Walking on the right track via RICE and stable ankles

While your arches make the foot delicate, it gets chunkier just above them. The ankle protrudes, skin stretches over it. The common name for it – ankle joint – only partly encompasses what’s going on inside. Of course, it makes a difference if you jump. But each step, bob, pivot and turn matters. A lot goes on here, and strictly speaking, «the» ankle joint doesn’t really exist at all. If you look at it from a more philosophical point of view, along the lines of «Who am I – and if so, how many?», it consists of two parts, which in turn consist of many others.

For starters, there’s the tibia, fibula and talus, which you may be more likely to recognise as the shin, calf and ankle bone. Together, they form the upper ankle. This is what lets you lift and lower your foot, and, to a very limited extent, move it sideways. Below that sits the lower ankle, which is part of the foot. This section enables you to tilt your ankle a little and swivel it in and out. In reality, we can’t neatly delineate these movements. «In 1911, Fick symbolically referred to the complex movement of the foot as a 'slap in the face movement', in which the individual components can’t be distinctly separated from each other,» according to the trauma surgery practice book – Praxisbuch Unfallchirurgie (in German). So I’d rather keep schtum and let a picture do the talking. It only shows some of the movements that are possible.

Twisted your ankle? Bad luck

Between the bones is where you find all the lovely ligaments that we’re likely to injure at some point in our lives. When this happens, the lower leg muscles can’t do their normal job properly, namely actively working to stabilise the ankle in dicey situations. And that’s when we roll our ankle. When the whole beautiful gait system is out of whack, it makes us fall and dishes out stabbing pains.

What also shoots through your head are four letters – the same ones recommended by sports physician Professor Scherr as an immediate treatment method. «RICE» is his brief answer to my question about what you should do in an emergency. It stands for «rest, ice, compression, elevation». The guidance is to limit cooling the soft tissue injury to about two hours in order to relieve any pain and swelling. Various studies showed that prolonged treatment with ice could be counterproductive. This is because excessive cooling suppresses inflammatory processes that are necessary for healing later on.

Because the structures of the ankle joint get so forcibly twisted and as contorted as doctors’ handwriting when you go over on your ankle, it’s not a good idea to grit your teeth and hobble on. Even if you’re all on your own. «Get an Uber!» Scherr recommends with a laugh. But he does mean it seriously. One problem with continued impact is that it can lead to repetitive injuries, which can cause the tissue to scar excessively. «If you don’t rest and the area keeps tearing open, it can lead to dehiscence, which in turn results in hyperlaxibility.» Sounds unhealthy. And it is. The tissue starts to separate and the joint becomes loose. «This increases the risk that you’ll keep getting injured.»

Prevention rather than injury

Conversely, you can increase the chances of not getting hurt. «In the ankle capsule, as well as in the muscles and tendons, we have in-built sensors that detect misalignment and can then correct muscle activity when we stumble,» says sports physician Scherr. «If you train them, less is likely to go wrong.» It’s about training proprioception. This is deep sensory perception that tells our brain where our muscles, tendons and joints are and if they’re activated or not. It’s like our body’s own superpower.

As we’re programmed to prefer being comfortable, most of us don’t do this preventively – only when something has already happened. Even still, training for this doesn’t give you obvious muscles; it’s more about invisible skills. «It’s not so much about strength, but about responsiveness,» says physiotherapist Pascale Gränicher, who helps me with the small but subtle exercises. While my first lesson at the foot school was on solid ground, it’s now getting shakier. But just a bit.

«You can train the sensors in muscles and tendons so they’re more sensitive and that way you notice earlier when you start to twist your ankle,» explains Pascale, while handling a small wooden board. The therapy board comes from a protected workshop (site in German) in Bubikon. It’s designed to help improve self-protection mechanisms. «It’s just a wooden board with half a log and three Velcro® strips you can use to attach it in various ways. This lets you play out buckling situations in a protected environment so that you can train your perception,» explains Pascale. «If you mount the bit of wood transversely, it simulates dorsal expansion and plantar flection.» The former happens when you tilt backwards on your heels, while the latter is activated with reverse movement towards your toes.

«You need to stand in the middle and try to first feel your three pressure points: root of the big toe, heel, bottom outer edge of the foot.» You’re supposed to recreate your arch and the «short foot». «At the outset, it’s good to hold on so you don’t have to concentrate on your balance,» says Pascale, and off you go with the simulated rolling movements. First with your hands on the hand rail, then letting go. But always with as much sensitivity as possible.

«The knees aren’t fully locked out. Instead, they’re slightly bent in a dynamic posture. From this position, we try not to tilt forward by shifting our weight, but instead to make the movement happen from the ankle.» It’s a subtle adjustment that doesn’t make the board hit the ground loudly, which is what makes it easy to detect. «Even though it’s a small bit of wood, you have to use a bit of strength and you can’t just be tempted to shift your body’s centre of gravity,» Pascale points out. «When we’re running, we don’t just want to let ourselves fall forward; our feet have to actively work with us.»

Tipping over the fear axis

If you twist your ankle, it usually happens from the outer edge of the foot. The result is a supination trauma, which often affects the ligaments. «After that, a lot of people are scared it’ll happen again. One strategy is to just not put your foot into a supination position any more.» It’s an easy way out, but it can take its toll eventually. «But that also means the muscles no longer know what they have to do if it happens again,» says Pascale. So it’s important to bring movement back to the foot again – and there are two ways to do this with the therapy board. «The safer option is when you have the board in front on the big toe side, as this is the more natural axis of movement.»

Then it’s the same game as before. Again, it’s all about tilting the board in a controlled manner. Except now it’s using an axis that can trigger other feelings after you’ve been injured: «For a lot of people, this movement alone can make them a bit fearful because it feels like supination,» explains Pascale. «But it can’t go any further, which allows you to get a sense for where you are and also have the reverse movement again.» As always, you want it to be nice and slow and avoid collapsing your arch. «It’s difficult to do this exercise in a controlled, fluid motion way,» says Pascale. If you’ve had an injury, you’d only do this after initial immobilisation in the acute wound healing phase. By that point, the connective tissue in the capsule-band apparatus is already more stable and has healed in the right function length and direction.

The classic sports injury

Supination trauma (site in German) that affects the outer ligaments is probably the most common sports injury. It could have been caused by a stone, the stairs, a foul or a careless step – either way, it’s happened. It’s rare that you end up going in the other direction. «You can also get a pronation trauma,» explains Pascale. «For instance, if you twist your ankle to such an extent that you fall back inwards.» It’s not a nice mental image. «Or if you go over on your ankle and fall inwards on a kerb. It’s not as common, but I’ve done it before.»

Well done to those who’ve avoided it. To a certain extent, it’s down to you, or rather, down to your ankles. By training them. «People never do this preventively, even though it would make sense,» says physiotherapist and athlete Pascale from experience. The only thing you actually need is motivation. «There are also training options without accessories, for example foot exercises on different surfaces.» You can mix it up and sometimes do them in a meadow, other times on a woodchip jogging trail or on gravel. That way you can give yourself different challenges. «You don’t necessarily need a board like this. It’s just that a lot of people don’t do anything unless they have a gadget,» says Pascale. That is until they hear a «crack!», and once they’re in rehabilitation following the RICE guidelines.