Academic blog post – Ankle sprain

An ankle sprain is when the tough bands of ligaments that surround the ankle bone are typically ‘overstretched’. This can be done by ‘twisting’ or ‘rolling’ the ankle in an awkward way. This injury normally happens when the client accidentally turns or twists the ankle in an awkward way. This is a very common injury that happens to the body. An ankle sprain can be recognised either by bruising, swelling, pain on palpation, redness and stiffness. An ankle sprain is typically managed by rest, ice, compression and elevation (RICE) and functional rehabilitation e.g. mobilisation with support (Hubbard & Wilkstrom, 2010). Depending on the severity of the injury, in more severe cases, it can be treated with crutches and no mobilisation (rest) for a few days. This injury is also known for a high reinjury occurrence, up to 70% of people’s injury reoccur with this injury. Further research has also suggested that short and long-term outcomes following rehabilitation is needed, this means with rehabilitation, this helps improve the stability of the ankle (Hubbard & Wilkstrom, 2010).

As previously stated, the best way to help with an ankle sprain is using the RICE technique. Rest, this helps as it can ease pain and discomfort, ice, use for 15-20 minutes to help with swelling, compression, this will also help with swelling and it will compress the ankle to help slow down swelling and to prevent it, important to not wrap the bandage too tight as you do not want to hinder circulation. Lastly, elevation is also used to help reduce swelling, it is important to elevate above the heart, especially at night, gravity helps reduce swelling by draining excess fluid.

Once the client can start weight bearing with the ankle sprain, as a rehabilitator one of the first steps to help the client is to give the client range of movement/motion (ROM) exercises, also need to. Making sure there is full ROM or it needs to be increased to get back to the normal ROM. After reaching full ROM, the therapist/rehabilitator will then provide the client with stretches, other exercises to help gain strength and stability back in the ankle, this is because once the ankle has been damaged, it becomes weak and is then easier to sprain the ankle again (reoccurring injury).

As this is one of the most common injuries in athletes (Beynnon., et al, 2002), it comes with risk factors that can affect play. According to statistics, 10-30% of athletic injuries are ankle injuries, and in many sports, ankle sprains make up 70% or more of all reported injuries (Kobayashi., et al, 2016). Ankle sprains are often partially treated, this means recurrent ankle sprains is more than 40%, and repeated ankle sprain can lead to chronic ankle instability (CAI) and ankle osteoarthritis (Kobayashi., et al, 2016). Another risk factor for ankle sprains is having laxity of the ligaments, thereare three main ligaments in the ankle joint, (also known as the talocrural joint), anterior talofibular ligament (ATFL),calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). This means that due to them being ‘overstretched’ or ‘torn’, the talocrural joint becomes loose and unsteady, meaning that the bands of tissue the connect bone to bone, becomes weak and can then have a high rate to reoccur. 

Ankle sprains come with risk factors, these are commonly classified as intrinsic and extrinsic factors, these need to be considered when dealing with this injury. Extrinsic factors are known factors that come from outside the body, whereas, intrinsic factors are those from within the body (Fong., et al, 2009). Extrinsic factors for dealing with an ankle sprain, could be a prescription of orthosis as this can stabilise the joint. In a recent study, Barker, Beynnon and Renstrom (1997), suggested that high-top shoes, could help decrease the risk of sustaining ankle sprain injuries. This could be because they can support the ankle better and can stabilise the ankle, so it doesn’t ‘roll’. Intrinsic factors could be due to, foot size, ankle eversion to inversion strength, plantarflexion strength and ratio between dorsiflexion and plantarflexion strength and limb dominance. These are all intrinsic factors that can increase the likelihood of causing an ankle sprain. On the other hand, joint laxity, foot type and ankle instability, is not identified as being risk factors. There are also other factors to consider with an ankle sprain, if players wear netball shoes with air cells in the heel, and don’t stretch before any exercise, it is up to 5 times more likely to sustain an ankle injury (McKay et al., 2001). People with inferior single leg (Trojian & McKeag, 2006) balance, and people who are overweight, were 2-3 times more likely to have a sprain injury (Tyler et al., 2006). Reduced ankle dorsiflexion range (Noronha et al., 2006), and having a posteriorly positioned fibula (Eren et al., 2003), has also been reported these as risk factors.

To enable to regain strength in the ankle, it is important to gain strength by doing exercises that will help that. With lateral ankle sprains, regaining full ROM, strength and neuromuscular co-ordination are paramount during rehabilitation. For ROM, the main focus should be on dorsiflexion and plantarflexion, these are to be performed passively and actively (Chinn et al., 2010). Once they are back weight bearing, the next stage of rehabilitation can be started, this means they can work on balance and neuromuscular control exercises and continue ROM exercises to help with rehabilitation stages. It is also important to make sure that you include specific drills into the rehabilitation process. This is important as most drills might not be sport specific, this means if they did short, sharp movements e.g. netball players, and this causes pain, this would mean they are not ready to return-to-play. Therefore, including sport specific exercises to the rehabilitation plan to ensure they are defiantly ready to return-to-play (Chinn et al., 2010).

Once the ligaments have healed, inversion and eversion exercises should be added to the rehabilitation process to ensure the ankle is stable. Resistance bands and ankle weight are a good way of gaining strength in all planes of motion. Once the athlete has gained strength back into the ankle, the therapist would then start adding change of direction and cutting drills. This would tie in with sport specific drills.

It is known that excessive inversion and plantarflexion is the main cause for lateral ankle sprains; these are mainly occurred in netball players, but there are other sports that this is very common in, e.g. basketball. Lateral ankle sprains are common among both active and inactive individuals. It is important in all sports to perform pre-rehabilitation in order to benefit the client and to prevent any injuries that could occur. Within the skeletal muscle, there are specific sensory neuron called ‘proprioceptors’, they monitor tension in the body and can send messages between muscle fibres and the central nervous system (CNS). The body replenishes with movement, so the more you repeat something, the better it becomes. Pre-rehabilitation exercises help to strengthen the neuromuscular connections that are responsible for creating human movement. More importantly, these exercises can help with; co-ordination, balance, speed, power, reaction time and agility (Akbari et al., 2006).

References:

Akbari, M., Karimi, H., Farahini, H. and Faghihzadeh, S. (2006) Balance problems after unilateral lateral ankle sprains. Journal of Rehabilitation Research & Development. Vol. 47, No. 3: 819-824.

Barker HB, Beynnon BD, Renstrom PA: Ankle injury risk factors in sports. Sports Medicine. 1997, 23 (2): 69-74. 10.2165/00007256-199723020-00001.

Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of athletic training, 37(4), 376–380.

Chinn, L., & Hertel, J. (2010). Rehabilitation of ankle and foot injuries in athletes. Clinics in sports medicine, 29(1), 157–167. https://doi.org/10.1016/j.csm.2009.09.

De Noronha M, Refshauge K, Herbert R, Kilbreath SL: Do voluntary strength, proprioception, range of motion, or postural sway predict occurrence of lateral ankle sprain?. British Journal of Sports Medicine. 2006, 40 (10): 824-828. 10.1136/bjsm.2006.029645.

Eren OT, Kucukkaya M, Kabukcuoglu Y, Kuzgun U: The role of a posteriorly positioned fibula in ankle sprain. American Journal of Sports Medicine. 2003, 31 (6): 995-998.

Fong, D.T., Chan, Y., Mok, K. et al. Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Sci Med Rehabil 1, 14 (2009). https://doi.org/10.1186/1758-2555-1-14

Hubbard, T. J., & Wikstrom, E. A. (2010). Ankle sprain: pathophysiology, predisposing factors, and management strategies. Open access journal of sports medicine, 1, 115–122. https://doi.org/10.2147/oajsm.s9060

McKay GD, Goldie PA, Payne WR, Oakes BW: Ankle injuries in basketball: injury rate and risk factors. British Journal of Sports Medicine. 2001, 35 (2): 103-108. 10.1136/bjsm.35.2.103.

Trojian TH, McKeag DB: Single leg balance test to identify risk of ankle sprains. British Journal of Sports Medicine. 2006, 40 (7): 610-613. 10.1136/bjsm.2005.024356.

Tyler TF, McHugh MP, Mirabella MR, Mullaney MJ, Micholas SJ: Risk factors for noncontact ankle sprains in high school football players: the role of previous ankle sprains and body mass index. American Journal of Sports Medicine. 2006, 34 (3): 471-475.