Denis came to see me a week after going over on his ankle during a soccer match. He had it checked out in A&E the day after the game and got the all clear for any fractures. He was given crutches and advised to use them until walking felt okay. That was it.
For a fit and healthy young man this may have turned out okay but Denis was three weeks away from his toughest ever endurance challenge, the Hardman Bantry Bay Triathlon. This was half Ironman distance so involved a 1.9 km swim, 90 km cycle, and of biggest concern to Denis, a 21.1 km run. His training had been going smoothly but filling in for his local soccer team seriously derailed his preparations.
Rehabilitation Plan
The purpose of this blog is to provide an insight into Denis' rehabilitation programme. I'd like to outline what we included and the purpose it served to helped prepare Denis for his race.
Session 1
In our first session all Denis wanted to know was whether it was realistic to attempt the race. He was sceptical about his chances but didn't want to see his training go to waste. However, the Initial recovery was positive. Denis ditched the crutches after two days and was walking relatively pain free when we met. He had also returned to work as an electrician and was managing quite well but by the end of the day he did experience pain in the ankle and reported it "looked bigger".
As with any initial appointment the information I gathered from speaking to Denis was just as important as the physical examination. Factors that worked in our favour were that Denis had never injured this ankle before, he had not experienced any instability or "wobbliness" of the ankle since the injury and the event Denis was aiming for was sub maximal in terms of force production and didn't involve any quick changes of direction. Denis gave me the impression he was not afraid to challenge his healing ankle and had already demonstrated he could tolerate some discomfort by getting through a working day.
When moving to the physical examination we needed to establish if there was any significant structural damage done to ligaments, tendons, nerves, muscles or other connective tissue around the foot and ankle. We also needed to establish what kind of stresses Denis could tolerate through the foot and ankle.
Reassuringly, when testing the ligaments there was no evidence of complete ligament rupture but tenderness on palpation and stretching of his anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) (Image 1) outlined some damage to these structures. As we would have expected, eversion (turning your foot out) power was reduced due to discomfort as the peroneal tendons typically undergo trauma during a lateral ankle sprain. Plantar flexion (pushing your foot down) ability was also reduced. The peroneal tendons contribute to plantar flexion and the ATFL ligament starts to be stretched during this activity too. Similarly, balance on single leg testing was impaired as after a lateral ankle sprain reduced function of the sensorimotor system is common.. For a detailed review of best practice assessment of an acute ankle sprain I highly recommend a recent publication from Eamonn Delahunt and his team.
With our key findings being reduced ankle range of motion, reduced force capacity around the foot and ankle and impaired balance we needed to formulate a plan to help Denis have a chance of completing his race. The programme we designed on day one is below.
1) Static Balance: Single leg stand (eyes closed). 3 minutes practice twice per day aiming for high quality holds.
2) Dynamic Balance: 3 point reach - 3 laps per set x 3 sets twice daily.
3) Banded Eversion: 15 reps x 3 sets performed twice daily.
4) Calf Raise: Double leg concentric and single leg eccentric (8 reps x 4 sets once daily).
5) Split Squat: Focus on stability of front leg - 8 reps x 4 sets once daily.
In our first session we also used some hands on techniques to help restore range of movement at the ankle. Dorsiflexion (moving your foot up towards your shin) is important during running and is typically reduced post ankle sprains.
Maintaining general cardiovascular fitness was critical and Denis was advised to swim as programmed and we planned bike sessions using his turbo trainer before trialing getting back on the road.
Session 2
When we met for our second session a week later Denis reported good progress on a day to day basis and felt he didn't have pain at the end of the day at work. The home exercise plan was well tolerated with Denis feeling like he got stronger at the exercises as the week went on. This was a green light to progress the exercises and "test the waters" to see how much Denis could manage.
We used the session to test tasks such as a single leg heel raises, double leg and single leg hopping and also introduced some running mechanics work. At the end of establishing what was reasonable to include we programmed the following session;
1) Double Leg Hop: 20 repetitions x 3 sets once daily.
2) Single leg hop - forward and back: 15 reps x 3 sets once daily.
3) Single leg hop - lateral: 15 reps x 3 sets once daily.
4) Run and stick: 5 "sticks" per set and 5 sets in total. Once daily.
5) Single leg (off step) heel raise: Maximum 12 left side x 4 sets. Add weight to ensure 12 reps is difficult.
6) Rear foot elevated split squat: 12 reps each side x 4 sets once daily.
If we are looking at the exercises with a critical eye it is clear that Denis' technique is not perfect. If you look at the double leg hop you can see that Denis doesn't point his foot down (plantarflex) as much on his left side as he leaves the ground . Ideally this would be equal on both sides but being honest we didn't have time to restore perfect range of motion before loading the ankle if we wanted to attempt the race. Importantly, Denis was relatively comfortable with each exercise even if they didn't look the prettiest!
At this stage we were 10 days out from the race. With Denis feeling okay during hopping drills I was happy for him to trial a very easy running session. We agreed on 2 minutes running: 1 minute walking x 5 sets. This would give us 10 minutes of total running time. If this was tolerated Denis was free to try a more typical run within his levels of comfort.
Session 3
When we met for our final session (August 5th) before the race (August 8th) Denis reported having completed the following running schedule.
July 30th - 2mins on: 1min off x 5 at an easy pace.
August 1st - 5km at race pace.
August 4th - 10km at race pace.
This was in addition to the exercise programme we designed and thankfully it all went smoothly. During the 10km run Denis felt quite comfortable and was confident his running style wasn't effected. A glaring compensatory pattern may have led to other issues arising during a 21km run.
We agreed we should try and promote as much recovery as possible before the race without inducing high levels of fatigue. Combining the hopping drills so that we had one large set of 45 hops (15 x vertical, 15 x lateral and 15 x forward and back) completed x 4 sets was introduced rather than completing anymore running sessions. We kept the balance exercises at the start of our session and completed this on August 5th and 6th. August 7th was kept as a complete recovery day before competing on August 8th.
On wrapping up our final session it was very encouraging to hear Denis express his confidence in completing the event. It was clear he had trained very well and a set back like this so close to race day can be demoralising.
The result?
Denis got in touch the day of the race and I was delighted to hear he finished in a very respectable 6 hours and 22 minutes.
Writing this piece is certainly not trying to claim Denis' achievement was a miracle due to physiotherapy! Three weeks to recover from an ankle sprain is a reasonable healing timeframe. The challenge we had was trying to push the healing tissues as much as possible to optimise recovery and maintain tissue capacity around structures like the calf, soleus and achilles tendon. This was achieved with what I felt was quite a straightforward rehabilitation plan that was pitched at a level to ensure each rehab session done at home really pushed Denis.
I was eager to share exactly what we did from day one and hopefully it has given an insight into what you can expect from physiotherapy. I would be more than happy to chat about this case in more detail with anyone who is interested and if anyone reading feels like they need help with an injury please get in touch.
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Thanks for reading,