Ask the Osteopath: Ankle Sprains

ankle-sprain

So I have had some emails and questions from followers and readers about ankle sprains as well as an increase in the number I have seen in work so I thought I would dedicate this blog to them. Ankle sprains almost everyone will have experienced one at some point in their life approximate 23,000 occur daily in the US alone. They also make up 45% of all sports injuries, 25% of all injuries in running and jumping sports with basketball leading the way with up to 41.1%. Waterman et al (2010).

What happens when you sprain your ankle?

The word “sprain” is characterised as a structural dysfunction to the make up and stability of a ligament. In the ankle the most common ligament to strain is called the Anterior talo-fibular ligament. 83% of all ankle sprains occur to the outside or lateral ankle and often occur when the person lands on one leg on an uneven surface. (Fong et al 2007)

As with many things the more you understand the mechanism behind it the better response you will normally have as a result. The biomechanical and physiological response so all the science bits will be similar for all ligament and soft tissue injuries. After the initial sprain the injury will cause local bleeding and damage to the surrounding ligaments and muscles. You body will react by causing you pain to warn you that you have hurt yourself and start the inflammatory process to try and heal the area.

Why is it common to restrain your ankle?

As many of your will know often once you have one significant sprain it is often very common to frequently roll your ankle. The reoccurrence rate is actually a staggering 73%, which is why the rehabilitation and initial care is so important in these injuries. (Yeung et al 1994) It is also important to remember that even with the healthiest ankle’s a fast, large award movement is going to cause injury and therefore if you do have a weakness there it would be extremity difficult to completely eliminate the risk of a recurrence once you return to the same activity and intensity of activity that cause the injury in the first place. (Hung 2015)

Chronic ankle instability is thought to be a combination of different aspects including neural (including balance), muscle strength and power as well as mechanical elements like ligament laxity. When you damage or hurt yourself your body will often remember how you did it to prevent you from doing it again and will compensate. Therefore its important to remind your brain that the movement is ok and so don’t get into bad habits and suddenly get used to moving it in a different way. Konradsen et al 1998. Tononi & Edekman, (1998) states that developing the correct movement patterns associated with ankle strengthening and flexibility cannot be overemphasized.

The swelling in ankle sprains is due to the ligaments become over stretched with the anterior lateral gutter building up with fluid as it try’s to start the anti-inflammatory process. (Smith ) It won’t surprise you but the best way to prevent you from having a chronic or long-term problem is to have the correct immediate care as well as rehabilitation straight away. It is also recommended to not only apply compression locally to the part of the ankle normally the outside as well as the ankle in general through ankle supports like tuby grips. The addition of additional compression to the most painful area will help remove the waste products that will build up as the tissue starts to heal.

Often your awareness of the area will be altered after you sprain your ankle as you will more conscious of the movements associated with the joint. The word proprioception means both awareness where your joint is in shape as well as the movement that occurs at the joint. It will be common for your practitioner to give you exercises to retrain your balance and stability in order to prevent another sprain or twist. A main feature of the rehabilitation process is to focus on developing strength and neuromuscular control in the ankle and foot to better protect the joint. When you sprain you ankle it can damage the sensors that detect movement in the ankle as they are often overstrained affectively making the joint clumsier. A study by Tropp et al who looked at 127 footballers and found that 42% players that struggled to do balance tests on a wobble board had previously experienced ankle injuries.

Grades of Lateral ankle sprains:

Grade 1 ankle sprain
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Grade 1: Stretching of the anterior talo-fibular & calcaneo-fibular ligaments

 

 

 

Grade 2 Ankle Sprain
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Grade 2: Anterior talo-fibular ligament is partially torn and the calcaneo-fibular ligament is stretched

 

 

 

 

Grade 3 Ankle Sprain
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Grade 3: Rupture of the ant talo-fibular and calcaneo-fibular ligament with partial tear of the posterior talo-fibular & tibio-fibular ligament.

 

 

Mattacola & Dwyer 2002

What should I do initially when I sprain my ankle?

The first thing you want to focus on when your have sprained your ankle is to reduce the swelling, pain and try to protect the joint by making it more stable.

RICE: Rest, Ice, Compression and Elevation

Rest: The first thing to do is to stop whatever activity you are doing not play on. As I have mentioned early ankle sprains commonly reoccur which is why it is so important to make sure that you take the time out to allow it to recovery fully.

Ice: It is recommended to ice as much as possible even as much as 6 times a day, make sure you only ice the ankle for around 8 minutes at a time. When you do ice the area make sure you wrap a tea towel around the ice and don’t put it straight onto your skin.

Compression: The protocol suggests to have compression locally over the lateral or painful area of the ankle at all times.

Elevation: This can be helpful in trying to bring down the swelling that will occur straight after the injury.

Common questions:

Do I need crutches?

As a rule as much as possible it best not to rely on have to use crutches and try to weight bear as soon as possible. If you feel you do need to use crutches try to use them only for the first 24-72 hours only. Obviously it will depend on the severity of the injury and pain level experienced by the individual to whether you need crutches or not. When you weight bare the forces will be transferred through the foot especially through the arch. When the forces are moved through the arch they will not only stretch the arch but will also help contract the lateral plantar artery which will help pump blood and oxygen into the joint and help remove the swelling away from the area.

Should I wear an ankle brace?

An ankle brace has been proven to help achieve mechanical stability as well as help with proprioception stimulation. The brace can actually make you more aware of what movements you are doing in the ankle give your brain more feedback on the injury, which will help in the healing process. It can be very useful and effective in order to give the ankle some more stability do to single leg exercises or sudden changes in movement throughout the rehabilitation phases. As with anything it isn’t advised for you to use it all the time. The brace can also affect your biomechanics, which you want to return to normal as soon as possible after the injury.

Rehabilitation:

Throughout rehabilitation it is important to strengthen both the symptomatic side as well as the non-painful side in order to prevent the injury from reoccurring. The majority of research points to the peroneal muscle (muscle at the front of the shin) being the most important in preventing ankle sprains through there is some controversy. Another aspect is the amount of strength and movement in turning your ankle out and in. Wilkerson et al (1997)

Phase 1: (Week 0-1)

Regardless of the pain and the ability to weight bare it is important to incorporate calf and Achilles stretching within the first 48-72hr after the injury. Strengthening of the weakened muscles is essential to a rapid recovery as well as preventing re-injury. (Thacker et al 1999) It is also important that your practitioner makes the rehabilitation exercises specific to you and your sport to achieve the best results. It may seem counter productive and painful but the function stress from doing the exercises early on will stimulate the recovery process and create stronger collagen as a result. Despite years of research is it still unclear what the most efficient protocol is for sprain especially in order to prevent the injury from happening again. The main principles of rehabilitation is to increase the awareness of movement at the ankle, tighten up the ligaments and the joint capsule as well as increase the stability and efficiency of the muscles. (Hung 2015)

Calf stretches:

seated-calf-stretch
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Seated towel stretch: By keeping your knee straight and looping a towel round the bottom of the ankle you can try to stretch out the calf.

Your should do this 5 times and hold it for 30 seconds each time this should be repeated 5 times daily. Later on you can develop this by using a resistance band instead of a towel.

 

calf-pump
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Calf Pump: When you first do this exercise unlike the picture don’t use a resistance band just practice moving your ankle. You want to bring your ankle up to your hand and then move it to slowly point it down to your toes. You want to repeat this 10 times and do 5 sets of this.

Proprioception Training:

The most common error with proprioception training is not experimenting enough you want to try lots of different movements at different speeds and intensities in order to achieve the best results. You want to vary the exercises that you do.

wobble board proprioception
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Wobble board: Using a wobble board all you want to do is try to stand on it with one leg. You want to do this for as long as possible, it may seem simple but it is a lot harder than it looks.

 

 

 

 Cardiovascular exercises: Start with swimming and then cycling.

Phase 2: Increasing rang of movement + early strengthening  (Week 1-2)

Proprioception:

toe-curl
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Toe curls/Toe raises/picking up pencil with toes: This is where we start to play around with the proprioception work. Start with crunching up the towel then move on to trying to pick the towel up.

You should do this exercise 10 time with 10 sets

 

 

side-step
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Side step: Using a step or a box it doesn’t have to be very high at all that is not the aim of the exercise. The aim is just to get your ankle used to moving from one side to the other. You want to start standing by the side of the step then moving on to of the step and then down to one side before switching over. You want to do this 10 time and 3 sets.

 

 

Strengthening exercises:

mini-squat
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Mini squats: For this exercise you want to keep your back straight and bend your knees to around 30 degrees. You can hold onto a firm object if you feel the need. You should do 3 sets of 10-15 repetitions. Later on in the next few stages you can progress to a fully squat.

 

Cardiovascular exercises:

Bike, cross training, treadmill walking or pool running

Phase 3: Strengthen (Weeks 2-3)

Strengthening exercises:

inversion/eversion
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Ankle inversion and eversion: You want to bring your ankle out to the side and then back to the centre. You want to do this in both directions. Start doing it without the band and build up to use the band to make it stronger. You want to so three sets of 12-15.

 

 

 

Exercise Associated Muscle Cramps
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Calf raises: Start by standing on the edge of a step or a ledge and drop your ankle off the edge. You then want to move to stand on your tip toes and then slowly bring them back down dropping your heel. You should feel this stretching your calf. You should aim for 3 sets of 15 exercises

 

 

 

 

Cardiovascular: At this point you can start to incorporate running

Phase 4: return to sport advanced strengthening week 3-5

Proprioception:

agility_training
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Drills working on balance and changing direction: At the point in time it is good to start to incur-operate some drills that involve changing in direction. This example i have given is going from side to side however you can adapt this depending on your individual sport and needs depending on your situation. You want to do this 5 times in total.

Strengthening:

box-jumps
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Box jumps: For this exercise you want to start with you feet shoulder width apart and then jump with both feet on top of the box. You should start with a small box or step and build it up as you get stronger. You want to do between 10-15 repetitions.

 

 

Cardiovascular: Start sprinting

References:

  • Smith, DK. Imaging of sports of the ankle and foot. Operative Techniques in Sports Medicine. Vol. 13(1). p. 48. Jan 1995.
  • EVIDENCE-BASED CLINICAL PROTOCOL FOR REHABILITATION OF LATERAL ANKLE SPRAINS boyle & Jacoby
  • Lateral Ankle Sprain Grade I-II Non-Operative Protocol Charles Lind
  • Konradsen L, Olesen S, Hansen HM. Ankle sensorimotor control and eversion strength after acute ankle inversion injuries. Am J Sports Med.1998;26:72–77.
  • Mattacola & Dwyer 2002 Rehabilitation of the ankle after acute sprain or chronic instability Journal of athletic training.
  • Hung 2015. Neuromuscular control and rehabilitation of the unstable ankle. World Journal of Orthopaedics.
  • Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. 2007 A systematic review on ankle injury and ankle sprain in sports. Sports Medicine
  • Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am 2010; 92:

 

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