Maggie McKay (Host): Hopefully, you've never had an ankle sprain, but if you do, it can be confusing to know if it's even a sprain or a break or how to treat it. So today, Dr. Fred Brennan, family and sports medicine physician, joins us to share what we need to know.

Welcome to BayCare HealthChat, a podcast from BayCare Health System. I'm Maggie McKay. So good to have you here today, Dr. Brennan. Would you please introduce yourself?

Fred H. Brennan, Jr., DO: Yeah. Hi, Maggie, Fred Brennan. I'm one of the sports medicine and family physicians in BayCare. Thanks for having me today.

Host: Absolutely. So, what happens when you sprain your ankle?

Fred H. Brennan, Jr., DO: The most common mechanism what happens when you sprain your ankle, you know, the classic thing is someone will step off a curb or you'll step on somebody's foot and you roll your ankle and sometimes you roll it inwards, sometimes you can roll it outwards. But what happens is the biggest thing that happens is you sprain a bunch of ligaments in your ankle or on your ankle and that's obviously extremely painful. And sometimes you have to discern, and we'll probably get to this later, is it more than just a sprain? But you basically, remember, you sprain ligaments and you strain muscles and tendons. So when your ankles sprain, you usually are spraining your ligaments in your ankle.

Host: And are there different types of ankle sprains?

Fred H. Brennan, Jr., DO: Yeah, there are. So, there's different grades of ankle sprains and there's different types. And I think the most common type is we've probably all experienced, if we've played any racquetball or basketball or gone for a run, is what we call an inversion sprain when our foot rolls in and you try to get up where you have a lot of pain on the outer aspect of your ankle. That's the most common, what they call an inversion ankle sprain when your foot rolls in. Then, the other type is when you roll your foot out, usually a much more serious injury and usually caused by someone hitting you and causing your foot and ankle to go out this way as opposed to rolling in that way. Very uncomfortable, typically a longer rehab. And so, inversion ankle sprains, the rolling, and that's the most common type; the eversion, typically a more serious injury, but thankfully less common.

Host: And how would someone decide if they need an ankle X-ray or if they should seek medical attention?

Fred H. Brennan, Jr., DO: So, a lot of folks, you know, try to decide on swelling when they see an ankle, it doesn't really matter on what grade, a 1, 2 or 3, 3 being the worst injury, they all swell a lot, typically. And so, some people will get really concerned, "Oh, my ankle is really black and blue. It's super swollen. I need to go see someone." But I think the biggest thing is can you bear weight on that ankle? If you can't bear weight and take a couple of steps without significant pain, that's usually a red flag that something more is going on.

The other thing is if the pain is getting worse. So, you do all the right things and we can talk about the treatment here shortly. And next day comes, it's getting worse. A day later, it's getting worse. More pain, more swelling, more bruising. That would be another indication that, yeah, you can't bear weight, can't take a couple of steps, pain's getting worse, you should go see somebody.

Host: And what are the options for treatment?

Fred H. Brennan, Jr., DO: So typically, if there's a swelling, you hear the principles of PRICE, which is Protect, which can be an ACE wrap, some sort of a lace-up ankle brace. Then, there's Rest, a relative rest, where you try to take it easy on that ankle. Icing, usually, people say, "Well, how long do you ice for?" In general, the first 72 to 96 hours, you want to be icing. And that helps get the swelling down. But there's no golden rule. Some people hate ice, and they want to do heat instead. But in general, you want to ice. That's the P-R-I. And then C is Compression, like an ACE wrap. And E is Elevation, which is keeping your extremity above the level of your heart. Now, I realize most of us can't keep our foot above the level of our heart most of the time, but the more you can keep off that ankle and keep that foot elevated will help the swelling go down quicker. So, that's the general principle of the treatment. But then, you can get more involved with, for example, therapy and such as well.

Host: What about physical therapy,I guess you would call it, or rehab?

Fred H. Brennan, Jr., DO: Yeah. So, physical therapy, you know, for most people with ankle sprains, may not need it. But there are some people that they're really having a tough time getting the swelling down or they just can't seem to get the range of motion back, and physical therapy can be very helpful for that. Sometimes it's only a matter of a couple of visits where you go to the therapist, they look at what's going on with your ankle, they give you an exercise program. And then, you demonstrate back to them that you know how to do it.

I personally don't like to give people a piece of paper and say, "Okay. Here's some rehab exercises. Go at it," because I find most of us, including myself, we don't do it right. We don't do it correctly. And then, you finally do see a therapist and therapist goes, "What are you doing?" And you said, "Well, I'm doing the exercise." They're like, "No, you're actually making things worse." So, even sometimes just going to a couple of visits with the therapist, having them show and giving you a home program makes a big difference. For those that are really struggling, swelling is difficult to get down, the range of motion is really not going there, a formal physical therapy program can be very, very helpful. A couple of times a week for an hour, they'll give you homework and then you take it from there.

Host: I'm sure every case is different. But generally, how long does it take before you can get back to your normal activities like running or racquetball, pickleball?

Fred H. Brennan, Jr., DO: It's a good question. It's really variable depending on a little bit on your age, obviously, younger folks get back quicker; how many ankle sprains you've had in the past and what kind of rehab; how long did it take you to get back in the past? Was the injury sort of a low-energy injury, where you just stepped off a curb, or did you get like in a car accident and jammed your ankle? Those high-energy ankle injuries typically take a lot longer. And again, whether it's an inversion ankle sprain, the common one, which usually is quicker, versus the eversion where it rolls out, those take longer. So, in general, you know, it's going to take three to six weeks for most people to get back to activity. But there's been some interesting studies that have shown that folks with just what we thought was an uncomplicated inversion ankle sprain, up to 30-40% of those people are still having issues six months later with some discomfort, some persistent swelling. So, ankle injuries are very common, but you don't recover sometimes as quick as you think you should. So, you have tobe patient and not push yourself too fast. Just gradually go from walking to jogging and see how it goes, but be patient with yourself, understanding you have three to six weeks for most ankle sprains, but it may take several months depending on your history.

Host: Do you ever need a cast or do they do that anymore?

Fred H. Brennan, Jr., DO: Not that often. You know, we have these walking boots now that's removable. The nice part about the walking boot is it can act like a cast, but you can take it off. And that's good in the sense that you want to get your range of motion going as quick as possible for most. But if you have a really bad ankle sprain, what they call a grade 3, you could consider casting and non-weight bearing with crutches two to four weeks. Let things calm down, let the swelling, but get them out of the cast, you know, relatively quickly, because you want to get that range of motion going. And that's the nice thing about a boot, a walking boot, which has sort of a rocker bottom, is it acts like a cast, but you can take it off and get therapy going sooner than later. The longer you keep an ankle immobilized, the stiffer it gets, the weaker it gets. And casts do put you at a little increased risk of getting a blood clot too, which you don't want that.

Host: Oh my goodness. You mentioned people who have had a few ankle sprains. Are you more prone to get them after you've had a couple?

Fred H. Brennan, Jr., DO: Yeah. You know, the ligaments, when they get injured, sprained, a lot of them get partial tearing, or even sometimes complete tearing, but they tend to scar down. But what people forget sometimes with ankles is that your brain and your ankle are connected. So, for example, if I were to take your finger and have you close your eyes, and I go like this, and I ask you, "Is your finger up or down?" You would say, "Down." Your eyes are closed. If I went like this, "Is your finger up or down?" You would say, "My finger is up." Well, your eyes are closed, how do you know that? Well, your joint has these little fibers, nerve fibers, that feed back to your brain and say, "Up, down," and that's how you know. When you hurt your ankle, or any other joint, that connection between your brain and the joint  malfunctions.

And a lot of folks don't understand that, so you get the swelling down, you get your motion back, you get your strength back, but you forget what's called proprioception, your joint's ability to recognize its position in space. So now you're walking along, you feel great, you step on some uneven grass, and you roll your ankle again, because your brain and your ankle didn't reconnect. You never got that training. Simple things like balancing on one leg and then closing your eyes, you're going to feel kind of unstable. But eventually, your ankle and your brain will start talking again together. So, the biggest thing is I found that people don't do this proprioceptive training, this balance training, and then never re-establish the connection between the brain and the joint, and then they keep getting ankle sprains over and over and over again. Even when they've strengthened it, even when they think they're good, the connection's not made and they keep rolling it over and over again.

Host: So, prevention for future injuries. Do you need an ankle brace? Does taping help?

Fred H. Brennan, Jr., DO: Yeah. So, that's always the big question, especially in the sports medicine world, where we spend a lot of money on taping, for example. The studies are all over the place with taping and bracing is "Do they work?" And I think most people do feel that, for example, taping your ankle does give the brain some feedback. Reminds you that, "Yes, I've had some injuries here, and I just need to be aware of it," sort of this unconscious awareness. But tape loses its strength very quickly. It stretches and you also sweat. So, you wrap, pre-wrap and you put tape on and you get it nice and snug. And then, you go out and play 20 or 30 minutes of soccer or volleyball or whatever, and guess what? You sweat, the tape stretches, it loses a lot of its effectiveness within the first half hour. But a lot of people like to tape and they still feel more confident with taping, the same thing with bracing.

So if you have someone who's done everything, they've strengthened, they've done this proprioceptive training with a therapist to reestablish that connection, and they just keep rolling their ankles, I think taping and/or bracing does have a role. But in general, the studies are very conflicting. Does it really prevent? Maybe prevents, but it doesn't prevent how serious the injury is. If you get hurt, it's still going to be a significant injury potential, even if you're braced, even if you're taped. But it has a role. We spend millions of dollars on taping and bracing, somewhat effective. Again, studies are very controversial. If you feel better being braced, if you feel better being taped, go for it. It's not going to make your muscles weaker. It's not going to make you stiffer. It's just a little bit of a crutch, but it's okay.

Host: This is a crazy question, Dr. Brennan, but does it strengthen your ankles to, every morning, rotate them both ways, you know, like clockwise and counterclockwise. For some reason, my mom was a huge advocate of that. She did it every morning. She never had a sprained ankle. I think she got it from Jack LaLanne. But is that true?

Fred H. Brennan, Jr., DO: Just doing that, it won't strengthen the ankles. But it does help maintain your range of motion. And that's a good thing because as we all get older, we do get tighter. We get stiffer, the joints do stiffen up. And so, it may not necessarily strengthen, it might help you maintain what you have. It won't make you stronger, but it will maintain what you have. And it does help with maintaining range of motion. So, that's a good thing. You don't want to get stiff. But will it kind of strengthen? Not really. But hey, if she enjoyed it and it works for her, I'm not going to bust her bubble. I think that's fine.

Host: Is there anything else you'd like to add that you think we could use?

Fred H. Brennan, Jr., DO: I think for kids, you got to be careful with children that are still growing. So, you talk about folks up until 18, their growth plates are still open. They come in with what we think is a sprained ankle, having difficulty walking on it, it's really swollen. And then, they go to an ER, urgent care or their doctors. And the X-rays are "negative," normal. The key for that is though, are they tender over the growth plate? So, the provider should definitely feel the bone all the way around both sides of the ankle. And if they hit a spot over the growth plate that's very tender, even though the X-ray says “normal,” actually, that is a injury, minor injury potentially, to the growth plate where it's been shaken up, if you will, and you need to treat that like a fracture, like a break.

So, sometimes with kids, bones aren't mature yet, they have growth plates, and they're told X-rays are normal, but your child is still limping a lot, they probably have a minor growth plate tweak, if you will. And that needs to be treated like a fracture and not like a sprain, which is very similar. But in this particular case, the child may need to be shut down from running and jumping and that type of thing.

Host: Well, thank you so much for sharing your expertise on this topic. It is so helpful and hopefully we'll never need it, but it's good to have in our back pocket.

Fred H. Brennan, Jr., DO: You're very welcome. My pleasure. Hope you never get one. Be careful with high heels. Those are famous culprits for ankle sprains.

Host: Isn't that the truth? Thanks again. That's Dr. Fred Brennan. And that wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast, and all the other BayCare podcasts. For more health tips and updates, follow us on your social channels. If you found this podcast informative, please share it on your social media and be sure to check out all the other interesting podcasts in our library. Thanks for listening. I'm Maggie McKay. This is BayCare HealthChat.