Ankle rehab – Did you know ankles are actually connected to people

Faraz Sethi – MSK Physiotherapist

Patient Perspectives

 ‘There is an inner voice of it reoccurring; the fear of having another episode prevents you from doing stuff, I don’t want to sound melodramatic, but there’s definitely a feeling of anxiety and low self confidence, I don’t feel good about myself or the world’

What the hell does the above statement have to do with an ankle sprain? Well, this is what I heard two weeks ago in clinical practice from a 34-year-old female, recreational netball player who had quite literally ‘had enough’ after no-one was able to validate her pain experience from the past 3 years. All she wanted was some empathy…not a diagnosis.

‘It was pointless going to A+E, waiting for six hours to be told by the junior doctor on call to rest it, ice it, no netball for four weeks’ she explained, as well as leaving with a bag full of medications and creams. Sound alarmingly familiar? Don’t worry. It’s pretty common practice and we have been in this predicament numerous times.

Rationale

The aim of this blog is to discuss reasons and rationales for why we still treat an ankle sprain as an innocuous injury or the long lost child of the human body? How many times have we read, heard or seen clinicians talk about a type of ankle sprain, the grade of an ankle sprain, the anatomy of an ankle sprain or what to do after an ankle sprain? Caffini et al, 2022 suggest that management of lateral ankle sprains need to be a lifelong learning process.

Do you get bored hearing and seeing the same monotonous information! I certainly do. After all, what’s the bloody fuss about an ankle sprain anyway?

We don’t know as much as we think we do

Let’s think about all the evidence based research at our disposal. When it comes to ankle sprains, try to visualise the diagram below. We are still only scratching the surface with what we know and what we do. There is a substantial amount of information that is undiscovered and we are still trying to figure it out. Ankle sprains are no different! One thing that will always remain a constant however, is our ability to communicate with our patients ensuring all their pains and problems are validated even if you can’t explain or fully understand them.

Statistics…sigh!

Granted, there are over 300,000 ankle sprains presenting to emergency departments annually in the UK (Ferran and Maffulli, 2006), 85% of which are accounted for, by lateral ankle sprains but are we actually taking a step back and understanding the person’s narrative. Approximately 64% of individuals who sustain a first time ankle sprain do not seek medical treatment (Hubbard-Turner, 2019). This is because patients can just Google the Ottawa Ankle Rules and make their own informed decisions about what they should or should not do. Patients can follow a particular ‘algorithm’ or ‘clinical practice guidelines’ (I hate these), that just position them into a box without actually validating what actually could have been the underlying and rudimentary cause of the ankle sprain.

In addition to an individual’s physical abilities, his or her mental state is also poignant for optimal recovery and return to normal life after an injury, not just the shitty ineffective no-evidence based treatments that we overvalue sometimes.

The lonesome ankle

Let’s compare an acute ankle sprain to an acute neck pain episode. Why are we so meticulous about shielding the neck and understanding people’s ideas, concerns and expectations as well as validating their pain experience whereas with the ankle we don’t give a shit and are only concerned with the mechanism, grade of injury or the return to play time frame?

By and large, clinicians focus on the biomedical model and very intermittently on the psychological, contextual and social components. How we move is ultimately dictated by patterns that our brain wants us to carry out and this is affected by all the things discussed above. Would you agree? If yes, then keep reading.

The expectations and beyond

Why do clinicians not consider how the brain can dampen pathways through the spinal cord to the ankle as communication breaks down? Why do we not think about social determinants  to ankle sprains such as depression, bereavement or redundancies like we do when considering mechanical back pain? The assumption that ligament damage at the ankle and the associated afferent sensory changes must be having an influence on efferent outputs is a million percent true!

Opinions are like assholes – everyone’s got one!

As a clinician I robustly believe we need to quickly shift from the pathophysiological process associated with ankle sprains and focus more on a person’s emotional state, cognitive processing abilities and subsequent behaviours.

According to a recent mixed method systematic review by Cotchett et al, 2022 looking at psychological factors associated with foot and ankle pain, 18 studies were included of which only 1 study looked at the impact of lateral ankle sprain on self efficacy and function! This is merely not good enough.

In my opinion (and it’s not always the best) this is what ankle rehab in 2022 looks like:

Brain, chain, ankle sprain

If we really want to advance our patient’s outcomes and expectations from these recurrent and sometimes chronic ankle sprains, there needs to be a paradigm shift in the research and also in the way we, as clinicians approach our patients. Let’s focus on a patient centered approach rather than how many side hops an individual can complete in 15 seconds. Let’s appreciate a patient’s commentary and background to their story rather than focusing on shitty, ineffective, non evidence based modalities. Progressively load the brain, chain and ankle sprain connection, not just physically but emotionally.

After all we are treating an individual with an ankle sprain not just an ankle sprain on an individual!

Key Points

• Validate your patient’s pain experience.
• Treat the ankle like family…not a friend.
• Communication, critical thinking and clinical reasoning are helpful, not hindering
• Think about things above the ankle! The brain and ultimately the person

Thanks for reading - Faraz