– THOMAS E,SPORTS MEDICINE
Between 13% and 15% of all sports injuries involve the ankle, and most of those involve the anterior talofibular ligament.
Ankle Sprains
Every ankle injury will require Arnica 6c as the first remedy. Repeat this every two hours for the first two days after injury.
The body’s natural reaction to a sprain or strain is to produce splinting, or spasm in the local tendons, and swelling in the area. These immobilise the injured joint, and protect it from further damage. Swelling is the result of extravasation and inflammation, and inflammation is essential for healing. Too much inflammation produces too much swelling, which is counter-productive because it delays recovery. Arnica tends to restrict the body’s reaction to almost exactly what is needed for speedy recovery.
It can work successfully even when given some time following an injury, as the following case shows.
CASE 15
Robert is a top-grade competitive skier. He injured his ankle in a fall during pre-season training in October, and had been diagnosed as having strained the talofibular ligaments of his right foot. He had received physiotherapy but the injury responded very slowly, and in February he still suffered too much pain to compete effectively. He was depressed by his lack of progress, and dissatisfied that he was not improving.
In my office he said that he was fine and probably did not need treatment. He also said he would like to compete in the British Championships that next March. I noticed that he kept his right foot and ankle well hidden whenever anyone moved around, and he agreed that he was very careful in case anyone touched his ankle. His ankle still felt bruised and sore. The last time he competed a friend noticed that he moaned as he negotiated each gate on the slalom course. His manager reported that he sat and thought, or brooded, for much of his time, and it was difficult to motivate him.
He preferred to be warm than cold, and he felt better when lying down.
Because of the time elapsed – five months between the injury and the consultation – I began treatment with Arnica 1M (the 1,000 potency), one tablet twice a day for three days.
The following week he started structured rehabilitation. He reported feeling much colder. His ankle felt worse when walking and when lying in bed. He was sleeping badly because he was restless, and wondered if he had overdone his training. He also reported some nausea and increased thirst for cold drinks.
I prescribed one Ruta 200c, twice daily for seven days. Rehabilitation was now going well and his ankle pain ceased, so after the first dose I advised him to stop taking the remedy. He competed in the British Championships and was free of pain.
Comment
You should expect to prescribe Arnica and Ruta for almost every ankle sprain because the injury almost always involves damage to ligaments. Arnica, given as soon as possible after the injury, will reduce the extravasation into the surrounding tissue and its resultant bruising, swelling and inflammation. Ruta has a specific affinity for tendons and ligaments, and will almost always assist the healing.
Immediate Treatment
Arnica
Give Arnica 30c as a first contact remedy in association with RICE. The patient should stop all exercise at first but gentle movement of the ankle can be resumed a few hours after injury. This will help to reduce swell-ing. Regular and frequent repetitions of static quadriceps exercises can be started almost immediately after injury. If ice cannot be tolerated then contrast bathing may be a more acceptable effective treatment.
The patient should be persuaded to rest, with the ankle higher than the hips, but with the whole leg supported with pillows while sitting and lying in bed. If the pain and swelling continue for more than a day, referral to a specialist for diagnosis may be recommended.
The routine prescription of Arnica immediately following injury, and of Ruta as a follow-up will have beneficial effects in most cases of ankle sprain.
Other remedies which may be useful for ankle sprains are:
Bellis Perennis
Bellis may be useful if Arnica does not seem to have worked, there is deep intense bruised pain, and the ankle feels as if it has an elastic bandage around it. The person feels chilled after being warm during exercise, but cold application to the ankle makes it better.
Dosage: One Bellis 30c, once or twice a day for two days.
Bryonia Alba
The person may feel that any movement at all is too painful to contemplate, even opening his eyes. Even the smallest movement of the injured part is painful. The joint is hot, red and swollen and pressure relieves the pain.
Dosage: One Bryonia 30c.
Phytolacca
The pain is like aching neuralgia in the ankle and in the tibia and toes. Cannot put the foot to the ground, and extending the ankle or leg is painful. Worse for motion. It may work in cases where Bryonia does not.
Dosage: One Phytolacca 30c.
Rhus Toxicodendron
The pain is tearing, shooting or stitching, worse at night and at rest. First movement painful but continued movement relieves the pain. Cannot rest, he gets up and walks around at night. Ankle swells after sitting or lying, and in the evening. Better after a hot bath (see page 00).
Dosage: One Rhus 30c.
Ruta Graveolens
Ruta has a special affinity with ligaments and tendons, and should be used when you suspect strain, damage or inflammation in the ligaments or tendons of the ankle.
It will often be effective when the pain is the result of over-use, and when there is pain from the slightest physical exertion. Bruised, sore and aching pain felt in the bones of the ankle.
Similarly to Rhus Tox., there is pain on first movement that is eased by continued movement. So, how do you decide which to use?
The pains of Ruta are bruised, sore and aching, and the person is able to rest if kept warm, and after massage. The person needing Rhus Tox. cannot rest. Also compare the mental symptoms of each remedy in the Materia Medica in Chapter 10.
The person feels worse from cold, damp or wet weather, lying on the injured limb, sitting, exertion, ascending or descending steps. Better for warmth, rubbing, gentle motion, rest if he can find a comfortable position, lying on his back, but too much rest makes him worse.
Dosage: One Ruta 30c, three times daily for three days.
Strontium Carbonicum
The pain feels like gnawing into the bones, there is spasm and swelling of the ankle joint with oedema and it feels immobile and paralysed. The ankle is sprained and puffy, and continues to swell up long after injury.
Dosage: One Strontium Carb. 30c, three times a day for three days.
Second Stage of Recovery
The most important influence on recovery is exercise in the form of specific rehabilitation, preferably prescribed and supervised by a chartered physiotherapist. Non-weight-bearing and non-impact exercise should be substituted for running, walking, and other high impact sports, dance and aerobics. Use swimming, cycling, Pilates technique and sport, activity and dance-specific weight training to maintain cardiovascular fitness, and recommend flexibility, stretching and mobilising exercises. Balance exercises are important. Tai Chi and Chi Gong exercises may be recommended.
If there is residual pain and stiffness, and swelling occurs at the end of the day there are some remedies which can help.
Causticum
The ankle feels weak, walking is unsteady and there is tearing rheumatic pain in the joint. The pain may also be described as burning. There is a feeling that the tendons and ligaments are contracted, preventing movement. Some cracking may be felt in the joint, there may be cramps in the foot and calf. Legs are restless at night, pain like electric shocks in leg. Stiffness is worse from sitting and relieved by walking.
Dosage: One Causticum 30c, twice a day until the stiffness eases, but no longer than three days.
Chelidonium
The ankle, usually the right one, is very stiff and burning, and very sore to the touch. The stiffness is worse from moving but better after warm bathing. The pain is worse at 4 pm and 4 am. He is lethargic and drowsy but has trouble sleeping because he wakes at 4 am. Anxious, despondent and guilty about being injured.
Dosage: One Chelidonium 30c or 200c, twice daily for not more than seven days, or until the stiffness and pain ease.
Ruta Graveolens
This remedy may be needed for any ankle injury. Refer to the description above in ‘First Stages of Recovery’ (page 00). A higher potency may be more effective.
Dosage: One Ruta 30c or 200c, three times daily for three days.
Silica
This remedy has always been known for its ability to disperse scar tissue and adhesions. There are sticking pains and increased sensitivity to pain. Stiffness from scarring to tissue. Chronically weak ankles and feet. Leg feels paralysed, cannot walk. Lacks determination to recover and confidence, but may be obstinate about some things. Worse from cold and draughts, touch and pressure, better wrapping up warmly. May have sweaty and smelly feet.
Dosage: One Silica 30c tablet daily for two days. (But first note the warning on page 00.)
Sulphur
Ankle swollen, stiff and feels heavy. Feet are burning hot and red so that he wants them uncovered. The pains are burning and stitching. Walks unsteadily, and is much worse when standing. Worse from bathing of any sort, may be averse to washing. Untidy, talks about theories, which may be outrageous and far-fetched. Tends to be a hot person, better in the open air.
Dosage: One Sulphur 30c, three times a day for three days. Rhus Tox. may also be needed. See Chapter 10 and page 00 above for details.
Long-Term Effects of Ankle Sprains
It is sometimes the case that a slight sprain of the ankle is much more painful than a serious ligament tear or even an avulsion fracture of either malleolus. The serious ligament tear may be dismissed from the accident clinic because there is no evident fracture. A serious sprain can, however, take months or even years to heal, as the following case illustrates. Joint instability is common following injury. It also demonstrates that the remedy chosen to fit the whole person will often be more effective than one for a specific injury, and that the correct remedy will work even years after the precipitating trauma.
CASE 16
Elizabeth sprained her right ankle when she was five years old, and consulted me when she was sixteen. She had become interested in hiking and mountain climbing, but the extra exertion was causing her problems. She had a continuous stabbing pain in the ankle, worse after a long walk in the hills. It was worse when she woke in the morning, and sometimes it woke her at night. The front part of her foot sometimes swelled up. She was afraid she would never recover, and was ‘fed up’.
Her ankle was worse from the touch of the bed clothes, and slightest pressure. She was very chatty, and talked a lot. Her mother described her as ‘starting to talk when she wakes, and not stopping until she is asleep again.’ Vivid dreams woke her most nights. She was a vegetarian, and disliked meat. She was afraid of wasps, describing them as ‘evil’, and feared all insects.
After Arsenicum Album 1M, one twice a day for three days, she reported back to me that her ankle had been ‘better on more days than it is worse.’ Six weeks later her ankle was better, and she was looking forward to increasing her walking and climbing.
The remedy that is chosen because it has an affinity for tendon and ligaments, or is a specific or local remedy, is not always the one that will cure most effectively. I chose Arsenicum Album on her mental, general and dream symptoms, and the chosen remedy also covered her ankle pain. This case is a good example of homoeopathy working on the whole person, not just on the presenting pathology.
The most effective homoeopathic sports injuries treatments will be those that follow the principles of homoeopathic prescribing.
Weak Ankles
As well as the remedies recommended for the second stage of recovery there are a few remedies which are specific for weakness in the ankles. These can be used in combination with strengthening, mobilising and balancing exercises prescribed by a chartered physiotherapist.
Calcarea Carbonica
Weak ankles which turn over too easily in heavily-built, overweight, flabby, fair children, young people and adults. Feet are always cold. Worse from exertion. Forgetful. Sour sweats about the head.
Dosage: One Calc. Carb. 30c tablet daily for two days.
Carbo Animalis
Weak ankles which turn over too easily, especially in children and young people. Foot and ankle are bluish-coloured. Feeble, has frequent colds and easy sprains. Ankle feels loose and dislocated.
Dosage: One Carbo Animalis 200c, twice a day for three days.
Natrum Carbonicum
Ankles weak, seem to dislocate and sprain easily, walks unsteadily. Trips over little obstructions or on rough ground. Burning pain in ankle, sole of foot tender, burns when walking. Cramp in ankle and foot. May be very thin or emaciated, cross, gloomy and irritable or indifferent. Dislikes thunderstorms. Much worse from heat.
Dosage: One Natrum Carb. 200c, twice a day for three days.
Nitric Acid
Weak ankles which crack when walking. Weakness may prevent walking. Tibia painfully sore, feeling of a splinter in the ankle. Ingrowing toenails, blue or yellow nails. Offensive foot sweat. Worse from touch, jarring, and cold. Better from steady pressure. Unwilling to work or make any effort, angry, curses and uses bad language.
Dosage: One Nitric Acid 200c, twice a day for three days.
Refer also to Rhus Tox., Silica and Sulphur above.
Prevention
Research has shown that an orthotic reduces the risk of further ankle sprains in athletes and dancers who have suffered previous ankle injury. A suitably experienced physiotherapist or podiatrist can prescribe an orthotic.
Fractures
What the layman commonly refers to as a ‘broken ankle’ is usually a fracture in the lower third of the tibia or fibula and really belongs to the lower leg. The repercussions such as swelling, pain and loss of mobility are manifested in the ankle joint. Homoeopathic treatment can be considered in two phases for fractures of the ankle such as avulsion fractures of the fibular or tibial malleolus or of both, and for dislocation of the ankle.
Phase 1:
Arnica
This of course is the first remedy and is necessary to counteract the trauma, to control the internal bleeding and to reduce the possibility of swelling and inflammation. The sooner it is taken, the shorter the recovery time will be.
Dosage: One Arnica 30c, three times daily for two days, will help. One can be taken anytime afterwards for relief of pain.
Aconite
Will help to relieve the immediate pain following trauma, especially when the person has been chilled, and if the injury occurred in cold weather. The pain is sticking, tearing, burning or tingling and the ankle feels deformed. The pain is worse at night, the patient is frightened by the injury or its circumstances, and anxious dreams and restlessness prevent sleep. Pale frightened face.
Dosage: One Aconite 30c, as frequently as necessary to control the pain. Stop when the pain ceases, or after three days.
Phase 2:
Symphytum
Once the fracture has been realigned or reduced and the bones reset, this remedy will encourage callus formation.
Dosage: One Symphytum 30c a day for two weeks.
Bryonia
This will help when the slightest movement, even of a distant part, causes pain in the injured joint. The swelling may be red, hot and painful to touch but – strangely – better when it is pressed, tightly bandaged or held. Look out for the characteristic mental symptoms of extreme irritability, wanting to be left alone, and wanting to go home before treatment is over or even before it begins. Bryonia will help when the person is reluctant to exercise while the lower leg is still immobilised, for example in a cast.
Dosage: One Bryonia 30c or 200c.
Kali Carbonicum
Aching, sciatic, shooting pains in the tibia and ankle which make the person bad-tempered and quarrelsome. (He is likely to be a bad-tempered person, but is normally able to keep this under control.)
Dosage: One Kali Carb. 30c.
Phytolacca
The pain is like aching neuralgia in the ankle and in the tibia and toes. Cannot put the foot to the ground, and extending the ankle or leg is painful. Worse for motion.
Dosage: One Phytolacca 30c, three times a day for two days.
Rhus Toxicodendron
Will alleviate pain when the ankle is rested, and when the pain is worse on first moving and relieved by continued movement. The ankle swells after the person has been resting or sitting for some time, and is more painful in cold, wet weather and at night. Look out for the typical mental symptoms of anxiety, depression and confusion, and the relief of pain from hot bathing. Rhus Tox. may be needed for some time following apparent recovery if the symptoms reappear.
Dosage: One Rhus Tox. 30c or 200c.
During recovery and rehabilitation the athlete or dancer may require remedies such as Rhus Tox., Bryonia and other remedies as indicated, especially when there is pain or stiffness as a result of rehabilitative treatment.
Achilles Tendon Rupture
When there is a partial or full rupture of the Achilles tendon there is a sudden severe pain which is similar to a blow to the calf. Typically, a doubles racquet player moves forward suddenly from the back of the court and thinks that his partner has hit his leg with his racquet.
Swelling and bruising may be present and the two ends of the tendon may leave a visible gap, but this is not always evident. The athlete or dancer falls at the moment of injury, and cannot walk. The most frequent cause of the injury is sudden strenuous activity such as sprinting, jumping or lunging when the muscle is either cold or very fatigued.
A ruptured tendon may need immobilisation for six weeks. In many cases it may be advisable to repair the rupture surgically. Treatment should be followed by rehabilitation which may be slow.
A partial rupture of the Achilles tendon produces sudden pain at the site of the injury. There is pain during physical activity and stiffness on moving before and after exercise. Local swelling is tender to touch, and the athlete experiences difficulty when the forward foot moves to the rear when walking.
Arnica
The injury is accompanied by bleeding into the tissues and can give rise to shock. It is necessary to limit the haemorrhage, exudates and subsequent inflammation, swelling and atrophy.
Dosage: Arnica in any potency available should be taken immediately and continued for three or four doses.
Ruta Graveolens
A partial rupture will take as long to recover as a full tear. Arnica is essential as a first remedy, followed by Ruta.
Dosage: Ruta 30c, one tablet twice daily for three days, will both relieve the pain and promote recovery.
Symphytum
If the tendon is repaired surgically, Symphytum 6c three times daily for two weeks will aid recovery. The same remedy will help recovery if the leg is immobilised.
Dosage: One Symphytum 6c, three times daily for two weeks.
Achilles Tendinitis and Peritendinitis
Pain and tenderness in the Achilles tendon is often caused by over-use and over-load. Tendinitis may be caused by a small tear in the tendon, long distance running on hard surfaces, or by the back of a shoe or boot impinging on the tendon. Running in sand dunes and steeply uphill can be a cause. Dance class on unsuitable and hard surfaces may also cause Achilles tendinitis and peritendinitis. The conditions are common in dancers when there is overexertion of calf muscles with insufficient warm up and stretching. There is a danger of the condition recurring and, in older people, of the tendon developing cystic degeneration.
Peritendinitis is sometimes caused by changing to low-heeled shoes, or shoes or boots with rigid soles. The Achilles tendon does not have a sheath, and after over-use the surrounding connective tissue becomes inflamed and there may be crepitus.
There are two specific remedies for inflammation of the Achilles tendon and its surrounding tissue:
Sepia
The tendon feels too short and the legs are restless and twitching. The feet feel cold. The person feels better after violent strenuous exercise, and from warmth. Hates cold. The typical mental and emotional symptoms of Sepia make it a remedy that may frequently apply to dancers (see Chapter 10).
Dosage: One Sepia 30c daily to reduce the inflammation.
Zinc
The pain is worse from heat, but better if the joint can be kept moving. Cannot keep the feet and legs still. The foot and toes feel swollen, even from a condition in the Achilles tendon, and there may be a sensation of itching or crawling over the skin which is better from rubbing or scratching.
Dosage: One Zinc 30c. (Rhus Tox. and Ruta may also be needed according to the symptoms.)
Osteoarthritis
Although it is not due exclusively to injury, osteoarthritis may be a sequel of fractures and other ankle injuries. It occurs mainly in footballers, runners, dancers, and rugby players. Unfortunately the condition rarely becomes evident until the person reaches middle age. Its eventual onset may be precipitated by a return to full activity before the joint has reached total rehabilitation.
My files include many cases where the pain and disability of osteoarthritis have been relieved by homoeopathic medicines. There is no doubt that the earlier homoeopathic treatment is started, the better chance there is of success.
There are several homoeopathic remedies which have been used to treat people with osteoarthritis successfully. They cannot reverse the deterioration and pathological tissue change, but they can relieve the pain significantly.
Causticum
For arthritis following ankle injuries. Tearing, burning, rheumatic pain in the ankle, better from warmth of bed. Deformity. Tendons contracted. Cracking in joint. Electric shocks in leg. Restless legs at night. Worse dry cold air, windy weather, evening, and 3-4 a.m.
Dosage: One Causticum 30c, daily for three days.
Chamomilla
Violent rheumatic pains drive the person out of bed at night. Ankles give way. Feels as if walking on the ends of the bones. Cannot step on feet at night. Quarrelsome, cross and uncivil. Worse at night, and after drinking coffee.
Dosage: One Chamomilla 30c daily for three days.
Rhus Toxicodendron
Hot painful swelling of ankle. Feet swell in evening. Condyles of bones sore. Worse after sitting or lying. Worse during rest. Cannot find a comfortable position to rest or sleep. Must keep moving leg and ankle. Much worse if ankle is lain on. First movement is extremely painful, but continued movement relieves the pain. Worse on wet nights. Better from hot bathing. Depressed about the pain.
Dosage: One Rhus Tox. 30c daily for three days. It may be necessary to repeat the chosen remedy at intervals if the symptoms return.
Warning: In every case of ankle pain or sprain the athlete or dancer must discuss with an expert whether to continue. If there is the least doubt about his or her ability to continue then the decision must be to stop. Never play, perform or exercise ‘through’ the pain.
Rehabilitation should begin as soon as possible after the injury, using exercises to prevent muscle atrophy.
After injury, the return to full competition or performance should be delayed until the joint is mechanically fully recovered and entirely pain-free.
Using the appropriate homoeopathic remedies at every stage can help to avoid or delay the onset of osteoarthritis.