Feature Article:::...

Ankle sprains common injury in athletes, non-athletes

By: Shannon Barker, P.T.

One of the most common orthopedic injuries is a sprained ankle. In fact, you or someone you know has suffered from a sprained ankle in the recent months. Research suggests that approximately 25,000 people experience this injury per day.

While ankle sprains make up about 15 percent of all athletic injuries, particularly common in basketball, volleyball, soccer, dance and football, a sprained ankle can occur in non-athletic populations in both children and adults.

Whether you are running after a soccer ball on the field or simply walking on uneven surfaces, the anatomy of the ankle can fail to support your body and can lead an ankle sprain. When considering this common injury, it is important to understand the anatomy of the ankle, symptoms and classification of ankle sprains, diagnoses and treatment of ankle sprains, and prevention of injury.

The ankle joint is made up of muscles, ligaments and congruent bones that help aid in the stability of the joint during activity. The tibia and fibula are the bones in the shin area of the lower leg that run down to the ankle creating the bony knots on the inside of the ankle (tibia) and the outside of the ankle (fibula).

Two other important bones of the ankle joint include the calcaneous (heel bone) and the talus. In order for the ankle to achieve stability, it mostly relies not only on the passive support of the ligaments, but also the bone-to-bone contact support and the active support of the muscles that control ankle mobility.

An ankle sprain has the potential to injure all of the structures in the ankle. However, ligaments are the most commonly injured with a sprained ankle.

Ligaments are elastic structures that connect bone to other bones. Nearly all of the major ligaments of the ankle run among the tibia, fibula and the calcaneous. Ligaments usually stretch within their normal limits and then return to their resting state during movement. Injury occurs when a ligament is forced beyond its normal “stretching” range.

Therefore, the definition of an ankle sprain is the stretching of the ankle ligament structures beyond their normal limits due to twisting, rolling or turning of the foot either to the inside (inversion ankle sprain) or outside (eversion ankle strain).

The ligament structures on the inside of the ankle are typically very thick and supportive; hence, eversion ankle sprains are much less common than inversion ankle sprains, also know as lateral ankle sprains.

The amount of force placed on the ankle during injury will determine the degree of injury and will lead to the classification, or grading, of the ankle injury. Ankle sprains, according to the American Academy of Orthopedic Surgeons (orthoinfo.aaos.org) are classified into Grades 1-3:

Grade 1, or minimal, sprains show minimal tenderness and swelling and have microscopic tearing of ligament fibers. Treatment consists of weight-bearing as tolerated, no splinting, isometric exercises, full range of motion and stretching/strengthening exercises as tolerated.

Grade 2, or moderate, sprains, show moderate tenderness and swelling, decreased mobility and possible instability, and have complete tears of some but not all ligament fibers. Treatment consists of immobilization with air splint and physical therapy treatment.

Grade 3, or severe, sprains, show significant swelling and tenderness, as well as instability, and have a complete tear or rupture of the ligament. Treatment consists of immobilization, physical therapy treatment, and possible surgical intervention.

In order to accurately classify an ankle sprain, your doctor may order diagnostic tests, such as X-rays or an MRI, and complete a physical exam to determine the severity of the ankle sprain and rule out other possible injuries.

Most people that experience an ankle sprain make a full recovery; however, an estimated 20 to 40 percent people continue to have problems that require medical assistance. The healing process normally takes four to six weeks. It is important to incorporate some early motion of the ankle during the healing phase to prevent stiffness.

For all grades of ankle sprains, the RICE principle should be followed.

First, REST your ankle by eliminating walking or walking with support of crutches.

Second, you should ICE your ankle immediately after injury and continue to ice 10 to 20 minutes three to four times per day.

Third, use COMPRESSIVE bandages wrapped from the bottom of the foot to the lower calf region to control swelling. When wrapping the bandage around the foot, be sure to use firmer pressure at the bottom of the ankle and gradually wrap with less pressure at the lower calf region to create an upward compression force to help limit swelling around the ankle.

Lastly, ELEVATE your ankle above your heart for the first 48 to 72 hours. Elevation combined with slow “ankle pumping” (like pumping a gas pedal) will allow gravity to further help control swelling at the site of injury.

Ankle sprains that are graded as 2 or 3 use this same principle, but often require some immobilization and more time for healing.

Regardless of the grade of ankle sprain, generally the injury progresses through the following stages: healing (RICE, one week), rehabilitation (range of motion and strengthening, two to four 4 weeks), and functional return (activity to improve balance, control, and return to activity/sport, four weeks to month). Surgical intervention is rarely needed for ankle sprains.

After swelling is controlled, it is important to start some simple mobility exercises. Your physical therapist can assist you with the development and progression of an exercise program for your sprained ankle. These exercises should be done in a pain-free range of motion and should accompany a gradual return of weight bearing/walking forces on the ankle. The following are exercises that can be completed for mild to moderate ankle sprains (usually two to three times per day):

Ankle pumps. Move ankle in an up and down fashion as if pressing gas pedal.
Ankle circles. Move ankle in clockwise and counter-clockwise circles.
Ankle ABC’s. Use ankle to trace the alphabet A through Z.
Towel curls with toes. Place towel on floor and crutch up using toes.

It is important that you seek the advice of your physician if the following occur: pain/swelling is uncontrollable, inability to walk or cannot walk without severe pain, ankle symptoms fail to improve within five to seven days.

Prevention of ankle sprains simply involves adequate flexibility, strength and balance of the ankle joint. Warming-up prior to exercise or vigorous activity can prevent ankle injuries. In addition to wearing good supportive shoes, you should pay attention to the surfaces that you are walking/training on. Finally, awareness of your endurance and signs and symptoms of fatigue can help you limit/stop your activities prior to a fatigue-related ankle sprain.

If symptoms do not improve within five to seven days, visit your primary care physician, who can give you options for further care for your ankle sprain.

If you and your primary care physician decide to try physical therapy, your physical therapist will perform an evaluation and establish a treatment program to help eliminate symptoms and problems associated with your sprained ankle. Please contact your primary care physician to discuss your appropriateness for physical therapy.

Source: American Academy of Orthopedic Surgeons orthoinfo.aaos.org.

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Shannon Barker, P.T., is clinical rehabilitation manager and a physical therapist at the Sullivan Center at Holston Valley Medical Center Outpatient Campus.