The latest research about
returning to sport after a sprained ankle.
Back in the day, the acute management of sprained ankle was to walk it off. People don’t tend to realise how bad an ankle sprain can be. Often times you’ll see people roll their ankle and keep playing or carrying on walking. It was just the way people dealt with an injury they. The management protocol has evolved greatly since those times. With an increased awareness of chronic pain and instability issues (not to mention the estimate annual costs due to ankle sprains), the rehabilitation of the injured ankle is now a bit more evidence based. An ankle sprain is an injury to a ligament; The Anterior Talofibular Ligament is the most commonly injured ligament of the ankle. It sits just in front of the lateral malleolus of the ankle. Ligament sprains are classified or graded as I, II or III according to severity.
- When there is only stretching of the ligament, this is considered a grade 1. There is usually mild or no swelling, small changes to the range of motion of the joint, and mild pain
- A partial tear is diagnosed as a grade 2. There is usually mild to moderate swelling, more joint laxity and feelings of instability, and moderate levels of pain.
- Grade 3 sprains are diagnosed with the complete rupture of the ligament. There is a lot more laxity and instability of the joint, large amounts of swelling, and severe or no pain due to a possible rupturing of nerve fibres in the ligament – therefor no pain signals sent to the brain.
Symptoms of an ankle
Pain, swelling and
difficulty weight bearing are common symptoms. Understanding the mechanism of
injury can also lead to a faster diagnosis. A lot of ankle sprains occur on
un-even ground or by landing from height onto someone else’s foot and inverting
the foot. These symptoms as well as a progressive loss in dynamic balance can
persist in instances where the ankle is poorly rehabilitated or when
rehabilitation is incomplete.
Treatment of an ankle
Today, in the acute stage
of an ankle injury, we are more likely to follow the RICER regime: Rest, Ice, Compression,
Elevation and Referral to a health professional. A recent study in the British
Medical Journal (Bleakely et.al, 2010) challenged this method with an
accelerated protocol for treatment involving supervised early exercise. Despite
the small sample size, the study did conclude that the group that received the
exercise protocol were more active earlier. There was however, no difference in
re-injury rates. If there is a large amount of swelling present at the time, a
sports trainer or physiotherapist can apply an “open basket” taping manoeuvre
which uses the compression of the tape to push the swelling back up the ankle
into the body’s circulation to be disposed of naturally. Once the athlete
returns to sport, taping has still been shown to reduce the risk of re-injury.
There is no research to suggest taping an ankle without any history of injury
will prevent or lower the risk of re-injury.
Beyond the acute stage, manual
therapy performed by a physiotherapist can offer a short-term reduction in pain
and an improvement in range of motion allowing pain free exercise. (Cosby et,al
2011). It is a well-known fact in the rehabilitation scene, that proprioceptive
training reduces the recurrence of injury. An ankle strength program designed
by a physiotherapist to rebuild strength in the joint is also very effective to
reduce re-injury. There is also some evidence to support unsupervised
proprioceptive exercises at home for reducing self-reported symptoms of
re-injury. (Hupperrets et.al 2009).
Risk of re-injury
While it is hard to predict
re-injury rates, the research offers some insight into who might be more prone
to re-injury. A study by Malliaropoulus et.al (2009) conducted on a population
of elite track and field athletes. They discovered that those with low-grade
injuries were more likely to re-injure themselves than those with grade 3
injuries! The fact is that ankle sprains are common. A large fraction of them
either re-sprain or do not resolve completely in a year. The latest research
(Middelkoop et.al, 2012) discovered that the self reported symptoms of pain at
rest and re-sprains at three months is a predictor for incomplete recovery at
one year! Sometimes a sprained ankle can start to get better over a few weeks
but then progressively worsen. If so, it’s imperative to get an MRI or X-ray
due to the possibility of a bony fragment being caught in the joint.
Complete recovery from an
ankle sprain means that the injured ankle feels and works the same or better
than at pre-injury level. That includes feeling pain free with all daily
activities and sport. This also means experiencing no swelling, stiffness or
feeling of instability. Sufficient functional balance is also important. As an
athlete recovering from an ankle sprain, it is important to be aware of any
residual symptoms of discomfort that may affect your return to sport. It’s
important to note that muscle injuries take a week or two to heal while ligament
injuries can take months to years to fully heal. This proves the importance of
If in doubt, do consult your Pivotal Motion Physiotherapist! Call 3352 5116 to make an appointment today.
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