ANKLE SPRAINS

Ankle injuries are common sporting injuries, particularly in tasks that require rapid directional change such as football, basketball, soccer and tennis.  Most of us have ‘rolled’ our ankle at some stage, but what exactly have we injured? What tissues are involved? What do I do if I have injured my ankle? How do I prevent it from happening again?

Anatomy…

The ankle is where the long bones of the leg (Tibia and Fibula) articulate with the foot. It is not a simple hinge joint, but instead two separate joints that work together: the Talocrural joint where the long bones meet the Talus, and the Subtalar joint where the talus meets the calcaneus (your heel).  As you can see by separate joint axis’, the Talocrural joint allows movement up and down (dorsiflexion and plantarflexion) whereas the Subtalar joint allows you to point your foot in and out inversion and eversion.

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Strong ligaments give these joints structural support and prevent excessive movement passively. On the inside of the ankle (Medially), the deltoid ligament provides the majority of the support, where laterally (the outside of the ankle) is predominantly supported by the calcaneofibula, posterior talofibula, and anterior talofibula ligaments.

The image below shows the ‘syndesmosis’. This refers to connective tissue that simply, keep the long bones of the leg together. This includes the posterior and anterior tibiofibula ligaments, and transverse tibiofibula ligament.

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Mechanism of injury…

Inversion and eversion injuries occur when movement/forces at the subtalar joint exceed what it’s supporting tissues can withstand. This can lead to tears and ruptures of the supporting ligaments, avulsion and intraarticular fractures, and injury to tendons acting on the joint.

Injuries to the syndesmosis are often referred to as ‘high ankle’ injuries. These injuries most commonly occur when your foot is planted on the ground and then an excessive outwards twisting of your foot occurs. This can also occur with heavily loaded dorsiflexion (your foot is pointed up), such being tackled at football and extra force pushing your foot up. Return to full function and sport tends to be slower with these injuries.

What should I do if I have sprained my ankle?

It is a good idea to consult your Physiotherapist immediately to assess the full extent of your injury, particularly if you are struggling to put weight on your ankle. Based on assessment findings, your physiotherapist will determine if x-rays are required to rule out fractures, provide advice about how to protect the ankle, manage pain and swelling. Small avulsion fractures, where the ligaments have not failed but instead pull bone away from there attachment, may only require a brief period of immobilisation, whereas more severe injuries require surgery so it is important to get the right advice! Your Physiotherapist may utilise taping techniques, ankle braces, or below knee orthotic devices such as an AirCast Boot, to aid early mobilisation safely, and promote healing.

Should I apply the RICE Principles?

(Rest Ice Compression and Elevation).

R: Certainly modifying activity/load to protect healing tissues and manage your pain is necessary, however commencing early exercise and functional training is associated with faster recovery times.

I: Despite being common place in the medical/sports profession and considered conventional treatment post acute injury, there is only moderate evidence supporting intermittent application of ice. Intervals of 20 minutes appears more effective than sustained use.

CE: In regard to compression and elevation, there is little evidence of high quality available to make specific recommendations as to their method of application or their effectiveness (Van den Bekerom 2012).

Should I take anti-inflammatories?

While, over the years, NSAIDs such as ibuprofen have been commonly used in the management of such injuries, emerging evidence is questioning their use. When compared with paracetomol, it has increased potential for side effects, and can limit healing time by dampening the inflammatory reaction that is crucial for healing. This is particularly important in the first 48 hours when the healing process is at its peak. In summary, if you need pain relief in the first 48 hours, use paracetomol.  It has been proven to be just as effective as most NSAIDs (Williams 2012). After that, it is a good idea to discuss with your GP if anti-inflammatories are safe and appropriate.

Rehabilitation…

As your symptoms allow, you will need to increase your strength, proprioception, neuromuscular and postural control. Early exercise is associated with improved pain, swelling, and function. More advanced rehabilitation appears vital in preventing a recurrence of your injury. Research indicates:

  • 34% of people incur a residual problem within 3 years following their first ankle-injury.
  • 1 year post injury:
    • 5-33% of patients still experience pain and instability
    • 34% report at least one re-sprain
    • 15-64% report that they have not recovered fully from their initial injury (Van Rijn et al 2008).

Encouragingly, Bleakley et al (2008) found that ‘early neuromuscular training has a positive effect on pain and ankle function, and that supervised neuromuscular training can decrease the incidence of re-injury for up to 12 months’.

Summary…

Although RICE and immobilisation has been considered conventional management for ankle injuries for many years, the evidence supports early mobilisation and exercise, and more advanced rehabilitation to improve strength and neuromuscular control. Such high recurrence rates certainly suggests ‘conventional’ management is insufficient in many cases.

At The Injury Clinic, our therapists can assess the severity of your injury, guide you through the acute phases of your injury, and supervise your safe return to work and sport. Please call or email us on (03) 5229 3911 or info@theinjuryclinic.com.au if you have any questions you think we may be able to help you with.

References…

Bleakley, C., McDonough, S.,  and MacAuley, D (2008). Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Australian Journal of Physiotherapy Vol. 54

Hiller, C., Nightingale, E., Lin, C., Coughlan, G., Caulfield, B., and Delahunt, E (2011). Characteristics of people with recurrent ankle sprains: a systematic review with met analysis Br J Sports Med ;45:660–672. doi:10.1136/bjsm.2010.077404

Van den Bekerom, M., Struijs, P., Blankevoort, L., Welling, L., van Dijk, C., Kerkhoffs, G (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?Journal of Athletic Training 2012;47(4):435–443 doi: 10.4085/1062-6050-47.4.14

Van Rijn, RM., van Os, AG., Bernsen, RM., Luijsterburg, PA., Koes, BW., Bierma-Zeinstra, SM (2008). What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med;121:324-31 e6.

Williams, K (2012). Evidence on NSAID use in soft tissue injuries. Retrieved 05/06/17 from https://www.nursingtimes.net/clinical-archive/pain-management/evidence-on-nsaid-use-in-soft-tissue-injuries/5051324.article

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