Ankle Sprains - by Claire Griffin

This is the second article supplied by Physiotherapist, Claire Griffin.

I hope you find it as interesting as I have.

Ankle sprains

I’m sure that everybody knows at least one person who takes part in sport who has sustained a sprained ankle, as it is a very common sporting injury.  But a large percentage of the non-sporting population also suffer this injury .  The most common injury to the ankle is to the lateral (outside) aspect of it, usually damaging one or more ligaments (tissues that attach from bone to bone), giving rise to what is called a sprain.  A lateral ankle sprain usually results from “going over” on the ankle, in which the foot is inverted and plantarflexed.  In other words, the foot is turned inward, with the toes pointing downwards towards the floor.  This may result from awkward placement of the foot e.g. coming down a step awkwardly, landing awkwardly on the foot after jumping, or landing on another player’s foot during sport.  They are commonly seen in activities requiring rapid changes in direction (such as basketball, football, rugby), especially if these take place on an uneven surface such as grass.

The mechanism of injury is an important clue to diagnosis following an ankle sprain.  A Chartered Physiotherapist can diagnose with ease what structures are damaged.  An inversion injury suggests lateral ligament damage and an eversion injury (in which the foot is turned outward, with the arch closest to the floor) suggests medial (inside) ligament damage.  Lateral sprains are more common than medial sprains as the medial ligament (also known as the deltoid ligament) is much stronger than the lateral ligament, and is composed of two layers (Brukner and Khan, 1997).

Ankle sprains may commonly be accompanied by an audible snap, crack or tear, which, although is of great concern to the athlete sustaining the injury, is of no diagnostic significance in the case of ankle injuries (Brukner and Khan, 2007).  Depending on the severity of the injury, the athlete may continue to play or may have to rest immediately.  Swelling is usually immediate.  Ligament injuries may be mild, moderate or severe (Reid, 1992).

So how is it managed?

It is imperative that a correct diagnosis as to the severity of the injury is obtained from a Chartered Physiotherapist, as this will guide rehabilitation and prevent prolonged injury and delayed return to sport.  If a fracture is suspected, a Chartered Physiotherapist will advise an Xray.

Immediate management (24 – 48hours) involves PRICE (Protection Rest Ice Compression Elevation to limit pain and swelling that may cause damage within the ankle joint and restrict range of motion.  The injured athlete should avoid promoting swelling and excessive blood flow to the region such as hot showers, alcohol, and excessive weight-bearing.  If mobility is painful, the patient may use crutches to mobilise.

After 48 hours, progressive weight-bearing is encouraged as from this point onwards, helps to reduce swelling, increase ankle motion and enhances rehabilitation (Brukner and Khan, 2007).  Early mobility is essential to increase ligament strength and restore function (Eiff, Smith and Smith, 1994) and can be done without aggravating the injury.  If crutches are being used, partial weight-bearing may be initiated in normal heel-toe gait pattern, gradually progressing to using one crutch (using the crutch on the opposite side to the injured ankle), then full weight-bearing without a crutch.

Rehabilitation

Non-weight-bearing active strengthening exercise can begin using a theraband to improve plantarflexion, dorsiflexion (moving foot and toes upwards towards the ceiling), inversion and eversion.  Weight-bearing exercise (e.g. calf raises, wobble board exercises) begins as pain allows, preferably from the second day after injury.  Proprioceptive training is an extremely important part of the rehabilitation.   Proprioception describes the joint’s ability to determine position, motion, vibration and pressure.  This is impaired after injury, lending to impaired balance and decreased coordination.  Research has proven that improved proprioception increases ankle joint stability and decreases recurrent ankle sprains (Ross et al, 2007).  This begins with balancing on the injured leg, and progresses to balance work on a mini trampoline.  As rehabilitation progresses, functional exercises (sport-specific) are included e.g. jumping, running in a figure-of-eight.  The athlete can return to sport when functional exercises can be completed without pain during or after activity.

References:

Brukner P and Khan K 2007 Clinical Sports Medicine.  Pain: where is it coming from?  pp 27 – 33.  3^rd edn.  McGraw Hill: Sydney

Eiff MP, Smith AT, Smith GE 1994 Early mobilisation versus immobilisation in the treatment of lateral ankle sprains.  American Journal of Sports Medicine 22: 83 - 88

Reid DC 1992 Sports Injury Assessment and Rehabilitation.  Churchill Livingstone, Edinburgh

Ross SE, Arnold BL, Blackburn JT, Brown CN, Guskiewicz KM 2007 Enhanced balance associated with coordination training with stochastic resonance stimulation in subjects with functional ankle instability: an experimental trial.  Journal of NeuroEngineering and Rehabilitation 17:4:47