Ankle sprains are one of the most common injuries seen by Physiotherapists. They occur frequently on the sports field, but also as a result of work related and daily stresses induced by uneven ground and awkward landings. The emphasis here will be on some of the soft tissue damage and basic treatment principles seen with lateral ankle sprains rather than fractures, but consideration of bone trauma is obviously essential in the assessment of any acute ankle injury.
Physiotherapy is the treatment of choice for ankle sprains. Many are relatively straight forward and respond well to treatment, but surgical reconstruction is considered in severe injuries or in cases of chronic instability if conservative therapy fails.
- 85% of ankle sprains involve the lateral ligaments and are caused by rapid plantarflexion and inversion. 40% of those injured will suffer recurrent sprains, so getting the right advice and treatment first time round is vital. The anterior talo-fibular ligament (ATFL) is the most commonly damaged structure, with the calcaneo-fibular ligament (CFL) and posterior talo-fibular ligament (PTFL) stressed with increasing magnitudes of inversion.
- Less frequently, strains of the medial ligaments (inner aspect of the ankle) are seen. These are significantly thicker and stronger, so greater force is usually required to cause injury, and recovery times are frequently slower.
Do I need an X-Ray?
We get asked this all the time, so its helpful to know why we will or won't refer you for an X-ray. Most of the time, it is unnecessary and we can thoroughly assess and manage the extent of soft tissue injuries during the course of your treatment. However, worldwide there is a ‘gold standard’ for defining a patient’s need for radiological assessment following injury known as the 'The Ottawa Classification System'. If you have any of these and they arouse our suspicions (your Physio will let you know), its off for a scan you go!
- Inability to weight bear at the time of injury, or inability to take 4 steps on presentation in our clinic
- Tenderness on palpation of the malleoli and/or distal posterior shafts of the tibia or fibula,
- Tenderness on palpation of the navicular
- Tenderness on palpation over the base of the 5th metatarsal.
Following these rules, there is a 95% chance that an ankle or foot fracture will be identified if present (this doesn't mean you have broken your ankle!!). The positive predictive value of the rules is around 17% for ankle fractures and 20% for the foot — i.e. approximately 1 in 5 patients referred will return a positive result. But, as a precaution, that is when we will refer you on.
REHAB: Strength, Balance and 'Proprioception'
Early treatment will involve supportive taping, modalities, manual therapy and simple exercises to help you recover. In the longer term, we need to consider some more complicated aspects of your recovery:
- Retraining of the peroneal muscles on the outside of the lower leg is a common rehab practice. It may include specific strengthening as well as a variety of balance stimulating activities to enhance reaction times and neuromuscular control. The aim is to reduce the chance or even prevent another inversion sprain from occurring.
- Proprioception and maintaining balance is both conscious and involuntary. Concentrating during during challenging activities is one thing, but a more reflexive element is involved with unexpected stress. There is a time lag between a force occurring, the signals travelling to our brains, and our muscular reaction to (hopefully) prevent our ankle from giving way. This response time slows in those with a history of ankle injury, with some studies seeing a delayed reaction on both sides, not just the injured side!
- Proper conservative rehabilitation of ankle sprains is a vital factor in preventing re-injury at lower speeds of inversion stress. It may assist in reducing the risk of injury with higher grade forces as well, but the sheer magnitude and velocity of sporting stresses is sometimes simply too great. That's why we are here as Physios, to help you get back on track ASAP!