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Ankle Sprain

Ankle sprains are one of the most common musculoskeletal injuries, making up 85% of ankle injuries and 15-45% of all sports related injuries (Bleakley et al., 2010; Ferrn et al., 2006). Whilst most ankle sprains affect the lateral ligament complex secondary to plantarflexion-inversion mechanism, syndesmotic and medial ligament complex sprains may also occur. Injury to non-ligamentus structures must also be considered when an inability to weight-bear, gross swelling, loss or range of movement and significant ligamentus laxity is observed.

How bad is it?
Ligament injuries are graded based on ligamentous damage and morbility (pain). In a grade 1 sprain the ligament is stretched and few fibers are torn but no frank ligamentous disruption is present, whereas a grade 3 sprain implies complete disruption of the ligament and possibly a capsular tear that compromises stability (Malliaropoulos et al., 2008). In the instance of a lateral ankle sprain the Anterior Talofibular Ligament, Calcaneofibular Ligament and Posterior Talofibular Ligament are typically distrupted respectively.

Whilst all grades of sprain can impact on function and sporting performance in the short term, careful management and time to return to sport varies according to severity and can be anywhere between 1-24 weeks. Residual symptoms, chronic joint instability and recurrence can persist where rehab and management is insufficient, as reported in up to 30% of athletes. In this instance chronic ankle instability (CAI) is suspected where both mechanical instability (i.e. pathological laxity, impaired arthrokinetics and joint degenerative changes) and functional instability (altered neuromuscular control, strength deficits and deficit postural control) are manifest (Kaminski et al., 13). Consequently comprehensive assessment and treatment planning is paramount.

What does treatment involve?
On your initial assessment the degree of severity will be established and a management plan formulated with your Physiotherapist,  Chiropractor or Osteopath based on your mechanical and functional limitations, onset of injury, time elapsed since injury and rehabilitation goals. In the instance of a recurrent or a chronic injury particular attention will be paid to underlying intrinsic and extrinsic risk factors that may predispose compromised healing and a persistent problem. Intrinsic risk factors may include increased postural sway, decreased concentric inversion strength (Hiller et al 11); slower running speed, cardiovascular (CV) endurance, reduced DF and coordination have also been implicated. Extrinsic risk factors refer to training errors, inappropriate footwear and training drills. Each will be examined with your therapist.

Rehabilitation is crucial for the restoration of joint stability and dynamic ankle function. This will incorporate range of movement, strength and proprioceptive drills and functional recovery based on the inflammation, fibroblastic and remodelling phases of ligament healing.

Manual therapy may also be utilised as an adjunct to rehabilitation as a means of restoring normal arthrokinematic motion and improving function (Category B evidence; Kaminski et al., 13). Myofascial therapy alongside thrust and non thrust manipulation and exercise has been shown to further improve outcome compared with manipulation and exercise alone and may be utilised by your therapist Truylos- Domi et al. (13). A recent Cochrane review comparing surgical versus conservative treatment for acute ankle sprain showed both regimes to be equivocal (Kamper & Groothans., 2012)

When can I return to sport?
It is recognised that high-level athletes demand faster rehab whilst ensuring the prescribed rehab criteria is fulfilled to reduce risk of further injury.
There is consistent good quality evidence that functional rehabilitation is more effective than immobilization for grade 1 & 2 sprains (Kaminski et al., 13). A randomised control trial by Bleakley et al (10) showed improved ankle function in a group receiving an accelerated exercise protocol during the first week after ankle sprain compared to a standard PRICE intervention. This may be attributed to a reduction in arthrogenic muscle inhibition caused by pain and swelling where mechanical loading is an important modular of tissue repair.

Once range of movement, strength and proprioception have been restored functional performance testing will be used to assist return to play decision making. This may include plyometric exercises, single legged hop for distance and the star excursion balance test; before returning to sports specific task functional performance should measure a minimum of 80% of the uninjured side (Kaminski et al, 13).
There is moderate evidence that athletes with a previous history of ankle sprain may benefit from a prophylactic ankle support to reduce the risk of recurrent injury. A maintenance programme once rehabilitation is complete may also be required in order to avoid the problem reoccurring. Your therapist will be able to advise and guide you through each rehab stage and clinical trial return to sport.

Contributing Author
Zoe Browne MSc, BSc (Hons), MCSP, HCPC

References
Bleakley, C., O' Connor, S., Tulty, M. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964.
Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle
ligament complex. Foot Ankle Clin 2006; 11:659-62.
Kamper, S. ^ Grootjans, S. Cochrane systematic review: Surgical versus conservative treatment for acute ankle sprains. Br J Sports Med. 2012.46: 77-78
Malliaropoulos, N., Papalexandris, S., Papacostas, E., Maffulli. Acute lateral ankle sprains: healing processes and acceleration of rehabilitation. International Journal of Health Science. 2008.
Truyols-Domí, N., Salom-Moreno, J., Abian-Vicent, J., Cleland, J., Fernández-de-Las-Peñas, C. Efficacy of thrust and nonthrust manipulation and exercise with or without the addition of myofascial therapy for the management of acute inversion ankle sprain: a randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy [2013, 43(5):300-309]
Tully, M., Bleakley, C., O'Connor, S., McDonough, S. Functional management of ankle sprains: what volume and intensity of walking is undertaken in the first week postinjury. Br J Sports Med. 2012 Sep;46(12):877-82.