Let me paint a picture for you.
Event: A yelp as a player jumps for the rebound and lands, rolling their foot inwards on the basketball court.
Response: someone yells “TIME”. The player gets help limping off the court, the limb gets elevated with ice applied. Lots of faff and a few ibuprofens later, he’s at home trying to get to sleep with a pounding ankle.
Day 2: the player hobbles along putting as little weight through the leg as possible as well as keeping the foot immobilised. They hang on to the one thing (besides from 30:2) they remember from their first aid training: R.I.C.E (rest, ice, compression and elevation). They plan to give it a few days to see if it recovers by itself, and if it doesn’t, then they’ll go get it checked out.
Day 10: It finally feels relatively comfortable walking again. Still hobbling somewhat, but pretty sure it’ll pass.
Day 20: Yup, can somewhat jump and jog on the spot – let’s strap the sh*t out of this ankle and smash these guys!! Yew!
What happens next? Refer to the text at the beginning of this page starting at ‘Event’ and go from there. Why? Because the risk of this series of events occurring again based on how it was managed is extremely high.
This happens way too often – and not just at sporting events. You can tell just by how many people claim to have “weak ankles”. THIS DOESN’T HAVE TO BE A THING!
Let’s start at the beginning.
Firstly, R.I.C.E guidelines are three generations old and we are now meant to adopt the all-embracing ‘PEACE & LOVE’ guidelines that sound much more holistic than a sack of grain. Wouldn’t you say?
I know… I sighed when I heard a new acronym was in the works, but this is a good one that emphasises messages that need to be emphasised and eliminates unnecessary, or even detrimental, actions that are commonly carried out with soft-tissue injuries. We’ll keep the basketball injury event as the example throughout because of this “weak ankle” pandemic sweeping the world.
As with any injury, protect the area first to ensure that you don’t stress it more, potentially making it worse (1). At the time of injury it’s going to hurt, but the experience of pain is subjective and hard to objectively measure, and, even if you could measure it, that doesn’t represent just how serious or not serious the injury is. So limp off the court so that the extent of damage can be assessed and appropriate steps (excuse the pun) taken from there.
Above heart height is the rule of thumb to go with. Why? Although strong supporting evidence is limited, the idea is that it’ll help prevent interstitial fluid flowing into the tissue – i.e. it’ll help prevent the ankle swelling up like a balloon (1). This is often the limiting factor when it comes to movement in the ankle, and unless you’ve seriously damaged something you will want to regain range of motion as quickly as possible to get the best outcome.
Yup, you heard me. No NSAIDs (Non-steroidal anti inflammatories) such as Ibuprofen (Nurofen) or Aspirin for pain relief as their anti-inflammatory properties can be detrimental to future tissue healing (2). If you have to take something, take paracetamol… or a tablespoon of cement 🙂
This is another element to first aid that has persisted over the years. Similar to elevation, external mechanical pressure has been shown to help with swelling in the joint, and therefore optimise the benefit of rehab. (3).
As a physio, education is one of the most important parts of any treatment. The main message to bring across at this stage is that active rehab is the way to go (1,4). Passive modalities such as TENS, massage, and dry needling are all forms of symptom modification that are only temporary and could in fact be detrimental to outcomes in the long-term. If the physio you go to doesn’t educate you on what’s going on, what the management plan, and they spend more than 25% of the consult performing manual therapy – run far away and in the direction of 1/184 Parry Street.
After the above has all been carried out, fretting stakeholders can finally relax (I’m fine, mum, you can breathe again) and we can move onto the romantic phase of your ankle rehab.
As previously mentioned, ensure your rehab program has an active approach, but is done in such a way that the activity you do is appropriate to the injury you have sustained. Progressive overload ensures that you are challenging what you can do, but aren’t putting too much stress through the structures so as to cause harm. This is where a good physio can help guide you along.
Yes, you’ve hurt yourself. Yes it hurts, and that sucks. But barriers to recovery can often be linked to your psychology and perspective on the situation. Catastrophization of the pain experience has been associated with sub-optimal outcomes (5). It is important to remain realistic about the expectations of the rehab process, but doing it with a smile helps things along more than you think!
Staying active with the injury is not only beneficial for vascularisation, (increasing blood flow to the area) but also helps with the previous point we addressed – optimism and motivation. You’re body doesn’t fall apart and stop working just because you’ve injured your ankle. Performing aerobic activity of some sort (evidence to identify the amount is yet to come) and mobilising the ankle early has countless benefits (4).
The most important one if you don’t want the debilitating ‘weak ankles’ condition persisting throughout all activities for the rest of your life.
Management of soft-tissue injuries doesn’t stop when you’re pain-free and able to walk. At least, they definitely shouldn’t. Your rehab program should revolve around progressive overload to ensure you return to your goal activity at 120%. Reaching ‘baseline’ isn’t sufficient because although there was an element of bad luck involved when it initially happened, you want a certain level of “insurance” to reduce the risk of the injury recurring.
So although my example was an ankle sprain, ‘PEACE & LOVE’ is applicable to any soft-tissue injury. Finding the right balance between protection and loading is what most people struggle with. Too often we see hamstring tears that re-bleed because the person couldn’t sit still on the sidelines at their footy game, or ankles with very limited movement because they’ve wanted to protect it for too long. So be smart about it – which includes reaching out for help if you’re unsure.
Alright. PEACE and LOVE guys. That’s always the way to go.
- Bleakley CM, Glasgow PD, Phillips N, et al. Guidelines on the management of acute soft tissue injury using protection rest ice compression and elevation. London: ACPSM, 2011
- Duchesne E, Dufresne SS, Dumont NA. Impact of inflammation and anti-inflammatory modalities on skeletal muscle healing: From fundamental research to the clinic. Phys Ther Sport 2017;97: 807-17.
- Hansrani V, Khanbhai M, Bhandari S, et al. The role of compression in the management of soft tissue ankle injuries: A systematic review. Eur J Orthop Surg Traumatol 2015;25: 987-95.
- Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: Randomised controlled trial. BMJ 2010;340: c1964.
- Briet JP, Houwert RM, Hageman MGJS, et al. Factors associated with pain intensity and physical limitations after lateral ankle sprains. Injury2016;47: 2565-9.