By: Camryn Cothran, SPT
Revised: Dr. Darryl Richmond, PT, DPT, MSc
Ankle injuries in the United States are very common, with approximately 1 million recorded ankle injuries annually. Nearly 85% of ankle injuries are considered sprains, with inversion ankle sprains being most common secondary to weakness of the lateral ligaments (Wexler, 1998). Lateral ligaments of the ankle are most frequently injured in athletes especially in sports that require a vast amount of jumping such as tennis, volleyball, basketball, football, etc. In addition, athletes that have suffered a previous ankle sprain are highly susceptible to reinjury due to the laxity of the previously injured ligaments. Oftentimes, the athlete has not received treatment for the sprain, causing them to re-injure much more frequently.
What is an ankle sprain?
An ankle sprain is a minor/major tear in one, or multiple, ligaments of the ankle. Ligaments are a fibrous connective tissue that joins one bone to another and also provides stability to a joint.
Types of ankle sprains:
Inversion ankle sprain - occurs when the foot is twisted upward and the ankle rolls inward and oftentimes damages the anterior talofibular ligament.
Eversion ankle sprain - occurs when the ankle rolls outward and damages the deltoid ligament
High ankle sprain - occurs when the ankle is forced into rotation, dorsiflexion, or a combination of both. Damage is done to the ligaments superior to the ankle.
Classification of An Inversion Ankle Sprain
Grade 1 : Ligaments are intact, but there is point tenderness over the anterior talofibular ligament with minimal edema. Athletes are able to ambulate with little to no pain.
Grade 2: A partial tear in the anterior talofibular ligament along with localized swelling and bruising. The athlete is recommended to be on crutches and non weight bearing until one can ambulate pain free.
Grade 3: A complete tear of the anterior talofibular ligament with the possibility of a small tear in the calcaneofibular ligament. Resulting in swelling and tenderness on the lateral and medial segments of the ankle joint. The athlete is unable to ambulate without causing immense pain.
Types of Treatment For Ankle Sprains
Non Surgical Treatment
If an athlete has suffered from a grade 1 sprain, it can be best treated through rest, ice, compression and elevation along with taking non-steroidal anti-inflammatory drugs to control the swelling and aid in pain (Wexler, 1988). If the athlete has a grade 2 sprain, it is advised to begin physical therapy in combination with rest, ice, compression, elevation and the taking of non-steroidal anti-inflammatory drugs. If conservative therapy isn’t working at this stage, it is best to start injection therapy as the next form of treatment. A corticosteroid injection allows the athlete to feel relief from pain for a period of time so the ankle can be rehabilitated effectively.
Surgical Treatment
When it comes to a grade 3 sprain, there are differing opinions on what treatment is best. Some experts say that if the patient is under 40 years old, it is recommended that the patient undergoes surgery. However, if the patient is over the age of 40, they should take the conservative route such as physical therapy and only undergo surgery if necessary (Rusanen,et. Al 1987). Others will say that if the anterior talofibular ligament was the only ligament involved, then casting is sufficient. However, if the anterior talofibular and calcaneofibular ligaments are both torn then surgery is advised (Prins, 1978). In contrast, Brostrom, a very well known clinical researcher, stated that surgery with rehabilitation is best for athletes that have suffered from a grade 3 sprain, but not for those who aren’t competitive athletes.
Rehabilitation
Performing rehabilitation activities and exercises are of the highest importance once an ankle sprain occurs. If exercises aren’t performed, the chances of re-injury increases dramatically. It’s imperative that athletes start with exercises that improve range of motion, and strengthening activities to improve both anterior and lateral compartments of the lower leg. If the athlete was to undergo surgery, there is a standard protocol that an athlete must follow. Below is an example of what that may consist of:
Phase 1
Protection Phase
0-2 weeks after surgery
Exercises that improve flexibility and range of motion
Reduce pain and inflammation
Important not to perform exercises/activities that induce pain and/or swelling
Phase 2
Progressive ROM and Early Strengthening
1-3 weeks after surgery
Introduce strength and endurance exercises
Advance to active and passive ROM
Include ankle stabilization exercises to improve proprioception and control
Phase 3
Advanced Strengthening & Neuromuscular Control
2-6 weeks after surgery
Begin agility/power exercises
Athlete is able to return to strength training (modify exercises as needed)
Advancement of proximal stability
Phase 4
Return To Sport
3-8 weeks after surgery
Incorporate sport specific exercises/drills
Individualized rehabilitation program
Progression of agility/power exercises
Reference: Sanford Orthopedics Sports Medicine
How To Prevent Recurrence
Once the lateral ligaments of the ankle have been injured, it is highly likely the injury will reoccur. As previously mentioned, athletes, week-end warriors, & newly active people return to sports and other activities too quickly. The ligaments should have enough time to properly heal with an individualized rehab treatment program. The best way to prevent ankle sprains entirely is to warm up properly before any physical activity, perform routine ankle strengthening exercises, and adapt to training on uneven surfaces. Studies have also shown that the use of an ankle brace reduces the inversion velocity which results in the lower leg and ankle musculature to have more time to activate and protect the ankle from a more severe inversion injury. The use of an ankle brace has also shown to make the athlete feel more confident and reassured when playing their sport (Hall, et. Al 2016). Unfortunately, once an ankle sprain has occurred, the joint will never be as strong as it was prior to the injury. So it’s encouraged that the athlete continues strengthening exercises at a gym, home, or physical therapy.
At Motion Rx, we specialize in diagnosing and treating ankle injuries for athletes. If you or someone you know needs further evaluation for a nagging ankle injury, please reach out to us by phone at 469-967-1278 or email at info@motionrxdfw.com. We are dedicated to helping you reach your maximum potential through functional movement, rehabilitation, and recovery.