"Doc, I twisted my ankle; it's swollen, and hurts; how soon before it's healed? How soon before I can ski?" Ankle injuries are common. Usually they are minor and heal quickly. But too often they lead to chronically unstable ankles that give out repeatedly and ruin a season. This consequence is avoidable if specific treatments are started immediately after the injury.

Ankle soft tissue injuries are divided into three grades, I,II and III. Grade I describes a stretching of the ankle ligaments without tearing of the collagen fibers that provide the bulk of the structure. Grade II describes a partial tearing of the fibers without a complete rupture. Grade III is a complete rupture. A careful physical exam of the ankle joint by an experienced examiner can accurately grade the injury. X-rays can determine if a bone fracture has occurred with the ligament rupture. The initial treatment of most ankle injuries, independent of their grade, is the same, and will be described below. Fortunately, surgery is rarely required initially because if specific treatments are instituted early, the results of nonoperative treatment can often match the operative treatment; conversely, the results of late surgical treatment of unstable ankles can be excellent in experienced hands.

When an ankle is injured from twisting in towards the other foot, called an inversion injury, most commonly the anterior talofibular ligament is stretched or torn. If the two other primary ligaments on the outside of the ankle (the posterior talofibular ligament and the calcaneofibular ligament) are also injured the primary bone of the ankle, the talus, can be displaced from beneath the tibia, and the ankle "shucks" out of joint. A physician or trainer examining the ankle soon after injury can compare the amount of "shuck" to the opposite ankle and develop a grade for the amount of injury suffered. Usually, if the injury is limited to one ligament, the instability is less. If all three are involved , the ankle is more unstable. The nerve supply to injured ligaments can also be injured. The nerves provide "proprioception" or position sense, in effect telling the brain where the foot is in space. In the healing process, it is critical to re-train the healing ligaments to regain the neural connections required for a stable ankle. Specific exercises can effectively do this.

Ankle injuries, in the past, were often treated with cast immobilization for six weeks or more. We have found that this is detrimental to the healing tissues. When injured collagen tissues are immobilized, the collagen heals in a disorganized fashion, producing scar. The tissues are weakened by the lack of normal motion and stress required for tissue nutrition and organization. The injured nerve fibers have difficulty reestablishing the proprioceptive sense for the ankle. The result is a higher incidence of chronic instability. Unfortunately statements like, "Doc, I injured my ankle years ago. It has never been the same since, and sometimes gives out beneath me." are heard far too often.

Treatment

The freshly injured ankle usually swells and hurts at the site of the ligament damage. The principles of treatment are icing, stabilization, early motion, and proprioceptive and strength training. Immediate icing diminishes the swelling and actually speeds healing by decreasing the subsequent swelling induced limitation of motion. Icing three to four times a day for the first 24 to 48 hours is required, as the maximal tissue swelling occurs during this period. Heat is only used in fresh injuries after the initial swelling period has resolved. In general, heat is used to warm up before exercise, and icing after exercise to diminish swelling. Stabilization of the injured ankle is best provided by an ankle splint under-wrapped with a compression bandage which provides both compression and protection, but simultaneously permits motion in the safe range for the injured ligaments. If  such a splint is not available, ace wrapping and taping the ankle can help. Early motion exercises of the injured ankle are required in order to diminish the swelling and prevent ankle stiffness. By carefully identifying which ligaments are injured, the safe range of motion that gently stress the ligament while avoiding harmful deformation can be prescribed. The stimulation of new collagen formation along the lines of maximal stress is critical to achieve a strong healed ligament. The first day after an ankle injury, proprioceptive and strengthening exercises can be commenced if within the safe range of motion. For proprioception, "stork stances", which are single leg standing with the eyes closed for one minute, provide excellent rapid small muscle training for the foot stabilizers.

Since ankle injuries occur by rolling the ankle over to the inside, any motion in the same direction or opposite should be avoided. Therefore straight pointing and flexing of the ankle in a pain free range of motion is recommended 7-10 times daily. If any of these exercises causes pain, don't do them!

The gastrocnemius and soleus muscles of the calf are the prime movers that point the foot away from the body. To exercise these muscles, place the uninjured foot beneath the ball of the injured foot. Gently apply tension and push the foot straight away from the body. To strengthen the main muscle in the front of your ankle, the anterior tibialis, place the uninjured foot on the top of the injured ankle and slowly flex the ankle toward the knees, hold and slowly return to the starting position. Do both exercises for 3 sets of 10-20 repetitions. Additional exercises may be performed if pain free. A very simple exercise is the two legged one-third knee dip. Stand with equal weight on each leg in a partially bent knee position, slowly bend both knees to a 90 degree angle and slowly return to start position. Progression into a single stance one-third knee dip is started when the athlete is able to perform the exercise without pain. Do 3 sets of 2-3 minutes. All exercises should be performed in the ankle brace to help give support, control motion, and most importantly to protect the ankle from rolling over again. To maintain or improve cardiovascular ability, non-impact exercises such as swimming or single leg stationary biking, are recommended.

At 2-3 weeks, skiing can be resumed if the ankle is pain free in the ski boot. At 4-6 weeks, upon physician approval, gentle straight forward running, inversion, and eversion exercises may be started. Before actually running, two legged stationary bicycling and running in place should be tested. If performance is pain free then outside bicycling and running is allowed.

The goal of early motion and strengthening exercises is to return the athlete to sports with a stable strong ankle, which should be able to be accomplished in most ankle ligament injuries.

Surgery is highly successful for chronically unstable ankles that have not adequately responded to an exercise program. Our surgical technique of primary repair of the torn ligaments followed by our specific rehabilitation program has led to excellent stability with return to full sports with a full range of ankle motion.

Prevention of ankle ligament injuries is accomplished by conditioning the lower extremities prior to playing sports, and by wearing supportive shoe wear. The exercises described above are best performed prior to injury.

Summary

Ankle injuries can be diminished by preseason training and supportive shoe wear. They should be aggressively treated to provide the most stable result and the earliest return to sports. For chronically unstable ankles, a careful exercise program can improve performance and if necessary, a carefully designed surgical procedure can correct the most difficult of chronic instabilities.