Managing lower-limb sprains: an experiential perspective

I’ve now sprained three of the six joints in my lower limbs (although thankfully, not all the different ligaments that are possible to sprain!) and in the process I’ve learned some things about sprains.

Go to a doctor

If you experienced a severe enough pain in your joint to make you hesitant about weight-bearing, or if the joint swells a lot, bruises, feels unstable, or doesn’t feel better within a couple days, go to the doctor. Initial diagnoses can be made by emergency room or urgent care doctors, but ideally, try to get an appointment within the first few weeks with a specialist, either a general orthopod or a specialist in the particular joint you injured (like a podiatrist for foot or ankle injuries). Don’t put this off; it can make the difference between great treatment and not-so-great treatment.

Listen to the doctor, but don’t take their advice as gospel

A lot of doctors still prescribe RICE protocol and don’t automatically recommend physical therapy for less severe sprains, especially ankle sprains. Research I’ve done since I was first injured suggests that the RICE protocol may be out of date and incorrect. It’s been partly recanted by its original proponent!

RICE or MEAT?

In particular, too much rest, extended use of ice, and anti-inflammatories are not necessarily beneficial to healing. You probably want to do your own research on this and consult with a professional if you aren’t sure. What I can say is that the research I’ve done points me to not wanting to go fully RICE in the future (especially with anti-inflammatories), and my own experience with physical therapy is that you want a good therapist on board as soon as possible if you have anything but the most mild sprain.

In general I’ve found that self-education is really key for me in terms of understanding the anatomy of the injury, the tests the doctors do, what to expect in terms of pain, prognoses, etc. This might not be true for everyone as I’m kind of an anatomy geek to start with, but knowing that bruising along the heel is a sign of CFL injury or that the MCL attaches further down and farther from the kneecap than the pain I had would have/has helped me understand the subjective pain I experience and what to do about it. I do usually use Google for this and I try to look for medical papers, reputable medical sites, or care centers publishing articles about their treatment philosophy with citations.

How do ligaments heal?

Some people don’t rest at all, figuring “it’s just a sprain” or needing to get back to work, or wanting to take a trip. This is generally not a good idea. The part of “rest” that is no longer thought to be a good idea is complete immobilization or lack of targeted exercises and gradual increases in weight-bearing. Doing too much is also a recipe for pain and slow healing.

Ligaments heal in three phases – first, the acute inflammatory phase (3-5 days) where inflammation occurs and blood flow to the area increases, bringing lots of “stuff” to the joint. This is where rest is good (to avoid exacerbating the injury), and too much ice and anti-inflammatories are not, since that “stuff” is needed. Second, the proliferative phase where lots of new cells are created. This is usually about 3 weeks but might vary a bit depending on the severity and type of sprain. Finally, the tissue remodeling phase, which can last 3 weeks up to a year, where the new cells line up and become part of mature tissue.

Ligaments rarely heal back to their original strength and capacity. For whatever reason the right kind of collagen fibers usually aren’t created. And the healing takes time. So you want to start back to activity starting very slow and gentle usually either after the inflammatory phase or after the proliferative phase. Not getting activity means the ligament doesn’t develop properly. But too much is still going to be bad and might lead to re-injury. Wear a brace during activity or sports if you need to. Sprains often lead to increased risks of arthritis in the joint in the future due to poor healing, so heal up as well as you can and don’t be afraid to take your time about it.

If you need to travel or want to do things early on, make sure you have the right support in terms of bracing/wrapping and assistive devices (crutches, wheelchair). I personally didn’t do enough with assistive devices the first time, and since then I’m a fan of always having the devices available until you’re sure you won’t need them.

I don’t know if everyone feels this way, but personally I think sprains really hurt! And you get weird feelings and weird pains sometimes. I tend to check with my physical therapist on those (see next section) but it helped a lot when I looked up a knee message board one night when I couldn’t sleep from pain and people were bitching on it about how much their Grade II MCL sprains hurt. Ah, I’m not the only one! This is not a catastrophe that means I will never heal or was misdiagnosed.

Physical therapy

Physical therapy was absolutely key to my ankle recovery and I started it very early with my knee sprains since I was already in care with a PT at the time (it’s recommended early anyway for MCL injuries, according to the Internet). I recommend it highly. Try to find a physical therapist who knows a lot and listens to you, pushing you when necessary but respecting it when you report issues or a need to dial back a little. My original PT was super helpful, but had a tendency to graduate me too early when I still needed additional guidance in ramping up. My body personally behaves badly when I ramp up too fast, which is something I now know and which helps me take care of and advocate for myself.

Imaging, surgery, and second opinions

I’ve had two MRIs of my ankle (not proximate to the injuries) and they were both uninformative. MRI can be really helpful if you are experiencing pain after conservative (non-surgical) treatment, but they can also not be. And they’re horribly expensive, either for you or for your insurance company if you have one. MRIs can be misread and suggest surgery when it’s not needed, or miss what is needed. I’ve also seen several regular doctors, two podiatrists and three orthopods. I wish that I had gotten a second opinion earlier on for my first sprain and I’m glad I got one quickly after what appeared to be the second (it was actually something different from a sprain, but similar). On the other hand, all the doctors I’ve seen about my knees were in agreement about what happened (Grade II MCL on the right, Grade I on the left, no torn meniscus although one was suspected for a while) so I haven’t hugely benefited from multiple appointments except in peace of mind (and in the second appointment with the first doctor where I reported significant pain levels trying to bear weight without crutches and got a better bracing setup).

I haven’t had surgery so I won’t say much about it, except that sometimes it’s needed and other times it’s not, and even when it’s needed it can be a mixed bag due to complications, and might not need to be done right away. I didn’t tear my ACL, which is one of the common ligaments to need surgery, but even if I had, ACL injuries are now usually treated conservatively first. So if you find you aren’t getting surgery when you expect to, ask questions, but understand that that might be a good thing.

There are a few injuries where immediate surgery is recommended. When I imagined I might have torn my quadriceps tendon (I definitely did not, I’d actually irritated a structure in the knee called a plica) that’s one that does get fixed right away typically. And some injuries just don’t seem to heal with surgery, in which case, go find a second opinion for sure.

Listen to your body

I’ve talked about this a little in the previous sections, but for me it’s been really key to understand my body as an individual body and how it reacts to injury. My body reacts pretty badly to trauma. I have tight muscles at the best of times, and an injury and its associated stress tend to really exaggerate that. I don’t seem to heal quickly, and I seem to experience a lot of pain with injury compared to others. Nociceptors (pain receptors) can be modulated up and down by a lot of factors – the pain you experience isn’t always exactly correspondent to the existence or threat of injury. So I seem to tend to modulate them up.

As a result, it can be hard for me to believe that I’m not chronically re-injuring myself when inflammation flares up, and I really need the help of PT with massage and massage itself in order to properly heal from an injury. My first podiatrist didn’t like physical therapists (according to him they try too aggressively to mobilize the ankle, leading to long-term laxity) and I really shouldn’t have listened to him on that.

I also tend to do too little over too much, especially after my first experience doing too much, which was super awful. (I took a plane trip from Portland to Victoria BC two weeks out from my first ankle injury, without crutches or a wheelchair. Pain was had.) So I need encouragement but also understanding about my fear. And it’s helpful for me to understand specifics of anatomy so that I know what’s concerning tenderness in the injury area and what’s just muscle pain or some other issue. I really like my current PT because he knows so much about anatomy and explains things to me and uses that knowledge to get me healthier safely.

Conclusion

Your version of these lessons might be quite different – maybe you don’t experience a lot of pain, rehab very quickly and have to be reminded not to do too much. That’s awesome – you do you, and if the doctors are trying to overrule you, think carefully about whether you’re wrong or they’re wrong.

In closing, I’ll leave you with the advice that my PT gave me about rehabbing my knee sprains: If the pain with an activity is severe or progressive, or involves new symptoms, back off and consult a professional. If it’s mild and seems to improve or stay the same as you do the activity, don’t worry about it.

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