An early morning run out on the trails. The smell of fall is in the air, the sound of crisp fallen leaves crunching under your feet. It seems that it is finally cooling off after a long scorching summer. You look forward to enjoying more brisk morning runs as your end of season race approaches. Suddenly your foot rolls out from under you. You catch your balance, but nearly fall. You look back on the trail and there is a stick emerging from under the color of rusting leaves, barely visible. You turn and run off hardly paying attention to the aching in you ankle. It doesn’t hurt, except every time you land on a root, a pinecone or even an acorn. The next day the ankle is sore and swollen with a mild throbbing pain with the first few steps. You don’t think much about it. After all of the ankle sprains you had before, how would this be any different. A little ice, dig out that ace wrap and you think you’ll be good as new.
Ankle sprains are the single most common injury in sports. They can lead to considerable disability, premature arthritis and long-term pain. Worse (if you are a runner) they can keep you from running. Thankfully for runners, in most cases they are avoidable.
So what exactly is a sprain? A “sprain” is an over-stretching of a ligament that results in tears. An ankle sprain is classified by the location of the injured ligament as well as severity. 85% of all ankle sprains involve the lateral ligaments (those at the outside of the ankle). There are three lateral ankle ligaments. Of the three ligaments the anterior talofibular ligament (ATFL) is far more frequently injured than the others.
A Grade I ankle sprain is a minor injury typically involving only partial tears of the ATFL. There is usually little loss of function with this type of injury, such as described in the opening paragraph. A Grade II sprain involves a complete tear of the ATFL and may include stretching or partial tearing of the other ligaments. This will involve more pain, difficulty walking and a risk of long-term problems with ankle instability if not correctly treated and rehabilitated. A Grade III sprain is a severe ankle sprain. Most people with a Grade III sprain cannot walk. They usually also have significant bruising and swelling. These injuries require intensive treatment to get back to activity.
Fortunately, the minor sprains are the most common variety. Most people who have had an ankle sprain, have actually suffered several ankle sprains. Many of these folks actually have sprains so frequently that they don’t even think of them as injuries. The reason for this is that when the ATFL (the primary stabilizing ankle ligament) becomes weak or completely torn after an initial sprain, the ankle becomes unstable. Then merely stepping on an uneven surface, a rock, or a tree root can cause the ankle to roll. Those that have been through this become accustomed to this instability. In many cases, they have rolled the ankles so many times that the nerve fibers in the area have been damaged and it hardly even hurts. So if it doesn’t always hurt, why does it matter?
It matters because even minor sprains have the potential to cause far more serious damage. Every time the ankle rolls (whether you fall down or not) there is a risk of a number of small fractures of the talus (the bone at the top of the foot that moves up and down in the ankle). These fractures can lead to pain, locking of the ankle, or pre-mature arthritis with damage to the cartilage that cushions and absorbs shock. It is also possible to tear other ligaments that stabilize the tendons at the ankle and control the motion of the foot.
The good news is that distance runners, particularly those who run on roads, are at low risk of an ankle sprain while training. But there are times when the risk goes way up. Trail running and cross-country running significantly increase the risk due to uneven terrain. Often these surface irregularities are not even visible due to grass, leaves and other forms of ground cover.
Interestingly, during organized road races (on very flat paved roads) there are lots of ankle sprains. The reason for this is that runners trust the road to be flat, but they cannot see very far ahead. Think about a marathon start. You and several thousand other excited highly trained runners finally getting to head away from the start and out on the course. You could reach your arm out in any direction and touch a different person. During the first few miles, most of your focus is on the people around you, just trying not to bump into them while attempting to maintain your desired pace.
All it takes is a dropped water bottle, a centerline reflector, or a small pothole. Step on one of these while you are staring at the back of the runner in front of you and your ankle can roll right out from under you. So that brings up the obvious…keep your eyes on the road. If possible, try to keep a little distance so you see a water bottle just before you step on it. If you run on the crown of the road, avoid the paint and that will keep you off the reflectors. If it is raining, stay way off the paint…it is extremely slippery when wet and can easily send you to the ground. Wearing worn out shoes have also been shown to contribute to ankle sprains, but you should know better by now.
If you know that you have unstable ankles, get checked out. There are many ways to reduce your risk of further injury and recurring sprains. Strengthening exercises can re-train the muscles surrounding the ankle to work in sync and take over some of the lost function from the injured ligaments. There are also ways to tape or brace and restore enough stability to allow for running without any difficulty. If you do suffer an ankle sprain, the standard initial treatment is P.R.I.C.E (protection, rest, ice, compression, elevation). However, the key is rehabilitation, not just decreasing pain. Most people underestimate the significance of an ankle sprain and the importance of restoring the function of the ankle through a proper ankle rehab program. When properly treated, ankle sprains recover well, and most of the time without any surgery.
With fall training weather comes renewed delight with running as the trees start to change. Keep your eyes on the road or the trail (as the case may be). Just don’t let the roots trip you up and watch out for the errant pinecone or acorn.
Christopher Segler, DPM, AACFAS
Stay Fit. Go Long. Run Fast. Be Strong.
My ankle's been swollen for three months , is there anything I can do so it would heal ?
ReplyDeleteAssuming that you had an ankle sprain, maybe yes and maybe no. Persistent swelling after an ankle sprain can be as sign of a worse injury that wasn't diagnosed, an outward sign of incomplete healing, or a completely normal part of the healing process.
ReplyDeleteThe anterior talofibular ligament (ATFL) is the most commonly torn ligament that is injured in an ankle sprain. The ATFL is really just a thick reinforcing band or bundle of collagen inside the ankle joint capsule. If the tear is really significant, it is possible that 3 months after you rolled the ankle you might still have some swelling. This could be normal. It all depends on the severity of your ankle sprain, the treatment that was provided and the other variables in the course of your ankle sprain recovery and treatment.
It is also possible that you have had a fracture of the talus bone. There are 2 types ("lateral process fractures" and "osteochonral lesions") that are associated with bad ankle sprains. These are also difficult to see on an x-ray and might go unnoticed when first diagnosed with an ankle sprain.
In 2006 I won an award of the American College of Foot and Ankle Surgeons, for a research project on "lateral process fractures" of the talus bone (also often called "snowboarder's fracture"). The initial patient review included about 6,000 patients who had a history of ankle sprain or ankle injury. In that study it was determined that lataeral talar process fractures are more than 10 times as common as previously thought.
You can view that research by clicking here:
http://www.anklecenter.com/images/pdfs/lateral_process_talus_fracture_research_san_francisco_podiatrist.pdf
In general, swelling is sign that something is wrong. 3 months after an ankle injury is a little to early to say for sure that something is wrong, given that I don't really know the injury or history of the recovery.
If it was just a Grade 1 ankle sprain, and it was treated appropriately, I would expect there to be little if any swelling 3 months after the spain. If it was a Grade 3 ankle sprain and it wasn't treated aggressively, I wouldn't be surprised if there was a lot of swelling at the end of the day. If it was a lateral talar process fracture that was never diagnosed and was never treated, I would expect the ankle continue to swell, and hurt, until it is treated.
There are always treatments that can reduce swelling, but without knowing the history and performing an exam it is impossible to say what would be best to get the swelling to calm down now. Unfortunately it all depends upon the injury you sustained, the treatment that was provided, and how your doctor thinks you have responded to those treatments. If yo have been treated and have a lot of swelling, I would certainly go back to your treating ankle doctor.
Get well... and stay active!
Dr. Christopher Segler
Doc On The Run San Francisco Podiatry House Calls
http://www.anklecenter.com/