Wendy from New York, NY, USA writes:

I’m a full-time rock climber and sprained my ankle 4 months ago when I rolled it on an uneven surface in the climbing gym. I was able to ice and elevate it almost immediately and put on an ankle brace. However, the next few days I had to do a lot of driving and walking. Like many other rock climbers in the U.S., I have no health insurance, so I did not seek professional help.

Recently, after rehabbing as best I could using the RICE protocol and theraband exercises, I’ve started to climb again. Slowly and surely I regained movement in my ankle as the swelling lessened. Unfortunately, there is pain again in the upper part of my foot, radiating from the top of my ankle bone.

My questions are:

1)    Is it too late to for RICE? Does ice and elevation have much effect at this point in my injury?

2)    Should I still keep my foot in a brace all day, or attempt to regain full range of motion by walking normally?

3) Does pain always indicate a person should STOP what they’re doing and rest? Or, is minor pain just a sign that my ankle is fragile and healing?

Dear Wendy:

I’m sorry to hear that you’ve fallen victim to one of the most common injuries in and out of sport. Ankle sprains account for 20-40% of all athletic injuries (Dubin et al, 2011). Whether your ankle sprain is minor and simple  or  severe and complex, you can speed your recovery and decrease the risk for long-term complications by following a standard and/or individualised ankle rehab program.

To answer your questions:

1) RICE is the acronym for rest, ice, compression, elevation. This protocol should be implemented immediately after spraining your ankle. The purpose of RICE is simply to reduce the body’s inflammatory response to injury, decrease pain and protect the ankle from further injury. The inflammatory phase after injury lasts approximately 24-72 hours. After about 3 days, the effectiveness of RICE decreases as the body is no longer in an inflammatory phase. HOWEVER, when returning to activity eg walking, working, driving, sport etc, it can be very helpful to ice and elevate afterwards to reduce swelling and pain that may result from stressing the recently injured area.
At 4 months post injury, there is not much support to keep using the RICE protocol, EXCEPT for pain and swelling control following your physical activities.

2) Ankle braces are an excellent way to protect your ankle immediately after injury and during high loads/ complex movement patterns when returning to sport. The rigid support from a brace restricts the ankle from moving in way that can further stress the damaged tissues. This is helpful in the initial stage of healing, but also when returning to an activity that involves uneven surfaces, lateral movements, external perturbations etc. HOWEVER (there’s always a catch!), wearing a brace full-time, long-term can decrease your body’s ability to regain its proprioception.
Although balance and proprioception are related and are often interchanged, they are not one and the same. It is difficult to have great balance without a minimal level of proprioception. Balance simply refers to the ability to maintain the centre of gravity within the base of support with minimal postural sway. Proprioception, on the other hand, is the sense of where your body parts are in space. That’s a whole mouthful which means: if your ankle doesn’t know where it is in space, it cannot tell your brain that it’s about to roll over. When you injure your ankle you decrease its proprioceptive ability which makes you at risk for another injury in the future. Because of this, it is important to begin balance and proprioception exercises early in the rehabilitation process.
As a Physiotherapist, I usually suggest my patients to wear a brace full-time for 2 weeks, then only during complex activities after that. Further, I try to wean my patients from using an ankle brace long-term during their sport or complex activities within 4-6 months UNLESS they have an ankle instability (complete rupture or major laxity of a ligament)- which I suggest to indefinitely wear their brace during these activities.
At 4 months post injury I would suggest ONLY wearing your brace when you are on uneven surfaces or doing complex movements eg hiking, running, climbing, sports etc.

3) Pain is a very under-studied, highly complex area of science. It is important to understand that pain is 100% of the time produced by the brain. When receptors in the body sense mechanical, chemical or temperature changes in the tissues this information is sent to the spinal cord and brain. It is the brain that has to make the decision whether there is a threat in these messages. If the brain decides these tissue changes are dangerous, it will result in pain.
Pain occurs soon after an injury and persists while it is healing and vulnerable. During this stage pain should be a guide in your activity because it warns you when you may be pushing things a little too hard.
At 4 months post injury, it is normal to feel pain or tenderness when performing activities or movements that the recently injured tissues are not accustomed to doing. Low levels of pain are acceptable. If you could rate your pain from 0 (no pain) to 10 (the most pain), generally a 3/10 is ok. Anything above this can indicate that your tissues are not behaving normally and that more treatment, therapy etc is needed

If you are feeling pain in your ankle 4 months after your original injury, I would highly suggest seeking at least ONE physiotherapy appointment. A physiotherapist can assess your ankle to identify the structures or movement patterns that are contributing to your lingering pain and give treatment and suggestions of specific home exercises that are individual to your injury. There are many joints within the ankle and foot combined. Often after ankle sprains one or more of these joints become stiff or stuck. A Physiotherapist can perform manual therapy techniques to loosen these areas and to get your foot and ankle moving better. A Physiotherapist can also take a look at the rest of your body to determine if there is any other area that may be hindering your progression in healing.

To read more in-depth about ankle injuries check out this great article by Dubin et al(2011).

You can also check out Wendy from New York’s inspiring climbing and lifestyle blog, Cllimbfind Heroes here.

Do you have a sports medicine, health and wellness or active living related question? Ask a Physio!

Tags: ankle brace, ankle injury, ankle pain, ankle sprain, Ask a physio, physio, physiotherapy, RICE, rock climbing