Ankle injury story

I would like to share about my recent ankle injury and my recovery. I have had similar ankle injuries in the past(few years ago). These were related to some sort of low-level recreational sport.  I now compare my approach to this recent injury to the past treatments I was offered. My intention is not to criticise any practise but simply to observe the changes that occurred both in myself and in field of physiotherapy management of acute ankle sprains. So hope you like this and may take some points from my experience.

 About 4 weeks ago, I twisted my ankle, and I did not seek any medical attention this time. Having said that, I’m a physiotherapist by background and I treat musculoskeletal injuries as full-time job. But, for both my previous injuries I had some physiotherapy treatments- ultrasound therapy and taping/strapping. In the past I recovered within few weeks (don’t exactly remember how long but I recovered quickly within a month, maybe I was very young) and I had no persistent trouble in my ankle.

Almost 10 years into my physiotherapy practice, I am beginning to understand that non-serious musculoskeletal injuries can improve without any treatment intervention.  Sometimes you may need a consultation with a health care professional, but I wouldn’t agree with multiple treatment sessions like I was recommended in the past. Some practices continue to offer unnecessary treatments for some simple musculoskeletal problems that are likely improve by themselves or with time.

What can be the harm in over-treating or offering unnecessary treatments? But before we get into that I will tell you about my recent injury.

Firstly, the horrible part- the injury - this occurred in a squash court. I had the classic inversion sprain- heard a ‘crunch’ and felt a ‘rip’ at outside of my ankle. Immediately felt a slight pain in ankle (swiftly my previous injuries crossed my memory). This time, I stood up and I went through ‘Ottawa Ankle rules’ (here). I was able to put weight thorough the leg and I was able to walk few steps. I was confident

that I didn’t break it. I sat down for some time and felt around ankle bones. It was numb. My pain subsided a little bit and I was able to resume some gentle play. Driving was bit uncomfortable on my way back home. After watching me limping inside the home, my 4-year-old twins offered me some ice packs. I noticed some swelling; it was like a little egg around lateral malleolus. There was no immediate bruising (discolouration in skin). I took it as good sign that it wasn’t a serious injury. I took paracetamol and was able to fall asleep.

Day 1 I tried to walk as normal as I can. I felt comfortable with trainer type of shoes and formal shoes were uncomfortable. I could only walk slow but I walked as normal as I can.

In the following 2-3 days, I noticed that swelling spread slightly outside of the ankle and around the top and side of foot.

Bruising appeared after 4 to 5 days along outside of foot, which is often a common symptom in ankle sprain. Soft tissue injuries can cause minor bleeding inside and this often takes hours to days to appear on the skin. If it is a major injury bruising would appear more rapidly(here).

I continued to ice each day for about 5 minutes in my first week. My walking pace and stride length started to improve in few days. Though it hurt to move my ankle I tried little gradual ankle movements. 

I recently started to run, and I was making a gradual progress until this injury. I was a bit frustrated as I felt this injury was a setback. I reiterated myself that the injury did not appear to be a serious one and I carried on.

On week 2, I started to walk on treadmill, and I used a wraparound ankle support. I felt comfortable so I picked my pace up and I jogged slowly, completed 2.5 K without much trouble. I also did little hopping, squats, lunges and burpees- a cardio session. I felt mild to moderate discomfort which was within my acceptable limits. I continued to exercise with ankle wrap 2 to 3 times a week.

On week 3, I noticed that the egg like swelling in my ankle joint disappeared and it started to appear like my other ankle (don’t want to use the word ‘normal’ here). Full ankle movements started to feel more tolerable, don’t get me wrong it still hurt but I was able to take my ankle to that end range.

I’m now few days into my week 5, I feel 95 % recovered from this injury. My plan is to resume running without the brace.

What did I do differently this time?  After couple of days of rest (not a complete rest), when the initial pain has settled, I moved and loaded the joint gradually. More importantly, I resumed physical activities steadily. Besides ice pack, I did not seek any medical assistance this occasion. I used an ankle splint as this gave me a sense of support that my ankle was more stable with the splint. I could have tried physical activity without this but perhaps due to previous injuries I was perhaps bit more fearful, so I went for some support. In some people this perception of fear to resume normal activities after injuries can turn into kinesiophobia/fear of movement and they may get overprotective of injured site, leading to chronic pain.

I recovered from this injury despite being 15 years older than when I first had the same type of injury. The caveat here is that I possibly may have only sustained a moderate ankle sprain and, I have some clinical knowledge. Would I have done anything different if I sustained more severe ankle sprain? Probably not!! I may have been on some mobility aids/crutches for some time and probably it would have taken longer to return to some simple activities as ankle sprains can sometimes take long time to improve significantly (significant improvement does not mean pain free, you would be able to return to your daily activities comfortably). I would have still aimed to return to some level of physical activity.

What was the role of therapeutic ultrasound in my past injuries? Research shows that it is probably not as useful as once believed. van den Bekerom and colleagues in 2011 found that people who had ultrasound therapy for ankle sprain improved regardless of whether the therapy was applied with the machine turned off or on (also here). A placebo response/ positive perception that this modality was doing something to my injury could have possibly had a role in my case too. This challenges the physiological benefits that ultrasound therapy claims to have on acute soft tissue injuries.

LASER, pulsed electrotherapy, and shortwave diathermy were also other commonly used modalities to treat acute soft tissue injuries, probably still being used. We know that these does not add any value in our recovery during acute soft tissue injuries like sprain(here).

So, what could we do for an acute ankle sprain?

Firstly, relative rest for few days – not complete rest, which is to keep moving as much as possible and rest when needed. We are designed to heal while we move (Louis Gifford)

Secondly, gradual movements of injured joint- small movements but often.

Start with simple exercises, strength training is an important aspect; balance training comes at later stage (exercises picture!!). Discomfort during exercises is expected- remember it is not a sign of damage.

Simple analgesics for pain relief may be useful at initial stages, seek doctor’s advise.

Ice may be useful for pain relief, you can apply ice for few days, but may not be for swelling.

Splints are useful during first few weeks, but careful not to get used to it, as it may be difficult wean off after few weeks.

How long it will take to get better?

Pain from ankle sprain should significantly improve in 2-3 weeks’ time (here). Sometimes pain may get aggravated when we try to resume our normal life after the injury. It doesn’t mean that we are causing any new damage to the injured site. It is recommended to progress gradually as long as the discomfort is within our acceptable limits.

Musculoskeletal healing is rarely a smooth sail, there will be ups and downs as shown in the graph- people have good and bad days. Some people may continue to experience some discomfort up to 4 years. If you are confident that you have attempted your rehabilitation / strengthening program up to 3 months’ time and you still continue to experience persistent discomfort you can contact physiotherapist or a doctor for further advise.

Why unnecessary treatments are not recommended?

Firstly, too much of passive interventions are not as effective during acute injury phase. Also, it may not make our tissues to heal faster.

Unnecessary treatments can also potentially feed into fear of movements for patients. It gives a false notion that site is damaged and needs protecting for as long as the treatment continues. We know people who received too many ineffective treatments at acute phase of simple musculoskeletal injuries took longer to get better than people who did not receive any intervention (here). Also, clinicians’ misconceptions and beliefs about injuries can negatively influence a patient leading to long term disability (here).

Therefore, it is important that we are informed about recommended treatment guidelines as per current evidence.

So let us..

·         Simplify information to our clients

·         Explain the process of tissue healing and that it can take time; ups and downs during recovery is to be expected

·         Empower people with better self-management plan- exercise program, reassurance that it is safe to load the joint, intermittent follow ups only if needed

·         Promote active strategies – simple physical activities and strength training

Physiotherapist’s role is more like a coach and be willing to travel with patient’s rehabilitation journey rather than standing at bedside with some passive devises on our hand.