Introduction Ankle Injuries are the most common injuries in sport or exercise. Ankle injuries can also occur when you are not involved in a particular sporting event. Such injuries are related closely to sports that require running, jumping and change of direction. A sprain most likely occurs when a foot that is on an uneven surface rolls in, or moves in an inward position. What is an Ankle Sprain? Ankle sprain is an injury that occurs from a twisting action, where the ligaments in the ankle stretch or tear. There are many small bones, ligaments, tendons and muscles that make up the ankle joint. This means there is more opportunity for injury to occur. You may ask what all these ligaments, tendons etc. do. Ligaments attach bone to bone and tendons attach muscle to bone. Muscles allow bones and joints to move. A sprain means that a ligament is injured and a strain means a muscle or tendon is injured. Many ankle injuries affect one or more of the ligaments that hold the ankle joint in place. A serious injury can lead to damage of the tendons that attach the muscles to the bones. Ligaments in the ankle joint keep it in place and provide stability. The lateral (on the outside) ligaments are most commonly affected in an ankle sprain. More specifically, the three major ligaments that help to stop the ankle from rolling forward and outward are the anterior talofibular, posterior talofibular and calcaneofibular ligaments. 3 Degrees of Sprains First degree: the least severe, minor ligament stretching with mild pain, swelling and joint stiffness. There will be slight loss in joint stability. Second degree: some ligaments will stretch and tear. There is increased swelling and pain there will be a moderate loss of stability of the ankle joint. Third degree: this is the most severe type of ankle sprain, there is a complete tear or rupture of one or more ligaments in the ankle joint. There will be massive swelling, severe pain and gross instability. In a severe injury most of the localized pain will go away because nerve endings may be severed, this might lead to a lack of sensation at the injury site. Bruising might result because of the ruptured blood vessels. Causes and Risk Factors There are many causes and risk factors to ankle sprains, but the most common cause is a lack of conditioning. If the structures (i.e. muscles, tendons and ligaments) around the ankle joint have not been properly trained, there will be weakness and that will lead to an ankle sprain. A conditioning program should balance out strength and flexibility differences. Another major cause of problems is not stretching and warming up. A study was conducted in the British Journal of Sports Medicine on basketball players and it was concluded that players who did not stretch during the warm up were 2.7 times more likely to injure their ankle than players who stretched. Kabaddi specific causes of ankle sprains include a lack of footwear and running and playing on uneven grounds at times. Obviously, the most common risk factor of an ankle sprain is a previous history of ankle sprains. Meaning that if you have had an ankle injury in the past, you are highly susceptible to suffer another injury if you do not seriously rehabilitate the area with conditioning and strengthening and take preventative measures. How to Prevent Ankle Sprains: 1. Proper Warm-up This prepares the body for activity. If performed well your heart, lungs, muscles, joints and mind are ready to play. 2. Plyometric Training this includes jumping, skipping, bounding, and hopping type activities. These explosive types of exercises help to condition and prepare the muscles, tendons and ligaments at the ankle joint. 3. Balancing Exercises Any activity that challenges your ability to balance, and keep your balance, will help with proprioception: meaning the position sense of various parts of the body relative to each other. 4. Stretch and Strengthen (I will have a separate article on this topic). 5. Footwear this is very important to have since it helps to keep your ankle stable and protects your foot and lower leg during running and walking. However in Kabaddi, since an athlete does not wear any shoes a lack thereof could lead to increased problems in the ankle joint. 6. Strapping or taping these two methods can provide extra support and stability to weak or injured ankles, particularly for a Kabaddi player. The MOST IMPORTANT initial management of a sprain is; The RICE regime, will lead to faster and proper healing afterwards. RICE meaning, (R) rest, (I) ice, (C) compression, (E) elevation. This method decreases recovery time, and could possibly lay the foundation to lead to a full recovery. Shortly after an injury there could be bleeding and swelling, the swelling will increase pressure on the nerves which will increase the pain sensation. Rest – Initially try not to move the ankle, this is done to prevent further injury to the area. Ice its application is very important as it will decrease the swelling, pain and bleeding to the area. Try to apply ice as soon as possible right after the injury. Ideally you should use crushed ice in a plastic bag. Do not apply ice directly to the skin as it can burn your skin and cause damage. Usually a paper towel or towel between the ice and skin will suffice. Try not to use frozen vegetables as they will get soggy after a while and will not be useful for you or the cook of the house. (Best to leave them for the ahlu gobi subji). You can make a home made gel pack by adding some alcohol to water in a zip-lock bag, and putting it in another zip-lock bag. Once you have done this freeze the zip-lock bag and you will find that the water freezes and the alcohol will form the “gel” part. Ideally, for the first 72 hours apply ice for 15-20 minutes every 2 hours. This will change for children, elderly and those sensitive to cold and with circulatory problems. Compression this will reduce the swelling around the injured area and provide support. Out on the field I usually use a wide compression bandage or pro-wrap to achieve compression. At home wrap a wide compression bandage around the ankle start by the foot and work your way up the ankle, this will create compression toward the heart and remove blood and swelling in the area. Elevation will allow gravity to remove the blood and swelling away from the injured ankle toward the heart. This can be achieved by raising the ankle to a position where it is comfortably above the heart. What to avoid in the first 72 hours; hot showers heat rubs (methylsalicylate counter-irritants such as "Ben Gay") hot packs drinking alcohol Aspirin - prolongs the clotting time of blood and may cause more bleeding into the ankle. (Tylenol or Ibuprofen may be taken to help with pain, but will not speed up the healing process). Consult with your Medical Doctor before taking any medications. When is it appropriate for a referral to a doctor? If there is an obvious fracture or dislocation then the athlete should be transported to the medical facilities right away. If you believe it is sprained, start with the RICE method and you can determine for sure if the injury is more severe by getting an x- ray of the ankle. At this time the health care practitioner should be able to give you instructions on rehabilitation methods of the injury. What happens after the injury occurs? After the initial stage of injury the tissue tries to repair itself by laying down scar tissue which is protein fibers that bind torn or ruptured ligaments together. Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged ligaments in an effort to draw the damaged fibers back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. Some times it may be possible to feel this bulky mass under the skin. When scar tissue forms around an injury site, it is never as strong as the ligaments it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue decreased, but the tissue will not be as flexible. How to avoid the formation of scar tissue? Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity. Don't listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Light activity promotes blood circulation, but it will also activate the lymphatic system. The lymphatic system is important in cleaning out the toxins and waste products in the body which may be present in the injured area. Physical activity is the only way to allow the lymphatic system to start working. Take your time to return to full weight bearing activities. If you are performing an activity that leads to more pain in the injured area, STOP! Always use your best judgment and your body will tell you its limitations. Treatment To remove scar tissue, physiotherapists will try to increase blood flow to the area in order to replenish nutrients and oxygen to the area, and the methods used include ultrasound and heat. TENS (Transcutaneous Electrical Nerve Stimulation) uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues. Ultrasound is also effective in heating the area to break down the scar tissue formation. Also myofasical release therapy or ART is specific in that it will help to successfully breakdown scar tissue. Rehabilitation Most of the pain will go away in a few weeks however it is important to continue rehabilitation exercises for a few months. The more severe the injury is the longer it will take to heal. For each exercise, perform two sets of 10-15 repetitions two to three times a day. Each athlete will progress through the exercises at different rates. For some it will take seven days to get through the three groups. For others it will take almost two months. If any of the following exercises increase pain discontinue. If there is no improvement after about a week of doing these exercises it is recommended that you see your physician for concentrated physical therapy rehabilitation. GROUP 1 EXERCISES EXERCISE 1. The 'alphabets.' While seated with the edge of the heel on the floor, patients draw the entire alphabet one letter at a time by moving the injured ankle and using the great toe as the 'pen.' FIGURE 1. FIGURE 2. FIGURE 3. Windshield Seated calf Single-leg wiper. Sit raise. Sit stand (partial with the foot with the weight- flat on the injured foot bearing). floor and flat on the Stand while facing placing one floor. Lift straight hand on a the heel as ahead. Rotate table. Shift far as the affected some of the foot to mimic possible weight to the a windshield while injured foot wiper blade: keeping the for 15 Pivot the foot toes on the floor, then return seconds. outward and the heel to the floor. Increase the touch the inside edge of the foot time spent on the injured foot by to the floor (A), then rotate it 15 seconds until you can stand for inward and touch the outside of 45 seconds. Then gradually the foot to the floor (B). increase the amount of weight supported by the injured foot until full body weight is used. FIGURE 4. Eversion FIGURE 5. Exercise and inversion band eversion and isometrics. Eversion inversion. Eversion: Sit (A): Stand and place with the involved leg the outside of the straight. Tie a loop in an injured foot against elastic exercise band a table leg or door and attach the other jamb. Push outward end to a heavy object with the foot for 2 to such as a table leg. 3 seconds. Inversion Place the loop around (B): Stand with the the ball of the foot (A). inside of the foot Rotate (evert) the foot against the table leg away from the table leg or door jamb and and return it to the push inward for 2 to starting position (1 3 seconds. repetition). Do not rotate the leg to do the exercise. Inversion (B): Reverse the position of the exercise band and rotate (invert) the foot inward, away from the table leg. Once patients can do group 1 exercises, they can progress to group 2. GROUP 2 EXERCISES FIGURE 6. FIGURE 7. Gastrocnemius stretch. Soleus stretch. Place the injured foot Stand with the behind the uninjured injured foot in foot and keep the back front of the other knee straight, with the foot. Bend the heel firmly planted on knee of the back the floor. Lean forward foot and lower against a wall so that your body toward you feel a stretch in the the floor without calf farthest from the letting the back wall. Hold for 30 heel rise off the seconds. floor. You should feel the stretch in the lower calf of the back leg. FIGURE 8. Fullweight-bearing single- FIGURE 9. Single-leg leg stand and standing calf raise. stand with a towel. Roll a Stand with the injured foot on the towel into a strip 4 floor and the other leg bent at the inches wide, 1 to 2 knee and off the floor (as shown for inches high, and 12 to the standing calf raise). Maintain full 18 inches long. Stand weight on injured leg for 30 seconds. with the injured ankle on Standing calf raise. Raise up on the the towel as for the ball of the injured foot then return the single-leg stand (figure heel to the floor. Weight is supported 3). Hold for 30 seconds. only on the injured side. GROUP 3 EXERCISES FIGURE 10. Lateral step and lateral bound. Step: Place a rolled towel on the ground and stand with both feet to one side of the towel (A). Step over the towel with the injured ankle (B), and remain on one foot (C). Reverse the process and step over the towel in the opposite direction. Increase speed as pain will allow. Bound: The starting position is the same as for the step. With both feet on one side of the towel, hop over the towel and land on the right foot. Then, hop back over the towel and land on the left foot. Gradually increase speed and height of bound as comfort allows. Dr. Tarveen Ahluwalia is a Chiropractor practicing in the Bay Area of California. To contact her for further questions email email@example.com. July 2005. Acknowledgements: Sandor, R. & Brone, S. Rehabilititating Ankle Sprains. The Physician and Sports Medicine. Vol. 30(8). Aug. 2002. www.physsportsmed.com/issues/2002/08_02/sandor.htm Sports Med Web; www.rice.edu/~jenky/sports/ankle.sprain.html. 2005. The Stretching & Sports Injury Newsletter; http://www.thestretchinghandbook.com/newsletter.htm. 2005.