Introduction Sprained ankles are one of the leading causes of athletes to miss games during the season. Many times they are taped up & rushed back to the field without proper rehabilitation. More often than not, the ankle gets re-injured or worse, they end up with a knee, hip or low back injury. These injuries can be prevented by providing the proper healing time and rehabilitation. The same premise holds true for non-athletes. I have worked with a number of patients that have had multiple ankle sprains that were never given the opportunity to fully rehabilitate. The most common complaint is that their ankle turns over at any time without warning. All it takes is a slight bend in the pavement and the ankle turns. This type of injury is frustrating and can become debilitating. This article discusses the different types of ankle sprains, what to do following a sprain, and what does rehabilitation of the ankle involve?
Brief Anatomy The ankle is made up of three primary bones. The tibia & fibula, which are the longs bones of the lower leg and the talus which is a major bone of the foot. Together they make up the talocrural joint. The mobility of these bones allows the foot to flex and extend which is required for propulsion during walking. The other major joint of the ankle is formed by the lower portion of the talus and the upper portion of the calcaneus (heel bone). These two bones form what is called the subtalar joint, which allows for movement in and out (inversion/eversion). This inversion motion is the most common mechanism of injury. The ligaments are tissues that connect bone to bone. Their function is to provide stability to the joint. There are three main ligaments on the outside of the ankle called the lateral collateral ligaments. Their function is to prevent the ankle from inverting too far. The inside of the ankle is protected by the deltoid ligament, which functions to prevent excessive eversion or turning out.
Mechanism of injury – The most typical ankle sprain is an inversion sprain. This occurs when the ankle turns inward and the bodies weight compresses the ankle brining the lateral malleolus close to the floor. This excessive movement places the lateral ligaments on strain, stretches the tendons crossing the joint and can also lead to some of the tarsal bones compressing on one another. The greater the inversion force results in a more severe ankle sprain or fracture. For the purposes of this article, I will only be covering ankle sprains, not fractures.
What is the difference between a sprain and a strain? This is a common question. A sprain results from a stress placed upon a ligament. Remember a ligament connects one bone to another bone. A sprain is a partial or full tear in the ligament or at the junction of where the ligament attaches to the bone. A strain results from an excessive force or overload on a muscle leading to micro-tears in the muscle belly or tendon. A tendon is a tissue similar in strength to a ligament that connects a muscle to the bone. Both ligaments and tendons are non-contractile tissue. Only muscle has the ability to contract (shorten).
Grading an ankle sprain There are three different grades of an ankle sprain based on the severity of the injury.
Grade I (1st degree)– This is the most common type of sprain. The ligaments are overstretched but no visible tear has occurred. Microscopic tears have occurred that will heal if treated properly. Minimal swelling should occur and only minor ankle instability will be present.
Grade II (2nd degree)– This is a more severe injury and the ligament has sustained a partial tear. The ankle will typically be more swollen and ecchymosis (bruising) will usually occur. The ankle will be more unstable and painful compared to a grade I.
Grade III (3rd degree)– This is the most severe injury as the ligament has been completely torn. This is the most painful ankle sprain and will typically present as very hot and swollen with a lot of ecchymosis sometimes tracking halfway up the lower leg.
Immediate care following ankle sprain – Following a turned ankle, it is difficult to determine the severity based on a number of factors. Swelling may occur immediately making the injury seem worse than it actually is. If the ankle does not swell, this does not necessarily minimize the possibility of torn ligaments. Tenderness will usually be present on the outside of the ankle with an inversion sprain. It also may be difficult to stand on the injured foot. The safest advice would be to keep the shoe/sneaker tied tight to prevent the ankle from swelling. Keep the weight off the foot as much as possible. When the shoe is taken off, the leg should be elevated above the heart and an ice pack should be compressed against the ankle. This will help decrease both the pain and swelling. This technique is called R.I.C.E standing for Rest, Ice, Compression, Elevation. R.I.C.E is a good pneumonic for any injury to the extremities.
Should I go to the hospital? If you are having difficulty putting weight on the foot, if the swelling is severe, and the pain has not reduced after a few hours of using the R.I.C.E technique, a visit to the hospital is recommended. Prepare to wait in the emergency room for a while. Ankle sprains are not usually treated as a priority. The doctor will examine the ankle looking for joint and ligament instabilities. He/She may also order an X-ray to check for fractures. On occasion, an MRI will be ordered to assess ligament damage.
Physical Therapy/Rehabilitation It is common following an ankle sprain to be placed on crutches. More severe sprains are placed in a boot or air cast to help with ankle stability. There are four major categories of impairments that occur following an ankle sprain. These include 1. Ankle joint instability due to weakened ligamentous structures 2. Muscle weakness 3. Poor balance (proprioception) 4. Pain and swelling. Each of these impairments must be addressed for a successful rehabilitation. Physical therapists will utilize various massage techniques and modalities to reduce inflammation. Manual therapy techniques will be used to restore normal joint mechanics and to retrain the proper muscle firing patterns necessary for stability. An effort is required to normalize your walking (gait) as quickly as possible to prevent compensations. Finally, a specific strengthening program that incorporates the entire lower extremity and core muscles is provided to improve overall strength, balance and coordination. Each ankle sprain is different from the next & everybody heals at a different rate. Typically, rehabilitation following an ankle sprain can be as short as two weeks (4 visits) up to eight weeks (20 visits). This does not take into account any other co-morbidities.
Conclusion Ankle sprains if managed properly through physical therapy and a conscious effort to comply with a home exercise program are usually rehabilitated very successfully with low chance of re-injury. However, if an ankle sprain is not fully rehabilitated, the chances of re-injury with more severe damage increase greatly.