Natural Sports Medicine Blog: December 2008

Wednesday, December 10, 2008

Ankle Sprains... What Do You Do?

So, you step wrong while running and you hear that crack from your ankle. From my past blogs, you know the first thing you do is to apply ice compresses. Hopefully you make your way to a good sports chiropractor (hint-hint) or athletic trainer for a proper exam and good care.

But, you're likely to go to the local drugstore and buy an Ace-bandage or a neoprene ankle support or somthing else similar. I've always liked a good elaborate tape job with lateral & medial ankle stays (stirrups), double heel locks and the classic figure eight around the ankle. Of course that was a pain to have to have done every day, especially to try doing it to yourself. I went from classic white to self-grip tape, but the effectiveness of the tape wears off after maybe an hour, if that. Ace-type elastic bandages will give you some support, not much and similarly those neoprene sleeve give you a little support as well. Nothing really great.

When used properlt, the air-ankle stirrup is probably the best. Used properly means wearing it with a properly laced up sneaker or shoe. As I've said previously, I like to use it in hi-top basketball sneakers.

So it seems this is the best.....or so I thought until June 2006

A couple years ago I came across an article in The American Journal of Sports Medicine. The authors of the study concluded that the best, most efficient method is a combination of using an elastic bandage around the ankle AND the air-stirrup. Here's an excerpt from the article

Results: Treatment of grade I sprains with the Air-Stirrup brace combined
with an elastic wrap returned subjects to normal walking and stair climbing in
half the time required for those treated with the Air-Stirrup brace alone and in
half the time required for those treated with an elastic wrap alone. Treatment
of grade II sprains with the Air-Stirrup brace combined with the elastic wrap
allowed patients to return to normal walking and stair climbing in the shortest
time interval. Treatment of grade III sprains with the Air-Stirrup brace or a
walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for
frequency of reinjury, ankle motion, and function.

Conclusion: Treatment of first-time grade I and II ankle ligament
sprains with the Air-Stirrup brace combined with an elastic wrap provides
earlier return to preinjury function compared to use of the Air-Stirrup brace
alone, an elastic wrap alone, or a walking cast for 10 days.

Here's a link to the antire abstract: http://ajs.sagepub.com/cgi/content/abstract/34/9/1401

Today is day 5 of my ankle sprain ordeal. I guess you can call this the the Ankle Sprain Chronicles..... The things I'm telling you in this and the 2 prior blog posts are the things I do for myself(and other sports chiropractors do...). My ankle is a Grade II+ sprain possibly a grade 3. It is quite unstable, very painful if not kept in a neutral position. But, with the 3" elastic bandage around the ankle and the air-stirrup and my hi-top sneakers(Love thos New Balance B-Sall Sneakers), I'm able to walk around my office and treat patients. Yesterday, I even went to the gym and worked out with my trainer....non-weight bearing of course.

Here are pictures of the air-stirrup with the elastic bandage and a picture of it in the sneaker. This is how it's done. If you have any questions about ankle sprain diagnosis, treatment or rehab, feel free to email me at miamibeachdoc@yahoo.com

As soon as I'm ready I will be posting short videos to show you the types of rehab I'll be doing...look for that in future blog posts.

'nuff said

DocT

http://ajs.sagepub.com/cgi/content/abstract/34/9/1401

Sunday, December 7, 2008

What A Difference A Day Makes (and a good ankle support brace!!!) Day 2 of my ankle sprain saga

Yesterday was pretty awful with the right ankle. (Click here to read what happened)I did 6 sessions of Ice/Compression/Elevation/Interferential Stimulation throughout the day. The worst was getting around on crutches. I've never had to crutches in my life and I hope I never have to again. But here's my problem. I'm like the typical guy. I don't like to let injuries slow me down. I need to get up ad get going again.

The support the E.R. nurses dressed me with was adequate at best. I understand what they were trying to do. Lock my ankle from any lateral or medial movement. First was a 3" ace bandage in a figure 8 around the ankle and heel. Next a soft fluffy cushion layer over the foot, ankle and 3/4 of the way of the calf. Then a material that molded to the medal and lateral (inside and outside) of my foot-ankle and calf that eventually hardened into a rigid, almost cast-like material. Then, the entire thing was wrapped up and secured in a 4" Ace bandage. With all of this, there was still some medial and lateral play in the ankle and it was difficult to get around. It was bulky, awkward, but sufficient. They did exactly what they were supposed to do. Make sure it's not broken, secure it up and refer me to a specialist.

I went out to a holiday party last night with my hospital setup and crutches. Hobbling around on crutches wasn't much fun and due to the slight instability in the current bracing, I'd get twinges of pain. I needed something better and I knew exactly what it was....

Years ago when I sprained my right ankle for the last time doing something relatively simple, I discovered a really great tools that allowed me to get up and walk like a normal human being again. What is it? An Ankle Air-Stirrup Brace

<--that ankle="" brace="" div="" my="" new="" s="">

The one I'm using is called the Air-Lite Ankle Stirrup from Core Products. Now, there's a secret to using this thing. You can't use it like it appears in the picture...there's one thing missing. I have had many patients come in from their orthopedists with this thing strapped to their foot, on top of their sock and in maybe a flip-flop type shoe or a slipper. This is absolutely, 100% wrong.

It's meant to be put inside a lace up shoe or sneaker. I prefer high top sneakers like basketball style sneakers for this. Here's a few pictures of how this thing is properly worn. Yes, this is me in my brace.

Under my sock I have a 3" Ace bandage wrapped in a moderately snug figure-8. Then the sock, then the ankle air-stirrup. You really have to pull your laces wide in order to fit your foot and ankle into your sneaker. Then, you tighten up the laces, tie your laces and then when you stand. Ahhhhhh, stability. I can walk 98% normally on this thing now. It allows my ankle to flex up and down but locks it from bending or twisting (or rolling) to the inside or outside.

It's simple to put on and simple to take off. This makes getting around SIGNIFICANTLY easier. This is hold the ankle so stable that I can stand on the side of the sole of my sneaker and my ankle remains locked in neutral. This this is also very simple to take off and putting back on for my frequent therapy sessions, making it all much less of a hassle.
So, now, the "tough guy" can prevail. I can stand, walk and now, tomorrow morning I can work. But Ill be taking my own medicine with frequent ice/interferential sessions. I'll use Graston Technique to help further break up the bruising and reduce the swelling and I'll get my wife to adjust my ankle. Yes, I said adjust my ankle. And no, I'm not crazy. When one side sprains, the other side of the ankle gets jammed up. Ever jam your finger? Well, this isn't much different. Ultimately I need all those little joints in my ankle to function normally. Chiropractic helps restore normal joint movement and that something I need too. It's not just about the pain, the swelling and the bruising. When it's all said and done, the joints need to function normally again too. It's kind of a whole package deal.
Thanks to my ankle stirrup, life will be good again for me as I make my recovery from this thing.
'nuff said
DocT

Dr. Narson is a 2-term past president of the Florida Chiropractic Association’s Council on Sports Injuries, Physical Fitness & Rehabilitation and was honored as the recipient of the coveted Chiropractic Sports Physician of the Year Award in 1999-2000. He practices in Miami Beach, Florida at the Miami Beach Family & Sports Chiropractic Center; A Facility for Natural Sports Medicine.

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Saturday, December 6, 2008

When A Doctor Gets To Taste His Own Medicine...The Story of My Ankle Sprain

So this morning I'm running and I missed the curb I was targeting for my next step. I was at the tail end of my stride when my forefoot caught the outside of the curb and my foot and ankle

inverted (rolled over) with a vengeance and the weight of my full 200-lbs coming down on it.

C-R-A-C-K from the ankle then boom as I dropped to the floor. I've never felt pain like this. It was severe, it was intense, I immediately became nauseated and light headed. The pain brought tears to my eyes. Ironically, it all happened in a handicap parking space.

It took me about 10 minutes before I was able to handle the pain and think about getting off the ground. My son's surf camp instructor had brought me an instant ice pack that I help on there while I lay on the ground. I swore I broke it. I've sprained my right ankle 6 times earlier in my life which prompted me to study and research how and why ankle sprains tend to reoccur so often. This time felt much different, much more severe. I tried getting up with the help of my son's Sufing camp instructors and walked about 8 steps when I was overwhelmed with chills and light-headedness and before I actually passed out, I sat back on the ground (this time on the grass) for another 10 minutes until I was able to get up.

Before getting up I started examining my ankle. There was light tenderness at the lateral talus, lateral calcaneus and at the distal fibula. Why was the pain so intense from the injury yet when I examined it, it was so mild? Because the inflammatory process hadn't start to really kick in yet. When I moved my ankle to test its stability, wow.. there was some pain when I inverted it. OUCH! If it was fractured, I was going to have to get to the E.R. quickly before the inflammation started to build up. Often, periosteal swelling (an onion-skin like tissue layer on bones) can block some fractures from being seen on an x-ray.

I was eventually able to drive myself to Mt. Sinai Medical Center where I was quickly brought into the emergency room. I waited maybe...maybe 5 or 6 minutes. A very nice nurse practitioner came in to check me, took a history and did a cursory exam and ordered some x-rays. I asked for a bag of ice and an ace bandage and I started to take my own medicine. I placed a paper towel on the skin, placed the bag of ice on the lateral ankle and then, with the help of a nurse, wrapped the ankle moderately tight with the Ace bandage. I elevated the ankle and waited for the radiology tech to take me for an X-ray. After X-ray, I re-wrapped it and waited for the attending physician, Richard Menendez, MD to give me the news. Dr. Menendez was very nice, very thorough and explained the injury and my options. Of course I knew all of this because this is exactly the type of injury I take care of at my office on a daily basis. I knew what I was in for.

So for me, it was mixed news. The x-ray was negative for fracture. This may seem odd that I say this. But with most simple fractures, they will most often heal faster and stronger than a bad ankle sprain. Turns out I have a "bad ankle sprain". Which means weeks and weeks of therapy and more weeks and weeks of rehab with emphasis on proprioceptive neuromuscular re-education. Yes, a mouthful I know. But, probably one of the most important aspects of getting an ankle that was badly sprained to be functional again. Especially when it's the ankle of an athlete...or me, the wanna be athlete.

So, what's my medicine???

To start with: R.I.C.E. Rest, Ice, Compression & Elevation. I happened to have a Rich-Mar Auto-Sound/Multiwaveform Combo unit at my house and a Sub-Zero freezer full of ice packs. I've been using Interferential stim with ice 30 minutes every 1-2 hours since I got home. I will continue this for the next 2-4 weeks depending on my body's response. Tomorrow I will start passive ROM within a non-painful ARC of motion. As the ankle swells up and gets purple, I'll use Graston Technique (http://www.grastontechnique.com/) to increase the lymphatic drainage of the ankle and reduce the swelling. This is incredible for inflammation of most things inflamed (ankles, knees, wrists, knuckles....whatever). Then there will be light Isometric resistance and an anti-inflammatory diet (not to mention some actual anti-inflammatory meds because this sucker is really throbbing with pain). I will put a little pressure on my heel a couple times per day so the capsule / ligaments around the ankle doen't get too tight due to the lack of normal movement and weight bearing.

You see, there has to be a balance between ligamentous stability and joint/tendon/muscle flexibility. Very important and all of us sports docs and sports therapists are still working on the perfect recipe for this.

Over the next weeks I will work in increasing pain free ROM, increasing muscle strength and stability. All things we do in our office, the same stuff I do with my patients. I can't wait to see the faces of my ankle sprain patients on Monday when they see me starting the process from scratch.

Eventually my life will be filled with balance and wobble boards. Working with them "eyes open" and eventually "eyes closed" to stress and rehab the higher proprioceptive centers. Eventually introducing Most Heat rather than the ice and then finishing it off with strength training with the most wonderful ankle rehab device.... The Ankle Rehab Master (To order an Ankle Rehab Master, call 954.752.2299).

Luckily, the Ankle Rehab Master happens to be manafactured by my father (I know, lucky me). What a great tool for strengthening ankles in combined vectors of motion. For those therapists, trainers and sports chiropractors out there.... not only can it easily do plantar flexion, dorsiflexion....it will allow the patient (in this case...'Mwa') to do resisted inversion and eversion. Then there the combined movements of inversion with plantar flexion, eversion with dorsiflexion and everything in-between.

I'll be ready for that in about 4 weeks.... I hope.

But Monday morning, I'll be ordering an Air-Ankle stirrup to strap on my ankle so I can walk without these crutches. A recent study shows a sprained ankle will heal quicker when you wrap the ankle with an Ace bandage and use the Ankle Stirrup together. I’ve tried it with a few patients and it seems to be a good thing.

So, I know what I'm in for and I'm willing to take my own medicine.

Now it's time for more R.I.C.E.

'nuff said

DocT