Seema had gone for a grand European tour, 7 countries in 10 days. Lots of sightseeing, lots of walking. Unfortunately, she twisted her ankle while coming out of a party just 2 days before. She had worn high heels. She had a lot of swelling. She got scared that her trip would be on jeopardy. She went to the doctor the next day. The doctor prescribed her strong pain killers, asked her to rest and gave her crepe bandage. In two days she was quite better. She went to her trip, she wore sports shoes. She limped but she completed her trip. She came back, slowly she was ok. She thought the ankle sprain has healed. However, she could not walk fast, she could not wear heels and she frequently felt unstable. So now the doctors sent her to an Orthopedic surgeon, who gave her a cast. She was immobilised in a cast for 6 weeks. Once she came out of the cast, she was given some exercises, gradually things became alright. However, she could never feel the same strength in ankle again.
The story of Seema is routine occurrence. 9 out of 10 ankle sprains are treated this way - Rest, elevation, cast or cast boot and medications.
However, lot of patients never feel normal in their activities. Some develop instabilities. Some people adjust to it, others suffer in silence.
So How should any ankle sprain be treated?
First, let us learn what is an ankle sprain:
The ankle joint is held in place by ligaments on outer and inner side. On inner side there is a very strong deltoid ligament. It is broad and tough and hence chances of it tearing are less.On the outer side, there are there are narrow, thin ligaments which insert from narrow fibula bone to talus and calcaneus. Due to forces acting while walking and narrow and thin ligaments, they are under higher loads and more likely to fail. Hence, ligament tear of ankle in more common on outer aspect.
Why is ankle ligament tear so disabling:
Due to tear of the ligament, the ankle loses the sense of balance and steadiness. This results in patient trying to walk abnormally by taking excessive weight on the heel in order to keep the balance. This results in excessive strain on heel, ankle and knee joint. When this continues for a long period of time, it results in significant disability in walking, climbing or any other activities.
What are the misconceptions in treatment:
First and the foremost misconception is that ankle ligament tear needs immobilisation by cast or splint. The biggest disadvantage of immobilisation is that it weakens the muscles around the ankle and stiffens the ankle joint. This delays the recovery significantly.
What is the first step to be taken once you get ankle sprain:
The first thing you must do when you get ankle injury is
- Get an x ray done to see if you have fracture
- Elevate your leg, apply Ice, take anti-Inflammatory medicines as per advised by your doctor.
Once the swelling and pain subsides, we should start the important part of treatment, which is Rehabilitation of the affected ankle joint.
The Important parts of Rehabilitation of ankle injury:
1. Avoid re-injury: Avoid walking on uneven surfaces, avoid sudden changes in directions like in playing, running etc. Wear Protective footwear- floaters or sports shoes.
2. Braces: There are number of braces available in market, from small straps to huge immobiliser braces. Initially ankle strap may have a role to prevent the ankle from twisting, but long term use of any brace is not recommended.
3. Proper Exercise Program: Exercises are the cornerstone of treatment of ankle injury.
There are 4 parts of ankle rehabilitation:
a. To strengthen outer muscles of ankle: Evertors, to compensate for the loss of ligament on that side.
b. To strengthen foot intrinsic muscles, so as to get proper grip and balance while walking.
c. Gait training: so as to walk with a proper stance to avoid excessive strain on ankle joint.
d. Balance training: To improve patient’s proprioception. This is the most important part as it helps gain the feeling of stability back. This is the part which lets the patient get back to previous activity levels.
Role of Surgery: Most of the patients can do well by following this protocol. However, there are some patients who have severe ligament injury. This leads to mechanical instability. This needs surgery, especially if the patient is very high demand like sports personnel.