High Ankle Sprain

Typical ankle sprains are sprains of the anterior talo fibular ligament. The high ankle sprain also involves the syndesmosis between the tibia and fibula as well. The big difference is that while the ATF ligament sprain does well with early mobilization, the high ankle sprain needs to be stabilized in a cast boot for three to six weeks. Failure to do so almost ensures arthritis long term. Once out of the boot, the rehab is about the same as for any ankle sprain.

You should progress from balance to balance challenges to loading (lunging and elevation changes) , to impact loading (jumping and hopping) to running with cutting, stop/start and turning.

Acutely, RICE therapy is appropriate, but weight bearing should be in a cast boot for the best outcome. Its best to wear the cast boot for at least 6 weeks to allow the tissue to heal to a sufficiently strong repair.

Remember at 3 weeks, the scar will be present, but weak, only 15% of its final integrity. At 6 weeks, the scar will be 42% of its final integrity. At six weeks, 42% strong, the scar can tolerate much more loading than at any time earlier.

Better safe than sorry. A high ankle sprain in a cast boot means back on the field with little or no residual long term effects. To early back to the field of competition, and you are risking a chronically irritated ankle with arthritis developing over time.

Why 6 Weeks to Return to Sport?

In a word, scar tissue formation.

Interestingly, the way the body deals with an injury is by forming scar tissue. We repair, and we do so with remarkable alacrity. The process of the scar both becoming stable and tolerant of tensile stress is pre-determined. Assuming everything goes well, there are very specific time lines.

• Between 0 and 4 days, there is no prepair per se', just bleeding
• Between 4 days and 15 days the construction of the "scaffolding of repair" takes place. This scaffolding is not tolerant of tension, but it gradually picks up strength
• By day 21, the scar achieves 15 percent of its final tensile strength. This is good because at three weeks loading is important to help organize the scar and make it as strong as possible - more of this later.
  
• By day 42, six weeks, the scar achieves about 40% of its final integrity, and there is much that one can do on a scar like that has achieved this level of tolerance without irritating the injury.
• And by day 90, the scar achieves 90# of its final integrity.
  

The process that the scar undergoes, building of a scar from the initial injury, is significantly impacted by the introduction of tension. The reason for this is that the cells that build scar, fibroblasts, have a pole like the earth has a pole, and with intermittent tension, the cells align themselves parallel to the lines of stress, and the scar tissue fibers they lay down are also placed parrallell to the lines of stress. This leads to a stronger and healthier scar that is tolerant of stress as those fibers bond with adjacent fibers.

The trouble with return to activity after ACL surgery

The trouble with return to activity after ACL surgery

I often find myself talking people with recent ACL repairs to hold off on returning to running activity for as long as possible. The reason is that long term studies show that ACL repaired knees have more degenerative changes 10 years out than ACL rupture knees that were not repaired. I firmly believe that the reason for this is premature return to activity.

Returning to full function should be something that one does on a gradient. This means that functional strength needs to be fully restored over a six month period and the transition to athletic running (cutting, spinning, sprinting and generally changing direction) should be fully recovered after the ability to lunge, jump (take off on one leg land on two) and hop (take off and land on one leg) has been fully restored in all three planes.

Return to play, then should happen after that and again, there should be a gradual increase in field time at match pace. This is especially true in contact sports like soccer, basketball and football.

As an athlete in these sports, my advice is to work up to full match participation by gradually increasing the amount of time you practice at full speed and similarly gradually increase your time on the field in competition.

The moral of the story? Be PATIENT. Recover fully before participating, and protect your knee's long term health after ACL reconstruction.