Ankle Sprains - DOC

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					                                                         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
drtarveen@gmail.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.

				
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