Ankle Sprain

Introduction

An ankle sprain is a common musculoskeletal injury involving stretching or tearing (partial or total) of the ankle ligaments. It occurs when the ankle moves outside of its normal range of motion, mainly in active and athletic people [1].

Epidemiology

The ankle is the second most injured joint in sports, and ankle sprains are the most common injury to the ankle. [2]

The most common type of ankle sprain is the lateral ligament injury, accounting for approximately 85% of all ankle sprains, and the least common are acute medial and syndesmotic ankle sprains, which occur more frequently in women than in men and children [3 ].

In the United States, the total cost of ankle sprains is approximately $2 billion [4] [5]. Poor and delayed rehabilitation, according to a 4-year study of 39,340 ankle sprain patients by the U.S. Military Health System After an initial sprain, there is an increased chance of recurrence of this injury and an increased incidence of ankle-related medical visits [6] [7].

A meta-analysis by Doherty et al. found that indoor sports such as basketball were associated with the greatest risk of ankle sprains at a rate of 7 per 1000 cumulative exposures [8]. Basketball players frequently suffer severe ankle sprains, and these players have a higher recurrence rate than 70%[9]. In a study of elite Australian basketball players, McKay et al. (2001) reported that the incidence of ankle injuries was 3.85 per 1000, resulting in 37 players with ankle injuries missing 81.5 weeks of competition [10]. Athletes With Chronic Ankle Instability Often Miss Training And competition requires constant care to keep physically active and perform sub-optimally.

Clinically Relevant Anatomy

For the lateral ankle ligament complex, the most commonly injured ligament is the anterior talofibular ligament (ATFL). The mechanism of ATFL and calcaneofibular ligament (CFL) sprains is when the plantarflexed foot is forced upside down. In this case, it means The calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) are less likely to withstand damaging loads. PTFL is rarely injured unless associated with dislocation of the talus [11].

As for the medial side, the strong triangular ligament complex consisting of the posterior tibiotalar (PTTL), tibiotalar (TCL), tibioscaphoid (TNL), and anterior tibiotalar (ATTL) Injuried. [12]

The stabilizing ligaments of the distal tibiofibular syndesmosis are the anterior inferior, posterior inferior, and transverse tibiofibular ligaments, the interosseous ligament, and the inferior transverse ligament. Syndesmotic (high ankle) sprains occur with combined external rotation Dorsiflexion of the leg and ankle [13].

Risk Factors

Several intrinsic and extrinsic risk factors predispose athletes to chronic ankle instability.

1. Extrinsic factors: History of previous sprain (previous sprain may compromise the strength and integrity of the stabilizer and interrupt sensory nerve fibers) [14]
2. Intrinsic factors: gender, height, weight, limb dominance, postural sway, and foot anatomy [15]

Other extrinsic factors include lace-up support shoe type game duration and activity intensity.

Mechanism of Injury/Pathological Process

Lateral ankle sprains usually occur when the body’s center of gravity is shifted rapidly on the landing or weight-bearing foot. The ankle rolls outward while the foot turns inward, causing the lateral ligaments to stretch and tear. When a ligament is torn or overstretched, its previous elasticity and Elasticity rarely returns to normal. Some researchers have described situations in which play was allowed to resume too early, which interfered with adequate repair of the ligaments. [16] It has been reported that the greater the degree of plantar flexion, the higher the likelihood of a sprain [17].

According to a study of 94 young Brazilian competitive volleyball and basketball players, when the EMG reaction time of the dominant peroneus brevis muscle in the left calf was greater than 80 ms, the likelihood of an ankle sprain was 80.6%. Dampers and playing positions [18].

In addition, Yeung et al. 1994 reported in an epidemiological study of unilateral ankle sprains that the dominant leg was 2.4 times more likely to be sprained than the nondominant leg. [9] [7]. A less common mechanism of injury involves a forceful eversion movement at the ankle, which injures the ankle Strong deltoid ligament.

Mechanism of Aspect Injury Ligaments Lateral Varus and Plantarflexion dorsiflexion anterior inferior tibiofibular ligament posterior inferior tibiofibular ligament transverse tibiofibular ligament interosseous membrane interosseous ligament inferior transverse ligament

Clinical Presentation

Signs and symptoms of an ankle sprain vary depending on the type and severity of the injury and include:

1. pain especially when putting weight on the affected leg
2. tenderness on palpation of the ankle joint
3. bruising, edema and swelling
4. limited range of motion and instability at the joint level[1] .
5. complaints of cold feet or paresthesia which may indicate neurovascular compromise of peroneal nerve[19] .
6. inversion injury or strain
7. past history of ankle injury or instability
8. Special tests: positive signs in Anterior Draw Talar Tilt or Squeeze Test (depending on included programs) .

Note that: Passive inversion or plantar flexion with inversion should reproduce symptoms of a lateral ligament sprain and passive eversion should reproduce symptoms of a medial ligament sprain.

Differential Diagnosis

The Ottawa Ankle Clinical Prediction Rules are an accurate tool for excluding fractures in the first week after an ankle injury.[20]

Other differential diagnoses to watch out for:[21]

• Impingement
• Tarsal Tunnel Syndrome
• Sinus Tarsi Syndrome
• Cartilage or osteochondral injuries
• Peroneal Tendinopathy or subluxation
• Posterior Tibial Tendon Dysfunction

Classification Grading Systems

There are several classification systems for soft tissues, each with their own strengths and weaknesses. Different practitioners may use different schedules so effective continuity of care requires the patient to see the same practitioner every time. Writers don’t always reveal which a system used that reduced the rigor and quality of a study[22].

The traditional system of nerve injury classification focuses on a single nerve[22].

• Grade I represents a microscopic injury that does not expand the tissue on a macroscopic level.
• Grade II has macroscopic stretching but the ligament remains intact.
• Grade III is a complete rupture of the tendons.

As there are multiple ankle ligaments on the joint it may not always be straightforward to use a grading system designed to describe the status of a single ligament unless it is certain that only one ligament is injured. Thus some authors have resorted to grading lateral ankle ligament sprains by the number of tendons injured[23]. However, it is difficult to determine the number of tears unless there is clear high-level radiographic or surgical evidence.

A third system that can be adopted is a 3 graded classification based on the severity of the sprain injury[22].

• Grade I Mild – Minimal and mild swelling with minimal impact on function
• Grade II Moderate – Moderate swelling pain and effect on function. Decreased proprioception ROM and instability
• Grade III Severe – Complete rupture major swelling high tenderness loss of function and marked instability

This scale is highly subjective due to individual therapist interpretation. However, the same can be said for the other classifications unless there is clear radiographic evidence or it has been evaluated and treated by surgical intervention.

Outcome Measures

• Lower Extremity Functional Scale (LEFS)
• Foot and Ankle Ability Measure (FAAM)
• Foot and Ankle Disability Index (FADI)

Clinical Examination

With an ankle sprain, multiple structures may be involved so a comprehensive foot and ankle examination is recommended[22] with an approach to injury assessment that takes into account the patient’s gait pattern standing and wearing on the person’s shoes among. Any deformity of severe mal-alignment or muscle tenderness should also be observed and noted as well as any edema and/or ecchymosis.

Touch is used to sense the systems potentially affected by the injury including skeletal muscles and tendons followed by active and passive motion analysis.

[25][26]

Special Tests

• Anterior Draw – tests the ATFL
• Talar Tilt – tests the CFL
• Posterior Draw – tests the PTFL
• Squeeze test – a wode kyere syndesmotic sprain
• External cyclic stress test (Kleiger’s test) – syndesmotic sprain

These tests are recommended to be performed within 4-7 days of acute injury to allow the initial swelling and pain to resolve which will allow the clinician to make a more accurate diagnosis[22].

Physical Therapy Management

Mild Ankle Sprain

• Natural full recovery within 14 days
• Taping and follow-up to monitor treatment progress[20][27].

A first-time pelvic sprain can be a harmless injury that heals quickly with minimal intervention and some techniques indicate that only minimal intervention is necessary. NICE guidelines 2016 recommend counseling and pain management but not regular exercise referrals[28]. But whatever it is it has also been confirmed that the frequency of recurrence of a first vertebral fracture is 70%[29]. Given the very high frequency of recurrences and guidelines that do not recommend any maintenance, this approach has been questioned[30].

Severe Ankle Sprain

Exercise is important as it has been shown to be more effective for effective treatment of the ankle than immobilization. Functional therapeutic treatment can be divided into 4 stages to the next level as endocrinology allows [20].

1. Inflammatory phase,
2. Proliferative phase, 
3. Early Remodelling,
4. Late Maturation and Restructuring. [20] [27] [31]

Inflammatory Phase (0-3 days)

Goals:

Reduced pain and inflammation and improved circulation and supportive leg area

The most common method for managing an ankle sprain is the PRICE protocol: Protection Rest Ice Compression and Elevation[33] .

Recommendations for the Patient:

• Safety: Protect the ankle from further injury by avoiding rest and activities that could lead to further injury and/or pain
• Rest: Advise rest for the first 24 hours after injury possibly using crutches to place materials to remove the injured ankle and changing work and sports and exercise requirements as needed
• Ice: Apply a cold compress (15 to 20 minutes once to three times a day) .
• Compression: Apply a compression bandage to control swelling caused by the broken toe
• Elevation: Ideally elevate the ankle above the level of the heart, but at least avoid a position-dependent position of the ankle relative to the body

Despite its widespread clinical use, the precise physiological response to ice application has not been fully elucidated. Furthermore, the reasons for using it at different stages of recovery are quite different. Insufficient evidence from randomized controlled trials to determine relative effectiveness RICE for the treatment of acute ankle sprains in adults. But there is no evidence of rejection of the RICE deal. [34]

Foot and Ankle ROM:

• The patient performs active movement of the toes and ankle in a pain-free range to improve local circulation. [27][35][36]
• Acute manual therapy can also effectively increase ankle dorsiflexion. [37]
• Anterior-posterior manipulation and RICE improved range of motion to a greater extent than RICE alone. [38]

Proliferative Phase (4-10 days)

Goals:

Restores foot and ankle function and improves load-bearing capacity.

1. Patient education about gradually increasing activity levels based on symptoms.

2. Practise Foot and Ankle Functions

• Range of Motion
• Active Stability 
• Motor Coordination

It is important to start ankle rehabilitation as early as possible. The first week of exercise produced significant improvements in short-term ankle function. [39]

3. Tape/Brace :

• Apply the tape as soon as the swelling subsides.
• Use of tape or braces depends on patient preference
• Boyce et al found that treatment of lateral ankle ligament sprains with the Aircast Ankle Brace resulted in significantly improved ankle function compared to standard treatment with an elastic support bandage. [40] (evidence level 2b)
• However, it is still uncertain which treatment (bandage or tape) will be most beneficial. [20]

Two examples of ankle sprain taping techniques, but there are many others that vary.

[41]([42](l

Early Remodelling (11 -21 days)

Goals: 

Improves muscle strength Active (functional) stability Foot/ankle mobility (walking stairs running).

Education:

• Provide information on possible preventive measures (tape or braces)
• Advice on wearing appropriate footwear during physical activity related to the type of movement and the surface

Practice foot and ankle function (see resource video below)

• Practice balancing muscle strength ankle/foot movement and flexibility (running with stairs).
• Look for a symmetric walk pattern.
• Once the load capacity allows to focus on balance and coordination exercises, dynamic stability training begins. Gradually progress the load from static exercises to dynamic exercises, from partial load exercises to full load exercises, and from easy exercises to functional multitasking exercises. alternate cycle Engage in acyclic movements (sudden irregular movements). Use different types of surfaces to increase the difficulty.
• Encourage the patient to continue practicing functional activities at home and state exactly what to expect from each exercise.

Taping/bracing

• Wearing tape or braces is recommended during physical activity until the patient can confidently perform static and dynamic balance and motor coordination exercises.

Late Remodelling and Maturation

Goals:

Improve local weight-bearing walking ability and improve skills required for activities of daily living and work and sports.

Practice and adjust foot abilities (function and movement)

• Practice motor coordination skills while performing mobile exercises
• Continue the load-bearing progression as described above until you reach the pre-injury load-bearing level
• Increase the coordination intensity of high-intensity exercise at various levels until pre-injury levels are reached
• Encourage the patient to continue practicing at home

Return to Activities after Ankle Sprain

Ankle sprains are often thought of as harmless injuries but we have seen before that they can lead to subsequent diseases such as osteoarthritis or chronic ankle instability.

Some protocols and standardizations of Return To Sport have been implemented for conditions such as post- LCA surgery or hamstring injury but remain unknown to many. There is no evidence-based medicine specifically for the foot and ankle to help decide whether to allow. athlete goes RTS. As a result of a recent systematic review by Tessigol et al. we are aware that there are currently no published evidence-based criteria for determining RTS measures for patients with LAS injuries. [43] .

Even if the literature doesn’t help us find a common basis for resuming sport after an ankle sprain that doesn’t mean athletes shouldn’t be tested.

Tests and Criteria

• Ankle Mobility: knee to wall test
• Lower Limb Strength: The typical loading rate for a single-leg vertical jump is about 1.5 of your own body weight [44]; in fact in order to carry out certain active activities it would be desirable for him to have the capacity to transmit force (and friction) equivalent to 1.5 times his own body weight. Lee Herrington and others. [45]following previously demonstrated data the ability to perform 10 repetitions of single leg presses (1.5 times body weight) was introduced as the standard for return to running after cruciate ligament injury. While not diagnosed as an ankle sprain it can help tremendously with returning an athlete to running.
• Static Balance Test: Y balance test
• Dynamic balance test: LESS or HOP test
• Agility test: Illinois Test T test or some sport-specific agility tests.

Chronic Ankle Instability

Persistent problems following lateral ankle ligament injury have been reported in 19-72% of patients. Evidence of deficits in ability to perform certain motor tasks during the Star Excursion Balance Test and self-report function quantified using foot and ankle ability measures can be Used in a clinical setting as a predictor of chronic ankle instability (CAI) outcome in patients with a first lateral ankle sprain [46]. About 20% of people develop CAI, which is attributed to delayed muscle reflexes that stabilize deficient calf muscles Calf muscle strength deficits in kinesthesia or impaired postural control [47][48].

Chronic ankle instability has been described as a combination of mechanical (pathologically flaccid joint movement limitation and degenerative and synovial changes) and functional (impaired proprioceptive and neuromuscular control and strength deficits) deficits [49]. perfect treatment plan Mechanical and functional deficiencies must be adhered to.

Conservative treatment is recommended for all patients to improve stability and improve muscle reflexes and strength in the stabilizer muscles of the lower extremities. While this will help some people, it will not compensate for defects in the lateral ligament complex, and surgery is Occasionally required [47].

Transect technique for lateral ankle sprains

Ankle Bracing and Taping

Ankle braces and straps are often used as a preventive measure and are increasingly being researched. Ankle taping can be used to help stabilize the joint by limiting motion and proprioception. Ankle taping is said to be better than initial at preventing recurrent strains Sprain [10]. A study of basketball players has detailed the effectiveness of ankle taping in reducing the risk of re-injury in athletes with a history of ankle ligament sprains. The large sample size of the study (n=10393) and the identification of 40 ankle injuries increased the reliability of the results Express. A 1985 study by Tropp et al. of football players wearing ankle braces. Participants in the brace group had a significantly lower incidence of ankle sprains compared with no intervention [50]. A similar effect was described by Surve et al. 1994 in their prospective study with braces, but noted no difference in ankle sprain severity between braced and unbraced groups [51].

Reports on the effectiveness of ankle taping are inconclusive. Some reports indicate that taping is ineffective [10][52]. Its effectiveness is also influenced by taper experience. Some advantages of braces compared to recordings are; Cost[53] Reusability No need for expertise Minimal effects for application and allergic reactions [54].

Resources

• Ankle Sprains at Connecticut Orthopedic Surgery Center contains a series of resources on ankle sprains, including patient resources and surgical techniques.

Coordination Health TV Ankle Sprain Video Series

Denver-Vail Orthopedics P.C Ankle Sprain Video Series