Ankle Sprain

Causes of Ankle Sprain

Ankle sprain is a very common injury, not only in professional or amateur sports but also during everyday household activities. This is mainly due to the complex structure of the ankle joint, which includes an intricate ligamentous apparatus, and the numerous external forces that place the joint under strain during movement.

The risk of injury is often linked to activities requiring extensive twisting movements (e.g., playing tennis or basketball) or running on uneven terrain. An ankle sprain or twist occurs due to improper foot positioning during running, landing from a jump, or even walking. Additional risk factors include a history of prior injuries, muscle imbalance, proprioceptive deficits (impaired deep sensation), generalized ligament laxity, and abnormal foot biomechanics (e.g., flat feet).

An ankle sprain involves stretching or tearing of the ligaments along with damage to the joint capsule. The anterior talofibular ligament, which serves as the main stabilizer of the ankle joint, is the most commonly injured structure. Less frequently, particularly in severe injuries, the calcaneofibular ligament may also be damaged.

Types of ankle sprains:

• Lateral sprain: The sole of the foot twists inward, damaging the anterior talofibular ligament.
• Medial sprain: The sole of the foot twists outward, causing injury to the deltoid ligament.

Symptoms of a Sprained Ankle

An ankle sprain or midfoot sprain involves partial or complete damage to the capsuloligamentous structures of the ankle complex. Identifying the mechanism of the injury is crucial for accurate diagnosis. The severity of symptoms often depends on the extent of tissue damage.

Three-Grade Scale of Ankle Sprain Severity:

• Grade I Sprain: Stretching of the ligaments and joint capsule; mild pain, swelling, and restricted mobility; no instability.
• Grade II Sprain: Tearing of the joint capsule and partial ligament rupture; significant pain, pronounced swelling, partial instability, and limping gait.
• Grade III Sprain: Tearing of the joint capsule and complete ligament rupture; joint instability, severe swelling and pain, and difficulty walking.

The most common area of discomfort is the anterolateral part of the ankle joint, which may indicate damage to the anterior talofibular ligament.

An ankle sprain can be a serious injury. Given the complexity of such injuries, consulting an orthopedist, diagnostician, or physiotherapist is advisable to prevent further damage and expedite recovery.

Ankle Sprain – First Aid

As with other sports injuries, the first aid for an injured ankle joint involves the PRICE protocol. This approach is most commonly used for first-degree injuries, primarily for immediate treatment. However, it does not address the later stages of tissue healing.

PRICE Protocol:

P – Protection: Protect the injured area to prevent further damage.
R – Rest: Limit movement to allow strained tissues to rest and recover.
I – Ice: Apply cold compresses (preferably gel packs) to reduce swelling.
C – Compression: Use light compression to decrease inflammation and swelling.
E – Elevation: Elevate the limb above heart level to minimize swelling.

Another widely used post-injury protocol is POLICE, which introduces a strategy for managing the injury right from the initial days. This protocol emphasizes optimal loading to maintain the movement memory of the injured joint.

POLICE Protocol:

P – Protection: Protect the injury with orthopedic measures such as taping, including rigid taping to limit joint movement and prevent further damage.
OL – Optimal Loading: Gradual movement of the injured joint to promote tissue healing while staying within the pain threshold.
I – Ice: Similar to the PRICE protocol, although some sources suggest avoiding direct application of ice. The goal is to reduce metabolic activity by limiting blood flow to the cooled tissues. Extremely low temperatures applied for longer than 8 minutes may worsen swelling.
C – Compression: Apply gentle compression to reduce inflammation and swelling.
E – Elevation: Elevate the limb above the heart to limit swelling.

The PEACE & LOVE Protocol

Recently, there has been increasing discussion about another protocol called PEACE & LOVE, which consists of two phases:

PEACE (calm): Followed immediately after a soft tissue injury.
LOVE (care): Implemented in the days following the injury.

Phase I – PEACE

P – Protect: Limit movement for 2-3 days to minimize the risk of worsening the condition. Offload the injured tissues to reduce pain.
E – Elevation: As in the PRICE protocol, elevate the limb above the heart to reduce swelling and facilitate fluid drainage.
A – Avoid Anti-Inflammatories: Allow inflammation to aid in tissue regeneration. Suppressing this process with anti-inflammatory drugs or cryotherapy may hinder the formation of strong tissue.
C – Compression: Use elastic bandages or kinesiotaping to reduce swelling.
E – Education: Educate the patient about injury management. This is a crucial part of the treatment process, as the effectiveness of rehabilitation heavily relies on patient cooperation with the physiotherapist.

Phase II – LOVE

L – Load: Gradually load the injured joint, returning to daily activities within a pain-free range of motion.
O – Optimism: Maintain a positive attitude toward rehabilitation, as optimism, alongside patient education, is considered essential for proper recovery.
V – Vascularization: Stimulate the cardiovascular system to support the healing of musculoskeletal injuries.
E – Exercise: Engage in pain-free physical activity a few days after the injury to restore mobility, strength, and proprioception.

Additional Tips for Ankle Sprain Management

An injured person suspecting an ankle sprain should avoid activities that increase blood flow and swelling, such as:

Overloading the injured ankle joint.
Applying warming ointments or exposing the area to heat, such as hot baths.
Thorough diagnostics, including a physical examination, X-rays, and ultrasound, are essential in cases of ankle sprain. This helps determine the severity of the injury and rule out more serious complications, such as fractures, dislocations, or breaks.

Further Treatment
A sprained ankle often requires further treatment depending on the severity of the injury. If an orthopedic specialist rules out serious pathologies (e.g., fractures) through clinical examination and imaging, rehabilitation under a physiotherapist's guidance can begin immediately.

Rehabilitation involves implementing an individualized program with optimally tailored loads, accelerating the return to activity and protecting against future injuries. A sprained ankle becomes weaker and more prone to recurrent injuries without proper treatment.

Ankle Rehabilitation After Sprain

Rehabilitation of the ankle joint following a sprain initially focuses on pain reduction, swelling control, and restoring full range of motion in the joint. The next phase involves stabilization training, which aims to rebuild stability in the foot. However, it is important to note that when returning to sports after significant ankle joint damage, using a stabilizer at first is advisable. A sprained ankle should be well-supported.

Treatment for Ankle Sprain

Treatment of an ankle sprain or dislocation depends on the type and severity of the injury:

• Grade I Ankle Sprain (mildest form of ankle sprain): Cooling the joint, limiting movement, and wearing a stabilizer are recommended. Recovery typically takes about 10 days.
• Grade II Ankle Sprain: Cooling the joint, unloading the leg until the pain subsides, and using a stabilizer.
• Grade III Ankle Sprain (most severe form): Cooling, unloading the leg for approximately three weeks, and wearing a stabilizer for about six weeks. In this case, conservative treatment is often insufficient, and surgical intervention, such as ankle arthroscopy, may be required.

Rehabilitation After an Ankle Sprain

In most cases, physiotherapy is necessary after an ankle sprain. For Grade II and III injuries, ankle rehabilitation is recommended to restore full foot function. A physiotherapist will also demonstrate exercises that improve proprioception, overall stabilization, and reduce the risk of recurrent ankle sprains. It is crucial to remember that the ankle joint becomes more susceptible to future injuries, making adherence to medical advice and preventive care essential.

Key Rehabilitation Exercises

Rehabilitation following an ankle sprain relies on appropriately selected exercises, supervised by a physiotherapist or physician. The difficulty of exercises is tailored individually and progresses gradually depending on the recovery stage. Performing these exercises can help prevent further injuries.

Stabilization and Proprioception Exercises

• Static Exercises on Stable Surfaces:
  Begin by standing on one leg with eyes open, then progress to eyes closed. Additional variations include calf raises, half squats, or moving the other leg in various directions, often called "the four corners of the world."
• Static Exercises on Unstable Surfaces:
  Once the above exercises are mastered, repeat them on unstable surfaces such as a mat, cushion, sensory disk, Bosu ball, or trampoline.
• Dynamic Exercises on Stable Surfaces:
  Include forward and backward lunges, single-leg hops over low obstacles, or two-footed jumps landing on one leg. These exercises mimic functional movements and prepare the joint for daily loads.
• Dynamic Exercises on Unstable Surfaces:
  Perform lunges onto a cushion or balance disk, and jumps and hops onto mats or sensory cushions. These exercises are introduced in the final stages of rehabilitation.

Muscle Strengthening Exercises

• Strengthening the Peroneal Muscle Group:
  The peroneal muscles are overstretched during lateral subluxation, leading to improper function. Isolated strengthening of these muscles, both in contraction and during lengthening (eccentric movement), helps restore proper functionality. Moving the foot outward activates these muscles.
• Strengthening the Dorsiflexors (Anterior Tibial Group):
  These muscles assist in moving the foot outward. After a sprain, this movement may show deficits in range. Lifting the foot and toes upward activates these muscles.
• Strengthening the Calf Muscles:
  It is also essential to strengthen the calf muscles (gastrocnemius, soleus, posterior tibialis). Despite being overly tense, they may also exhibit weakness, impairing proper push-off during walking. Dysfunction of the posterior tibial muscle can lead to pain in its tendon on the medial side of the foot.

Restoring Proper Ankle Joint Function

After an ankle injury, reflexive offloading of the affected limb occurs, impacting larger muscle groups in the knee and hip joint areas. Detailed evaluation of movement quality and overall lower limb function through functional tests under physiotherapist supervision is critical. Addressing any imbalance before starting dynamic training is key.

How to Prevent Ankle Sprains

Ankle sprains (ankle joint injuries) are acute injuries, making full prevention challenging. However, focusing on general physical conditioning is crucial, as lack of stabilization and excessive trunk movements are risk factors. Training should target correcting muscle imbalances, improving stabilization of the entire lower limb, and refining movement patterns specific to the required functions.

The feet play a vital role in the locomotor system, bearing the body's weight and ensuring joint stability. The sole of the foot is a critical area that gathers information about terrain irregularities, enabling the nervous system to generate immediate muscle tension responses. Any abnormalities in the foot, such as flat feet, high arches, or heel valgus and varus, can affect the positioning of the knee, hip, and even the spine. Conversely, imbalances in areas like the hip can impact the ankle joint and foot.

Related Articles
Learn about other possible foot and ankle injuries.

References:

• Journal of Education, Health and Sport - "Kompleksowe postępowanie fizjoterapeutyczne w skręceniu stawu skokowego" - Paulina Brzezińska, Jan Mieszkowski - 2015
• "Skręcenie stawu skokowego i następstwa jego leczenia" - Monika Bilewicz, Robert Stebe, Anna Czerkies - 2012
• National Library of Medicine - "Acute Ankle Sprain" - Scott W. Melanson; Victoria L. Shuman.- 2022
• Sports-Health - "Ankle Sprain and Strain Signs and Symptoms" - Julia Bruene, MD - 2014