Rock and Roll(ed Ankles)

Rolled ankles are one of the most common injuries that can occur on the trails. 

Let’s face it, we love trails because of the natural surfaces, but roots and rocks can lead to unstable footing and twisted or rolled ankles. Even putting a foot down when trying to stabilize yourself on the bike can lead to an ankle injury.

Your ankle twists. Maybe you hear a “pop” and within a few hours it's sore, swollen and maybe black and blue.

According to UpToDate, “Multiple studies show that ankle sprain is the most common injury in organized sport. Aeroball, basketball, indoor volleyball, field sports, and climbing had the highest incidence of lateral ankle sprain in one systematic review.” 

And while I have no idea what Aeroball is, it was my wet walk in the woods this morning that inspired me to write about this topic…

Here's a brief anatomy lesson on the foot and ankle, followed by some things you can do to treat and prevent injuries in the future.

Feet & Ankles 101

Each foot contains 26 bones, 19 large muscles and more than 100 ligaments. Technically, your ankle joint is the point where your foot joins your lower leg. The ankle joint is made up of the tibia (main weight-bearing bone of the lower leg), fibula (smaller supporting bone of the lower leg), and the talus (upper most bone of the foot). The bumps that you feel, your “ankle bones” if you will, are the bottom portions of the tibia and fibula, specifically called the “medial malleolus” (tibia/inner leg) and “lateral malleolus” (fibula/outer leg). 

The ankle joint itself only allows the motion of your foot moving up and down, like when you tap your toes. Any other movement (twisting, turning) is done by the sliding motion of the bones in the foot. The ligaments on the outside of the ankle are usually the ones injured because the foot is more likely to turn inward from a fall or unstable movement. A sprain occurs when these ligaments are stretched too far, with the main ligaments connecting the tibia, fibula, talus and/or the calcaneus (heel bone) in various configurations. Sprain can happen to one or multiple ligaments and they can be rated by the level of stretch and associated tearing. For example, a third degree sprain means that the injured ligament is completely torn. It also means you’ll be off the trails for a while. I should also note that sometimes the ligaments are stronger then the bone and the ligament remains intact but it pulls a piece of bone off where it attaches. 

If you do hurt your ankle, the first thing to do is to try to figure out how bad it is. Telling the difference between a severe ankle sprain and a fracture can be difficult, but with mild pain and swelling, it’s unlikely that a bone is broken (and remember, a broken bone is fractured—the two words mean the same thing).

We have a screening tool that *can* be used to help determine who needs an ankle X-ray and who doesn’t, but the reality is that anyone with an ankle injury typically gets a one.

The Ottawa Ankle Rule is good at excluding "significant" fractures, but again, most of the time X-rays are done. 

X-rays are only going to tell you if the bones are broken or not. If you go to an Urgent Care or Emergency Department, don’t expect to get much more info than "break or no break." At the initial assessment it’s almost impossible to specifically determine which ligament(s) is(are) injured, the degree of injury, nor how long the recovery will be.

I should also note that while the ankle joint is where most of the attention goes with that twisting type injury, that same twisting motion can cause a break higher up on the fibula (fibular head), by the knee or on the outer side of the foot (5th metatarsal), so x-rays may need to be done there as well.

Assuming that there’s no broken bones, ankle sprains can be mild and need minimal care, or they can be really annoying and take weeks to recover from. For minor injuries, some rest, elevation, anti-inflammatory medications (if you can take them) and support should be enough to get the healing started. Early range-of-motion exercises can help too.

As you ease back into activity, one of the problems to be aware of is that with ankle sprains there can still be some residual weakness in the muscles and ligaments that stabilize the joint and while pain and swelling might be improved, too much activity too soon and make someone prone to re-injury and/or delayed recovery.  And while many common exercises will develop the muscles of the ankle for up and down motion, they don't do much to strengthen them for side-to-side movement or stability. If you’re prone to ankle sprains, certain exercises can help strengthen the joint but physical therapy can really target the muscles. 

So phase one of recovery is rest, phase two is early movement to restore range of motion.

And for the third phase, let’s hear from Tom Cookson, a cyclist and now retired physical therapist with about 40 years of experience. “You can start to put your weight on it as long as there is no pain. If it still hurts, you need to back off. The fine line between active recovery and overdoing it should not be crossed.” 

“With the third phase,” he says, ”you can return to exercises that will help to strengthen and stabilize the ankle." Easy cycling could be okay too. 

“To strengthen and stabilize the ankle, use single leg stance activities starting with simply balancing, and progressing to standing on an unstable surface like a couch cushion with your eyes closed. Finally, progress to lateral movements such as pivoting, cutting and lateral agility drills,” he adds. 

The bad news is that once you have an ankle injury, your chances of re-injuring that ankle are pretty high. But as Cookson points out, “proper training is the key to preventing injuries."  

”If you continue with the same exercises that help you recover, and work them into your regular workouts, you’ll keep the ankle and foot strong and stable," he says.

Initial Treatment (but remember to transition from R.I.C.E. to M.E.A.T.)

• Protection-limit stress to the injured foot through limited activity, bracing or non-weight bearing with crutches.
• Rest-allows the injured part adequate time to heal and decrease swelling.
• Ice-apply ice to the ankle. Use a damp towel on the skin and apply the ice over the towel on the affected area for 15 minutes at a time. Do not leave the ice on longer than 20 minutes as frostbite may develop.
• Compression-apply pressure with an ace wrap or direct pressure to control further swelling. When using a compression bandage, always wrap from the bottom up, to squeeze the fluid up towards the body’s core.
• Elevation-studies suggest that elevation is the most effective way to decrease swelling. I suggest ½ hour cycles of elevation 3-5 times per day depending on the severity of the injury. I.e. more swelling = more elevation. Elevation means to have the affected part higher than the heart. (Fluids flow downhill not uphill)

And of course, this was all a discussion about ankle sprains. If there was a break, that's a whole other can of worms, and treatment ranges from not much different than a bad sprain all the way up to surgery with pins and plates and screws. So, do yourself a favor and don't break your ankle.

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