Barbell Medicine - From Bench to Bedside

You rolled your ankle, whether it be in a pick-up basketball game, stepping awkwardly off the platform, or performing your best interpretive dance of Kenny Loggins’ “Danger Zone”. The ankle is now swollen, painful, and you are wondering what to do next. This article will provide a guide to return to doing the things you love.

What is an Ankle Sprain?

The bones and joints of our skeleton are held together by connective tissues called ligaments. By definition, a “sprain” describes a stretching of a ligament beyond its capacity. Sprains vary in severity on a spectrum, ranging from small micro-tears to complete ligament ruptures. Most systems used to grade the severity of an ankle sprain use ambiguous labels like “mild,” “moderate,” and “severe” that do not provide a clear description of the injury.

Upwards of 85-90% of ankle sprains involve an inversion or lateral ankle injury. This describes a situation where the foot rolls inward, injuring the ligament on the outer part of the ankle. The specific anatomic structures that can be involved include the anterior-talofibular ligament (ATFL), calcaneofibular ligament (CFL), and/or posterior-talofibular ligament (PTFL). The ATFL is the most commonly injured structure in a lateral ankle sprain. In fact, lateral ankle sprains are the most common skeletal injury in physically active populations, so if you have experienced this you are certainly not alone. Pain typically decreases rapidly within the first two weeks after injury. Timing the return to normal activity depends on the severity of the injury, as well as the level of performance a person needs. For a regular person doing recreational activity this may be a few weeks, whereas a high-performance athlete may take a longer, on the order of a few months, to return to peak performance.

Although much less common, people can also experience eversion or medial ankle sprain. In this situation the ankle rolls outward, leading to an injury of the inner ankle that affects the deltoid ligament. Isolated deltoid ligament sprains are uncommon and often require further medical evaluation to check for fractured bones (see criteria below).

The third type of injury is a “high ankle sprain”, or syndesmotic ankle sprain. These involve the thick ligaments that hold together the tibia and fibula, which are the two major bones of the shin. This injury typically involves extreme dorsiflexion (pulling your toes up towards your head) and external rotation. They are more common in American football, rugby, and downhill skiing. Of the three mechanisms of injury, high ankle sprains typically require the longest recovery, and may even involve a period of non-weight bearing on the injured leg.

The main question that arises after an ankle sprain is, “Do I need to see a medical professional?” While a severe ankle sprain can be cause for concern, the major reason for evaluation is the need to rule out bone fractures. For that, we use a validated system known as the Ottawa Ankle Rules. These guidelines offer predictive value for a fracture that would change the course of evaluation, and are as follows:

  • Could you take 4 steps immediately after the injury and now?
  • Bony tenderness along distal 6 cm of posterior edge of fibula (bone on outside of leg)
  • Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
  • Bony tenderness at the base of the 5th metatarsal
  • Bony tenderness at the navicular

The obvious counterpoints here being that after an acute injury, it is pretty common for everything to hurt and you need to have an understanding of anatomy to know where these locations are to palpate. As a result, these rules are best applied by a trained professional. But to distill the recommendation down to practical recommendations for regular folks: if you cannot bear weight on your leg after spraining your ankle, you need to be evaluated by a medical professional.

If you can bear weight, and are not tender in the aforementioned areas, it is likely that the injury can be managed with conservative care and continued activity. However, programming adjustments are likely required, depending on the person’s abilities, limitations, and goals. A powerlifter looking to continue squatting will have a different set of needs than an athlete needing to return to basketball. One athlete’s sport is predicated on standing in one spot while the other needs to be able to constantly change directions and land on the ankle. This will change the set of things that each athlete would benefit from performing as part of their rehabilitation.

What options are available to manage an ankle sprain?

RICE, PRICE, PEACE and LOVE

The traditional advice following an ankle sprain has been Rest, Ice, Compression, and Elevation (RICE), and subsequently added “Protection”, turning the acronym into PRICE. However, absolute rest rarely does an athlete any favors. Noone has ever maintained any athleticism with absolute rest, nor does the evidence support rest as a primary treatment after a sprain. In fact, rest and immobilization lead to worse outcomes compared with continued activity and functional support.

The evidence for ice and compression is lacking as well. To be clear: you certainly can use ice and compression after an ankle sprain for symptom relief, but there is no good evidence that these can expedite healing or return to sport.

The most recent iteration of the management acronym has become “PEACE and LOVE” standing for: Protection, Elevation, Avoiding Anti-inflammatories and Icing, Compression, Education, as well as Load, Optimism, Vascularization, and Exercise. This is discussed in further detail in this article [PDF].

NSAIDs

There are a host of modalities that are often offered as a way to decrease inflammation and expedite recovery but we often forget that inflammation is a necessary component of the healing process and needs to be involved for proper healing. To that end, non-steroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen, naproxen, or meloxicam) have shown to result in decreased pain without increasing risk of harms compared to placebo in the short term (<14 days). There is however, some theoretical concern that they may delay the natural healing process, which has led to some controversy and debate around their use.

Things Clinicians Do To You

In this category are modalities such as kinesiotaping, scraping, cupping, dry needling, laser or other treatments that require someone else to apply something to an athlete’s body. There is no good evidence for any of these modalities for ankle sprains. They are not breaking up scar tissue, releasing adhesions, changing inflammatory responses, or any of the typical explanations given for their use. As mentioned above, most symptoms subside on their own within the first few weeks. While it does take patience on the part of the person, no amount of extra “modalities” will expedite this process. The only thing being sped up by these treatments is removal of money from a person’s wallet.

Bracing/Assistive Devices

 If you have difficulty bearing weight initially, and further injuries (like bone fractures) have been ruled out, you still may need to use an assisted device such as crutches in the short term. In this instance, people are typically recommended to “weight bear as tolerated”, meaning put as much weight on the injured leg as is tolerable. This will help get some movement through your ankle but also allow much more ease with getting around. Once you can walk without a limp, it is okay to wean off crutches. Prolonged non-weight bearing or immobilization is not recommended, unless you have been advised otherwise by a medical professional for a specific reason — which should be explained.

If you feel as though you need additional support to perform activities, an over-the-counter ankle brace can be helpful. A simple lace-up or semi-rigid brace is sufficient and preferable to elastic bandages. Most studies still compare this to immobilization, so bracing beats rest, likely because a person is permitted to maintain some level of activity while recovering. Bracing is not a long-term solution, and while it can offer support in the short term, it is not necessary to return to sport or to reduce the risk of further injury.

Exercise/Loading

As in many other contexts, we argue that exercise should be the main component of a rehabilitation program for ankle sprains, but what exactly does that mean? Symptoms should guide your return to normal activities. If you are experiencing significant pain, your initial exercise may involve shifting weight onto the injured leg and holding it there for a few seconds. It ultimately comes down to determining the entry point an athlete needs, while maintaining as much foundational athleticism as possible. Consider the following progression:

Phase I: Normalize daily activities and weight bearing

If you are unable to bear full body weight on your leg after a sprain you likely do not need to be performing squats or deadlifts yet. The goals in this phase are to be able to walk without significant symptoms, as well as perform normal activities around the house like going up and down stairs. Exercises in this phase should include different forms of single-leg stance, starting with stationary balance, then progressing to exercises like a curtsy lunge, single leg cone touches, calf raises and step ups/downs.

While deadlifts and squats are temporarily out of the picture, you can work on maintaining lower body strength using machines. Leg extensions, hamstring curls, and hip abduction/adduction are adequate substitutes until you can return to the bar. If ever there was a time to work on getting more yoked, recovering from an ankle sprain is an excellent time to work on your biceps curls and triceps extensions, too!

A sample workout may look like:

  • Seated Knee Extensions
    • 4 sets of 8 at RPE 8
  • Hamstring curls
    • 4 sets of 8 at RPE 8
  • Bench Press
    • 1 set of 6 at RPE 6
    • 1 set of 6 at RPE 7
    • 2 sets of 6 at RPE 8
  • Lat Pulldown
    • 3 sets of 10 at RPE 9
  • Single-leg cone touches
    • 3 sets of 8 per leg
  • Curtsy squats
    • 3 sets of 8 per leg through tolerable range of motion

Phase II: Normalize slow athletic movements and work on balance

As activities like walking and stairs normalize, you can begin returning to barbell work. Keep in mind that these initial workouts are intended to expose your ankle to the loads, not raise your one rep max. You may initially be limited to variations such as pin squats or block pulls to allow for moving through tolerable range of motion. The modification does allow for two points of progression with a focus on increased range of motion, and increasing load both being points of success.

At this point, you may still need to incorporate machine training or other supplemental work. The primary goal is still to improve symptoms in your ankle and there is no need to push loads at the expense of increasing symptoms significantly. It is also beneficial to incorporate some dedicated calf work in this phase. The simplest form of this could involve bodyweight calf raises, progressing to calf raises from a step that allows for increased range of motion. From there, progression to weighted calf machines can be useful to achieve the desired load to increase strength. If an athlete’s goal is to dunk a basketball, a bodyweight calf raise is likely an insufficient dose of stress for returning to sport.

A full discussion on what constitutes balance is beyond the scope of this article and we will use a rudimentary definition of “how hard are you to knock over.” If the goal is to accomplish this, when standing on one leg, then we need to train standing on one leg. For the powerlifter whose sport is predicated on both feet being firmly planted on the ground at all times, it is unlikely that a great deal of work is necessary here, but being a powerlifting “athlete” still implies that you are an athlete and, in our opinion, should be able to do some broader spectrum of athletic movements anyway.

There are numerous ways to accomplish this task with exercises and drills from box step ups to rear foot elevated split squats. Emphasizing placing the majority of weight on the affected leg and working on control of the movement is key. Single-leg work in this manner offers a controlled means of beginning to work on balance. As these movements are tolerated better, it is time to introduce speed and change of direction into programming.

A sample workout may look like this:

  • Weighted calf raises
    • 3 sets of 15 at RPE 8
  • Pin Squats with pins at tolerable range of motion
    • 4 sets of 6 at RPE 7
  • Bench Press
    • 1 set of 6 at RPE 6
    • 1 set of 6 at RPE 7
    • 2 sets of 6 at RPE 8
  • Romanian deadlift
    • 4 sets of 8 at RPE 7
  • High box step-ups
    • 3 sets of 8 at RPE 7
  • Rear foot elevated split squats
    • 3 sets of 8 at RPE 7

Phase III: Normalize going fast and changing direction

This phase will reintroduce power, or the ability to produce force in the shortest amount of time. Activities like jumping and sprinting reenter the program, but under the umbrella of balance, it is as much the landing and the slowing down that will be the focus of drills and exercises. Just as the force-time curve of a barbell back squat and a clean differ, there are differences in a maximum effort vertical jump, a maximal effort horizontal jump, and multiple single leg jumps where the emphasis is on speed off the ground. That is not to say that one is better than the other; while a volleyball player may focus more on the vertical jump, there is still benefit from drills that develop horizontal skills. It is great to be able to hit a perfectly set ball, but it is a rare occurrence when an athlete is not going to be pushed out from a set and needs to adjust with some lateral direction to their jump.

Drills here should emphasize speed and force in terms of not only how high, but how fast. For dosing these into a program, maximal effort is equivalent to RPE 9/10 exercises. As a result, they should not comprise a large amount of a workout’s total volume. Like a heavy squat, they should be max effort, followed by near-full recovery. This may look like 3-10 reps of a max effort jump, or 10-20” as many reps as possible.

A sample workout for this phase may look like:

  • Single-leg forward hops for maximum distance
    • 3 rounds of 10 meters on each leg
  • Single-leg lateral hops from one leg to the other
    • 4 rounds of 20 seconds with 90 seconds rest
  • A-skips
    • 2 rounds of 10 meters
  • B-skips
    • 2 rounds of 10 meters
  • Bounding
    • 2 rounds of 10 meters
  • ***If powerlifters are reading this first part and feeling themselves breathing hard, they may benefit from some of these drills in their GPP to increase their overall conditioning.
  • Back Squat
    • Work up to a set of 4 reps at RPE 8
    • Drop 10% and complete 2 additional sets of 4
  • Bench Press
    • Work to a set of 4 at RPE 8
    • Drop 5% of complete 2 additional sets of 4
  • Reactive cutting drills
    • 5-10 minutes of drills working on having to change direction predicated on an opponent or coach making the athlete react to their movements.

These are sample workouts and there will be a high degree of variation when it comes to return to sport outside of powerlifting. If you need guidance, our pain and rehabilitation team is happy to help with a consultation and/or programming. For most athletes, if you can bear weight after the injury, you can continue training. Rehab may take squats and deadlifts out of the program for a few weeks, but there are countless ways that you can work around the injury.

Ankle sprains are a common injury that many of us have experienced. As with many other injuries, there is dramatic improvement with time and the overall goals will be finding an entry point to continue training and return to prior levels. There is no evidence that any modality speeds up the healing process, and while many modalities tout reducing inflammation, we need inflammation for proper healing to occur. If you find that a technique, icing, or bracing give you symptom relief, it is perfectly okay to use. Ultimately, the goal is to maintain some level of strength and conditioning while your ankle heals, and likely incorporating some balance and power-oriented exercises to make you more athletic, and harder to knock over.

About Derek Miles

Derek Miles is a residency trained physical therapist currently working at Stanford Children’s Hospital as the Advanced Clinical Specialist in the rehabilitation department. He worked at the University of Florida prior for 10 years in sports medicine treating a variety of athletic injuries from overuse to post-operative. He is involved in the peer review process for academic journals and has spoken at national level conferences within the physical therapy profession. If not treating patients or in the gym Derek is likely either cooking some form of meat or reading books related to various random topics. He occasionally brews a pretty good American Pale Ale as well.

Read More by Derek Miles

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