First Aid for Ankle Injuries -
An Athletic Trainer’s Guide For Coaches
by Ray Chronister, ATC (Retired) US Naval Academy, Annapolis, MD
Ankle injuries are the most common injuries in sports. For most, the three areas of concern are early management of swelling, proper rehabilitation of the muscle complex that controls normal joint function and prophylactic bracing upon return to activity. Specific tactics are used in Sports Medicine to aid an Athlete’s recovery and rapid return to activity that make a big difference. This guide is focused on those front end or the “First Aid” tactics that anyone who is prepared can provide for the injured person.
Managing swelling is critical. Studies show that swelling delays recovery more than any other factor. You can greatly reduce recovery time by acting quickly to prevent it. The conventional R.I.C.E. (Rest-Ice-Compression-Elevation) guidelines are a general treatment checklist. They assume that swelling has occurred and that ankle range of motion has been lost. They are grossly inadequate for a rapid recovery.
As with most injuries, how quickly you treat it likely determines how long an athlete is sidelined. In minutes an injured ankle can swell enough to greatly delay recovery. Swelling limits range of motion (ROM) and leads to loss of strength. Pain free ROM must be either retained or regained in order to rehab. It is far easier to retain ROM than it is to regain it, so, the more swelling prevented, the better. This is why immediate treatment is so important. Even with an athletic trainer in house, the time lost getting the athlete and trainer connected could catapult recovery from days to weeks. The Good News is that anyone can apply proper first aid for ankle injuries with a little information and preparation.
The “I rolled my ankle” lateral sprain accounts for nearly ninety percent of ankle injuries. The odds are greatly in your favor that the injury you may treat as a coach, parent or teammate isn’t an injury you can make worse by your efforts. You’ll do more harm by delaying treatment than with any attempt to prevent swelling. A pre treatment diagnosis is unnecessary because ankle injuries all get treated the same on the front end regardless of severity. We use several simple tests to rule out a fracture. For those without immediate access to medical staff attention a good rule of thumb is if the injured party can’t bear any weight on the injury they should seek medical help ASAP, but DON’T DELAY TREATMENT.
Originally doctors told people to use ice so that they didn’t use heat. Ice doesn’t prevent swelling. Crushed ice compressed under a wrap nests into the little hollow areas around an ankle’s knobs. This allows equal pressure to be placed around the joint, preventing swelling from collecting in uncompressed tissues. We call this “focal compression”. This combination of focal compression and cold are the preferred standard of athletic trainers. But, ice is not nearly as important as a proper focal compression wrap for an ankle injury. Ice is a nice, but don’t waste time trying to find ice if it is not already on hand.
You can create a “make do” focal compression pad by rolling or coiling up a sock or cutting a ½ inch stack of paper towels or napkins into a U-shaped pad and using it to fill the hollows around the ankle knobs until a more suitable device can be applied. If a wrap is not available put a sock and high top shoe on over the make shift pads and tighten the laces as snuggly as possible. Again, don’t delay treatment. If there’s only enough material to make one pad for the lateral side of the ankle that is much better than nothing or a further delay. When proper materials are acquired, be sure to place focal compression pads on both sides of the ankle. If only applied to one side, swelling will pool into the uncompressed hollows of the other side. So, always apply the pads to both sides. Following is the rationale and method of treatment for acute ankle injuries we used at the Naval Academy. New materials made the old method simpler, faster, more effective and less expensive.
As soon as my athlete injures their ankle:
1. ASAP Focal Compression Wrap – First with crushed ice (if available) and followed with donut pads
Apply crushed ice pack with plastic or elastic wrap to compress in place, 20-30 minutes. Ice is a luxury not necessary to succeed at preventing swelling in ankle first aid. Proper compression is much more important than ice. As described above, only crushed ice can be molded in to the hollows around the ankle knob creating focal compression with the added benefit of cold.
Apply The FirStep™ Donut Pads to continue focal compression with wrap
Protekt Motion’s FirStep™ Donut Pads are crucial. They continue the focal compression over night and into the next day. Peel and stick one donut on each side of the maleolus (ankle knob) and apply the compression wrap. The athlete can now put on his shoe.
2. Continue Focal Compression - The wrap MUST be left in place for 24-36 hours minimum to control swelling (mandatory).
3. Overnight Elevation – At the foot of the bed, Athletes must place a box, pillow or suitcase between the mattress and springs the first few nights for constant elevation overnight. This is much more effective than the athlete trying to rest their foot on a pillow between the sheets and mattress.
4. Slush baths and bicycle regiment – This therapy is encouraged twice daily. Remove the compression wrap after the 24-hour period (but not the donuts). Start an ice and water slush bath with 15-20 minute intervals for three cycles. Pedaling a stationary bicycle between cold bath cycles (5-10 minutes) should increase recovery response. Replace the compression wrap to slow edema during the bicycle regiment and the rest of the daily activity phase.
This is where the FirStep Donut Pads are a huge help, as an athlete can easily re-wrap their ankle with both hands free to apply the wrap.
This is not the case with non-adhesive compression pads. Frequently athletes returned to the training facility the next morning with a badly swollen ankle, as they were unable to reapply the wrap by themselves. This non-compliance issue is resolved with the FirStep self-adhering pads. So, considering an athletes ability to comply with your treatment plan, after they’ve left the training room, is possibly as critical to a rapid recovery as is immediate treatment.
5. Stimulate mobility - I encourage walking to stimulate tissue mobility as early as possible. As soon as the athlete can transit stairs comfortably, start light jogging activity with the compression wrap and FirStep Donut Pads in place for support and to help the athlete’s comfort zone. The donut pads also work very well placed inside a lace up ankle support or an elastic compression sleeve. It is imperative that resistance exercises are done isolating the lateral muscle complex of the lower leg that controls the normal function of the ankle joint. This is what allows an athlete to “recover” to normal activity levels long before ligaments that may have been damaged by the injury have healed.
Focal Compression of injured ankles has been a method of care at the US Naval Academy since the early 1980’s. The self-adhering FirStep kits were crucial to our getting our athletes back to activity ASAP. We apply them within minutes post injury and leave the wrap on for at least 24 hours.