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Healing a Sprained Ankle - Part Two

Sprained ankles are the worst. Talus about it!


Trouble is afoot.

Well, it wouldn't be a blog of mine if it didn't have at least one bad pun. Now this one has two. At least we got it out of the way. As a reminder, I am not a doctor or physical therapist and if you have medical questions you need to go visit a medical provider.


Last week I wrote up a basic primer to the sprained ankle: why it happens, why your body reacts the way it does, and what to do in the immediate aftermath.


This week, we're going to limp our way into part two. Most injuries follow this basic pattern:


Step one: Immediately hurts really bad.

Step two: Still hurts but you can mostly live your life.

Step three: Doesn't hurt anymore but not functionally better.

Step four: You forget which ankle it was.


You know when someone asks you which arm you had surgery on and you say, "The right one. Wait...was it the right one? Maybe it was the left?" That's the dream for injury healing, when it becomes nothing more than something that happened to you. (This is true psychologically as well, although of course those scars are made of a stiffer material.)

The dream is to forget what happened.

Your nervous system remembers injuries like the IRS remembers that you once made a four dollar mistake on Part F of your 1992 state tax return regarding the consulting you did for your kid's school's library fundraiser. It REALLY doesn't want to let you off the hook for past mistakes. Sure, maybe it made sense in the beginning, but after a while you just want to file your taxes without a field audit led by screaming goats.


We will get into detail about how and why the nervous system remembers injuries, because there are differences between acute pain and chronic pain. But for now, the acute pain of a sprained ankle is your body's defense mechanism. Pain is literal miles of nerves screaming at you to sit the fuck down or it will turn this car around.


When your brain stops worrying that you'll worsen the problem, that's when you'll start feeling better. The funny thing is that even if it has bothered you for years, when an injury disappears you usually don't even realize it's gone. Your injured leg is like your buddy with a bad hangover. They keep telling you that they want to die and then next thing you know they're at dinner excitedly ordering a double long island, please and thank you.

If it hurts just a little bit, that means it hurts.

In the beginning of a sprained ankle (or other minor traumas), you're dealing with sharp, acute pain. Managing acute pain is all about working with what's available at any given moment. You don't have to push anything too hard. You don't have to struggle through difficult rehab workouts. Instead, you'll progressively work on range of motion, which is basic stuff that you would do naturally, without anyone instructing you. Pointing, flexing, inversion, eversion, small circles. Walking gradually becomes easier. Shifting weight on that foot until you can stand on it without holding on, and then balancing there for a while. Remember that anything you can do pain-free is within limits. If it "hurts just a little bit," that means it "hurts." Don't do it.


As your leg feels better, you'll start wondering when you can use it again. The swelling and bruising is gone, you can walk without much limp, and you're eager to start running/jumping/walking down stairs/chasing your 18 month old. How do you know when you're ready?


There's never a perfect answer for this, but rehab follows the same protocol as we have been talking about.


Be judicious but not afraid. If you never push it, you'll never regain full use of that body part. Don't hate yourself if you do something that winds up being a bad idea. Just remember it was a bad idea, and adjust your next workout accordingly.


Moving into pain is bad. This is the part of rehab where I start distinguishing discomfort from pain. Discomfort I'm good with. Pain I'm not good with. Start asking yourself what the difference is.


Feeling confident is good. This is always good, in every movement for the rest of your life. If you've lost confidence in some movements, start asking yourself why and what you can do to improve it.


When a movement is borderline painful, try slowing down, reducing the range of motion, or both. If you're moving glacially slowly and it still hurts, it's probably best to switch to something else.


The more you use your hurt ankle, the more you'll understand what it is and is not willing to do. Any time you can safely add more load, feel free to do it. But there are rules. Number one, you're not Kerri Strug. You don't have to vault on ninety-seven broken bones. Heroic efforts to force yourself through workouts will only add recovery time, not reduce it. Number two, work in a way that makes you feel better about the next attempt. You want to finish a rehab workout and think, "Awesome! Next time I should be able to try [fill in the blank]." It's all about trial, error, and the most recent successful performance. Here are a couple examples of what I mean.


If you can't walk comfortably for a solid twenty minutes, you're probably not in a good place to try running.


If you can run ten steps but it hurts, you're still not ready to run.


If you can run ten steps and it doesn't hurt but it does *make you nervous*, see if slowing down makes you feel more comfortable. If it doesn't, it's risky.


Why? Your brain communicates in real time with every cell and every nerve. It has the most up-to-date understanding of the situation in every part of your body. Pain is only part of the picture. In rehab, you need to go beyond Does It Still Hurt? and into Does It Still Make Me Nervous? That feeling of dread suggests that your tissues still have a beef with you. It's like when you fight with your spouse and you think it's over and then they come marching back with one finger lifted high and a "AND ANOTHER THING!"


What if you try a workout and your ankle sucks afterwards? That might be ok. It's not necessarily bad if your injury hurts a bit more after testing it. 24 hours is about my limit for post-injury workout pain. If it hurts more than usual but quiets down in less than a day, then I feel like I'm within reasonable training limits. If it's still killing me three or four days later, I know I went too hard.


Your joints can be nervous for a long time after the pain stops. I've worked with people who had surgery or trauma decades ago and they never realized their joint was operating at a substandard level. Careful work over months or years can be a game changer. This is why it can be hugely helpful to have an experienced pair of eyes looking at your body. Pithy Instagram posts are cute, and occasionally they have a nugget you can take with you, but they simply cannot replace a human who has worked with a lot of bodies, seen a lot of movements, and dug through the research.


I want to finish part two here by answering a question I got after part one. A friend texted to say, "I thought you couldn't create new tendons, as in they don't regenerate. Don't they just form scar tissue? Isn't this the whole problem with healing tendons and ligaments?"


First, a video.



Although my video is incredible, here is more specific detail on scar tissue and how and why it forms. There are a lot of myths surrounding scar tissue but nearly everyone thinks of it as a hard lump of filler cement in the middle of a joint. Just like any other tissue, scar tissue is made of living, active cells which communicate with the rest of your body and are thus able to be influenced.


First of all, you can and do regenerate ligaments, tendons, cartilage, and other notoriously non-healing tissues. Obviously they do not regrow into their original form, which is why scientists are working furiously to discover better ways of encouraging good healing. Here's how it works.


Your tendons and nearby tissues contain both tendon cells (tenocytes) and stem cells. The tenocytes can only replicate to become more tenocytes, and although they do do this both in normal tissue and in injury repair, they have a limited capacity to fill gaps. If the gap is too large, we don't naturally have the ability to seamlessly lay down new tendon right along the lines that we need it.


The stem cells can become literally any cell in the body, which would be great but it seems that without extremely specific genetic directives for what to turn into, the stem cells aren't sure what they need to do. So the stem cells in the area of the injury will produce a bunch of possibly useful things, which include native tendon cells, but can't or don't know how to produce the necessary amount. It's like writing out the first draft of a paper. There's some verbs and some adjectives and a whole hell of a lot of adverbs and too many commas and semi-colons because who doesn't love semi-colons; all of the words do create a paper but they haven't been put to great use.


So the rest of the work falls to scar tissue, which is made of collagen just like tendons are made of collagen. The difference between scar tissue and native tissue is that scar tissue is made of a different, thinner type of collagen which is easier to lay down quickly. You might be like hey, wtf, collagen? I can wait! Gimme a good tendon, not a half-priced copy! Sadly, your body has other concerns besides your intramural soccer dreams. Science thinks that scar tissue is laid down because evolutionarily, the wound healing and infection prevention would have been more important than the regeneration of a perfect new tendon, which would be a slower process.


Scar tissue is not laid down in lines, but more like throwing a box of toothpicks on the floor, with the fibers just crisscrossed haphazardly in order to makeshift a rapid solution. (This is why a skin scar looks different from the skin around it.) The movement after injury is essential, because if you're (gently) using the tendon during that makeshift tossing down of fibers, we know that it encourages them to line up a little bit better, which means the healed tendon more closely replicates the native tendon.

If it still makes you nervous, it's not healed.

Scars will be found in any grievous injury, but the body does regenerate native tissue alongside scar tissue. So the goal is to get moving as soon as is safely possible. You want to encourage the repaired tissue to grow in the direction of movement, instead of any direction it pleases. If you know anyone with a hip replacement, you know that they had half of their leg sawed off but doctors still got them up and walking within hours, because if that trauma is left to itself, the amount of scar tissue is going to overwhelm the joint and severely inhibit future movement. The poor recipients of early hip replacements (in 1891 what?!) learned this the hard way, being told to lie down for weeks or months of recovery only to discover they had a hell of a time walking after that.

In part three of this glorious series on sprained ankles, we'll answer the all-important next step: Is it going to happen again? Because we all want to unsubscribe from needing this sprained ankle content.

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