By Dr. Beau Beard
It always strikes when you least expect it. You're cruising down your favorite trail enjoying the joy and solitude of that sought after single track when all of a sudden, WHAM!
That sickening feeling as you feel the pop and the immediate warm rush of pain move through your ankle. An inversion sprain is to a trail runner as garlic is to a vampire. If you accumulate any amount of trail time, you are more than likely going to deal with an ankle injury at some point. So the question becomes what are the most up to date ideas and methods to speed recovery and prevent future injury.
According to the Ottawa Ankle Rules, which are established guidelines determine if you need an x-ray or MRI, a good rule of thumb is if you can’t bear weight or walk (even with a limp) within 12-24 hours you should probably seek a medical consult and possible imaging.
The most significant predictor of future injury is prior injury, so what you do with your ankle injury in the first 4-5 days can set the stage for long-term success, or it could drag your recovery out setting you up for future injury.
It used to be common practice to immobilize an ankle sprain via an air cast, brace or boot, but research shows that early mobilization leads to improved long-term outcomes. While we don't want to overdo it in the first 48-72 hours, it is best to perform open chain exercises such as high-intensity ankle circles, drawing your ABC's and isometric holds.
Also using a towel or band to create resistance you can perform isometric holds in all directions of the ankle, holding each position for 45 seconds, research. Being barefoot as much as possible during this period also helps stimulate the thousands of free nerve endings in the bottoms of your feet. This can speed recovery and ward off issues with ankle instability later.
Gabe Mirkin, MD coined the term RICE (Rest Ice Compression Elevation) in the late 70's, and this was the gold standard for any soft tissue injury for the ensuing 40 years or so. However, Dr. Mirkin changed his tune in light of new research and now agrees that movement is the key to improved tissue healing and swelling control. It is true that after 72 hours we want to reduce swelling as much as possible, but in the first 48 hours, swelling is our friend! This natural process is bringing all of the inflammatory agents needed to repair tissue. After 2-3 days if swelling persists a compression ankle sleeve can aid in swelling reduction along with light movement.
Early phase movement is also crucial to quickly regain joint awareness or propioception. A reduction in feedback from an ankle post sprain is thought to lead to repeated ankle sprains and possible chronic ankle instability.
Sub Acute Care
As the injury progresses we want to start loading the ankle with body weight and performing movements with the ankle in a stable position, while at the same time creating motion through the knee and the hip. This again plays a significant role in creating a clearer picture of the injured area in the motor cortex of your brain. The following are some great examples of closed chain movements to implement in the early stage of ankle rehab.
Cycling and rowing are great exercises to implement during this phase as it keeps your aerobic capacity up while creating some semblance of stability for your ankle during the exercise.
After 2-3 weeks it is safe to start creating some ballistic load on the ankle, it goes without saying, let pain be your guide. I like the stoplight system, pain of 0-2 out of 10 is a green light, proceed. Pain of 2-6 out of 10 is a yellow light, modify what you are doing and proceed with caution, pain of 7 or higher and you need more time in the sub-acute phase of rehab. Some ideas for ballistic loading that do not involve running include jump rope, water jogging and possible light running, barefoot would be the ideal choice at this point if possible.
Even though soft tissue, such as ligament, muscle, and tendon, takes anywhere from 4-8 weeks to heal fully. That does not mean that we have to stay away from running until that full-time frame is up. Of course, always consult with your local medical professional to help determine when you're ready to return to running.
As much as we may be jonesing to hit the trail, it's not always the best idea to jump right back into running if there is still significant pain present. When pain repeatedly occurs while running or performing any movement, we will inevitably compensate or change our movement, and this opens up Pandora's box for alterations in our running gait...and ain't nobody got time for that.
Back to Running
When you start to hit the trail again there will inevitably be some stiffness and some kinks that need to be worked out, be sure to warm-up adequately and take your ankle through some mobility drills such as this;
Triplanar Ankle Mobilization (Will provide pictures, descriptions or videos whatever works best)
The same compression brace that can be used for moderating swelling can also be used to create some stability and improved feedback, much like kinesiology tape as we get back into running.
Break your first few runs up into intervals so instead of crushing all the miles the first time out, force yourself to stop every mile and do some simple drills to keep the ankle feeling good, your ankle will thank you.
Trail runners may never be able to avoid ankle sprains completely, but the best way to bulletproof your ankles is to put in the work before you hit the trail.
Dr. Beau Beard is an avid trail runner, sports chiropractor, photographer, and amateur conservationist. He lives in Birmingham, AL, with his wife, the other Dr. Beard, and he calls the trails at Oak Mountain State Park his second home.
The American Journal of Sports Medicine, January, 2004;32(1):251-261
Journal of American Academy of Orthopedic Surgeons, Vol 7, No 5, 1999