Ankle Injuries

Sprained Ankle

What you may have felt:

• Immediate pain on the outside of your ankle.
• Unable to walk on it due to pain.
• Noises – crack/pop/snap.
• You can roll your ankle both inwards and outwards. However outwards is the most common.

What should you initially do?

You should perform the PRICER acronym:

• Protect: Avoid further injury by using crutches if available.
• Rest: Avoid exercise until cleared by your Physiotherapist.
• Ice: Every hour place an ice pack on the sore area for 20 minutes.
• Compression: Use Tubigrip, skins or another compression garment around your ankle to decrease swelling.
• Elevation: When resting keep your ankle above your heart level to decreas swelling.
• Referral; to your Physiotherapist and/or Sports Medicine Doctor. Check with our physiotherapists / clinic if a doctor’s referral is needed before your  appointment.

You should avoid:

• Heat
• Alcohol
• Running
• Massage

What type of treatment is best?

See your Physiotherapist and/or Sports Medicine Doctor.

• They will diagnose the injury and provide the best local treatment, and/or medication.
• Commonly the ankle will be bandaged or strapped to protect from further damage and help reduce the swelling.
• Some injuries require a “Moon Boot” and possibly crutches.
• Early mobilisations from the Physiotherapist assist healing and regaining control of the ankle movements.

Then what type of rehabilitation is best?

Once the pain and swelling has decreased, an exercise program will be given to you by your Physiotherapist. It will include:

• Balance exercises – improve co-ordination of ankle muscles.
• Strength exercise – improve the ankles ability to withstand forceful movements.
• Sport based exercises (hopping, zig-zag running) – to prepare you for sport.

How long until you can return to sport?

The severity of your symptoms determines how long you have off sport, however generally:

• Grade 1: 1-3 weeks
• Grade 2: 4-6 weeks
• Grade 3: 6-12 weeks
• Grade 4: Surgery – More than 6 months.

Recurrent Ankle sprains are very common, and a significant number of these can be prevented with early treatment and a properly designed exercise program.

Strapping is usually an essential part of returning to sport safely, and is regularly required for up to 6 months after the initial injury.

Ankle Joint Ligament Sprains

Ligament injuries of the ankle are the most common of all sporting injuries. Every sprain causes damage to the stabilising tissues of the joint with bleeding, swelling and tenderness.

The damage to the ligament can be partial or total. Sometimes a small portion of bone is torn away at the point of ligamentous attachment, whilst the ligament itself remains intact.

In about 70% of ankle joint injuries the anterior talofibular ligament is injured. In 20% of cases the calcaneofibular ligament is also involved. The mechanism of injury is usually a rolling over of the outside of the foot. The inside (deltoid) ligaments can also be damaged, however this is much less common.

The treatment of an ankle joint sprain depends entirely on the severity of the injury and the structures injured. Such injuries must be immediately treated with Rest, Ice, Compression and Elevation.

Physiotherapy and medications will prevent further swelling and assist in the removal of excess swelling, thus speeding recovery. The healing of an ankle joint ligament can take 2-8 weeks and problems can remain for up to 8-10 months after the incident.

Treatment is directed towards regaining full pain free movement of the ankle, full strength of the surrounding musculature and full proprioception (position sense) of the joint.

An untreated ligament injury can lead to permanent instability with recurrent sprains. If necessary a ligament can be sutured together or reconstructed by surgery.

Ankle Injuries

Ligaments are the body tissue used to hold our bones together. Ligament injuries around the ankle are among the most common sporting injuries, especially in those sports involving twisting and jumping.

Common problem and causes:

Inversion injuries, where the foot is forcefully rolled inwards at the ankle, are by far the most common ankle injuries. This is thought to be due to less extensive bony structures and relatively weaker ligaments on the outside of the ankle compared to the inside of the ankle.

Injury occurs when the ligaments are forcefully stretched past their normal length such that they are sprained or ruptured. Swelling and bruising normally accompanies ankle injuries and the extent is often a good indicator of severity.

It is very important to limit the bleeding and swelling as much as possible as the accumulation of blood slows down the healing process dramatically. The athlete should be taken immediately from the playing field and the RICER regimen performed. This aims to minimise bleeding and promote healing.

Physiotherapy plays a very important part in the rehabilitation of ankle injuries. A comprehensive rehabilitation program is normally required if the athletes are to return to their sport at full capacity and avoid recurrence of the injury.

“Don’t wait to get better”

Ankle Impingement

This is a common condition in footballers. The player will often present to the trainer or Physiotherapist with pain across the front of the ankle, with no apparent recent injury such as the more common “rolling” the ankle.

Players may complain of pain across the front line of the ankle joint, pain when the foot is fully pointed such as whilst kicking or pain on pushing off from a standing start or from sudden change of speed or direction.

Many of these players have had previous ankle injuries, and these symptoms gradually come on over some weeks. They usually get progressively worse as the season goes on if not addressed, and can get to the stage where the player trains and plays less and less.

The cause of this problem is often “Anterior Ankle Impingement“, meaning pinching of the ligamentous capsule at the front of the ankle. To understand this injury further, imagine a paper-thin layer of tough fibrous tissue across the front of the ankle attached to the bottom of the tibia, and the talus or bone in the top of the foot.

As the ankle points down (plantar flexion), this tissue is stretched. As the ankle is bent up (dorsiflexion), the tissue is pinched or caught between the bones. This pinching is the impingement.

Normally an ankle has enough room not to pinch the capsule, but if the capsule is somewhat swollen, or the bones slightly worn at the front, causing burring or “osteophytes“, the capsule can literally be pinched. This explains why the pain occurs with kicking and with pushing off. The problem gets progressively worse, as the pinching causes more inflammation and swelling, which means less room, and more pinching.

Examination will also show pain on pressure at the end of range plantar flexion and dorsiflexion. An x-ray is often taken, and will sometimes show the bony burrs that almost look like sharp edges. Often there may be other bony material or loose bodies in the front of the ankle joint. The player will also be tender to touch across the front of the ankle.

This injury is probably one of the most common reasons why so many AFL players have ankle operations in the off season, to clear out any debris, and smooth off some of the bone at the front of the joint that may be impinging.

However, you can’t do this during the season, as it will take some weeks after the operation until they could recommence any running. So the treatment for this condition is often management to control the swelling, and minimise the aggravation. Here are the steps to follow:

Diagnosis: Have the problem diagnosed by your Physiotherapist and/or Sports Physician/Doctor.

Minimise Aggravations: The Trainer liaises with the coach to minimise any aggravation at training. The player needs to avoid painful kicking and/or pushing off on that foot.

Follow the advice of your Physiotherapist and Sports Physician in regards to medications and local treatment which are both essential to control any swelling and pain.

RICER treatment after games and training.

Strap for support, and if required to limit painful end of range movements (speak to your Physio on how this can best be done).

Rest: Some players may be best having a week off to settle the problem, especially if they are getting worse and finals are coming.

Stretches: Often tight calves can aggravate this condition.

Follow up: At the end of the season get in to see the Physiotherapist and Sports Physician to ensure it is not a problem next year.

Many players finish the season, and the pain calms down. This does not mean it is fixed, and may just be waiting to happen again next year. If treatment or an operation are required to settle the problem and correct it, the more recovery time available the better.

Don’t wait for it to get better!

This common ankle problem need not interfere with an otherwise successful year for a player, and they should in most cases be able to see the year out if properly managed by the trainer, Physiotherapist and Sports Physician as a team.