More than 'just a sprain'
Acute ankle sprains are an injury we see a lot in the clinic. One of the main reasons for this is that within sporting populations and physically active individuals it is one of the most common injuries experienced.
Statistics for this vary however it is suggested that the incidence is around 26 people per 1000 will experience an ankle injury per year with 7 of the 1000 needing to present to ED. This makes the Ankle joint the 2nd most injured body part in sport.
Within the professional sporting arena, these findings stack up. With over 12,138 days missed by athletes or 2033 matches over 2 seasons within 91 professional football teams.
Unfortunately, that’s not the end of the bad news. With research finding that up to 46% of acute ankle sprains were recurrent injuries.
It is this damning finding that makes having previously had an ankle sprain, one of the biggest risk factors in sustaining an ankle strain or injury.
This recurrence rate in combination with the frequency of ankle sprains occurring is one of the reasons why we take ankle sprains and appropriate rehabilitation so seriously.
Because as the above statistics suggest if we don’t, then it won’t be the last and potentially could be a lot more serious.
What is an ankle sprain?
An ankle sprain is generally classified as a rapid rolling, twisting or turning of the ankle joint commonly resulting in one or more of the ligaments and connective tissue in the area being stretched, torn or ruptured.
Depending on the force and rate of the movement this can also involve the development of bony fracture, typically where these structures insert onto the foot or lower leg, as well as boney Oedema, swelling and inflammation.
What are the different classifications?
Typically we grade ankle sprain through severity and also mechanism and area in which the injury has occurred.
Below is an outline of severity:
Grade 1 (Mild) - Little swelling and tenderness with little impact on function. Often a high degree of stretch to the ligament, however, remains intact.
Grade 2 (Moderate) - Significant swelling, pain and significant loss of function. Reduced proprioception, range of motion and instability. Often in association with incomplete or partial tears of 1 or more ligaments.
Grade 3 (Severe) - Complete rupture of 1 or more ligaments, large evident swelling, high tenderness on touch, complete loss of function and inability to weight-bear with significant instability
We will also implement the, The Ottawa Ankle Clinical Prediction Rules, which help to evaluate likelihood of fracture throughout high risk areas post ankle sprain and need for further imaging.
We then marry grading with mechanism and location:
Lateral Ankle Sprain
This is the most common presentation. With around 85% of all presentations involving the outside of the ankle. The mechanism here is usually when the ankle is rolled out and toes are pointed down.
Commonly this will involve ligament injury to:
ATFL (anterior talofibular ligament)
CFL (calcaneo-fibular ligament)
PTFL (posterior talofibular ligament)
In severe cases, there is often boney fracture to the outside of the midfoot (5th metatarsal), outside of the ankle (lateral malleolus) and within the inside margin of the ankle joint (talas, medial malleolus or navicular).
Syndesmosis Injury “High Ankle Sprain“
This is often a result of a higher grade ankle sprain. Because of the force and range during a lateral ankle sprain, we can sometimes have separation of the tibia & fibula (the two bones within your shin) and injury to the ligament (AIFTL) which holds them in place.
Initially syndesmosis injuries appear very similar to that of a lateral ankle sprain however pain will present slightly higher up the ankle and will often be present once initial swelling and symptoms have subsided.
Medial Ankle Sprain
Here we are talking about sprains where the ankle is rolled in. These are less common however are just as serious.
Most commonly this will involve injury to the Deltoid Ligament on the inside of your arch and ankle. This ligament is made up of several different ligaments (posterior tibiotalar ligament, tibiocalcaneal ligament, tibionavicular ligament, anterior tibiotalar ligament) and provides structure in maintaining the arch of the foot.
Chronic Ankle instability
This typically involves continued issues following a lateral ligament sprain or injury. Unfortunately it is reported in 19-72% of those who report a lateral ankle injury and around 20% of people may develop this instability from their first ankle sprain.
Below are a couple of applicable clinical tests that we can also implement to further exclude or confirm diagnosis:
Anterior Draw- Tests integrity of ATFL ligament
Talar Tilt- Tests integrity of CFL ligament
Posterior Draw- Tests integrity of PTFL Ligament
Squeeze Test- Tests pain and intenrigty of AITFL/Syndesmosis
Kleiger’s- Test for Syndesmosis injury
One we have worked through this scaffold, it enables us to be able to make an accurate diagnosis on grading, location and treatment pathway.
How is an Ankle sprain treated?
Initially this will involve reducing pain and depending on severity facilitating the appropriate offloading or intervention to provide stability to the ankle. However, the longer term overarching goal once this is achieved is to increase the capacity, strength and stability of the joint to be able to return to activity comfortably but to also reduce the risk of recurrence.
Conservative Management
Acute offloading, Pain management & Movement
For lower grade injuries, treatment is often guided by the common acronym POLICE. This is an update to the RICE protocol and now focuses on early movement and loading.
Here this can incorporate changes to footwear, taping and even Moon boots for short periods of time in combination with activity modification.
Rehabilitation
Hands down the most important intervention. The focus will be on initially placing tolerable force through the major stabilisers of the ankle and calf while also progressing intrinsic foot strength and working on proprioception and balance.
Progression will incorporate heavier, slow strength based exercises to the distal (lower) and proximal (upper) limb focusing on building the foundational strength and capacity.
Before attention then turns to the ability of these structures to generate power and absorb higher loading rates though plyometric and ballistic exercises.
Throughout this there will be a gradual reintegration of activity and return to sport markers.
Longer term offloading
This may be required if structural characteristics of the foot and ankle increase the risk of recurrence and can help to enable a quicker return to sport and higher intensity activity.
Orthotic
Redistributes load away from specific aspects of the foot and ankle, particularly those at higher risk of injury or decreased capacity and integrity.
Bracing
Provides external stability to the ankle in assistance to the ligaments to enable reduced range though particular joints.
Surgical Management
This is more applicable for higher grade ankle sprains, non-healing fractures, chronic ankle instability cases or injury to the syndesmosis.
Here this may involve pinning of bony structures, the use of synthetic fibres to repair and tighten ligaments and provide structure and stability to the joint.
Outcomes post surgery for syndesmosis injuries are fantastic. When paired with appropriate longer term rehabilitation return to sport times and recurrence rates are low and longer term outcomes are just as good as pre-injury.
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