Probably the most common injury to the lower extremity is the sprained ankle. It is frequently unrelated to athletic activity. The ballet dancer - perfect in her execution of thirty-two fouettes, endless pique turns and changements - walks out of the studio and trips over a microscopic crack in the sidewalk. She turns her ankle and is out of action for six weeks! In sports such as basketball, volley-ball, track or racket-sports, an improper landing or a quick cut may result in the inversion injury and, consequently, a sprain.
Ligaments connect bone to bone. Ligaments are plastic, but relatively inelastic. In the case of an ankle sprain the foot usually turns under, (inversion) stressing the ligaments on the outside and front of the ankle. If sufficient force is involved, these ligaments tear. The degree of tearing is dependent on the direction and amount of force, the strength and balance of the muscles surrounding the ankle, and the underlying foot mechanics.
Unless the injury is of exceptional force, the big problem is not the initial trauma. Far more important is the swelling and bleeding that, without proper handling, occurs afterward. This effects further stretching (read: tearing) of the involved ligaments and, reflexively, protective spasm of the leg muscles. The latter diminishes return circulation, perpetuating the vicious cycle: pain, swelling, spasm, ligament damage. Disability is thus prolonged. The duration of that disability is directly proportional to the time it takes to begin RICE:
Rest, non-weight-bearing, Ice packs with Compression, and Elevation of the limb above heart level are essential. Ice is the most effective natural remedy for acute sports injuries. When appropriately applied, ice reduces swelling by decreasing bleeding and loss of fluid into the tissues. RICE will result in a profound abatement in both the duration and severity of post-trauma disability. The key, then, to successful care of the sprained ankle is in the initial management. Of prime significance: prompt non-weight bearing.
Immediately following injury there is an abrupt increase in the local and systemic endorphin level (the body’s natural pain killers). Did you ever cut yourself and not realize it until you started bleeding? There is no instantaneous way of telling how badly you’ve hurt yourself because you simply can’t feel it. Just get off it! You don’t get to limp home. If at all possible, stay off it from the moment of injury until you’ve seen a doctor. Keep it up and continue with the ice, twenty to thirty minutes on, one hour off.
At Catskill Rehabilitation and Sports Medicine, our ankle sprain protocol calls for a rapid return to weight-bearing after the initial period of non-weight-bearing, the duration of which depends on the severity of the injury. This protocol is particularly aggressive, calling for infiltration of the area around the damaged ligaments with a local anaesthetic, as soon as possible after the injury. On the next day we use electrical stimulation and massage with active, non-weight-bearing movement. Then passive mobilization and ultrasound are added, with weight-bearing (supported by bracing) by the third or fourth day. Ice applications for twenty to thirty minutes every two to three hours are continued during the first three days. Depending on patient sensitivity, early institution of therapy with non-steroid anti-inflammatories is routine.
The next steps are, in order, restoration of range of motion, strengthening, and restoring proprioceptive sense. The latter is the neurologic reflex mechanism which tells our brain where our body parts are in space.
In most cases, we have been able, with early (same or next day) intervention to reduce the period of disability from six to eight weeks to as little as seven to ten days and frequently less. This has been extremely valuable to many amateur and professional dancers and to avocational athletes, including runners and racket sports participants.
Not all sports medicine practitioners follow this protocol, and it’s important to realize that there is no single "correct" way to treat this or any other type of injury. What is presented here is what works for us, supported by a substantial body of scientific research and experience. Whatever the follow-up, the secret of success is in the initial self-management, RICE.