Nearly all of us at some point in time, whether it be walking on an uneven footpath, wearing high heel shoes or playing sport have rolled or twisted our ankle. That is because lateral ankle sprains or inversion sprains are one of the most common musculoskeletal injuries both in sports and in the general population.
Unfortunately though, we see too many patients who either do not undertake any rehabilitation following an ankle sprain, often resulting in longer term ankle pain and dysfunction, or carry out suboptimal ankle rehabilitation often resulting in longer recovery times and persistent ankle symptoms. In this blog Melbourne sports chiropractor Dr. Nicholas Shannon provides a higher level overview of lateral ankle sprains highlighting best practice for assessment and rehabilitation.
Lateral Ankle Anatomy
Lateral ankle strains occur when the foot is suddenly forced into plantar flexion, supination and adduction. In this position the supporting ligament structures in the anterior and lateral ankle are put under extreme tensile load.
These structures include the anterior inferior tibo-fibular ligament (AITFL), anterior talo-fibular ligament (ATFL), posterior talo-fibular ligament (PTFL), calcaneofibular ligament. Additionally, the peroneal tendons, peroneal retinaculum (fibrous tissue which holds the peroneal tendons against the fibular) and lateral malleolus (bony tip on the outside of the ankle) undergo high stress loads during lateral ankle sprains.
Risk Factors for Lateral Ankle Sprains
There are both intrinsic and extrinsic risk factors associated with lateral ankle sprains. As discussed in previous posts, intrinsic risk factors are those related to the individual, while extrinsic risk factors involve those factors not directly related to the individual such as the environment.
Intrinsic
- Reduced ankle dorsiflexion range of motion (how your foot flexes)
- Reduced proprioception (sensory/positional receptors)
- Deficiencies in postural control and balance (single leg balance test)
- Lower BMI
- Reduced lower limb / ankle strength and coordination
- Females > males
- Peroneal muscle reaction time
Extrinsic
- Type of sport played – basketball, volleyball, field sports, climbing
- Landing after a jump (volleyball), grass versus artificial turf (soccer)
- Footwear – shoe type, high heel shoes
Grading Lateral Ankle Sprains
The first structure to fail in a lateral ankle sprain is usually the ATFL, followed then by the calcaneofibular ligament, followed by the peroneal tendons and/or retinaculum. The PTFL is usually only involved in ankle fractures, while the AITFL is torn in high ankle sprains. Lateral ankle sprains are graded I to III where a grade I (mild) strain involves strain of the ligament complex without rupture or instability. Grade II (moderate) strains involve partial tearing/rupture of the ligament with moderate instability. Grade III (severe) strains involve complete rupture of one or more ligaments with marked reduction in function and instability.
The optimal time to have a lateral ankle sprain clinically assessed to determine if the ATFL has been ruptured is approximately 4 to 5 days post injury. However, sports diagnostic ultrasound (which is offered by the Shannon Clinic Melbourne Chiropractic and Sports Care clinic) can be employed immediately without having to wait 4-5 days post injury; it is more accurate at detecting ATFL and calcaneofibular ligament tears than orthopaedic tests, therefore leading to an earlier diagnosis and the faster implementation of more targeted treatment and rehabilitation.
Rehabilitation of Lateral Ankle Sprains
Early treatment and rehabilitation is extremely important for acute lateral ankle sprains. With high re-injury rates (up to 34% experience a recurrent sprain in the following 12 months) and 33% still experiencing ankle pain 1 year after an ankle sprain, together suggesting individuals may not be rehabilitating their ankles correctly. This is consistent with what Melbourne sports chiropractor, Dr. Nicholas Shannon sees in clinical practice, where patients presenting with chronic ankle pain detail a history of an incomplete or absent rehabilitation program, residual range of motion, strength and balance deficits at the ankle and lower limb.
Acute interventions
More broadley speaking most grade I, II and III ankle sprains can be managed conservatively, surgery is usually only considered on an individual basis, particularly in the case of gross instability. In the early inflammatory phase of the injury (first 3-4 days) controlling the pain, swelling and inflammation is important. NSAID’s can be used, but they may interfere with the early wound healing process. Although there isn’t supportive evidence for its use, ice and compression may help provide some comfort.
Functional Supports
Functional support (bracing, taping) and exercises are more favourable to immobilization unless immobilization is warranted, as in presence of an avulsion fractures or distal fibular fractures. In terms of bracing, lace up braces are preferred over soft compression braces, while kinsiotape is unlikely to provide any meaningful mechanical stability. Compression sleeves/bandages provide no benefit after the initial acute inflammatory phase of the injury.
Exercise Therapy
Exercise therapy, which consists of strengthening, neuromuscular and proprioceptive exercises should be initiated early with evidence showing their efficacy; reduced injury re-injury rates and functional instability; coupled with quicker recovery times and better outcomes.
Injury Prevention
Post rehabilitation, there is evidence to support the implementation of an injury prevention programme which includes a balance/proprioceptive component to reduce the risk of lateral ankle sprains in those with and without a history of a lateral ankle sprain.
Our Approach to Lateral Ankle Sprains
At the Shannon Clinic – Melbourne Chiropractic and Sports Care our approach is driven by the literature. We utilize point of care (in clinic) sports diagnostic ultrasound as apart of our work up, if there is a need to rule out ligament ruptures, avulsion fractures and/or retinaculum tears. Then, provided the patient can weight-bear we initiate exercise therapy as early as possible, even if this requires a functional brace. Additionally, we advocate the use of a functional brace with sport for the following 3 to 6 months post injury to reduce the risk of re-injury.
Following this approach, our patient outcomes closely align with the literature in terms of reduced re-injury rates, faster recovery times with better outcomes. Furthermore, patients we see with chronic ankle pain with minimal to no ankle instability following poor or no rehabilitation from a prior lateral ankle sprain or multiple sprains have favourable outcomes.
To have your ankle assessed you can book online below, our sports chiropractic clinic is located on the corner of Collins Street and Swanston Street in the CBD of Melbourne. Which is easily accessible via Flinders Street Station, Trams on Collins and Swanston Street and parking at Federation Square. If you want to read more on how you can improve your performance and what you can do to keep sharp while injured have a read of our blog on mental imagery.
