One of the most common sporting injuries is a sprained ankle. Lateral ankle sprains usually occur with a rolling in (inversion) of the ankle. Ankle sprains are often sustained during a mis-step, giving out on a pivoting movement or landing on an opponent’s foot during a jump. If the speed of the force is too quick or great for the muscular system to react the result can be an injury to the non-muscular structures of the ankle.
Anatomy of your ankle
Your Talocrural Joint
The proper term for the ankle is the talocrural joint. This joint is formed by the distal portions of the tibia and fibula. The furthest regions of them can be seen as the bulges on the inner and outer parts of your ankle. At these ends they are known as the medial malleolus and lateral malleolus (plural malleoli). Underneath the malleoli sit the talus. Together this joint is referred to as the talocrural joint and is one of the primary movers for going up on your toes or squatting.
Your Subtalar Joint
Underneath the talus is the calcaneus bone. The joint formed by the talus and the calcaneus is referred to as the subtalar joint. This joint assists with twisting movements of the body (with the foot on the ground) and proper movement of this region is required to allow for adaptation of the foot and ankle to unstable surfaces (like sand or grass) and for assisting with proper load transfer during walking, running and jumping tasks. Poor movement through the subtalar joint can result in pain syndromes of the foot and heel.
Ligaments of your Ankle
The talocrural joint has a series of ligaments on the outer part of the ankle to limit rolling in of the ankle. From front to back these are the anterior talofibular ligaments (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament (PTFL).
Ligaments of other regions are also susceptible to injury with the same mechanism of injury. These include the lateral subtalar ligaments and the ligaments of the distal tibiofibular joint.
Lateral ankle sprain
Lateral ankle sprains usually occur with a rolling in (inversion) of the ankle. Most commonly, this injury involves one of the three ligaments of the talocrural joint. As a group, these ligaments resist inversion of the ankle. However each ligament resists inversion of the ankle at different ranges of motion. The ATFL is susceptible to injury when the ankle was injured with the foot on the ground and in front of you, the CFL is susceptible to injury when the sprain occurred with your leg underneath you, and the PTFL is more vulnerable to injury when the ankle inverts in a squat or with the leg behind you.
Your physiotherapist can stress each ligament individually to determine which of these ligaments have been injured. The amount of looseness of the ligament on testing is an indication of the severity of the tear. Tears are graded from grade 1 (minor tearing) to grade 3 (complete tear).
An inversion injury can also sprain the ligaments of the subtalar or distal tibiofibular joints and should be assessed by a physiotherapist trained in assessing and treating sports injuries.
Pain and swelling are the most common initial signs of an ankle sprain. In most cases the symptoms will prevent continuing to play with more sever ankle injuries resulting in more significant pain and swelling.
Although these injuries can result in swelling and can be extremely, imaging studies including X-Rays are rarely indicated. The Ottawa ankle rules are often used to determine whether an X-Ray is indicated. The criteria for this group of tests include:
- Pain in the malleolar zone of the ankle or midfoot
- And bony tenderness of the medial or lateral malleolus, the base of the 5th metatarsal or navicular
- If the injured individual is totally unable to four total steps (2 with the injured ankle) immediately after the injury and in the emergency department
Management of a Lateral Ankle Sprain
Anti-Inflammatory
There is strong evidence on the use of anti-inflammatory medication. This does not have to be prescription but can be over the counter medications such as Ibuprofen or Aspirin. You should make sure with your doctor or pharmacist that anti-inflammatory medications are appropriate for your health history.
Reducing swelling and pain
In the acute phase of the injury swelling and pain are the common complaints. Elastic bandages can be used to wrap the injury to reduce excessive amounts of swelling in the area.
Our previous blog post discussed the use of ice versus heat for injuries. To summarize, if the injury is hot and swollen ice can be used to reduce swelling and pain however results re best when combined with an exercise therapy program.
There is strong evidence for the use of specific bracing or taping strategies to reduce movement and improve function.
Immobilization
Protecting the acutely injured area is important to allow for improved function. It is also important to note that these immobilization strategies are meant to reduce pain during functional tasks and should not be used to completely immobilize the area for prolonged periods of time. Studies have shown that early mobilization within pain limits is important for proper scar tissue formation.
The type and amount that the brace should be used are dependent on which structures were injured and is determined during an initial consultation with your physiotherapist. Early treatment strategies revolve around protecting the injured structure while maintaining your overall conditioning through cross training in safe ways for your ankle. Early pain free range of motion has been show to be beneficial in improving scar tissue healing and pain.
Manual Therapy
In the early phase of injury manual therapy of the injured tissue is likely not indicated. However there have been benefits shown in chronic ankle instability cases for the use of manual therapy to improve ROM. Additionally, during your comprehensive initial consultation your physiotherapist may identify areas of restricted movement that haven't been injured. Manual therapy can be used in different ways according to your movement restrictions, your physiotherapist’s training and your expectations. These areas can contribute to a slower return to sport and may be addressed through hands on treatment or a specific exercise program.
Return to Sport and Function
Once the acute nature of the injury has healed treatment should consist of targeted techniques to restore movement, a progressive strengthening program including proprioception retraining that is sports appropriate. These may include not just strengthening exercises to retrain specific muscles of the foot and ankle, but also lower extremity exercises to address movement problems that may result in increased loading of your foot and ankle. These exercises will progress to dynamic exercises to minimize, the chance of re-injury and compensatory pain that may lead to foot or knee pain.
You’re not alone
Have you been unable to return to your usual self after an ankle sprain? Have you had repeated ankle sprains that have been progressively limiting you? The physiotherapists and massage therapists at Family Physiotherapy have the experience and training to get you back to achieving your health and wellness goals! Contact us for a consultation. Don’t let pain ruin your day!
References:
Dohert, Bleakley, Dlehunt and Holden “Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis” British Journal of Sports Medicine 2017 (51)
