Definition

A musculoskeletal injury in which the ligaments of the ankle partially or completely tear due to sudden stretching.


Etiologic Considerations

Trauma—sporting injury, running (especially on uneven surfaces), activities involving rapid changes in direction, jumping and landing on another player’s foot. Volleyball, netball, all types of football or rugby codes.

Can occur in daily life, walking on unusual surfaces or stepping into a hole in the ground, “rolling the ankle.”


Predisposing Factors

Poor rehabilitation of previous ankle sprains, general hypermobility (lax ankle ligaments), impaired muscular coordination, alcohol.


Discussion

Ankle sprains are a very common condition to seek help for, in most cases it can be treated successfully on the sporting field or at home. The ligaments on the outside of the ankle are the most susceptible to injury, this happens when the ankle is forcefully rotated inward (inversion strain). As the ankle quickly moves inward, the lateral collateral ligaments are stretched beyond their limits and are torn. There are three grades of injury:

  • Grade 1 involves a partial tear of the anterior talofibular ligament or part of the calcaniofibular. The ankle will be sore and swollen, but there won’t be any accompanied joint laxity.
  • In grade 2 strains, a complete tear of the anterior talofibular ligament is common with significant damage to the calcaniofibular. Some laxity, but with a hard end-feel.
  • Grade 3 strains occur when all three ligaments are completely torn, significant joint laxity will be present, but the pain will be minimal.

Ankle Sprains GraphicA complete tear of the ligaments does not necessarily mean surgery; most cases will heal well over time, with the conservative approach outlined in this chapter. A 2002 Cochrane review found the outcomes from surgery were poorer than early mobilization.

At the time of injury a snap, crack, or pop may be heard; this sound has no indication to the degree of injury and does not necessarily indicate a fracture. A qualified practitioner (medical doctor, osteopath, physiotherapist, or naturopath) will examine the joint, palpate the ligaments, test for stability, and grade the degree of injury.

It is possible to strain the ligaments on the inside of the ankle, but this is much less common, due to the strong ligamentous support. Fracture and complete dislocation can occur, and if any of the signs below are present, you should seek emergency assistance.

When to seek emergency assistance (X-ray diagnosis needed)

  • Unable to walk and bear weight
  • Bone tenderness present when palpating over the medial malleolus or the base of the fifth metatarsal, indicating a fracture
  • Severe, uncontrolled pain
  • Ankle cannot be moved
  • Ankle or foot misshapen (beyond normal swelling)
  • Numbness in the foot
  • Persistent pain or instability, unresponsive to 6 weeks of conservative treatment

Most cases of ankle sprains are minor and can be resolved at home, without drugs or surgery, following a few simple guidelines.


Treatment

Initial Management—The First Twenty-four Hours

When the ligaments are torn, small blood vessels are damaged, leading to bleeding and swelling. The blood can accumulate around the damaged tissues and compress them, leading to secondary tissue damage by restricting fresh oxygen supply (hypoxic injury). Too much swelling can also irritate the joint capsule, leading to further joint restriction.

Initial management is designed to limit the swelling of the joint and is abbreviated to RICE (rest, ice, compression, elevation).

Rest

Immediately stop all activity. If the heart rate increases, the swelling will as well. If playing sport, come off the field immediately; it is not advisable to “play through the pain.”

Ice

The best method is to place ice in a wet tea towel, then put it directly on the outside of the ankle. Apply for 15 minutes every 1 to 2 hours. Gradually reduce use after 24 hours.

Compression

Compression reduces bleeding and swelling. Apply a bandage firmly wrapping around the mid-foot, then wrap up the ankle. It is important not to block the circulation.

Elevation

This reduces the accumulation of fluid in the tissues around the ankle. Lie on your back and raise the foot on a few pillows or a chair. Ensure the foot is above the level of the pelvis.

In the first 24 hours after the injury, it is important to avoid all factors that will increase the bleeding, including alcohol, heat rubs, hot baths, and intense physical activity. Strong massage should also be avoided at this stage. Women should avoid high-heeled shoes. Many allopathic doctors will prescribe NSAIDs, but their efficacy for ankle sprains has not been proven.

Secondary Management — After Forty-eight Hours

It is important to start weight bearing on the ankle as soon as possible after an injury. Prolonged immobility is detrimental to recovery. If crutches have been used, try placing more and more weight on the ankle, as this will help reduce the swelling and enhance the rehabilitation. You can gently massage the joint yourself, but it would be best to see a professional to start gentle joint mobilization.

Mobilization of the ankle into dorsiflexion. The practitioner grasps the heel and the top of the foot, then rhythmically rocks the ankle, encouraging the toes to move toward the patient’s head into dorsiflexion.

Mobilization-Eversion: Holding onto the forefoot, the practitioner rhythmically moves the patient’s ankle into eversion (toes moving up and outward, flattening the arch of the foot).

Restoring Full Joint Range of Motion

Start using the ankle more and begin full weight bearing as soon as possible. Protecting the joint with strapping, taping, or over-the-counter lace-up braces may help.

Start moving the ankle in all directions against gravity and focus on pulling the toes up, stretching the calf (dorsiflexion). Stationary cycling is a good way to help regain full mobility.

Muscle Restrengthening

When a joint is injured the muscles around become weaker through disuse atrophy. This process is surprisingly quick; a significant amount of muscle strength can be lost in forty-eight hours. It is very important to regain this strength and recover full use of the ankle. As soon as the pain allows, start to move the ankle against resistance. Using exercise bands (commonly available in sporting-good stores) is a great way to rehabilitate the ankle.

Exercise 1: Ensure the foot is fully plantar flexed (toe pointing), slowly and carefully pull the toes up and out against the resistance of the exercise band. Then control the foot as you bring it back to the starting position. Repeat 20 times.

Exercise 2: Wrap the exercise band around the forefoot and hold the other ends in hand. Point the toes (as if pressing on the gas pedal) against the resistance. Repeat 20 times.

Exercise 3: Tie the band around a firm anchor, like a table leg or pole. Have your foot inside the loop and pull the toes against the resistance. Repeat 20 times.

Regaining Balance — Proprioception

Inside the ligaments of the ankle are specialized receptors that help monitor the position of the joint. This effectively allows the body to know what angle we are placing the ankle in when we step. These receptors are invariably damaged in ankle sprains, leading to a deficit in ability to sense joint position. Therefore, it is much more likely to place the ankle in a rolled-in position and reinjure the ankle. It is vital to retrain this sense of joint position (proprioception) to prevent recurring ankle problems. Balance training can begin from 1 to 2 days after an injury.

  • Start by balancing on the injured foot.
  • Progress to balancing on the injured foot with your eyes closed. (This is much more difficult.) Try to maintain balance for a full minute.
  • Once you can balance for a full minute, it is time to add additional challenge in the form of an unstable surface. Place a pillow under the foot, then try balancing for 2 minutes with the eyes closed.
  • Try toe-to-heel walking for 5 minutes per day.
  • If available, start rocker/wobble board training or balancing exercises on a mini-trampoline.

Functional Exercises

The next step begins when all swelling has reduced, full range of motion and strength is restored, and balance and proprioception has been retrained. It is then time to start day-to-day (functional) and sport-specific training. This includes running, jumping, and figure-8 running. Once these functional and sport-specific exercises can be completed without pain, the ankle has been successfully rehabilitated and sporting persons can return to competition.

For sporting persons with grade 3 strains, taping or a brace should be worn for 6 to 12 months, especially during games.

Holistic Considerations

The whole body, person, and situation need to be considered for every medical problem. Ankle injuries can have a cascading effect on the body and can lead to knee, hip, and back pain. A therapist should treat these areas at the same time as the ankle. Particular importance should be paid to the psychological impact of the injury. Professional athletes, performers, and manual laborers may be concerned about the potential impact on their career and finances. It is helpful to reiterate that the vast majority of cases resolve without complication. Time off work or out of competition may be needed for full recovery, but if the injury is rehabilitated properly, they will most likely be able to return to the same level of competition or higher.

Excerpts from Better Health Through Natural Healing 3rd Edition

First published in 1985, Better Health through Natural Healing has become one of the most successful and authoritative resources of its type, with more than 1.5 million copies sold worldwide. Since the original publication of this comprehensive guide, alternative therapies have become more and more accepted by the mainstream, and patients and practitioners of the wider medical community are embracing complementary medicine as an effective treatment option for a range of medical conditions.

The book is available at the West End clinic, exclusively in Australia.


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