Ankle sprains, particularly Lateral Ankle Sprains (LAS), are the most common injuries in sport, and ­­­­­­­are extremely common among the general public (Wikstrom et al., 2020). The lateral ankle ligament complex consists of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL) (Ferran et al., 2006), while the medial ankle ligament complex, commonly known as the deltoid ligament complex consists of 3 main components; the tibionavicular, tibiotalar, and tibiocalcaneal ligaments (Mengiardi et a;., 2016). In this academic blog post I will discuss potential risk factors for ankle sprains, as well as training types and other measures that can be used in prehabilitation of ankle sprains.

There are various risk factors which can increase the prevalence of ankle sprains. One main risk factor is gender, with females being more prone to the injury. A study found an incidence rate of 13.6 per 1000 exposures in females, in comparison to just 6.94 per 1000 exposures in males (Doherty et al,. 2014). There are different theories as to why females are at greater risk; a study by Shahraki et al., (2020) found a decreased level of proprioception during the female menstrual cycle. Proprioception is a human’s ability to precisely sense the position, speed and torque of their body parts, and is essential to human motor control (Clites et al., 2018). If women experience decreased proprioception as a result of their menstrual cycle, they are at a greater risk of sustaining an ankle sprain as they have less awareness of the position of their ankle during activity. Another risk factor for ankle sprains is age. A study by Waterman et al., (2010) found that the peak incidence rate of ankle sprains is between 10 and 19 years of age. While this could be due to anatomical differences, with their bodies still developing, this could also reflect participation levels. The age bracket of 10-19 years old will have a much higher participation rate in sports and exercise to that of the older population, meaning they are more predisposed to the injury. The final key risk factor identified for ankle sprains is the weight of an individual. A significant correlation has been found between high body mass index (BMI) and LAS (Kobayashi et al., 2016), with a study conducted by Tyler et al., (2006) concluding that an overweight individual was 19 times more likely to sprain their ankle than a person of normal weight.

The key movements at the ankle joint are dorsi and plantarflexion, occurring in the sagittal plane, abduction and adduction occurring in the transverse plane, and inversion and eversion occurring in the frontal plane (Brockett et al., 2016). Previous ankle sprains often account for problems in the future such as decreased strength, balance and proprioception as a result of damage to the mechanoreceptors in the ligament (Solomonow, 2006). These deficiencies can lead to an individual being at an increased risk for re-injury, with studies finding that 73% of ankle sprains occur in ankles that have already been sprained (Akbari et al., 2006). Ankle sprains have been found to be more prevalent in fast paced contact sports such as football, rugby and basketball. If an individual has been previously injured, their biomechanical factors may be affected e.g. taking too long of a stride and being off balance, which subsequently results in them getting re-injured. It is essential that athletes complete full rehabilitation following an ankle sprain to ensure minimal loss of balance, strength and proprioception, therefore reducing the risk of reinjuring the structure.

Various training techniques can be used in prehabilitation of an ankle sprain to reduce the chance of injury striking, or minimising the damage done if it unfortunately does. A study was conducted into the effects of proprioceptive training on the ankle in healthy subjects by Hoffman and Payne (1995). This was done over a 10-week period with subjects training 3 times per week. Post testing of the participants found the study had a significant effect on proprioception as measured by postural sway, with postural sway during a single limb stance test being a direct measure of proprioception. In relation to ankle sprains, the results concluded that proprioceptive training decreases the incidence of ankle injury. This is supported by Ekstrand et al., study (1983) who aimed to measure the effect of prevention programmes in soccer players, with results showing an 82% reduction in ankle sprains in comparison to control groups. The prevention programmes consisted of more in-depth warm-ups and cool downs, with flexibility exercises emphasised. This large reduction in incidence rate of ankle sprains demonstrates the effect such measures can have on the prevention of ankle sprains.  More recent research also emphasises the impact that neuromuscular or proprioceptive training can have on the ankle, with a literature review by Verhagen and Bay (2010) concluding that proprioceptive training such as balance boards and unilateral training being the most effective measures, with strength training not having a significant effect when performed on its own.

Ankle sprains have always been and will continue to be one of the most prevalent injuries in sports due to the nature of most fast paced, contact sports. Various risk factors have been identified to increase the chance of ankle sprain occurring, including gender, age and weight. While factors such as gender and age cannot be influenced, it gives health professionals a focus group to give prevention programmes to, as these are the people most at risk of the injury. Another key risk factor identified was history of previous ankle sprains, with a study showing 73% of ankle sprains being reported in previously sprained ankles. This is because of the effect sprained ankles can have on an individual’s proprioception, balance, strength, and general biomechanics. Various studies shown the effect that proprioceptive training in the form of balance and unilateral exercises can have, with all reporting a significant decrease in ankle injuries following a training programme. This demonstrates how prehabilition can be implemented into athletes, and the general public to reduce the amount of ankle sprains occurring.

 

References:

Akbari, M., Karimi, H., Farahini, H., & Faghihzadeh, S. (2006). Balance problems after unilateral lateral ankle sprains. Journal of rehabilitation research and development, 43(7), 819.

Brockett, C. L., & Chapman, G. J. (2016). Biomechanics of the ankle. Orthopaedics and trauma, 30(3), 232-238.

Clites, T. R., Carty, M. J., Ullauri, J. B., Carney, M. E., Mooney, L. M., Duval, J. F., … & Herr, H. M. (2018). Proprioception from a neurally controlled lower-extremity prosthesis. Science translational medicine, 10(443), eaap8373.

Doherty, C., Delahunt, E., Caulfield, B., Hertel, J., Ryan, J., & Bleakley, C. (2014). The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports medicine, 44(1), 123-140.

Dubin, J. C., Comeau, D., McClelland, R. I., Dubin, R. A., & Ferrel, E. (2011). Lateral and syndesmotic ankle sprain injuries: a narrative literature review. Journal of chiropractic medicine, 10(3), 204-219.

Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer partment of Physical Medicine and Rehabilitation, Mayo injuries: supervision by doctor and physiotherapist. Am J Sports Med 1983

Ferran, N. A., & Maffulli, N. (2006). Epidemiology of sprains of the lateral ankle ligament complex. Foot and ankle clinics, 11(3), 659-662.

Hoffman, M., & Payne, V. G. (1995). The effects of proprioceptive ankle disk training on healthy subjects. Journal of Orthopaedic & Sports Physical Therapy, 21(2), 90-93.

Kobayashi, T., Tanaka, M., & Shida, M. (2016). Intrinsic risk factors of lateral ankle sprain: a systematic review and meta-analysis. Sports health, 8(2), 190-193.

Mengiardi, B., Pinto, C., & Zanetti, M. (2016, February). Medial collateral ligament complex of the ankle: MR imaging anatomy and findings in medial instability. In Seminars in musculoskeletal radiology (Vol. 20, No. 01, pp. 091-103). Thieme Medical Publishers.

Shahraki, S. F., Minoonejad, H., & Tabrizi, Y. M. (2020). Comparison of some intrinsic risk factors of shoulder injury in three phases of menstrual cycle in collegiate female athletes. Physical Therapy in Sport.

Solomonow, M. (2006). Sensory–motor control of ligaments and associated neuromuscular disorders. Journal of Electromyography and Kinesiology, 16(6), 549-567.

Tyler, T. F., Mchugh, M. P., Mirabella, M. R., Mullaney, M. J., & Nicholas, S. J. (2006). Risk factors for noncontact ankle sprains in high school football players: the role of previous ankle sprains and body mass index. The American journal of sports medicine, 34(3), 471-475.

Verhagen, E. A. L. M., & Bay, K. (2010). Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. British journal of sports medicine, 44(15), 1082-1088.

Waterman, B. R., Owens, B. D., Davey, S., Zacchilli, M. A., & Belmont Jr, P. J. (2010). The epidemiology of ankle sprains in the United States. JBJS, 92(13), 2279-2284.

Wikstrom, E. A., Mueller, C., & Cain, M. S. (2020). Lack of Consensus on Return-to-Sport Criteria Following Lateral Ankle Sprain: A Systematic Review of Expert Opinions. Journal of Sport Rehabilitation, 29(2), 231-237.