ankle sprain

LATERAL ANKLE SPRAIN AN UPDATE

Shibli Nuhmani

Department of Rehabilitation SciencesJamia Hamdard University, Hamdard Nagar

New Delhi, India

Moazzam Hussain Khan

Jamia Millia Islamia UniversityNew Delhi, India

[email protected]

Received 4 September 2013Accepted 23 January 2014Published 12 March 2014

ABSTRACTAnkle sprain injuries are the most common injury sustained during sporting activities. One-sixth of allsports injury loss time is from ankle sprains. Each year, an estimated 1 million people present tophysicians with acute ankle injuries. Three-quarters of ankle injuries involve the lateral ligamentouscomplex, comprised of the anterior talobular ligament (ATFL), the calcaneobular ligament (CFL)and the posterior talobular ligament (PTFL). Lateral ankle sprains typically occur when the rearfootundergoes excessive supination on an externally rotated lower leg. The diagnosis of a sprain relies onthe medical history including symptoms, as well as making a differential diagnosis mainly in dis-tinguishing it from strains or bone fractures. Despite their prevalence in society, ankle sprains stillremain a difcult diagnostic and therapeutic challenge in the athlete, as well as in society in general.The high incidence of ligamentous ankle injuries requires clearly dened acute care and a broadknowledge of new methods in rehabilitation. In addition to rapid pain relief, the main objective oftreatment is to quickly restore the range of motion of the ankle without any major loss of proprio-ception, thereby restoring full activity as soon as possible. The purpose of this article is to review theanatomy, pathomechanics, investigation, diagnosis and management of lateral ankle sprains.

Keywords: Lateral ankle sprain; Lateral collateral ligaments; Functional rehabilitation.

*Correspondence to: Moazzam Hussain Khan, Jamia Millia Islamia (Central University), New Delhi, India. E-mail: [email protected]

Journal of Musculoskeletal Research, Vol. 16, No. 4 (2013) 1330003 (10 pages) World Scientic Publishing CompanyDOI: 10.1142/S0218957713300032

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INTRODUCTION

Injuries to the lateral ligaments of the anklecomplex are the most common musculo skeletalinjuries seen among the recreational and com-petitive athletes.21,44 It creates long-term dis-abilities. It has signicant impact on cost, athleticparticipation and activities of daily life.22

Since most sports activities involve running,jumping and turning, high stresses are often puton the joints of the lower limbs, including theankle. Hansen et al.23 reported that 67.3% of theirfootball players had sprained their ankles duringsports. Smith and Reischl49 reported that 70% oftheir basketball players had a history of anklesprain and 80% of them had multiple sprains.Chronic ankle problems such as chronic pain,muscular weaknesses and ease of giving waywere not uncommon for those athletes with ahistory of ankle sprain.19,50

Traditionally, the diagnosis of ankle sprain isbased on history and delayed physical examina-tion, 57 days after initial trauma.55 The mostcommon injury mechanisms are supination andadduction (called inversion) with the foot plantarexed. Any additional X-rays are used only toexclude other diagnoses, such as a fracture ordisturbance of the joint congruency, based on theOttawa ankle rules.2 Generally, the prognosis ofankle injuries is good, whatever treatment is fol-lowed.63 Zeegers has showed that at least 80% ofpatients in all compared treatment groups werefree of complaints after one year.42 However,there is still potential for improvement in 20% ofthese patients.

ANATOMY AND PATHOMECHANICS

The ankle joint comprises of three major artic-ulations: the talocrural joint, the subtalar jointand the distal tibiobular syndesmosis.25 Thetalocrural joint is also termed as the tibiotalarjoint or the mortise joint, and is formed by the

articulation of the dome of talus, the tibial pla-fond, the medial malleolus and the lateral mal-leolus. This joint, in isolation, behaves rather likea hinge joint that allows mainly plantarexionand dorsiexion. The bula extends further to thelateral malleolus than the tibia does to the medialmalleolus, thus creating a block to eversion.1

Such body feature mainly allows larger range ofinversion than eversion, thus, inversion sprainsare more common than eversion ones.24

The ligaments that surround the ankle jointconsist of the lateral collateral ligaments, syn-desmotic ligaments and the medial collateralligaments (MCLs). The lateral collateral liga-ments consist of the anterior talobular ligament(ATFL), calcaneobular ligament (CFL) and theposterior talobular ligament (PTFL).11,57 Gener-ally, the lateral collateral ligaments are weakerand more prone to injury than MCL. The ATFL isthe most frequently damaged lateral collateralligament followed by CFL and then PTFL whichis rarely injured. The ATFL extend from the an-terior portion of the distal bula stretching for-ward to insert on the talus. Its role in the anklemechanics is checking plantar exion and inver-sion of the ankle. Thus, it is these movements thatstress the ligaments most and cause it to bedamaged.27,31,53,60

The higher incidence of inversion trauma overeversion sprain injuries can be partially explainedby two anatomical considerations. First, is medialmalleolus is shorter than lateral malleolus whichallow the talus to invert than evert. Second, theligament structures on the lateral side of the jointoccur as a discrete fascicular bundle and thereforeare not strong as the broader, expansive deltoidligament on the medial side and hence rupture.

MECHANISM OF INJURY

Lateral ankle sprains most commonly occur dueto excessive supination of the rear foot about an

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externally rotated lower leg soon after initialcontact of the rear foot during gait or landingfrom a jump.3,18 The ATFL is the rst to rupturewith such forced inversion of the ankle. Ruptureof the ATFL is always associated with rupture ofthe joint capsule because the ligament is incor-porated into capsule.

Rupture of ATFL because of forced inversionallows the anterior subluxation of the talus out ofthe ankle mortise. Forced plantar exion incombination with adduction causes rupture ofthe ATFL, followed by partial rupture of CFL. Ifthe continued force is applied the CFL rupturescompletely followed by the rupture of PTFL.

CLASSIFICATION

Lateral ankle sprains are based on a grade 1 to 3classication. A grade 1 ankle sprain usuallyentails microscopic tearing of the ATFL. Symp-toms may include minimal swelling and pointtenderness directly over the ATFL; however,there is no instability, and the athlete can am-bulate with little or no pain. A grade 2 anklesprain involves microscopic tearing of a largercross-sectional portion of the ATFL. Symptomsmay include a broader region of point tendernessover the lateral aspect of the ankle, a painfullimp if able to ambulate and bruising and local-ized swelling due to tearing of the anterior jointcapsule, ATFL, and surrounding soft tissuestructures. A grade 3 ankle sprain entails acomplete rupture of the ATFL and may also in-volve microscopic or complete failure of the CFL.The PTFL is rarely injured during inversionankle sprains. Symptoms may include diffuseswelling that obliterates the margins of theAchilles tendon, inability to ambulate and ten-derness on the lateral and medial aspects of theankle joint.6,43,57

The following orthopedic tests may proveuseful in aiding diagnosis.4,5,28,37,40,45,51,62

Anterior drawer test: Stabilizing the tibiaand bula, the foot is held in 20 of plantarexion while the talus is drawn forward in theankle mortise. This tests the integrity of the ATFLand anterior joint capsule. A positive test resultwould be greater than 5mm of anterior motion ofthe STJ as compared with the noninjured ankle,and an audible clunk may be elicited. If the ankleis inverted while conducting the anterior drawertest, it also evaluates the integrity of the CFL.Talar tilt test: The ankle is held in anatomi-

cal position, and the talus is tilted into adductionand abduction. This primarily tests the integrityof the CFL when the foot is in a neutral position;when the test is performed with plantar exion, italso evaluates the integrity of the ATFL. A posi-tive test result would be 5 to 10 of increasedinversion as compared with the noninjured ankleand would be indicative of a tear of the CFL.External rotation test: Manual passive ex-

ternal rotation of the foot and ankle in a neutralor slightly dorsiexed position would widen theankle mortise. Pain over the distal syndesmosis ispositive for a syndesmotic injury.Tibia=fibula squeeze test: Result is positive

for a syndesmotic sprain if compression of thetibia and bula in the midcalf region producespain over the distal syndesmosis.

Stabilization test: Tape is applied around thedistal syndesmotic region for support. A positivetest result for syndesmotic injury would reducepain over the distal syndesmosis during ambu-lation or when performing a heel raise.

INVESTIGATION

Plane radiograph: Radiographs are taken to ruleout fracture of the medial and lateral malleoli, thetalus and the fth metatarsal layer.Stress radiograph: It is helpful in determin-

ing the completeness of the ligamentous tear ordetermining the presence of avulsed fragments of

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the bone. Traction forces are applied to the ankleto promote tilt or drawer effect and comparisonare made between injured and uninjured side.Arthrography: It is performed within 48 h of

the injury to evaluate multiple ligament injury.Tenography: It is used for detecting multiple

ligament rupture but an isolated ATFL injurycannot be detected by this technique.MRI: It is the highly reliable and accurate

imaging modality for evaluation of precise loca-tion and extends of partial to complete tear ofcollateral ligaments.

DIFFERENTIAL DIAGNOSIS

Medial ligament sprainSyndesmosis sprainBifurcate ligament injuryAchillus tendon rupturePeroneal tendon suluxation or dislocationFlexor hallucis longus injuryLateral periostitisOstrigonum injuryAnterior tibial tendon injuryFractures

MANAGEMENT

Acute phase: Early management includes rest,ice, compression and elevation (RICE). Cryo-therapy should be used immediately after theinjury. Heat should not be applied to an acutelyinjured ankle joint because it encourages swellingand inammation through hyperaemia.30 Cru-shed ice in a plastic bag may be applied to themedial and lateral ankle over a thin layer of cloth.Alternatively, the foot and ankle may be cooledby immersion in water at a temperature ofapproximately 12.7C (55F). The foot and ankleshould be cooled for approximately 20min everytwo to three h for the rst 48 h or until edemaand inammation have stabilized. Benets of

cryotherapy include a decrease in metabolismthat limits secondary hypoxic injury.30 In subacute phase, the goals include continued reduc-tion of swelling, inammation and pain whilesome motion strengthening and appropriatecontrolled weight bearing are started. The reha-bilitative phase focuses on improving strength,endurance, tolerance and weight bearing propri-oception.

Treatment modalities during functional reha-bilitation focus upon improving ankle mobiliza-tion and proprioception. The stationary bicycleand swimming can be useful to improve the anklerange of motion. Strengthening is begun onlyafter normal weight bearing and pain-free rangeof motion. Therapy focused on improving pro-prioception can utilize the tilt board and tram-poline as a means to increase balance andneuromuscular control. Boyce et al.10 reportedthat the use of an Aircast ankle brace producedsignicant improvement in ankle joint function in10 days and one month compared with an elasticsupport bandage. Madras and Barr34 reportedthat ankle disk training on wobble board wereeffective in enhancing single leg balance and re-ducing recurrent sprain injury, while Osborneand co-workers41 and Sheth and co-workers48

reported the effect of ankle disk training in en-hancing peroneal muscle reaction time. De Simoniand co-workers16 suggested that a 12-week pre-scription of orthosis was effective in improvingfunctional stability at the ankle joint. Recently,Christakou et al.13 suggested that imagery may beeffective in improving muscle endurance in therehabilitation of grade 2 ankle sprain.

Treatment of Grade 1 and 2 AnkleSprains for Which Types/Severityof Injuries?

The goals of therapy are to accentuate the normalhealing process and protect the ligament from


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further injury. The acronym PRICESMMS standsfor proprioception training, rest/modied activ-ity, ice, compression, elevation, stabilization,medications (nonsteroidal anti-inammatorydrugs), mobilization and strength training.12

These rehabilitation techniques should be appliedappropriately during each phase of treatment.Progression of the treatment plan depends onthe severity of injury, the patients response totherapy and the achievement of goals duringeach treatment phase.52,57

Acute Inammatory Phase (2472h)

. Ice therapy should be applied for 20min on/1hoff throughout the day, with a compressionbandage and the leg elevated above the heart.Cryotherapy reduces pain, edema and second-ary hypoxic damage to injured tissues.8,9,37,43

. Nonsteroidal anti-inammatory drugs, electricmuscle stimulation, pulsed ultrasound, anti-edema massage and low-level laser therapymay help in reducing inammation.43,47,57

. Ankle pumps, 10 to 20 pumps per hour, shouldbe conducted in a pain-free range to decreaseedema and increase circulation.57

. Ambulate weight bearing as tolerated withaxillary crutches if necessary. A semirigid or-thosis, laceup style brace or tape provides me-chanical joint stability in the frontal plane14,15

. Depending on the severity of injury, pain-freemodied activity can be used to maintain car-diovascular tness. Examples of modiedactivity may include deep-water pool running,swimming with a pool buoy between the legsor stationary cycling.7,35,57

. Several studies were conducted on grade 1 andgrade 2 ankle inversion injuries using manip-ulation of the TCJ. Two studies showed ma-nipulation of the talus in an anterior toposterior vector improved range of motion indorsiexion at the ankle mortise.20,32 Another

study showed that manipulation of the jointsand soft tissue improved dorsiexion as well asreduced pain and edema.17

. Active or passive soft tissue techniques such asActive Release Technique, Graston Technique,muscle energy technique and transverse fric-tion massage can be applied directly to theligament and surrounding soft tissue structuresto facilitate early ligament healing.

Numerous clinical studies support the use oftransverse friction massage in the treatment ofligament sprains.58 Recently, Loghmani andWarden33 conducted a study on instrument-assisted crossber massage (IACFM) and its ef-fect on ligament healing. Bilateral MCL injurieswere induced on the knees of 51 rodents. TheIACFM was commenced with a Graston hand-held tool on one of the rodents MCLs one weekpost injury, at a frequency of three sessions perweek and for duration of a minute. The contralateral MCL was used as the nontreated control.Histological sections were obtained four weekspost-injury. The scar region of the IACFM-treatedligaments, as compared with the contra-lateralnontreated ligaments, appeared to have greatercellularity; and the collagen bers appeared to bealigned more longitudinally. This study suggeststhat IACFM may accelerate early tissue-levelhealing.33

A more cautious approach to treatment may benecessary if there is suspicion of a grade 3 lateralankle sprain.57 In the opinion of one of the authors,if the initial examination reveals severe swelling,pain and inability to bear weight, the athleteshould be placed in a functional walking orthosisand instructed to ambulate with crutches in anonweight bearing gait. Nonsteroidal anti-in-ammatory drugs, ice, compression and elevationshould be used to attempt to reduce swelling andpain. A re-examination should be conducted threedays later. If there is no observable improvement,


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anMRI study should be used to assess the severityof injury. If the MRI indicates a completely tornligament, the athlete should continue to follow theabove regimen for approximately four more days,thereby allowing the retracted ligament ends toheal appropriately before progressing to the nextstage of treatment.

Reparative Phase (35 days, CollagenProduction Intensies 1014 days)

Goals include reducing inammation, facilitatingthe ligament healing process, restoring active andpassive ranges of motion, minimizing loss ofstrength, maintaining cardiovascular tness andstarting Propioceptive rehabilitation.7,46,57

. Joint mobilization and soft tissue techniquesof the TCJ and the STJ to free up joint restric-tions and aid in improving range ofmotion.17,20,32,43,57

. Passive stretch of the gastrocnemius and soleusmusculature with a towel, 3 sets of 30-s holds.Stretching on a slant board or with a pro-stretch can be incorporated when the patientcan at least partially bear weight with minimalpain.

. Isometric exercise should be conducted as soonas the patient can tolerate it to prevent muscleatrophy.47 Active and passive range of motioncan be conducted with minimal pain in dorsi-exion, plantar exion, eversion and the pain-free range of inversion. The therapist mayconduct 3 sets of 10 with a 3- to 5-s hold at thepassive end range. The patient can conductisometric exercises at home.

. Strengthen the peroneii, tibialis anterior andextensors, and the triceps surae with thera-Band, 3 sets of 10 to 15 reps for each musclegroup57 also strengthen the gluteus mediusmusculature to prevent lateral sway61 once thepatient can fully weight bear without pain, hecan add resistance greater than body weight as

tolerated. This may include standing andseated calf raises. If no weights are available,teach the patient to go up on the toes on bothfeet and then shift all the weight to the injuredside and lower down on that leg.

. Standing proprioception training can be con-ducted on the oor, a wobble board or an air-lled cushion. Start with single-leg standing ona at surface, 3 times with 30-s holds; useupper extremity support from a counter ifnecessary. Progress to eyes closed. Progress toexercises on an air-lled cushion. Have patientbalance on a wobble board for 30 to 60 s con-ducting various drills.35,56,59 Proprioceptiontraining has been shown to reduce the occur-rence and reoccurrence of ankle sprains38,54

. Proprioception training in the seated positionwith the biomechanical ankle platform system(BAPS) board.

. Shoe gear modication depending on theathletes foot structure and the playing sur-face.5

. At the end of each treatment session, applyice therapy and other modalities to controlInammation.43

The above exercises should be conducted rel-atively pain-free and progressed based on thepatients response to therapy and based on theprinciples of ligament healing. After demon-strating prociency in conducting the exercisesunder the supervision of a therapist, the patientcan be given a home exercise routine. If there isan excessive increase in swelling or pain, tem-porarily reduce the intensity or duration of theexercises followed by inammation control.

Remodeling Phase (1528 Days, 3 WeeksRegain 60% Strength, 3 Months Regain100% Strength)

Goals include restoration of tensile strength,proprioception and return to sport.46,57


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. Modied training may progress and includeactivities such as jumping rope, higher-intensitytraining runs or sprints.

. Incorporation of multidirectional agility drillscan begin at this stage. Start with controlledexercises that are on both legs; then progress tosingle leg. Progress to jumping over a height,such as a low cone. Progress to increasing inspeed. It is important to vary the speed andintensity of sport-specic exercises to continu-ally challenge the proprioceptive system.36 Allprogressions should be performed only as pain,comfort and stability allow.

Begin jumping forward and backward over aline.

Progress to jumping laterally over a line. Progress to box drills. Incorporate multidirectional sport-specicproprioceptive exercises.

After being discharged from care, the athleteshould be encouraged to continue a home exerciseprogram to ensure full restoration of impairmentsand to prevent reinjury. McHugh et al.39 hadfootball players with a history of ankle sprainsperform single-leg stance on a foam stability padfor 5min each leg. This was done ve days a weekfor four weeks of pre-season and two days a weekfor nine weeks during the season. This was theonly preventative exercise used and was done ontheir own. The study showed a 77% decrease ininjury incidence. A study by Hupperts et al.26

showed a similar decrease in injury risk with un-supervised exercises, demonstrating that a homeprogram can be an effective tool in rehabilitation.

Functional Treatment

Although the overall quality of studies on func-tional treatment is somewhat limited, a system-atic review of 21 trials (2184 total participants)showed that functional treatment is superior to

immobilization for treatment of ankle sprains.29

Five of the trials showed that, compared withimmobilization, more patients undergoing func-tional treatment returned to sports during thestudy period, and two trials showed that thesepatients returned to sports 4.6 days sooner (95%condence interval (CI), 1.5 to 7.6). Seven of thetrials showed that patients undergoing functionaltreatment returned to work 7.1 days sooner thanthose treated with immobilization (95% CI, 5.6 to8.7). Although the extent and type of benet as-sociated with functional treatment varied amongindividual studies, no benets were seen withimmobilization.

Functional treatment usually consists of threephases: (1) the PRICE protocol is initiated within24 h of injury to minimize pain and swelling andlimit the spread of injury; (2) exercises to restoremotion and strength usually begin within 48 to72 h of injury (see accompanying patient handoutfor exercise descriptions); and (3) endurancetraining, sport-specic drills and training toimprove balance begin when the second phase iswell underway.

CONCLUSION

This paper summarizes the current knowledge onlateral ankle sprain which is the one of the mostcommon sports related injury. An accurate diag-nosis and prompt treatment can minimize anathletes time lost from sport and prevent future reinjury. Key points of rehabilitation are control ofpain and swelling acutely with nonsteroidal anti-inammatories and RICE, then restoring normalrange of motion, strengthening muscle groupsand retraining proprioception of the ankle joint.

ACKNOWLEDGMENT

We represent that this submission is originalwork, and is not under consideration for publi-cation with any other journal.


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LATERAL ANKLE SPRAIN AN UPDATEINTRODUCTIONANATOMY AND PATHOMECHANICSMECHANISM OF INJURYCLASSIFICATIONINVESTIGATIONDIFFERENTIAL DIAGNOSISMANAGEMENTTreatment of Grade 1 and 2 Ankle Sprainsfor Which Types/Severity of Injuries?Acute Inflammatory Phase (2472h)Reparative Phase (35 days, Collagen Production Intensifies 1014 days)Remodeling Phase (1528 Days, 3 Weeks Regain 60% Strength, 3 Months Regain 100% Strength)Functional Treatment

CONCLUSIONACKNOWLEDGMENTReferences

ankle sprain

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