Ankle distorsions part III; How to rehabilitate the foot? And when can the athlete return to sports?

The rehabilitation will take the time it needs. The injury will determine the time needed to regain normal function. If it’s a very small injury, active rest a couple of days can be enough. During this time the ankle should of course be trained, but also swimming, bicycling and strength training of the rest of the body should be performed – to keep the physical level. A more severe injury can take up to several weeks, and if really bad; several months, in case or surgery for example.

The goal is to regain full mobility and then gradually increase the load and resistance. That is, beginning with very easy movements without weight or load (just actively pumping the foot up and down, and working side-side), then adding gait training (walking forward, backward, rolling of the foot etc). Start with balance training as soon as the you can put your full weight on 1 leg, and start easy by just standing on the floor and move on to more challenging exercises when possible.

To increase strength you need resistance training of the foot; this is done for example by training the foot in different directions with a rubber band, and with heel raises for example. And then move on adding agility training, jumping, and so on. The amount of swelling determines which level or phase you start your rehabilitation.

When can players participate in regular training again?
In the perfect world of sports, there should of course be no swelling or pain in the foot and ankle during everyday life, with the same range of motion in both ankles, i.e. normal mobility. But for sports medicin professionals - functional testing must be performed! Namely; running forward and backward, running sideways, running in an 8-figure, jumps and landings - even landing on one foot in balance - and performing hard decelerations... The player must pass the functional tests without pain and cheating - i.e. trying to relieve the injured side. 
Although the foot isn't completely healed, for it can take a very long time for tendons and ligaments to heal, the foot is still functionally stable (normalised balance and near-muscular coordination). Put on an ankle orthotics and get back to regular training.
To avoid re-inury, studies have shown that the athlete still needs to continue with rehabilitation a few weeks (ankle strength, balance and so on). This is due to the muscles and nerves that take time to learn and maintain proper cooperation again after an injury.

Repeated injuries can lead to unnecessary complications in the future, which can be difficult to get rid of. Make sure to use a proper ankle orthotics that allows enough mobility in flexion and extension for running and jumping, but keeps the ankle stabile side-ways. You really shouldn't slack with that!

When can players participate in matches/games again? That's the fourth and last topic in the ankle distorsion series.

Ankle distorsions part II; How to know the severity of the ankle injury?

Start with finding out if the player can take a number of steps after the injury. If the answer is yes, no need for an X-ray directly. However, the foot must be wrapped tightly directly – compression is the most important treatment in the acute stage – and then wrapped medium to hard after 20 minutes. The foot may not be unwrapped the first 48 hours at all. If a sports medicine knowledgeable physical therapist / chiropractor / doctor is on site; he or she should also palpate the foot and check the areas that are common for fractures to exclude that possibility.

After 4-7 days you can test the foot for anatomical stability - ie testing the ligaments. You can check the skin for bleeding earlier – that provides you information on whether the injured ligaments and joint capsule could be ruptured. Unfortunately, examination of anatomical stability before these 4-7 days does not give reliable results.

If reduced mobility and joint-play is found, that would make me suspect the possibility of swelling in the joint, which, if the athlete is unlucky, could depend on a blow to the cartilage inside the ankle joint. Increased pressure on the joint will of course aggravate the pain and prolong the healing, and the ability to start running and jumping will take much longer. In this case, the foot should be X-rayed to rule out small bone chips loose in the area (but not acute - better if a few days pass, as the damage is usually more visible on x-ray).

How should the foot be rehabilitated? And how long is the rehabilitation? When can the athlete return to normal training and play games again? Information and discussion on this topic in the coming posts!

Ankle distorsions part I; what exactly is an ankle distorsion?

A Swedish doctor named Per Renström, with a specialty in the subject of ankle injuries, lectured on the topic in the Sports Medicine course I most recently participated in. He was up to date on the latest research in the area; there is some research, but mainly on the general population. Some information about this;

• Ankle sprains is still one of the most common injuries athletes encounter - does not matter if you are into recreational sports or an elite athlete.
• Functional training of the ankle is a successful rehabilitation. But studies have shown that about 20% have residual problems after rehabilitation.
• In addition to these 20%, many people do not take care of their ankle sprains, or do not go through the whole rehabilitation.

A common sight of a quite severe
injury that wasn't taken care of
immediately.

I will focus on the more common kind of the distortion – the lateral distortion (outside of the ankle).

However, an ankle sprain is not so bad...!? Must I rehabilitate it? You just jump in and continue to play / train, right...? Well, not always, depends on how much has been damaged - and if the player still has the good function of the foot. I’ll return to the subject of good function later. There is a risk of greater damage, and the damage which already occurred could worsen - and when the swelling is allowed to expand, the healing time is much longer. (If you haven’t read the post, "Take care of your acute injuries!", I advise you to do so).

An ankle sprain is simply a dislocation, where the person often steps down with the whole weight on one foot that is entirely on the side. The trauma this causes depends on the force directed downward and how long it lasts. One can step a little crooked, but get the foot back to the normal position quickly - not such a big trauma, but if you land on the foot when it is in the wrong position - major trauma.

The damage occurs then on several tissues;

1. There are two exterior ligaments that can be damaged, if the trauma is great, often both ligaments are damaged - which of course provides greater anatomical instability. If unlucky and the tear is from the ligaments’ attachments to the bone; small bone fragments can detach and cause pain until found and removed or resolved/decomposed by the body.
2. Inside the ligaments, we have a joint capsule. This joint capsule encloses the entire ankle joint from all sides, encloses the lower legs and covers down to the bone parts in foot. The joint capsule could be damaged and stretched - and if there is a discoloration of the foot, it has also often been torn.
3. The ankle consists of several joint surfaces. Above all, it is the top that can be affected. The upper ankle joint consists of three parts; the two lower legs that create a dome, and the Talus. When the foot is situated laterally, the Talus hits the dome roof above in two different places. It can be a gentle force so that it does not create a big reaction in the ankle and cartilage, but it can also be a nasty blow that damages the cartilage, and can (although it is quite rare) cause a tiny sliver detachment of Talus’ edge.
4. Dislocation of the Fibularis muscles tendons, which lifts the foot outward, and are functionally stabilizers of the foot laterally. The tendons starts sliding over the outer malleolus instead of being stuck behind the ankle - which both hurts and degrades the functional stability.
5. Many more things can happen, but som more unusual than the last two points. Among other things, one can encounter syndesmosis injury inte the lower leg, avulsion fractures in the foot, compression injury to the inside of the foot, nerve damage / irritation on the outside of the foot due to the stretching.

Bony parts of the upper ankle
joint.

How do you know the severity of the injury, and when the athlete can return to sports? Well, that is not easy, but I'll do my best to go through it in the next post...