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A twisted ankle has all the characteristics just described for a scratch but is bigger and plays out its course in three dimensions. The initial sharp pain is followed by a deep spreading pain. The ankle becomes hot and swollen. Here are the cardinal signs of inflammation with which we are now familiar. However, there is a new phase in addition to the local signs. The whole foot and lower leg are tender. The leg hurts if moved and is guarded and not permitted to touch the ground or bear weight.

The pain now originates not only from the original site of injury but also from tissue distant from the injury. A touch to undamaged tissue that would normally be felt as innocuous pressure now feels painful. The origin of this distant pain comes from the readjustment of spinal-cord circuits to produce a widespread area of pain well beyond the small local injury. The effect is to prevent any movement of the injured part and thereby to facilitate recovery. The pain that located the site of injury in the first phase now spreads widely and is associated with immobilisation of the body part.

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