Healing a Sprained Ankle (and other injuries) - Part Three
For parts three and four, I'm the home team again and I'm excited to dig into your joints with you. Under no circumstances do you need a sprained ankle to benefit from this, but for the sake of continuity I'm going to continue using that injury as the main example. However, these two late parts of the series can be applied to most any injury recovery, and by some extension into arthritis, surgeries, and joint replacements.
Obviously our two rules will continue to apply:
1) If you have to choose, listen to your body over anything in this blog, and any blog.
2) Do not move into pain. (But remember that discomfort and pain are separate entities.)
Most advice treats rehabilitation as get rid of the pain and you'll be good. But this is the most important thing to understand about injuries: it won't truly be good until you can move well again.
Everything in your body has an available range of motion. Forward, backward, sideways, twisting, compression, extension. In order to get better again, you'll need to be able to move the injured part forward, backward, sideways, twisting, compressed, and extended in the same way (or as closely as possible) as you could before it happened. Any joint that isn't moving is red-flagged by your body as an issue.
Even without pain, your joint might be scared.
We all talk a lot about pain because pain sucks, but there's more to a joint health assessment than "hurts" and "doesn't hurt." Last week, we said that the third stage of recovery is when the pain is gone but you're not functionally better. Your body is still scared to use the injured ankle. Your balance is bad or you're terrified it's going to hurt. All of these reactions are normal PTSD after an injury. Be understanding that it might take a while to put back together. Plus, I get how the pain can last for so long that it's a huge victory when it ends.
But this isn't the true finish line for most injuries. There's a lot that can still go wrong. Stopping your recovery at pain relief is gonna end up like a Lifetime movie where everything is great at first but then next thing you know your stepfather is a ruthless drug dealer con artist trying to steal money from your disabled mom and severely bullied half sister. Total shitshow.
This is what I'm talking about when I talk about the third stage of recovery. Even when your pain is long gone, your ankle might still be scared (needs strength), restricted (needs mobility), or both.
And the third stage is a swamp. DRAIN THE SWAMP. The creatures lurking in it can range from the Perfect Again Pelican, to the Oh Shit! Snapping Alligator!, to the Eughgheughuegh No-Mobility Turtle. It's hard for anyone to predict how an injury will heal in your body and it might go through all three of these on the way, or add in some other slithery creatures.
The Perfect Again Pelican
Look at this gorgeous creature. The Perfect Again Pelican is the injured athlete's dream. She is an arcing brushstroke from A to B where you get hurt, do what you're told, and within the exact predicted timeframe wake up one day and discover that you feel great. The Perfect Again Pelican is a regular visitor to children and teenagers, but she is a rarer and more precious sighting in the older adult swamp trees. Not much to say here, except that if she visits you, I encourage you to feel grateful, and then jump right back into whatever you were doing without a second thought. This injury is done. You're perfect. Get back to work.
The Oh Shit! Snapping Alligator!
This dude lurks quietly under the surface, only the eyes visible, terrifying in his silence. You know he's there as you kayak gingerly through the swamp, hoping you don't have to interact. Just trying to get downriver without an incident. Suddenly you feel your oar brush against the slightest resistance. A mere nothing. What creature could even notice such a minuscule tou—Oh Shit! Snapping Alligator!!!!!!
Why does sharp pain come on so suddenly, even (especially!) when it feels like you haven't done anything differently? Your pain is essentially gone, but every once in a while you pick up a fork you dropped and it's like Voldemort firing the Cruciatus curse straight into your veins. Twenty seconds later, it's fine. What the hell is that?
It's happening because the injury isn't done yet. Every human body is different, but chances are good that your pain is happening because the Snapping Alligator is buddying up with the Eughgheughuegh No-Mobility Turtle, the most commonly-seen animal in the swamp. This dynamic duo is like Timon and Puumba, but with all the farts and none of the comedy.
The Eughgheughuegh No-Mobility Turtle
Oh man. How hard can we all relate to this guy? He's named for the sound we all make when we're struggling to get up, over, or around something. The way your brain sees it, you got hurt because you moved your ankle too much (by falling off a curb/stepping on a Lego, imitating the Sound of Music gazebo scene). If your ankle can't move as much, you're less likely to do it again. It's like a disappointed parent. Your brain grounds you.
Of course, just like good parenting, these imposed limitations aren't meant to be punishment. It's protection. Your body is always operating from a defensive standpoint. Its first job is to keep you alive and safe. Your nervous system doesn't care if you play tennis again. It cares if you can escape from a gorilla sneaking up behind you. (It also ensures that your defecation systems are ready for times like these, omg.)
Your brain's solution to this problem of getting hurt was super great for the cavemen, who had very real concerns about being hunted by large animals with large teeth. Evolutionarily, it's brilliant: Heal well enough in the shortest amount of time. (Thus, scar tissue.) Unfortunately, it isn't very good for modern humans. Given that we no longer hunt, chop, gather, climb, build, drag, or evade with any regularity, maintaining our fitness in more sophisticated ways is increasingly important. We're interested in as complete a recovery as possible, because we know we want a hundred years of working joints. Unfortunately, most of us (myself included) don't bother with complete recovery. We're too impatient, bored, or time-constrained to care. But then, naturally, we start experiencing pain either at the site or somewhere else. And what does everyone (myself included) start to chant?
"I'm too old for this."
You're not too old for this. It's much more likely that you've got a few half-recovered injuries floating around your body, just waiting for you to take them out on a hot date with some serious one-on-one attention. I want you to round home with your ankle dorsiflexion, ok?
Extra forces ALWAYS get taken up by another joint.
Take this example:
You sprain your ankle.
Your ankle mostly heals. Let's say it can move 80% of what it used to be able to move. 80% is more than enough motion for day-to-day life. Most of the time it doesn't bother you, but every once in a while you're reminded of it.
So remember in high school physics when you learned that energy must always be conserved? Finally! You can tell your high school self that you are using this crap in real life. If your ankle is only able to translate 80% of the energy powering through it, it means that the other 20% of force MUST be taken up somewhere else in your body.
a) the Achilles tendon (Achilles tendinopathy)
b) your foot bones (stress fractures)
c) the knee (IT band syndrome)
d) the hip (Do you know any way I can stretch the outside of my hip? It's SO tight.)
e) the lower back (Standing is weirdly painful recently)
f) all of the above (yes, yes, yes, yes, and yes)
These forces churn through your body all day long, while you walk, browse a bookstore, or scream at the person in the crosswalk where you're trying to drive. Exercise adds even more dynamic to the dynamics. If a 5k race costs 5,000 steps, that means that in one race, your body has to absorb extra energy 5,000 times. You get hurt on every step: landing on the injured leg, and then a shitty push to land poorly on the other leg. Over time, something is going to get tired of doing the extra work. (Remember group projects in high school? Remember the kid who said he was going to write the paper and you knew it was going to be a disaster so you just did it for him and put his name on it? Your ankle is that kid and your knee is the one writing the paper for it.)
This transfer of forces is true for any lingering trouble in a joint or tissue. A nagging shoulder sets the table for Golfer's Elbow, while a rigid wrist invites Tennis Elbow in. Some leftover disc herniation in the lumbar spine is basically like a three year old's birthday party in the rest of your body. These are the snapping alligators. If you can make the turtle GTFO, you can usually get the alligators out too. Hey, how do you know if you were looking at an alligator or a crocodile? It depends if you see them later or in a little while.
It's hard to trust in a joint that doesn't move well. Distrusting one joint leads to problems in another. Then a reduction in activity because we're scared of getting hurt more. Which makes us slower, less powerful, nervous to try anything that seems risky. After that, it becomes a free fall of sarcopenia, osteoporosis, joint replacements, and golf. For the love of god, don't let yourself develop golf. There is another way.
People falling is always funny, but this guy is a perfect example of why humans need mobility. Look at everything that takes this guy down to the ground. (Ignore his technique. This is only about mechanics.) He has almost no spinal rotation, and he has zero hip rotation. Since his spine and hips can't pivot, he is forced to shift his weight hard to the right in order to swing. But now watch his right ankle—when he steps sideways to catch his momentum, his ankle also isn't mobile enough to plant. He can't put his heel down. His knee has no leverage to help, and we already know his hip isn't prepared for any of this. He cannot stay upright. This is why mobility matters. Nothing in his body is able to move at that kind of speed, or handle those kinds of weight shifts.
It doesn't matter how much this guy improves his technique, because his body can't do the technique in the first place. Try to imagine him in his kitchen, reaching behind him for a cabinet to grab a measuring cup. How good are the odds that he falls? (Spoiler alert: very good odds.) And by the way, this guy's hips and back didn't start deteriorating at age sixty. They started at age thirty.
Now check out this kid.
Yes, he's a kid and kids are magical creatures. But check out his body in this swing. Hips and spine pivot around a central point, so he doesn't need to shift side to side. He moves with power and speed, but is able to handle all that force. You can see it moving up from the ground, through his body and out the club. This is #goals.
OK, so how do we become awesome golfer kid?
It starts with reconsidering your body. Way back at the beginning of this blog, I said that only one part of joint health assessment is HURTS and DOESN'T HURT. (A designation of "doesn't hurt" means there is no part of motion that hurts. Not "mostly feels fine." No part of motion that hurts.)
There is also MOVES and DOESN'T MOVE. (A designation of "moves" means full range of motion for that joint, without abnormal tightness, nervy tingling, feeling like it's stuck, clicking, popping, or the sense that if someone would just take a sledgehammer to it it would be fine.)
As well as STRONG and ISN'T STRONG. (A designation of "strong" means that your joint feels secure in every part of its range of motion. For example, a strong shoulder can hold a weight overhead, push something, and pull something, without needing to use sixteen other body parts to complete the work.)
Here's what that looks like, if you aren't sure:
This man's right shoulder moves, does not look like it's in pain, but utterly fails the strength question. (It does, however, raise many other questions.)
You can use these three metrics in combination to get a whole lot more information about yourself. If you've been bitching and moaning for years about your Erstwhile Sprained Ankle or Highly Doubtful Hip or Is It Totally Fucked Forever Foot, try evaluating your body on this scale and see how it comes out.
Maybe your ankle doesn't hurt, but also doesn't move and isn't strong. This is likely to develop into a chronic injury.
Perhaps your hip moves, but hurts and isn't strong. This joint is at risk of a more traumatic event.
Evaluate anything on your body that ever had an issue. If you've got at least one good score in the pain/movement/strength categories, focus on improving the other two. The odds are high that if you can improve one, it'll positively impact the other two.
However, if you score negatively on all three categories (you have pain, you cannot move well, and it has no strength) then either your injury is active and needs more time off, or, if it's an old injury, you need some professional eyes looking at it.
Play with your assessments and see how they affect other parts of your body. How to improve them? Read part four. But don't worry, it's going tibia-kay ;)