Need to know: Ankle Sprain

The ankle sprain… One of the most common reasons patients see me in the office. Here is all the information you need to know if this happens to you.  It will be just like if you were visiting me in the office!

An ankle sprain occurs when your foot rolls in or out putting extra stress on the ligaments.  This causes the ligaments to stretch/tear, which is by definition an ankle sprain. If your ankle rolls where sole is facing in, it is called an inversion injury (most common). If your ankle rolls where with your sole facing out, it is an eversion injury. These injuries can happen during sports, basketball and volleyball are common, or in any setting when athletes can land awkwardly from any jump or step. Sometimes though for the unlucky patient the injury can occur during day-to-day activities, something as simple as stepping off a curb wrong at the grocery store.  I have seen all of the above (and more) in my office!

During the sprain, the ligaments are stretched/torn which causes pain and swelling. The great news is these ligaments are not typically the type we need to fix with surgery, and most people heal quickly without long-term problems.  However, more complex types of sprains do exist that take longer to heal or may need more intervention.  For example, a “high ankle” sprain results from a more forceful twist that injures the ligaments above the ankle between the lower leg bones in an area called the syndesmosis. With other high energy injuries, you can also injure ligaments lower down in the foot or even break the bones.  If you are a kid and still growing, your growth plates are weaker than the ligaments.  Because of this when you twist your ankle, the bones may be more likely to break than for a ligament to tear.  This is a commonly missed injury by non-orthopedic physicians, can take longer to heal, and needs a correct diagnosis to be treated properly.

 Today we focus on the essential adult ankle sprain, the inversion (sole of foot turning in) injury that tears ligaments mainly on the outside part of the ankle. The most common injured ligament is called the ATFL, or anterior talofibular ligament.  If you look at your right foot it is that approximately at the 2 o’clock position on the top of your foot about 1 cm from the ankle joint. 

The injury causes a tear/stretch of this ligament resulting in pain, swelling, and bruising. 

 Treatment is usually very straightforward. I recommend starting with ice for the first 24-48 hours with rest (doing as little as possible) and elevation (at or above the level of the heart) for swelling. You should only do light activities that do not increase pain. If you have a more significant injury and you cannot walk normally, sometimes I recommend using a brace or other support device like a medical grade boot short term.

The timeline for recovery is variable and depends on how bad the injury is and what your goals for return to activity are. If you have a small injury and are doing low impact movements (sitting/walking) a full recovery is quicker than if you have a larger injury and play sports that require cutting, jumping, or pivoting. 

The biggest risk with an ankle sprain is repeat injury. Once the ligaments are injured, your ankle is more unstable and weaker.  You are more likely to sprain it again or injure it further if you have not fully regained all your strength, balance, and coordination lost with the initial injury.  Your body normally controls ankle stability (balance and strength) with proprioception. Proprioception is a protective sensation where your brain sends a signal to a joint and the joint responds with position updates.  Think of it like you brain asking your ankle, “Hey, how’s it going down there, which way are you pointing, how stable is that ground?” And your ankle responds, “I am okay, pointing straight ahead, ground stable no cause for concern.”  This happens constantly and nearly instantaneously with movement.  Consider this – don’t you always know where your ankle is without even having to think about it?  When you have an injury that feedback communication does not work as well.  The ankle’s response can be slowed and inaccurate.  This causes an increased risk of a second injury.

We can improve the ankle’s ability to communicate via proprioception, as well as its strength and our balance with physical therapy. A physical therapist can assess how the ankle is moving and what needs to happen to retrain it to be pain free and moving well. In my office I see people with the initial injury and then depending on the degree of injury will either send them straight to physical therapy or will send after a period of rest. It takes several weeks to get the ankle back to moving normally, but most often after doing so people do very well.  

One common question I get is why the swelling lasts so long after the injury, even if they are progressing well otherwise. This is usually not cause for concern. In addition to injuring the ankle ligaments the other soft tissues around the ankle were injured.  Because of this, swelling can persist for many months even after your ankle feels better.  Another common question is why the ankle feels stiff or not quite like the other ankle.  The stiffness is from the lack of movement in the early recovery and from scar tissue that forms during healing. The great news as that the stiffness dramatically with time and work with physical therapy. 

My goal with treating an ankle sprain is to get patients safely back to all the activities they love as soon as possible.  At my initial evaluation we make a plan for what one should expect in the next few days to week and schedule a follow up to assess progress.  Having two visits helps me understand your trajectory for healing – two data points helps me see the line of how quickly you are progressing much better than single point.  Once physical therapy is started, I continue to monitor progress and help determine when one can return to sport activities. 

A final word on return to sport.  I return most people cautiously.  As I mentioned, recurrent injuries happen.  I unfortunately see patients that have long term chronic ankle pain or instability due to having multiple sprains.  This is a harder problem to fix and may even require surgery.  Getting the physical therapy right from the first injury can help prevent this problem.  For those with recurrent sprains, optimizing a physical therapy program and integrating ankle rehab into your exercise will absolutely be helpful and may also prevent the above. 

Any questions about ankle sprains? Let me know!  Share this with anyone you know that may find this useful. 

The ICU is not what you see on TV.

Sunrise over our local hospital.

But you don’t want to find this out first hand.

I saw a picture of a group of physicians and nurses in the “COVID ICU” on social media today. It was the same intensive care unit I worked in for years as a medical trainee. I recognized it right away with its beige tiled floor, clear glass rooms, and that awful yellowish paneled wood work area. Suddenly a flood of emotions passed over me. Memories unrolling one after another. And I realized something…

After all these years I still feel deeply the pang of the long hours in that ICU spending hour after hour with the sickest of the sick. I still hear the alarm beeps. I smell the cleaner in the air and feel the cold as the temperature drops in the wee hours of the morning only rectified by the overly starched heated hospital blankets. And I still remember the patients.

I can see the cancer patient getting treatment with medications making them so sick they could no longer breath on their own. In the corner I see the young cystic fibrosis patient praying for a miracle transplant. I remember standing in a pool of blood putting giant tubes down throats for patients with massive stomach bleeds on the brink of death. And I will never forget the numerous patients so sick with infections in their blood all their organs were failing them, one after another. I hear the ‘code blue’ alarm ringing and nurses yelling for help. I can feel my stomach drop and my heart race a bit as I run towards the room for CPR. 

Sometimes I was there with you alone at 3am, doing everything possible to save you. And other times your family was at your bedside when the ultimate tragedy struck. Tears could not be stopped on either side of our exchange as they said goodbye.

Seeing that picture I remembered everything so vividly my heart felt heavy in my chest. I realized suddenly very few people know this experience. Very few ever have the emotional experiences attached to seeing that ICU. Most Americans (luckily) have never personally witnessed the wrath an ICU on the delicate human body. Most have not had a loved one suffer through countless procedures or treatments, with lines and tubes sticking in and out of every body part possible. They haven’t seen their beloved spend day after day hooked up to breathing machines and machines mimicking kidneys when their bodies basic systems start to fail. They haven’t seen the trees of pumps with IV medications surging into large veins in the neck and groin, while their loved ones lay paralyzed and asleep in a bed growing more and more swollen from the fluids trying to sustain life. This isn’t the television version of the ICU you have been shown before. It isn’t glamorous. At all. People don’t always survive and there is nothing TV viewable about the actual ICU experience.

I know one thing for certain. Be happy you haven’t been there and don’t know that experience. But more importantly just because you haven’t seen it doesn’t mean it isn’t real. It is real. It is the most tragic existence you’ll never be able to imagine.

Wear a mask. Stay home. Stay distanced when you must go out. Please avoid groups. And keep yourself safe. You don’t want to learn what the ICU is really like, trust me.

What is a stress fracture? And when should I worry?

Given the state of the world, people are increasingly turning to outdoor recreation and exercise. More people than ever are out running! This is awesome. However, with this, comes the possibility of new injuries. Runners are some my favorite patients because as a runner myself, I see the motivation and time commitment as well as the joy that being a runner can provide. Unfortunately, when I am seeing patients in the office, usually, they are having pain or have had an injury. An injury that has presented more often recently due to people turning to the streets for exercise is something called a stress fracture.

A stress fracture is essentially breakdown of the bone that occurs from repeated small forces. When we run or do other high-impact activities (jumping, plyometrics, or other exercises when both feet are off the ground at once) our bones break down and then heal when we rest. This is a normal process that happens on the microscopic level and is the way the bone stays strong by regularly “remodeling” itself. When the balance between breakdown and healing becomes unequal, we can develop a stress fracture. This stress fracture is a weakness in a small area of the bone that does not have a chance to heal before the next round of impacts, an overuse injury.  

Other factors sometimes contribute to the development of the fracture.  Remember I said that they start by a disruption in the balance of breakdown and healing of the bone. For a person training for their first marathon it seems that an increase in the breakdown forces would be the cause.  Well, what about the other side?  What if the breakdown hasn’t changed, but the healing side can’t keep up?  This can also be a reason why stress fractures occur.  Why does this happen?  The reason we have slower healing can often be attributed to nutritional factors, hormonal factors, weakened bones from medications, or simply aging.

The main symptom of a stress fracture is pain usually described as an achy sensation deep in the area of the body that is affected.  What can be tricky is most people can continue to run but then experience this achy pain after the run or even at night. The lower extremities are where stress fractures usually develop.  This makes sense as are often due to the impact of running.  Common places are in the lower leg bone (the tibia) and the foot bones (metatarsals).  Occasionally, one can also develop stress fractures in the small bone on the side of the leg (fibula), in the upper large leg bone (femur), or in the hip socket or pelvis. How serious the stress fracture is depends on a few factors, and one of the most important is where it is located – that is, some locations are more high risk than others for bad problems!

When I see someone in my clinic that has a stress fracture, the story they tell usually goes a little something like this… they have increased their mileage, or they changed their running routine in some other way.  They may have started to train for a marathon having never done one before, or maybe they are just training harder to get to a faster race time. Maybe they are new to running… 

They usually report pain in a small area in one of the body parts we mentioned before.  

After we talk, I do a physical examination.  We get an x-ray that gives me a basic overview of the bone shapes, structures and the space between them. 

Sometimes we can see the stress fracture on the x-ray. If we do see it, we see a slight change in the contour of the edge of the bone that I like to refer as a “scaffold” (think scaffold on the side of a new building being built). This is what your body does in response to a stress fracture developing. It works overtime to build this scaffold to try to patch (heal) and protect the bone. If that scaffold continues to get abused by your activities (i.e. you kept running despite the pain), the body can’t keep up and the scaffold breaks down as well.  This shows up on the x-ray as a dark black line through your bone and is a more serious problem, the so-called “dreaded black line.”  This means that the stress fracture has progressed, is no longer microscopic and is a more serious problem.  In this instance, x-rays are great tools.  But keep in mind not seeing a stress fracture on an x-ray does not necessarily mean you do not have a stress fracture.  If only things were easy right!  So, what do we do if we highly suspect you have one and don’t see anything on the x-ray? Sometimes we need more information, and in this instance, we may do an MRI to evaluate the bone structures further. The MRI gives us more information because it not only shows us the bone but also can show swelling in the bone, the bone matrix in more detail, and any “black line” cracks are very apparent. Both imaging modalities can be helpful, and you don’t always need one or the other.  (We try to be thoughtful about ordering tests in medicine, so if things will not change the treatment, we just use the history and physical examination!)

To heal a stress fracture, we must first rest from the insult that was causing the problem.  Second, we must address what if anything in your body that caused a deficiency that the bones couldn’t keep up with. That is very important. If we just allow you to rest from running, and then you start back doing the exact same thing at the exact same speed and pace that you were before without addressing all the other factors, it is extremely likely that the stress fracture will recur. 

We also investigate why the stress fracture developed. This may mean you need an evaluation of your running gait and the strength and control of your lower extremity muscles. Sometimes all we need to do is discuss your specific training program and see how their progression and amount of running, volume of training, volume of cross-training, and rest all may have contributed to the injury (as a sports medicine physician my favorite part is to help you get back to running and sport ASAP!)  We also discuss nutrition, and whether finding a way to optimize this or other associated factors (think hormones, vitamins, blood tests, etc…) are needed as well. More on these topics another day.

If you have, questions about stress fractures let me know!

What is it like?

What is it like to visit a doctor’s office right now during the pandemic?

Sitting in my office today I realized that given the state of the COVID-19 pandemic there has been increased anxiety in my patients about visiting the doctor.  They just don’t know what to expect and for good reason are worried.  It is intimidating and can be associated with anxiety to begin with, and now with any new protocols or potential increased risks patients are (rightfully) concerned. However, I want to tell you that it is not that much different.  To alleviate some fear, I’ll walk you through the process and discuss what new protocols you can expect when visiting.  

First and foremost, we are here, and we are seeing patients who need us.  There are a couple different ways to visit the doctor right now.  You can definitely come in person to see us as you would normally, or if you feel uncomfortable and worried given either the pandemic or your risk given your personal medical conditions, we are also offering telemedicine visits, which I have talked about before Here! (essentially where a doctor and you can video chat). 

Next when you have decided to make a doctor’s appointment, what changes should you be aware of?  Let’s walk through the process.  You start by calling for an appointment as always, but you will likely notice the first change here with the conversation you have with the scheduler.  Your scheduler will ask you about symptoms for COVID-19 as well as any other risk factors for exposure.  They will inform you about some of the measures in the clinic that we are taking to try to protect our patients.  Once you complete the screen, you make your appointment and are good to go.  Face coverings are mandated in the buildings, so you will be reminded have one for your appointment. And in case you forget, don’t panic!  You will be provided with a mask if you do not have one when you arrive.  Like you, the doctor, nurses, and all staff you meet will also be wearing a mask throughout the visit.  When you arrive at the office you will be asked to fill out a questionnaire about possible symptoms and exposure and have your temperature checked with an infrared forehead thermometer.  If you do not have a fever, or active symptoms you will “pass” this portion.  You may notice that our waiting rooms have been changed to help with social (physical) distancing.  This means chairs have been removed and spaced far apart. In some cases, you may bypass the waiting room altogether and move immediately from check in to your examination room.  This helps keep everyone safely distanced and separated. Heads up, this may mean you sit in the exam room longer than normal while waiting for the doctor, but it helps keep everyone away from each other, which is the goal of social distancing.  

The visit with the doctor should feel pretty normal overall.  Sure, we are limiting handshakes, but the doctor will still examine and treat you in our normal way.  There is lots of handwashing for us these days! But honestly not much different from how we normally operate. Hand washing has long been a part of our infection control practices in hospitals. 

What happens next?  Once you see the doctor if we need an MRI or another test it is absolutely still available.  In some cases, there may be a bit longer wait given those facilities are also implementing procedures for social distancing and cleaning, which may mean more time between appointments.  But overall, tests, medical procedures and surgeries are being done as they were before this pandemic with a little additional caution. 

After visits with my patients, I am asking folks to stay in the room, and once the coast is clear from other patients in the common areas, my staff review any needed next steps with you directly and help you exit seamlessly and as socially distant as possible.  Once you exit our building our staff does a diligent job in cleaning the rooms before we move on to our next patient.

Bottom line:  there are some small changes to protocols to try to keep patients safe, but no other large ones you should worry about. You need to be mindful of local stay-at-home orders and the pandemic is absolutely still out there. But, we are here for you, and we are all doing the best we can in this challenging time.  Stay safe!