I think I broke my ankle while out running! (updated)

I went for a long run in the hills with my brother-in-law 10 days ago. It was very wet, windy and cold. I went over on my ankle. There I lay in the mud, clutching my ankle, screaming every four letter word in the vocab (good pain management technique).

Choosing pain over death from cold, I hobbled my way towards home, even managing to break into a laboured one-legged trot now and then.

The actual damage to the outside of the ankle that was sprained did not seem that serious despite the bleeding and swelling (I have such skinny ankles that swelling never looks that bad). What really hurt the most was the inside of the ankle affecting the base of the tibia bone.

Treatment

Well, first priority was to warm up, so it was straight into a big hot bath of Epsom Salts (And a beer!) for an hour or so as soon as I got home with my ankle propped up (elevation). I did not bother with ice or compression, much preferring elevation as the best means of preventing further bleeding while not compromising circulation and metabolism (Bear in mind that well over an hour had already passed since the sprain so the initial clotting was complete).

You can see in the photos the damage to both sides of the ankle and the associated bleeding and swelling (Photos taken 12 hrs post injury).

Within 12 hours I was walking carefully trying to maintain proper foot mechanics and not allowing the foot to turn outwards. Proper foot posture and normal movement during healing ensures scar tissue is laid down in the right places and in the right direction.

I did not compress or ice the injury at all, preferring to continue the elevation and relying on normal movement to manage any swelling.

At about 36 hours I had my partner, Alofa, commenced very gentle massage on the area to promote circulation and reduce the swelling. This massage became progressively more vigorous as each day passed with the emphasis more on softening up the injured areas.

There has been no change in diet other than to take some glucosamine, chondroitin, Reparen and MSM to help recover from the destructive wrench to the joint and damage to the surrounding tendons and ligaments.

A quite large lump of hard gristle was found behind the Achilles tendon. This was an area that had given some pain over previous years when doing extremes of exercise, so the opportunity has been taken to do deep tissue massage to soften and free this up.

As swelling diminished and pain disappeared it became apparent that I might have fractured the medial maleolus of the ankle. When I went over I think I compression-chipped the margin of the ankle joint and possibly caused a hairline fracture a few mm further up. Still, no worries: 10 days have passed and I am walking without a limp and kind of jogging. My goal was to be running within a week; but that might have to be put back a few weeks.

While I wait for the bone to settle, I can do some house-keeping like dealing with that troublesome lump of gristle.

Questions:

Why didn't I go to the hospital?

• The thought of a hot bath was much more inviting than hanging about for hours in the A&E. If I thought it was more serious than it first appeared I would have been off to the Doc the next day.  
• Going straight to hospital risks sitting about with the ankle blowing up with blood.  Medically there is nothing that can be done other than to x-ray, strap the ankle, give you a pair of crutches and show your the door!  It is better to go home and stabilise the injury, get warm and dry and have a feed.

If you think you fractured your ankle shouldn't it be in plaster?

• Probably, but it is not an unstable fracture as far as I can tell and so long as I am careful it should heal quickly. Besides, I am able to maintain muscle strength and balance thus avoiding the problems of rehab once plaster is removed.

Why did you sprain your ankle?

• Other than the fact I was running down a very muddy, slippery trail, I think it has a lot to do with my shoes. I switched from wearing Asics trail shoes to a similar pair of Nike. I mildly sprained my ankle the first run in the Nike and a further time not long ago. This is despite them being designed for off-road stability. I think I am being sent a message: go back to the Asics!!

(Gary Moller is available for individual consultations about training and injury issues)
For the latest article about this injury go here.

Medial ankle pain following a lateral ankle inversion injury

I am from Korea and I used to be college basketball player but recently moved to U.S.  I had superior athlete body shape before I injured my ankle last November.  It was eversion sprain(deltoid ligament), I usually have multiple inversion sprain during practice or game but this one was pretty severe so I decided to use crutches. I lost noticible muscle on lower leg.

A warning about rigid sports ankle braces

Of growing popularity among athletes with weak ankles is the use of rigid or semi-rigid ankle braces, similar to the ones in the photo to the left.

While these may reduce the risk of further ankle injury by way of spraining, there may be the risk of developing serious injury to the Achilles tendon and calf muscle where the edges of the ankle brace bite into the tissue during vigorous and repetitive movement.

Such was the case of an elite netball player who presented with what she thought was a calf muscle tear. On examination, it was discovered that there was evidence of a calf muscle injury at the junction where the Achilles and the calf muscle merge. The point of injury was exactly where the upper borders of her ankle braces were biting into the back of the legs. There were clear indentations in the flesh. These indentations can be seen when you look very carefully at the photos of the legs (Double-click on the images to blow them to full size).

Conclusions:

• Rigid ankle braces are capable of causing injury to the calf and Achilles tendon.
  
• If you have weak ankles, a rigid ankle brace may be beneficial; but should only be regarded as a temporary crutch to be used while normal ankle strength and function is restored.
  

Struggling with pain from an ankle injury

Hi, I am a 30 year old struggling with pain from an ankle sprain injury that has not healed. I sprained my ankle in an inversion type of injury in June 2007. There was never any swelling in the ankle at all, and I did not seek treatment. Over the coarse of the next 3 weeks, I noticed a throbbing ache in the outer aspect of my foot toward my outer heel area. I wrapped with an Ace bandage and tried to limit my walking. I also was a runner/could run 4-5 miles 3 times a week until this injury.

Eventually I saw the primary care dr. and he dx me with an ankle sprain and ordered a air cast for my foot. It seemed to help the pain at first and I increased my walking and 5 days later I could not bear weight on the foot.

I had an MRI and a CT scan which showed no torn tendons/ but small tears in my post tib tendon with an accessory navicular bone. Also a tarsal coalition that I never knew I had was dx'd at this time, however my foot looks completely normal. All of my pain is on the outside of my foot. I have done pt for 3 months with ttle improvement. I am doing accupuncture now, but still take a lot of medicine for pain. Ibuporfen/Aleve/tylenol arthritis. I can stand and walk for 1.5 hours on my foot and have a lot of muscle wasting in my calf on my left leg as I continually favor that leg.

My doctor wants me to start on a medicine called Cymbalta which is an antidepressant. Apparently this medicine is also for neuropothy. This pain is real and I can't seem to find any help for my pain. I will try to do your exercises for the calf muscles. do you have any thoughts? I also am doing accupressure massage to my peroneals. Thanks for your time! -Joi
_________________________________________
Gary Moller responds:
Joi,
Therapy to assist recovery following an injury should always focus on assisting the body with healing itself. On occasion, there can be a place for various drugs, surgery and immobilisation. But these should never be at the cost of impairing natural healing processes. Nutrition, some supplements, rest/exercise, massage and Old Man Time should be the mainstays of injury rehabilitation.

Please have a read of my other articles about ankle pain here.

From what you have written, I can see no reason for prescribing Cymbalta for your ankle pain, if that is the reason given. While the injury may be depressing and frustrating, this medication has far too many risky side effects. The best action for feeling depressed about a sore ankle is to deal as best one can with the ankle through positive action. All that anti-depressants can do is dull the brain to the reality of the situation. Avoidance by way of dulling the brain is not positive action. I might add the same cautions about adverse short and long term side effects apply as well to the various pain medications that you are presently relying on to get through the day. Having said this, please discuss your needs with your doctor, including what is advised in this article, thank you.

You should heed my advice here about ankle pain.

In addition, you need to take the accupressure massage a step further. Find a trained therapist who can deeply massage all of the knotted and painful areas of the calf and ankle. This should be done about every 4th or 5th day with rest between to allow healing. The therapist should also be mobilising and tractioning the ankle and the various other joints of the foot. Where you have painful joint margins, the therapist should massage these, applying progressive finger pressure as pain permits. This massage breaks up and softens areas of scar, swelling and toxic buildups. As the massage progresses during a session, the intensity of the pain should diminish. You may feel a little bruised for a few days after. This is to be expected and the bruised gristle will eventually be replaced by healthy, supple tissue that is pain free.

The supplements, including vitamin C referred to in the article here are important when getting this kind of massage therapy. If it is going to work, you will notice a significant improvement in the pain levels after 4-6 sessions. Each session should last about an hour. Above all else, give things time and do not be panicked into radical therapies that can not be reversed.

Please keep in touch and let me know how you get on.

Severe ankle sprain, chronic ankle pain and cortisone injections

Dear Gary,
You have a great website. You must feel proud and blessed to have helped so many injured people. May God bless you.

Long story short, severe right ankle sprain in July 2007, 4wks. later MRI shows 2 torn ligaments and sinus tarsi syndrome, sl. marrow edema, alot of pain w/ weight bearing and less at sleep, Oct. 2007 MRI shows slight diastasis of tibia, and one remaining torn ligament, worsening of sinus tarsi syndrome, have had pain everyday, worse w/ increase in weight bearing, can be pain free while sitting, pain at night varies, off and on. Saw the lead instructor at the XXXX school of podiatry, he was doing very conservative treatment, but my workman's comp. agent and family was annoyed at my slow progress and inability to walk much (due to increased pain w/ ambulation). So I saw another doc , ankle/foot surgeon from XXXX University Hosp. He focused on the 4mm? diastasis occurring by my fibula, pulling away from my tibia, and wanted to do surgery and insert a syndesmotic device which is a screw in the tibia, then a screw in the fibula, then a wire that pulls and keeps the bones together, which will "fix my ankle". I read up on this device, and being overweight, I am not a "good candidate". In Nov.15th, 2007, I saw another ortho. ankle doc at XXXX Hospital. He did stress fracture xrays and then injected my ankle w/ 4cc =1cc of cortisone agent and 3cc of lidocaine=4cc injection. My gut told me that's alot of fluid, and where will it all go in the ankle area? Well it went in OK, he injected under guidance of an xray, (not ultrasound). I was in pain that day and severe pain that night. Called the next day, his nurse told me I was having an injection flare, very common. Keep taking motrin and ice it. I did so all weekend. The next week the pain continued, I called and called, saw him the next Monday11 days after the injection, I also was running a low grade temperature everyday 99.3-99.8, even with motrin everyday. He said I did not have an infection. The site looked sl. swollen, like the fluid was under the skin, but it 'Burned" so bad, off and on, the pain was worse than before I saw him. He told me he was baffled and I should see his partner. He took more xrays, which showed nothing new. He did not address the fever, as they did not have a thermometer to check my temp. He gave me a note to be off work for 1 week, as I was now back in a walking cast and on crutches. It hurt too much to walk. The next week, Dec. 3rd I returned to work, non weight bearing, desk duty, 4 hours a day only. He wants me to begin physical therapy now. I did nothing this week but work.

I am scared. I still have a really intense deep burning that occurs usually after I have been on the foot abit, in the area he injected. It's a very intense burn, that stops me in my tracks, and I have to shake the foot as it feels like it's on fire. Then it passes, and I can breathe. What do I do now?

How can I flush or minimize the cortisone/lidocaine from eating up my nerves or ligaments? Have increased my fluids.

Photo: An example of a cortisone injection gone wrong

I never had this burn, until after the injection. My low grade fever broke on Thursday Dec.6th...98.8 and 98.3. I had no other illnesses, no UTI, not a sniffle. I am healthy except for this ankle.

Also, I have sprained this ankle before, in 2002, and again in 2005. I was off work 1 week in 2005, then returned to weight bearing duty quickly, and did PT....found PT little to no help. During my last session, the P.T. had electrodes that burned my skin, so I skipped any future sessions and seemed to heal OK. My ankle would hurt if I was on my feet all day, hiking, or really walking non-stop for 8hours. Then I would take motrin and it was better.

_____________________________________

Gary Moller replies:

Charlotte,

I appreciate your deep concerns about what is happening and the pain you are suffering right now (I fractured my own ankle a few months ago and have suffered several bad sprains over the years).
Ankle sprains, even severe ones tend to resolve of their own accord if given the time. An ankle sprain can remain painful for a year or longer. I am very much in favour of conservative treatment and giving the body time to do its healing work. To administer cortisone injections into the painful site just months after the injury is not conservative. Even if there are signs of slight instability between the tibia and fibula, I would still play a waiting game rather than operate. It just makes no sense to chemically excise structural tissue that is already weakened through injury. Having said this, please discuss your needs with your doctor, including what is advised in this article, thank you.

The body has a remarkable capacity to heal of its own accord. All you have to do is help it by providing the right conditions such as:

• Going on a weight loss programme if overweight - not by starvation but by a natural wholefoods diet plus exercise
• Exercise in the form of aquajogging and aquaerobics - the partial weightbearing and hydraulic pressure burns calories, stimulates the citrculation, reduces swelling and strengthens the muscles
• Glucosamine and chondroitin 3 times daily to assist joint healing
• 2,000 mg vitamin C daily to assist healing and to reduce inflammation
• 2,000 mg daily of fish oil with vitamin E to assist healing and as a natural anti-inflammatory
• MSM (Methysulfonylmethane) daily. MSM is a natural anti-inflammatory and aids healing.
• Massage the area using effleurage and depp tissue massage techniques. The effleurage can begin immediately following a sprain and the deep tissue massage which can be painful can commence gently within 3-4 days of the injury and become more "forceful" as the weeks turn into months.
• Soak daily for up to an hour in a very warm Epsom Salt bath. The Magnesium and Sulphur aids healing and relaxes and the heat improves circulation.

All of these products are available from my website store

These measures may assist with giving you some relief from the pain associated with the cortisone that was injected. You might like to add a quality natural vitamin B complex to the supplements, since any deficiency in these will add to muscle and nerve pain and you don't want that.

Please go easy on the Motrim which has a raft of nasty side effects if taken over a prolonged time, including liver and kidney damage. Try as much as possible to put up with the pain and to use natural remedies like those listed above that improve health, rather than risk compromising it.

Your history of repeated sprains indicates that you have disrupted the nerve proprioceptors in your ankle. A weak ankle is more to do with the way your reflexes respond, rather than to do with weak muscles. As you ankle pain subsides, you need to commence doing balance exercises. You need nothing other than to be bare foot and practice balancing on one foot and then the other. Once you are proficient, progress to balancing on the ball of each foot. Once you master this, practice these with your eyes closed. Do these daily and you will develop strong and stable ankles.Charlotte, I hope that this advice helps somewhat for what is a painful injury that is very slow to recover from at the best of times. Whatever has been done from the cortisone is done and dusted and the focus must now be on recovery. Having said this, I would still be going back to the Dr that injected you and ask what he/she is going to do for you (So long as it does not involve more drugs or invasive treatment), since the cortisone appears to have made you worse, rather than better.

Take your time, give healing time and do not panic. Time heals eventually.

Treating a sprained ankle

Dear Gary,
I have quite a nasty sprained ankle that happened whilst running (in the dark!) on Wenesday morning last week. I landed badly on some uneven ground and my foot went over and I felt intense pain and some bad pulling/tearing sensations on the outside of my ankle - either side of the bone. I managed to make it home, but the next day it was quite swollen, and has come down now but is still tender.

I can walk quite happily, but don't want to get back running too soon in case of more damage. How long do you think I should wait before beginning to run on it again? Should I have had any treatment on it, or will it just take time to heal? Do you forsee any long term problems - or are there some exercises that I could do to help strengthen it apart from just running? I would appreciate your advice, as I am really missing my runs at the moment!
_____________________________
My reply:
I think you will be ready to start running now. Ankle pain can last for months but is no reason not to get out there.

Read this carefully: http://freerangers.blogspot.com/2006/05/pouring-cold-water-on-ice-therapy-for.html

Start on soft ground and gradually build your speed and duration. You might like to do some aquajogging as well, if you are inclined.

Another measure is to purchase some Nutra-Life Joint and Cartilage Repair and take it regularly for as long as there is any discomfort.



Go to a sandy beach and power walk up and down the soft dunes barefoot and then briskly wade in the cold shallows for 15-20 minutes.

Finally, practice balancing on each foot, eventually with eyes closed. This restores the reflexes to the ankle as well as strength.

I hope that this helps. Let me know how it goes, thanks.