What Is An Ankle Sprain? And How Can Physio Treatment Help?
Lateral (outer) ankle sprains are among the most common musculoskeletal lower limb injuries seen by physio’s and GP’s. They are very common in sports like footy, basketball, netball, tennis and running (especially on trails), and they also occur in the general population, eg a slip or trip in shoes with higher heels. They make up about 15% of all sports injuries.
Unfortunately, because they are so common, many people just expect them to resolve by themselves so they don’t get proper treatment (see below). This leads to high incidences of chronic instability (i.e. recurrent sprains) and then a reduction in physical activity and sports participation. Research shows the one-year recurrence rate for ankle sprains is very high, up to 80%. And this is the big problem with ankle sprains: the initial pain usually does go away fairly quickly, within a week or so, but the initial injury reduces your ankle stability so up to 8 out of 10 people will re-sprain their ankle within 12 months!
This inadequate treatment producing chronic ankle instability is very common, with 40-88% of first-time sprains causing chronic problems. What is also now being shown by research is that chronic instability also greatly increases your risk of developing early onset ankle osteo-arthritis (OA). So getting the right treatment for “simple” ankle sprains is important, not just for reducing your initial pain and swelling, but for strengthening your ankle to reduce your risk of future sprains.
Common Symptoms Of Ankle Sprains
Clients with an ankle sprain usually come in with pain around the outside (lateral) or front (anterior) of the ankle joint. Sometimes pain can also be felt on the inside (medial) part of the ankle. The most common mechanism of injury is an “inversion sprain”, where your foot rolls in underneath the inside of your ankle. The common ligaments involved in a lateral ankle sprain are the anterior talofibular, calcaneo-fibular & the posterior talofibular ligament.
Swelling, bruising and discolouration are often extensive around the ankle as well as down to the foot. The peroneal muscle area, which extends up the outer part of the shin/calf, can also be bruised & sore because these muscles can be strained as they attempt to stop the inversion sprain happening.
Walking is often very hard, and stairs are impossible to do with a normal pattern. There is reduced weight-bearing possible on your foot, you are often unable to push-off through your toes, and your stride length is short because you can’t bring your knee forwards over your foot. The outer area of your ankle and the top of your foot is often very tender to touch.
Do You Need An X-Ray? Using The Ottawa Ankle Rules
When you see your physio for your ankle sprain, we use the Ottawa Ankle Rules to determine if you need an x-ray. The Ottawa Ankle & Foot Rules are the gold standard to determine if an initial x-ray is required. Research shows that they have a very high predictive value to see if you are likely to have a bony injury (In case you’re interested in research statistics they have a sensitivity of >94% and a specificity 49% for the ankle & 79% for the foot.). We use these rules to avoid unnecessary use of x-rays.
You need to see your physiotherapist to assess your ankle using these rules. These evidence-based rules state that;
An ankle x-ray is only required if there is pain in the malleolar zone & there is:
1. Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
2. An inability to bear weight both immediately & at initial consultation for at least 4 steps.
A foot x-ray is only required if there is pain in the midfoot zone & there is:
1. Bone tenderness at the base of the 5th metatarsal, OR
2. Bone tenderness at the navicular bone, OR
3. An inability to bear weight both immediately & at initial consultation for at least 4 steps
Ankle Injury Significantly Increases Incidence Of Ankle Osteoarthritis (OA)
Whilst the ankle joint is relatively resilient to primary spontaneous OA changes (15%, compared to 85% at the knee), it has a much more significant response to injury. Post-injury OA is reported at 78% for the ankle compared to just 8-12% for the hip & knee.
OA changes after lateral ankle sprains usually occur in the inner (medial) compartment of the ankle joint. It’s high prevalence is due to poor or failed rehabilitation leading to chronic ankle instability. In this scenario patients report frequent minor ankle sprains with associated repeated joint trauma.
The onset of ankle OA is also significantly earlier in post-injury populations when compared to the primary ankle OA. The difference between the two population groups is 16 years (51 years old vs 67 years old). The latency between injury & the development of OA is also dependent on the severity of the injury, for example a grade II ankle sprain will have a later onset than osteochondral damage & fractures (bone injury).
What the above figures mean is that while ankle OA is far less common in people who haven’t had an ankle injury, it is much more common and occurs much earlier in people who have had an ankle injury. The reason for this big post-injury increase is usually due to poor rehab (see below) leading to chronic ankle instability and recurrent sprains.
Treatment For Ankle Sprains
Current best-practice shows that all ankle sprains, including full ruptures (Grade III) & avulsions (where the ligament pulls off the bone), should initially be treated with physiotherapy. If the patient’s pain, swelling & function do not normalise with 6-8 weeks of physio treatment, or they show recurrent instability, then further investigation with an orthopaedic review is indicated.
Unfortunately, patients spend on average only 2.5 weeks recovering from an ankle sprain, whilst the best research indicates that a supervised rehabilitation program of a duration of 6-10 weeks is required to decrease re-injury rates by 50% (Hertel 2008; Kidgell 2007; Verhagen 2000).
Initial Treatment – Focus On Returning To Normal Daily Function
Early treatment goals focus on reducing pain & swelling, increasing range of movement & restoring a normal walking gait. Immediate local compression (tubi-grip & taping +/- padding for specific pressure) for up to 10 days with the use
of cryokinetics (ice + movement) is indicated. Manual therapy for restoring joint mobility & muscle length is also effective.
Non-steroidal anti-inflammatories may be indicated for reducing pain, swelling & improving function. However, there is currently no research into the long-term outcomes & injury recurrence rates with respect to influence on ligament tissue remodelling capacity. We need to remember that inflammation is a normal and necessary part of our healing process, so medications that significantly reduce or shorten the inflammatory process may affect our long-term tissue healing and resilience properties, even though they may make us feel better in the short term.
Mid-Stage Treatment For Ankle Sprains
The main areas to focus on in this phase are;
1. Restore full ankle range of motion in both the talocrural & subtalar joints
2. Strengthen up the major muscle groups: calf, peroneal & hip (Fox 2008)
3. Static & dynamic balance & proprioception retraining.
Restoring full balance and stability is critical for reducing your risk of future sprains. Think of it like this: imagine you’re pivoting quickly on a netball court, or running on a trail and land on an uneven rock. Your body has to sense the change in your ankle position in a split second, then your brain has to recruit a complex combination of muscles to control this shift in ankle position, stabilise it with your full body weight coming down on top of it, plus push you off for your next step, all without rolling your ankle again! Testing your static balance, control and proprioception is often initially done using the Lower Quadrant Y-Balance Test (below).
End-Stage Treatment For Ankle Sprains
In this stage we focus on a safe return to full sport and activity. This means preparing you both physically and mentally for a full return to sport without re-spraining your ankle. Treatment involves progressive exercise prescription including high-level strength and proprioception (balance/control) drills, plus exercises that mimic as much as possible the demands of your sport. Exercise priorities usually include;
• Functional strengthening – building a solid foundation of base strength is important
• Sport-specific & ballistic strengthening – we introduce more fast-paced, whole-body and explosive power exercises
• Ensuring specific return-to-sport markers are reached – this is important for your confidence and mental preparedness for returning to sport, as well as your physical ability
• Continued progression of your home program to minimise future injury risk – this is critical for preventing chronic ankle instability
Need Physio Advice For An Ankle Sprain?
If you’ve just sprained your ankle and need treatment, or if you’ve sprained your ankle a few times in the past and want advice on how to prevent more sprains, feel free to contact our physio team, book online, or give us a call on 9280 2322.