Christopher Lim, PT, BHSc, MPT
Ankle injuries are very common, and have been estimated to account for 30% of all injuries seen in sports medicine clinics. They are the most frequently seen musculoskeletal injury seen by primary health care providers.
A lateral ankle sprain, also known as an inversion ankle sprain, occurs when the foot is forced beyond its natural ability to turn inward. A sudden twist, turn, or roll of the ankle excessively stresses the ligaments, causing the tissue to stretch or tear. In sport, common mechanisms are losing balance when changing direction, landing on another player’s shoe, or stepping onto uneven ground.
Ligaments – tissues connecting a bone to another bone – are designed to provide a firm end range to movement. When a joint is abruptly stretched beyond its end range, tears in the ligamentous tissues may occur. These tears are graded accordingly:
• Grade 1 Sprains: Stretching and microscopic tearing have occurred. The ankle is painful, but there is minimal swelling. Often you are able to bear weight, and closer examination will determine that the joint has not become unstable.
• Grade 2 Sprains: Partial tearing has occurred. The ankle is painful and swollen. You have trouble bearing weight, and closer examination reveals mild to moderate joint instability.
• Grade 3 Sprains: A complete rupture has occurred. Swelling occurs immediately, and worsens over 24 hours. There may have been an audible pop during the injury, and blood (bruising) may be mixed with the swelling. It is very difficult to bear weight without pain, and closer examination reveals moderate to severe instability of the joint.
The anterior talofibular ligament, calcanealfibular ligament, and posterior talofibular ligament are the most commonly injured tissues with a lateral ankle sprain; however, many other tissues may also be damaged.
• Bone: A sudden pull through a ligament may separate a small piece of bone in what is known as an avulsion fracture. It is possible for an avulsion fracture to occur in association with an ankle sprain. With more traumatic forces, large based fractures may also occur through bones above or below the ankle joint. Bone and avulsion fractures are important to detect, as they may be best treated with a form of immobilization in the early stages of healing.
• Muscle/tendon: Muscle, the tissues that dynamically move your joint, or tendon, the tissues connecting a muscle to a bone, may also be damaged during an ankle sprain. Most commonly, the peroneal muscles which turn the foot outward (and/or their tendons) are overstretched. As a result, they weaken, and lose their ability to contract at the right times during movement. Strength and motor control must be retrained during the later stages of recovery.
• Other ligaments: Beyond the lateral ankle, ligaments above, and on the opposite side may be injured during an inversion sprain. The deltoid ligament – a confluence of four ligaments and capsular tissue – is occasionally affected; the syndesmotic ligament – the attachment of the two large bones above the ankle joint – can be damaged in high force mechanisms of injury, in what is known as a high ankle sprain. Also for consideration, there are many small ligaments connecting the 26 bones of the foot. In a similar manner, these ligaments may be overstretched, resulting in pain and/or instability.
• Mechanoreceptors: Mechanoreceptors are sensory receptors that give us feedback to process balance and proprioception (the perception of where our body is in space). Many mechanoreceptors lie within the lateral ligaments, and are damaged with even the most minor of sprains. Recent protocols suggest that balance should be retrained for 3 months following an ankle sprain.
In the immediate moment of a sprain, avoid rushing to stand or return to activity. If a sprain occurs during a sporting event and an on-field health professional is available, allow them to assess the injury and assist you off field if appropriate: Pushing through pain can be detrimental to your healing process.
A useful acronym for early self-care is PRICE:
• Protect the area against further traumas or excessive movements
• Relative rest is important to promote proper tissue healing; in some cases a walking aid such as crutches may be appropriate
• Icing the area in the amount of 15-20 minutes per hour can help control inflammation without compromising healing
• Compression or support such as a tensor bandage can prevent inflammation, but take caution not limit circulation to the toes
• Elevating the involved ankle can also decrease swelling and help with drainage
It is of utmost importance to receive a thorough assessment from an accredited healthcare professional. Doing so will clarify an accurate diagnosis, rule out other more serious complications, and determine which interventions should be explored for maximum recovery. For athletes, an experienced healthcare professional can also delineate appropriate boundaries and allowances to expedite a safe return to sport.
Recent protocols explain that it is imperative to consult a healthcare professional if:
• Your joint feels unstable, or moves beyond its normal range of motion
• Your bone appears deformed, or angulates abnormally
• Pain prevents you from bearing weight after 24 hours
• Weight bearing remains difficult beyond four days
• Extreme pain, bruising, or swelling is present
• Your toes become numb, discolor, or are cold to touch
In these situations, a healthcare professional (such as a doctor, chiropractor, or physiotherapist) should thoroughly assess the injury, and communicate either a diagnosis, or if further tests/assessments are necessary.
Acute treatment will often focus on controlling pain and swelling. Depending on the healthcare professional you consult, you may be initiated on a course of anti-inflammatories, or instructed to execute light exercises or alternative positioning to drain inflammation and encourage early movement. In more severe circumstances, you may be ordered to use a gait aid (such as crutches or a cane) or a form of immobilization (such as a brace) for a finite amount of time to control stability of the ankle while it advances through the acute stage of healing.
Early treatment will then focus on maximizing movement and guiding tissue healing. In this stage, treatment should encompass a combination of active and passive interventions. Exercises should advance from gentle exploration of pain-free movements to more challenging stretches into stiff positions. Manual (“hands-on”) techniques may be used to stretch tissues, move away inflammation, or even unlock joints that have become fixed in an abnormal position. As an example of a manual technique, a cross-friction massage (which can be provided by a chiropractor, registered massage therapist, or physiotherapist) can align the new collagen tissues in a more efficient manner, promoting ligamentous strength and decreasing scar tissue. Additionally, a physiotherapist or chiropractor may apply other modalities, such a needling technique or therapeutic ultrasound, to further assist healing and promote recovery.
Continued treatment will then incorporate strengthening exercises, not only about the ankle, but also in collaborative muscles in the buttock, thigh, and core. Additionally, balance and proprioceptive exercises will retrain the timing of muscular activity to ensure joint stability through increasingly challenging activity. In this stage, a physiotherapist or chiropractor may employ electric stimulation to assist with the timing and quality of muscle contractions. Most rehabilitation should be done without pain, unless advised by a knowledgeable therapist.
Return to sport/activity encompasses complex motor patterns, such as bounding or lunging. It is importance you receive clearance prior to twisting, jumping, hopping, running, or cutting. At this stage, you should have full range of motion, normal strength, and normal balance/proprioception. In some situations, a therapist may advise you to participate with athletic tape or a brace when participating in strenuous activities.
Even with grade 3 sprains, conservative therapy is recommended for at least 6 weeks. If conservative therapies are ineffective in resolving your ankle sprain, a doctor may recommend interventional treatment options, such as a therapeutic injection or surgery. Other alternatives include more aggressive therapies, such as extracorporeal shockwave therapy. There is no evidence to suggest that these interventions are more effective than conservative treatment – it is simply a different approach.
The general principal of a therapeutic injection is that the injected agent will ‘jump-start’ the body’s healing process. Therapeutic injections, such as cortisone injections, platelet-rich plasma therapy, or prolotherapy, should be thoroughly discussed and administered by a medical doctor.
Extracorporeal shockwave therapy is applied with a handheld unit that delivers a rapid barrage of mechanical pressures in the form of shockwaves to stimulate tissues on the cellular level and re-initiate the healing process. The force of treatment is aggressive, and can be painful depending on the site of application. As there are many contraindications to the treatment, shockwave therapy should therefore only be provided by a trained doctor, chiropractor, or physiotherapist.
Surgical interventions are most often performed by orthopaedic surgeons, and are predicated by a surgical consultation. During the consultation, imaging will be reviewed; based on these images and a physical assessment, you will be informed if any surgeries are recommended, and what they may entail.
An appropriate amount of rest, and a well-timed graduated-return to activity is quintessential to the prevention of chronic repetitive ankle sprains. When poorly treated, recovery may slow down notwithstanding residual laxity of the ligaments or disorganized scar tissues and adhesions. In some situations, you may be recommended to receive athletic taping or wear a brace during high risk activities.
Most important of all, risk reduction begins with prevention through specific exercises designed to keep your ankle in excellent shape and mitigate abnormal compensations.
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