Ankle sprain, inversion injury, ligament rupture, syndesmosis injury, ankle rehabilitation, sports injury
Ankle sprains are the most common sports injury and the most frequent reason to seek medical attention after trauma. In an ankle sprain, the ankle ligaments either stretch or partially or completely tear. Ankle sprains often occur during trips or falls, but they are also common in other situations.
Previously, ligament injuries caused by sprains were almost always treated through surgery, but nowadays the treatment approach is almost always conservative. With this change also the attitudes towards ankle sprains have shifted, and it is easy to think that the ankle will heal on its own if surgery is not necessary.
However, an ankle ligament injury can persist and cause prolonged discomfort if not properly treated, so investing in rehabilitation is important. Good early-stage rehabilitation can reduce pain and promote normal ankle function. Poor or delayed rehabilitation after the initial sprain also increases the risk of re-injury and leads to increased medical expenses due to additional doctor visits.
Epidemiology
The ankle typically sprains during sports activities or walking. The most common type of ankle sprain occurs inward, where the outer ligaments of the ankle stretch or tear. These account for approximately 80-90% of all ankle sprains, but an outward sprain is also possible.
An outward sprain often happens when stepping on the edge of something with the outer side of the foot, causing excessive outward turning of the foot and stretching or tearing of the ligaments on the inner side of the ankle. As a result of such a sprain, fractures of the lower end of the fibula are also common.
The ankle can also sprain in an increased dorsiflexion angle, where the talar bone gets wedged between the the ankle joint, causing a syndesmotic injury and possibly a tear of the posterior ligaments.
Regardless of the direction of the sprain, ankle sprains often occur in sports that involve running and jumping. Also, sports played on uneven surfaces or sports with frequent changes in direction experience a high number of sprains. Some examples of such sports include:
Basketball
Volleyball
Floorball
Football
Tennis
Cross-country running
A mild ankle sprain without ligament tearing typically heals well on its own, but more severe sprains require thorough examination and treatment.
Clinically relevant anatomy of the ankle
The ankle functions as the lowest part of the functional chain of the lower limb, supporting body weight and enabling forward movement. The ankle is supported by strong ligaments on the sides of the joint.
The outer ligaments support the outer edge of the ankle and prevent excessive inward bending of the ankle. These consist of three separate ligaments, each with its own specific function:
Anterior Talofibular Ligament (lig. talofibulare anterior) runs from the front and tip of the fibula to the neck of the talus bone, limiting excessive inversion (inward bending) of the ankle joint and excessive forward movement of the foot.
Calcaneofibular Ligament (lig. calcaneofibulare) runs from the front and tip of the fibula to the middle of the outer surface of the calcaneus bone (heel bone), limiting excessive inversion of the upper ankle joint.
Posterior Talofibular Ligament (lig. talofibulare posterior): It runs from the back of the fibula to the outer prominence of the talus bone, limiting excessive abduction (outward movement) of the fibula and excessive backward movement of the foot.
These ligaments play a crucial role in providing stability to the ankle joint and preventing excessive movements that could lead to sprains or other injuries.
The medial ligament (lig. Deltoideum) is a triangular structure that consists of multiple different parts, which can be divided into superficial and deep layers.
The main function of the Deltoid ligament is to limit excessive eversion, which is the outward bending or turning, of both the upper and lower ankle joints, as well as the talus-navicular joint.
The Deltoid ligament plays a crucial role in providing stability to the inner side of the ankle joint and preventing excessive movements that could lead to sprains or other injuries.
The syndesmosis, located between the tibia and fibula, consists of several ligaments and a membrane structure that runs between the bones. Its main function is to stabilize the tibiofibular joint, formed by the tibia and fibula, and provide support to the ankle joint.
Risk factors
The biggest risk factor for ankle sprains and ligament injuries is a previous ankle sprain or ligament injury. Other risk factors include impaired proprioception (sense of position), poor balance, challenges in force production, and deviations in joint mobility of the ankle and foot.
External factors that increase the risk include walking or engaging in other activities on uneven surfaces, wearing footwear that does not provide adequate ankle support, or participating in sports that involve a lot of running, directional changes, or jumping.
Mechanism of injury
In sprains and tears of the outer ligaments of the ankle, the foot excessively turns inward, causing a strain or tear in the ligaments located on the outer side of the ankle. Injuries to the FTA (anterior talofibular ligament) and FC (calcaneofibular ligament) are the most common in this category. Injuries to the FTP (posterior talofibular ligament) primarily occur in cases of dislocation of the talus bone, making them rare.
Injuries to the inner ligament (lig. deltoideum) occur in severe sprains that involve forceful outward or rotational movements, but they are relatively uncommon. This is partly because the inner ligament is significantly stronger than the outer ligaments, and partly because the lower end of the fibula provides support to the ankle, preventing excessive outward bending.
Syndesmotic injuries occur when the ankle is excessively dorsiflexed (bent upward). This can happen, for example, during landings after jumps, where the knee extends beyond the toe line, or when landing on a stone with the forefoot, causing increased dorsiflexion of the ankle joint. The primary treatment for syndesmotic injuries is still surgery.
An ankle sprain typically occurs when the ankle is extended while being subjected to a lateral or rotational movement. Ankle sprains rarely occur when the foot is fully planted on the ground. This is because when the ankle is flexed, the fork-like structure formed by the tibia and fibula supports the ligaments, protecting the ankle from sprains. The more the ankle is extended, the smaller the bony support, and more of the load is transferred to the ligaments. Interestingly, sprains are more common in the dominant foot compared to the non-dominant foot.
When a ligament is torn or stretched too far, its previous elasticity and flexibility may not fully recover.
Symptoms
The symptoms of an ankle sprain can vary significantly depending on the type and severity of the injury, but typical symptoms include:
Pain in the ankle area, which worsens while weight bearing
Tenderness in the area of sprain or tear upon touch
Bruising and swelling in the area of sprain or tear
Increased temperature and throbbing pain in the ankle, indicating inflammation
Limited range of motion in the ankle and foot, along with a feeling of instability at the joint
Sensation of coldness or sensory disturbances in the foot, which may indicate neurovascular damage to a nerve.
Ankle sprain classification
Ankle sprains can be classified either based on the tissue-based injury grade or the degree of impairment caused by the injury.
Tissue-based classification:
Grade I injury: Mild stretching of the ligament without significant tissue damage
Grade II injury: Partial tear of the ligament
Grade III injury: Complete tear of the ligament
Classification based on the degree of impairment:
Class I: Mild impairment - Minor swelling and tenderness, with minimal impact on functionality Class II: Moderate impairment - Moderate swelling, pain, tenderness, along with limited range of motion and ankle instability
Class III: Severe impairment - Significant swelling, tenderness, loss of function, and pronounced instability
Grade and class I injuries typically heal well on their own without treatment or further investigations, but Grade and class II and III injuries require rehabilitation and may need additional investigations.
The need for imaging is typically determined using the Ottawa Ankle Rules method, where symptoms and findings related to the sprain are scored, and if the score reaches a certain threshold, X-ray imaging of the ankle is performed. Taking an MRI scan is generally unnecessary, but it may be considered if the sprain does not appear to improve with time and rehabilitation or if the damage seems extensive.
Peace & Love
When the ankle sprains, the "RICE" (Rest, Ice, Compression, Elevation) approach was previously considered the basis for initial first aid. Compression and elevation were aimed at reducing bleeding and controlling swelling, while cold therapy was used to alleviate the inflammation caused by the sprain.
However, based on recent research, this approach is now considered outdated. While compression and elevation are still important for controlling swelling and bleeding, anti-inflammatory methods should be avoided in the early stages. It has been shown that early inhibition of the inflammatory response can impede tissue healing following an acute injury. Therefore, the "three K's" rule has been replaced with the acronym "Peace & Love":
P (Protect) – Avoid weight-bearing and limit movement during the first few days (1-3) following the injury to reduce bleeding and prevent further damage to the injured area.
E (Elevate) – Elevate the injured area above the level of the heart, if possible, to facilitate the drainage of fluid from the injured area.
A (Avoid anti-inflammatory modalities) – Use anti-inflammatory treatment methods with caution. Factors that affect the inflammatory process, such as anti-inflammatory drugs, can reduce the beneficial effects of the inflammatory response in tissue recovery. There is insufficient evidence to support the effectiveness of cold therapy in the treatment of acute sports injuries, and prolonged cold therapy may also interfere with healing. Therefore, use anti-inflammatory drugs and cold therapy judiciously, and prefer acetaminophen for pain management.
C (Compress) – Mechanical compression of the injured area reduces swelling and internal tissue bleeding.
E (Educate) – Encourage the patient to engage in active and self-directed rehabilitation. Passive treatment modalities are rarely beneficial in the management of acute injuries.
After the initial days have passed, soft tissues require "love".
L (Load) – Rest is recommended to be replaced with appropriate loading. The new recommendation emphasizes starting loading and continuing normal activities as soon as symptoms allow. With appropriate loading, the intensification of pain is avoided, and tissue healing is promoted through movement. Normal training often needs to be replaced with substitute exercises to ensure the formation of a small and durable scar.
O (Optimism) – Support a positive attitude towards recovery while also maintaining a realistic understanding of the healing timeline. Worry, depression, and fear of movement are associated with poorer outcomes in recovering from an injury. Encouraging a positive mindset, providing emotional support, and addressing any psychological concerns can contribute to a more successful rehabilitation process. It is important to acknowledge and address any negative emotions or fears while emphasizing the importance of gradually returning to normal activities and regaining confidence in movement.
V (Vascularisation) – A few days after the injury, initiating aerobic exercise promotes the restoration of normal blood circulation, aiding in tissue healing. Early mobilization improves functional capacity and reduces the need for pain medication. Engaging in appropriate low-impact activities, such as walking or cycling, can help increase blood flow to the injured area, promote tissue repair, and prevent complications associated with prolonged immobilization.
E (Exercise) – Early-stage rehabilitative exercise helps restore range of motion, strength, and proprioception. The focus should be on gradually increasing mobility and regaining functional abilities while avoiding exacerbating pain. The exercise program should be guided by pain relief, allowing pain reduction to determine the progression of the program. Therapeutic exercises that support the neuromuscular system can help prevent future injuries. Neglecting active rehabilitation can compromise the area's long-term load-bearing capacity and increase the risk of injury recurrence.
Physiotherapy
After a good early-stage treatment, ankle ligament injuries require progressive exercise to restore normal ankle function and strength. The treatment approach is determined by the extent and severity of the injury but is primarily conservative in nature. Physiotherapy plays a significant role in the recovery from a injury and in designing a rehabilitation program. In the early stages, the goals often include reducing pain and swelling, maintaining or increasing range of motion and improving proprioception and stability.
Once the most severe pain and swelling have subsided, rehabilitation focuses on improving active ankle support by strengthening the muscles that cross the ankle joint. For athletes, specific requirements of their sport are taken into consideration when planning the rehabilitation program. Therefore, rehabilitation is always individualized but generally consists of ankle mobility exercises, strengthening exercises, balance and proprioception training and plyometric exercises. The goal of rehabilitation is to restore ankle stability, mobility, control and proprioception.
The timing of when to return to sports is determined by the severity of the injury and the functional performance of the ankle. With the help of a physiotherapist, the functionality of the ankle can be assessed and compared to the uninjured side. This comparison allows for determining when it is safe to return to sports. Functional tests are used in the assessment to evaluate ankle control, balance, agility, and tests that measure strength production. Adequate mobility is also necessary for a safe return to sports.
Self care
Peace & Love: After an acute tissue injury, the primary treatment approach should follow the "Peace & Love" principles. This ensures a good start to the treatment and promotes tissue healing.
Gentle Movement: Move the foot and ankle through its full range of motion without significant pain. Perform exercises such as ankle flexion and extension, toe curls and extensions and careful ankle rotations. This helps improve mobility and prevent stiffness. Perform the movements gently without causing excessive pain.
Strength Training: Strengthen the muscles that cross the ankle joint either through bodyweight exercises or using light resistance. For example, perform toe raises while initially leaning against a wall with your hands, lift the forefoot while leaning your back against a wall, or move the foot against a resistance band.
Balance and Proprioceptive Training: Perform exercises that improve balance and proprioception. Stand on one leg and try to maintain balance, you can make it more challenging by performing it on an uneven or soft surface or by closing your eyes.
Mobility Training: Increase ankle mobility by performing mobility exercises. Good examples include pushing the knee over the toe line or sitting on the heels while pushing the heels towards the toes with your hand.
Professional Guidance: Consult a physiotherapist or healthcare professional who can assess your situation and provide appropriate guidance. You will receive tailored exercises based on your individual needs and advice on when to progress in your training or when to return to your specific sport.
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