teamCSSM - Camberwell Sports and Spinal Medicine
I rolled my ankle, AGAIN!
Ankle sprains are the most common type of ankle injury and can account for up to 20% of all sporting injuries (Fong, Hong, Chan, Yung, & Chan, 2007). Poor management and insufficient rehabilitation can lead to recurrent ankle sprains, impairment of athletic performance (Yeung, Chan, So, & Yuan, 1994) and persistent disability (Petersen et al., 2013).
What happens when you roll your ankle?
An ankle sprain occurs when the foot rolls inwards, causing over stretching or tearing to the ligaments on the outside of the ankle.
Fig 1 Inversion injury of the ankle showing damage to the lateral ankle ligaments.
How bad is it?
There are 3 types of sprains which are defined by the extent of damage to the ligaments.
Grade 1: Stretched ligaments
Ligaments are stretched during a slight ankle roll. Common versions of this occur when running onto a patch of uneven grass or during an over step in tennis. You may immediately experience mild pain and a small limp. After a few minutes of rest, most people are usually able to continue their activity. Some swelling may occur within 24 hours and with appropriate management, you can expect return to preinjury state within 1-2 weeks.
Grade 2: Partial thickness tear of ligament
Ligament tearing occurs when the ankle rolls further than the ligaments can stretch. You may experience moderate pain, a limp and usually cannot continue to play. Swelling and bruising may occur within 24 hrs and weight baring is particularly painful. If you experience these symptoms, you should seek medical advice to determine the extent of damage. Depending on this, recovery can take between 2 – 6 weeks.
Grade 3: Complete rupture of ligament
Complete ligament rupture is a progression of grade two and occurs when the ankle has rolled beyond its normal limits. Initially, individuals are unable to walk on the effected ankle and can complain of it feeling “unstable”. Excess swelling and dark bruising would be expected 24 hours after injury. On a case by case basis, grade 3 sprains may require surgical intervention or up to 12 weeks of rehabilitation.
So you’ve sprained your ankle, what to do now?
After following the basic “RICE” principles (rest, ice, compress and elevation), you should seek medical advice from a physiotherapist as soon as possible. Physiotherapists are highly trained health professions who specialise in the assessment, diagnosis and management of ankle injuries.
What to expect when your see the physio?
Your physiotherapist will ask you questions regarding your injury and what symptoms you are experiencing. If pain allows, an assessment will be performed to diagnose your injury and explain the extent of damage. An accurate diagnosis is crucial in ensuring appropriate management and treatment can be provided. (Wolfe, Uhl, Mattacola, & McCluskey, 2001).
Firstly, pain and swelling management is commenced. This may involve icing, taping, bracing, crutches or a moon boot. Secondly, your physiotherapist will discuss your diagnosis and expected recovery time, as well as appropriate activity modification. Thirdly, pain free range of motion and strength exercises can commence. Fourthly, an individualised rehabilitation program will be developed and implemented. Goals and sport specific tasks will be incorporated once adequate function has been regained. Completion of your rehabilitation program results in positive outcome measures, optimal recovery and reduced risk of chronic ankle instability (Mattacola & Dwyer, 2002).
But don’t I need an x-ray?
Physiotherapists follow a set of guidelines called the Ottawa Ankle Rules that are used to determine whether a fracture is suspected (Ivins, 2006). These guidelines have an extremely high sensitivity and are used to reduce the number of unnecessary radiographs by 30-40% (Bachmann, Kolb, Koller, Steurer, & ter Riet, 2003) (Dowling et al., 2009). If your physiotherapist suspects a fracture, an x-ray will be organised.
Can I stop this from happening again?
Extensive research demonstrates that individuals who adhered to a rehabilitation program involving balance and proprioceptive training were significantly less likely to experience a recurrent ankle sprain (Petersen et al., 2013) (Hupperets, Verhagen, & van Mechelen, 2009) (Postle, Pak, & Smith, 2012). While the risk of re-injury can be reduced, unfortunately accidents can still happen.
Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ, 326(7386), 417. doi:10.1136/bmj.326.7386.417
Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P., & Wright, R. B. (2009). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med, 16(4), 277-287. doi:10.1111/j.1553-2712.2008.00333.x
Fong, D. T., Hong, Y., Chan, L. K., Yung, P. S., & Chan, K. M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Med, 37(1), 73-94.
Hupperets, M. D., Verhagen, E. A., & van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ, 339, b2684. doi:10.1136/bmj.b2684
Ivins, D. (2006). Acute ankle sprain: an update. Am Fam Physician, 74(10), 1714-1720.
Mattacola, C. G., & Dwyer, M. K. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train, 37(4), 413-429.
Petersen, W., Rembitzki, I. V., Koppenburg, A. G., Ellermann, A., Liebau, C., Bruggemann, G. P., & Best, R. (2013). Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg, 133(8), 1129-1141. doi:10.1007/s00402-013-1742-5
Postle, K., Pak, D., & Smith, T. O. (2012). Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis. Man Ther, 17(4), 285-291. doi:10.1016/j.math.2012.02.016
Wolfe, M. W., Uhl, T. L., Mattacola, C. G., & McCluskey, L. C. (2001). Management of ankle sprains. Am Fam Physician, 63(1), 93-104.
Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. Br J Sports Med, 28(2), 112-116.
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