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Sprains and fractures
How do I know if my ankle sprain is NOT a fracture?
There are two critical questions after a sprain:
Can you take weight on that ankle at all? Even if you limp heavily, but can at least walk home or to your car, continue the run/tennis match, it is quite unlikely to be a fracture.
Secondly, if the pain is in quite specific regions, according to the Ottawa Ankle Rules. These rules are extremely specific and if we apply these, we are unlikely to miss a fracture.
If you want to be on the safe side, treat every sprain like a fracture until you are convinced that it is not. Treat it carefully and with respect.
Note that it is impossible to accurately diagnose a sprain in the first 3 – 4 days post injury. It is important to note how and what happened at the time of injury, rule out fractures and then proceed with the PRICE regime.
How do I care for my sprained ankle?
The PRICE regime has stood up to extensive scrutiny in the academic literature.
P – Protect – Do not do activities that aggravate the pain. If you need a crutch to walk, use one as it is better than to limp about.
R – Rest – Same as above. If running hurts, don’t do it. In other words, avoid painful actions or activities. Avoid the injuring movement/the movement that caused the sprain namely an inwards roll of the ankle with the foot pointed!
I – Ice is a good analgesic. Apply a cold bandage all around the ankle and compress for 10 minutes or so. If you need medication for pain, a paracetamol should suffice.
C – Compression – A nice tight bandage, taping or brace applied to the ankle will keep the swelling under control.
E – Elevation – Keeping your ankle and foot elevated above the level of your heart will also keep the swelling under control. In other words, lie flat with your leg up and supported on a few cushions, and make sure that your ankle does not drop into a pointed position.
So, is an ankle sprain a “big deal”?
Sprains are categorised by their degree of seriousness.
- Mild sprains – you might have a little bit of swelling. It will be sore if you run, but you can walk fine – just gingerly.
- Moderate sprains or grade II sprains are more painful as they involve partial tears to the ligaments and some bruising to the cartilage of the ankle. They are very swollen and painful to walk on.
- Grade III implies severe pain and swelling, and you will not be able to bear weight. In fact, these are the patients that require an x-ray to rule out a fracture.
After three days, it is easier to assess the specifics of the sprain more accurately. If we suspect more than just a sprain, an x-ray could be indicated. (Make sure x-rays are done while you are standing up!)
You might also be immobilised for a few days in a “moonboot” to protect the ligaments from stretching more. The secret is not just the boot as such, but to unload the ankle joints – this means using crutches (cheap and effective) and avoiding the inward pointing of the ankle movement, as well as bending it a lot (dorsi-flexion).
In the case of a moderate and serious sprain, there are often injuries to the bones, cartilage as well as the ligaments.
Patients are often told to ‘do the alphabet’ or circle their ankle to loosen the injured join. This is exactly what we do not want. We do not want to loosen the ligaments! We want them to heal!
The biggest problem with ankle sprains is that many become chronically unstable so that patients continue to sprain their ankles as they become weak and cannot tolerate unstable terrains. This is called chronic ankle instability.
How do sprains become complicated?
The way in which a sprain happened may result in complications. Examples of these causes are:
your foot was flat on the ground when you sprained it (more contact, more likely to sustain bone bruising);
you landed from jumping from a height ;
there was someone or some load on your back which caused extra force/ impact when you landed;
your foot got stuck in a hole/ditch and then got twisted both forwards and outwards.
Ankle sprains are often worse in high intensity court sports (netball or indoor soccer) where there are sudden stops and starts, jamming the bones together. Adolescents and young athletes are often very mobile, and the resistance and stability of the ligaments are not optimal yet.
How does a physiotherapist treat sprains?
Lace-up braces are helpful in preventing further damage when you have had a sprain, but rehabilitation is the ultimate key to improving your future capacity and preventing another sprain. Without rehab, your chances of another sprain are almost 100%!
In South Africa, physiotherapists are first line practitioners. You may consult a physiotherapist to treat your ankle sprain without a medical doctor’s referral. If necessary, your physiotherapist may also refer you for basic x-rays if indicated.
Surgery and rehab
Expected outcomes after surgery
The ankle is an incredible feat of engineering, where little bones (lots of them) with loads of ligaments have to carry our bodyweight and more, but still move rapidly in a three-dimensional way.
What makes outcomes unpredictable is that no injury is the same, because no person has the same size feet, arches, and strength of muscles in their ankles and feet.
It is safe to say that we consider a successful outcome of surgery as follows: no pain with walking, and pain-free range in your ankle to be able to walk on even terrain.
When we refer to range, we mean the ability to stand with your toes against the wall and touch the wall with that knee. That is enough range for comfortable walking. Pointing your ankle and foot, or turning it in and out, is often not regained and might remain stiff. This is an attempt to protect the weightbearing cartilage in the ankle joint. Here, we can use orthotics, braces, and customised shoes to assist.
Swelling of the ankle and foot may last as long as a year but does eventually settle. It is quite normal for the ankle and foot complex to be swollen and tired at the end of a day of standing or walking. It should recover overnight to its usual size. If your swelling is associated with a lot of pain in the joint and the joint loses range or feels hot, there might be something else going on. Rest up for at least three days from loading the joint. If there is not a significant improvement, contact your physiotherapist.
Of course, the aim is that you should be able to return to your normal daily activities. Again, it does take at least a year of slowly increasing your load. Many patients agree that this is the hardest part of their recovery – to be patient!
In cases of major trauma where the cartilage in the ankle is damaged, impact activities are discouraged. This does not mean never, but you will have to train smarter (less load) and focus on activities where there is less time on the feet, less impact (like jumping) to preserve your ankle cartilage and slow the onset of arthritis.
For example, if you cannot run, try walking or hiking (just not on technical terrain).
If walking is painful, try walking with trekking poles to unload or try two shorter walks a day (with a long rest in between), or vary impact days with days of no load, with activities like Pilates, swimming or gentle cycling.
If you like golf, save the load on your ankle by renting a cart of get a caddy (or both).
Good shoes are necessary! Contact your physiotherapist for advice on how to get the best out of your footwear.
Often, ongoing pain is caused by maladaptive compensatory actions. This can be ironed out and corrected by an observant physiotherapist, podiatrist or biokineticist. I recommend filming your walking to show you what could be happening. Specialised running shops also offer this service.
What to expect from your rehab sessions
Good rehabilitation is a collaborative effort. If you do not “buy in” or understand the importance of certain exercises and thus are non-compliant, the outcomes of the surgery can be affected. This can also be the case if you do not listen to your body. Pain is your friendly protectometer. At the same time, expect to experience some discomfort while you recover (but not pain).
I divide the rehab in two stages (at physiotherapy). There are four to five stages overall, the final being the return to sport.
Stage 1 can be anything from 10 days to 10 weeks. This is the time where you are not allowed to take full weight on the ankle foot complex. You will be using crutches with a boot or a brace during this phase. The surgery and the surgeon, and your perception of pain will determine how soon you progress through this phase. Listen to your body and report pain to your therapist. If it hurts the exercise might be too heavy or you might not get it quite right. This stage should be relatively pain-free. I call it the foundations phase, where we retrain and learn to do things well.
Most important is to walk well.
Before you may progress to stage 2, the functional stage, you should be able to walk full weight bearing, with minimal pain and limping and have good range.
Stage 2 is the functional stage. We now increase the load from two feet to eventually one-legged activity. The repetitions will be increased as well as the complexity of your exercises. This is aimed at improving all brain activity, your ankle and body’s sixth sense – proprioception.
During this stage it’s important to make sure that your footwear is correct – that is offers enough support and cushioning. Discuss this with your physiotherapist. There is a trendy belief that walking on the beach will strengthen your foot and ankle – this is sadly not so. Just like leaning to drive a car, actions must be learnt – the brain and the feet have to connect cognitively.
It is also important to engage in a cardiovascular activity to get the endorphins going. We have learnt that being unfit and overweight is a risk factor to re-injury when you return to sport.
Patients say that they are more compliant when their rehab is customised to their individualised requirements. We set a realistic timeline together with small achievable goals. If a goal is achieved, we celebrate it! There is no such thing as a recipe.
The 6 most frequently asked questions by patients after surgery
When should I go to physio after surgery?
It is important to go to physiotherapy after your surgery. Make your appointments as you book your surgery to make sure you can start when you need to. I have a waiting list of about 6 weeks.
If you have not been advised to go for physiotherapy, ask your surgeon. You would usually start 2 – 6 weeks post- surgery, depending on the type of surgery. I do not recommend that you start sooner than 2 weeks as I prefer the scars and inflammatory process to have settled. There are always exceptions and in some cases the surgeon will request that we start sooner. I see my clients once per week for an hour.
Any tips for using crutches?
Make sure your crutches have good rubber bottoms that will not slip.
You may require gloves for your hands – cycling gloves seem to help.
Knee scooters are recommended. This does not mean that you should not practice your walking, but it makes life so much easier! Especially if you live on your own, want to go out and do shopping after your 2 weeks at home. It is a game changer.
Is there anything I can do to make sleeping more comfortable?
Patients often complain that their pain gets worse when trying to rest or sleep. They just cannot get comfortable. It is important to keep the foot and ankle elevated as you want to minimise swelling. A swollen limb makes it difficult for the scar to heal properly. Your leg swells as you are not able to engage your calf muscles (your second heart) to pump the blood from your foot to your heart.
Here are a few tips:
- Trying to get comfortable will require a LOT of pillows. Feather is ideal as it stays in place and doesn’t make you feel hot. You can rearrange them to keep pressure off the heel. Keep your knee slightly bent to avoid stretching the sciatic nerve. This is important if you have lower back issues.
- You can turn onto your side for short periods. Again, use the pillows to keep the ankle/foot slightly higher than the rest of your body.
- Use only light blankets and duvets to avoid pulling onto your foot and the boot. In fact, it helps to keep the foot part of the boot open.
- If you rent a gutter cushion, they are useful. Line it with cotton and use a small pillow under the knee.
- You can also loosen the boot a bit – especially the front bit. It must stay in the gutter though, to avoid the ankle twisting sideways and down. The idea behind keeping it “open” is to see your foot and move your toes with ease. If you are not sure of this, please as your physiotherapist.
- If your surgeon has prescribed sleeping tablets, rather take them and sleep than not get a good night’s rest. The body needs sleep to recover.
- Your lower leg should be less swollen in the morning when waking. If not, you might consider a type of compression garment. Discuss this with your surgeon and physiotherapist. Depending on the severity of your swelling, you will be advised as to exactly what type of stocking you need.
How do I shower or bath?
I do not have a preference for patients to bath or shower, but showers are often easier!
- Take your time to plan your bathroom excursion and get everything together in a plastic basket.
- Think and plan how you are going to get in and out of the shower or bath.
- Make sure someone is nearby and do not lock the bathroom door.
- It is important that the chair you use will not slip, and that the area you move in does not have slippery bath mats or something you can trip or slip on. Patients recommend the scooter in the bathroom, but cover the seat with a towel, so you don’t slip on the wet surface.
- There are special shower socks available which you can purchase. Patients have simply found that keeping the foot out of the shower / bath is ok. Or cover with a black bag and tape to seal the top.
- You’ll need two chairs: one in the shower, and one just outside to sit on while drying and dressing. The outside chair must be sturdy with non-slip rubbers on the feet.
- Use a shower chair to sit on. You can even rent them. There are several models. Make sure it fits in your shower. Put a non-slip cover on and under it to be safe.
- A hand shower is great but make sure you keep the “head” facing downwards.
- Watch the floor for splashes and dry first before getting on your scooter and out the shower. The other foot is useful for this mopping up.
- Sometimes you just want to lie in a bath. This is fine, if you can get in and out without taking all your weight on the operated foot.
- Rest the operated leg on the side of the bath.
- A hand shower is good but keep the head of the shower down.
- Do not make the water too hot as it could make the operated leg ache.
- Empty the bath first before getting out. Then dry your body and hands in the bath before trying to get onto your chair, next to the bath.
Any tips for driving?
My patients all say that choice of driver is key. You don’t want someone who makes sudden stops!
A larger car, which is high off the ground, is easier to get in and out of – SUV-style. You need space to fit your crutches and the scooter. Make sure you and your driver know how to fold the scooter closed and open and lock it in position. Keep your crutches close to you/ next to you as hopping next to a car is often dangerous.
“Uber assist” can be booked and the drivers are usually keen to assist with the scooter too.
Patients prefer to sit in the front as there is more leg room. Otherwise sliding in and out with your bottom first into the back, is a good option. Hold on to the top of the car roof to assist you up and down, rather than the door that is not secure. This process takes time – do not park in a quick drop-off place. The last thing you want to do is to rush and feel stressed as you are holding up the traffic.
Driving for the first time:
Cabin fever will make you crazy and you will probably want to drive your car sooner than allowed. Please wait for the go-ahead from your surgeon. You must be able to brake (without your boot) before you can consider driving!
Renting an automatic is a good option if you do not have one.
Ask someone to take you to a nice open road. Do not start driving in your driveway! Get behind the steering wheel and make sure you know where everything is. It helps to put the seat back a little as you do not have to bend your ankle as much then. Your ankle often is so stiff in the early days.
Another tip is to tilt the back rest slightly back as your tight leg muscles will not be so stretched. This is also easier for the getting in and out part. Put your crutches on the passenger seat, and scooter on the back seat, where it is accessible (it’s too much effort to hop to the boot of your car).
Then drive home slowly and expect to be exhausted. Next time – try going to the shops or friends.
What are the best rehab tips?
I therefore take time to explain the uniqueness of your surgery and the individualised exercise regime. At your physiotherapist, we are retraining the basics and the focus will be on quality rather than quantity.
Other useful tips in your rehabilitation:
Focus on your achievements, not the failures. As the road is long, make the goals small and achievable.
Make sure you are able to walk comfortably as instructed. The boot stops excessive movement, the crutches unload the joint. If you need bones to heal, it requires some unloading in the initial stages. Every surgery is different. We are dealing with a complex structure that has small bones yet must manage heavy loads. It takes TIME! YOur physio can help you understand the surgeons instructions.
I usually give my patients no more than three exercises. Minimum equipment and maximum benefit are my motto. It should be fun, functional, and NOT painful to do (literally and figuratively).
If you belong to a gym, that can be especially useful. There’s lot of equipment you may use while sitting down. Of course, there are other options like mat classes where you do not stand up. I recommend that your physiotherapist liaises with the biokineticist at the gym who supervises your exercise regime. I encourage the biokineticists to focus on the rest of the body conditioning – not just the injured leg.
If you do not know of someone, please ask your physiotherapist to recommend a biokineticist who knows the post-surgery recovery drill. It is critical that we work together as a team to ensure your return to health.
Swimming and or aqua classes:
The wound must be completely healed before you even contemplate getting into a pool!
Negotiating a pool deck is “dangerous” on crutches. And getting in and out can also be precarious.
There are physios with a special interest in aqua rehabilitation. They have the skill set as well as the equipment you might need to get in and out of the pool.