[vc_row][vc_column][vc_column_text]By Nick Petroski DPT, and Mike Valerio CSCS
While some injuries can be considered ‘sport specific’, think UCL injuries in baseball, ankle sprains are anything but that. Ankle injuries occur in all sports, and ankle sprains are by far the most common injury. Ligament injuries occur when ligaments are overloaded or exposed to demands greater than they can withstand the tissues will fail resulting in partial or complete discontinuities. After these discontinuities or ‘tears’ the body will try to heal itself through distinct cellular events.
An ankle sprain among collegiate athletes in the United States was the most reported injury, representing 15% of all injuries reported in the population (Herzog, Kerr, Marshall, & Wikstrom, 2019). Similar to college sports in the 2004 Olympic Games ankle sprains were among the most frequent injuries (Herzog, Kerr, Marshall, & Wikstrom, 2019). These stats not only show us that ankle sprains happen in a wide variety of sports but, it also shows that it would be irresponsible not to focus some attention on ankle and foot function because of such a high rate of injury. Not only is an ankle sprain at the top of the list of potential injuries, recurrent ankle sprains happen even more frequently. For example, 46% of acute ankle sprains that occurred in volleyball, 43% in American football, 28% in basketball, and 19% in soccer were recurrent injuries.Other researchers identified the proportion of recurrent ankle sprains as 12% to 47% (Herzog, Kerr, Marshall, & Wikstrom, 2019).
What’s Involved?
While the term ‘ankle sprain’ may seem consistent across all ankle injuries, they can actually be extremely complex and affect a wide variety of structures. The most common layman’s term for ankle sprains are ‘high’ ankle sprain, and ‘low’ ankle sprain. While these may be the most common they are not the only ankle sprain injuries, and they certainly can be confusing. The difference between a high and low ankle sprain is the area which is affected.
In a high ankle sprain the injured area actually isn’t part of the ankle joint at all. The injured area is slightly higher and the term describes an injury to the ligaments that connect the tibia and fibula, named the interosseous membrane, and three other ligaments that assist to stabilize the two bones. These types of ankle sprain make up 50%-75% of the ankle sprains in collision sports like football, rugby, and hockey.
As one may expect, these injuries occur after a high force to the ankle. Typically, these occur when the ankle structure is forcefully externally rotated, when another athlete comes in forceful contact with the player’s lower leg, or when a direct blow to the heel of the athlete. Obviously there will be pain accompanied by the sprain, and a lot of pain may occur when pushing off the toes during walking and when trying to pivot on the foot. The injured athlete may also experience bruising at the front of the leg, or have tenderness when the two leg bones are squeezed mid way up the lower leg.
While high ankle sprains are common, low ankle sprains are even more complex, and even more common. The complexity of low ankle sprains increases because there are a larger variety of ligaments that can be affected. As we noted, in the high ankle sprains there are typically two bones, and 4 ligaments involved in the injury. In the low ankle sprain, there are more structures affected and often these injuries are more complex. There is a potential involvement of 6 bones and a surplus of 10 ligaments. Most commonly, about 65% of cases involve isolated injury to the anterior talofibular ligament, another 20% of cases involve multiple lateral ankle ligaments and the remaining 15% of low ankle sprains involve ligaments on the medial aspect of the ankle.
Obviously athletes are most susceptible to low ankle sprains because of their need for cutting, change of direction, movements on unstable surfaces, and collision. There is significant research that athletes with a history of ankle injuries, impaired balance or localized ankle strength, and increased joint laxity have a higher risk of injury. For example, an overweight athlete with a prior ankle sprain is 19 times more likely to incur other ankle sprain than a control counterpart. This highlights the importance of rehab immediately after an ankle sprain.
Benefits of Ankle Strength and Mobility
With ankle sprains being one of the most common injuries in sports, reinjury rates are equally as high. Chronic Ankle Instability (CAI) is characterized by the laxity and mechanical instability of the ankle, interfering with activity (Herzog, Kerr, Marshall, & Wikstrom, 2019). CAI can develop after an initial ankle sprain, or from multiple injuries to the same area.
Although ankle sprains may be inevitable, putting yourself in the right position by developing strong and mobile ankles is something that is in our control. The first step towards preventing ankle sprains would be finding a program that focuses on musculoskeletal strengthening, balance, proprioception, and improving biomechanics. With a proper warm up that includes these 4 things it has been seen to have well-known benefits for preventing lower body injuries.
Proprioception, the sense of self-movement, force, body position and balance, have been shown to be effective in reducing ankle sprains. In a 6 prospective analysis of a balance-training program, ankle sprains were reduced by 81% (Herzog, Kerr, Marshall, & Wikstrom, 2019). Not only did they see an improvement from balance training they put together a trial that included a multistation proprioceptive exercise program that resulted in a 65% reduction in the odds of an ankle sprain (Herzog, Kerr, Marshall, & Wikstrom, 2019). This shows that training programs including proprioceptive programs are beneficial in reducing ankle sprains.
Goals of Initial Rehab
The old adage of letting it rest has worn out its welcome in the sports medicine world. In regards to ankle sprains, we would argue that ‘letting it rest’ is quite possibly the worst advice you can receive.
Healing takes place in three overlapping stages that range from minutes after the initial injury to months (or years) later. In the initial stages, blood will collect at the site of injury and platelet cells interact with a certain matrix to initiate a clot formation. At this growth factors are released to provide a platform for the healing cellular events to occur. One of the growth factors released aids in new blood vessel formation which promotes vascularity of the area and helps collagen and cartilage formation. This also allows cells to migrate to the injured tissue and remove debris and damaged cells. The tissue initially appears as disorganized scar tissue with more blood vessels, fat cells and inflammatory cells then normal ligament tissue. This is the point that highlights the importance of early physical therapy after a ligament sprain of any kind, specifically an ankle sprain. Without beginning the proper mobilization and movement parameters the newly laid collagen will be disorganized and smaller in diameter than typical ligament tissue. This will result in persistent dysfunction and structure of the ligament and could lead to further instability. If abnormalities persist, they can have profound impact on the joint biomechanics. As the ligament is properly stressed and mobilized it will become aligned with the long axis of the ligament and function as a typical ligament would. On the contrary, even fully remodeled scar tissue remains functionally different from normal tissue.
This process of tissue repair and remodeling can last months to years. It is important to provide applied load to the ligament so that it can adapt with functional improvements. Applying appropriate stress through the ligaments and surrounding muscle of the ankle is imperative in all stages of healing. Preparing the ligaments for increased load can decrease the laxity of the ligaments, and strengthen surrounding muscles which will assist in maintaining proper joint mechanics, muscle efficiency, and load distribution of the ankle joint.
Early exercises may include manual resistance, controlled active range of motion exercises and repetitive loading can have extremely beneficial effects and increase cellular synthetic and proliferative effects, increase strength, size and collagen content of the ligaments of the ankle. Early active range of motion exercises has been shown to form more connective tissue and result in stronger tissue than its counterparts. When the ankle is loaded early, cells within the sprained ligaments will detect tissue strains and respond by modifying the tissue.
Athletes who treated ankle sprains with movement earlier were able to return to sports quicker, and demonstrate higher long term stability of the ankle. Early loading and mobilization has also shown to decrease pain , swelling, stiffness, and decrease muscle atrophy. Carefully monitored, exercise, loading, mobilization and stress promotes the healing of injured ligaments.
An example of early stage rehab progressions for a lateral ankle sprain may look something like this:
Manually Loaded Eversion of the ankle from full inversion →High rep ankle eversion with band →Closed Chain Loading in ankle Inversion→compound movement with ankle in inversion
Return to Play
The return to play process after any injury, especially an ankle sprain is one that can have many ups and downs. This process is greatly impacted by how quickly someone can heal from the injury. Not exactly knowing how fast a person heals from certain injuries makes it difficult to precisely predict when the athlete can return to sport because everyone’s time table is different. This makes it crucial to not only have an in depth assessment when the athlete comes in but to revisit that same assessment and retest to see if improvements were made.
Objective improvements give us a good idea of where the athlete can be but it is still very important to slowly introduce high impact things like jumping and sprinting back into the program. Progressing slowly should allow the foot to build strength and allow the body to be reacclimated to absorbing and producing forces. This will not only build the necessary strength capabilities the athlete needs but will give this athlete confidence in that ankle.
When implementing jumping exercises it is very beneficial to start with something as simple as a bilateral drop jump off a small box. Starting with a box 6 inches and progressing to a 12 inch box can be helpful in teaching proper landing mechanics when the feet come in contact with the ground. After the athlete shows sufficiency in the bilateral depth jump, progressing to a unilateral depth jump following the same guidelines with box height will be a good place to go next. As the athlete continues to progress, the use of box jumps starting off with a shorter box bilaterally then eventually progressing to unilaterally would continue to strengthen the ankle while also building confidence within the athlete. Starting off with a smaller box first is the most ideal because it will lessen the distance the athlete has to descend and will lessen the impact while landing. The next step would be to implement more intense jumping exercises like depth jumps which are performed by jumping off box onto the ground and then immediately jumping as high as possible off ground. Jump progressions are essential to returning an athlete to sport after an ankle sprain but it is not always a linear progression. The progression comes at the athletes’ readiness.
During the return to play process it would be ideal to transition to sprinting to challenge the ankle at the highest intensity. It would be in the best interest of the athlete to start at a low total volume of sprinting keeping everything linear. As time goes on you can introduce some curved running starting with that same low total volume and keep their curves dull to start. Curved sprinting will challenge every aspect of the ankle as the curves get sharper and intensity increases. The return to play process is one that changes athlete to athlete and meeting them halfway is crucial to their return to sport.
Citations
Williams, G. N., & Allen, E. J. (2010). Rehabilitation of syndesmotic (high) ankle sprains. Sports Health: A Multidisciplinary Approach, 2(6), 460–470. https://doi.org/10.1177/1941738110384573
Houser, R. A. (n.d.). Ligament Injury and Healing: An Overview of Current Clinical Concepts. Journal of Prolotherapy.
Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical Aspects and Algorithmic Approach. World Journal of Orthopedics, 11(12), 534–558. https://doi.org/10.5312/wjo.v11.i12.534
Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical Aspects and Algorithmic Approach. World Journal of Orthopedics, 11(12), 534–558. https://doi.org/10.5312/wjo.v11.i12.534
LaPlaca, David A. PhD, CSCS1; Seedman, Joel PhD, CSCS2. The Importance of the Foot and Ankle in Athletic Performance. Strength and Conditioning Journal 43(3):p 67-79, June 2021. | DOI: 10.1519/SSC.0000000000000598
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