A number of weeks ago, I had a conversation with a friend on the side-line of a game who was noticeably injured. Being the curious (some would say nosey) physiotherapist I am, I had to ask what was keeping them on the side-lines.
My friend reported they had rolled their ankle in the two weeks previously and now out of action. They were not sure, as yet, when they would be back. They had to return to their therapist next week to get a better idea. Until then, they were to ‘rest up and keep it moving’.
As much as I tried to remain just a friend having a chat rather than a nosy physio, I could not help myself. I asked what they were doing to stay fit. Very little. Still going to the gym? Not really.
This is not an unusual conversation. Working as a sports therapist and then as a physiotherapist in sport for over ten years now, its quiet common to rock up at training and see injured athletes observing from the sidelines with arms folded.
A few years back, I was very privileged to work in Australian Rules Football in Melbourne. My role was to help keep injured players busy during training. At first, it was quiet daunting. A player rocks up in a moon boot and I’m supposed to help keep them fit for this sport? Not a chance
The learning curve was steep and creativity juices were flowing in every session. No matter the injury, if the player manages to turn up the grounds, and the goal of performing in their sport remains the goal, we can challenge their body in some way. I became quiet adept with boxing pads in that season and trying to unleash the inner Mike Tyson in players. Ending up with bilateral elbow tendinopathies at one point as a result.
The acronym of PRICE has been the bedrock of recovery in our industry for many years now. Protect, Rest, Ice, Compression and Elevation. An editorial in the British Journal of Sports Medicine over ten years ago reports however, a paucity of evidence to support these recommendations.
The evidence for icing an injury is very conflicting. It is clear that ice will have an analgesic effect on injured body parts, making an injury ‘feel better’.
Personally, I feel it also might help facilitate swelling management for severe injuries and therefore help a joint move easier in the initial stages. Research however has suggested ice delays the natural recovery of the tissues by impacting on hormonal factors important for the healing process.
A Physio Network blog from Zenia Wood goes into this is some very useful detail here.
This PRICE acronym has recently been updated to PEACE & LOVE in a recent piece in the British Medical Journal. In this updated recommendation, ice and rest have been removed and early, gradual returning to load is emphasised with the addition of targeted exercise to restore range of motion, strength and proprioception (awareness of body position in space).
As therapists, we should be quiet judicious when advising our patients to put their feet up. In some cases, this is necessary, especially in an era when long COVID is quiet prolific. However, for the majority of soft tissue injuries, illnesses and orthopaedic surgeries, early mobilisation is vitally important to create a progressive healing environment within the body.
As with my friend above with the ankle injury, having one limb injured presents an opportunity to not just accelerate recover but also work on the other three limbs. There is quiet a lot of exciting research out there indicating that training the unaffected limb with heavy strength resistance training can help reduce muscle loss on the affected limb.
NBA S&C coach Chris Chase coined a fantastic term in recent years called the Trainable Menu. In essence, its an emphasis on what the person in front of you CAN do rather than CANNOT do. With an acute ankle injury, we as therapists sometimes focus what we CANNOT do and communicate that to the patient. At times, this approach is warranted especially to certain gung ho patients but not everyone.
In this case, with this ankle injury, the trainable menu available to my friend was extensive but unfortunately not visible to them as yet.
What CAN they do?
1: Can we restore range of motion to the affected ankle with regular active mobility? For example; draw your name on the ceiling with imaginary torch shining out of your big toe, BIG LETTERS!
2: Can the ankle accept some element of loading? This could be gentle plantar flexion into theraband? Monitoring pain response during and after.
3: Can we load the unaffected leg with movements like Bulgarian Split Squat, Leg Press, Knee Extension, Hamstring Slides? This, as above, may help give us carryover to the affected leg and reduce the rate of muscle wasting on this leg.
4: Can we use modalities like Blood Flow Restriction in our rehab to get a hypertrophy affect on the affected limb with a lot less load (approx. 30% of max) or even using electrical stimulation together with BFR to build muscle whilst the tissue repairs.
5: Can we explore creative ways to continue energy system development using a heart rate monitor. The aim being to mitigate losses in match fitness whilst the tissues involved at the ankle recover. This could include Ski Erg workouts, pad work, rowing with a skate board under the affected foot (Sonny Bill style).
6: Can we look at work ons in the upper body that may translate to the sporting demands the patient has. Have we looked at an upper body power phase in the past? Is hypertrophy needed or helpful? Is this something the patient would like guidance on?
Obviously, this menu is created in close consultation with the person themselves but it can get extensive and we have not looked into ankle rehab in detail there as yet.
When you are injured, please consider the cost of rest and think what CAN I do to keep the show on the road. What’s on the menu?
Thanks for reading.