Ankle Sprain

                                                                                                       Ankle Sprain

Definition:     

 Ankle sprain injury is one of  most common sport injuries  seen in athletes. It is a type of soft tissue injuries that occurs to the lateral ligaments of the ankle especially the anterior talo-fibular ligament that is the weakest ligament of the lateral ligaments leading to acute ankle sprain. 

Causes:

The ligaments around the ankle can be divided into the lateral collateral ligaments and the medial collateral ligament. The lateral collateral ligaments consist of the anterior talo-fibular ligament, the calcaneo-fibular ligament, and the posterior talo-fibular ligament.

Mechanism of Injury:

The most common mechanism of injury to the ankle ligament is inversion of the foot, with this mechanism of injury , anterior talo-fibular ligament is the first or the only injured ligament. The cause of the most ankle sprain injuries is incorrect foot positioning at landing during the initial contact of the foot with the ground.

Signs and symptoms:

• Swelling in the ankle.
• Pain
• Tenderness over the sight of lesion.
• Loss of ankle function.
• Ligamentous laxity.
• Decrease of ankle motion.

Grades of ankle sprain :

Ankle ligament sprains are usually graded according to the severity into three grades :

• • Grade 1 (mild) :a mild stretching of the ligaments without rapture or joint instability.
  • Grade 2 (moderate): a partial rapture of the ligament ( anterior talo–fibular ligament).
  • Grade 3 (severe): a complete rapture of the anterior talo-fibular ligament and injury of the calcaneo-fibular ligament.

Treatment and rehabilitation:

1.First line of treatment (acute stage):

Ankle sprain is a soft tissue injury. And as Blaise D (2020)  said, soft tissue injuries need PEACE and LOVE as a first line of treatment.

The first word is PEACE:                                               

• P is for protection: which means the patient has to rest his injured ankle and avoid any exercises or movement that might provoke the pain.
• E is for elevation: and that means that the injured ankle should be elevated above the level of the heart to decrease the edema and subside the swelling. Using ice will also help reducing pain and swelling.
• A is for Avoiding taking any anti-inflammatory drugs because the inflammation is important for the healing process after that, the inflammatory process help repair the injured tissue and thus the healing process occurs easily.
• C is for compression, the patient may use an elastic bandage or compression stockings to decrease the swelling.
• E is for education, the patient has to understand his case and doesn’t use any unnecessary interventions.

The next word is LOVE:

• L for load, the patient has to let the pain guide him to know his limits and he shouldn’t increase the load until the pain is reduced and feeling secure enough.
• O for being optimistic, knowing that the recovery will occur and he shouldn’t stress himself.
• V for vascularization, which means increasing the blood flow to the injured tissue by using cardiovascular exercises but these exercises should be pain free.
• E for exercises, which means gradual exercises help restore mobility and strength. Exercises also reduce the prevalence of recurrent ankle sprain.

2. Mulligan mobilization:

It is a sustained anterior-posterior cranial glide of the lateral malleolus on the fibula while the glide is maintained. The patient then performs active planter flexion & inversion while the therapist put over-pressure at the end of the range.

This technique should be pain free. After the mobilization, the glide should be maintained with a specific tape applied at the direction of mobilization to maintain the correct position.

3. Exercises:

► Exercises by the supervision of the therapist:   

• Single leg balance:

 The patient is asked to raise one foot from the floor while balancing on the other leg, and hold for 3 seconds. Start by raising the affected foot and balancing over the sound leg then progress to stand on the affected leg.

• Single leg balance with crossed arms:

This is a progression of the single leg balance exercise to increase its difficulty. It’s the same position as above but with arm crossed.

• Single leg balance with closed eyes:

This is the next progression of the single leg balance exercise. The same position as the previous exercise but with closed eyes to increase the difficulty of the exercise because  vision is one of the senses of balance.

• On foam mattress:

The same progression as the previous exercises but on the foam mattress. The foam mattress services as an unstable surface which challenges the proprioceptive system and thus increase the stability.

• Again on the firm surface:

The therapist will throw a ball while the patient is standing on a single leg and try to catch the ball and throw it back to the therapist to increase the difficulty of the exercise. The therapist may use the balance board as a progression.

►Home exercises for the patient:

•  Ankle strengthening exercises with Thera band:

There are different  colours of Thera band with different resistance. The yellow colour of Thera band is the lightest one, so this is the one to start the exercise with and then proceed to the other colours respectively.

• For planter-flexion and dorsiflexion:

The patient will be sitting  with his legs stretched in front of him and prop a rolled towel underneath his ankle (specifically under the Achilles tendon) to make the movement of the ankle easier.

Then make a little loop at the end of the band and place it around the foot of the affected ankle (specifically around the balls of the foot)  and hold the other end with the hand of the same side to have a good resistance.

 Then the patient has to move his foot backward away from his body slowly as far as he can while giving himself resistance with his hand that is holding the band by pulling it towards his body and then come back by moving his foot forward towards his body slowly as far as he can.

The repetitions for this exercise are 10 to 15 at beginning and then progress to 20 to 25.

• For eversion:

The patient has to place the band in the inside of the foot by the big toe and then wrap the band around the other foot. The patient has to move the ankle out slowly as far as he can while his hand that is holding the band is giving resistance by pulling the band towards his body.

His other hand is stabilizing his leg to avoid moving his leg instead of his ankle. The repetitions for this exercise are 10 to 15 at beginning and then progress to 20 to 25. 

• For inversion:

The patient has to cross his leg over so his sound ankle is above the injured one and place the band around the ball of the foot so the knot of the loop is towards the little toe  and then wrap the band around the other foot.

The patient has to move his injured foot away from the other foot slowly while giving himself resistance with the hand that is holding the band. The repetitions for this exercise are 10 to 15 at beginning and then progress to 20 to 25.

Also read:  PLANTAR FASCIITIS PROTOCOL

References:

1.  Fong, D. T., Chan, Y. Y., Mok, K. M., Yung, P. S., & Chan, K. M. (2009). Understanding acute ankle ligamentous sprain injury in sports. BMC Sports Science, Medicine and Rehabilitation, 1(1), 14.

2. Chan, K. W., Ding, B. C., &Mroczek, K. J. (2011). Acute and Chronic lateral ankle instability in the athlete. Bulletin of theNY ospital for joint diseases, 69(1), 17.

3. Golanó, P., Vega, J., De Leeuw, P. A., Malagelada, F., Manzanares, M. C., Götzens, V., & Van Dijk, C. N. (2010). Anatomy of the ankle ligaments: a pictorial essay. Knee Surgery, Sports Traumatology, Arthroscopy, 18(5), 557-569.

4. Kobayashi, T., Tanaka, M., & Shida, M. (2016). Intrinsic risk factors of lateral ankle sprain: a systematic review and meta analysis. Sports health, 8(2), 190-193.

5. Petersen, W., Rembitzki, I. V., Koppenburg, A. G., Ellermann, A., Liebau, C., Brüggemann, G. P., & Best, R. (2013). Treatment of acute ankle ligament injuries: a systematic review. Archives of orthopaedic and trauma surgery, 133(8), 1129-1141.

6. McGovern, R. P., & Martin, R. L. (2016). Managing ankle ligament sprains and tears: current opinion. Open access journal of sports medicine, 7, 33.

7. Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72-73.

8. Mau, H., & Baker, R. T. (2014). A MODIFIED MOBILIZATION-WITH-MOVEMENT TO TREAT A LATERAL ANKLE SPRAIN. International journal of sports physical therapy, 9(4), 540.

9. Chaiwanichsiri, D., Lorprayoon, E., &Noomanoch, L. (2005). Star excursion balance training: effects on ankle functional stability after ankle sprain. ASSOCIATION OF THAILAND, 88, S90. JOURNAL-MEDICAL 7.