Everything you need to know about ankle sprains
Chapter 1: So what is an ankle sprain?
A sprain is a stretch and/or a tear of a ligament, which is a
strong band of tissue that connects the end of one bone to another and its role
is to stop excessive motions of that joint. In this case the ankle joint.
What is the most common type of ankle sprain?
This is a sprain to the Anterior Talofibular ligament, which
is on the outside of the ankle joint.
What are the different severities of ankle sprains?
Grade I - mild stretching of the ligament complex without
joint instability.
Grade II - partial rupture of the ligament complex without
joint instability.
Grade III - complete rupture of the ligament complex with
instability of the joint.
What causes ankle sprains?
Basically a sprain will occur as a result of abnormal or
excessive forces applied to a joint.
People who frequently participate in sport are more likely
to sprain their ankle.
Particularly sports that involve contact and are fast paced
with a stop start nature and involve rapid changes of direction. Examples are
sports such as football or basketball.
Poor strength and flexibility will increase your risk of an
ankle sprain.
Poor exercise technique or form will also increase your
risk.
Wearing inappropriate footwear is another potential risk
factor.
Inadequate warm up and cool down after exercising increases
the risk too.
Muscle fatigue - Tired muscles are less likely to provide
adequate support for the joints.
The most obvious cause is a sudden trauma, such as a fall,
twist, or blow.
Another risk factor is generalised joint laxity.
Medical conditions such as epilepsy or balance disorders
will obviously increase the risk.
Excessive alcohol intake and the use of drugs that can cause
drowsiness.
Being overweight or obese - this can put pressure on the
joints.
Finally having had a previous sprain will increase your risk
too.
Chapter 2: How common are sprains?
Tendon and ligament injuries account for about 30-50% of
musculoskeletal injuries primary care and ankle injury is most common in both
athletes and sedentary people.
In all sports injuries, ankle sprains are 15 to 20 % of them
according to Peterson et al (2013).
Doherty et al (2014) found that ankle sprains were more
common in females. Children are more likely than in adolescents but adolescents
were more likely than adults. The highest incidence of ankle sprain was with
indoor/court type sports. Overall a Lateral ankle sprain was the most commonly
observed type of ankle sprain.
Prognosis:
The prognosis of a sprain massively depends on the severity
of the injury. The majority of grades I, II & III lateral ankle ligament
ruptures can be managed without surgery (Peterson et al 2013).
It is considered that a mild sprain will usually heal within
a few weeks with conservative treatment, with minimal long-term complications.
A moderate sprain should heal within a few weeks, but there
is a high risk of further injury in the first 4-6 weeks.
A severe injury may take months to heal fully, require
surgical treatment, and result in complications, such as:
Chronic instability, loss of function, pain, and secondary
degenerative changes in the affected joint.
As a rough guide:
Walking within 1-2 weeks, normal function after 6-8 weeks
and a return to sport after 8-12 weeks (de
Bie et al 2006).
Pain and intermittent swelling especially on the outer side
of the ankle, are the most common residual problems (Struijs and Kerkhoffs, 2010).
References for Chapter 1 and 2:
de Bie, R.A., Hendriks, et al ( 2006 ) Clinical practice
guidelines for physical therapy in patients with acute ankle sprain. .
www.kngf.n
Doherty, Cailbhe, et al. "The incidence and prevalence
of ankle sprain injury: a systematic review and meta-analysis of prospective
epidemiological studies." Sports medicine 44.1 (2014): 123-140.
Petersen, Wolf, et al. "Treatment of acute ankle
ligament injuries: a systematic review." Archives of orthopaedic and
trauma surgery 133.8 (2013): 1129-1141.
Struijs, P.A., Kerkhoffs and G.M. ( 2010 ) Ankle sprain.
Clinical Evidence. www.clinicalevidence.com
Chapter 3: So how do you diagnosis a lateral ankle sprain?
According to Polzer et al (2012), the way that you injured
it is important to understand what injury you have sustained. This is called
the mechanism of injury.
To injure the lateral ligaments you usually need to invert
the ankle forcefully in a weight bearing state.
In 77–99% of cases X-rays are taken (Cameron & Naylor
1999), although only 9–15% of cases have actually fractured the ankle or foot (Keogh et al 1998).
So Most of the time an X-ray will be negative for a fracture
so there is something called the Ottawa Ankle Rule (OAR) and the Ottawa Foot
Rule (OFR) which was devised by Stiell et al (1992, 1992, 1993, 1994 1995) to avoid
unnecessary X-rays.
So what is the Ottawa ankle rule?
Ankle X-ray is only required if:
There is any pain in the malleolar zone and any one of the
following:
1: Bone tenderness along the distal 6 cm of the posterior
edge of the tibia or tip of the medial malleolus.
2: Bone tenderness along the distal 6 cm of the posterior
edge of the fibula or tip of the lateral malleolus.
3: An inability to bear weight both immediately and in the
emergency department for four steps.
So what is the Ottawa foot rule?
A foot X-ray is only needed if:
There is any pain in the midfoot zone and any one of the
following:
1: Bone tenderness at the base of the fifth metatarsal.
2: Bone tenderness at the navicular bone.
3: An inability to bear weight both immediately and in the
emergency department for four steps.
Once you rule out a fracture with or without an X-ray then
the symptoms will help a lot with diagnosis of what the soft tissue injury is
and the severity of it.
Symptoms of a sprain typically include pain around the
affected joint, tenderness, swelling, bruising, functional loss (for example
pain on weight-bearing), and mechanical instability mainly if the sprain is
severe.
The severity of symptoms will depend on the severity of the
injury.
Symptom duration of more than a few days can suggest more
severe injury.
Next you need to have a physical examination.
Palpation of the ankle for swelling, heat, deformity or
postural abnormality.
Check for normal sensation in case of damage to nerves or
circulation.
Check range of motion of the joint. This will be limited and
painful. For a lateral ligament sprain inversion will be the worst motion.
According to Puffer (2001), a Physio can also perform some
Orthopaedic stress tests to determine the injury further. Examples of this are:
Anterior draw test of the ankle:
If the Anterior
Talofibular ligament (ATFL) is ruptured (Grade 3), in 50% of cases a dimple sign can be seen in the
anterior aspect of the joint.
Talar tilt test:
This tests the Anterior
Talofibular ligament (ATFL) and the Calcaneofibular ligament (CFL).
A positive stress test with pain on palpation at the site of
ligament, and a hematoma have been shown to have a sensitivity of 96% for
diagnosing a ruptured ligament.
If you are unsure of diagnosis then there may be a need to
arrange investigations.
Investigations commonly used are:
X-rays:
X-rays to rule out fracture if indicated. They cannot
diagnose the sprain however.
Diagnostic Ultrasound:
Diagnostic ultrasound evaluation is strongly dependent on
the expertise of the technician and is more commonly used to look at tendons
than ligament (Jacobson 1999).
Arthrography:
Rupture of the
ATFL can be diagnosed with a sensitivity of 96–100% using arthrography but this
technique is invasive as it involves injecting into the joint. Another issue is
that it has no more accuracy then clinical assessment (van Dijk et al 1999).
MRI (Magnetic resonance imaging):
Ruptures of lateral ligaments of the ankle can be diagnosed
on MRI with a sensitivity of 75–100% but are very expensive and only used with
more difficult cases (Gaebler et al
1997).
So remember to subscribe to the channel and check out the
next videos in the series which will take you through everything you need to
know about your ankle sprain and how to get back to full fitness and sport as
quickly and easily as possible.
References for chapter 3:
Cameron C, Naylor
CD. No impact from active dissemination of the Ottawa Ankle Rules: further
evidence of the need for local implementation of practice guidelines. CMAJ. 1999;160:1165–8.
Gaebler C, Kukla
C, Breitenseher MJ, et al. Diagnosis of lateral ankle ligament injuries.
Comparison between talar tilt, MRI and operative findings in 112
athletes. Acta Orthop Scand. 1997;68:286–90.
Jacobson JA.
Musculoskeletal sonography and MR imaging. A role for both imaging
methods. Radiol Clin North Am. 1999;37:713–35.
Keogh SP, Shafi
A, Wijetunge DB. Comparison of Ottawa ankle rules and current local guidelines
for use of radiography in acute ankle injuries. J
R Coll Surg Edinb. 1998;43:341–3.
Polzer, Hans, et al. "Diagnosis and treatment of acute
ankle injuries: development of an evidence-based algorithm." Orthopedic
reviews 4.1 (2012).
Puffer JC. The sprained ankle. Clin Cornerstone.
2001;3:38–49.
Stiell I, Wells G, Laupacis A, et al. Multicentre trial to
introduce the Ottawa ankle rules for use of radiography in acute ankle
injuries. Multicentre Ankle Rule Study Group. BMJ. 1995;311:594–7.
Stiell IG, Greenberg GH, McKnight RD, et al. A study to
develop clinical decision rules for the use of radiography in acute ankle
injuries. Ann Emerg Med. 1992;21:384–90.
Stiell IG, McKnight RD, Greenberg GH, et al. Interobserver
agreement in the examination of acute ankle injury patients. Am J Emerg Med.
1992;10:14–7.
Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules
for the use of radiography in acute ankle injuries. Refinement and prospective
validation. JAMA. 1993;269:1127–32.
Stiell IG, McKnight RD, Greenberg GH, et al. Implementation
of the Ottawa ankle rules. JAMA. 1994;271:827–32.
van Dijk CN,
Molenaar AH, Cohen RH, et al. Value of arthrography after supination trauma of
the ankle. Skeletal Radiol. 1998;27:256–61.
Chapter 4: How to treat an ankle sprain:
Acute Phase: First 72 hours:
Use paracetamol or a nonsteroidal anti-inflammatory drug
(NSAID), such as ibuprofen gel.
If pain is very severe then use Codeine, if necessary.
Mostly try not to use anti-inflammatories after 72 hours but
if the ankle is still hot and throbbing then consider using an oral NSAID (for
example ibuprofen or naproxen).
Use the acronym P.O.L.I.C.E. in the first 72 hours
P: Protect the injury:
Consider a support and wear good supportive footwear
O.L: Optimal loading:
Don’t absolutely rest the ankle. You need to move it gently,
put some weight through it and walk as normally as possible on it. However
optimal means that there are no adverse reactions after doing so. So monitor
pain levels, heat and swelling after all of this. Adjust frequency and
intensity of this as required.
I: Ice:
Place ice in a damp tea towel and place over the injury.
Leave in place for 15-20 minutes and re-apply every 2 hours.
C: Compression:
For grade 1’s and 2’s you don’t what to immobilise the ankle
but you can use elastic bandaging to assist proprioceptive function of the ankle
joint (Fousekis et al 2012). With an acute sprained ankle, recovery might be
faster with a semi-rigid ankle or lace-up support (Kerkhoffs et al 2002).
Most effective treatment for grade 3 lateral ankle injuries
is short-term immobilization followed by semi-rigid brace (Peterson et al 2013)
E: Elevate:
When you aren’t doing your optimal loading simply keep your
ankle elevated but don’t spend long periods at a time immobile.
Also avoid H.A.R.M in the first 72 hours after the injury:
Heat - for example hot baths, saunas, and heat packs.
Alcohol - increases bleeding and swelling and decreases
healing.
Running - or any other form of exercise which may cause
further damage.
Massage - may increase bleeding and swelling.
72 hours to 1 week:
At the beginning of this phase it
may be very difficult to move the ankle even a small amount so Neuromuscular
electrical stimulation such as Compex is very useful.
Settings such as capillarisation can
increase blood flow by 300% and therefore assist healing and help to assist
lymphatic drainage of the swelling.
You can also use active recovery,
recovery plus and massage settings.
The pad placements are as follows:
Once able then begin light
range of motion exercises as soon as they can be tolerated without excessive
pain as there is strong evidence for early mobilisation (Doherty et al 2017).
See this video on general ankle range of movement exercises
here:
1 week to 6 weeks:
Continue with the general range of
movement exercises but advance the range of movement as tolerated.
Once you can weight bear without
irritation then you need to stretch your Calf and Achilles as these will
shorten very quickly due to not walking normally.
Here are the stretches for this
here:
There is moderate evidence supporting exercise & manual therapy techniques, for pain, swelling & function (Doherty et al 2017).
Evidence suggests that manual therapy with exercise is
superior to an exercise alone in inversion ankle sprains (Cleland et al 2013).
Manual joint mobilisation diminished pain & increased
dorsiflexion range of motion (Loudon et al 2014).
Manual therapy & joint
mobilisations are performed by a Physiotherapist and so it is important to get
this type of treatment from them.
Acupuncture for acute ankle sprains: No reliable support for
either the effectiveness or safety of acupuncture treatments (Kim et al 2014).
Obviously exercise is vital for an
ankle sprain but initially, due to neurological inhibition of the nerve the
muscle will not be firing well and will be very weak. It is important to get
these muscles working better within pain limits.
This is another point in which using
the Compex Neuromuscular electrical stimulation is very useful.
If you have a unit with the ankle
twist prevention setting then use this in a supported resting position on your
Peroneals. If your unit doesn’t have this then use explosive strength on your
Peroneals.
See pad placement here:
As you improve the exercises that
you can do without irritation will be able to be advanced.
Obviously these exercises will need
to be prescribed by a physio at the right time and level but here are some
examples of exercises for an ankle sprain rehabilitation:
Single leg balance:
Weight bearing Peroneals (ankle)
strengthening
If the problem becomes chronic and lasts for over 12 weeks:
Exercise therapy & bracing are supported in the
prevention of Chronic ankle instability (Doherty et al 2017).
There is moderate evidence to support the use of foot
orthotics in the treatment of Chronic ankle instability (Gabriner et al 2015).
Recurrent Ankle sprain & instability: Manipulative
therapy & rehab was better for short-term pain relief than rehab alone
(Lubbe et al 2015).
4 to 6 weeks of balance training enhances static &
dynamic stability in Chronic ankle instability (Wortmann & Docherty 2013).
There is lack of high-quality evidence for the effects of
proprioceptive exercise & taping in ankle instability (Hughes &
Rochester 2008).
So overall this gives a rough guide
of how to treat an ankle sprain but remember to get it checked out and only do
exercises if you have been prescribed them by a professional.
References for chapter 4:
Cleland, Joshua A., et al. "Manual physical therapy and
exercise versus supervised home exercise in the management of patients with
inversion ankle sprain: a multicenter randomized clinical trial." journal
of orthopaedic & sports physical therapy 43.7 (2013): 443-455.
Doherty, Cailbhe, et al. "Treatment and prevention of
acute and recurrent ankle sprain: an overview of systematic reviews with
meta-analysis." Br J Sports Med 51.2 (2017): 113-125.
Fousekis, Konstantinos, Elias Tsepis, and George Vagenas.
"Intrinsic risk factors of noncontact ankle sprains in soccer: a
prospective study on 100 professional players." The American journal of
sports medicine 40.8 (2012): 1842-1850.
Gabriner, Michael L., et al. "The effectiveness of foot
orthotics in improving postural control in individuals with chronic ankle
instability: a critically appraised topic." Journal of sport
rehabilitation 24.1 (2015): 68-71.
Hughes, Tom, and Patsy Rochester. "The effects of proprioceptive
exercise and taping on proprioception in subjects with functional ankle
instability: a review of the literature." Physical Therapy in Sport 9.3
(2008): 136-147.
Kerkhoffs, G. M., et al. "Different functional
treatment strategies for acute lateral ankle ligament injuries in adults."
Cochrane Database Syst Rev 3.3 (2002).
Kim, Kun Hyung, et al. "Acupuncture as analgesia for
non-emergent acute non-specific neck pain, ankle sprain and primary headache in
an emergency department setting: a protocol for a parallel group, randomised,
controlled pilot trial." BMJ open 4.6 (2014): e004994.
Loudon, Janice K., Michael P. Reiman, and Jonathan Sylvain.
"The efficacy of manual joint mobilisation/manipulation in treatment of
lateral ankle sprains: a systematic review." Br J Sports Med 48.5 (2014):
365-370.
Lubbe, Danella, et al. "Manipulative therapy and
rehabilitation for recurrent ankle sprain with functional instability: a
short-term, assessor-blind, parallel-group randomized trial." Journal of
manipulative and physiological therapeutics 38.1 (2015): 22-34.
Petersen, Wolf, et al. "Treatment of acute ankle
ligament injuries: a systematic review." Archives of orthopaedic and
trauma surgery 133.8 (2013): 1129-1141.
Wortmann, Maraike Alice, and Carrie L. Docherty.
"Effect of balance training on postural stability in subjects with chronic
ankle instability." Journal of sport rehabilitation 22.2 (2013): 143-149.
Chapter 5: How to prevent an ankle sprain
So it’s true what they say: “Prevention is better than cure”.
So what can you do to minimise the risk of ankle sprain or a re-sprain?
Strength and conditioning:
In order to reduce the risk of spraining your ankle it is advisable
to develop a balanced fitness program that incorporates cardiovascular
exercise, strength training, proprioceptive training and flexibility training.
As with any new exercise you should add activities and new
exercises cautiously otherwise you will increase your injury risk.
Lauersen et al (2014) found that strength training reduced sports
injuries to less than 1/3 so strengthening your ankles will help.
It was found that proprioceptive training was effective at
reducing the rate of ankle sprains in sport, especially with previous sprains
(Schiftan et al 2015).
Another study by Riva et al (2015) found that improved
proprioceptive control with single leg balance exercises reduced ankle sprains
by 81%.
Correct warm-up and cool down procedures:
Make sure that you warm up before exercising by doing an
aerobic activity at an easy pace to gently increase the heart rate and get the
body and muscles ready for more intense activity. A cool down after exercising by
gradually decreasing the exercise intensity level until breathing and heart
rate have returned to normal, then doing gentle stretches whilst the muscles
are still warm will help with injury prevention.
Correct equipment:
Always use proper equipment for what you will be doing. More
specifically wear appropriate shoes, and replace shoes as they wear out. Wear
comfortable, loose-fitting clothes that allow free movement.
Appropriate Recovery:
Schedule regular days off from exercise and periodise your
training correctly otherwise you will become over-trained and fatigued making
you more likely to sprain your ankle.
Environmental factors:
Practice safety measures to help prevent falls, such as keeping
stairways and walkways free of clutter, using anti-slip mats under rugs,
clearing ice and snow from footpaths in the winter, and wearing appropriate
footwear in icy conditions (flat footwear with rubber soles rather than
leather-soled or high-heeled shoes).
Medication:
Take particular care when taking drugs that cause drowsiness
(for example opioid analgesics) or if they have a medical condition that
predisposes them to falls (for example epilepsy or balance disorders).
Alcohol:
Avoid getting drunk. Not the easiest one for most people but
it obviously will lower your injury risk.
Weight:
Maintain a healthy weight as becoming overweight requires
more strength to control your movements and impact forces will be greater.
Supports and braces:
It has been found that there is a significant reduction in
ankle sprains in people allocated external ankle supports such as a semi-rigid
orthosis or air-cast brace (Quinn et al 2000).
15% of ankle sprain patients who used an ankle brace
re-sprained, compared with 27% who did neuromuscular training (Janssen et al
2014).
Summary:
So as you can see you can reduce the risk or ankle sprains
and re-sprains with many measures so get out and implement these things and
maybe I’ll never need to see you in my clinic with an ankle sprain!
References for chapter 5:
Janssen, Kasper W., Willem van Mechelen, and Evert ALM
Verhagen. "Bracing superior to neuromuscular training for the prevention
of self-reported recurrent ankle sprains: a three-arm randomised controlled
trial." Br J Sports Med (2014): bjsports-2013.
Lauersen, Jeppe Bo, Ditte Marie Bertelsen, and Lars Bo
Andersen. "The effectiveness of exercise interventions to prevent sports
injuries: a systematic review and meta-analysis of randomised controlled
trials." Br J Sports Med 48.11 (2014): 871-877.
Quinn, K., Parker, P., de Bie, R., Rowe, B., Handoll, H. “Interventions
for preventing ankle ligament injuries.” Cochrane Database Syst Rev. (2000); (2):CD000018.
Riva, Dario, et al. "Proprioceptive training and injury
prevention in a professional men's basketball team: a six-year prospective
study." Journal of strength and conditioning research 30.2 (2016): 461.
Schiftan, Gabriella Sophie, Lauren Ashleigh Ross, and Andrew
John Hahne. "The effectiveness of proprioceptive training in preventing
ankle sprains in sporting populations: a systematic review and
meta-analysis." Journal of science and medicine in sport 18.3 (2015):
238-244.
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