THE PROBLEM IS COMMON WORLDWIDE
Ankle injuries happen all the time and they keep physios and doctors in general practice and emergency departments around the world really-really-really busy. They equate to 90% of trauma to ankles. I bet you didn’t know that it is estimated that everyday in the UK there is 5,000 ankle sprains and in the US there is 23,000 – Holy Crap!
Those in Scandinavia who sprain an ankle constitute 7-10% of those examined in hospital emergency, and 3% in the UK hospital emergency departments, 20% of those attending Orthopedic outpatient departments and 6% of a physiotherapists case load at any one time.
Well what about the incidence of ankle sprain in Australia. I don’t actually know the real answer to this. With summer fast approaching flip flops and bare feet will be back in vogue. And in spring-summer women will be getting all dolled up in some slightly to highest of high heels. The most common age group to spraining an ankle are < 35 years and it typically occurs playing sports such as netball, dance, basketball, soccer and loads more.
A lateral ankle sprain is always traumatic. Of those attending accident and emergency departments, between 16% and 30% have sustained a fracture. Doctors and Physios are experts at identifying who may require imaging such as an xray, Ultrasound or CT to determine the extent of the injury.
Although the “sprained ankle” is a relatively benign injury, inadequate rehabilitation can lead to a chronically painful ankle, reduced functional ability and increased likelihood of re-injury.THE PROBLEM IS RECURRENT (I.E CAN KEEP HAPPENING)
Figure 1: appearance of bruising in the first 3-7 days of an ankle ligament tear
Figure 2: Bones and ligaments of the outer ankle injured in an ankle ligament tear
The most common sites of soft tissue ankle sprains are the ATFL (Anterior Talo-Fibular Ligament), with more severe trauma also involving the CFL (Calcaneo-Fibular Ligament). It is important to note that when you tear a ligament the location of the tear will not grow back in its original cell state. That is, a ligament will not regrow ligament cells. The ligament tear will fill up with scar tissue. Scar tissue is the poorer and less sturdy partner in crime. Scar tissue in its infancy has an awesome tendency to realign to the lines of stretch. It also has a natural history of wanting to contract (shorten). These are the two VITAL reasons for early physiotherapy (mobility of soft tissues and stretching in the right planes of motion).
It is also why once you have sprained your ankle ligaments you are TWICE as likely to have a recurrent ankle sprain. The 3rd VITAL reason for getting this condition thoroughly rehabilitated is that the ankle ligaments role is to send information to the brain about what is happening in the ankle at every second of the day. For example when you stretch the ligament because you are walking on the soft sand this summer, the reason you would not sprain and tear the ligament is that the brain as a reflex sends information back down to the surrounding muscles and tendons to contract to brace and protect the ligament from stretching too far (smart). So when the ligament is torn (even slightly torn), it affects the quality and quantity of this information about your ‘exact GPS’ ankle position reaching the brain. So if your GPS is out of whack even slightly you might twist the ankle again, and again and again. The brain will actually mask this reduction of information by relying more heavily on your other senses such as vision. All of this leads to poorer ankle stability, body balance and commonly ‘respraining’ the ligament. Vicious circle huh?
Hubbard-Turner, T., Wikstrom, E. A., Guderian, S., & Turner, M. J. (2015) recently published the impact of a single ankle sprain in mice. There results showed that a single ankle sprain episode significantly decreases physical activity across the lifespan in mice. This decrease in physical activity can potentially lead to the development of numerous chronic diseases. An ankle sprain thus has the potential to lead to significant long term health risks if not treated and rehabilitated appropriately.
Hupperets, M. D., Verhagen, E. A., & Van Mechelen, W. (2009) researched the use of an 8 week proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences. This proprioceptive training was very beneficial in athletes whose original sprain was not medically treated. During the one year follow-up, 145 athletes reported a recurrent ankle sprain: 56 (22%) in the intervention group and 89 (33%) in the control group. The programme was associated with a 35% reduction in risk of recurrence. Analysis showed significantly fewer recurrent ankle sprains in the intervention than in the control group.
MANAGEMENT OF LIGAMENT RUPTURES AND SPRAINS
The evidence provided by the medical world out there points very strongly and clearly toward conservative treatment with early functional rehabilitation. Early mobilisation compared with immobilisation in a plaster offers the most rapid return to normal functional activity. Get to your physio straight away for an ideal outcome, waiting a few weeks or months will likely mean that we are working with ‘matured’ thicker scar tissue which offers us a poorer starting point, increasing the likelihood of more treatment sessions and a poor outcome.AN IDEAL PHYSIOTHERAPY TREATMENT PLAN WOULD LOOK LIKE THIS:
Week 1-3 Short period of protection (in a boot or brace) + RICE Protocol à Early weightbearing (+/- crutches) + range of motion exercises
Ice in the first 3 days is as effective as NSAIDs (Neurofen/Voltaren/Celebrex/Mobic) at reducing the pain and swelling. There is limited evidence to support the use of 80’s machines such as ultrasound and TENs units.
Week 2-6+ à Neuromuscular (strength/balance/proprioception) training. 75%-100% of patients will have a good outcome at 1 year post injury.
Homework from bounceREHAB If patients are seen early by bounceREHAB, management progresses through the following rough stages:
Day 1 – RICE à Rest Ice Compression Elevation
Day 2 – RICE + non weight bearing movements (NWB) + walking
Week 1 – NWB movements + isometric exercises + possible early weight bearing (WB) exercises
Week 2 – WB exercises + stretching exercises + early balance exercises
Week 3 – Progress WB exercises + stretching + balance + strengthening exercises
Week 4 – Functional rehabilitation + eyes open/closed
The exact time scale for patient progress depends on the severity of the injury and their responses to the exercise. Exercises need to stress the damaged ligament using a safe and specific progression of forces, often this will cause some pain and discomfort. This routine helps to strengthen and remodel the scar tissue and will significantly reduce the future risk of ankle sprains from occurring.
1. Immediate physiotherapy session with all acute ankle sprains (first 2 weeks is ideal) 2. Functional retraining for those of you that experience difficulty wearing high heels, walking up/down hills, walking or running sideways along a gradient (hill), pain and instability with jumping or running. 3. Anyone that notices difficulty standing on 1 leg (< 30seconds + no vestibular issues) 4. Those returning to work or sports and leisure activities on an uneven ground surface (such as sand, gravel, grass, bushland, golf course, high heels, thongs) need functional retraining with lot’s of homework. Perhaps even an ankle stabilising brace or strapping. Persistent problems of functional instability will be avoided in many patients if they are properly rehabilitated. Don’t ignore the evidence !
bounceREHAB hire and sell– Immobilisation boots, Crutches, Braces, Compression garments, Wobble boards, Inversion sticks, Magnesium cream, Anti-Flamme creams, Portable microcurrent and EPRT for collagen synthesis, Rocktape and other sports strapping to get back to running. Call now on (02) 9571 7606
www.bouncerehab.com.au or call (02) 9571 7606 for more information.
Matthew Craig B.App.Sci. (Physiotherapy), CSCS (Strength and Conditioning Specialist)
References: Hubbard-Turner, T., Wikstrom, E. A., Guderian, S., & Turner, M. J. (2015). An Acute Lateral Ankle Sprain Significantly Decreases Physical Activity across the Lifespan. Journal of sports science & medicine, 14(3), 556.
Hupperets, M. D., Verhagen, E. A., & Van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. Bmj, 339.