Lateral ankle ligament injuries, or twisted ankle as it is more commonly known is the most common acute injury to occur at the ankle. These injuries are caused by excessive ankle inversion (sole facing inwards) in a weight bearing position (walking, running, landing, etc). These injuries can occur at any time but are more likely to be seen throughout sports and activities such as, basketball, volleyball, netball, and football which require rapid changes in direction (especially on uneven surfaces) and jumping/landing (especially when landing on opponents feet).
General symptoms related to this injury include immediate pain, ankle weakness and stability, swelling (can be immediate or delayed), bruising (24-48 hours post injury), and ankle laxity with grade III tears (sever). Some lateral ankle ligament tears/sprains are also accompanied by an audible snap, crack, or tear which has been found to have no diagnostic significance. Depending on severity of the injury, pain and swelling may be present for up to a few weeks post injury but most minor injuries display quicker recovery times.
Treatment & Rehabilitation
Before treatment and rehabilitation commences it is important that you have been assessed by a therapist to identify the severity of the injury. Lateral ankle sprains/tears can be categorised into grades I-III, grade I being the most minor injury (small percentage of ligament fibres torn) and grade III being the most sever (complete rupture of ligaments). It is therefore not surprising that grade III tears require significantly more time to recover than grade I or II. An assessment is also important to rule out further related damage e.g. fracture (x-ray) or high ankle sprain (MRI) which would effect the rehabilitation process.
The management of all 3 grades follows the same principles. After minimising initial damage and reducing pain, the aims are to restore range of motion, muscle strength, proprioception, and progress into sport specific training.
Rest, ice, compression and elevation (RICE) are essential treatments in the initial stages of an ankle sprain. These treatments help reduce swelling and consequently restricted joint range of motion. Anything that promotes blood flow to the area should be avoided here (hot showers, heat rubs, excessive weight bearing). However, it is important to gradually increase weight bearing activity to improve ankle ROM.
Reduction of pain and swelling
After 48 hours, gentle soft tissue therapy and mobilisation may reduce pain. By reducing pain and swelling, muscle inhibition around the joint is minimised so that you can achieve greater ROM.
Restoring full ROM
After 48 hours, partial-full weight bearing walking should commence to help reduce swelling and encourage movement within the ankle. Additionally, passive and active mobilisation exercises can begin as soon as pain permits.
Active strengthening exercises working through all ranges of motion should also begin as soon as pain permits. All exercises should be progressive (increasing difficulty or resistance) with extra attention focussed on plantar flexion (toes pointing down) and eversion (foot turned out). Weight bearing activity is also beneficial for increasing strength.
Proprioception is impaired after ankle ligament injuries. Progressive proprioception training should begin early in rehabilitation and gradually increase in difficulty. Proprioception training generally involves weight bearing on an unstable surface to improve balance and stability at the ankle.
Functional exercises can be performed when the ankle is pain free, has full ROM, and adequate strength and proprioception. Specific technical training not only accelerates a persons return to full function but can also significantly reduce the risk of re-injury. Roughly 75% of those who have suffered an ankle ligament injury have had a previous injury, often that has not been fully rehabilitated.
Return to sport is permitted when functional exercises can be performed without pain during or after activity. However, anyone that has suffered a significant lateral ligament injury has an increased risk of injury recurrence for at least 6 months. Either taping/bracing and neuromuscular retraining are effective ways to reduce the increased risk of ankle sprain recurrences in the future. However, taping/bracing should be seen as a short term option while neuromuscular retraining is more of a long term option as it targets the underlying impairment by re-establishing and strengthening the ligaments, muscles, and protective reflexes of the ankle.
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