In the first of this three-part masterclass article, Chris Mallac discusses the progression from acute ankle sprain to chronic and recurrent instability, the relevant anatomy and biomechanics, and how chronic instability can be identified in the athlete.
Ankle sprains are one of the most common injuries experienced by athletes, and account for a large percentage of lost time from competition(1,2). The frequency of acute ankle sprain is relatively high in the athletic population, with some researchers claiming that injuries to the ankle joint account for 20% of all joint injuries(3). A comprehensive review found that lateral ankle sprain was the most common ankle injury in 33 out of 43 sports(1). The lateral ligament complex is the most frequently injured ankle structure, with medial ligament (deltoid) injuries and syndesmosis injuries being less prevalent.
The majority of acute ankle injuries recover reasonably quickly with conservative treatment, which incorporates strengthening, ankle mobilisations, balance and proprioception and protective braces and strapping. However, a number of acute ankle sprain sufferers may go on to develop later-stage chronic or recurrent ankle instability. This results in a feeling that the ankle feels vulnerable, episodes of catching and ongoing pain and further episodes of repeat ankle sprains(4). One of the highest risk factors for an ankle injury is in fact a history of previous ankle injury(5). Of further significance is that ankle sprains have a high rate of recurrence (as high as 80% in high-risk sports)(5,6). This suggests that many ankle sprain sufferers will most likely sprain their ankles again, and this may then cascade to late stage chronic ankle instability (CAI).
When the ankle is fully loaded into weight-bearing and dorsiflexion, the articular surfaces and joint congruency are the main stabilisers of the ankle, and prevent the talus from rotating and sliding(7). The ligaments of the ankle do play a role in stability in this position; however they become a lot more crucial in ankle stability as the ankle approaches plantarflexion. In plantarflexion, the talocrural joint is in a loose-packed position and therefore joint congruency and inherent joint stability are reduced. This means the ankle ligaments play a much larger role in ankle stability (and thus are more vulnerable to injury) in this position.
The ligaments of the ankle include the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL), and deltoid ligament on the medial side of the ankle (see figure 1). The ATFL, PTFL, and CFL support the lateral aspect of the ankle, while the deltoid ligament provides medial joint stability. For the purposes of this article the deltoid ligament will not be discussed and the focus will remain on the lateral ankle ligaments, the ATFL, CFL and PTFL.
Our international team of qualified experts (see above) spend hours poring over scores of technical journals and medical papers that even the most interested professionals don't have time to read.
For 17 years, we've helped hard-working physiotherapists and sports professionals like you, overwhelmed by the vast amount of new research, bring science to their treatment. Sports Injury Bulletin is the ideal resource for practitioners too busy to cull through all the monthly journals to find meaningful and applicable studies.
*includes 3 coaching manuals
Get Inspired
All the latest techniques and approaches
Sports Injury Bulletin brings together a worldwide panel of experts – including physiotherapists, doctors, researchers and sports scientists. Together we deliver everything you need to help your clients avoid – or recover as quickly as possible from – injuries.
We strip away the scientific jargon and deliver you easy-to-follow training exercises, nutrition tips, psychological strategies and recovery programmes and exercises in plain English.