Photo credit Jeffrey F Lin
Ankle Injuries in Sport: The Immediate Treatment of a Simple Sprained Ankle:
A sprained ankle is probably one of the most frequently sustained injuries in sport and in everyday life.
A sprain is the medical term used to describe the tearing or partial tearing of a ligament; with a ligament defined as the structure which joins bone to bone.
Correct early management can make a huge difference and significantly reduce the recovery time after a ligamentous ankle sprain.
The vast majority of ankle sprains are sustained to the lateral, or outer, side of the ankle; with the ligament most affected being the Anterior Talo-Fibular Ligament, or ATFL as it is commonly referred to.
ATFL sprains are one of the most common lower limb injuries sustained in football, and were recorded as comprising 7% of all lower limb injuries surveyed in a UEFA injury study in 2009 (Ekstrand et al, 2011).
The functional anatomy of the ankle involves the talus, or ankle bone, which is a wedge-shaped bone articulating with the lower end of the tibia, or shin bone, and the lower part of the fibula. The tibia is a fully weight-bearing bone while the fibula is the long thin bone that runs down the outside of the leg.
The function of the fibula is essentially to provide the origins for the muscles that act on the foot and the lateral (or outside part) of the ankle including the ligamentous structures that support the joint.
The fibula is usually referred to as a non-weight bearing bone whose primary purpose is to provide attachments for the muscles of the calf and the lateral ligaments of the ankle and knee.
Because of the involvement of the fibula in the lateral ankle complex, some weight-bearing is inevitable and various authors have proposed that the exact extent of this varies between 6.7% (Takabe et al, 1984) and 17% (Wang et al, 1996) of body weight.
Although others may differ in opinion, some authors argue that the fibula bears no physical weight at all.
Below the talus sits the calcaneus, or heel bone, and the joint formed by the articulation between these two bones is known as the sub-talar joint. This is where the inversion, or ‘turning-in’ movement together with the opposite –eversion - occurs.
All the bones in the ankle complex are bound together by strong ligaments; of which the most frequently injured is the anterior talo-fibular ligament; or ATFL for short.
In the adult population, the ATFL has been found to have the lowest tensile strength of all the ankle ligaments and is the weakest in comparison to the others (Pincivero et al, 1993).
It is the combination of movements between the ankle and sub-talar joints that leads to ligamentous sprains.
Lateral ankle ligamentous sprains can occur either by indirect contact such as putting the foot in a divot on the pitch or by jumping and landing awkwardly.
These injuries can also be sustained through direct contact with an opponent; and in contact sports can occur frequently in training and matches.
Direct contact injuries are impossible to legislate for; and while the incidence of non-contact injuries can be just as difficult to predict, often associated injuries accompanying the actual ligamentous sprain itself can complicate issues further.
Fousekis at al (2003) looked at ankle injuries in soccer and found that a high percentage of these (17%) did not involve direct contact with an opponent. Players who had sustained previous ankle injuries leading to ankle instability were also deemed to be at a higher risk of recurrent ankle injuries in the future.
Most of the injuries to the lateral ankle complex involved the ATFL and these usually result from forced inversion movements combined with plantarflexion which leads to tissue damage, bleeding, inflammation, and swelling.
Lateral ankle sprains are often misdiagnosed in the early stages as several associated injuries can complicate matters.
Caine et al (2006) noted that in a series of studies, acute injuries to the growth plates accounted for 30% of adolescent sport injuries; most of which were reported as sprains, and not all of these were seen by a physician.
These are discussed in greater depth on the “Youth & Adolescent Injuries” page of this website.
Early stage injury management
In terms of basic injury management, all the available evidence suggests that the important period in treating any injury is during the immediate 48 – 72 hrs after the injury has been sustained.
During this period the body needs time for the injury to settle and for the acute period to pass. However, although we talk about the first 48 hrs being the important time, in reality this acute stage can last up until 5 – 7 days depending on the severity of the injury sustained.
During this early stage, the priorities in the treatment for all soft-tissue injuries are to relieve pain, limit swelling, and protect the body from further injury.
Acute injuries such as ankle sprains and muscle strains are very easily aggravated and not only need time to settle, they also need to be allowed time to settle without being exposed to the risk of further injury.
Protection from further damage, therefore, becomes the first priority in injury treatment.
Cold is required as opposed to heat at this stage, and ice is applied to relieve pain and reduce swelling. Ice has a sedative effect on nerve endings, and the resultant cold treatment also limits any swelling present.
If we take a typical ankle sprain, for example, the best thing to do is to apply an ice-pack as quickly as possible. This will relieve some of the pain and help to control any swelling.
In addition to applying ice in the acute stage, it’s also helpful to add some form of compression such as a light bandage to wrap around the injured area. Compression is applied to support the injured ankle in addition to assisting with controlling any swelling.
Since most ankle injuries typically swell within the first few hours of being sustained, applying a compression can be quite effective.
Finally, elevating the injured part uses gravity to assist recovery and allows any swelling to drain away from the injured area.
Using a “Game Ready” compression unit for the immediate management of injury
At professional level, though, the treatment modality of choice favoured by most clubs today is a piece of equipment called the ‘Game Ready Compression Unit’; which essentially provides high pressure cold compression which relieves pain and reduces swelling.
This can be used on other areas of the body; although the unit is particularly helpful in the management of injuries to the ankle and knee.
Using the ‘Game Ready’ machine really does reduce swelling and relieve pain far more effectively than in the days of the old ice-packs; thus justifying the break from the older, more traditional approach.
Nowadays, professional players will simply have their injuries assessed by the physios virtually as soon as they are sustained, and the ‘Game Ready’ compression unit will be applied immediately in order to maximise the required combination of cold and compression.
This helps an injury to respond at the right speed by meeting the essential components of early stage injury management.
Naturally, it’s vital to rest. By that, however, the emphasis is on resting from activities that are known to aggravate the injury such as running and excessive walking. It is still possible to keep mobile and get around but the key is in not doing anything to make things worse during the acute stage.
It is important, though, to keep the injured part moving. Gentle ankle movements in the elevated position will help to prevent the ankle from becoming stiff.
However, the actual movements themselves have to be quite specific. Moving the foot and ankle backwards and forwards without turning the ankle inwards or outwards will help to avoid the ankle becoming too stiff during the first 48 hours or so.
The ideal scenario involves using an “Aircast Boot” and crutches
Of course, the ideal scenario is to have the injured ankle placed in an Aircast boot together with the use of crutches; but not everyone has access to that sort of treatment.
Often referred to as an “Aircast Walker”, this is a protective plastic boot that contains an inflatable padded inner cushion that once applied, can be pumped up to provide support and protection to the injured part.
These pneumatic walker boots basically provide a cushion of air via an inflatable sleeve fitted inside a solid outer plastic shell; which provides compression and support to the ankle or foot without the usual constrictions that a normal plaster cast would have.
The inner lining can be inflated to a comfortable pressure which enables gradual compression to the injured tissues while the solid external casing gives protection from further injury to the ankle as a whole.
Being light and removable, these are also ideal for allowing players to train while injured and at the same time allowing the body weight to be taken through the ankle and foot.
This helps to increase the functional capability of the injured joint while at the same time avoiding compromising an injury further by unprotected movements.
At professional level, the combination of early applications of the Game Ready compression unit together with immobilising the foot in an Aircast walker and use of crutches has proved to be highly effective.
Replicating this at local level can be difficult but not impossible provided the basic principles of applying an ice pack to the injury as soon as possible together with some light compression can be adhered to. Supporting the ankle in elevation is essential.
So too is protection from further injury. It is not a good idea to apply ice for ten minutes to an injured ankle and then hobble for a quarter a mile! Neither is it a good idea to try to “run the injury off” as frequently referred to in sports commentaries.
Ankle inversion injuries are typically synonymous with some instability and attempting to run through these can lead to further injury.
The normal procedure following this type of injury is to concentrate on active rehabilitation aiming to restore movement ranges and improve strength and balance as the injury begins to heal. This is in direct contrast with the way in which severe ankle ligamentous sprains used to be immobilised in a cast.
Although this prevented any movement taking place and allowed ligaments to heal in a stable position, immobilisation often resulted in so much stiffness being present after removal of the cast that a longer period of active rehab was required.
Additionally, excess muscle wastage would take place as a direct result of the ankle being immobilised, and it took intensive training to get these back up to pre-injury strength levels.
Summary of injury management
In summary, therefore, following a soft-tissue inversion injury to the ankle, protection from further injury followed by ice, compression and elevation are the key factors applicable. Additionally, avoiding aggravating the injury by over-enthusiastic examination is an essential aspect of early stage injury management!
As with all injuries, correct examination and diagnosis is essential. Consultation with a doctor and / or visiting the Accident and Emergency Department of the nearest hospital is advised.
One of the first things that needs to be excluded when dealing with ankle injuries is the presence of a fracture; and this is discussed in the section dealing with the Ottawa Ankle Rules further down the page.
However, research shows that ligamentous sprains are often more difficult to deal with in reality than a straight-forward ankle fracture (Singh, 2003). In the early stages, the management of ankle fractures tends to be centred on the fracture alone as opposed to addressing the ligamentous damage that will have simultaneously occurred.
This can lead to delayed recovery unless all aspects of the injury are considered in the treatment plan.
Examination by a physician will provide appropriate guidance on whether X-rays or further investigation is indicated.
See the next page for fractures of the fibula which can be a complication of ankle injuries; together with the academic references...
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