Friday, 1 October 2010

Rehabilitating a sprained ankle

So I sprained my ankle quite badly way back on August 10th this year. I’ve sprained my ankles a ton of times before and recovered fine so I know the rehab drill. A bunch of years had passed since my last sprain so I thought I’d check out how the advice had improved. Unfortunately it hadn’t improved much at all. 

My ankle 2 days after the sprain
The advice I really want to follow was that I received from a sports physio while I was at Loughborough because it’s just the best I’ve ever received. The guy just knew his stuff so completely and explained to me exactly what to do, when and why. 

The problem is that I didn’t use the web back then and definitely didn’t blog so I have no record of what he said and what worked.

I’m frustrated that there is no step by step guide to rehabilitating a sprained ankle despite it being just about the most common injury from sport. Thousands of people sprain their ankles every week yet no one seems to have bothered to post a simple step by step idiots guide. There’s just a basic, vague set of guidelines to follow.

So I thought I’d document my treatment and the results so I do have a record for the next time I need it and so I can advise my wife and kids in the future. This way I’ve got a record of what I did over time and some analysis of what worked and what didn’t.

As you’ll see some decisions I made really improved the speed and quality of my recovery and some really held it back. Atleast now I’ve got the benefit of this experience next time I or some one I know has a sprain.

I should also note that I wanted to get back to fitness really quickly because I had just joined a couple of local tennis leagues. I’d been waiting for a tennis league to play in for years so I didn’t want to miss out. The sprain occurred just a few days before my first match was scheduled. So I hoped to get back out and playing as soon as I could because there weren’t many weeks left of the league.
So the first thing to talk about is what happened. I was just playing football and went to block a pass. The ball hit my foot when I wasn’t expecting it. The foot got pushed right under my ankle so quickly I couldn’t do anything about it. So quick in fact I'm not sure if I even stepped on it while it was pushed like this.

Anywho, the point of this description is to highlight the first thing the physio from Loughborough taught me that I hadn’t done well enough. That is, prevent injury by strengthening my ankle muscle complex. I play so much tennis all the time I assumed it would be well prepared. Sadly i was wrong.

What I’m supposed to do is a bunch of exercises to improve the strength and coordination around my ankle. Particularly the small muscles. This work makes such a difference to my balance and reflexes. More than once I’ve stepped on a divot and felt my ankle go, only for the ankle reflexes I’ve trained to kick in and straighten the ankle before any serious damage is done.

That’s what I needed here. My foot moved so quickly I needed a reflex reaction to save it. I couldn’t have done anything consciously. So it’s just a reminder that football, for me has greater demands on the ankle and needs greater preparation.  

The next issue is about first aid. What to do when you’ve just had a sprain. It was during lunch at work that the sprain occurred and I felt a bit cheeky suddenly asking to go home ill. In hindsight I have to say what was I thinking but then then that’s what I’m like. It was during the height of the summer holiday season and we were really low on the ground in numbers so i didn’t want to let the team down.  I often put work over my health and I think I’m not the only one.

I’m writing this on 2nd October. I can play tennis again so my ankle is a lot better but the scaffolding that the body creates to prevent further injury still hasn’t gone making my ankle stiff unless I warm it up well. I don’t remember this stiffness lingering for so long after a sprain and I think it’s mainly due to the lack of basic first aid I gave my ankle.

It sounds silly but, as you’ll see throughout this article. since I had no notes and the info on what to do can be confusing or awkward to do I thought I’d try a minimalist, natural approach because I’d never done that before. I thought I’d see it as a chance to learn and preserve a record for the future.

It’s common knowledge rest, ice, compression and elevation are the basic first aid for sprains. But I’d heard a few things arguing against the benefits of ice. Well, I’m convinced now that ice in particular is critical in the first stages, the first 48 hours to minimise the swelling that occurs. Compression I’ve always found hard to do but resr, ice and elevation are easy enough when you’re at home. So the first thing I should have done is gone straight home and started rice straight away.

Technically protection is now added so the acronym is PRICE and you can get some nice plastic things that protect your foot when you start walking.

So the next day, a Wednesday, and for the rest of the week II worked from home so I could rest the ankle properly. You can see from the photo how bad it looked once the swelling and bruising came out after a few days. The only time I can remember bruising and swelling this bad was when I sprained my ankle on holiday in Spain. That was another time I didn’t use any of the basic first aid and it also had more advanced swelling than usual. Shame I couldn’t blog about that at the time. Would have saved me some hassle.

I have been hearing how doctors now encourage people to get back to activity soon than they used to. So, over the weekend we bought some crutches so I was able to get around a little bit. It didn’t seem to be making my ankle worse and it meant that I could keep the strength up in the rest of my body. So I went to work on Monday. I thought I should atleast try to go in.

It was worth a try but it’s just not easy to elevate your ankle at work and it was actually quite cold even though it was in the summer so my ankle wasn’t going to heal very well. So I took the rest of the week off. I just properly rested. Just doing the basic rehab exercises to develop my ankle when the pain had subsided.

I went back to work the next week when I was able to get around much better. I could put weight back on my ankle and was starting to walk. Albeit relatively slowly. I couldn’t stand straight on the ankle yet. My ankle felt ready to take weight so I used walking as its own rehab.

This worked well for the first couple of days. Then I found my calk muscles got very tender. So I was in pain for the rest of the week. It wasn’t til the end that I found that I needed to stretch my calves, then the pain went away. I thought I’d just pushed too hard and was paying the price when in fact  I just needed a quick stretch. All of a suddent I could walk far more naturally. The limp had pretty much gone except when I was going downstairs.

I then had a bit of luck since I had two weeks holiday booked off. I could just do what I needed to sort my ankle out. It started off well. I was able to work on the next phase of rehab that the loughborough physio taught me about. He explained that scar tissue normally forms inside the joint when RICE hasn’t been followed correctly. What he did at the time was push through it. He physically pushed my ankle through the scar tissue. He explained that this tissue cannot be allowed to linger. Once the ligaments were on their way to healing you had to get active to break down the scar tissue.

When I saw him it had been 3 weeks since my sprain. He said I could have got rid of the scar tissue even earlier. So this time that’s what i did. I just kept on doing a little more with my ankle each day until tuesday night of that week. That’s when the next thing went wrong.  

At first I just seemed to have a trapped nerve. I went to bed early figuring rest would be the best cure. How wrong I was. The pain got so much worse. I started having pain when breathing. It felt like one of my ribs was pinching my lungs when I breathed. It meant I could only take short sharp breathes. I couldn’t really get a full breath.

Then I started feeling shooting pains down my spine. Every time I moved was complete agony. I couldn’t even sleep because doing anything but sitting up dead straight was so painful. It’s so rare that anything goes that wrong with my body I’m really not used to this kind of situation so I didn’t know what to do. I tried painkillers but they did nothing. I even called NHS direct it was so bad but all they did was make it clear it wasn’t on their list of serious problems.

So while it was really painful. Atleast I knew it was unlikely to be anything really bad. Still, even the trip to get painkillers was agony and then to find that it had no effect. That was a real bummer. I eventually managed to get to sleep by propping myself up with a ton of pillows.

The strange thing was that I was a lot better by the morning. I still manage to play my first game of tennis in weeks. I thought playing would be better than sitting around. I just focused on taking care of my back. No sudden movements and basically using good technique. I really felt better for the exercise. But that night I had the same problems and pain. I was losing faith that this was going to pass quickly. So the next day I booked an appointment with the doctor. I couldn’t get an appointment til the next day so I just put up with it.

My memory is a bit vague at this point but I remember that by the next morning I had start to feel better. I think the day before I had talked to my wife about the pains and she told me she’d had similar ones before. That they had gone away when she exercised her back. That reminded me about another basic principal of rehab that I hadn’t quite followed properly. I hadn’t been ensuring all my muscle groups and joints were kept active.

I’d focused on weight bearing activities forgetting about activities for my back, core and upper body. My walking wasn’t a natural motion yet and I’d just started a light jog. The action most likely put strain on my sholuders and back which were weak from weeks of sitting and lying. I’d forgotten about these areas of my body because I’d been so focused on my ankle and legs. it just shows how easy it is to forget the whole and focus on the specific.

I think it was that night, the thursday, that I specifically started working my back and shoulders and on the friday  From then on the pains began to disappear. It still took a few days but eventually they went completely.

I’ve included these details about my back pain as a reminder that during rehabilitation you have to take care of all the parts of your body not just those that are obviously affected. Other parts need to get the same care they normally would. It also shows what can happen if your back doesn’t get the regular exercise it needs. It reminded me of previous times I’ve had severe back pain. Each time it was when I’d become lazy and spent too much time sitting or lying down. Once I addressed that the pain quickly went away.

After these initial setbacks I’ve foudn my ankle has progressed quickly. Once I got back to work a month after the sprain I had already played a few games of tennis. So I began building on that. I probably overplayed but then I wanted to see just how far I could push myself. I was just focusing on good technique and using the activity itself to push my ankle through the barriers it needed to overcome.

I found that over a few days the ankle seemed to get a bit swollen so I just let it rest. I was wondering if I was just pushing it too faor. Maybe it just needed a good rest to fix itself. I didn’t do much with it at all. After about four days I found it was still quite stiff in the mornings. While there was no pain. I coudl tell just about all the ligament damage was fixed but still the ligaments that had been damaged were very tight.

Four days of rest had done nothing so I then resolved that I needed daily stretching and mobililty to slowly teach these ligaments how to be flexible and strong again. I consider this to be part of talking to my body. By stretching the joint, warming it up and then working through it’s range of motion I tell my body very clearly that i need strong and supply joints and ligaments. It then takes this feedback and does what it needs to to get rid of the scar tissue and replace it with proper ligaments.

That’s my final hurdle. I am writing this on the 1st October. Almost 7 weeks after I sprained my ankle. It’s no longer painful and the ligaments have mostly healed but I’ve still not got full range of motion. This week I noticed that I wasn’t pushing off on my damaged ankle properly when trying to run. I had to focus on correcting this. I quickly fixed it and from then on the muscle tone has returned much more to the calf.

It’s been lots of little things like this that I would have appreciated advice on. I may have been able to get this from a physiotherapist but I’m not convinced they all have much training on preparing you for sports. Even then I can’t afford the £30 an hour for something that I know will fix itself given time.

I’ve covered most of what I wanted to cover. I feel I’ve learnt and recorded some useful tips for the next time this happens. I feel the main lesson is the mobility restriction I have now is down to the lack of RICE at the start. It what I’ve always been told. Now I have proof. I hoped this natural scaffolding my body provided to protect my body would be easier to shift but unfortunately it hasn’t been.

The good news is that I don’t really notice it any more playing tennis. I’m finding that I’m just nervous of playing fully on it. When I work on that, and make sure I run properly rather than trying to protect my ankle, I feel much better.

I hope this helps any one else who bothers to get this far. I know this has been a long one but then I didn’t expect my sprained ankle to lead to quite so much drama.


edit 20110510
So I've got an update. I've been using my ankle for a long time but it hasn't quite healed properly. It's pretty much fixed now. I carried on for quite a while with a few problems because I just didn't quite know how to fix them. 


Improved tennis footwork.
I like to use my injuries to force me to improve my sports technique. Might aswell get something useful out of it. I rested up for several weeks but that didn't help at all. So I decided to improve my footwork during tennis to reduce the impact on my ankles. I figured the main issue was the impact in terms of jumping up and down. Since I found walking helped my ankles but running didn't. 


So I changed my footwork from running to kind of gliding or stepping. I always keep one foot on the ground and focus on landing gently. It took a little thought at first but now it's second nature. The big plus is that I've got so much more balance and speed. I can turn on a dime and my game has improved no end. My ankle was getting very tense previously but training this way they were fine.


Built ankle strength, coordination and proprioception
At the same time I visited the physio to check if I should be doing more. She reminded me that I hadn't been developing my ankle strength and coordination to pre injury levels. When she observed me she commented on these aspects which is useful because there is no measure or comparison that you can find on the web. You need someone knowledgeable to tell you.


So I did generic exercises to build strength and balance in my ankle. Like standing on one leg, First on the flow, Then on a cushion. Later, with my eyes closed. I came across my old sports injury magazines and was reminded I could progress to lunges that build balance, strength and flexibility. The progress to more difficult exercises. But I read these too late so I went straight to balancing on one leg, then lowering myself until I could touch the floor with both hands, then stand up again. All on one leg. 

This was really difficult. it highlighted the weakness and lack of coordination on my left side. I could do it easily on my right but with my left I kept dropping my hips and losing balance. After a week of trying it finally worked. My ankle quickly felt stronger and better.


Adding to this I also started striding while crouching a little. It would look funny but I was building up the ability to change direction while crouched down, I also kept stopping on one leg and balancing to improve my dynamic balance and control. There was no impact involed so it was still a gentle exercise to build up the ankle.

At the same time I was building strength in my ankle doing one leg raises on the stairs. And also doing side to side movements with my ankles while sitting down to improve their lateral strength.


Built ankle flexibility.and tendon plasticity
At this point I knew I was pretty much there. The slight lateral ankle pain I'd been feeling for months finally stopped. Indicating the ligament had healed. I think the strengthening and proprioception work really helped there. It was noticeable how much less pain there was after I did those exercises. Also, as my balance and strength improved so did the pain.

A lingering problem had been synovitis where the synovial membrane in the ankle seems to have swollen indicating some friction in the ankle. that has gone down consistently as each symptom has cleared up. The last symptom is the calf tendon and muscle feeling tight. Particularly after intense training but often just at the end of the day through normal wear and tear. It didn't feel like normal muscle tiredness. I'm used to that. It felt as thought the muscle was caught in a tight net.


I went through this process to learn about my body and I kept remembering that the tendons and ligaments are a complex themselves and work with the muscles. They really contain the muscles and the ankle tendons actually run right up the leg to the hip. they're also repaired using collagen but need help regaining their pre injury plasticity. that is their ability to stretch and recoil naturally. 


They're a very important part of normal movement and key to maximum power in most tennis strokes. They're also used in walking to push off as the heel leaves the ground. So it's only natural they'd be sore at the end of the day. It would also explain the synovitis because the ankle wouldn't absorb the forces correctly. The bones, cartilage and synovium would rub together leading to inflammation.


The solution has been a combination of stretching, both standing and laying down to get a full ankle stretch without aggravating the synovitis.I've also been doing gentle hops from one foot to the other during matches and any time I felt like it. Just encouraging the tendons to regain their plasticity. Very quickly this seems to have worked. Right now I've got full range of motion back, the synovitis has pretty much gone and there's no pain. I'm pretty much back to full strength.

Overall

In hindsight I just wish I'd remembered these exercises very early on. Once I started these training routines everything fell into place. I'm happy because it proves I didn't come back too soon. I just didn't know how to continue playing whilst minimising impact on my ankle. I also didn't have a bunch of techniques designed for rehabilitation. Atleast now I can adapt my tennis to rehab my ankle. So I don't have to take any time off. In fact I need to play to improve my recovery. That's the big score here for me.

Good news

This article paints a very bleak picture of recovery from a sprained ankle. I haven't fed back much because I was still learning. I have never been so active so regularly before which is why this has been a problem. I used to heal quickly because I wasn't so active.

My task has been to learn how to heal an injury to such a core part of my body without stopping my activity. Now I have learnt what I needed to do so that if I suffer a similar fate it won't take me long to fix it. As is usual the answers are pretty straightforward though the path to finding them was long.

In a future post I will describe what I did to fix my ankle and the other injuries I have incurred recently. For now I shared my recent experiences with no ankle pain after 7 sets of tennis. The proof is in the pudding as they say and this is the best example I can give to the state of my ankle now. 

What I have learnt has been tremendous and I look forward to sharing it in the near future.
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