Have you ever sprained your ankle? Odds are you have. It seems no one is safe out there when it comes to sprained ankles. When I was a kid I used to sprain my ankle ALL THE TIME! I was not super coordinated or athletic growing up. During my recoveries I tried everything from epsom salt baths and ACE bandages to just ignoring it and pushing through. Looking back it’s interesting to me that I didn’t end up with chronic ankle instability. So what set me apart? With chronic ankle instability being so common and me having that background shouldn’t it have set me up for chronic ankle pain?
What are ankle sprains and what causes them to become chronic?
Ankle sprains are one of the most common injuries. I’m sure you’re all familiar with the causes, since it seems it can be about anything. You missed that last step coming down the stairs… or going up sometimes, that crack in the sidewalk decided to suddenly expand somehow and suck your foot into it, you’re mid sporting activity when you land or push of and you feel that whoomp whoomp of your ankle giving out to the side…or maybe you’re trying out those new heels and feel that same whoomp whoomp of the ankle when you stepped wrong.
Most of us have been there. 75% of ankle sprains involve the outside portion of the ankle with the Anterior Talofibular Ligament (ATFL) being the injured structure 73% of the time.
An initial ankle sprain results in the stretching or disruption of the involved ligaments, causing structural tissue damage. This injury occurs when the ankle rapidly rolls outward, especially if the ankle is pointed slightly down (plantar flexion).
After the sprain, people quickly develop the clinical signs and symptoms of pain, swelling, and inflammation. At the same time people experience a less obvious decline in proprioception. Impairments in proprioception affect your balance, the ability of your muscles to respond and the ability of your ankle to feel what position it’s in.
You might be surprised to hear that 46% of people who sprain their ankle go on to experience chronic ankle instability and are 3x more likely to experience another ankle sprain!
What causes ankle sprains to become chronic?
The International Ankle Consorteum has defined chronic ankle instability as being more than 12 months removed from the initial sprain and experiencing recurrent ankle sprains, frequent episodes or perceptions of the ankle giving way, and persistent symptoms such as pain, swelling, limited motion, weakness, and diminished self-reported function.
So why is chronic ankle instability so common? 46% is really high! The answer is complicated, as are our bodies. There are a lot of theories out there ranging from “the cause is purely a mechanical issue” to “it’s purely a psychological issue”. The true answer, like so many things, is that it’s a combination of both. The injured tissues, inflammatory responses, and the person's psychological and emotional responses to the injury can drive the impairments that can cause an individual to deviate from successful healing toward chronic ankle instability.
On the mechanical side of things chronic ankle instability can develop when the ankle ligament complex fails to provide enough stability to match the demands of a given activity. When ligaments are injured they can lengthen, leading to increased movement at the joint. If our muscles that surround that same joint aren’t strong enough to control that extra movement the result is an instability at the joint. This can be the main cause or just part of the cause of chronic ankle instability.
The mind is a very powerful thing! The initial impairments that we’ve already mentioned combined with avoiding or fear of using the ankle can also lead to a dangerous cycle of compensations and continued pain that will send us down the path to experiencing the symptoms of chronic ankle instability. How people respond to an initial injury has been shown to have a big impact on the outcome.
The Melzack neuromatrix theory of pain indicates that in chronic pain conditions, the pain is generated not exclusively by sensory input in response to injury, inflammation, or other damage at the site of symptoms. It is instead produced by the output of the neuromatrix, a widely distributed neural network in the brain.
What does that mean? It means that the initial tissue damage that was present and causing pain in the beginning is not what causes pain a year down the road. Your injury has healed, but your brain is still telling you that there’s pain.
What could prevent an ankle sprain from becoming chronic?
The standard initial management of an acute ankle sprain has historically followed the RICE protocol: Rest, Ice, Compression, and Elevation. However, a more contemporary protocol follows POLICE:
Optimal loading replaces rest and encourages early weight-bearing and return to activity. The Journal of Nurse Practitioners states that early return to activity results in better outcomes for ankle sprains. They found that people returning to exercise and activity in the first week following injury experienced decreased long term pain and improved overall function. They also found that immobilization with a cast or boot should be reserved for the most severe sprains.
What should I include my your rehab?
So get back out there and allow yourself to get moving. No, this doesn’t mean go run a marathon the week of your ankle sprain. It means after a sprain you need gradual exposure to activity starting very early on. This can mean walking, doing some gentle calf raises or even just doing some ankle circles, anything to start to reintroduce movement and encourage blood flow in that area.
As you are able to tolerate more, you should challenge yourself more. Studies have shown that exercises focusing on strength, balance, and proprioception have led to the best results following an ankle sprain. So, focus on those areas as you start to reintroduce activities and movements.
One indicator of poor prognosis following an ankle sprain is pain with walking 4 weeks out from injury. So if walking is still an issue for you after 4 weeks you are at a greater risk for chronic issues. If this is you, give us a call. We want to see you back on the court, or back in those heels, or whatever it is that you’ve been avoiding because of your ankle.