I sprained my ankle, what do I do pt. 3

So, you’ve sprained your ankle or are rehabbing some other injury.  How do you know when to progress your exercises and try more challenging tasks?  As a therapist I can tell you that this is the hardest part of helping someone rehab an injury.  You want to push them so they progress as quickly as possible, but you definitely don’t want to push them too hard causing a setback.  The line between progressing to quickly and not quickly enough is very fine but there are some rules you can use to guide you. 

Rule 1 – Rehab exercises should be pain free.  Pain is your body’s way of telling you that what you are doing is potentially harmful and damaging.  That being said, you may have some mild discomfort with some exercises.  You need to be able to distinguish between the discomfort of challenging a healing tissue and the pain of damaging a healing tissue.  Err on the side of caution with pain, sharp pain is a definite ‘stop what you are doing’.  You also need to assess how you are feeling in the hours and day after you do your rehab exercises.  The inflammation and accompanying pain of overdoing it may not reveal themselves until later. 

Rule 2 – Do the same exercise routine twice on two separate days before you progress the exercises.  For example, on Monday you might do 3 sets of 15 repetitions of a new exercise at a certain resistance.  You experience no pain during or after.  On Tuesday you should do the same routine again and if you experience no pain during or after and are able to perform all of the prescribed repetitions you can progress the exercise.

Rule 3 – Only increase one variable of a given exercise at a time.  Variables are the sets, repetitions and resistance in a typical exercise.  Lets say you are doing calf raises to help strengthen your ankle.  On Monday and Tuesday you do 2 sets of 10 reps with your body weight on the floor with no pain during or after.  On Wednesday you could add one of these next three things: 

1.     An extra set of 10

2.     More reps within your two sets

3.     Add some extra resistance to your original 2 sets of 10

In terms of exercise prescription for an ankle sprain, in the last post we got as far as doing isometric strengthening, active range of motion and single leg balancing for proprioception.  Now we need to add strengthening through a full range of motion (ROM).  Resistance bands are perfect for ankle rehab exercises.  The exercises are the same as the isometric strengthening in part 2 except now you actually move your ankle through a full range of motion with resistance in each direction.  When you can achieve 3 sets of 15 reps with a certain resistance you should use a stiffer band to continue to challenge the muscles of the lower leg. 

Calf raises are a great exercise to strengthen the ankle while also working on range of motion and balance.  Start on the floor with just your body weight. Progress to doing them off of a step letting your heel drop below the level of the step to stretch your calf and promote increased dorsi flexion.  Add resistance as tolerated by holding onto some weights at your sides.

Calf raise from step

You should be doing some walking as well, you can use a treadmill and add some incline to actively stretch your calf muscles and improve dorsi flexion.  Treat walking like any other rehab exercise and use the progression rules outlined above. 

Multi joint leg strengthening exercises such as squats and lunges can be done once you have full pain free ROM and have progressed through full ROM strengthening with resistance bands.  Once again, use a conservative approach to adding these exercises and progressing them. 

Light jogging for short durations can be attempted as well as long as its pain free, progress as tolerated within the guidelines outlined above.  

By no means is this an exhaustive list of exercises to rehab an ankle, so do your own research and enlist the help of a therapist if in doubt or if you are not getting a bit better every day.

I sprained my ankle, what do I do? pt. 2

The first post in this series about ankle sprains dealt with the most acute phase of injury (inflammation).  Inflammation usually lasts a few days, after your ankle is no longer hot to the touch and swollen it's ready to start healing.  Healing occurs in stages the details of which I will not go into heavily for this post in the interest of keeping things simple.  The most important thing to do when rehabbing any injury is to not re-injure it in the process.  For the majority of us a conservative approach to rehab exercises will accomplish our goals while protecting us from the urge to push it too hard.  

Stage 1-Active range of motion (ROM), isometric strengthening and proprioception.

Your first objective with rehab is to regain your full range of motion.  How do you know what your full range of motion is?  Assuming your other ankle is healthy, that's a good place to start, your goal is for symmetry between both of your ankles.  You were already doing some passive and pain free active ROM during the inflammatory phase, now its time to push a little harder.  You still want to keep this pain free, move your ankle to the absolute limit of your pain free range in the four directions it moves.  Up and down (dorsiflexion and plantar flexion respectively) and side to side (inversion and eversion).  Do 15 repetitions of each movement 2-3 times at least once a day, preferably 2 or 3 times.  You can still do passive ROM as well by moving your ankle around in those same ranges with your hands if your passive ROM is still larger than your active range.  

Isometric strengthening involves contracting the muscles that control your ankle against resistance but without moving the ankle through any ROM.  You can use any immovable object to accomplish this, such as a wall, desk, chair etc.  You will likely be able to do this best sitting with your leg outstretched in front of you and supported, the floor is a good place to do this.  Place your foot against a wall and push trying to use only your ankle.  

Keep the reps high and pain free, 2-3 sets of 15 repetitions of 6 second holds 2-3 times a day.  

Proprioception refers to your bodies ability to sense its position in space.  Proprioception is reliant on sensors in your muscles, ligaments, and joints.  When you injure these tissues it disrupts those sensors ability to function properly.  There are a few ways to improve proprioception.  If weight bearing is still uncomfortable you can practice drawing the alphabet with your foot in the air, this also helps with your ROM, bonus!  If you can weight bear well progress to a single leg stance on solid ground, try to hold it for 15/30/60 seconds progressively.  If that's easy try closing your eyes.  As you improve you can start adding instability such as standing on a pillow, when that's easy fold the pillow in half and you will notice more instability.  

Ok next post we will talk about the next step, how to know when to progress to more challenging exercises.

I sprained my ankle, what do I do?

While playing basketball last week in North Toronto I sprained my ankle pretty badly (ouch!).  Although I have the knowledge and training to deal with my injuries appropriately, that didn't change the fact that it hurt!  With this in mind, I decided to write a basic guide to this injury for those who might not know exactly what to do.  I'm going to talk about inversion ankle sprains specifically but much of this advice could be applied to any soft tissue injury.  

What is an inversion ankle sprain?

Your ankle moves in 4 basic motions, dorsiflexion and plantar flexion are when you pull your toes up and down respectively.  Inversion and eversion are when you move your foot inwards and outwards respectively.  An inversion injury occurs when you "roll" your ankle inwards beyond its natural and normal range of motion.  This can happen many ways, stepping off of a street curb partially, landing on someones' foot when jumping etc.  This can result in a sprain (partial or complete tearing of the lateral ligaments of the ankle), strain (partial or complete tearing of one or more of the muscles of the lateral ankle and lower leg), or fracture (partial or complete breaking of one or more of the bones of the ankle).  Assuming you haven't fractured a bone you likely have a combination of a sprain and strain of the soft tissue of the lateral ankle.  If you think you have a fracture you should see a Medical Doctor or Nurse Practitioner for consideration of an x-ray.  The Ottawa ankle rules are the standard for determining the need for an x-ray. http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf

It may be difficult to apply and interpret these rules on your own ankle so if in doubt go see a Medical Clinician.

So let's say you're sure its not broken, now what?  You may have heard some snaps or pops when you rolled your ankle which is a pretty good sign that you have done damage to some ligaments or muscles.  You will likely notice some swelling around the lateral aspect (outside) of your ankle.  This is the normal and natural response to a soft tissue injury known as inflammation.  Inflammation gets a bad rap but its a necessary process in the healing cycle.  The problem with inflammation is that the body tends to overdo it and swelling that sticks around for a long time and doesn't leave the injured area ends up hindering the healing process.  You may have heard that you should ice an injury to decrease swelling. This is true but ice is not the best weapon you have in your bag.  When you tear ligaments and muscles they bleed. Would you put ice on a cut on your arm to stop the bleeding?  Probably not! Hopefully you would put direct pressure on the cut to stop the bleeding and that is exactly what you should do with your ankle.  If you can use compression and ice at the same time along with elevating the injury above the level of your heart, that is ideal.  A tensor bandage is great for applying pressure, if you can find some foam to cut into horseshoes, this is even better.  

If you can't remember all of this you can use this acronym PIER - Pressure Ice Elevation Rest.

Inflammation usually lasts for about three days, during this time use only cold, no heat yet.  If you're unsure if your ankle is still inflamed put your bare hands on your ankle and feel for excess heat.  If it's hot and red then it's inflamed. Do not use heat on inflamed tissues.  Ice for 20 minutes on and 40 minutes off as much as possible and keep the pressure on.  Try not to wrap your ankle so tight that you cut off circulation. While the wrap is on press your toe nails and they should turn white and then back to red quickly. If they stay white for more than a few seconds your wrap is too tight.

During this inflammatory period try to move your ankle through as much pain free range of motion as you can a few times a day. If it is painful to move actively then just use your hands to move it around in a pain free manner for a few minutes every few hours.  You're just trying to maintain as much range of motion as you can right now, the more you can maintain now, the less work you'll have to do later.  

Ok thats it for now, 3 days or so of PIER and pain free range of motion.  Next post I will talk about what to do after the inflammation stage is over.

Gluten confusion

I came across this article about the issue of gluten intolerance and found it very useful.  The writing is a bit abrasive but it gets the point across.  

Just click HERE and you will be re-directed to the original article by @foodspin

Happy reading!

Ready, Set, RUN!

It's spring time again and as the weather improves many of us get back to outdoor activities we have abandoned for the winter months.  Running in particular tends to cause the most problems in terms of injuries for people either re-establishing a running routine or starting to run for the first time.  

The goal of this post is to provide some easy tips and tools to decrease the chances of acquiring a running related injury this spring.  Running is a difficult and dynamic exercise that takes practice to develop the form and endurance necessary to make it a rewarding experience.  Running form is a lengthy discussion and not the goal of this discussion, what will be discussed are things you can do before, during and after your run to prepare and care for your body.

1.  Warm up:  Often neglected or poorly done, this is essential in preparing your body for the more intense exercise to come.  Start with a light cardiovascular activity to warm the bodies tissues, increase heart rate and breathing rate and increase blood (oxygen) delivery to the working muscles.  This can be a light jog or quick walk, bike, skip etc.  The bottom line is to be on the verge of sweating, it should take about 5 minutes.  The muscles in your body work better when they are warm, they become more elastic and are able to contract with greater force.  Now you are ready to do some dynamic stretching.  Dynamic stretching involves performing controlled movements through a full range of motion that mimic and prepare the body for the exercises you will be performing.  

a) Start with some leg swings, grab a wall and swing your legs one at a time forward and backwards and side to side slowly easing into a bigger range of motion each time, about 15 reps of each will do.  This provides a stretch to hip flexors, hamstrings, abductors and adductors of the hip.  

b) Knee tucks-while standing, grab your knees alternately and pull them up in front of you trying to touch your knee to your chest.  Do 15 per side.

c) Butt kicks-start jogging slowly, now try and bring your heel all the up to your glutes, in essence kicking your own butt.  This helps to warm up the hamstrings.  Do a couple sets of 30.

d)High knees-just like butt kicks but now you are trying to bring your knees as high as you can in front of you.  Do a couple sets of 30.  Don't forget to pump those arms!

Ok, you're ready to go, there are many more dynamic stretches you can do before you run, consider this list the bare minimum.  

2.  Use a running progression:  Even if you are an experienced runner it is advisable after some time off to use some kind of progression to build back up to longer distances and higher intensities.  This can be a walk/run program for beginners where you alternate between running and walking in a set ratio such as running for 1 minute and walking for 2.  Slowly increase the running time and decrease the walking time with each running day until you are running continuously.  For more experienced runners starting with slow short runs and increasing distance and speed over successive runs is an option.

3.  Cool down and recovery:  After your run keep moving for a bit to let your heart rate and breathing rate slow down gradually.  Your muscles may feel tight and if you feel like doing some traditional static stretching now is the time.  Static stretching involves holding a muscle at its most lengthened position for a period of time often 30-60 seconds.  Most people have done this type of stretching before, post running stretching should focus on the legs, calves and hamstrings are often areas of tension after running.  Evidence suggests static stretching does not prevent injury but there is no harm in doing it if it makes you feel better, just keep it to after your run and use dynamic stretching before you exercise.