Better early management for better long-term outcomes
‘The Injury Report’ will be a regular review of common injuries we see here in the clinic and how best to manage them. They won’t be step-by-step guides on how to conduct your own rehab, but a bit of a general overview. The aim is to give people a better understanding of these injuries so they are able to perform appropriate acute management and seek the right assessment and treatment for optimal recovery.
In this post, we will take a look at ankle sprains. It will focus on how to identify them, the best way to manage them in the first instance, rehabilitating them back to full fitness and how to prevent them in the future.
Managing Ankle Sprains
With our first Injury Report, I thought it would be useful to take a look at one of the most common injuries we would see – the ankle sprain. Ankle sprains would have to be one of the most prevalent injuries in the sporting community, but also in the general public. According to the American College of Sports Medicine (ACSM), ankle injuries account for half of all sporting injuries.
These ankle injuries are particularly common in sports which involve running, jumping or twisting (ie. most of them)(1,2), and involve rapid changes of direction(3). It is also seen that people with a history of ankle injury were almost five times more likely to sustain an ankle injury whilst playing sport(4).
An ankle sprain occurs through inversion of the ankle, where the foot turns in and you roll out on the ankle. Essentially like this:
This can happen if someone lands on the outer edge of the foot, such as landing awkwardly when turning, or coming down onto someone else’s foot, causing the ankle to roll out. This, along with our body-weight, places significant stress on the structures on the outside of the foot and ankle (the lateral side).
Generally, the Anterior Talofibular Ligament (ATFL) cops the brunt of this force, and is the most commonly injured.
The ATFL forms part of the capsule surrounding that lateral ankle. It is accompanied by the Calcaneo-fibular ligament (CFL) and Posterior talofibular ligament (PTFL), which you can see in the above image Both of these are general thicker and stronger that the ATFL, and provide more stability to the ankle. They are also generally less commonly injured (but can be present in major ankle injuries), with the PTFL almost never being injured in isolation from the other ligaments(7).
What is the best approach for dealing with an ankle injury?
First and foremost, you need to rule out any serious injury (ie. fracture). This can be sometimes difficult to determine just by looking at it, as ankle sprains tend to swell and often bruise, and make it difficult to walk on. It is estimated that roughly around 15% of inversion injuries result in fractures(4). There are guidelines used to determine whether an ankle X-ray is warranted for your ankle, so if you have doubts, it’s worth having it assessed by a medical professional. If it comes back clear, then great, we are likely just dealing with the ligaments.
The simplest way you can tell whether you should get an X-Ray, is whether or not you can walk on the affected ankle. If you can, then it’s a good sign things are ok. If you can’t, it’s worth getting it checked out (8).
It’s not broken, what next?
Good news, there’s no fracture! In this instance, we need to give the tissues a chance to heal. Ankle sprains of varying degrees of severity can all look very different. Obviously the more swollen and bruised it is can be a sign of the extent of injury. Having said that, everyone is a little different. I’ve injured my ankles many, many (many!) times, all with varying severity. They’ve swollen to different sizes, but never once have I bruised. I clearly don’t bruise easily.
In other people, I’ve seen injuries on similar severity to what I have had who have bruised from toe to shin.
Regardless of this, we need to respect the healing process the body is undertaking. Your body will be repairing the ligament with collagen fibres, so essentially we need to give it a chance to do its job, without doing anything to screw it up. These ligaments can take anywhere from 6-12 weeks to heal properly (obviously dependent on severity of damage), so we need to bear this in mind when trying to return to activity.
Making sure we keep the ankle and you moving, without overdoing it is key.
Managing pain and swelling through ice, compression and elevation in the first 48 hours is important. In the long term, swelling is important for healing, but in the short term we sacrifice that to allow better movement and quicker return to activity.
Using a brace or support can be useful in the short term to allow you to get moving quicker. The sooner you can get walking again (within reason) the better the outcomes tend to be. If you have ankle braces you already use for sport, these can be handy, as they provide some side-to-side support of the ankle while still allowing it to move.
On some occasions, a CAMboot (or moonboot) may be useful to stabilise the ankle, but this is usually only in severe cases or when the ankle is very unstable. Often we tend to see this over-prescribed for less severe cases in the interest of being cautious, but this is usually counterproductive in most cases. If at all possible, it is best to avoid it, as this will immobilise the ankle, While this may be more comfortable initially, too long in the boot will delay movement and return to activity. If you do use a boot, it’s best to limit get out of it as soon as your able.
Eventually the goal is to get you walking without it.
How severe is it?
When we look at ankle injuries (and indeed most soft tissue injuries), we tend to categories them into grades based on their severity. There are 3 Grades, with Grade 1 injuries being less severe and Grade 3 injuries being more severe.
A note on Grade 3 Injuries
In some instances, a Grade 3 injury will result in a recommendation for surgery. This is usually not based on pain or swelling, but on the instability within the ankle itself. Despite this, there isn’t good evidence that surgery in these circumstances is more effective than conservative management (early mobilisation and strengthening) or provides better outcomes(9). Other studies show that there is actually better outcomes with conservative management over surgery(10).
Obviously any decision on surgery vs conservative management would need to be on a case by case basis, and the easiest way to figure that out is to have it assessed. Given the invasive nature of surgery, is generally accepted that a trial of conservative management for at least a 6-week period in most Grade 3 injuries(3). If there is ongoing instability or pain after this, then surgery may be worthwhile.
Getting your rehab in.
Assuming the ankle injury is at least a moderate one, we need to focus on a number of goals, which generally are:
Restoration of range of movement;
Building strength and proprioception (balance);
Progressing power and function;
Return to sport.
Phase 1 – Range of Movement
In the first week or two, the focus is mostly on getting back range of movement and walking comfortably. If it is particularly painful to walk, you might use crutches for a short period, but with the aim of progressing off them in the first 24-48 hours(3). Attempts should still be made to put weight through the foot while using crutches. Exercises are quite basic, and generally consist of moving the ankle forward and back, making circles with the ankle and walking. Once comfortable, using a stationary bike might be useful to get some active movement.
Phase 2 – Strength and Balance
Once this is comfortable, we progress onto performing some strength and balance exercises. Generally, you may start with some gentle heel raises, using both feet to get the ankle used to it again Progression might mean moving up to doing this on the edge of a step in a pain free range, increasing that range as pain allows, then moving to performing the exercises on one leg. Strengthening eversion (the movement opposite to the way you rolled the ankle) with the ankle fully plantar-flexed (toes pointed) is important for the prevention of future ligament injuries(3).
Balance exercises would include simple single leg balance. To progress this, we essentially make that single leg balance harder. This may include closing your eyes, bending down to touch your toes whilst maintaining balance, moving the other leg at the same time or doing single leg squats. There are many ways to progress this, some more creative and abstract than others! Use of rocker or wobble boards is useful here as well.
This begins to improve your joint proprioception, which is basically your body’s ability to know where your joints are in space. It’s the system which allows you jump up and catch a ball or run without having to watch your feet. Understandably, it’s quite important in preventing ankle injuries. This is usually impaired following an ankle injury (or in the corresponding limb for any joint injury for that matter)(3).
If you want a good example of proprioception, close your eyes and hold your arm out in front of yourself. Now move your hand around while keeping your eyes closed. Are you able to tell where your hand is even if you can’t see it? That’s proprioception.
Phase 3 – Restoring power and Function
As we get better at slow and controlled strength exercises and our pain improves, it’s time to test ourselves with more explosive movements. These include jumping and hopping movements, which would initially begin just forward and back, nothing side-to-side at this stage. Some of the exercises I would give out might be jumping up onto a step or box, first with two feet then with one, before moving to jumping off the step. As you can imagine, this would also help with our landing ability, which will be important for preventing re-injury.
With power improving, it’s time to apply that to functional tasks, like running. As before, this would happen just in a straight line, and just jogging. Start out with a small distance, then increase. The better you tolerate this, the faster you can go, eventually progressing to fast take-offs and stops to work on sprinting. Then we’d look at turning and zig-zag movements, combining this with agility and side-to-side jumping movements.
Specific training not only gets you back to sport faster, but can greatly reduce your risk of re-injury(3).
Phase 5 – Return to sport
Returning to sport comes down to a couple of things: time, and your ability to perform the required movements. These would be a little bit different for each sport, though most would be generalised. Having said that, sports such as netball or basketball are going to be a bit riskier for the returning ankle than say, hockey, so that would also need to be taken into account.
You might start by returning to some light training, involving yourself in drills, then returning to sport once you feel comfortable.
This whole process might take anywhere from 4-12 weeks, depending on severity, but the phases themselves wouldn’t change. Just how long it would take to progress through each one. Rather than following specific time frames, we would determine progress by gradually challenging the ankle more, ensuring we don’t increase pain or swelling.
The most important factor for returning to sport is that the ankle feels comfortable when performing the movements you need to. It is important you don’t push to return to quickly. In the early stages (the first 6 weeks or so), risk of re-injury is higher. As well as this, returning too quickly can cause increased irritation to surrounding structures.
Bear in mind, about 75% of people who sustain an ankle ligament injury have had a previous injury, and in many cases it has not been fully rehabilitated(3). Good rehabilitation and preparation before returning to sport greatly reduces the risk of re-injury (and that goes for most injuries, not just ankles. Hamstrings are another notorious one for re-injury after poor rehab).
I generally recommend that for at least the first few weeks back on the field or sport, that some taping or bracing is used to prevent recurrence of injury. I often get asked which is better, and to be honest, there isn’t a definitive answer.
I prefer taping, because it’s lighter and feels more natural, as well as provides some feedback through the skin to improve proprioception. It’s cheaper in the short term, but not if you’re going to be doing it on an ongoing basis, and requires you are able to tape it yourself if you don’t have someone who can do it for you. Obviously I am able to tape myself, and have access to tape (perks of the job), so I’m a tad biased.
Braces tend to be bigger initial outlay, but are cheaper in the long run if you want ankle support in the long-term. Sometimes they aren’t as comfortable, though ensuring the right fit can make a big difference. They tend to be useful for sports such as netball and basketball, but less so for football or soccer, especially if it’s your dominant leg because it can interfere with the kicking action.
But it’s purely personal preference.
Some sources recommend using protective taping or bracing for 6 to 12 months following an injury(3).
Hopefully this gives you a bit of insight into the best way to manage ankle injuries, particularly early on. As with most acute injuries, good management early is the key to good outcomes in the long run, so if you aren't sure, ask!
Main Points to takeaway:
Ankle sprains are one of the most common sporting injuries;
Three major ligaments make up the lateral complex of the ankle;
People with a history of ankle injuries are more likely to sustain recurring injuries;
The large majority of ankle injuries are able to be treated conservatively, even the more severe injuries;
Early mobilisation is a key factor in a speedy recovery;
Rehab is a step by step process of gradually introducing more strenuous movements and activities;
75% of people who sustain an ankle injury have sustained a previous injury which has not been fully rehabilitated.
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Waterman, BR, Owens, BD, Davey, S, Zacchilli, MA, and Belmont, PJ, 2010, The Epidemiology of Ankle Sprains in the United States, Journal of Bone & Joint Surgery, Vol: 92, Iss: 13, p2279–2284, doi: 10.2106/JBJS.I.01537;
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2012, https://myankle.wordpress.com/2012/04/17/inversion-vs-eversion-sprains/, accessed 1/8/17
Multiple contributors, 2017, Anterior Talofibular Ligament, http://medical-dictionary.thefreedictionary.com/ATFL, accessed: 1/8/17;
Furston, T and Platt, S, 2012, The Incidence and Significance of Posterior Talofibular Ligament Injury on Magnetic Resonance Imaging, Orthopaedic Proceedings, vol. 94-B no. SUPP XXII 56;
Kerhoffs, M, et al, 2012, Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline, British Journal of Sports Medicine, 46:854–860, doi:10.1136/bjsports-2011-090490;
Kerkhoffs, GM, Handoll, HH, de Bie R, Rowe BH, and Struijs PA., 2007, Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults, Cochrane Database Syst Rev, (2):CD000380;
Kaikkonen, A, Kannus, P, and Järvinen, M., 1996, Surgery versus functional treatment in ankle ligament tears. A prospective study, Clin Orthop Relat Res, (326):194-202.