make adjustments to correct your balance.  A wobble board, as can be found at many gyms, is a nice tool to aid in this exercise.  Try to use it for 5-10 minutes twice a day.  Initially use it seated, then progress to standing.  Use your foot to rotate the board clockwise, then counter-clockwise.

Sub-Acute Injuries (It's been hurting for a while-what could be going on?)

Another class of ankle injuries is the sub-acute injury-meaning, you may or not be exactly sure when it started hurting; it hurts bad enough for you to notice it, but not bad enough for you to stop training, and you aren't sure if you need to see a doctor.  There are several syndromes that can occur months after an ankle sprain or as a result of repetitive small injuries, which lead to chronic ankle pain and arthritis-type syndromes.  While discussion of each of these syndromes is beyond the scope of this article, ask your doctor about the symptoms of sinus tarsi syndrome, osteochondral lesions of the talar dome (bone chips in the ankle joint), and talo-tibial exostosis (abnormal bone formation of the ankle joint).  Each of these syndromes cause symptoms akin to an ankle sprain, but lasting much longer and with a more insidious onset and course.  Specific treatments including joint injections and even surgery may be treatment options if one of these conditions is diagnosed.

As you return to training, use of an ankle support, which you can find at any sports or medical equipment store, will provide more support to your lateral ligaments and allow you to return to training with less apprehension.  Most people with a simple sprain will be back to full activity within 4-8 weeks.  Remember-RICE therapy, functional rehabilitation, and patience are the keys to getting back in the game.  Axe!!!


* Disclaimer: without a hands-on exam of your injury by a qualified professional, such as a physician or nurse with orthopedics training, you won't know exactly what's wrong, and the advice above may not apply to you.  If you have any questions, make an appointment to see your doctor.


Previously:
Doctor Capoeira - Ankle Injuries (Part 1)


Brian Lin, MD, FAAEM, is a Board-Certified Emergency Physician. He practices Emergency Medicine at Kaiser Permanente, San Francisco. He is an Assistant Clinical Professor with the Department of Emergency Medicine at UC San Francisco. In Capoeira circles he goes by the apelido Cebolinha. Brian is an estagiario a graduado (Blue/Red Cord) with Grupo Capoeira Brasil, San Francisco, and has trained Capoeira since 2001. He currently trains under Profesor Aranha, supervised by Mestre Cabeca.

Capoeira photo by j_silla via CC BY-SA 2.0
Ankle rehab photos by Brian Lin