All about ankle sprains

Most people know someone who has sprained their ankle more than once, but why is re injury so common and what can be done to prevent this happening.

Ankle sprains are a very common injury among sports and everyday activities. Lateral (inversion) sprains are more common than medial (eversion) sprains and they occur when the foot is turned inwards and too much force is placed on the outside of the ankle. The Anterior Talofibular Ligament (ATFL) is the most common ligament to get injured and this occurs in 90% of all sprains. The Calcanofibular ligament is twice as strong as the ATFL and normally only gets injured in more severe sprains. The ATFL is attached to the capsule surrounding the ankle and as a result of getting torn, a lot of bleeding and swelling results. This is the body’s natural defence and healing mechanism and it acts as a cushion and limits movement to protect the joint as well as bringing the vital cells and chemicals that the tissue needs to heal and regenerate.

What to do when you’ve sprained you ankle

First thing is to assess how serious it is and if you need to go to A & E with a suspected fracture. The Ottawa ankle rules have been developed to help rule in or out a fracture. Put simple they state that an X-Ray is needed if you have pain in the malleoli (ankle bones) area or mid foot and one of the following: palpation pain over the 5th metatarsal or narvicular bone and an inability to walk 4 steps immediately or when you go for assessment. Research from the BJSM has shown that only 15% of ankle sprains result in a fracture but if in doubt, get it checked out.

The POLICE guidelines should then be followed and more can be read about these here. There is some controversy about the application of Ice and compression. The aim of this is to reduce swelling, but as stated earlier this is the natural healing process and there are views that we should allow this to happen. However too much swelling leads to pain, reduced movement and reduced muscle activity and proprioception so the best thing is try to strike a balance where you ice and compress but do not over do it. 5-10 minutes at the time over the first few days should be fine.

In the first couple of days do small up and down pain free movements with the ankle which will he help restore motion and limit stiffness. Avoid side to side movements. Depending on the severity of the sprain, weight can be applied but do not cause pain. The body is in the early part of tissue healing and we do not want to disrupt or cause further damage. It is said that ligaments normally take 12 weeks to heal so in the first few days and up to 3 or 4 weeks the ankle is still vulnerable to excessive load.

If you have a moderate to severe sprain the following guidelines can be followed.

After 7 – 14 days you can start to add proprioception work which is extremely important for the ankle joint. A simple way to do this is to sit down and put a ball under your foot and with your eyes closed roll the ball around. Proprioception is the body’s ability to recognize its position in space and is linked to balance and movement.

Isometric exercises can then be started where you contract the muscle but the joint does not move. This can be done by pushing the feet against a wall or using the other foot to stop movement in a certain direction. Range of motion exercises should be increased in range but again, with no pain.

After two weeks the tissue will still be healing. Scar tissue is thought to take around 21 days to be capable of handling loads and stress so caution is still needed during this time. Avoid any twisting or sudden movements. Proprioception can be done on a single leg and theraband exercises can now be started. Heel raises can be commenced but on two legs .

By week 3 or 4 single leg calf raises can be done if comfortable and pain free. Mini squats can be started to help get dorsiflexion back in the ankle. Dorsiflexion is especially important for running and if this is not restored it can lead to knee, hip and even back problems. Cross training should also be started but in a straight line.

As the tissue strengthens and mobility improves there are a number of exercises that can be done. Also if returning to sport then movements and drills that are specific to that sport will have to be trained. Your aim should be to make your body stronger that before and be able to tolerate the stresses that the sport places on your body.

Returning to sport

You should not return to sport unless you have full range of movement back, good muscle power and equal calf strength on both sides. The ankle should be stable and not feel like its going to give away and you should have no pain on impact when running. Again every injury and individual is different and you should be checked out by your medical professional. Re injuries are normally more severe and take longer to heal so it is best to do it right the first time and aim to have the joint stronger than it was pre-injury.

If you sprain your ankle make it a priority to have it checked out by a medical professional to rule out a fracture and also to guide you in rehab. It is not uncommon to hear of people who sprain their ankles regularly so get it checked out and rehabbed properly so you do not become one of these people. 

References

Kerhoff GM et al (2012). Diagnosis, treatment and prevention of ankle sprains:an evidence based clinical guidline. Br J Sports Med: 46:854-860

Brukner PD, Khan KM. (2009) Clinical Sports Medicine, 4th ed. McGraw Hill

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