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Lateral ankle sprains…. they see me rollin’

Ankles are amazing! They have the ability tilt and twist all while allowing us to walk, run, jump and land on pretty much any surface safely.  They have the perfect combination of mobility, stability, strength and power. Usually. Unfortunately though we ask just a bit too much of them and they become injured.

Most people will have experienced a lateral ankle sprain (LAS) at least once in their lives, be it from stepping on uneven ground or playing an intense game of basketball. They are often the first time a child/adolescent has ever experienced real pain, leading to a traumatic experience as they hobble off the court or field. But because of how common they are, they are often dismissed as something minor with very few (less than 10%) of people seeking assessment and rehabilitation, with many chasing simply to rest the ankle until the pain goes away and then returning to sport. Unfortunately this very often leads to  many teenagers develop recurrent LAS, often described as having weak ankles. Sadly this can lead to an abrupt end to organised sport altogether.

It is very important that these young athletes see the physio as soon as possible, regardless of how ‘minor’ the ankle sprain may seem. The physio can determine the severity of the injury and, more importantly, get them moving forward towards full rehabilitation and return to sport as quickly and safely as possible.

This article will explain what a LAS is, how physiotherapy can help, the short- and long-term management, and some guidelines on returning to sport.

Mechanism of injury and anatomy

 

LAS are caused by putting too much force on an in-turned (inverted) ankle. In sport this commonly occurs by landing awkwardly or on another players foot and rolling off, or stepping in a pot-hole on a field. This puts excessive stress on the ligaments on the outside of the foot, collectively known as the lateral ankle complex. When intact, this complex prevents too much inward movement (inversion) of the foot and the movement of pointing your toes (plantarflexion); this is why the foot may feel more unstable or wobbly after injury, as the foot has essentially (temporarily) lost some of its harness. Furthermore, this complex keeps the heel bones close to the lower leg bones; if injured, the foot can slide forward a little bit, initially limiting its ability to bend upwards (dorsiflexion). Overall the foot and ankle just doesn’t feel or move well, leading to pain and dysfunction and potentially further injury.

 

Patients with LAS typically present with 

  • Difficulty weight-bearing and walking well on the affected foot.
  • Tenderness, swelling and/or bruising on the outer aspect of the ankle and foot, but can track down and make the whole foot quite swollen.
  • Reduced stability/control of the ankle – feels like it gives way and is not strong.

Up to 40% of ankle sprains typically lead to repeated injuries and resulting in chronic ankle instability (Chen, McInnis & Borg-Stein 2019). This is due to reduced muscle activation of the foot and calf muscles, maladaptive response to instability, and even altered muscle patterns of the thigh muscles. In short, recurrent LAS occur when a person doesn’t fully rehabilitate after the initial injury. Therefore, it is important that ankle sprains are assessed and rehabilitated treated properly, especially for the young athlete, to prevent longer-term issues or reinjuries.

How can physios help?

Physios can help ankle sprains by:

  • Helping determine the severity of the sprain
  • Providing a clear path to returning to sport or physical activity, individualised to the patient’s goals and circumstances
  • Providing relevant short- and long-term management, such as taping, pain relief and exercises

To do this, physios will thoroughly assess the acutely injured ankle by:

  • Asking questions about how the injury occured, namely in which position the foot may have twisted, and if this has happened before
  • Observing any noticeable bruising or swelling in the area.
  • Conducting some range of motion tests to see how much normal movement there is at the ankle.
  • Assessing other movements, such as wiggling the toes, to determine any potential neurological changes (rare).
  • Asking the patient to stand on one or both feet, to see how much weight can be placed on the ankle.
  • Assessing how well the patient can walk on the ankle.
  • Potentially conducting specific ankle ligament tests, to determine how lax the ankle has become and which ligaments in particular may be compromised.

Acute (short-term) care

Sustaining an LAS in the middle of a game can be very stressful. The initial pain is often quite intense, often made worse by the amount of adrenalin in the system from competing. With the injury the body goes into a ‘fight or flight’ response often resulting in a further increase in adrenalin for a few seconds. That can result in the injured person literally screaming out loud seemingly in incredible pain. It is important to note that this initial pain response is not indicative of the severity of injury. 

So the very first recommendation when someone sustains a LAS during sport is DON’T PANIC! Take a minute or two to calm the breathing and settle the mind. The adrenalin rush will pass in a few minutes and then you will be able to assess how bad the injury is. If you injure your ankle during sport and it really hurts initially but then seems to settle don’t be tempted to return to play that game. It may not be a serious injury, but the ligament will be temporarily compromised and at risk of further damage. Instead move to acute care principles below.

Applying the principles of the mnemonic P.O.L.I.C.E is effective during the early stages of LAS (first 48 hours), as it can manage swelling and pain and promote early healing.

PProtect the injured area from further injury by stopping sport and if unable to walk without significant pain, using crutches or a moonboot (see below) or simply staying off it

OLOptimal Loading – this can be tricky to work out – consult your physiotherapist to find what is right for you based on the severity of the injury. It does mean some movement from the very beginning.

I Ice for pain relief and to help manage swelling.

CCompression with an elastic bandage to manage swelling and pain

EElevation to manage swelling, bruising and pain.

 

Do I need imaging (XRay or Ultrasound)?

There is a specific protocol known as the Ottawa ankle rules which can help determine the need for an XRay after a LAS. Unfortunately it is not appropriate for the average person to apply them without proper training. The best advice is to follow what we have recommended above, particularly in relation to calming the injured person down. If after a period of time (perhaps half an hour) and they are still in immense pain with any form ankle movement or weight bearing it may be appropriate to visit the emergency department for an XRay to rule out a fracture. 

An Ultrasound is a specialised medical imaging technique commonly used to assess soft tissue such as ligaments. It is generally not recommended as first line assessment for a LAS as it generally doesn’t change the course of treatment. An ultrasound may cause undue anguish as it will not only pick up an acute injury (such as ligament damage) but also all the old injuries within the area. The severity of ligament damage does not necessarily correlate with function or return to play. 

What about moon-boots or crutches?

Moonboots and/or crutches can be used in the first 48 hours and up to the first week after a LAS for pain relief. The aim for LAS rehabilitation is to have the patient out of the boot or off crutches within a week at most. A boot or crutches may still be helpful to relieve pressure of the ankle at the end of a day as a means of pain relief after a lot of walking. However, it is not necessary and actually detrimental to recovery. Prolonged immobilisation (> 2 weeks) delays recovery as ligaments heal and adapt better, stronger and faster when appropriate and progressive amount of load (force) are placed through them. 

Of course, there are times where moon-boots should be prescribed, such as with a complete rupture of the majority of the ankle ligaments, or with an ankle fracture. However, these are very serious injuries and uncommon. The evidence shows that functional support and compression, such compression bandages, taping and bracing, provide the necessary stability and pain relief without compromising functional recovery (Lin, Hiller & de Bie 2010). We’ll show you how to strap an ankle later in this article.

Acute injury – Initial Physio Exercises

 

Exercises in the initial stage of treatment are important to get you back to your daily activities and sporting commitments as soon as possible. They allow for movement of the ankle providing relief from swelling and stiffness. The activate muscles as well as stimulate the injured ligament(s) into healing. 

Some common examples include:

  • Ankle alphabet

Try drawing the letters of the alphabet with your foot in the air. This is a great way to increase range of motion in the ankle in all directions, without putting weight on it.

  • Sliding feet

Sitting in a chair, with a towel under your foot, slide your foot beneath you. This is a great way to slowly reintroduce bending to your ankle (dorsiflexion). 

  • Weight-bearing

Stand on both legs (with support if required), and slowly shift your weight over from one foot to the other. Doing this within tolerance levels is a great way to increase confidence on the ankle, and reintroduce yourself to walking and balance.

  • Squats
    • Attempting small squats encouraged better ankle positioning (ankle bone on lower leg bone) as well as being useful to maintain movement of your other body parts, such as your knees and hips.

 

Exercise progressions

An individiualised progressive exercise program is essential for early and competent return to sport following an LAS.

Your physio will progress the basic strength exercises of the calf and foot as well as improve and challenge balance and coordination. As improvement occurs there will be a progression towards functional and sport specific tasks such as landing techniques and agility/changing direction.

These exercises are not just important for ligament recovery but also to build confidence in the athlete as often the final stumbling block to return to play is self confidence.

 

Return to sport

Returning to sport is often the most important goal for the young athletes that visit us at Vital Core Physiotherapy. Even though ligaments typically take six-to-twelve weeks to heal, return to sport can be much sooner (often by 6 weeks) with appropriate management and education. It can be achieved when painless range of motion and strength is restored, and that specific sports activities can be performed without pain or limitation (Chen, McInnis & Borg-Stein 2019). As such, there are several key assessments that physios perform to determine if the patient is ready to return.

When returning to sport, it should be done in a gradual manner, such as starting with basic, non-contact drills in training before progressing to match play. Furthermore, non-rigid ankle bracing is recommended for athletic activity even up to a year after the injury to prevent recurrence.  Watch a taping of an ankle here:

 

 

Importantly, the journey doesn’t end at the return to sport. Progressive exercises and management are necessary to reduce the risk of chronic ankle instability, and also to prevent compensatory movement patterns from occurring in other parts of the body, such as the knees or hips. This is addressed effectively in our classes at Vital Core Physiotherapy, specifically Kid- and Teen-Fit classes, where young athletes progress by developing the strength and control of muscles, with exercises advancing each week.

Conclusion

Overall, while LAS may seem trivial, to the young athlete, they are impactful to their confidence, performance, and ability to play the sports they love. They can also lead to chronic ankle instability, progressively worse injuries and sharply reducing the ability to return to sport at all. Therefore, it’s important to get the ankle checked by your physiotherapist, to help your child return to their sports in the quickest and safest way.

 

https://journals.lww.com/acsm-csmr/fulltext/2019/06000/ankle_sprains__evaluation,_rehabilitation,_and.7.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103112/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251008/