When Ankles Go Bad

This week's guest columnist is Dr. Danielle Fuselier, a Family Practice resident at the University Hospital and Clinics here in Lafayette. It's the time of the year for leaves to change, pumpkin lattes to be served, and fall sports- and ankle injuries???  Yes! With sports comes consequences of inadequate summer conditioning, over-aggressive drills when the season starts, and new cleats with their fresh, turf-catching studs.  Ankle sprains are one of the most common injuries we see in the Pediatric Emergency Department, and not just in athletes.  With kids getting fatter and exercising thumbs more than legs, more non-athlete ankles are giving out too. What are ankle sprains?  Ankle and foot bones are bound together with tough, fibrous bands called ligaments.  Sprain is when those bands get jerked so hard they begin to tear.  The "inversion" injury is most common, when the foot is wrenched inward so the victim ends up standing on the outside of the foot.  Then he goes "yowch" and hops around. Ligament injuries come in three grades: Grade 1 is simple pulls, where ligaments are only bruised by the force.  Grade 2 is partial tears; Grade 3 is full tears, with complete joint instability.  Ankle bones can break too, with strong enough force, like when stepping in a hole while running, or landing wrong when jumping in basketball.  Also kids' ligaments are often stronger than the bones they're anchored on, making fractures even more possible. When do children need x-rays?  If the ankle hurts when squeezed where fractures are most likely, or if the child cannot walk on it at all, then x-rays are necessary to look for breaks.  The degree of swelling doesn't help decide.  Swelling happens with both ligament and bone injuries, so a more swollen ankle doesn't mean fracture. The best treatment for ankle injuries is, of course, prevention.  Athletes should have careful, supervised stretching before and after work-outs.  Conditioning should increase gradually, avoiding over-exertion, when fatigued muscles that support joints give out.  Kids with frequent ankle injuries should have velcro or lace-up braces, or be taped before practice and games. Your 10 year-old Tim Tebow was throwing a pass when tackled.  Unable to walk on his ankle, he's brought to us.  After the x-ray, parents often ask, "is it broken, or fractured?"  This question makes us pause and scratch our heads, since in medical terminology, fracture IS a broken bone.  We're not sure what people think the difference might be. If a bone's broken, the child gets a cast, crutches, and a referral to Orthopedics, who  make sure the bone heals properly.  Occasionally, ankle fractures are so bad they need surgery.  Either way, that's it for the season- it takes a month or two for fractures to heal.  We'll write the child an excuse for PE and sports until the orthopedic doctor clears her. If the ankle is sprained, the injured ligaments usually heal in a week or so.  Caring for sprains is actually more work for the parents and patient than fractures, because there's more things for them to do, remembered by the acronym RICE. R is for Rest.  Parents need to limit kid's walking for the first days.  Occasionally rest means crutches, so the child can get around school and home without putting weight on the ankle.  Don't leave the doctor's without that PE excuse!  I is for Ice.  Wrap a bag of ice or a cold pack on the swollen part to decrease pain and swelling. C is for Compression, with an ACE bandage or velcro brace, wrapped from toes to lower leg.  This minimizes swelling and gives ankles some support. E is for Elevation: sprained ankles swell and throb, so propping them up on pillows or footstools will decrease swelling and throbbing with gravity assistance.  Finally, don't forget pain medicine (maybe the acronym should include an M, like MR. ICE instead of RICE).  Sprains and fractures hurt, so don't skimp on ibuprofen (AKA Motrin or Advil), which is better than acetaminophen (Tylenol).  Both ease pain, but ibuprofen also decreases inflammation in the injury, which eases swelling too. Like we said above, prevention is the best treatment.  Get your kids off the couch and running around outside, so that they self-condition those legs.  Feed them less junk  they don't get overweight and strain those ankles.  And don't push the Tim Tebow thing- kids should condition in their own good time.