Ulrik Larsen offers guidance on how to spot and treat the kind of lateral ankle damage that can ruin an athletic career.
What is the most common sporting injury? Chances are that anyone who has done any kind of weight-bearing sport has had it happen: a sprained ankle. But there is a vast difference between mild sprains and moderate to severe lateral ankle sprains which actually damage the ankle.
Incorrect management can easily turn a recovery time from 3-4 months into a 12-18 month epic. I’ve seen it happen and made the mistakes myself as a younger clinician!
To establish an accurate diagnosis and treatment schedule you need to know where a sprain fits into the spectrum. The key question is this: what are the signs and symptoms that distinguish a sprained ankle that is damaged? Only by identifying these features can we undertake the crucial early management, and predict which sprains will require longer time frames for recovery.
I am not talking here about mild ankle sprains that will always get better regardless of what is done to them – most athletes will ‘walk them off’ because there is no real damage to the ankle. Nor will I discuss medial ankle sprains, or acute forefoot/mid-foot injuries. And finally, I will not be looking at the obviously severe injuries that need orthopaedic referral: fractures of tibia and/or fibula, talar dome and ankle dislocations. Usually these will be picked up in the emergency department of the local hospital. If the injury happens on the field, the severity of pain would be enough to convince anyone to summon an ambulance and have immediate X-rays!
So what does that leave? Precisely the tricky sprains in which damage to the ankle is unlikely to show up positive on X-ray. Commonly these injuries have a history of having occurred with some heavy weight-bearing and rotary force; they present with significant swelling, pain, lack of normal range of movement; and the client will be unable to walk and/or run without pain and aggravation.
An athlete in this situation is certainly going to be frustrated, because they will probably present after a few weeks have gone by and things are not resolving, having been given the all-important all-clear on X-ray. So their expectations will have been skewed towards thinking that they will be back on the field within two to four weeks.
The most common mistake that clinicians, coaches and athletes make is to underrate the severity of damage and return to activity too early. The fatal assumption is that when the X-ray is negative, then the damage can’t be too bad… Wrong! The best result will often be had by overrating the damage in the first month, and being extra cautious, rather than pushing for progress.
Let’s paint a couple of painful pictures to help us understand how a damaged ankle sprain happens.
You’re running at speed with the ball and step heavily off your left foot to move quickly to your right. But the ground doesn’t feel quite like you thought it would. In a split second your foot has rolled underneath your leg, resulting in a feeling of more than one ‘crack’ followed shortly afterwards by a searing pain that envelops your whole foot and leaves you writhing in agony on the ground.
While contesting the ball among a few other players you jump as high as you can to reach it. You land while you are twisting around, catching the edge of another player’s shoe, and causing your foot to land on the ground on its outside edge. The crunch that you feel is nauseating and soon so is the pain.
Both these situations will very likely result in damage to bone, joint, ligament, tendon or nerve that will require profound rest for complete healing to take place. How long and to what degree the rest needs to be enforced (and many athletes will not be happy to hear that they need to be on crutches for two to four weeks if normal weight-bearing is preventing good healing) depends on the all-important diagnosis.
The first few days is the critical phase for diagnosis because it immediately determines the management and time frames for full recovery:
If you don’t have a good working diagnosis, none of these questions can be answered.
While there isn’t any hard evidence to back this up, the issue of whether the athlete can reasonably weight-bear during the first week seems to be critical in establishing whether any of the four ‘nasties’ discussed below has occurred. This is because for the foot not to be able to stand simple weight- bearing implies that the weight-bearing surface and/or the stability mechanisms of the ankle must have been severely compromised.
This, therefore, is your first key diagnostic and management judgement: if it is painful to weight-bear on the foot in the first week, significant damage has occurred. The athlete needs to be non-weight bearing, on crutches, to the level that ensures there is no pain.
The option of soft-casting the ankle to hold it still will often need to be considered to achieve complete immobilisation. Any negative secondary effects of non-weight bearing for a week will be far outweighed by further damage caused by painful weight bearing.
From non-weight bearing, you will need to take the client conservatively through each new progression:
Delay each new step rather than re- aggravate the symptoms. Put the client in the water to practise each successive stage to reduce body weight and rehearse technique. A good idea is to use weight scales to objectify the graduated weight-bearing increases: stand them next to the scales and get them to load to 10kg and listen to how their ankle feels; that may be all they do for the first few days: holding that same level of pressure for 10 seconds, and repeating for 5-10 reps. The action must be pain-free.
There are four main types of primary damage that may in isolation or in combination prevent reasonable weight bearing in the first week.
This is damage to the surface chondral layer of the bone; the damage may be simple bruising, through to a displaced segment of cartilage. It may occur on the talar dome, the inferior tibial surface (‘tibial plafond’) or the medial fibular surface in the lateral gutter of the ankle.
The damage to various parts of the bony surfaces is commonly the result of the twisting force of landing, which causes the talus to invert and medially rotate in the tight angular ankle joint.
Recovery time-frame: three to six months.
Recovery time-frame: will heal by itself with sufficient rest over two to six weeks, depending on severity.
This is significant tearing (Grade II), through to complete rupture (Grade III) of the anterior talo-fibular (ATFL) and/or calcaneo-fibular (CFL) ligaments. Complete rupture of the lateral ligament complex requires immediate orthopaedic referral for stabilisation surgery.
Recovery time-frame: three to six months, depending on other damage.
Also known as ‘high ankle sprain’. Can be very nasty, requiring orthopaedic referral to prevent long-term arthritic changes. The fibula will usually fracture laterally as well, preventing further damage along the line of the syndesmosis.
Recovery time-frame: absolutely critical to prevent weight bearing on foot for up to three or four weeks with a more conservative progression through partial to full weight bearing. In total, allow six to eight months to return to sport.
If things are not going well, or you are noticing new symptoms, consider the following secondary damage issues. These may not clearly manifest until the worst of the pain, swelling and disability has receded, but they need to be addressed in their own right as part of the mid- to late- stage rehabilitation process. These are the most common ones:
This leads to capsular synovitis/lateral impingement of fibula and talus in the lateral gutter.
Also known as ‘complex regional pain syndrome’ or Sudeck’s atrophy. A relatively uncommon condition of burning pain, pins and needles or numbness, ongoing and excessive swelling, often spreading up the whole shin, and discoloration of the foot and/or leg. It arises from a disturbance in the sympathetic nervous system that controls the blood flow and sweat glands to the limb. The neural disturbance may have its origins in over-stretching of nerve tissue during the ankle sprain, changing the way the nerve impulses are sent and causing a short circuit or overactivity.
Reams of research and knowledge have been developed to aid our understanding of how a severe disruption to the normal functioning of a joint or body part can then create long-term damage to the brain-body connection to that body part. The brain’s ability to be aware of and to coordinate reflexes at the injured ankle can set up a chain of injuries elsewhere through the lower limbs unless the proprioceptive deficit is corrected through an exercise programme.
Once there is clarity about the nature and severity of damage to structures, you will be able to develop time frames for recovery and then tackle the challenge of restricting the athlete to crutches and prescribing safe exercise for the ankle.
More often than generally acknowledged, a period on crutches can be critical for the initial phase of healing, and to prevent side effects such as ongoing instability, long-term swelling and ankle thickening, and even reflex sympathetic dystrophy.
If you manage the rest and the healing phases thoroughly, you will help your client minimise their time out of action from the sport and they will have long-term reason to be thankful for your patient care.
Ulrik Larsen BThpy MAPA is an APA sports physiotherapist with a special interest in clinical Pilates. He is physiotherapist to Queensland Academy of Sport men’s water polo team
Illustrations by Viv Mullett