Sprained ankle
A sprained ankle is an injury where sprain occurs on one or more ligaments of the ankle. It is the most commonly occurring injury in sports, mainly in ball sports as well as racquet sports.
Ankle sprains are also among the most common acute dance injuries, often causing pain around the ankle and, in more severe cases, swelling and bruising.
Signs and symptoms
Knowing the symptoms that can be experienced with a sprain is important in determining that the injury is not really a break in the bone. When a sprain occurs, hematoma occurs within the tissue that surrounds the joint, causing a bruise. White blood cells responsible for inflammation migrate to the area, and blood flow increases as well. Along with this inflammation, swelling and pain is experienced. The nerves in the area become more sensitive when the injury is suffered, so pain is felt as throbbing and will worsen if there is pressure placed on the area. Warmth and redness are also seen as blood flow is increased. There is also decreased ability to move the joint.Cause
Movements – especially turning, and rolling of the foot – are the primary cause of an ankle sprain.The risk of a sprain is greatest during activities that involve explosive side-to-side motion, such as tennis, skateboarding or basketball. Sprained ankles can also occur during normal daily activities such as stepping off a curb or slipping on ice.
Returning to activity before the ligaments have fully healed may cause them to heal in a stretched position, resulting in less stability at the ankle joint. This can lead to a condition known as Chronic Ankle Instability, and an increased risk of ankle sprains.
The following factors can contribute to an increased risk of ankle sprains:
- Weak muscles/tendons that cross the ankle joint, especially the muscles of the lower leg that cross the outside, or lateral aspect of the ankle joint
- Weak or lax ligaments that join the bones of the ankle joint – this can be hereditary or due to overstretching of ligaments as a result of repetitive ankle sprains
- Inadequate joint proprioception ;
- Slow neuron muscular response to an off-balance position;
- Running or stepping on uneven surfaces;
- Shoes with inadequate heel support; and
- Wearing high-heeled shoes – due to the weak position of the ankle joint with an elevated heel, and a small base of support.
Diagnosis
The diagnosis of a sprain relies on the medical history, including symptoms, as well as making a differential diagnosis, mainly in distinguishing it from strains or bone fractures. The Ottawa ankle rule is a simple, widely used rule to help differentiate fractures of the ankle or mid-foot from other ankle injuries that do not require x-ray radiography. It has a sensitivity of nearly 100%, meaning that a patient who tests negative, according to the rule almost certainly does not have an ankle fracture. If ankle pain is persistent 6–8 weeks after initial sprain, MRI imaging of the joint can be considered to rule out peroneal tendon, osteochondral, or syndesmotic injury.Classification of severity
Ankle sprains are classified as grade 1, 2, or 3, and, depending on the amount of damage or the number of ligaments that are damaged, each sprain is classified from mild to severe. A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint. A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose. A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.Types
Inversion (lateral) ankle sprain
The most common type of ankle sprain occurs when the foot rolls inwards, or has a force, typically one's body weight, causing it to internally rotate beyond its normal range, affecting the lateral side of the ankle. When this type of ankle sprain happens, the outer, or lateral, ligaments are stretched too much. The anterior talofibular ligament is one of the most commonly involved ligaments in this type of sprain, followed by the calcaneofibular ligament and posterior talofibular ligament respectively, the latter found in more severe ankle sprains. Approximately 70–85% of ankle sprains are inversion injuries.When the ankle becomes inverted, the anterior talofibular and calcaneofibular ligaments are damaged. This is the most common ankle sprain.
Eversion (medial) ankle sprain
A less common type of ankle sprain is called an eversion injury, affecting the medial side of the foot. This happens when, instead of the ankle rotating medially resulting in an inversion injury, the ankle rotates laterally resulting in an eversion injury. When this occurs, the medial, or deltoid, ligament is strained.High (syndesmotic) ankle sprain
A high ankle sprain is an injury to the large ligaments above the ankle that join the two long bones of the lower leg, called the tibia and fibula. High ankle sprains commonly occur from a sudden and forceful outward twisting of the foot. This commonly occurs in contact and cutting sports such as football, rugby, ice hockey, roller derby, basketball, volleyball, lacrosse, softball, baseball, track, ultimate frisbee, soccer, tennis and badminton and horse riding.Treatment
Initial treatment commonly consists of rest, icing, compression and elevation. These elements have been recommended by physicians for decades for the treatment of soft tissue damage, and sprained ankles, one of the most common soft tissue injuries. RICE helps limit the amount of swelling to the area, and "facilitates venous and lymphatic drainage". While nearly universally accepted as a treatment, there is insufficient evidence to determine its relative effectiveness as therapy for acute ankle sprains in adults, and the National Athletic Trainers Association notes that most of the rationale for using RICE or individual components is based largely on low-quality clinical trials and laboratory studies with uninjured participants or animal models.For most ankle sprains, functional treatment is generally preferred over immobilization. Studies have shown patients return back to normal activities sooner when management is focused on restoring ankle function - typically by using braces, taping or elastic bandages, rather than complete immobilization such as a plaster casting. Functional treatment generally consists of three phases: the first is the RICE regime in the first 24 to 48 hours to reduce swelling and pain. The second phase is range of motion and ankle strengthening exercises within 48 to 72 hours. Finally the third phase involves progressive endurance and balance training during recovery.
The beginning of progressive exercise therapy must be made in the first week. RICE alone is no longer considered sufficient for full recovery from an ankle sprain.
Balance and Neuromuscular Training; Programs such as wobble board training, hopping exercises and single-leg balance with the help of balance reduce the recurrence rates of up to 40 and 50 percent.
Supervised vs. Home Rehab; Balance, strength and faster recovery to sport are always better in supervised rehab programs than in supervised home exercise.
Bracing for Prevention; The possibility of preventing reinjury with ankle braces is better than with taping, particularly in high-risk sports within the first 6 to 12 months.
Conservative measures
Ice is often used to reduce swelling in cycles of 15–20 minutes on and 20–30 minutes off. Icing an ankle too long can cause cold injuries, which is indicated by the area turning white. Also, it is often recommended that ice not be applied directly to the skin, but should have a thin buffer between the ice and the affected area, and some professionals think ice need not be applied at all. Recently, Gabe Mirkin, MD, who coined and popularized the acronym RICE in his The Sportsmedicine Book in 1978, no longer recommends "complete" rest or ice for healing a sprain. After reviewing modern studies, he notes that because ice closes off the blood vessels, "ice doesn't increase healing—it delays it," and "complete Rest may delay healing." He now advises skipping ice altogether unless needed to reduce pain from swelling. A small but growing number of doctors no longer recommend RICE for sprains.In uncomplicated lateral ankle sprains, swelling of the soft tissue can be prevented with compression around both malleoli, elevation of the injured ankle higher than the heart, and pain-free exercises.
An orthopedic walking boot is often used for the treatment of a sprained ankle injury. Braces and crutches are also used to help alleviate the pain so the injured ankle can heal as quickly and painlessly as possible.
Although found to be less effective than casts, compression bandages are used to provide support and compression for sprained ankles. Wrapping is started at the ball of the foot and slowly continued up to the base of the calf muscle; this allows the swelling to travel up toward the center of the body so that it does not gather in the foot. In addition, other external supports such as Kinesio taping does not "improve ankle functioning or performance in people with or without ankle injuries." The "current evidence does not support or encourage the use of Kinesio taping applied to the ankle for improvements in functional performance, regardless the population."