what-is-an-ankle-sprain-explained-by-a-physiotherapist

Ankle Sprain Explained: A Physiotherapist’s Perspective

Physiotherapists Treat Ankle Sprains More Than You Think

“Rolling an ankle” is extremely common and if you have never rolled it, chances are you probably know someone who has. There's usually a bump on your foot that appears soon after. But what you don’t see is what happens underneath the bump. How severe is the injury? How long does a sprained ankle take to heal? How do you know if you sprained your ankle? This blog post will dive into an ankle sprain so you can understand what to look out for and when to see a physiotherapist.

Understanding How An Ankle Functions and What It Means for Physio Treatments

The body has passive supportive tissues otherwise known as ligaments, and their purpose is to support different joints and provide stability throughout the joint’s range of motion. A ligament sprain happens when the joint is forced past its natural range of motion.

 

Some examples of when ankle sprains may occur include stepping down from a curb or step, landing from a jump, or rapidly changing directions when playing sports.

The common mechanism for a rolled ankle is a combined movement of plantar flexion (foot points down) and inversion (bottom of the foot turns in). Commonly affected ligaments are on the lateral (outside) of the ankle including the anterior talofibular ligament (ATFL), the calcaneal fibular ligament (CFL), and in some instances the posterior talofibular ligament (PTFL). In rare instances, a rolled ankle outward can affect the medial (inside) deltoid ligaments. That means the ankle doesn't "look right."

In some cases, there may be more than a sprained ligament. If the forces are high enough (like jumping off a step), an avulsion fracture may occur where the ligament pulls on the bony attachment causing a piece of the bone to detach.

Symptoms of a Sprained Ankle

  • Severe pain
  • Bruising
  • Swelling
  • Decreased range of motion
  • Limited strength
  • Inability to walk

How To Identify A Sprained Ankle

How do physiotherapists know if you’ve sprained your ankle? The Ottawa Ankle Rules help physiotherapists determine just how bad an ankle sprain is. There are 5 components to look out for (see image below).

diagram-ottawa-ankle-rulesA. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
C. Bony tenderness at the base of 5th metatarsal
D. Bony tenderness at the navicular
E. Inability to bear weight both immediately after injury and for 4 steps during initial evaluation

The Ottawa Ankle Rules are a quick and easy way to scan for potential fractures within the ankle. For examples:

  • If components A, C, and E are present, there is a chance of a fracture on the lateral side, which is outside of the ankle.
  • If B, D, and E are present, there is a chance of a medial ankle fracture.
  • If the former is present after a rolled ankle, it would be a good idea to get some imaging done and consult with an orthopaedic surgeon to discuss the following steps.
  • If none of the above causes pain and weight bearing is tolerable, then visiting a physiotherapy for rehab exercises would be ideal to optimize recovery.

Grades of Injury

If a fracture has been ruled out, the next steps for a physiotherapist would be to determine the extent of the sprain. There are 3 different grades of an ankle injury:

  • Grade 1
    • Microscopic structural damage
    • Local tenderness
    • No loss of joint stability
  • Grade 2
    • Partial rupture of ligament(s)
    • Swelling and tenderness
    • Little to no loss of joint stability
  • Grade 3
    • Full rupture of ligament(s)
    • Significant swelling
    • Loss of joint stability

In addition to the Ottawa Ankle Rules, there are other special tests the physiotherapist can perform to determine the extent of the injury. Following the initial assessment, the physiotherapist will determine the next steps of your recovery, to help manage your symptoms and to begin some exercises appropriate to the stage of healing.

You've rolled your ankle... now what?

In most scenarios, ankle sprains will follow the body’s natural course of healing. Some things that can be done to facilitate this recovery include:

1. Decrease swelling
2. Gentle pain-free range of motion
3. Banded exercises
4. Body-weight exercises – when appropriate
5. Balance and proprioception exercises
6. Improving/maintaining strength and range of motion in the adjacent areas of the foot and knee

How long does a sprained ankle take to heal?

It depends on the severity listed above, but ligament healing time is generally 6 weeks to 3 months. Gradual return to activities would be expected throughout the process. The key is to begin the recovery process as soon as possible to help strengthen and prevent recurrent ankle sprains.

Prognosis

Almost everyone will return to their daily activities, sport and recreation with little to no issues. Your physiotherapist can provide you with graded exercises to help strengthen the tissues and improve the tolerance to your activities. Occasionally, a patient may experience chronic and recurring ankle sprains. However, with the proper treatment and continuation of home exercises, the risk of chronic pain is low. A home exercise program is beneficial as it improves outcomes and prevents recurrent ankle sprains, allowing the patient to return to a normal lifestyle. The key is to start the recovery process as soon as possible.

As always, as physios, we always recommend prevention. Make sure to warm up before physical activity, and don't hesitate to reach out if you have any nagging ankle pain.


The Physio Shop specializes in evidence-based physiotherapy and massage therapy in a sweet commercial drive clinic, with a friendly barbershop feel. Plus, we do virtual sessions too, because 2020 right? If you’re dealing with nagging aches and pains, schedule a session with our finest Physiotherapists or Massage Therapists today. Or stop by and say hello to Sophie, that works too.

References
Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train. 2008 Sep-Oct;43(5):523-9. doi: 10.4085/1062-6050-43.5.523. PMID: 18833315; PMCID: PMC2547872.

Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, Kivlan BR, Carreira D. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021 Apr;51(4):CPG1-CPG80. doi: 10.2519/jospt.2021.0302. PMID: 33789434.

Athlete Performing a Stretch on a Track

A Neurological Outlook on Pain and Performance Pt 2: Breathing

A Neurological Outlook on Pain and Performance Pt 2: Breathing

In part two of  an "Neurological Outlook on Pain and Performance", Physiotherapist Ken Moy dives into the power of a breath. How does it relate to chronic pain? How can we use breathing to improve our day-to-day?

What is breathing?

As discussed in part 1, the brain’s biggest priority is to keep us alive. Breathing is the fundamental task the brain and body needs to ensure basic human function and movement. And this is both volitional (meaning manual) and automatic. Mammals (like humans) in particular display a distinct feature called the diaphragm, otherwise known as ‘the breathing muscle’.

At rest, the diaphragm performs the active component of the inspiration breath, which creates a doming effect and expands the rib cage, allowing air to rush in from the environment. (As physicians, inspiration is the process of taking air into the lungs). The diaphragm works constantly to keep us alive, which is why learning how it works will help us understand the phenomenal process in athletes and in the general population.

How is Breathing Linked to Chronic Pain?

To understand how breathing is linked to chronic pain, we first must understand the concept of compensation.

Compensation happens when there is a pain signal sent up to the brain, which can lead to muscle imbalance and movement inefficiency as the brain attempts to protect our bodies from feeling pain. Believe it or not, like all movements, the act of breathing is also subject to the effects of compensation. If you’re thinking, “does that mean it hurts the body to breathe?” The answer is yes. For example, do you experience chronic neck and shoulder tension despite consistent stretching and warm ups? If yes, keep reading below.

How Inefficient Breathing Leads to Unwanted Tension and Pain

One form of compensation that can occur in a breathing pattern is the use of accessory or other muscles to help the diaphragm. In such a case, the muscles in the neck, pecs, and upper back play a bigger role than they normally would to assist in your breathing. On average a person breathes 22,000 times per day (Notter). Over a long period of time, muscles in the neck, pecs, and upper back will develop inefficient movements and unwanted tension. With this tension, the nervous system is also more likely to “work harder” (operating at an elevated level), and will continue to feed pain signals to the brain.

One form of compensation that can occur in a breathing pattern is the use of accessory or other muscles to help the diaphragm. In such a case, the muscles in the neck, pecs, and upper back play a bigger role than they normally would to assist in your breathing.

So, what can patients and physiotherapist's do with this information?

By accessing more of the diaphragm and thus the parasympathetic nervous system, we can improve treatments, particularly for those suffering from chronic pain. Understanding and bringing awareness to this movement compensation is the first step in breaking compensation patterns and stopping pain signals to the brain.

On a more mechanical level, inefficient breathing can also impede other functions. Active expiration (think of when you are exercising) involves muscles of the abdominals and in between ribs. If there is poor engagement of the intercostal muscles, rib positions can look flared up and out, rather than “hugged” in, therefore destabilizing the trunk (Grey). In this position, the diaphragm is not fully utilized because breathing will more likely look like an elevation of the rib cage rather than an expansion of the diaphragm. This can also negatively affect stability and function of the lower limbs because the ribs are connected to the pelvis (fascial connections).

For those interested in diving deeper, The Prague School of Rehabilitation also discusses something similar called Dynamic Neuromuscular Stability, and it all starts at the diaphragm. Ultimately, we want to teach the body to stabilize centrally in the intended areas (diaphragm), rather than continuously feeding into compensatory loops caused by pain signals.

diaphragmatic-motion-breathing-diagramExercise: How to Use Breathing to Improve Chronic Pain at Home

See if you can try this exercise, a task taken from my mentor, Dr. Jeff Almon, creator of the Ground Control program for neurological reprogramming of chronic pain.

  1. Lie down on your back with knees bent. Place your hands on top of your hip bone. Cough or sniff to feel your trunk engage (Dr. Jeff Almon calls this step pressurizing the cylinder). Hold this contraction and breath through it! Think of expanding the ribs and try to feel the sensation of the breath end at your mid-back
  2. Perform for 10 minutes, progress to 20 minutes. Make sure everything else in the body is relaxed (take note of neck, shoulders, and glutes)

Challenging right? It takes time to reprogram what your body has grown accustomed to, like stabilizing via muscular compensation. It takes a great deal of focus, motivation, and mass practice – the primary teachings of this program. Check out this video to try it at home.

Summary

As you can see, breathing is truly the central aspect of the human body. Quality, purposeful breathing is the root of trunk stability and plays a big role in the nervous system. Studies have shown proper breathing to improve learning and memory (particularly with nasal breathing), alertness and reaction time (Huberman).

It’s easy for many of us to compensate for pain from daily life, poor posture, or common injuries with breathing. Even physiotherapists do it! If you have seen me for treatment in the past, you probably heard me say that inefficient breathing is the ultimate compensation. Whether you are a high-level athlete looking to optimize physiology or someone going through rehab from an injury, breathing is a fundamental aspect of human physiology. Curious? Let’s chat ☺

As always, as physios, we always recommend prevention. Make sure to warm up before physical activity, and don't hesitate to reach out if you have any nagging pain.

 


The Physio Shop specializes in evidence-based physiotherapy and massage therapy in a sweet commercial drive clinic, with a friendly barbershop feel. Plus, we do virtual sessions too, because 2020 right? If you’re dealing with nagging aches and pains, schedule a session with our finest Physiotherapists or Massage Therapists today. Or stop by and say hello to Sophie, that works too.

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