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Lateral ankle Sprain

ankle sprain

Ankle sprain is relatively a common phenomenon in many dynamic sporting activities. Activities in which many pivot motions, sudden stops in movement and sharp direction changes occur such as football, basketball, rugby, dancing etc. none the less, people who do not engage in sporting activities are liable for this type of injury due to variable unstable terrain conditions in rural and urban areas alike.

In order to understand the injury mechanism, one first has to understand the anatomy of the ankle.

Ankle Anatomy:

The ankle is divided into 2 joints:

  1. The fibula and tibia bones that appear anatomically as the two malleolus bones (the two bulgy bones at the distal part of the shin) and the talus bone located in between them are considered as the upper ankle joint or Talo-Crural joint. This joint allows for a dorsi and plantar flexion movements (forward and backwards movement of the ankle), when the talus bone moves in a hinge between the the distal fibula and tibia.
  2. Underneath the Talus bone is the lower ankle joint or the Sub-Talar joint. This joint in comprised of the calcaneus bone (the heel bone) and the Talus itself. The Calcaneus glides in a lateral and medial (sideways) motions under the talus, allowing for supination and pronation (or eversion and inversion) movements of the ankle.
  3. There is a fibrous link between the lower part of the fibula and Tibia, manifested as a strong ligamentous structure called the syndesmosis, which is also considered a type of joint. The purpose of the joint is to stabilize the “cup” or “socket” part of the talo crural joint.

The structural stability of these joints is reinforced by ligaments. Among them, the primary ones connects the the talus and fibula on the lateral (outer) side of the ankle (The anterior Talo fibular ligament-ATFL). The Deltoid ligament attaches the talus and Tibia on the medial (inner) side. This ligament is a delta shaped ligament hence its name the deltoid. The third main ligament attaches the calcaneus with the fibula (calcaneo-fubular ligament or CFL).

The lateral side of the ankle is the most vulnerable one and so is the range of motion towards the medial side.

Injury mechanism:

The most common injury in the ankle is a lateral sprain that affects the lateral ligaments and structures of the ankle. During the injury, a person will feel as if his ankle “gives way” and his foot turns inwards and medially towards the body in combination with a plantar flexion (a forward motion of the ankle). The main ligaments involved is the ATFL and CFL. It is also common that other structures and ligaments in the mid-foot itself will be affected depending on the intensity and angulation of the injury. In this situation the ligaments will undergo one of the 3 scenarios:

  1. An overstretch in the ligaments that will cause one or a few micro tears.
  2. A partial or complete tear.
  3. An avulsion fracture in which the ligament itself isn't torn but due to the intense pulling force, the ligament will avulse or brake away a piece of the bone to which it's attached.

The injury causes a vascular reaction in the form of an inflammatory reaction, due to the tear of blood vessels in the ligament. This is manifested by an immediate swelling, redness, localized warmth and tenderness due to the pressure the swelling is placing on sensory nerve endings.

After the initial 48-72 hours post injury, the body will start the healing process of the affected tissues. The body does that by adding connective tissue (like construction glue or cement to a break in a wall) or scar tissue. Scar tissue doesn't posses the quality of the original tissue (as much as glue or cement aren't an organic part of the original wall). Like scar tissue on the skin isn't skin itself. E.g It'll never grow sweat glands, hair etc. With time this tissue has a tendency to shorten.

The problem continues when the body doesn't just add scar tissue where the damaged area is, but also adds it arbitrarily, thus connecting points A & B though a matrix of spider web like connections of adhesions that attach to adjacent healthy tissues as well. This fprocess leads to a limitation in the functional range of motion and pain during movement since the scar is pulling on healthy tissue as well while disturbing the normal movement pattern.

Influencing factors on the injury:

  1. A past history of ankle traumas- fractures, sprains, dislocations etc. after the ligament undergoes this process of hyper stretch or “creep”, it doesn't reverse itself to its original length but stays elongated, thus endangering the stability of the new “loose” area. This condition will disable the ligament from providing the necessary stability at the right timing.
  2. Instability or lack of control in the rest of the lower limb muscles and the pelvis.
    strength in these muscles is not enough. The ability of the nervous system to control the activity and timing of contraction of these muscles is just as important. There’s a vast system of sensors situated in muscles, tendons, joint capsules and even the skin that sends signals associated with stretch, tension, muscle contraction respectively to the brain The brain processes all of these signals and develops a picture of how the movement is carried out. If this system is untrained or neglected, the movement image in the brain isn't presented properly. Therefore, over use of muscles, unbalanced contractions can occur and lead to overload on more distal structures like the knee and ankle. This system is also known as the proprioceptive system and its sensors- the propriosensors.
    proprioception
  3. Limitation in range of motion in the knee, hip, pelvis and low back: The ability of the body to generate a well co-ordinated movement depends upon the kinetic movement chain that starts at the center of the body and ends at the foot. A limitation in one of the pieces of that kinetic chain will eventually over load other structures that will have to compensate for that loss by excessive range of motion on their part.
  4. Weakness and lack of central stability in the abdominal muscles, buttocks etc: as described in paragraph 3, range of motion isn't the only important factor in the kinetic chain. Muscles that mobilize and stabilize this kinetic chain have to be adequately strong fulfill their function. Failure to achieve their goal due to multifactorial reasons will again over load other structures as the ankle, knee, hip and making them more prone to injury.
  5. Strenuous activity on uneven surfaces like running on the sand or grass, use of inappropriate footwear, faulty training habits and exercise.

Treatment:

  1. in the first 48-72 hours it is advised to place an ice pack on the inflamed area for 10-15 minutes every 3-5 hours. This is done in order to control the inflammation process and the intensity of the vascular reaction to the trauma. Elevation of the lower limb will also help to supply better drainage for the swelling. Certain taping and strapping techniques to the ankle will also assist to achieve that goal.
  2. In the 2nd phase of rehabilitation its advisable to start activating the ankle in controlled movements in order to prevent adhesions (as mentioned earlier as the sporadic adding of scar tissue in the damaged area). The activation is done both actively by the patient in the form of exercises and passively by the physiotherapist who performs specific accessory movements to the joint, soft tissue mobilizations, stretches and massage. If the articulating parts of the joint will be moved in a correct and functional way according to their bio-mechanical model, adhesions will be less likely to form while non -functional existing adhesions will be torn and be removed.
    ankle treatment
  3. In later stages its advisable to start gradually various stability, Co-ordination and proprioception exercises in order to train the proprioceptive system in the body that was hindered during the injury. In addition, range of motion exercises are continued along with the manual therapy and a continued exercise program targeted towards loading the tissues with the intention of returning to sports.
    ankle sprain 2
  4. If a limitation is found in the pelvis, hip, knee, its better not to neglect it and treat it in order to prevent unnecessary over load on the ankle and prevent the recurrence of the injury. In addition, its also advisable to check the trainer's footwear, insoles and other external factors that might influence the recurrence of the injury.
  5. An avulsion fracture might require a supporting brace for a few weeks, depending on the severity of the case, and complete tears of the ligaments might require a reconstructive surgery in some cases.
  6. Taping- athletic or kinesiotaping are special sticky straps, placed by the physiotherapist, intended to unload and protect the damaged tissues, placing a joint in a more functional position, facilitating or inhibiting certain muscles. Taping also helps in activating the proprioceptive system through the propriosensors in the skin, joint, fascia and muscles.

In conclusion:

Ankle sprain is a common injury among athletes and the non training population alike. Its an injury that requires a proper diagnosis of the movement system and treatment in physiotherapy. Most important, it's preventable to a certain degree. Remember that a physical examination and screening of the movement system to the entire kinetic chain from the center of the body to the foot, a regular training regime of balance, strengthening, flexibility and range of motion exercises can have a great benefit in preventing this type of injury and others. Also the prevention exercises regime can decrease the severity of the ankle sprain if it does reoccur.

***This article mentions several methods of evaluation and treatment. These are merely guidelines. They are not an independent treatment program nor intended to replace a thorough evaluation and treatment program executed by a certified physiotherapist. Its advised to undergo such evaluation and treatment by a certified physiotherapist if such injury occurs and act upon their professional judgement call***