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CHAPTER 13:
The Ankle

The ankle's unique structure allows you to move your foot in many directions. The foot's up-and-down movement enables you to walk by first striking the ground with the heel and then pushing off from your toes. Without this movement, you would be able to walk only with your foot flat on the floor.

      The other important ankle movements are rolling the foot to the inside and to the outside. This allows you to adjust your foot to uneven surfaces so that you can walk on the side of a hill or step on a pebble and not fall.

      And there's the rub. When the foot rolls to the outside on an uneven surface, it may continue to roll over until it has stretched and sprained the not-so-strong ligaments on the outside of the ankle. The presence of small holes in playing fields leads to many sprains. Even on a flat surface such as a basketball court, a player can always step on someone else's foot and turn the ankle over. Ankle sprains account for as much as one-fifth of the injuries seen at sports medicine clinics.

      In the ankle, three bones form what is called a "mortise" joint. The dome of the ankle bone (talus) sits in a squared-off socket formed by the two bones of the lower leg (tibia and fibula). The joint is held together by three moderately strong ligaments on the outside of the ankle and one very large, very strong ligament on the inside.

ANKLE SPRAINS

All the years I was with the New York and New Jersey Nets, we kept a small garbage can filled with ice and water in the locker room during games. Every sprained ankle was immediately doused in it. This is not a particularly humane treatment, but it really cuts down on disability and swelling, and no one has come up with a better solution.

      All-Pro forward Rick Barry particularly hated sticking his ankle into the ice water, and he always belly-ached about doing it. But our longtime trainer, Fritz Massmann, would hear none of it. Superstar or not, Rick's ankle was treated the same as anyone else's.

      The ankle suffers only two types of injury: a sprain and a fracture. But it's very difficult to differentiate the two. A large, swollen ankle may only be sprained, whereas a healthier-looking ankle may be broken. For this reason, I recommend that every ankle injury, except the most minimal sprains, be x-rayed. As a kind of mental exercise, I try to predict whether an ankle is broken or sprained before I have it x-rayed. I'm wrong more often than with any other joint, even though I've seen tens of thousands of ankle injuries. There really is no way to predict accurately, so every ankle injury must be x-rayed before a fracture can be ruled out.

      If an athlete goes down with a severe ankle injury, the ankle should be splinted and the athlete sent to an emergency room. It may look silly, but nobody will laugh at a sprained ankle with a splint on it, and splinting will help protect the ankle if it's broken.

      There are three grades of ankle sprain. When a jogger steps gently off a curb and "twists" her ankle, she simply stretches the ligaments, with no real tearing. That's a mild, or grade 1, sprain. When a tennis player lunges out over a poorly planted foot, partially tearing the fibers of the ligament, that's a moderate, or grade 2, sprain. When a volleyball player jumps and lands on another player's foot, twisting and forcing her ankle violently to the court, most or all of the fibers tear. That's a severe, or grade 3, sprain. A moderate sprain requires vigorous treatment and a severe sprain may put you in a cast or require surgery.

      Treat a sprained ankle right, and you can be on your feet in a few days and back in action in a few weeks. A severe or mistreated sprain, however, may not heal for six months or more. Therefore, all but the mildest sprains should be medically checked.

Outward Sprain

The most common ankle sprain happens when you roll off the outer part of your foot and sprain the ligaments on the outside of the ankle. You will have swelling and pain in the outer area of the ankle, and you may have black and blue marks around the injury. Within a few days, your foot and toes may also be discolored. Don't sound the alarm; this is just blood from the broken vessels flowing downward due to gravity. It is my experience that many people don't bother to treat a sprain at first, and then, when blood shows up in the foot, they panic and rush in to see me.

      If you feel pain on the inside of the ankle as well, you absolutely should have it x-rayed. When the foot rolls over, the central bone of the ankle can knock against the tibia on the inside of the ankle. This may bruise the bone or even break a piece off of it, which turns the injury into a fracture.

Inward Sprain

An injury from rolling off the inside of your foot is much less common than an outward sprain and usually results in a fracture rather than a sprain. The inside ligament is actually stronger than the inside bone, and rather than spraining, it may pull off a piece of bone where it attaches. This type of ankle sprain always requires an x-ray.

Forward Sprain

A third type of sprain results when you catch the front of your foot on the ground and roll over your toes. This pulls the tendons in front of the ankle and tears the ankle capsule, the membrane that surrounds the ankle bones. The capsule forms a closed compartment around the ankle's structures and helps to stabilize the ankle. It also secretes the fluid that lubricates the joint. A forward sprain can take two to three times as long to heal as the other two types of sprains.

The Steps to Recovery

The best immediate treatment for an ankle sprain is RICE (see Chapter 4). Your goal is to limit internal bleeding and swelling. If the sprain is severe, you may need to splint the ankle.

      Rest your ankle immediately. A sprain's intense pain eases after a few minutes, and you may be tempted to keep walking or playing. Hours later, you may find yourself with a swollen, discolored ankle too sore to stand on. If you stay off the ankle until the swelling stabilizes, usually you can walk easily within 24 hours. You may need crutches for a day or two.

      Ice your ankle until the swelling disappears. The ice curtails bleeding by narrowing blood vessels and helps reduce swelling. Fill a plastic bag with crushed ice and strap it onto the ankle with a towel or elastic bandage. Or you can use a bag of frozen peas or carrots from the supermarket.

      Some doctors recommend icing the ankle for 24 hours and then using heat. I prefer ice therapy throughout treatment. Continue icing your ankle for 20 minutes or until it starts to feel numb, and then take off the ice pack and give the ankle enough time to regain some warmth, usually about 20 minutes. Keep icing for 20 minutes on and 20 minutes off for 48 hours or until the ankle returns to normal size.

      Compress the ankle in between icings and at night by wrapping it with an elastic bandage, which limits the swelling and bruising.

      Elevate the ankle so that it's above your hips and, if possible, above your heart. At night, rest it on pillows or put a suitcase under the mattress at the foot of your bed.

      As soon as you can, begin range-of-motion exercises. These can help reduce stiffness and restore mobility.

      You should try to put weight on the ankle as soon as possible, depending on the severity of the sprain. If you need crutches, put a little weight on your ankle as you use them to walk as soon as it feels comfortable. Do not put your full weight on the ankle until you can walk with a normal heel-to-toe gait. Do not "duck walk" by turning your foot to the side in order to be rid of the crutches.

Ankle-Strengthening Exercises

Once your range of motion is near normal, you can begin strengthening exercises.

      Also do the Toe Raise and Heel Drop (see Chapter 12), alternating them until your ankle is fatigued. As your ankle gets stronger, lift up your good foot and put all your weight on the injured ankle.

      Each of these exercises should be done to the point of total muscle fatigue, so that you can't do even one more.

      Balancing is important in retraining an injured ankle to sense where the foot is in relation to the ground. Practice by balancing on one foot with your arms stretched out to the sides until you lose balance or become fatigued. When your ankle gets better, do this exercise with your eyes closed.

      If the sprain is severe or if you need to return to activity quickly for a big event, you should consider a good physical therapy program. All of the preceding exercises can be done on machines, which are much more effective than weights and pieces of rope. For balance training you can stand on a balancing board, which is a board that rests on a cylinder and allows you to roll back and forth. These exercises can be combined with electrotherapy, range-of-motion exercises, and massage under the direction of a physical therapist, who knows when and how hard to push you.

Preventing Another Ankle Sprain

The tried-and-true method of protecting a sprained ankle is to wrap the ankle tightly in athletic tape. But that requires learning the intricacies of proper ankle taping. What's more, tape tends to loosen with activity. As an alternative, use a lace-up cloth brace, which can be tightened during a time-out. Elastic braces or bandages are of little value in preventing reinjury because they stretch if the ankle starts to turn over again.

      If your ankle is still weak, you can use an Air-Cast®, which consists of two sets of inflatable bladders that are laced together and run up both sides of the ankle. This $20 brace holds the ankle firm and allows you to run. You can wear it until your ankle is fully restrengthened.

      If you have problems with recurring sprains, an orthotic device with a lateral flange or builtup area over the side of the heel can prevent the ankle from turning over. Persistent sprains may require surgical repair of the ankle ligaments.

      People with tight ligaments, such as those with a supinating or Morton's foot, may have continuing problems. The supinating foot tends to land on the outside and predisposes the ankle to turn out over the foot. Similarly, the person with a Morton's foot is susceptible to ankle sprains because the foot lands on the outside, which makes the ankle prone to turn outward.

      Ankle sprains should be taken seriously. Follow an aggressive rehabilitation program to speed recovery and reduce the chances of reinjury. Push yourself just to the point of pain; otherwise, rehabilitation may be too conservative and keep you out of action longer than necessary. Maintain your cardiovascular fitness through cycling and water workouts while you rehabilitate your ankle.

BROKEN ANKLE

In sports an ankle can break if it is turned severely with great force. This happens in basketball when a player comes down from a rebound and lands on the side of another player's foot, turning the ankle with the force of his full weight. A football or soccer player can break an ankle if his cleats are dug into the ground and someone falls on or rolls into his ankle. In baseball, catching the cleats while sliding into a base is a common cause of broken ankles.

      Common signs of a difficult-to-spot broken ankle include a recurrent, diffuse ache in the ankle that increases with exercise; swelling after exercise, followed by pain-free periods; limited movement; bruising in the ankle; and an unremitting ache.

      There are many types and combinations of fractures, from simple, small chips to complex situations that require surgery. All ankle fractures require medical care and prolonged casting or surgery. It is outside the scope of this book to discuss all of the various ankle fractures. Suffice it to say that if you break your ankle, you need to see a doctor.

      Most important, be sure to undertake an adequate rehabilitation program after the cast is removed from your ankle. Your ankle will be weak because the muscles will have atrophied, and you will have lost full range of motion. You must bring the ankle back up to 100 percent strength in order to compete at your previous level without the threat of reinjury.

      Many orthopedists, however, do not follow through on rehabilitation. I see patient after patient whose doctor felt that his responsibility ended once the cast was off and the bone had healed. An athlete can't return to activity and compete in that weakened condition. So make sure that you see a doctor who specializes in sports injuries.




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