Ankle Sprain: Injury management How to heal a serious ankle sprain

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.

Scenario 1

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.

Scenario 2

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:

• Are further investigations warranted?
• Do you need to refer the client to a specialist?
• Do they need a cast or crutches?
• Roughly how long will their rehabilitation take?

If you don’t have a good working diagnosis, none of these questions can be answered.

The crucial first week

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:

• partial weight bearing to…
• full weight bearing to…
• walking to …
• transitional drills to …
• running.

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.

1. Osteochondral defect (OCD)

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.

Signs

• usually there is no obvious sign on initial X-ray, but closer inspection or re-X-ray may reveal disruption to the joint margins
• significant pain on weight bearing
• the medial and lateral anterior talar dome, anterior tip of tibia or fibula will be very tender on palpation
• swelling all around joint lCT or MRI should tell all
• if sufficiently disrupted, this may require surgical referral.

Recovery time-frame: three to six months.

2. Bone stress short of fracture

Signs

• not visible on X-ray; bone scan will confirm but is not really necessary
• extreme tenderness on palpation, on medial/lateral malleolus or along shaft of tibia or fibula will confirm diagnosis
• maybe positive to squeeze or stress tests (where the bone is gently stressed as if you were trying to bend a stick).

Recovery time-frame: will heal by itself with sufficient rest over two to six weeks, depending on severity.

3. Lateral ankle ligament tear leading to gross instability

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.

Signs

• the most common result of a plantar-flexion/inversion sprain, rarely occurs in isolation from bony injury
• talocruraljoint demonstrates instability, leading to overloading of capsular and/or ligamentous structures and later possibly synovitis (thickened and inflamed capsule)
• client is unlikely to be able to weight- bear for initial period because of likely involvement of bony structure damage
• trial taping for diagnostic purposes: stirrups and heel locks can artificially stabilise the lateral ankle complex and help to diagnose a pure instability problem
• perform anterior drawer (ATFL) and possible medial glide of talus/calcaneum to gauge the end-feel of ligaments.

Recovery time-frame: three to six months, depending on other damage.

4. Tibio-fibular ligament/syndesmosis damage leading to instability

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.

Signs

• landing with twisting is very likely to stress and drive the tibia and fibula apart, causing a tear of the ligament and syndesmosis (in addition to damage to other structures above)
• palpation of the anterior shin between tibia and fibula will show tenderness; medial/lateral stress test holding the calcaneum will reveal gapping and laxity between tibia and fibula.
• with significant instability, separation of tibio-fibular articulation is likely to be seen on a weight-bearing (heel pressure) X-ray, compared with other side
• it may be useful at a later stage to re-Xray in weight bearing at end-of-range dorsiflexion (if that was not possible at the outset because of pain) to detect any ongoing instability of the tibio-fibular complex compared with other ankle. With luck it may show up negative at the three-month stage with fibrosing and scar tissue doing a sufficient job of holding it together
• tibio-fibular compression taping may help with stabilising in the early weight- bearing phases.

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.

The lateral ankle: key injury sites

Continued pain at 4 to 8 weeks

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:

1. Talo-crural joint hypomobility/restriction

This leads to capsular synovitis/lateral impingement of fibula and talus in the lateral gutter.

Signs

• a very common side effect of any ankle sprain; it is critical to maintain maximum mobility to promote the best rate of healing
• if the talus cannot posteriorly glide during weight bearing it will cause ongoing impingement of anterior bony structures
• after the acute phase, perform manual posterior glides of talus and dorsiflexion testing at a wall to establish the extent of dorsiflexion deficit and the sites of restrictions (based on points of pain). Never stretch forward in weight bearing to improve dorsiflexion, as this risks aggravating the damaged structures
• fibrosis and thickening of the posterior capsule responds well to manual loosening procedures. Deep tissue massage of uninjured soft tissues (especially calf) is very useful in the acute phase. The use of seat belts in the mid to late stages of rehab can help to force the various bones to glide in normal ways again to gain final degrees of dorsiflexion – this should be done by an experienced physiotherapist.

2. Peroneal tendinopathy

Signs

• damage of the peroneal muscles and tendons is possible, but would not prevent normal weight bearing initially. Undertake static muscle testing, especially in dorsiflexion to note pain and weakness (there could be a tear in the muscle belly)
• treat as any muscle injury through to full return to function
• restricted or fibrosed peroneus longus can prevent normal dorsiflexion at later stages of rehab; massage and stretching is the answer
• the peroneal tendon can sublux from a torn tendon sheath posterior to the lateral malleolus, leading to chronic clicking and pain that may require surgery.

3. Reflex sympathetic dystrophy

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.

Signs

• the risk of developing this may increase with too aggressive a rehabilitation strategy – go slow!
• keep this diagnosis (even in ‘mild’ forms) at the back of your mind if strange things are happening to the ankle that are really slowing down the return to function
• look for positive neural signs and paresthesia
• continueto work on range of movement and pain relief. Personally I find deep tissue massage/ trigger-point release to gastrocnemius and soleus muscles is critical for mobility gains. Acupuncture has occasionally worked wonders for pain relief
• can severely delay return to function, from three to 12 months
• adverse neural tension testing, done by a physiotherapist, can determine what level of nerve tethering or dysfunction is present.

4. Proprioceptive deficit

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.

Signs

• do this test on yourself if you have ever badly injured an ankle or knee joint: in a completely dark room, stand on each leg in turn. Note the significant challenge of standing easily on the previously injured leg!
• proprioception in every damaged ankle will have been moderately to severely affected; this will need to be addressed during the mid to late stages of rehabilitation.

Conclusion

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