Ankle Sprains In Sport
Sport is an important part of many peoples lives. Be it as a participant or a spectator, sport pumps through the blood of most Melbournian’s. Though the physical effort involved in sport is of great value to our physiological health, it comes with significant risk of injury. In fact, Fong (2007) reports that sports injuries are comparable to those of traffic accidents. As a result of the adverse effects of sports, significant effort is placed on preventative strategies and evidence based management to help minimise the risk of long lasting impairment post injury.
Who Is Susceptible To Rolling Their Ankle?
Ankle sprains are one of the most common musculoskeletal injuries and comprises 15-20% of all sporting injuries (Peterson, 2013). Of these, most are lateral ankle sprains or inversion sprains. This is when the foot rolls on to the outside surface, resulting in damage to the supporting ligaments, tendons & bone.
A major predictive factor for these sprains is the history of a previous sprain. Mugno (2021) reports 61% of people who have rolled their ankle have a history of a previous sprain.
When comparing sex, there isn’t strong correlation to an increased risk of ankle sprain though when looking at age it does tend to happen more in younger populations (Pourkazemi et al, 2018). Regarding race, African Americans & Caucasians have a significantly higher incidence when compared to Hispanics (Mugno, 2021).
What Is The Incidence In Sport?
We commonly see sprains in people playing sports with running/change of direction. Though the incidence of ankle injuries is significant in sport, the benefits of sport far outweigh the potential for injury.
As we can unsurprisingly see in the table above, lower limb injuries are prevalent in sports involving running & jumping. Fong (2007) reports the most common injury across these sports are sprains, followed by fractures. For this reason, it is essential that sports people take their injuries seriously and employ preventative strategies through the preseason & throughout competition.
How Are Ankle Sprains Graded & What Does It Mean?
Grade 1
A mild overstretching of the structures on the outside of the ankle. There may be some minor tearing but no resultant instability. Typically there is mild swelling and the patient is able to put some/all of their weight on to their foot.
Grade 2
Increased tearing of the ligaments on the outside of the ankle (typically the ATFL), with significant swelling and bruising. There is mild/moderate ankle instability with significant difficulty with putting weight on the foot.
Grade 3
A complete rupture of the ligament/s on the outside of the ankle & severe instability. Swelling & bruising present immediately and the patient typically cannot weightbear.
What Should You Do If You Roll Your Ankle?
Though there is no reported evidence regarding the effectiveness of PRICE (Mungo, 2021), the symptoms of an acute ankle sprain can be eased through its use.
Protect - Prevent further injury
Rest - This refers to relative rest not complete res
Ice - Can be useful in managing swelling and pain.
Compress - Use of compressive bandages can help minimise swelling and provide the feeling of support
Elevate - To help limit swelling and pain
What Is The Role Of Physiotherapy In Ankle Sprains?
Physio plays several rolls in ankle sprains
Assessing acute & chronic sprains, ruling out serious pathologies, grading the extent of your injury, prescribing ‘Moonboots’ or crutches where necessary & developing an appropriate rehab strategy.
Guiding post-surgical rehabilitation, liaising with your surgeon & progressing your recovery to meet your goals.
What Are Some Of The Serious Injuries Physios Look For?
Syndesmosis Injuries / High Ankle Sprain
The Syndesmosis is a connective tissue found between the two bones (Tibia & Fibula) of the lower leg. When the foot is forced up or extreme rotation is generated in the joint, this structure and surrounding connective tissues can tear. A serious condition that result in a surgery to repair the region.
Osteochondral Defects
Osteochondral Defects or OCD’s can be a significant complication following a severe ankle sprain. These occur when the surface of the ankle joint gets damaged from the trauma of an ankle sprain. The cartilage & underlying bone can be injured, resulting in degenerative changes, deep pain in the ankle & persistent swelling.
Fibula Fractures
Fractures of the Fibula are not uncommon with ankle sprains and we do have patients walk in on a Monday morning who are later found to have a broken bone. As we roll the foot, the pressure of the Talus on our Fibula can result in various different fractures. We pride ourselves on screening acute ankle injuries for fracture & will refer you for an x-ray if we’re unsure about your presentation.
Peroneal Tendinopathies
The peroneal tendons are found around the outside of the ankle. They play an important roll in ankle stability and can be come injured after an ankle sprain or a chronically unstable ankle.
How Do Physio’s Help Rehab Ankles?
Education
It may sound odd but physiotherapists are fantastic at explaining what is going on with your ankle & can help alleviate your concerns. The team at Richmond Rehab believe educating the patient can empower them to make decisions, help them identify when things aren’t quite right, and decreases anxieties associated with pains that are normal during an ankle rehab.
Part of education is to empower you to help manage your symptoms with strategies such as RICE therapy (Rest, Ice, Compression, Elevation). During the acute phase this can help to reduce pain, swelling, and inflammation. (Doherty et al., 2017)
Suportive Braces
Depending on your level of injury or the demand on your ankle, supportive taping or bracing may be prescribed. These strategies can help the joint feel protected, can ease pain, or can be useful as you progress in to more physical activity. Kaminski et al (2013) reports taping and bracing help to provide support and stability to an injured ankle.
In severe cases, a CAM Boot (Moon Boot) may be used to completely offload the area & protect your ankle while allowing you to still walk, though a little awkwardly.
Range Of Motion Exercises
Exercises to maintain joint mobility and prevent stiffness can be an important part of recovering from an ankle sprain (Linens et al., 2019).
Balance Exercises
An unfortunate symptom of ankle sprains is a reduction on balance. This can be through a structural instability through tissue damage, or through decreased joint perception (proprioception). Balance and proprioception exercises help improve joint stability and prevent re-injury. (McKeon and Hertel, 2008). Through a tailored balance program, patients typically experience improvements in the balance which helps build their confidence when returning to sport.
Strengthening Exercises
It is not uncommon for an ankle to lose significant strength following a sprain, particularly following the use of a CAM Boot. Strengthening exercises are shown improve muscle function and prevent future ankle injuries. (Doherty et al., 2017)
Manual Therapy
Linens et al. (2019) report manual therapy techniques such as massage and joint mobilisation can be used to reduce pain and improve joint mobility. Strategies such as these are helpful in the managing the your symptoms in the journey to recovery but they only make up part of your rehab.
Return To Sport Drills
Following a significant ankle sprain, patient’s often report concerns about returning to sport. Fears of re-injury or ‘not trusting’ their ankle are common descriptors for an injured patient.
A gradual return to weight-bearing activities and sport-specific training are important to restore normal function and prevent re-injury of the ankle (van Rijn et al., 2008).
Physio can help breakdown your exercise demands and structure your recovery in a staged approach. This allows us to monitor your reaction to loading and adjust your recovery appropriately. An example would be the demands of a football player typically require fast change of directions while running. A rehab strategy may progress from walking to jogging, then jogging to straight line running, and onwards to change of direction drills.
References
Linens SW, Ross SE, Arnold BL. Management of ankle sprains. Am Fam Physician. 2019 Jul 15;100(2):120-128.