Lateral ankle sprains (LAS) are common musculoskeletal injuries with a high prevalence among the general population and individuals who participate in sports. Despite the high prevalence, it is reported that approximately 50% of individuals who sustain a LAS will seek medical attention; and the worrying statistic? A large proportion of those who sustain a LAS will develop chronic ankle instability (CAI).
Chronic ankle instability (CAI) can be defined as persistent complaints of pain, swelling and/or giving way in combination with recurrent sprains for at least 12 months after the initial ankle sprain. In addition, structural changes may be associated over this period including joint degeneration and osteochondral lesions.
Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint. Most LAS occur on the lateral ligaments on the outside of the ankle. These lateral ligaments are a combination of ligaments that are collective called the lateral collateral ligaments and comprise of the anterior talofibular (ATFL), the calcaneofibular (CFL), and the posterior talofibular ligaments (PTFL).
Patients often “know” when they’ve sprained an ankle. Below is a list of a few of the typical things patients will present to us with in the clinic:
- Limping is a telltale sign! But sometimes patients come in with crutches
- Bruising along the outer and/or inner aspects of the ankle joint, around the prominent ankle bones and sometimes over the surface of the upper ankle
- Tenderness along the ankle bones
- Pain and soreness when rolling the ankle in or out
- Instability of the ankle - a feeling of giving way
Assessment and Diagnosis
First and foremost, our role is to rule out any major red flags including fractures. Currently, a useful tool we use both on field and in the clinic is the Ottawa Ankle Rules, which assists physios to determine if there is any chance of fractures and reduce the need for any unnecessary imaging.
A typical assessment with a physiotherapist would start with some light palpation to determine which ligaments are likely to be affected. Light palpation around the ankle and / or in combination with some ligament stretching would shed light on which of the ligaments may be damaged or injured.
Following this check, we would then check range of motion. In the early stages, range may be limited and painful. As range of motion improves, a common test we use is the ‘Knee to Wall’ test. We look to restore range of motion typically to 10-12+ cm.
Grades of Ankle Sprains
Having determined the ligaments involved, we can grade the severity of injury and begin determining time frames for healing and recovery. The typical grading system is summarised as below:
Grade I Mild - Little swelling and tenderness with little impact on function
Grade II Moderate - Moderate swelling, pain and impact on function. Reduced proprioception, ROM and instability
Grade III Severe - Complete rupture, large swelling, high tenderness loss of function and marked instability
A 2018 clinical guideline was developed with the existing up to date research, lead by Vuurberg and colleagues. The following were their recommendations for management and guidelines that many clinicians will follow.
Rest, ice, compression and elevation have typically been the go to advice in the earliest stages of an ankle sprain. However there is little scientific support for the use of RICE alone and if applied, should be in combination with exercise therapy which we will touch on below.
A hot topic of “should I tape or use a brace” is often asked in our clinic. Current guidelines suggest the use of external support for 4-6 weeks prove superior to complete immobilisation (within a cast) or loose support (like tubi-grip or elastic bandage). In the early stages, we’ll often use taping to initially provide support, and will often guide patients in perhaps investing in a lace up or semi rigid brace if we deem it necessary for our long term goals.
Physiotherapists are trained in joint mobilisation and can apply manual joint gliding and manipulations to help aid joint movement. Current evidence suggests that manual joint mobilisation can provide short term increases in ankle joint range of motion and decrease pain, and is even more effective when paired with an exercise program.
Following any LAS, exercise remains an integral part of the ligament management. Early exercises are encouraged and will often comprise of neuromuscular (brain to muscle) and balance (proprioceptive) exercises. Exercise programs that are initiated early have been shown to reduce the prevalence of recurrent ankle injuries and improve ankle stability.
Key Take Home Messages!
- Ankle sprains are common and can be managed very well with a combination of early functional immobilisation, controlling inflammation and progressing to weight bearing type exercises as soon as possible
- Prevention of chronic ankle instability and injury should include progressive ankle strengthening that also have neuromuscular and proprioceptive exercises that challenge and stimulate the balance systems