ankle sprain treatment

Ankle sprains are among the most common sporting injuries. Most athletes, particularly in running and jumping sports, have had some experience with ankle sprains, whether it is themselves or fellow athletes. There is often a misconception that with a bit of rest you will be back on the field or court in a few weeks.

Athletes sustaining grade 1 and low grade 2 sprains usually recover – given sufficient rest – without recourse to specialist advice. This passive approach to rehabilitation is unlikely to do them any favours in the longer term, and if they apply the same recovery formula to higher-grade ligament sprains they will quickly run into problems.

Typically, they fail to manage the ankle correctly initially, and try to return to sport too early and without rehabilitating their injury. Secondary complications ensue. Only then will they consult a physiotherapist and expect them to magic up a quick fix – which we all know is not possible.

Inadequate rehabilitation

Brett Everyman (see box below) is a typical scenario that I’m sure we have all encountered. His case describes one of two classifications of the ‘difficult ankle’: inadequate rehabilitation. Athletes such as Brett will usually present with one or more of the following: hypomobility of the talocrural joint and subtalar joint; poor proprioception and muscle conditioning; persistent swelling and/or synovitis of the talocrural joint.

Subsequent excessive movement of the talus post-sprain can cause pain in the sinus tarsi, tarsal tunnel or plantar fascia. Posterior pain can also be present as a result of too much activity on a hypomobile talocrural joint. With rest, treatment and a graded return to activity, patients such as Brett will respond well. If the joint is quite irritated, always be cautious with the prognosis because it could take up to a couple of months to settle.

The case of Brett Everyman

Brett, 40, is a social basketball player. After jumping for a rebound he lands on an opponent’s foot and suffers a grade 2-minus anterior talofibular ligament sprain (the ATFL is the most commonly sprained lateral ligament). Brett puts ice on his ankle for 20 minutes, but only after he has had a couple of post-match beers with his team and a shower on returning home. The next morning he applies a bandage and goes off to work, hobbling around all day on his swollen ankle.

After two weeks of resting from sport and running, the ankle starts to feel quite good when Brett walks. He goes along to watch his team play, packing his gear just in case they need him. He manages 15 minutes on court, but still feels quite uncomfortable. He rests. A week later he tries again to play – unsuccessfully. Having rested for three weeks, Brett is by now bemused as to why his ankle remains so painful. He decides to get it looked at and books in to see a physio.

Brett now has a very stiff ankle joint with very limited dorsiflexion. He demonstrates significant tenderness over the ATFL and throughout the lateral aspect of the talocrural joint. His description of pain and tenderness are indicative of moderate synovitis. Brett has also started noticing pain medially and shows signs of tarsal tunnel irritation. Brett wants to be ‘good to go’ in two weeks for his semi-final and is shocked when the physio tells him that his ankle will take up to four weeks to settle down with treatment.

Severe trauma

The second classification is when the athlete suffers severe damage during the initial trauma that requires a prolonged recovery time or possibly surgery. Keep in mind that there will very often be more then one cause of persistent ankle pain after a severe sprain.

There are two key guidelines in dealing with this second category: using available resources to get the diagnosis right; and then setting a rehabilitation plan that is realistically time-framed. If these guidelines aren’t followed, the patient will become confused and frustrated as time passes, lacking an expectation as to their rate of improvement. This can obviously jeopardise the intended outcome.

To assess the ankle for the cause of ongoing symptoms is difficult. You must have a good knowledge of the differential diagnoses, be very accurate with your palpation to identify tenderness, know your special tests and be able to refer your client for further investigations when they show certain symptoms. The table on p5 demonstrates differential diagnoses and appropriate testing.

Once the diagnosis has been confirmed, a rehabilitation plan must be drawn up. Many of the above injuries require a significant period of rest, during which time the athlete’s motivation can be a problem.

Develop a timeline for return to sport and along the way set progressive goals for range of movement, proprioception and function (jogging, sprinting etc). This encourages the athlete to concentrate on aspects of their injury other then the pain. By setting progressive goals, you make their improvement evident and keep them in a positive state of mind. Be sure also to help the athlete maintain condition through cross-training.

Differential diagnosis	Investigations / special tests
Osteochondral fracture of the talar dome (Grade 1-4)	X-ray – will show if severe; bone scan, MRI – used to grade
Avulsion fracture of the base of the 5th metatarsal	X-ray
Fracture of the tibial plafond	Bone scan
Fracture of the posterior process of the talus or os trigonum	X-ray
Fracture of the lateral process of the talus	X-ray – mortise view
Fracture of the anterior process of the calcaneum	X-ray – oblique view; bone scan may be needed
Anterior inferior tibiofibular ligament sprain	Dorsiflexion with rotation of the foot; standing & twisting on the foot; X-ray – weight bearing, if severe, will show separation of tibia and fibular
Dislocation of the peroneal tendons	May dislocate on plantar-flexion
Anterior Impingement Syndrome (if previous multiple sprains)	X-ray while lunging – lateral view
Posterior Impingement Syndrome	Passive plantar-flexion with overpressure. If necessary, local anaesthetic into area and then retesting
Anterolateral impingement	Intermittent catching sensation, meniscoid lesion seen as grey discoloured tissue in anterolateral gutter during arthroscope
Rupture of tibialis posterior tendon	Flattened medial arch, unable to raise heel in standing, MRI
Sinus tarsi irritation	Monitoring effect of local anaesthetic injection into sinus tarsi
Chronic instability	Increased pain with unstable positions (eg, ball of foot standing) and high level activities, significant laxity on ligament tests
RSD/Complex Regional Pain Syndrome	Temperature and skin changes, X-ray – patchy areas of demineralisation; bone scan

Progressive goals: examples

i. ROM The most commonly restricted range of movement is dorsiflexion. A knee-to-wall test is an easy and effective way to measure this. The patient stands facing the wall with his/her foot flat and the end of the big toe a predetermined distance from the wall. The patient then has to bend the knee and push it towards the wall while keeping the heel on the ground and the foot straight. Range of movement can be compared to the other side and should be approximately 11 to 14cm. Make sure you use tests that can be measured and reproduced.

ii. Proprioception The three tests outlined below can be used as high-level, end-of-rehabilitation proprioception goals.

50 consecutive single-leg knee bends with eyes closed and no touch-downs with the other leg.
30 seconds single-leg balancing on ball of foot.
30 maximal hops while keeping inside a circle of 20cm diameter.

These tests are good for any athletes who have shown signs of chronic instability and for monitoring the endurance of the muscles around the ankle and foot area.

iii. Function For functional goals, you can set out markers in patterns and do sport-specific timed drills. Use your imagination to keep the athlete interested and determined.

Accurate assessment and effective planning of rehabilitation are the keys to making the ankle less difficult. The battle is half won if your level of understanding allows you to explain in simple terms to the patient why they are continuing to get pain. Show them some light at the end of the tunnel by setting goals and your job will become a whole lot easier.