Contents
Ankle Inversion Sprains
Ankle Eversion Sprains
High Ankle Sprain (Syndesmosis)
Ankle Inversion Sprain
Definition
Ankle inversion sprains are the most common sports trauma. They typically occur as the foot flexes downward (plantarflexion) and rolls in (inversion/supination). The outside (lateral) ankle ligamentous complex is typically damaged during an ankle inversion sprain. The outside stabilizing ligaments of the ankle are much more susceptible to injury and are much more commonly damaged in comparison to the stronger inside ligaments of the ankle. The outside ligamentous complex is comprised of three ligaments:
-
The anterior talofibular ligament (ATFL) is the most easily injured
-
The calcaneofibular ligament (CFL) may also be injured along with the ATFL during an ankle inversion sprain
-
The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured during an inversion sprain
Causes
Ankle inversion sprains are usually traumatic in nature. Ankle sprains can occur in a variety of different situations and everyone is vulnerable to these sprains. With that in mind, runners and anyone who have had a past history of ankle injuries are more predisposed to re-injury of that particular ankle.
Facts & Statistics
Symptoms
Symptoms of an ankle inversion sprain vary depending on the severity of the ankle sprain. The following is the break down of the various grades of injury:
-
Grade 1 sprain
- Mild injury, stretching ligament without any large amounts of tearing
- Mild pain
-
Grade 2 sprain
- Moderate injury, involves larger tearing of the ligament
- Moderate to severe amounts of pain, swelling, tenderness
- No instability of the joint
- Positive ligament stress tests for pain and mild-moderate laxity
-
Grade 3 sprain
- Severe injury, involves a complete rupture of the ligament
- Severe swelling
- Tenderness & pain varies from moderate to severe as a complete tear can be less painful than a partial tear
- Joint in unstable
- Positive ligament stress tests for laxity
Similar Conditions
Conditions in which symptoms are similar to an ankle inversion sprain and need to be ruled out by health care professional may include:
-
Lateral malleoli fracture
-
Avulsion fracture (small piece of bone torn away by tendon)
-
Bruised lateral malleoli
-
Peroneal brevis tendonitis
-
Syndesmosis sprain (high ankle sprain)
-
Fracture of the fifth metatarsal head
Diagnosis
After a proper history (situation and mechanism of injury, previous injury to the ankle) and a physical examination is conducted, the diagnosis of an ankle inversion sprain (and affected ligaments) should be rather straight forward.
Special tests can be conducted by a physiotherapist to rule in/out various structures so that a proper diagnosis can be formulated.
When to Seek a Professional
Runners should seek the advice of a professional such as a physiotherapist if they experience or suspect:
-
A “pop” was heard during injury
-
Difficulty using the joint after initial injury (unstable, tripping over objects)
-
Severe fracture or dislocation
-
Neurovascular compromise (nerve or blood flow compromise)
-
Symptoms that are not proportional to the degree of trauma
Predisposing Factors
There are factors that will increase the likelihood of developing an ankle inversion sprain include:
Progress & Duration of Condition
Ankle inversion sprains are traumatic in nature and the healing process depends on the severity of the initial injury (grade of sprain).
Treatment/ Rehabilitation Examples
The primary treatment goal of rehabilitation of an ankle sprain is to quickly restore the range of motion and strength of the ankle without any major loss of proprioception (balance), thereby restoring full activity as soon as possible
-
Immobilization should be reserved for the worst cases as it can cause local irritation, joint stiffness, muscle atrophy, and extensive loss of proprioception
-
Complications of an immobilized joint can happen very quickly so the quicker rehabilitation can start the more beneficial to recovery
-
Immobilization should be for a minimum time for an ankle sprain, no more than a 7 days, and should be weaned off at the end of the week
- Immobilization may give the ligaments enough time to heal properly and so that re-injury does not occur
Rehabilitation can be divided up into various phases of treatment:
-
Initial phase:
- Reduction in swelling. Rest, Ice, Compression, Elevation in conjunction with electrotherapy/ultrasound
-
Early Rehabilitation phase:
- Restore normal ROM with manual treatments
- Calf stretch (weight bearing and non-weight bearing)
- Ankle alphabet (write the alphabet on the floor with your big toe while sitting)
- Tilt board, uneven surfaces (start with double leg balance and progress to single leg stance)
-
Late Rehabilitation phase:
- Muscle strength and endurance
- Mini-trampoline
- Wobble board (optimal dimensions for stimulating lower limb muscles, diameter is 350mm, placed on a ball with 50mm of curvature)
-
Functional phase:
- Full activity, incorporate job demands and functional strengthening
- Running, jumping, cutting
- Figure 8’s
Prevention
As ankle injuries are traumatic in nature, prevention is indicated for those who have suffered a past ankle sprain and prevention is aimed to reduce the number of sprains in the future:
-
Wobble board training for a period of 12 weeks beginning 1 week after the ankle sprain is effective in reducing the number of recurrent distortions and preventing functional instability of the ankle in patients with primary ankle sprains
-
Make sure running shoes are providing adequate support
-
Scheduling Relative Rest into your running program
- Allowing a minimum of 24hours after a strenuous run for recovery
- Gradual increase of mileage NOT exceeding 10% per week
- Proper building of mileage scheduling rest weeks into your program
- For an example of how to schedule (periodize) your running program click here
-
Proper warm-up and cool-down
- For an example of how to properly warm-up & cool down for runners, click here
- Stretch to maintain muscle flexibility or correct muscle shortening
- For our advice on stretching for runners, click here
-
Running with lightweight footwear that has minimal wear & compression
- For advice on footwear for runners, click here
- Replace running shoes every 600-800km of running depending upon running surface and body weight
-
Correct biomechanical problems in the lower extremities
- Visit a Physiotherapist or Orthotist for orthotics if needed
-
Running on level, forgiving surfaces for the majority of mileage or long runs
-
Avoid running on hills and uneven surfaces
References
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Ankle Eversion Sprain
Definition
Eversion sprains are much less common than ankle inversion sprains. They typically occur as the foot flexes upward (dorsiflexion) and rolls out (eversion/pronation). The inside ankle ligamentous complex is typically damaged during an ankle eversion sprain. Eversion sprains only account for about 5% of ankle sprains. This is because the deltoid ligaments on the inside (medial) aspect of the ankle are much stronger than the outside (lateral) ligaments.
The deltoid ligaments of the ankle consist of the following ligaments:
-
Tibionavicular ligaments
-
Tibiocalcaneal ligaments
-
Anterior tibiotalar
-
Posterior tibiotalar
Causes
Injury to the deltoid (inside of ankle) ligaments is usually caused by severe forces and a direction of force that may result in either an ankle fracture or significant ankle instability. Ankle eversion sprains are generally far more traumatic in nature and surrounding structures need to be assessed by a health professional.
Facts & Statistics
Symptoms
Symptoms of an ankle eversion sprain vary depending on the severity of the ankle sprain. The following is the break down of the various grades of sprains:
-
Grade 1 sprain
- Mild injury, stretching ligament without any large amounts of tearing
- Mild pain
-
• Grade 2 sprain
- Moderate injury, involves larger tearing of the ligament
- Moderate to severe amounts of pain, swelling, tenderness
- No instability of the joint
- Positive ligament stress tests for pain and mild-moderate laxity
-
Grade 3 sprain
- Severe injury, involves a complete rupture of the ligament
- Severe swelling
- Tenderness & pain varies from moderate to severe as a complete tear can be less painful than a partial tear
- Joint in unstable
- Positive ligament stress tests for laxity
Similar Conditions
Conditions whose symptoms are similar to an ankle eversion sprain and need to be ruled out by a health care professional may include:
Diagnosis
Special tests can be conducted by a physiotherapist to rule in/out various structures so that a proper diagnosis can be formulated.
When to Seek a Professional
Runners should seek the advice of a professional such as a physiotherapist when they are experiencing:
-
A “pop” was heard during injury
-
Difficulty using the joint after initial injury (unstable, tripping over objects)
-
Severe fracture or dislocation
-
Neurovascular compromise (nerve or blood flow compromise)
-
Symptoms that are not proportional to the degree of trauma
Progress & Duration of Condition
Ankle eversion sprains are traumatic in nature and the healing process depends on the severity of the initial injury (grade of sprain).
-
Ankle instability may occur after injury
- Mechanical instability
- Abnormal increased mobility or movement of the ankle
- Tearing of the ankle ligaments
- Positive tests for ligament laxity (anterior drawer, eversion stress test)
- Functional instability
- Recurrent sprains
- Chronic feeling of “giving way” of ankle
Treatment/ Rehabilitation Examples
The primary treatment goal of rehabilitation of an ankle sprain is to quickly restore the range of motion and strength of the ankle without any major loss of proprioception (balance), thereby restoring full activity as soon as possible
-
Immobilization should be reserved for the worst cases as it can cause local irritation, joint stiffness, muscle atrophy, and extensive loss of proprioception
-
Complications of an immobilized joint can happen very quickly so the quicker rehabilitation can start the more beneficial to recovery
-
Immobilization should be for a minimal time period for an ankle sprain, no more than a 7 days, and should be weaned off at the end of the week
- Immobilization may give the ligaments enough time to heal properly and so that re injury does not occur
Rehabilitation can be divided up into various phases of treatment:
-
Initial phase:
- Reduction in swelling. Rest, Ice, Compression, Elevation in conjunction with electrotherapy/ultrasound
-
Early Rehabilitation phase:
- Restore normal ROM with manual treatments
- Calf stretch (weight bearing and non-weight bearing)
- Ankle alphabet (writing the alphabet with big toe on floor while sitting)
- Tilt board, uneven surfaces (start with double leg balance and progress to single leg stance)
-
Late Rehabilitation phase:
- Muscle strength and endurance
- Mini-trampoline
- Wobble board (optimal dimensions for stimulating lower limb muscles, diameter is 350mm, placed on a ball with 50mm of curvature)
-
Functional phase:
- Full activity, incorporate job demands and functional strengthening
- Running, jumping, cutting
- Figure 8’s
Prevention
As ankle injuries are traumatic in nature, prevention is indicated for those who have suffered a past ankle sprain and prevention is aimed to reduce the number of future sprains:
-
Wobble board training for a period of 12 weeks beginning 1 week after the ankle sprain is effective in reducing the number of recurrent distortions and preventing functional instability of ankle in patients with primary ankle sprains
-
Make sure running shoes are providing adequate support
-
Scheduling Relative Rest into your running program
- Allowing a minimum of 24hours after a strenuous run for recovery
- Gradual increase of mileage NOT exceeding 10% per week
- Proper building of mileage scheduling rest weeks into your program
- For an example of how to schedule (periodize) your running program click here
-
Proper warm-up and cool-down
- For an example of how to properly warm-up & cool down for runners, click here
- Stretch to maintain muscle flexibility or correct muscle shortening
- For our advice on stretching for runners, click here
-
Running with lightweight footwear that has minimal wear & compression
- For advice on footwear for runners, click here
- Replace running shoes every 600-800km of running depending upon running surface and body weight
-
Correct biomechanical problems in the lower extremities
- Visit a Physiotherapist or Orthotist for orthotics if needed
-
Running on level, forgiving surfaces for the majority of mileage or long runs
-
Avoid running on hills and uneven surfaces
References
top
Syndesmosis Sprain
AKA “High Ankle Sprain”
Definition
A "high" ankle sprain is an injury to the ligaments between the tibia and fibula at the level just above the ankle. The mechanism of injury usually occurs when the elevated (dorsiflexed) ankle is subjected to a outward rotation force. When the ankle is dorsiflexed (pointed upward) the talus is “locked”, and outward rotation results in tension on the ankle syndesmosis (the connection between the tibia and the fibula). There are various structures that can be injured during a syndesmosis sprain:
Causes
As with any injury there are various mechanisms of injury. A syndesmosis sprain may occur with any of the following mechanisms:
-
Outward rotation with the foot elevated (dorsiflexed)
- Forced outward rotation which acts to widen the tibia/fibular joint above the ankle
- Pushes the fibula away from the tibia resulting in tearing of the ligaments which hold the two bones together
-
Excessive elevation (dorsiflexion) of the foot
- Front portion of the talus is wider and wedges between the tibia & fibula during excessive dorsiflexion
- This occurs in runners when the foot is planted and body travels forward, or during a sudden stop when the foot planted and momentum carries the body forward
Facts & Statistics
Symptoms
Symptoms of an ankle syndesmosis sprain vary depending on the severity of the ankle sprain. Some symptoms may include:
-
Pain worsens during external rotation (rotating out) of the foot when the foot is pointed upward (dorsiflexion)
-
Pain on weight bearing or inability to weight bear
-
Severe pain (severe in comparison to an ankle inversion sprain)
-
Significant bruising/swelling
The following is the break down of the various grades of sprains:
-
Grade 1 sprain
- Mild injury, stretching ligament without any large amounts of tearing
- Mild pain
-
• Grade 2 sprain
- Moderate injury, involves larger tearing of the ligament
- Moderate to severe amounts of pain, swelling, tenderness
- No instability of the joint
- Positive ligament stress tests for pain and mild-moderate laxity
-
Grade 3 sprain
- Severe injury, involves a complete rupture of the ligament
- Severe swelling
- Tenderness & pain varies from moderate to severe as a complete tear can be less painful than a partial tear
- Joint in unstable
- Positive ligament stress tests for laxity
Similar Conditions
Conditions whose symptoms are similar to an ankle syndesmosis sprain and need to be ruled out by a health care professional may include:
-
Inversion/eversion ankle sprain
-
Fracture of the fibula (oblique or spiral fracture may occur)
-
Avulsion fracture
-
Tendonitis of tibialis anterior
-
Stress fracture
-
Shin splints
Diagnosis
Some of the tests that may be utilized to diagnosis a syndesmosis sprain may include:
When to Seek a Professional
Runners should seek the advice of a professional such as a physiotherapist when they are experiencing:
-
A “pop” was heard during injury and difficulty using the joint after the injury persists
-
Severe fracture or dislocation
-
Neurovascular compromise (nerve or blood flow compromise)
-
Symptoms that are not proportional to the degree of trauma
- Unrelieved, constant pain
Progress & Duration of Condition
Ankle syndesmosis sprains are traumatic in nature and the healing process depends on the severity of the initial injury (grade of sprain). As syndesmosis ankle sprains are much more complicated in nature than a regular ankle inversion sprain, healing times are usually twice as long and return to activity is usually a slow and gradual process.
-
Injury that does not require surgery
- Most syndesmosis ankle sprains can be treated with the RICE formula
- However they require much longer to heal (6-12 weeks)
- They will also need more strengthening and retraining of the musculature around the joint
-
Injury requiring surgical intervention
- Severe syndesmosis ankle sprains with fractures of the fibula or significant displacement of the bones (tibia and fibula) will need surgical intervention
Treatment/ Rehabilitation Examples
The primary treatment goal of rehabilitation of a syndesmosis ankle sprain is to quickly restore the range of motion and strength of the ankle without any major loss of proprioception, thereby restoring full activity as soon as possible. However one must be aware that a syndesmosis ankle sprain is much more complicated and takes up to twice as long to heal as a regular ankle inversion sprain.
-
High ankle sprains benefit from immobilization for approximately 6 weeks so that the ligaments can heal properly
- First 2 weeks in an air cast
- Following 4 weeks in a lace up brace with lateral supports
- Immobilization is necessary as to prevent the foot from jamming /splaying the tibia & fibula apart and re re-injuring the ligaments
-
Immobilization should be reserved for the worst cases as it can cause local irritation, joint stiffness, muscle atrophy, and extensive loss of proprioception
-
Complications of an immobilized joint can happen very quickly so the quicker rehabilitation can start the more beneficial to recovery
Rehabilitation can be divided up into various phases of treatment:
It is important to ensure that during early rehabilitation there is not excessive dorsiflexion (foot being jammed upward), as this will place additional stress on the already torn ligaments which hold the tibia and fibula together
-
Initial phase:
- Reduction in swelling. Rest, Ice, Compression, Elevation in conjunction with electrotherapy/ultrasound
-
Early Rehabilitation phase:
- Restore normal ROM with manual treatments
- Calf stretch (weight bearing and non-weight bearing)
- Ankle alphabet (writing the alphabet on the floor with big toe while sitting)
- Tilt board, uneven surfaces (single limb stance)
- Cardiovascular activities can be continued such as riding the bike with the brace on
-
Late Rehabilitation phase:
- Muscle strength and endurance
- Mini-trampoline
- Wobble board (optimal dimensions for stimulating lower limb muscles, diameter is 350mm, placed on a ball with 50mm of curvature)
-
Functional phase:
- Full activity, incorporate job demands and functional strengthening
- Running, jumping, cutting
- Figure 8’s
Prevention
As ankle injuries are traumatic in nature, prevention is indicated for those who have suffered a past ankle sprain and prevention is aimed to reduce the number of sprains in the future:
-
Wobble board training for a period of 12 weeks beginning 1 week after the ankle sprain is effective in reducing the number of recurrent distortions and preventing functional instability of ankle in patients with primary ankle sprains
-
Maintenance of strength and ROM of the ankle
-
Make sure running shoes are providing adequate support
-
Scheduling Relative Rest into your running program
- Allowing a minimum of 24hours after a strenuous run for recovery
- Gradual increase of mileage NOT exceeding 10% per week
- Proper building of mileage scheduling rest weeks into your program
- For an example of how to schedule (periodize) your running program click here
-
Proper warm-up and cool-down
- For an example of how to properly warm-up & cool down for runners, click here
- Stretch to maintain muscle flexibility or correct muscle shortening
- For our advice on stretching for runners, click here
-
Running with lightweight footwear that has minimal wear & compression
- For advice on footwear for runners, click here
- Replace running shoes every 600-800km of running depending upon running surface and body weight
-
Correct biomechanical problems in the lower extremities
- Visit a Physiotherapist or Orthotist for orthotics if needed
-
Running on level, forgiving surfaces for the majority of mileage or long runs
-
Avoid running on hills and uneven surfaces
References
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