RICE & MICE: The pain of high ankle sprains

RICE & MICE will periodically review injuries that are common, uncommon or just plain unique in hockey. I hope to provide some insight to the “how’s, why’s, and when’s” of the injuries that might keep players out of the lineup. 

Let’s talk ankle sprains. Sprains commonly refer to stretching or tearing of ligaments. In a general sense, ligaments connect bone to bone and offer stability to joints. They allow a certain amount of flexibility to account for uneven surfaces when we walk and to keep the joints aligned and moving correctly and even act as shock absorbers to some extent. 

A run-of-the-mill lateral, or inversion, ankle sprain is one of the more common injuries that happen regardless of a person’s athletic ability. I’ve seen just as many sprained ankles caused by things like stepping off of ladders, falls, and clumsiness in high heels as I have as a result of sports. The most common ankle sprain is the lateral ankle sprain. This type of sprain is often referred to as “rolling” the ankle and while it is commonly seen in basketball as a result of landing on an opponent’s foot when pulling down rebounds; it is not so commonly seen in ice hockey – but not unheard of. This type of sprain can be severe and debilitating at its worst, but most people can be treated and back in action with supportive taping or bracing that reinforce or compensate for the damage ligaments. These sprains typically heal in a short few weeks, sometimes sooner. Medial, or eversion, ankle sprains are far less common and since they occur very rarely in hockey, I am going to skip talking about them. 

The ankle joint typically sustains loads three times a person’s body weight with normal daily activity.  The bones that make up the ankle joint are the tibia, fibula, and talus. The tibia is your shin bone and bears the majority of the weight when you walk. If you run your hand down your shin bone you will find that it creates the bump on the inside of your ankle. Meanwhile, the fibula is the smaller neighbor of the tibia that makes the bump on the outside of your ankle. These two bones sit on top of the talus, which in turn sits on top of the calcaneus, or heel, bone. The calcaneus is the bone that Brett Favre fractured and, while an injury to it may cause pain, it rarely will cause instability.

The type of ankle sprain that has become more prevalent in hockey is the high ankle sprain. The tibia and fibula make up the lower leg and sit side by side atop of the talus. The force of normal walking acts to spread the tibia and fibula, so the series of ligaments that hold the bones together prevent that and absorb some of the force. You can imagine the force that these ligaments absorb only increases with running, cutting and pushing off when skating. When these ligaments are stretched or torn as in a high ankle sprain, the tibia and fibula will spread with each step, causing significant pain and instability.  Sometime in severe high ankle sprains, the talus is fractured which may require surgery and close monitoring. The talus doesn’t have the best blood supply, so fractures of this bone can cause avascular necrosis if not handled properly. Avascular necrosis is bone death caused by lack of blood supply and is what happened to Ray Emery’s hip last season. 

Borrowed from Google Images

High ankle sprains occur from sudden twisting injuries, either from the foot being planted and stationary while the leg twists to the inside, or from the foot being twisted to the outside, while the leg is stationary.

Other ways this type of sprain occurs include sliding into the boards feet first, sliding into the boards and catching the toe of the skate; if the tip of the skate catches the ice as the player falls backwards; if a player is down on the ice and receives a blow to the lateral aspect of the lower leg forcing the heel to the ice; or if a player receives a blow to the lateral aspect of the knee with the skate planted and rotated outward. 

High ankle sprains occur commonly in contact and cutting sports and have been a nuisance in the NHL for the past few years.

The most recent Flyer to suffer this injury was Michael Leighton, who was given an estimated time to recover of 8-10 weeks for his severe high ankle sprain late in the 2009-2010 season. Usually people will say that they felt a “pop” and pain, just as Leighton described,  “I went out to get the puck and it got away from me and I just went back on my leg and felt my [ankle] pop,” he said. “It was just the way I fell backwards. I felt something pop, and it didn’t feel good.” 

Other notables that have suffered this type of sprain include Sidney Crosby, T.J. Oshie, Ryan Miller, Marc-Andre Fleury, Max Talbot, Kristian Huselius and Milan Lucic. Of note, Oshie had a high ankle sprain in his rookie season and was out of the lineup for 14 games before attempting an early comeback, which resulted in an extra 10 game absence for a total of 24 games. It’s possible that it’s just a coincidence that Oshie fractured that same left ankle last week. I haven’t seen any reports of what bone was broken, but it did require surgery.

The high ankle sprain does not typically cause a great degree of local swelling or bruising and generally does not “look that bad.” Unfortunately, no type of bracing has been shown to treat or prevent these high ankle sprains. The initial treatment is the RICE method: Rest - Ice - Compression – Elevation and then MICE: Mobilization - Ice – Compression – Elevation.  The resting portion of this protocol is normally much longer than it takes to decrease swelling in other injuries and it is usually suggested that people use crutches until walking is pain free, approximately 4-6 weeks depending on the severity of the injury.  Players will often be placed in a walking boot.

Over time, athletes who have a high ankle sprain can often walk and even jog on level ground normally, but cannot push off on their skate edges and are limited in terms of their ability to return to activities. Because of the time allotted for rest in these sprains are much longer, physical therapy and rehab exercises are normally begun right away; however the high level of conditioning that hockey requires almost guarantees significant time lost. Since a high ankle sprain can predispose a player to subsequent high ankle sprains, much of the rehab is focused on strengthening the muscles of the calf and ankle. If a sprain is severe enough, surgery is required and a screw is placed in order to hold the bones in place.

Disclaimer: Information on found in RICE & MICE on flyersfaithful.com is not intended to be medical advice. Any information or materials posted on the web site are intended for general informational purposes only, and should not be construed as medical advice, medical opinion, diagnosis or treatment. Any information posted on the web site is NOT a substitute for medical attention. See your health-care professional for medical advice and treatment

  • Bob H

    I had what you’d call an eversion sprain about 6 years ago, playing hockey. Running for the ball, landed on a guy’s foot while in the corner, wrenched my left ankle. Had to go to a friend’s wedding 2 days later with it blown up. Not fun.

    • http://flyersfaithful.com pavialax

      Ouch! Inversion and eversion sprains tend to cause pretty significant swelling and bruising and no they are not fun at all. I’ve had a few pretty ugly inversion sprains myself.

  • Bob H

    I had what you’d call an eversion sprain about 6 years ago, playing hockey. Running for the ball, landed on a guy’s foot while in the corner, wrenched my left ankle. Had to go to a friend’s wedding 2 days later with it blown up. Not fun.

    • http://flyersfaithful.com pavialax

      Ouch! Inversion and eversion sprains tend to cause pretty significant swelling and bruising and no they are not fun at all. I’ve had a few pretty ugly inversion sprains myself.