Returning to Sports After a Lateral Ankle Sprain
Have you rolled your ankle while playing sports or fallen over while walking in a pair of heels or on uneven surfaces. You might be surprised to hear that ankle sprains are one of the most common lower limb and sports injury we see in clinic. We commonly treat ankle injuries from sports including rugby, netball, basketball, soccer, hockey and touch rugby. A study by Newsman (2019) has found that the vast majority, between 85%-90% of ankle injuries are lateral ankle sprains. This is partially due to the relative weakness of the outer supporting ligaments and the ankle’s natural tendency to roll out into inversion (D’Hooghe, 2020). These injuries typically occur when your foot initially hits the ground or at the moment of landing from a jump.
Lateral ankle sprain is commonly known as “rolled ankle” (see picture below) involves overstretching or tearing of the supporting ligaments. There are three ligaments supporting the outer aspect of the ankle: anterior Talo-Fibular Ligament (ATFL), Calcaneofibular ligament (CFL) and posterior Talo-Fibular Ligament (PTFL).
Depending on the impact and forces involved during the incident different grades of injury to the ligaments can occur. These are classified into 3 grades:
Grade I: mild injury where ligament fibres are stretched without macroscopic tear
Clinical presentation and findings:
Mild swelling and light tenderness on palpation
Hardly any functional impairment or loss of movement
No increased of joint laxity on testing
Grade II: moderate injury including partial tearing of the ligament
Clinical presentation and findings:
Moderate swelling with some bruising and tenderness on palpation
Moderate loss of function, that is walking with limp or difficulty walking up and down stairs/ hills, pivoting off the foot.
Moderate laxity of the joint on assessment
Grade III: severe injury where there is a complete tear/rupture of the ligaments
Clinical presentation and findings:
Severe bruising, swelling and pain
Significant loss of function
Feeling of instability
Increased laxity of the joint on testing
What should I do after my ankle sprain?
Your aim is to minimise further injury and manage swelling and pain. Place some ice around the injured area, keep your shoe (closed shoes) on as it can act as compression until you can get home or A&E or to your physio for a compression sleeve/ tubi grip.
When can I start going to the physio?
We typically see these injuries a day or two after the incident. However we have also seen cases who have presented to the physio within the first 12 hours for compression and light taping for support. If there is concern about the local bone or structure to the ankle. Go straight to emergency care.
What can the physiotherapist do for my ankle sprain?
The physio will be able to assess the extent of injury using special tests to identify which ligaments are involved and/or stability of the joint. Once the grade of injury is determined we can provide treatment and rehabilitation plans for your return to sports.
Appropriate management for higher grade sprains is critical to reduce ongoing pain or niggles. In some cases, grade III injuries will require bracing to support and immobilise the joint for a short period of time allowing the injured tissue to heal. Inappropriate care may lead to inadequate healing or ligaments healed in a stretched state. What does this mean long term when you are returning to sports? Poorly healed ligaments can result in increased joint movement (mechanical laxity), which may lead to the development of chronic ankle instability. This is a common complaint we hear from clients who describe ongoing symptoms characterised by persistent pain, feeling of giving way, swelling and recurring ankle sprains a year or two after a significant ankle sprain.
The hard questioN - When can I return to sports after a sprained ankle?
You may have been told that it varies between 4 to 6 weeks or 8 - 10 weeks, or several months as it is dependant on the grade of ligament injury and the sports you play. The ankle joint is complex and bears a force of approximately five times your body weight during normal walking, and up to 13 times your body weight during high impact activities such as running (Brockett, & Chapman, 2016). Hence, the timeframes for each individual are different. As physiotherapists we can develop a treatment and rehab programme specific to your goals to safely get you back into playing the sports you love.
Bearing that in mind your rehab consists of different stages: initially the goal is to reduce pain and swelling and optimising your movement guided by your pain, the POLICE (Protect, Optimal Loading, Ice, Compression and Elevation) protocol. This is followed by joint range of movement, muscular strength, balance/ proprioception retraining. Once you have regained your joint movement and have adequate strength and sense of balance, light training drills including landing and/or side movements are incorporated before getting you back on the pitch for higher impact and agility re-training. Once you are able to demonstrate good joint and postural control without compensatory movements and pain we can gradually put you back to team training and eventually game time.
It is important to note that achieving each stage of your rehab is paramount because poor joint flexibility, or muscle strength, or balance may lead to compensatory movements elsewhere. Common presentations we see are knee pain due to the lack of ankle movement or lateral hip or knee pain as a result of weakness and poor balance response. To avoid these problems, which may present months later from the initial injury, a bit of effort is required from you during rehab.
Do I need strapping after an ankle sprain you may ask?
Strapping or bracing can be a good stepping stone as we start to get you back to agility training and or during the first few weeks of game time as it can be nerve wrecking being able to run on the ankle again.
Before I leave you!
It is reported that your risk of reinjury is 2 to 5 times greater if you had rolled your ankle once.
A high proportion (as much as 70%) of patients will suffer from repetitive lateral ankle sprains, and chronic symptoms after the initial injury. These ongoing symptoms will impair your functional ability and long term have an impact on the health of the joint, leaving you with the increased risk of increased risk of osteoarthritis (Hubbard & Wikstorm 2010). remember your ankle is a high force bearing joint as mentioned above “the ankle joint is complex and bears a force of approximately five times your body weight during normal walking, and up to 13 times your body weight during high impact activities such as running”.
Written by Jenny Chen (Physiotherapist)
M.R.S physiotherapy
Reference:
Brockett, C. L., & Chapman, G. J. (2016). Biomechanics of the ankle. Orthopaedics and trauma, 30(3), 232–238. https://doi.org/10.1016/j.mporth.2016.04.015
Chen, Eric T. MD1,2; McInnis, Kelly C. DO1,2,3; Borg-Stein, Joanne MD1,2,4 Ankle Sprains: Evaluation, Rehabilitation, and Prevention, Current Sports Medicine Reports: June 2019 - Volume 18 - Issue 6 - p 217-223 doi: 10.1249/JSR.0000000000000603
Hubbard, T. J., & Wikstrom, E. A. (2010). Ankle sprain: pathophysiology, predisposing factors, and management strategies. Open access journal of sports medicine, 1, 115–122. https://doi.org/10.2147/oajsm.s9060
Newsham, K. (2019) The Ubiquitous Lateral Ankle Sprain: Time to Reconsider Our Management? The Journal for Nurse Practitioners, 15(5), 343-346.e3. https://doi.org/10.1016/j.nurpra.2019.01.019
Wikstrom, E. A., Mueller, C., & Cain, M. (2020). Lack of Consensus on Return-to-Sport Criteria Following Lateral Ankle Sprain: A Systematic Review of Expert Opinions, Journal of Sport Rehabilitation, 29(2), 231-237. Retrieved Aug 17, 2020, from https://journals.humankinetics.com/view/journals/jsr/29/2/article-p231.xml