chairs !!!

Researchers are beginning to hypothesize that there's a link between "forward head posture" and sitting around most of the day with your head slumped forward.




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So You Wrenched Your Ankle (part II)

Part 1 - what to look for right away.
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You have rested, iced, and elevated your bum ankle for a few days or weeks, depending on the situation. It's likely still swollen, but you're at the point where you can bear weight on it. You need to get moving again. The first thing is to try some light stretching of the ankle to recover dorsiflexion.

Place a belt or towel under the ball of the foot and pull back to apply more stretch.

Make sure the feet are "aiming" STRAIGHT toward the wall, not flared out.

You MAY need a little help

As mentioned in part one, look for pinching when the ankle is stretched in this manner, or with real life movements like squatting or walking down steps. If the motion feels blocked and there's pinching toward the front of the ankle rather than a pulling/stretching feeling in the back of the calf and ankle, you probably should be evaluated by professional. This is a very common, stubborn problem after an ankle sprain that won't show up on an X-ray.

A skilled doc, trainer, or (yes) PT should be able to determine if there's excessive laxity (the ankle ligaments have been overstretched or torn) that would warrant further imaging or a period of immobilization. They can also perform a trial of manipulations aimed at restoring normal spacing between the top foot bone (the talus) and the lower leg bones (the tibia and fibula). 

Take dorsiflexion seriously. Lacking this movement causes you to unconsciously shift strain to other areas on the same leg or to the other leg. Chronic ankle dysfunction can be particularly hard on the knee and low back, and researchers have measure differences in joint movements and muscle activation all the way up into the trunk.

The reccurance rate for ankle sprains is somewhere between 50 to 70%; pretty horrible numbers. My friends and I have definitely walked hobbled down this road. Exercises and braces are your first steps toward better...steps.

A word on exercise

This is one time when exercises I like to make fun of are actually called for. In the weeks to months after ankle (or knee) sprain, you should be working on balance and controlled movement on both stable and unstable surfaces. We won't get into the specifics of exercise progression right now, but here's a quick screen for sprained ankles:




The intermediate phase of ankle (and knee) rehab is one time when goofy squats and reaches on unstable surfaces are actually beneficial and I shouldn't make fun of you for doing it. Unless, well, yeah, this guy.






-Try to balance on one leg with your eyes closed - no wrapping the "up" leg behind the balancing leg.
-Try to do a full toe raise on one foot - no holding onto anything with your hands. 
-Try to stand on an 8 to 10-inch step and lightly tap the "good" heel forward on the floor - don't transfer your weight, just lightly touch the floor.
-Do a deep squat with your feet straight ahead and heels staying glued to the floor and your knees staying over your toes and your chest staying up without a forward trunk lean. 

Compare your injured side to the "good" side. People often feel wobbly on their injured side, or have to use different movement strategies due to weakness and inflexibility.

A word on bracing and shoes


The absolute BEST device for stability when you need stability, and explosive movement when you need explosive movement, is a primed and efficient nervous system! The best way to shut down all your lower leg muscles and hinder the ability of the brain to fine tune movement is to lock the foot in a concrete block of a shoe and brace/tape your ankles.

Many studies have examined the performance effects of wearing ankle braces. Although there's some conflicting findings in this area, recent work from the Division of Orthopedic Surgery at the University of Utah (and a few others) showed that ankle braces do decrease vertical jump height, broad jump distance, and maximum sprint velocity.

Other studies specifically address the price your body pays for increased ankle stability. Braces and tape at the ankle allow for less movement and sensory feedback from that joint, removing a large part of the shock absorption system of the leg. This leads to measurable increases in shear strain and torque (twisting strain) at the knee. Protection of the ankle may cost you at the knee, over time.

We do need to reach a balanced perspective, however. Sometimes athletes need to get back to the game sooner than later; before their ankle is completely recovered. Many sports involve hard cuts on uneven terrain and/or lanky athletes jumping and landing all over each other. In that instance, braces and tape just plain make sense. They may be the lesser of two evils.

The athlete that makes a living out-running, out-jumping, and "out-cutting" people should consider taping or bracing WITH an end-point in mind - maybe three to six months as they rehab in controlled environments. If taking a few percent from sprinting or jumping performance really doesn't mean that much, brace or tape for nine months to a year. But there should be an end in mind, for the sake of your knees, hips, and back. 

Surgery is sometimes needed. Rarely. I have a few specific stories on this for anybody who wants to hear, but this is already too long. Maybe a part 3 or maybe not.

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"Ron"

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He appears headless from behind. Literally. Ankles plantar flexed. Knees flexed. Hips flexed. Kyphotic thoracic spine, flexed. The whole thing, orthopedic nightmare, culminates in a neck and head stuck forward like a weepy Dr. Seuss tree.

We've been working with Ron (fake name) for months. He wasn't always like this, not before weeks of bed rest for a pulmonary complication left every joint fragile and locked tight, perfectly fit for a soft couch.

Lay him down on a treatment table. Massage the neck muscles. Apply traction, and pull that baby back. Pressure under his jaw and pull back. Out and back, out and back, out and back. Crank on the ankle and lower leg while pushing down just below the knee. Throw a whole leg over the therapists shoulder and lean in, again bringing force to straighten the knee. Drop the leg over tables edge to open a hip. Extend and rotate the spine.

Each position is held twelve or twenty times. Every single repetition feels like stretching a piece of wood. Who knew these Dr. Seuss trees were oak? 

The entire sequence is repeated on the other side.

More than half an hour later, Ron has gained some mobility. Maybe five or fifteen degrees, depending on the joint. It all adds up to a slightly looser, longer Ron. It's time to rise. In less than a minute, about one fourth of the time it takes him to gain his feet, it all falls apart. Ron strains hard to look you in the eye, standing right in front of him.

The therapist strains hard to look Ron in the eye. It hurts.

Ron needs to gain strength and postural stabilization to maintain the effects of all the discomfort that he (and the therapist) just endured. It is easier to climb Everest. His posture has annihilated various braces and corsets that we have tried.

Kim, my sweet assistant, treats Ron like a king. Jokes with him. Patiently waits fifteen minutes for him to walk from the rest room to the pulley system he tugs on. Purchases Easter eggs from Ron's steadfast, beautiful wife.

I think Kim prays for Ron more than I have.

Ron takes it in stride. Slow, short stride. He's awfully kind and gentle for someone that spends so much time looking at the floor. Ron's posture isn't the only thing that other patients notice. He's joyful, even.Yes, king Ron.

Ron chooses to keep pushing. Rehab gives him hope, if nothing else. I don't think that qualifies as skilled, medically necessary health care. Surely we are part of the reason why Ron can live independently at home without other medical issues. I don't feel too bad about those Medicare dollars.

We push with him, fighting gravity with his frail body, fighting despair with his strong mind. He'll eagerly show up for the fight and enjoy the therapists efforts and company, for as many days that God and Medicare "authorize."

I tend to think that number may be one and the same.

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So You Wrenched Your Ankle...

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You probably slipped, got hit, or came down on something uneven. Your ankle twisted, things popped, bones and gristle jammed and disengaged. You rolled around a little on your back, gritting your teeth. 


Someone assisted you back to your feet, telling you to apply ice and compression and it will be fine in a few days. You stood there, mostly on one leg, wondering how that first step on your blue balloon is going to be. Someone else advised you to get an X-ray, and once you sprain your ankle it's really never the same. 

You hardly heared either of them because you were just hoping for someone with Advil.

You, my friend, have wrenched your ankle. Don't feel too bad - it is estimated that about 22,999 other people in the United States have wrenched an ankle on the same day.

It's probably going to be fine. But maybe not. Really.

PTs get to deal with this.

If you can bear some weight through the injured foot and it's not highly sensitive to moderate pressure to the inside or outside of the lower leg, you don't need an immediate X-ray. I've seen ridiculously huge ankles displaying all colors of the rainbow recover fairly well in a week or two. Had a few of those myself.


I've also seen simple ankle sprains go from acute pain to chronic nag in no time. Had of few of those myself - one on each leg. It's April and I'm just now getting over an ankle sprain in October. The truth is that until you have the pain just a bit under control and some of the swelling down, it's very hard to tell if an ankle sprain is going to cost you days or months. 

Evidence of two mistakes:
Falling off my mountain bike and getting a Soundgarden tatoo.

Since about 15% of ankle injuries involve fractures, if you can't bare much weight on it two or three days later, you should probably get an X-ray. Fractures require (at least) a period of immobilization before moving on to much of what's described below. Otherwise, in the absence of fractures, getting to work on some of the details helps ensure that "never the same" doesn't come to fruition. 


The typical ankle wrenching causes persistent swelling. Supporting muscles and ligaments loosen. The result is vastly decreased proprioceptive (positional sense) feedback to your brain, which further weakens muscle drive as you unconsciously unload that leg. Researchers have measured altered movement patterns all the way up through the hip and trunk in people with a history of chronic ankle instability.

 The "high" ankle sprain involves separation of the lower leg bones as the talus (the top foot bone) is essentially driven up between them like a (wood) splitting iron. This injury usually has a longer recovery period and  different course of treatment than the typical inversion sprain pictured below. 


Early movement has been demonstrated to be helpful in many ways. Use common sense, of course. Don't go jumping and running around on a recently wrenched ankle. But that same ankle probably can and should be doing non weight bearing stretches and active movements that help restore mobility, decrease swelling, and add enough strain (but not too much) to stimulate a strong repair of collagen and other connective tissue. 




The typical inversion sprain.



Diagnostic imaging has shown that with even modest inversion sprains, the talus and outer ankle bone may slip forward, causing  some motions to increase and others to decrease. You're left with a predisposition to more ankle sprains and a mechanical blocking of movements needed for everyday life. 

One of the best indications of "displaced" ankle bones and loose ligaments is a pinching feeling in the front of the ankle when flexing the knee out over the foot (ankle dorsiflexion). If you get this anterior pinching after some of the swelling subsides, you really should check in with someone who knows what "posterior mobilization of the fibula and talus" looks like. 

As far as how soon to start pushing the envelope with higher level weighbearing exercise, I often go by how much pain and laxity is present with ligament stress tests. If anterior drawer and talar tilt tests are not too painful and reveal minimally increased laxity compared to the other ankle, then an advanced track of rehab and return to sports (or whatever) is usually appropriate. If those tests cause a lot of clunking around and pain, then a more conservative pace really is needed.


If that's the case, but you're a tough guy and too good for a time out, you could try playing basketball and flag football before it's adequately healed and stable. That will leave you (and your friends) suffering six or eight months of you playing hard and whining around because it hurts or playing easy and whining about not being at full speed.

The only option that doesn't involve a lot of whining is to just take a break, do some corrective exercise, and follow a gradual progression of impact activities.

The recurrence rate for ankle sprains is anywhere from 50 to 70%. What do helpful "higher level" exercises look like? Do you need to tape, brace, or buy different shoes? Will there be more pictures of nasty, probably stinky, swollen feet? 


Part two is coming.
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