Ankle Sprain

Ankle sprain is an injury to the tough bands of tissue (ligaments) that surround and connect the bones of the leg to the foot. The injury typically happens when you accidentally twist or turn your ankle in an awkward way. This can stretch or tear the ligaments that hold your ankle bones and joints together.

Sprained ankles most commonly involve injuries to the ligaments on the outside of the ankle (lateral).

A sprained ankle occurs when your ankle ligaments are overstretched. Ankle sprains vary in their severity, from mild “twisted ankle” or “rolled ankle” sprain through to severe complete ligament ruptures, avulsion fractures or broken bones.

EPIDEMIOLOGY AND CAUSES

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CAUSES

Your foot can twist unexpectedly during many different activities, such as:

Walking or exercising on an uneven surface

Falling down

Participating in sports that require cutting actions or rolling and twisting of the foot such as trail running, basketball, tennis, football, and soccer.

During sports activities, someone else may step on your foot while you are running, causing your foot to twist or roll to the side.

CLINICAL FEATURES AND PATHOPHYSIOLOGY

A sprained ankle is painful. Other symptoms may include:

Swelling

Bruising

Tenderness

Instability of the ankle may occur when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

Bruised and swollen ankle

Bruising and swelling are common signs of a sprained ankle.

If there is severe tearing of the ligaments, you might also hear or feel a “pop” when the sprain occurs.

PATHOPHYSIOLOGY

The lateral ankle complex, which is composed of the anterior talofibular, calcaneofibular, and posterior talofibular ligaments is the most commonly injured site. Approximately 85% of such sprains are inversion sprains of the lateral ligaments, 5% are eversion sprains of the deltoid or medial ligament, and 10% are syndesmotic injuries. The ATFL is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain. Osteochondral or chondral injuries of the talar dome should be considered when diagnosing an ankle injury.

During forced dorsiflexion, the PTFL can rupture. With forced internal rotation, ATFL rupture is followed by injury to the PTFL. Extreme external rotation disrupts the deep deltoid ligament on the medial side, and adduction in neutral and dorsiflexed positions can disrupt the CFL. In plantarflexion, the ATFL can be injured.

The strongest ankle capsule-ligament complex is the deltoid ligament, which has 2 parts: the superficial component and the deep component. The superficial component runs the farthest from the medial malleolus to the medial aspect of the calcaneus, posteriorly. The medial malleolus usually fractures before the deltoid ligament fails mechanically.

PHYSICAL EXAMINATION AND DIAGNOSIS

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Ottawa Ankle Rules

Ankle X-ray is only required if:

There is any pain in the malleolar zone and

Any one of the following

Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

OR

Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus ,

OR

An inability to bear weight both immediately and in the emergency department for four steps.

Foot X-ray series

The Ottawa ankle rules indicate whether a foot X-ray series is required.

It states that it is indicated if:

There is any pain in the midfoot zone and

Any one of the following:

Bone tenderness at the base of the fifth metatarsal ,

OR

Bone tenderness at the navicular bone ,

OR

An inability to bear weight both immediately and in the emergency department for four steps.

Along with physical examination X-ray Radiography, MRI etc are also used for better diagnosis.

PHYSIOTHERAPY MANAGEMENT

Physiotherapy is required with functional therapy of the ankle shown to be more efficient than immobilisation. Functional therapy treatment can be divided in 4 stages, moving onto to the next stage as tissue healing allows

Inflammatory phase

Proliferative phase

Early Remodelling

Late Maturation and Remodelling.

Inflammatory Phase (0-3 days)

Goals:

Reduction of pain and swelling and improve circulation and partial foot support

The most common approach to manage ankle sprain is the PRICE protocol: Protection, Rest, Ice, Compression, and Elevation.

Foot and Ankle ROM:

Patient performs active movements with the toes and ankle within pain free limits to improve local circulation.

Manual therapy in the acute phase could also effectively increase ankle dorsiflexion.

Anteroposterior manipulation and RICE results in greater improvement in range of movement than the application of RICE alone.

Proliferative Phase (4-10 days)

Goals:

Recovery of foot and ankle function and improve weight bearing.

1. Patient education regarding gradual increase in activity level.

2. Practice Foot and Ankle Functions

Range of Motion

Active Stability

Motor Coordination

It is important to begin early with the rehabilitation of the ankle. First week exercises produce significant improvements to short term ankle function.

3. Taping

Apply tape as soon as the swelling has decreased.

Tape or a brace use depends on patient preference

The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function compared with standard management with an elastic support bandage.

It remains uncertain, however, which treatment (brace, bandage or tape) is most beneficial.

Early Remodelling (11 -21 days)

Goals:

Improve muscle strength, active functional stability, foot/ankle motion, mobility .

Education:

Provide information about possible preventive measures (tape or brace)

Advice regarding appropriate shoes to wear during sport activities, in relation to the type of sport and surface

Practice foot and ankle functions

Practice balance, muscle strength, ankle motion and mobility .

Look for a symmetric walk pattern.
Work on dynamic stability as soon as load bearing is allowed

Focusing on balance and coordination exercises. Gradually progress the loading, from static to dynamic exercises, from partially loaded to fully loaded exercises and from simple to functional multi tasking exercises.

Alternate cycled with non cycled exercises (abrupt, irregular exercises).

Use different types of surfaces to increase the level of difficulty.

Taping

Advice wearing tape or a brace during physical activities until the patient is able to confidently perform static and dynamic balance and motor coordination exercises.

Late Remodelling and Maturation

Goals:

Improve the regional load bearing capacity, walking skills and improve the skills needed during activities of daily living as well as work and sports.

Practice and adjust foot abilities

Practice motor coordination skills while performing mobility exercises

Continue to progress the load-bearing capacity as described above until the pre-injury load bearing capacity is reached

Increase the complexity of motor coordination exercises in varied situations until the pre-injury level is reached

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Ankle Rehabilitation Exercises

https://youtu.be/omcyh8-aL24

Ankle Active Range of Motion

Standing Calf Stretch

Standing Soleus Stretch

Towel Stretch

Resisted Ankle Dorsiflexion

Resisted Ankle Plantar Flexion

Lateral Ankle Sprain Exercises

https://youtu.be/3JJayVC0-20

Eversion Ankle Sprain Exercises

https://youtu.be/RI5O5SpII4Q

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