When you think of sprains, your mind will likely go to the ankle. Ankle sprains are the most common lower extremity injury across all of sports. If you grew up as an athlete or are just an active human, chances are you know exactly what I’m talking about. However, for the purpose of this blog I want to take a step back and consider the “sprain” injury as a whole. We’ll use specific examples from various body parts, but I want to give you a framework to understand sprain injuries and what to do about them.
Before we can solve a problem, we have to define said problem. Culturally we use sprain and strain synonymously despite that erroneous assumption. A strain injury refers to or occurs in a muscle. A sprain injury is an injury of a ligament. A sprain injury can also cover a wide spectrum of injuries that are defined by grades as seen below.
Grade 1: stretching of the ligament with potentially small tearing, accompanied by mild pain and swelling without instability
Grade 2: stretching of the ligament with incomplete tearing, moderate pain and swelling with minimal structural instability
Grade 3: large or complete tearing of the ligament with severe pain, loss of function, and swelling accompanied by structural instability
The first two grades are injuries that respond well to conservative care, while grade 3 injuries are more likely to involve surgical consults. However, no matter what grade of sprain you have it’s essential to be proactive in your care. Statistically up to 33% of patients with sprains report pain over a year after injury. This is disturbing considering that many of these injuries are not severe.
So how to you recover from a sprain? Let’s get into it!
The thought process and plan for rehabbing sprains is different than other connective tissue injuries. Remember that tendons connect muscle to bone, while ligaments connect bone to bone. As I mentioned in a previous blog post “The Tale of Two Tendons”, tendons respond only to LOAD. You can recap that blog at: https://www.kprpt.com/post/the-tale-of-two-tendons.
While, tendon injuries are defined by load, ligamentous injuries are defined by LAXITY. Even in grade 1 and 2 injuries where there is little to no structural laxity, patients often feel unstable after a ligament injury. That’s because ligaments have a large role in sending proprioceptive input to our brain. In simple terms, they help give our brain information about how we’re moving and how to respond to our environment. Previously simple activities such as single leg balance, running, throwing, etc are now much more difficult because our brain is driving blind.
Driving blind turns out about as bad as you would think, and statistically 60% of athletes will have a recurring sprain. Meanwhile only 50% of individuals will seek medical help after a sprain.
3 Key Factors in Recovery:
1. Move early and often
Consistent throughout literature is overwhelming support for early mobilization following a sprain. However, you still need to be on the lookout for any sort of fracture. If you injure your ankle and cannot walk 4 steps or have significant bony tenderness, you need an x-ray to rule out fracture. (You can find the specific Ottawa ankle rules here:https://www.physio-pedia.com/Ottawa_Ankle_Rules). This concept applies to other areas of the body as well.
However, if you don’t meet the above-mentioned criteria the best thing you can do is MOVE. Early movement in sprain injuries is associated with decreased pain and faster return to sport/activity. The majority of pain reduction happens in the first few weeks after injury. If you’re resting, immobilizing with a sling, or on crutches you are missing out on crucial healing time and setting yourself up for long term dysfunction. Many health providers recommend crutches and slings for weeks post injury without understanding the literature and significant consequences of doing so. Spend time stretching, walking, moving your body in ways that you can tolerate. Weight bearing should be a top priority as well as specifically targeted range of motion for whichever joint is affected. This is the best time to seek help from a performance PT to ensure that your recovery is fast and you avoid common pitfalls or long term consequences.
2. Build DON’T brace
I just threw shade at the healthcare field for not knowing what the literature says. With that said, you can’t always take research at face value. You have to dive in. You have to critique and ask questions. Is it biased? Does it make practical sense?
For example, current ankle sprain literature recommends post sprain external bracing for one-year post injury. This is why many physicians recommend that you get a brace and shuffle you out the clinic door. The reasoning behind this is that bracing for one-year post injury statistically decreases the chance of reinjury with ankle sprains within that year. It’s statistically true, but it’s bad practice. Let me expound.
The problem is this: What happens after that year?
What happens when you take the brace off?
Of course bracing decreases reinjury rates! You are externally restricting the movement of a joint and providing it with reinforced pseudo strength. We would all be at a lower chance of ligament injury if we wore tight/strong external braces on every joint in our body at all times! Why don’t we do that? For one, we don’t want to walk around looking like RoboCop. Secondly, we understand that our body would become RELIANT on external bracing. When an external force is providing the stability that should come from muscular contraction and neuromuscular coordination, your intrinsic strength goes on vacation. Our bodies are always looking for efficiency, so why make muscles work if they don’t need to right?
Bracing has it’s place for very short term management, such as allowing an athlete to participate in a tournament with an acute injury. However, bracing long term is a recipe for developing reliance, weakness, and intrinsic instability. Instead, our long-term goal should be to BUILD all of the tissues that reinforce the joint and aid in stability and function. For an ankle this may look like targeted strengthening of the gastroc, soleus, peroneals, and tibialis anterior. For an AC joint injury (shoulder), this may be targeting strengthening the pecs, delts, and scapular complex, etc.
If you choose to brace, that is fine. Just understand that you will be reliant on that brace to prevent injury forever. Or you can choose the significantly harder but better path and build a resilient body.
3. Proprioception training is king
Since laxity and instability is a primary problem post sprain, proprioceptive training is a potent rehabilitation approach for these injuries.
The Journal of Athletic Training defined proprioception as, "the neural process by which the body takes in sensory input from the surrounding environment and integrates that information to produce a motor response." In practical terms, this means movements that require balance and dynamic force production.
These movements will have to be initiated cautiously and progressed based on pain and tolerance. The goal is to retrain your brain and muscles to be sensitive to movement and to successfully support your injured joint. In the upper extremity this may look like throwing/catching drills, planking on unstable surfaces, performing strength training with perturbation drills. In the lower extremity it often involves jumping, cutting, hopping, and balance drills. The specifics of your program will be dictated by your specific injury and current irritability. Even with a ligament that is torn, you can retrain your body and brain to provide the stability that you need for sport.
Sprains are common and often not severe, yet there continues to be significant confusion around how to manage them. If you follow the 3 keys listed above you will come out ahead of a vast majority of people with sprain injuries. As always, seek out a movement specialist in your area if you have significant injury that can help you navigate your specific case. Be proactive and don't settle for lifelong reliance on bracing. You'll thank me for it later.
As always. Stay kinetic friends.
References:
1.Rivera MJ, Winkelmann ZK, Powden CJ, Games KE. Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review. J Athl Train. 2017;52(11):1065-1067. doi:10.4085/1062-6050-52.11.16
2.McKeon PO, Donovan L. A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift. J Athl Train. 2019;54(6):628-638. doi:10.4085/1062-6050-474-17
Dr. Levi Kerby is a physical therapist, orthopedic certified specialist, and owner of Kinetic Performance and Rehab in Winston-Salem, NC. He enjoys fly fishing, guitar, various forms of fitness, and treating active and motivated individuals.
If you're dealing with an injury or pain, you can contact Kinetic Performance and Rehab directly below.
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