Ankle injuries and shin splints are fairly common in various outdoor activities. They are usually minor and can heal quickly when properly addressed.
Ankle soft tissue injuries are divided into three grades, I, II, and III.
- Grade I describes a stretching of the ankle ligaments without tearing of the collagen fibers that provide the bulk of the structure.
- Grade II describes a partial tearing of the fibers without a complete rupture.
- Grade III is a complete rupture.
A careful physical exam of the ankle joint by an experienced examiner can accurately grade the injury. X-rays can determine if a bone fracture has occurred with the ligament rupture.
Fortunately, surgery is rarely required initially because if specific treatments are instituted early, the results of non-operative treatment can often match the operative treatment; conversely, the results of late surgical treatment of unstable ankles can be excellent in experienced hands.
When an ankle is injured from twisting in towards the other foot, called an inversion injury, most commonly the anterior talofibular ligament is stretched or torn. If the two other primary ligaments on the outside of the ankle (the posterior talofibular ligament and the calcaneofibular ligament) are also injured the primary bone of the ankle, the talus, can be displaced from beneath the tibia, and the ankle “shucks” out of joint.
A physician or trainer examining the ankle soon after an injury can compare the amount of “shuck” to the opposite ankle and develop a grade for the amount of injury suffered. Usually, if the injury is limited to one ligament, the instability is less. If all three are involved, the ankle is more unstable.
The nerve supply to injured ligaments can also be injured. The nerves provide “proprioception” or position sense, in effect telling the brain where the foot is in space. In the healing process, it is critical to re-train the healing ligaments to regain the neural connections required for a stable ankle. Specific exercises can effectively do this.
Ankle injuries, in the past, were often treated with cast immobilization for six weeks or more. We have found that this is detrimental to the healing tissues. When injured collagen tissues are immobilized, the collagen heals in a disorganized fashion, producing scar tissue. The tissues are weakened by the lack of normal motion and stress required for tissue nutrition and organization. The injured nerve fibers have difficulty reestablishing the proprioceptive sense for the ankle.
Treating Ankle Injuries
A freshly injured ankle usually swells and hurts at the site of the ligament damage. The principles of treatment are icing, stabilization, early motion, and proprioceptive and strength training.
Immediate icing diminishes the swelling and actually speeds healing by decreasing the subsequent swelling-induced limitation of motion. Icing three to four times a day for the first 24 to 48 hours is required, as the maximal tissue swelling occurs during this period.
Heat is only used in fresh injuries after the initial swelling period has resolved. In general, heat is used to warm up before exercise, and icing after exercise to diminish swelling.
Stabilization of the injured ankle is best provided by an Aircast splint which provides both compression and protection, but simultaneously permits motion in the safe range for the injured ligaments. If such a splint is not available, ace wrapping and taping the ankle can help.
Early motion exercises of the injured ankle are required in order to diminish the swelling and prevent ankle stiffness. By carefully identifying which ligaments are injured, the safe range of motion that gently stresses the ligament while avoiding harmful deformation can be prescribed. The stimulation of new collagen formation along the lines of maximal stress is critical to achieving a strong healed ligament. The first day after an ankle injury, proprioceptive and strengthening exercises can be commenced if within the safe range of motion. For proprioception, “stork stances”, which are single-leg standing with the eyes closed for one minute, provide excellent rapid small muscle training for the foot stabilizers.
Since ankle injuries occur by rolling the ankle over to the inside, any motion in the same direction or opposite should be avoided. Therefore straight pointing and flexing of the ankle in a pain-free range of motion is recommended 7-10 times daily. If any of these exercises cause pain, don’t do them!
The gastrocnemius and soleus muscles of the calf are the prime movers that point the foot away from the body. To exercise these muscles, place the uninjured foot beneath the ball of the injured foot. Gently apply tension and push the foot straight away from the body.
To strengthen the main muscle in the front of your ankle, the anterior tibialis, place the uninjured foot on the top of the injured ankle and slowly flex the ankle toward the knees, hold and slowly return to the starting position. Do both exercises for 3 sets of 10-20 repetitions.
Additional exercises may be performed if pain-free.
A very simple exercise is the two-legged one-third knee dip. Stand with equal weight on each leg in a partially bent-knee position, slowly bend both knees to a 90-degree angle and slowly return to the start position. Progression into a single stance one-third knee dip is started when the athlete is able to perform the exercise without pain. Do 3 sets of 2-3 minutes. All exercises should be performed in the ankle brace to help give support, control motion, and most importantly to protect the ankle from rolling over again.
At 2-3 weeks, activity can be resumed if the ankle is pain-free in athletic footwear. At 4-6 weeks, upon physician approval, gentle straightforward running, inversion, and eversion exercises may be started. Before actually running, two-legged stationary bicycling and running in place should be tested. If performance is pain-free then outside bicycling and running is allowed.
The goal of early motion and strengthening exercises is to return the athlete to sports with a stable strong ankle, which should be able to be accomplished in most ankle ligament injuries.
Surgery is highly successful for chronically unstable ankles that have not adequately responded to an exercise program. Newly designed techniques that isolate the repair only to the ligaments and joints involved and careful rehabilitation exercises designed to be compatible with the surgical procedure immediately thereafter have resulted in excellent success rates.
Prevention of ankle ligament injuries is accomplished by conditioning the lower extremities prior to playing sports, and by wearing supportive shoe wear. The exercises described above are best performed prior to injury.
Ankle injuries can be diminished by preseason training and supportive shoe wear. They should be aggressively treated to provide the most stable result and the earliest return to sports. For chronically unstable ankles, a careful exercise program can improve performance and if necessary, a carefully designed surgical procedure can correct the most difficult of chronic instabilities.
Symptoms include pain in the calf or shin area (usually along the medial, lower half of the tibia, anywhere from a few inches above the ankle to halfway up the shin) that is sometimes accompanied by swelling or bumps over the bone. The repeated running cycle of pounding and push-off results in muscle fatigue, which may then lead to higher forces being applied to the fascia, the attachment of the fascia to the bone, and finally the bone itself. Respectively, this represents a spectrum from mild to severe. On the relatively more severe end of the scale, the injury may progress from a stress reaction within the bone to an actual stress fracture.
In the early stage of shin splints, a runner will describe a pain that is present when the run first begins, but then may disappear as running continues. This disappearance of the injury may be due to the warming of the muscle and added adrenalin. The pain will most likely return after exercise or later in the day. As the severeness of the shin splints progresses the runner will experience more and more pain, especially every time their foot meets the ground. This tender area caused by the shin splints can be felt by pressing with the fingertips along the bone. If ignored, or if the area of pain is sharp and focused on a small area along the tibia, a stress fracture may be considered.
Causes include overuse, imbalance between gastrocnemius, soleus, and tibialis anterior, old shoes, improperly fitted shoes, heavy foot strike, an extended period of down-hill running, improper gait, too much weight being carried while running.
Preventing Shin Splints
Prevention includes proper stretching and strengthening of the muscles of the calf to prevent any imbalance in that area. Be certain the landing of the foot is soft…especially when running downhill. Vary the runs, and increase the volume of intensity and distance slowly. Be certain the running shoes that are worn are fitted properly. In some cases, orthotics may be needed. In some cases, weight loss may be needed.
Treating Shin Splints
Treatment is rest. For a period of time, running may have to completely stop, all depending on the severity of this injury.
P.R.I.C.E. (Protection, Rest, Ice, Compression, and Elevation) is a treatment as is massage. However, the most important treatment and preventive strategy is to remedy the cause that leads to the injury. Understanding the circumstances that lead to the shin-splints is key to preventing them from recurring.